I

THE LIVED EXPERIENCE OF POST-TRAUMATIC STRESS DISORDER

AS DESCRIBED BY MOTOR VEHICLE ACCIDENT VICTIMS IN JORDAN

By:

Lilibeth Al-Kofahy

RN, BSN, MN

A thesis submitted in fulfilment of the requirements

for the degree of

Doctor of Philosophy (Health)

SCHOOL OF NURSING AND MIDWIFERY

QUEENSLAND UNIVERSITY OF TECHNOLOGY

2011

Principal Supervisor: Associate Professor Anthony Welch

Associate Supervisor: Dr Meng Lim

II

ABSTRACT

Aim: To explore the lived experience of post-traumatic stress disorder (PTSD) as described

by individuals who have been involved in a motor vehicle accident (MVA) in Jordan.

Background: Motor vehicle accident (MVA) survivors who develop post-traumatic stress

disorder (PTSD) have become an important health issue. The World Health Organisation

(WHO) states that trauma resulting from MVAs is a phenomenon of increasing concern,

with death from injuries projected to rise from 5.1 million in 1990 to 8.4 million in 2020

particularly in developing countries such as Jordan (WHO, 2002). The impact of trauma

from MVAs inevitably compromises the victim’s quality of life (WHO, 2002; Blanchard &

Hickling, 2007) resulting in psychological and emotional distress, occupational disability,

family disintegration, and socio-economic difficulty (Jordan Ministry of Health, 2005). The

development of PTSD as a result of an MVA is not limited to the individual, but also

extends to the family, friends, and the health care team involved in the person's care and

rehabilitation.

Design: A descriptive phenomenological approach was used for this study.

Method: This study was conducted in an orthopaedic unit in Amera Basma Hospital in

Irbid Jordan. Fifteen (15) participants were voluntary recruited through the process of

purposeful sampling. Data was collected by face-to-face in depth-interviews. Interviews

were digitally recorded and transcribed verbatim. The process of analysis was undertaken

using Colaizzi’s (1978) eight step approach with the addition of two extra steps.

Findings: The process of analysis identified seven themes explicated from the participants’

transcripts of interview. The seven themes were:

1. Feeling frustrated at a diminishing health status

2. Struggling to maintain a sense of independence

3. Harbouring feelings of not being able to recover

4. Feeling discriminated against and marginalised by society

5. Feeling ignored and neglected by health care professionals

III

6. Feeling abandoned by family, and

7. Moving toward acceptance through having faith in Allah.

Conclusion: The findings of this study have the potential to make a significant contribution

to extant knowledge on the topic which can inform future nursing practice, education,

policy development, and research initiatives in Jordan and internationally.

IV

DEFINITION OF KEY WORDS

Post-traumatic Stress Disorder – refers to a psychological disorder operationally defined by

the Diagnostic and Statistical Manual of Mental Disorders (APA, 2000). PTSD occurs in

people who have experienced PTSD following a motor vehicle accident to which they

respond with feelings of fear, or helplessness. PTSD is marked by three distinct sets of

symptoms such as re-experiencing the trauma, avoiding reminders of the trauma, and

experiencing increased physiological arousal.

Lived experience – is the existing expressions of an individual’s everyday world through own

words, feelings, emotions and behaviours (Colaizzi, 1978).

V

TABLE OF CONTENTS

ABSTRACT……………………………………………………………………………………….......II

DEFINITION OF KEY WORDS……………………………………………………………….........IV

TABLE OF CONTENTS.......................................................................................................................V

LIST OF PLATES................................................................................................................................XI

STATEMENT OF ORIGINAL AUTHORSHIP ……………………………………………..........XII

DECLARATION OF ENROLMENT………………………………………………………...........XIII

ACKNOWLEDGEMENT……………………………………………………………………..........XIV

CHAPTER ONE: INTRODUCTION…………………………………………………………….......1

1.1. Introduction.......…………………………...................................................................1

1.2. Historical Origins and Cultural Perspectives of Hashemite Kingdom of Jordan.....1

1.3. Motor Vehicle Accident: A Global Issue.....................................................................3

1.4. MVA: An Issue of Concern for Jordan.......................................................................4

1.5. Personal Background and Interest as a Researcher...................................................5

1.6. Purposes of the Study...................................................................................................6

1.7. Significance of the Study.............................................................................................7

1.8. Research Question........................................................................................................7

1.9. Conclusion....................................................................................................................7

CHAPTER TWO: LOCATING PTSD WITHIN AN HISTORICAL CONTEXT...............................9

2.1. Introduction…...........................................................................................................................9

2.2. Historical Overview of PTSD....................................................................................................9

2.3. Definition of PTSD..................................................................................................................11

2.4. Diagnostic Criteria of PTSD....................................................................................................13

2.5. PTSD Treatment and Best Practice............................…………………….............................15

2.5.1. Behavioural Therapy.......................................................................................................15

2.5.1.1. Applied Behaviour Analysis..............................................................................15

2.5.1.2. Neobehaviouristic Meditational Stimulus-Response Model..............................16

2.5.1.3. Social-Cognitive Theory....................................................................................17

2.5.1.4. Cognitive Behavioural Therapy.........................................................................17

2.5.1.4.1. Exposure Therapy..............................................................................18

VI

2.5.1.4.2. Stress Inoculation Training (SIT)......................................................19

2.5.1.4.3. Cognitive Restructuring Therapy.......................................................19

2.5.1.4.4. Eye Movement Desensitization and Reprocessing...................19

2.5.1.4.5. Multimodal Therapy................................................................21

2.5.1.4.6. Narrative Therapy....................................................................21

2.5.1.4.7. Creative Arts Therapy.............................................................22

2.6. Pharmacotherapy: Drugs used in PTSD......................................................................22

2.6.1. Propanolol and Clonidine.....................................................................................22

2.6.2. Serotonin Reuptake Inhibitors..............................................................................23

2.6.3. Guanfacine...........................................................................................................23

2.6.4. Venlafaxine..........................................................................................................23

2.6.5. Prazosin................................................................................................................24

2.7. Conclusion.....................................................................................................................24

CHAPTER THREE: PHILOSOPHICAL FRAMEWORK................................................................25

3.1. Introduction…………………………………………………………………………............25

3.2. The Origins of Phenomenological Thought..........................................................................25

3.3. What is Phenomenon?............................................................................................................26

3.4. The Constituents of Phenomenology............……………………………………….............26

3.5. Intentionality…………………………………………………………………………...........28

3.6. Intersubjectivity.......................................................................................................................27

3.7. The Transcendental Ego.........................................................................................................28

3.8. The phenomenological Attitude…………………………………………………………......28

3.9. Phenomenology Through the Eyes of Colaizzi.......................................................….......... 30

3.10. Phenomenology and Nursing…...…..………………………………………......................30

3.11. Phenomenology and the Experience Post-Traumatic Stress Disorder……..…….............31

3.12. Conclusion…………………………………………………………………………….........32

CHAPTER FOUR: METHOD………………………………………………………………….........33

4.1. Introduction…………………………………………………………………….....................33

4.2. Focus of the Study..................……………………………………………………….............33

4.3. The process of Participant Selection………………………...................................................33

4.4. Criteria for Participation in the Study....................................................................................33

4.4.1. Selection criteria for the study…………………………………………………….......34

VII

4.5. Number of Participants.................................………….……………….................................34

4.6. Accessing the Participants and the Recruitment Process......................................................34

4.7. Location of Information Gathering........................................................................................36

4.8. Information Gathering Process………………………………………...................................36

4.9. The Interview Process..............................................................................................................36

4.10. Information Analysis.............................................................................................................38

4.10.1. Transcribing all the participants’ transcripts………………………………...............38

4.10.2. Extracting significant statements................................................................................39

4.10.3. Participants symbolic and pictorial representations of their experience of PTSD......39

4.10.4. Creating formulated meanings ............................................................................…...40

4.10.5. Aggregating formulated meanings into theme cluster ..............................….............40

4.10.6. Developing an exhaustive description of the phenomenon........…............................41

4.10.7. Formulating the exhaustive description of the phenomenon..................................... 41

4.10.8. Validating the findings (the structure) with the participants.......................................41

4.10.9. Integrating information from the validating interview into the final description.......41

4.10.10. Reviewing the literature for understanding of the phenomenon...............................41

4.11. Ethical Considerations.......................................................................................…................42

4.11.1. Confidentiality/anonymity………………………………..………………................42

4.11.2. Informed consent……………………………………………….………...................42

4.11.3. Level of risk…………………………………………………………........................43

4.11.4. Storage of information...........................................................................….................44

4.11.5. Occupational Health and Safety Consideration...................................................…...44

4.12. Rigour of the study………....................................................................................................44

4.12.1. Credibility................................................................................................…...............45

4.12.2. Dependability............................................................................................…..............45

4.12.3. Transferability........................................................................................….................45

4.12.4. Confirmability..……………………………………………………...........................46

4.13. Conclusion................................................................................................…..........................46

CHAPTER FIVE: STUDY FINDINGS…………………………………..........................................47

5.1. Introduction…………………………………………………………………...........................47

5.2. Demographic Characteristics of the Participants…………………………………................47

Table 5.2.1. Demographic characteristics of the participant..……………………....................47

5.3. Significant Statements..............................................................................................................48

5.4. Created Formulated Meanings from the Significant Statements.......................................67

VIII

Table 5.4.1. Formulated meanings and relative significant statements.......................67

5.5. Conclusion.................................................................................................................................78

CHAPTER SIX: PRESENTATION AND DISCUSSION OF FINDINGS.....................................79

6.1. Introduction…..........................................................................................................................79

6.2. Discussion of Findings…………………................................................................................79

6.2.1. Theme One: Feeling frustrated at a diminishing health status......................................80

6.2.1.1. Researcher interpretation of theme 1..........................................................81

6.2.2. Theme Two: Struggling to maintain a sense of independence.....................................81

6.2.2.1. Researcher interpretation of theme 2.....................................................84

6.2.3. Theme Three: Harbouring feelings of not being able to recover..................................84

6.2.3.1. Researcher interpretation of theme 3...............................................................88

6.2.4. Theme Four: Feeling discriminated against and marginalised by society....................88

6.2.4.1. Researcher interpretation of theme 4...............................................................90

6.2.5. Theme Five: Feeling ignored and neglected by health care professionals...................90

6.2.5.1. Researcher interpretation of theme 5...............................................................93

6.2.6. Theme Six: Feeling abandoned by family....................................................................93

6.2.6.1. Researcher interpretation of theme 6..............................................................95

6.2.7. Theme Seven: Moving toward acceptance through having faith in Allah....................96

6.2.7.1. Researcher interpretation of theme 7..............................................................99

6.3. Exhaustive Description of the Phenomenon.........................................................................99

6.4. Fundamental Structure of the Phenomenon from the Participants’

Transcripts of Interview as Interpreted by the Researcher.................................................101

6.5. Participants’ Pictorial Representations................................................................................102

6.6. Exhaustive Description of the Pictorial Representations Provided by Participants..........105

6.7. Fundamental Structure of the Pictorial Representations Provided by

Participants as Interpreted by the Researcher..................................................................106

6.8. Conclusion.............................................................................................................................107

CHAPTER SEVEN: A REVIEW OF LITERATURE IN RELATION TO STUDY

FINDINGS………………………………………………………………………………………......108

7.1. Introduction…………………………………………………………………….…............108

7.2. Review of the Literature Related to the Theme..................................................................108

7.2.1. Theme One- Feeling frustrated at a diminishing health status…................................108

IX

7.2.2. Theme Two- Struggling to maintain a state of independence…………….................110

7.2.3. Theme Three- Harbouring feelings of not being able to recover.................................111

7.2.4. Theme Four- Feeling discriminated against and marginalised by society...................112

7.2.5. Theme Five- Feeling ignored and neglected by health care professionals..................114

7.2.6. Theme Six- Feeling abandoned by Family..................................................................115

7.2.7. Theme Seven- Making toward acceptance through having faith in Allah...................117

7.3. Conclusion..................................................................................................................119

CHAPTER EIGHT: FINAL REFLECTION THROUGH THE PHD JOURNEY………….........120

8.1. Introduction………………………………………………………………………..............120

8.2. The Research Journey..........................................................................................................121

8.2.1. Making the Decision to Undertake Doctoral studies...................................................121

8.2.2 Year 1: The Beginning of the Research Journey..........................................................122

8.2.3. Year 2: Data Collection in Jordan............................................................................... 125

8.2.4. Year 3: Completing my Dissertation...........................................................................127

8.3. Conclusion..............................................................................................................................129

CHAPTER NINE: SUMMARY, CONCLUSION, IMPLICATIONS

AND RECOMMENDATIONS OF THE STUDY…………………………………………….......130

9.1. Introduction………………………….....................................................................................130

9.2. Summary of Findings.............................................................................................................130

9.2.1. Theme One: Feeling frustrated at a diminishing health status.......................................131

9.2.2. Theme Two: Struggling to maintain a sense of independence......................................131

9.2.3. Theme Three: Harbouring fears that they may never recover.......................................131

9.2.4. Theme Four: Feeling discriminated against and marginalised by society.....................132

9.2.5. Theme Five: Feeling ignored and neglected by health care professionals....................132

9.2.6. Theme Six: Feeling abandoned by family.....................................................................132

9.2.7. Theme Seven: Making toward acceptance through having faith in Allah.....................133

9.3. The Uniqueness Input of the Study: What is the Study Adds to Extant Knowledge……....133

9.4. Limitation of the Study...........................................................................................................134

9.5. Implications and Recommendations Arising from the Study........................................…....135

9.5.1. View of the Study Findings..........................................................................................135

9.5.1.1. Recommendation One.....................................................................................135

9.5.1.2. Context of the Recommendation.................................................................... 135

9.5.1.3. Recommendation Two....................................................................................136

X

9.5.1.4. Context of the Recommendation.....................................................................136

9.5.1.5. Recommendation Three..................................................................................137

9.5.1.6. Context of the Recommendation.....................................................................137

9.5.1.7. Recommendation Four....................................................................................137

9.5.1.8. Context of the Recommendation.....................................................................137

9.5.1.9. Recommendation Five....................................................................................138

9.5.1.10. Context of the Recommendation...................................................................138

9.6. Conclusion.............................................................................................................................139

REFERENCES...................................................................................................................................140

APPENDICES....…………………………………………................................................................159

Appendix I-Invitation to Participate in a Research Project……………………………...............160

Appendix II-Consent Form………………………………………………………………...........161

Appendix III-Demographic questions……………………………………………………...........163

Appendix IV-Ethics Approval…..................................................................................................164

Appendix V-Consent from Amera Basma Hospital ………………………………....................167

Appendix VI-Copyright Permission.............................................................................................168

Appendix VI-1 Copyright permission from Faginandpagan

Faginandpagan 1@binternet.com ..........................................................................168

Appendix VI-2 Copyright permission from Info, Concierge

[Info@concierge.com.............................................................................................169

Appendix VI-3 Copyright permission from Geraldine Dukes

[zonezeb@yahoo.co.uk]...........................................................................................170

Appendix VI-4 Copyright permission from Colin Turvey

cretebirding@hotmail.co.uk.....................................................................................171

Appendix VI-5 Copyright permission from Michele Rosenthal [healmyptsd@gmail.com]........................................................................................172 Appendix VII-Figure 1: Framework of the lived experiences of PTSD patients of Jordan..........173

Appendix VIII-Figure 2: Framework of the meaning of being PTSD patients of Jordan.............174

Appendix IX-Figure 3: Framework for understanding PTSD amongst the

PTSD patients of Jordan.........................................................................................175

Appendix X-Participant Profiles...................................................................................................176

XI

LIST OF PLATES

Plate 1: Going over a water fall.............................................................................................................80

Plate 2: A walking blind person by Concierge.Com..............................................................................83

Plate 3: A beggar....................................................................................................................................86

Plate 4: An empty vessel by Rob...........................................................................................................87

Plate 5: A prisoner................................................................................................................................89

Plate 6: A dying flower by Geraldine Dukes...........................................................................92

Plate 7: A lost bird by Colin Turvey & Sue Turvey................................................................94 Plate 8: Moving toward acceptance.........................................................................................98 Plate 9: Reflection..................................................................................................................120 XOF P

XII

XIII

XIV

ACKNOWLEDGEMENTS

Above all I thank God for His guidance in completing this dissertation, for being with me on

the journey, for giving me inner peace and for all my blessings.

The thesis is informed by my professional experience as a clinician and academic nurse,

which has inspired me to improve the quality of clinical nursing care in Jordan. The thesis

would not have been possible without the contributions of the participants who shared their

experiences, feelings and needs with me. I owe them special thanks for their participation. I

would also like to thank the orthopaedic doctors, nurses and other staff for their contributions.

I would like to extend my special thanks to:

My family who provided me with love, understanding, hope, and continuous support to

accomplish what has been the most difficult task in my life. I would like to thank my beloved

husband of over 24 years for his patience, trust and support; Hisham thank you very much.

Thanks to all my children, Sabreen, Omar, Yousuf and Hamzeh for their encouragement and

allowing me in absent when they needed me most.

I will always be grateful to my principal supervisor, associate professor Anthony Welch, who

provided me with unlimited support and encouragement. You are an inspiration to all your

students for always believing in my ability to undertake this study. You are an excellent

mentor and I thank you very much.

To my second supervisor Dr. Meng Lim, thank you for all the support, encouragement and

friendship you have given me during my research journey.

And lastly, to all people at QUT and friends from Australia who supported me throughout my

studies. Thank you for being supportive.

1

CHAPTER ONE

INTRODUCTION

1.1. Introduction

This study explored the experiences of post-traumatic stress disorder (PTSD) as described

by individuals who were involved in a motor vehicle accident (MVA) in Jordan. PTSD is a

mental health condition that impacts on all aspects of a person’s patterns of daily living and

quality of life. This chapter begins by locating this study within an historical and cultural

context with a discussion of the historical and cultural perspectives of the Hashemite

Kingdom of Jordan followed by a discussion of the growing concern at the prevalence of

MVAs worldwide including Jordan. The background to this researcher’s interest to

undertake this study is then presented. The chapter concludes with a description of the

purpose of the study, the significance of undertaking this inquiry and the research question

that informed this dissertation.

1.2. Historical Origins and Cultural Perspective of the Hashemite Kingdom of Jordan

In the 21st century, the Hashemite Kingdom of Jordan is a constitutional monarchy located

in Southwest Asia. The Kingdom borders on a number of countries – Saudi Arabia to the

east and south, Syria to the north, Israel and the West Bank to the west, and Iraq to the

north-east. Within the context of history, the location of Jordan has been a prized

acquisition for many conquering civilizations eager to secure access to the lucrative trade

routes. Ancient civilizations including Assyrian, Chaldean, Persian, Babylonian, Nebatean,

Byzantine, Roman, and Ottoman Turks were transient occupiers of Jordan (The World Fact

Book, 2007). The original inhabitants of the Jordanian region were a conglomerate of

different tribes living nomadic or semi-nomadic Bedouin lives who overtime, settled in the

region forming small villages and towns (The World Fact Book, 2007).

At the end of World War 1, the defeated Ottoman Empire was dismantled and long

established Middle Eastern territorial borders were redrawn by the League of Nations and

the occupying powers – British, French and Zionist forces (The World Fact Book, 2007).

The end result was the creation of Syria and Palestine also referred to during this period as

2

Transjordan, which continued to remain under British rule until after World War 2 when

the country became an independent Kingdom (Zeilani, 2008).

In 1967, the signing of a military pact between Jordan and Egypt resulted in what has

become known as the Six Day War in which a concerted military attack on Israel was

launched by Jordan, Egypt and Syria. The outcome of this military engagement was Jordan

having to relinquish control of the West Bank and East Jerusalem to Israel (The World Fact

Book, 2007). In 1994, a treaty was signed by Jordan and Israel in which Jordan relinquished

all entitlements to the Israeli occupied territories while retaining administrative involvement

in Christian and Muslim holy places in Jerusalem (The World Fact Book, 2007).

Today, Jordanian culture is an amalgam of Arab and Islamic values, beliefs and language

intertwined with diverse cultural groupings of people from around the world who have

settled and assimilated into the Jordanian way of life (Jordan Department of Statistics,

2007).

In recent times the Hashemite Kingdom of Jordan has launched itself by deliberate intent

out of abject poverty (Jordan Department of Statistics, 2007). Its history is perhaps the most

extraordinary case of economic development in recent times (Jordan Ministry of Tourism,

2005). Thus, Jordan is classified as one of the most rapidly developing Arab countries with

all the external features of a Western society, particularly the lifestyle of the people (Jordan

Ministry of Information, 2006). Such lifestyle changes have resulted in a raft of advances in

technology and mechanisation. Throughout the past few years (2003-2008) Jordan has seen

rapid economic and social expansion and significant increases in government expenditure,

household revenues, and gross domestic product (Jordan-Times, 2008). Increases in the

global economy have resulted in an increase in the cost of living for the majority of

Jordanian families (Jordan Department of Information, 2006; Batieha, 2003). The number

of Jordanian women now seeking employment to help with the financial expenses of their

family has significantly increased (Batieha, 2003). Of particular note is the increase in the

use of motor vehicles as the essential mode of transport for the population. However, with

the increased use of motor vehicles comes an increase in the number of motor vehicle

accidents and associated trauma (Jordan Ministry of Health, 2005). For many victims of

road trauma, the consequential outcome is the development of post-traumatic stress disorder

(PTSD). The condition of PTSD is becoming an increasing issue of concern in Jordan. In

3

order to identify the significance of motor vehicle accidents in Jordan, a global perspective

is first presented.

1.3. Motor Vehicle Accidents: A Global Issue

The World Health Organisation (WHO) states that trauma resulting from MVAs is a

phenomenon of increasing concern, with death from injuries projected to rise from 5.1

million in 1990 to 8.4 million in 2020 particularly in developing countries such as Africa

and Middle East (WHO, 2002). A WHO (2002) report into MVAs identified road traffic

injuries as a leading cause of death by injury - the 10th leading cause of all deaths, and the

ninth leading contributor to the burden of disease worldwide.

In response to this phenomenon, the WHO (2002) is guiding an ongoing science-based

programme of activities in the prevention of road traffic injuries. The WHO Department of

Injuries and Violence Prevention has developed a multidisciplinary global strategy (Abess

& Neufeld, 2001; Peden, Krug, Mohan, Hyder, Norton, Mackay & Dora, 2001) directed

toward containing what appears to be an escalating world problem. The following long-

term sustainable goals have been targeted: to build capacity at a national and local level to

monitor the magnitude, severity and burden of road traffic collisions and injuries, to

incorporate road traffic injury prevention and to have input into the public health agendas

internationally, nationally and regionally, and to promote research concerning action-

oriented strategies for the prevention, control, and consequences to the health of

individuals involved in motor vehicle collisions (Ameratunga, Hijar & Norton, 2006, pp.

1533-1540).

However, despite local and international initiatives to reduce the number of MVAs, the

number of accidents continues to escalate along with an increase in the number of victims

developing PTSD. Blanchard and Hickling’s (2004) study found that PTSD is one of the

major consequences of MVAs in which personal injury occurs. Based on their studies to

date, PTSD is estimated to occur in 10 to 45 percent of survivors of MVAs. The findings of

Blanchard and Hickling’s (2004a) study are similar with road traffic statistics in Jordan on

PTSD involving personal injury (Blanchard & Hickling, 2003; Jeavons, 2001).

4

1.4. MVA: An Issue of Concern for Jordan

According to the WHO’s (2002) statistical report, trauma resulting from MVAs in Jordan is

a phenomenon of increasing concern. The Jordan Department of Statistics (2006) reported

that every year approximately 8,000 people sustain trauma from MVAs which ranks highest

among all vehicle types. Among other passenger-carrying vehicles, buses registered the

second highest rate of accident involvement (Jordan Department of Statistics, 2006). Based

on the report, the most prevalent group of road users are car and bus drivers. Car and bus

drivers constitute approximately 60 percent of MVA trauma events (Jordan Ministry of

Health, 2005).

Furthermore, the report indicated that people involved in these traumatic events were

primarily between the ages of 18 and 60 years (Jordan Department of Statistics, 2006). The

most frequent causes listed for MVAs and subsequent hospitalisation included speeding,

failing to stop at traffic lights and failure to abide by traffic regulations (Jordan Ministry of

Health, 2005; Jordan Ministry of Information, 2006). The proliferation of high-speed

highways has contributed to an increase in MVAs and its corollary, PTSD, which is now

recognised by the Jordanian Government as a major public health problem.

In the majority of countries, a license to drive a motor vehicle can be obtained at 17 years

(e.g. UK, France, Denmark, and Sweden). However, most States in Jordan only permit

licensure at age 18 but plan to reduce the age to 17 years. Despite the additional year in

being able to obtain a driver’s licence in Jordan the incidence of motor vehicle accidents for

this age group is extremely high in comparison to other age groups in the country. The main

causes of accidents for this adolescent group were speeding and high vehicle occupancy

(Jordan Department of Statistics, 2006), drinking violations, aggressive behaviour on the

road, speeding, and joyriding (Jordan National Highway and Safety Department, 2007).

In most developed countries, social health care services are well established to provide the

required assistance to patients with PTSD. However, in developing countries, this is not the

case. In Arab countries including Jordan, the social protection systems are non-existent or

under-developed, placing patients who have developed PTSD in the unenviable position of

having to rely on self or family for support and care (Jonsson & Halabi, 2006).

5

Traditionally, care of the sick or ill persons has been the obligation of family members,

through the extended family structure (Clapp & Beck, 2009). Parents, grandparents and

adult children were expected to provide support and look after the well-being of their

family members especially in relation to health problems. The presence of PTSD in a

family member significantly increases the burden of care for families.

The Jordanian government has initiated health care reforms aimed at improving the quality

of life for all Jordanians. According to the Ministry of Health (2002) report, the 1999 health

reforms were a significant step forward making the health of the Jordanian people a

priority. The outcome of the implementation of these reforms was meant to address the

health care needs of all Jordanians including the care of people with PTSD (these reforms

were the first national health strategies for PTSD patients in Jordan). However, the health

strategies failed to achieve their stated outcomes in terms of health care services (Jonsson &

Halibi, 2006). Reasons for the ineffectiveness of the reforms were attributed to a lack of

understanding and interpretation of the reforms, limited resources, poor service delivery,

and the socio-economic situation of the country (Jonsson & Halibi, 2006). The continuing

ineffective nature of the Jordanian health care system and a serious lack of health care

professionals have exacerbated the lack of appropriate care and treatment for people

suffering from PTSD with little evidence of improvement in the near future.

The socio-cultural background to this study was one factor in this researcher’s decision to

embark on this dissertation. Her own background and personal experiences as a health care

professional working with patients who had developed PTSD as a result of a MVA was

another.

1.5. Personal Background and Interest as a Researcher

As a means of contextualising further the background to this study a brief description of my

history is warranted. I was born in the Philippines and grew up as a Christian woman within

an Asian culture (I later married a Jordanian man and converted to Islam). After graduating

with a Bachelor of Nursing degree, I successfully passed the Philippines Nurse’s Board

examination for registration as a general nurse and commenced working in one of the major

general hospitals. After two years I applied to work overseas through a recruitment agency.

My destination was Jordan where I was employed to work in a surgical and orthopaedic

6

unit at Amera Basma Hospital. In 1985, I was offered a teaching position at Yarmouk

University where I was involved in the education of student nurses at the undergraduate

level. I continued my involvement in clinical nursing (a requirement of the university) in

the area of orthopaedics. During this period, I developed an interest in the area of motor

vehicle accident victims (MVAV) in particular, the impact of a MVA on the person’s

quality of life. I became increasingly aware that many of these patients exhibited symptoms

of stress, depression, anger, and agitation. It also became apparent to me that the staff –

doctors, nurses, and allied health personnel – appeared to lack understanding about what

was happening to these patients and therefore, seemed reticent to become involved in their

care. The way staff appeared to cope with the situation was to simply ignore there was

anything wrong. The apparent lack of concern by staff about the plight of these patients

only seemed to exacerbate their illness experience resulting in expressions of anger, and

aggression at times. My interest in, and concern for victims of motor vehicle accidents

continued fuelled by a growing desire to understand more about what these patients were

going through. That concern has extended to this dissertation.

1.6. Purposes of the Study

This study was undertaken with the following purposes in mind:

(1) The exploration and explication of the lived experience of PTSD as described by motor

vehicle accident victims who have developed PTSD as a result of the accident. The study

used a descriptive phenomenological approach to inquiry.

(2) To make a substantive contribution to extant knowledge about living with post-

traumatic stress.

(3) To disseminate findings of the study to health care practitioners working in the specialty

area of post-traumatic stresses for their personal reflection in relation to their current

understanding of the phenomenon and where appropriate, utilize such knowledge to guide

professional practice.

7

1.7. Significance of the Study

1. An extensive review of research literature concerning the experiences of PTSD as

articulated by MVA victims was undertaken. No studies were located that had

explored this phenomenon from the perspective of citizens of Jordan.

2. A descriptive phenomenological approach to inquiry has the potential to explicate

the life world of PTSD sufferers and to bring to light, a world of hidden meaning

of what it means to experience PTSD.

3. The findings of this study have the potential to contribute to extant knowledge

about the experience of PTSD and contribute to academic and clinical debate and

future directions of inquiry.

4. The findings have the potential to inform health care policy and professional

health care practice in Jordan in relation to the experience of PTSD.

5. The study is significant because it addressed what appears to be 'a blind spot' in

knowledge and a lack of understanding about PTSD from a Jordanian perspective.

1.8. Research Question

The research question which informed this study was:

What is the lived experience of post-traumatic stress disorder (PTSD) as

articulated by motor vehicle accident victims in Jordan?

1.9. Conclusion

This introductory chapter provided an overview of the background to this study. The

chapter began by providing a description of the origin and historical formation of the

Hashemite Kingdom of Jordan. Attention was given to providing a background

understanding of MVAs as a global issue and a national concern for the Kingdom of

Jordan. The chapter concluded by outlining the aims of the study, its significance to

knowledge development concerning the experience of PTSD, and a statement of the

research question informing this study.

Chapter Two provides a review of relevant literature in relation to the phenomenon under

study. Chapter Three presents a discussion of the methodology - descriptive

8

phenomenology - which underpinned this study. Chapter Four describes the research

methods used in carrying out this study. Chapter Five presents the participants’ profiles

followed by the presentation of the aggregated participant statements from the interview

transcripts, and metaphors/paintings as reflections of their experiences. Chapter Six

presents a discussion of findings of this study. Chapter Seven provides a review of literature

in relation to the explicated themes. Chapter Eight presents this researcher’s personal

reflection of her experience of the research process for this dissertation followed by a brief

summary of what this thesis contributes to extant knowledge about the experience of PTSD.

The chapter concludes with a discussion of the implications for nursing, and

recommendations for future nursing practice, research, education, and policy development

in Jordan.

9

CHAPTER TWO

LOCATING PTSD WITHIN AN HISTORICAL CONTEXT

2.1. Introduction

This chapter presents a contextual understanding of the historical origins and subsequent

development of posttraumatic stress disorder (PTSD) as a recognised mental health

condition. The chapter begins with an historical overview of PTSD since the American

Civil War (1861-1865) followed by a discussion of the various definitions of PTSD which

have evolved over time. The diagnostic criteria for PTSD are then presented. The chapter

concludes with a discussion of the various treatment modalities used in the treatment of

PTSD.

2.2. Historical Overview of PTSD

During the American Civil War (1861-1865), symptoms of PTSD were first identified in

soldiers from both sides of the conflict – confederate and union (Streisand, 2006). Early

descriptions of what is now known as PTSD included such symptoms as heart palpitations,

chest pain, shortness of breath, and sleep disturbances. Symptom presentation at this time

resulted in a diagnosis of an irritable heart (Streisand, 2006). Soldiers who experienced

symptoms of lethargy, loss of appetite, homesickness or longing for family were diagnosed

as suffering from nostalgia (Streisand, 2006). The diagnosis of nostalgia was made in

reference to soldiers who were experiencing a desire for the past, yearning for yesterday, or

a fondness for belongings and activities associated with days of yore (Hollbrook, 1993).

Soldiers who exhibited such symptomatology were considered to be of frail disposition,

“with highly developed imaginative faculties [and little capacity] to adjust to the hardships

of war as young men” (Mosse, 2000, p. 102) diminishing their effectiveness in battle.

Explanations provided by the medical profession to account for the pattern of symptom

presentation were attributed to exhausting military duties, exposure to toxic gas or

emotional stress. During the American Civil War, it was called Da Costa's syndrome

whilst, the British in World War 1 called it disordered shellshock or movement of the heart

(De Costa, 1871). The term ‘shell shock’ (Kriegsnurosen) was coined in Germany, and in

10

France the syndrome was known as malingering or hysteria (Ray, 2008). Shell shock was

considered to be a stress syndrome in which soldiers could end up confused, deaf, blind,

catatonic, or suffering loss of function or paralysis (Keating, 2003). Experts in psychiatry

believed that shell shock was caused by bursting shells that upset brain function. German

psychiatrists equated war neurosis or shell shock with a lack of will power rather than a

reaction to war itself (Keating, 2003). They believed those affected had weak dispositions,

and were fearful and frail (Mosse, 2000). The same symptoms were identified during World

War II. The term attributed to the display of PTSD symptoms was combat fatigue

characterised by loss of energy and tiredness (Keating, 2003). During this war, many

soldiers were discharged for psychological reasons brought about by what appeared to be

exhaustion or tiredness (Wilson, 1994). These early observations of symptom presentation

seemingly arising from the experience of war were the foundations of what is now known

as PTSD.

Mental health professionals began to consider external events such as combat as having

psychological consequences. Up to this time popular culture attributed ‘breakdowns’ to

biological reasons as a result of experiencing traumatic events resulting in battle fatigue.

By the end of World War II the military realised that each soldier had a breaking point

(Streisand, 2006). However, it was during the Vietnam War (1959-1974) that a group of

psychiatrists began to use the term ‘Post-Vietnam Syndrome’ (in the early 1970s) to

describe a delayed response to combat that included feelings of isolation, hopelessness,

anger and restlessness. It was the effort and activism of these psychiatrists on behalf of

Vietnam War Veterans that became a major driving force in the recognition of PTSD as a

mental health disorder (Streisand, 2006).

In recognising PTSD as an official disorder it is necessary to outline its development in the

Diagnostic and Statistical Manual of Mental Disorders (DSM). In the 1952 DSM addition

after World War II and before the Vietnam War, the American Psychiatric Association used

the term gross stress reaction to refer to a person’s response to severe stress such as war,

natural disaster, fires, earthquakes, explosions and collisions (APA, 1968; Wilson, 1994).

However, the DSM-II introduced the term temporary situational disorder to refer to a

reaction to unusual stress caused by any situation (Gersons & Carleir, 1992).

11

The initial diagnosis of PTSD and its causation was attributed to the experience of war

particularly as experienced by Vietnam War Veterans. In 1980 PTSD as a mental health

disorder was included in the Diagnostic and Statistical Manual III – Revised (DSM-III-R,

1980, and was not revised until the end of the Post-Vietnam Era (1975-2005). Initially

PTSD was viewed by the health care profession as a short-term response to a traumatic

event (in this case war). Consideration that PTSD could develop into a life-long disorder

requiring on-going therapeutic intervention was initially dismissed by the mental health

profession. The reluctance of the mental health profession to view PTSD as a potential

chronic condition was fuelled by a global perception that any psychological effects of a

traumatic event were time limited – given sufficient time the individual would recover from

the traumatic event and eventually resume a normal life (Yehuda, 2003). PTSD as a

diagnosed condition is now publicly accepted as a legitimate psychological reaction to

trauma having both short-term and long-term implications for the sufferers and their

families (Gersons & Carlier, 1992).

PTSD shares a number of clinical characteristics with other psychiatric disorders and is

rarely diagnosed in isolation (Davidson, Stein, Shalev & Yehuda, 2004). Green (1994)

calculated the prevalence of PTSD in people exposed to traumatic events such as war and

rape to be 25-30 per cent of the population. A study conducted by the National Council on

Disability (2009) found co-morbidity of medical conditions and mental disorders (PTSD) in

more than 80 percent of the study population. PTSD is now a recognised mental health

condition worldwide.

2.3. Definitions of PTSD

In order to gain a conceptual understanding of the meaning of PTSD, a review of how the

literature defines PTSD is warranted. In recent times, PTSD has become the focus for a

wide body of empirical and theoretical work. The fact that it is one of the few mental health

disorders to be associated with a relatively specific etiological mediator in the form of a

traumatic event, along with its characteristic clinical feature of frequent intrusive memories

has established an attraction for researchers (Brewin, Dalgeish & Joseph, 1996). The APA

(1994) defined PTSD as a mental health disorder stemming from exposure to traumatic

events such as accidents and personal injuries (Williams & Sommer, 2002). Blanchard and

Hickling (2007) posit a similar definition to that of the APA’s in conceptualising PTSD as a

12

condition of human exposure to a traumatic event such as physical injuries, a witness to a

death, sustaining a serious injury or being exposed to a life threatening situation resulting in

a stressful experience leading to significant symptoms of distress accompanied by

flashbacks and nightmares (Giarratano, 2004; Leys, 2000; Bryant & Harvey, 2005).

Responses to such traumatic experiences have been aligned with the experience of being

bereaved (High, Sander, Struchen & Hart, 2005; Stolorow, 2007). Yehuda (2003) described

PTSD as a syndrome that lasts longer than four weeks which creates behavioural symptoms

that interfere with the sufferer’s interpersonal relationships and quality of life. The

traumatic event is usually life threatening or an event capable of inflicting bodily harm. All

traumatic events have the ability to produce fear, helplessness, horror, and distress. These

responses lead to adverse psychological reactions that can result in posttraumatic stress

disorder (Corey, 2007). The definition of PTSD has changed over time from a focus on the

physical effects of trauma to one that includes emotional and social well-being. The range

of definitions which have been put forward over time to capture the essential nature of the

condition in many respects led to a lack of clarity and, to some extent confusion on what

actually constitutes PTSD. Ray (2008) who undertook an historical review of the various

definitions of PTSD came to the conclusion that PTSD is “a confusing concept that

originally meant physical trauma or organic damage to the central nervous system” (p.217).

He suggested further that the extreme diversity of symptom presentation and various

conceptualisations has resulted in PTSD being a curiosity that continues to evade a clear

definition (Ray, 2008).

Spinazzola (2005) defined PTSD as an anxiety disorder related to exposure to an intensely

traumatic event. Blanchard and Hickling (2007) also defined PTSD as a pervasive and

devastating anxiety disorder. In addition, PTSD following a major life threatening

experience or major trauma such as a natural disaster or traffic accident can impact on all

aspects of a person’s life and across their life spectrum. McGrail and Devilly (2006)

described PTSD as a human exposure to an intensely traumatic event with recurrent

intrusive recollections or flashbacks and generalised numbing of emotional responsiveness.

This suggests that with time, the flashbacks become progressively more intense and the

sufferer will be in need of increasing support to maintain his or her quality of life. Taylor,

Welch, Kim and Sherman (2007)suggest further that although these definitions vary

slightly, there appears to be an inseparable relationship between PTSD and trauma

13

experiences because PTSD is socio-culturally intertwined with general health outcomes

such as lifestyle. Over time diagnostic criteria have been developed for identifying the

presence of PTSD.

2.4. Diagnostic Criteria of PTSD

The fundamental criteria of PTSD are the development of characteristic symptoms

following exposure to an extreme traumatic stress or involving direct personal experience

of an event (APA, 2000). These diagnostic criteria were adapted from Russel’s (2011)

study which includes:

Criterion AI involving actual or threatened death or serious injury, threat to one's

physical integrity, witnessing an event that involves death and unexpected serious

harm.

Criterion A2 described that the person's response to the event must involve intense

fear, helplessness, or horror (or in children, the response must involve

disorganised or agitated behaviour).

Criterion B is the characteristic symptoms resulting from the exposure to extreme

trauma including persistent re-experiencing of the traumatic event.

Criterion C relates to the persistent avoidance of stimuli associated with the

trauma and numbing of general responsiveness.

Criterion D is persistent symptoms of increased arousal.

Criterion E is the full symptom picture must be present for more than 1 month and

Criterion F is the disturbances that cause clinically significant distress or

impairment in social, occupational, or other important areas of functioning

(Russel, 2011, p. 1).

People suffering from PTSD are trauma survivors who are unable to let go of the traumatic

event. Beck and Coffey (2007) classified PTSD symptoms into three categories. The first is

called re-experiencing symptoms. This refers to unwanted memories, distressing images or

nightmares and flashbacks or recalling the traumatic event. These symptoms cause

psychological distress to the person along with physical symptoms such as palpitations,

shortness of breath and panic attacks. The second is the avoidance of reminders of the

event. This includes people, places, or things linked with the trauma as well as becoming

14

emotionally numb or usually unresponsive to the situation. The final category is

hyperarousal which consists of physiological symptoms including irritability, impaired

absorption hyper-vigilance, sleep disturbances and startle responses (Beck & Cofey, 2007).

Furthermore, Russel’s (2011) study found that traumatic events that are experienced

directly from military combat, violent personal assault (e.g. sexual assault, robbery,

mugging, physical attack), kidnapping or hostage taking, torture, natural disaster accidents

and life threatening illness are not time limited disorders but have the potential to develop

into severe or long-lasting stressors.

For an individual to meet the DSM-IV (2000) criteria for PTSD, one or more of the

symptoms from the first re-experiencing category, three or more symptoms from the second

category, as well as two or more symptoms from the third category must be present. These

symptoms must be severe enough to cause extensive impairment in occupational, social and

interpersonal domains and must be present for at least one month in order to be measured

for a diagnosis of PTSD (Yehuda, 2004). Most common PTSD symptoms are flashbacks,

nightmares, irritability, sleep disturbances, shame, guilt, and intense panic. Golier and

Yehuda (2002) identified these symptoms as frequently surfacing in response to a condition

of not being clear, which may suggest that PTSD is a consequence of trauma. Yehuda

(2004) adds it is not always possible to diagnose PTSD immediately following a traumatic

event because the symptoms need to continue over time before an accurate diagnosis can be

confirmed.

It is often difficult to anticipate who will develop PTSD because of the idiosyncratic

responses by individuals to the traumatic event (Russel, 2011). An individual’s risk of

developing PTSD depends on a number of factors. The first factor which can contribute to

the development of PTSD is whether the person has experienced trauma in the past. Those

who have, have a greater propensity to develop PTSD. One example provided by Scott’s

(2007) study of multiple traumatic experiences and the development of PTSD found that

“the number and severity of traumas are related to severity of PTSD symptomatology” (p.

936). The second factor in susceptibility is a person’s psychological condition meaning, if

the individual has a history of anxiety or depression there is a higher risk of developing

PTSD for both men and women. Women are twice more likely to develop PTSD than men,

so gender is frequently viewed as an important factor as well. The third factor is the nature

15

of the traumatic experience which can also influence whether or not an individual develops

PTSD (Cowley, 2001; Ford, 2008).

2.5. PTSD Treatment and Best Practice

A large number of treatment modalities have been used in the treatment of PTSD.

Treatment of PTSD can be effective and helpful in regaining a sense of control over an

individual’s life. Accordingly, early and complete treatment of PTSD is recommended as

soon as the diagnosis is realised (Giarratano, 2004c; Haran, 2005; Blanchard & Hickling,

Some well-known approaches to therapeutic interventions include a number of behaviour

therapy options such as: applied behaviour analysis (operant conditioning), neo-

behaviouristic meditational stimulus-response model (classical conditioning), social-

learning theory and cognitive behavioural therapy treatments (exposure therapy, stress

inoculation training, and eye-movement desensitisation, reprocessing and cognitive

restructuring, narrative therapy and creative arts therapy) and the use of pharmacotherapy.

2.5.1. Behaviour therapy

Behaviour therapy is an approach to treatment the aim of which is behavioural change

(Corey, 2001-2007). In the 1950s, behaviour therapy which has its origins in behaviourist

theory was introduced as an option to psychoanalytic therapy (Austin, 1999). Behaviour

therapy is defined as the application of modern learning theory to the treatment of clinical

problems. It is viewed as a logical extension of behaviourism to complex forms of human

actions (Wilson, 2007). Behaviour therapy is based on the principles and procedures of

classical and operant conditioning which target a person’s abnormal feelings, behaviour and

thoughts (Corsini & Wedding, 2008).

“In contemporary behaviour therapy three main approaches have been identified: (1) applied behaviour analysis, (2) a neo-behaviouristic meditational stimulus-response model, and (3) social-learning theory. These three approaches differ in the extent to which they use cognitive concepts and procedures which focus exclusively on observable behaviour and rejects all cognitive mediating processes except social-learning theory which relies heavily on cognitive theories” (Corsini & Wedding, 2008, p. 236).

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2.5.1.1. Applied behaviour analysis

This approach is a direct extension of radical behaviourism. It was developed by B. F.

Skinner (1953). The approach is underpinned by the principles of operant conditioning - the

basic assumption being that behaviour is a purpose of its consequences. Radical

behaviourism began with the research of E. L. Thorndike. Thorndike discovered the law of

effect, which is the bond between stimulus and response. The response is strengthened if a

response, in the presence of a stimulus, is followed by something satisfying (Lilienfeld,

Lynn, Namy, &Woolf, 2009). The underlying assumption is that behaviour can change

when it is reinforced with something positive or negative. An example of positive

reinforcement is giving a child a reward for cleaning his or her room. An example of

negative reinforcement could be ending a child’s time-out for bad behavior once he has

stopped throwing a temper tantrum.

2.5.1.2. Neobehaviouristic Meditational Stimulus-Response Model

This approach is derived from the application of the principles of classical conditioning

which are based on the learning theories of Ivan Pavlov (1849-1936). Pavlov conducted

experiments with animals to help treat individuals with phobic disorders. Classical

conditioning, in contrast to operant conditioning, is where responses that are usually

reflexive (and thus elicited) are brought under the control of stimulus events that precede

the response. This is also called Pavlovian conditioning after Ivan Pavlov, who worked out

its fundamental principles through his studies of salivation in dogs, which he found could

be elicited by neutral stimuli such as a tone. Further research was conducted by Joseph

Wolpe and Arnold Lazarus. Wolpe (1915-1997) helped to develop the therapeutic

techniques of systematic desensitization and flooding which are based on classical

conditioning and is used in counselling clients diagnosed with PTSD. This approach to

therapy involves the process of introspection to identify the content and intensity of the

person’s negative emotional state. The approach presupposes that the patient has the ability

to remember, reason, think, judge, imagine, discriminate and can purposefully control

certain actions of his/her mind and overt behaviour (Locked, 2010). The sequence of

treatment is first to train the patient in progressive muscle relaxation exercises and then

gradually expose him/her to imagine or in vivo feared stimuli while simultaneously getting

the patient to relax (Wolpe & Plaud, 1997).

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2.5.1.3. Social-learning theory

One of the two approaches that falls under the umbrella of behavioural therapy is social-

learning theory. The core belief underpinning this approach is that individuals are both the

product and producers of their own environment. It is the goal of behavior modification to

increase an individual’s skill set so the patient has more options for responding to

situations, thereby providing the individual with enhanced freedom (Corey, 2001). Albert

Bandura (1977) developed the social learning approach. The theoretical underpinning of

this approach is that “behaviour is influenced by stimulus events, by external reinforcement,

and by cognitive meditational processes” (Corey, 2001, p. 258). It is the assumption of

social learning theory that individuals are capable of self-directed behaviour change.

Bandura (1986) described psychological functioning as a reciprocal interaction among three

interlocking sets of influences such as behaviour, cognitive processes, and environmental

factors. Bandura (1986) described the approach as follows:

“Personal and environmental factors do not function as independent determinants; rather, they determine each other. Nor can “persons” be considered causes independent of their behaviour. It is largely through their actions that people produce the environmental conditions that affect their behaviour in a reciprocal fashion. The experiences generated by behaviour also partly determine what individuals think, expect, and can do, which in turn affect their subsequent behaviour” (cited in Corsini & Wedding, 2008, p. 236).

2.5.1.4. Cognitive behaviour therapy

Cognitive behaviour therapy (CBT) is an encompassing term covering a broad range of

therapeutic interventions tomodify erroneous cognitions, as well as to reduce the intensity

and frequency of distressing negative emotional reactions via exposure to safe but feared

situations and objects. This approach is designed to promote effective coping (Cahil & Foa,

2007). The approach involves 9 to 12 individual counselling sessions over a period of

approximately 10 weeks. Each counselling session lasts 60 to 90 minutes. Between

sessions patients are often assigned homework in order to perform specific interventions.

These interventions are administered either as stand alone treatments or in combination

with a more comprehensive treatment program (Cahill & Foa, 2007). The use of CBT in the

treatment of PTSD depends on how severe the symptoms are and what the patient brings in

terms of their personal strength and abilities to the treatment sessions (Haran, 2005; High et

18

al., 2005). Ehlers and Clark (2000) evaluated the application of CBT to sufferers

experiencing trauma memories. The study involved two randomized control trials. Outcome

of the study led to develop of an effective version of CBT for PTSD.

Schnurr, Friedman, Engel, Foa, Shea, Chow, Resick Thurston, Orsillio, Haug, Turner and

Bernardy (2007) compared the effects of CBT among different populations of PTSD

sufferers. The randomized control trial involved female veterans and active-duty personnel

with PTSD recruited from 9 VA medical centres, 2 VA readjustment counselling centres,

and 1 military hospital from August 2002 through October 2005. The findings revealed that

those receiving cognitive behavioural therapy were most likely to no longer meet PTSD

diagnostic criteria. The effects were consistent over time in longitudinal analyses, although

in cross-sectional analyses most differences occurred immediately after treatment.

According to Schnurr et al’s (2007) study and Ehlers and Clark (2000) study, CBT is more

effective in reducing the symptoms of PTSD compared to those who did not receive this

therapy.

In a review of literature concerning PTSD treatment, seven forms of cognitive behaviour

therapy were identified: exposure therapy, stress inoculation training (SIT), cognitive

restructuring therapy, eye movement desensitization and reprocessing (EMDR), multimodal

therapy, narrative therapy and creative arts therapy.

2.5.1.4.1. Exposure therapy

Exposure therapy is designed to help individuals with PTSD confront their fears such as

thoughts, situations, objects, individuals, places, or activities that elicit anxiety or are

avoided by the individual because they are perceived as dangerous, even though they are

benign (Lombardo & Gray, 2005). This therapy typically involves imagining exposure to a

traumatic memory. The goal of exposure therapy is to help patient’s process traumatic

memories and to correct erroneous cognitions about the world and self. Exposure therapy is

typically used either alone or with other cognitive-behavioral procedures to challenge

PTSD related irrational thoughts (Lombardo & Gray, 2005).

19

The process of exposure therapy involves instructing the patient to close his/her eyes and

image whatever traumatic event they have endured that led them to PTSD (Cahill & Foa,

2007). They are instructed to imagine the experience as though it were happening in the

present moment. While they are imagining the trauma, they describe aloud what they

remember, including detailed descriptions of the sights, sounds, smells, tastes, and physical

sensations. They also describe their thoughts and emotional reactions that occurred during

the trauma. Narratives of the trauma are repeated several times in the therapy session and

recorded so patients may listen to them as daily homework (Cahill & Foa, 2007).

2.5.1.4.2. Stress inoculation training (SIT)

Stress inoculation training (SIT) uses a number of techniques to control traumatic situations

and difficult emotional reactions. SIT is used in PTSD therapy (Meichenbaum, 1993).

Although this is a recent development in CBT there is limited published evidence to support

the benefits of SIT (Cahill & Foa, 2007). This approach to therapy consists of acquiring

skills in breathing techniques, progressive muscle relaxation, guided positive imagery,

thought stopping, and cognitive restructuring. The theory of SIT is that individuals vary in

how they experience and articulate anxiety. The aim of treatment is to match interventions

with detailed symptoms (Cahill & Foa, 2007).

2.5.1.4.3. Cognitive restructuring therapy Cognitive restructuring therapy is based on the idea that it is not the actual events of the

trauma that cause problems to an individual’s emotional reactions, but an individual’s

interpretation of those events. Cognitive restructuring is designed to help patients identify

and challenge their unclear cognitions and replace them with more helpful ones (Cahill &

Foa, 2007). This is accomplished by systematically reviewing the evidence of a target belief

and whether or not it is beneficial for an individual to retain those beliefs. Cognitive

restructuring pays close attention to any possible consequences for challenging situations

(Cahill & Foa, 2007). Chard, Schumm, Owens, and Cottingham’s (2010) study examined

cognitive treatment for PTSD in Iraq war veterans and compared them with Vietnam War

veterans receiving the same treatment. The findings found that the Iraq war veterans

displayed less severe PTSD following cognitive therapy then did the Vietnam War veterans

receiving cognitive therapy.

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2.5.1.4.4. Eye movement desensitization and reprocessing

Eye movement desenzitation and reprocessing (EMDR) therapy originated with the idea

that trauma can disrupt typical functioning of the information-processing system, which

prevents recovery from PTSD symptoms. EMDR originated through the works of Francine

Shapiro, a Californian private psychologist. Shapiro (1987) described her own experiences

when she was walking in the woods, preoccupied by a host of disturbing thoughts. Shapiro

noticed her anxiety lifted when she was moving her eyes back and forth while observing

her surroundings and she experimented with variants of this process during therapy times

with patients. Shapiro’s (1987) study of EMDR published in 1989 has gained increasing

attention in the treatment of PTSD (Lilienfeld & Arkowitz, 2007).

Shapiro (1987) believed that the information-processing mechanism may be activated when

attention is elicited by listening carefully to outside cues such as tracking the therapist’s

fingers. She further speculated that simultaneous focus on traumatic memory may cause the

activated system to process dysfunctional stored material (Shapiro, 2001). EMDR has two

main components which include: (1) imaginable exposure to trauma-related thoughts,

images, and memories or desensitization, (2) is a form of cognitive restructuring refers to

reprocessing. The uniqueness of EMDR induces a series by therapist of rapid left-to-right

eye movements with the patients. This process commence by instructing the patient to

follow the therapist’s hand as it moves back and forth across the patient’s procession of

view during the process of desensitization and reprocessing. Two ways should be

accomplished to replace eye movements with several other possible forms of lateral

alteration such as having the patient tap alternately the left and right hand, or the therapist

may present auditory stimuli alternately on the left and right side of the patient.

Lilienfeld and Arkowitz (2007) identified the effectiveness of EMDR treatment which has

been called a miracle cure and paradigm shift in the treatment of anxiety. The EMDR

International Association of Clinicians is a group of mental health professionals dedicated

to promoting the technique of EMDR. The EMDR International Association of Clinicians

estimates that EMDR has been administered to approximately two million patients. The

findings indicate that patients experienced an ease in their anxiety when moving their eyes

(Cahill & Foa, 2007). Some proponents of EMDR claim that this approach is highly

21

significant in treating trauma among Vietnam War veterans (Zimmermann, Biesold, Barre,

& Lanczik, 2007).

2.5.1.4.5. Multimodal therapy

Multimodal therapy was developed by Arnold Lazarus (2005) who was frustrated by the

restrictions of cognitive behavioural therapy. Lazarus (2005) believed effective therapy

should address problems in each dimension and technique from all theories that can be used

to treat the pending problem (Davidson & Neale, 1994). Corey (2001-2007) described

multimodal therapy as an open system that encourages technical eclecticism – a belief that

people are an amalgam of seven different dimensions. These seven dimensions include: (1)

behaviour, (2) affective processes, (3) sensations, (4) images, (5) cognitions, (6)

interpersonal relationships and (7) biological functions. New techniques are constantly

being introduced to this approach to therapy. However, despite new approaches being

introduced Multimodal therapists posit a cautionary note that treatment should not be forced

to meet the needs of patients but rather to use treatment strategies best suited to the patients

particularly situation. Therefore, multimodal therapists are flexible in the use of different

styles and approaches to therapy consistent with the needs of patients (Lazarus, 2005;

Corey, 2007).

2.5.1.4.6. Narrative therapy

Narrative therapy offers the patient a chance to “adjust individual description to include the

trauma and its potential implications in a method that promotes a sense of stability, coping

and adaptation” (Borden, 1992, p. 136).Trauma can affect an individual’s cohesive sense of

past, present and future, a phenomenon known as the personal narrative (Cohler, 1982).

Furthermore, narrative intervention is:

“modelled after the individual behaviour who expressed mostly strong resilience during and after a traumatic event. Involvement with others in a significant action, engaging in rituals, creating and attributing meaning to symbols that signify a optimistic feature of the traumatic experience, thinking about core individual themes such as good and bad, life and death, expressing these themes in intensely own and individual ways; these are the normal and regular expressions of individuals struck by tragedy” (Petersen, Bull & Propst, 2005, p. 43).

22

In using narrative therapy, the patient tells their own story. The patient may include aspects

of the story that have been previously looked at and incorporates new aspects of the story

about how these aspects alter their meaning attributed to different events. The new

meanings are examined in relation to priorities, self-image and relationships. The narratives

are told in a manner that focuses on all aspects of the experience, not just the pain of the

experience allowing for a more complete story that enhances self-appraisal and exploration

of self-image and the whole image of the experience.

2.5.1.4.7. Creative arts therapy

Creative Arts Therapies have been used in a variety of creative approaches such as painting,

music, drama and poetry in the treatment of different types of mental disorders. Creative

Arts Therapies is relatively new in the treatment of individuals suffering from mental

disorders that were resistant to traditional therapies (Hamshar, 2010). The purposes of this

approach to therapy include: to reduce arousal symptoms, to develop emotional self-

efficacy, to reactivate positive emotions, and to create emotional safety and social bonds

among patients as a foundation for further therapeutic work. A study conducted by the

American Art Therapy Association (AATA) Research Committee (2005) which surveyed

conducted a surveyed registered art therapist in the USA found that art therapy shows

promise as a treatment for combat-related PTSD in relation to reducing immediate

symptoms and helping patients overcome avoidance and emotional numbing (cited in

Collie, Backos, Malchiodi & Spiegel, 2006).

2.6. Pharmacotherapy in PTSD

Recent research has been directed toward developing more effective treatments for PTSD

by using drug therapy. Vollenweider and Kometer’s (2010) study found that after a 40 year

of silence, there has been a paucity of research into understanding the effects and possible

uses of psychedelic drugs for treating various psychiatric disorders including PTSD.

However, some medications have previously been developed that alleviate some of the

symptoms of PTSD which include:

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2.6.1. Propranolol and Clonidine

Propranolol and clonidine are two drugs that have been helpful for other disorders where an

excess of adrenaline exists . Goleman’s (1992) study shows that medications can provide

symptom reduction such as anxiety that allows patients with PTSD to actively participate in

therapy.

2.6.2. Serotonin Reuptake Inhibitors

Serotonin reuptake inhibitors are used to treat combat veterans with PTSD. Despite earlier

pessimistic outcomes, increasing evidence supports the effectiveness of selective serotonin

reuptake inhibitors (SSRI’s) and monoamine oxidase inhibitors (MAOI’s) in reducing

PTSD symptomatology (Koch, O’Neill & Douglas, 2005). This type of medication allows

patients to think before the expression of anger and shortens the duration of the anger

response. Koch et al. (2005) posited that self-mastery of anger leads to an increase in self

respect and relief from a sense of humiliation by using Serotonin reuptake inhibitors. The

findings suggest that medication has a direct antidepressant effect and reduces PTSD

symptoms such as re-experiencing symptoms.

2.6.3. Venlafaxine

Venlafaxine is a serotonin and norepinephrine reuptake inhibitor that significantly reduces

symptoms of PTSD such as re-experiencing and avoidance/numbing symptoms.

Venlafaxine breaks the mind-body cycle of anger reactions by blocking the body effects of

adrenalin. Adrenalin reduces the ability of most combat PTSD sufferers to think clearly and

to consider noncombat potential in situations. By blocking the adrenalin effect on the body,

the mind is able to consider choices of action that are more appropriate to the situation

(Miller & Walling, 2007). Szalavitz’s (2006) study suggests that morphine given to patients

immediately following a traumatic event may lessen the symptoms of PTSD. In recent

times, Morphine acquired attention in prevention of PTSD. A recent study conducted by

Holbrook et al. (2010) found that morphine intake among injured combat veterans deployed

from Afghanistan were protected against the development of PTSD.

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2.6.4. Guanfacine

Guanfacine is an example of Beta-blockers and alpha-adrenergic agonists that are helpful in

reducing arousal and the re-experiencing of symptoms. One example provided by Horrigan

and Barnhill (1996) found that guanfacine has a significant effect in reducing nightmares.

Kaminer, Seedat and Stein’s (2005) study revealed similar findings to that of Horrigan and

Barnhill (1996) suggesting that guanfacine is effective in reducing symptoms in the early

stages of PTSD.

2.6.5. Prazosin

One symptom of PTSD that is being targeted with medication is sleep disturbance, which is

very frequent in people diagnosed with PTSD. Griffth’s (2005) study examined the effect of

Prazosin (an Alpha adrenergic blocker) among PTSD patients who had a medical history of

hypertension. The findings indicated that Prazosin reduced excessive brain noradrenergic

activity reducing hypertension and reducing sleep disturbances such as nightmares.

However, Griffth (2005) suggested that Prazosin should be considered in the treatment of

healthy patients with PTSD (no medical illness). On the other hand SSRIs have failed to

relieve the sleep disturbance.

2.7. Conclusion

This chapter provided an overview of PTSD within an historical context. The chapter began

by providing a historical understanding of PTSD. Attention was given to providing an

understanding of definition and criteria for diagnosis of PTSD. The chapter concluded by

outlining the PTSD treatment and best practice to knowledge development concerning the

behavioural therapy, different forms under cognitive behaviour therapy, and

pharmacotherapy in PTSD. The next chapter provides a description of the theoretical

framework underpinning this study.

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CHAPTER THREE

PHILOSOPHICAL FRAMEWORK

3.1. Introduction

This chapter provides a description of the philosophical framework which underpins this

study. The chapter commences by providing a definition of what constitutes a phenomenon.

A discussion concerning the evolution of phenomenological thought is then presented.

Colaizzi’s approach to phenomenology is then discussed. A discussion of the relationship

of phenomenology to the experience of post-traumatic stress disorder and the discipline of

nursing concludes the chapter to nursing followed by phenomenology and the experience of

post-traumatic stress disorder.

3.2. The Origins of Phenomenological Thought

The origin of the phenomenological movement has its foundations in the works of Franz

Brentano (1838-1917) which was expanded by Husserl (1859-1938), a pupil of Brentano.

Husserl’s motivation was spirited by a desire to examine the valid foundations of the

concepts and laws of arithmetic which lead to a preoccupation of the “a priori principles of

all human ‘cognition’ – knowledge and belief culminating in an exploration of the a priori

principles of human experience and understanding” (Solomon, 1980, p. 1). Husserl believed

that “philosophy should become a rigorous science that would restore contact with deeper

human concerns, and that phenomenology should become the foundation for all philosophy

and science” (Streubert & Carpenter, 1995, p. 32). What Husserl sought to establish was a

secure basis for human knowledge. In his search for a pathway to human knowledge he

gradually became increasingly aware of the need to step back from the phenomenon of

focus and to take a fresh look at the reality he wanted to understand. The ‘reality’, Husserl

looked to, is, as it presents itself to human consciousness. In his ‘search for reality’ Husserl

launched his program under the battle cry ‘back to the things themselves’ (Crotty, 1996).

To ground knowledge about reality, he looked to reality itself (Crotty, 1996) – the lifeworld

of everydayness.

In his last major work ‘The Crisis of European Sciences and Transcendental

Phenomenology’, Husserl (1913-1938) formulated the notion of the Lenbenswelt; the

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lifeworld, the everyday world in which we live in the natural, taken-for-granted attitude. It

is in this taken-for-granted everyday world of human encounters.

3.3. What is a Phenomenon?

Phenomena are that which can be articulated from a phenomenological perspective

(Solomon, 1974). A phenomenological perspective is the standpoint from which

phenomena are described. “The concept of a phenomenon represents both something that is

‘in’ experience and something that is the object itself” (Solomon, 1980, p. 13). Pearsall

(1999) suggests that a phenomenon is “something or situation” of which little is known that

is of interest to the researcher (Pearsall, 1999. p. 1071). In other words, a phenomenon from

a phenomenological philosophical standpoint can be described as objects, situations, or

events that form patterns of human existence (van Manen, 1997). In the study, the

phenomenon of interest to this researcher is the experience of post-traumatic stress disorder

as described by victims of a motor vehicle accident.

3.4. The Constituents of Phenomenology

The standpoint of phenomenological thought is essentially concerned with the study of the

life world of human beings – “the world as we immediately experience it pre-reflectively

rather than as we conceptualize, categorize, or reflect on it” (van Manen, 1997, p. 9).

Phenomenology is concerned with the search for foundations – “the structures that are

essential to any and every possible experience” (Solomon, 1980, p. 1). Structures or

essences suggests Brockelman (1980), are common or shared characteristics which are

present in the appearances of a phenomenon as revealed through experience.

Phenomenology holds the position of being pre-suppositionless, meaning, that any

supposition or proposition is available for scrutiny at any time. It is also considered to be

theory free, meaning that it does not promote or advance any theoretical position.

Phenomenology as a philosophical movement has continuously engaged in an examination

and recasting of the fundamental propositions underpinning the essential nature of what

constitutes phenomenology including, the nature of consciousness, the constituents of

experience, the foundations of knowledge, the nature of necessary truth, and the concept of

intentionality (Solomon, 1980).

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The task therefore, of a phenomenological researcher is one of “accessing the universal or

shared characteristics” (p. 11) of a phenomenon as it presents itself in the constructed

meaning of human experience through which an understanding of it’s essential nature is

obtained.

3.5. Intentionality

The concept of intentionality was initially coined by Bretano and further expanded on by

Husserl. The philosophical position underpinning the notion of intentionality is that human

action and world are co-constituted – meaning, that they are inextricably linked to each

other. It is in the context of co-constituting human existence – human action and world –

that the structure of everyday human experience takes form (Pollio et al, 1997). The notion

of intentionality as viewed through the conceptual lens of phenomenology is different from

the concept of intention which is concerned with a plan of action directed toward to achieve

a specified goal. It is a particular focus adopted by an individual directed toward achieving

a particular outcome. Through the phenomenological lens the concept of intentionality is

founded on the notion that human beings are inextricably related to the context in which

they live out their daily pattern of life. It is an essential component of being-in-the-world

(Pollio et al, 1997).

For Husserl, intentionality is the essence of consciousness - the way we interact with the

world we have come to know in all its certainty and uncertainty. A person’s awareness of

what is significant for them in daily living as expressed in actions and language provides

the essential backdrop for exploring lived experience. Intentionality is one of the

cornerstones of phenomenological thought; the others are intersubjectivity, the

transcendental ego, and the phenomenological attitude.

3.6. Intersubjectivity

An essential component of being human is to co-exist with others and the world around us.

As human beings were are part of the human community. It is concerned with recognition

of the existence of others “as the embodiment of minds and selves like our own. We not

only appreciate the world as given to others; we can also turn toward these others and

experience them as like ourselves, as datives of disclosure, who can reciprocate our

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recognition and see us as like themselves” (Sokolowski, 2000, pp. 152-153). The notion of

intersubjectivity brings to the fore that, as human beings there is much we share in common

– a world held in common. It is within the context of this sense of community that human

beings live out their daily pattern of existence and engage in collaborative enterprises with

others and the world around them.

3.7. The Transcendental Ego

The transcendental ego is a human being’s sense of identity. It is essentially the agent of

reason and truth for an individual that gives birth to moral behaviour and a rational life

(Sokowlaski, 2000). The transcendental ego is not separate from the person but a

fundamental domain. It is the origins of responsible acts and interactions with the world.

Besides being biological, psychological, and subjective beings, we also enter as agents into

the space of reasons, we enter into the domain of the rational, and when we do so we “go

beyond” we transcend our subjectivity; we act as transcendental egos...a responsible agent

of truth and verification (Sokowlaski, 2000, p. 116-152).

The transcendental ego is not a separate entity, the human intellect, but the ‘I’ of the person

capable of making intelligent assessments and responsible decisions that give birth to public

acts. The transcendental ego when that is manifest in the public arena constitutes the

transcendental you – “recognised not only by himself [sic] but also by others” (Sokolowski,

2000, p. 122). The transcendental ego is active in the natural attitude. However, when

human beings disengaged with the natural attitude and reflect on, and articulate the

transcendental ego in all its intentionalities, and bring to awareness the various ways the

ego constitutes and manifests itself to itself and to others, the human being engages in the

process of phenomenological reflection or what is termed the phenomenological attitude

(Sokowlaski, 2000).

3. 8. The Phenomenological Attitude

Husserl (1970) whose aim was to establish a science of understanding of phenomena or

“essences rather than of matters of facts” (Annells, 1996, p. 706) posited that two attitudes

exist as part of everyday life – the natural and philosophical. The natural attitude pertains to

the beliefs and theoretical conceptions held by humans about the ways in which human

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beings engage with the world of persons and objects as they go about their ordinary

everyday life. The notion of ordinary everyday life is meant to denote the activity of living

in which much of the person’s world is acted out through assumed and uncontested

awareness. To live in this manner suggests Husserl is to deny one access to deeper human

concerns pertaining to the nature of existence and what it means to be human. Cohen and

Omery (1994) summarise Husserl thoughts about the nature of the natural attitude in

stating:

This world of everyday experience is not immediately accessible in the ‘natural attitude’. We take for granted so much of what is commonplace that we fail to notice it. To really see what surrounds us requires phenomenological study (Cohen & Omery, 1994, p. 139).

For Husserl, adopting a phenomenological attitude is to re-engage with the world in original

awareness – as if for the first time. Achieving such a disposition involves questioning

presuppositions about phenomena in the natural world thus enabling one to move beyond

the natural to a phenomenological attitude. Moving to a stance in which one adopts a

phenomenological attitude involves the process of phenomenological reflection meaning

that the researcher interrogates and declares his/her natural attitude in order to explore a

particular experience or phenomenon. The term coined for interrogating and declaring

beliefs or presuppositions is ‘bracketing” (Burns & Groves, 1993; Cohen & Omery, 1994).

Engaging with the process of bracketing allows the researcher to peel away layers of

uncontested assumptions and beliefs as a means of being open to the phenomenon being

investigated. In other words it provides a ‘clearing’ in which the phenomenon can be

interrogated in its essential nature. As well the researcher does not conduct an extensive

literature review until data has been collected (Burns & Grove, 1993). In this way the

researcher does not become overwhelmed with the range of contemporary thought about the

phenomenon until he/she has completed the process of interrogation.

Phenomenology as a particular pathway of inquiry provides a valuable means to gaining

understanding of lived experience (Crotty, 1996; Omery & Mack, 1995; Stephenson &

Corben, 1997; Taylor, 1993; Benner, 1985; 1994) and ultimately ‘seeks to render lived

experience intelligible’ (Crotty, 1996, p. 14). Such sentiments are also in keeping with

Colaizzi’s (1978) understanding of phenomenology – the method of choice for this study.

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3.9. Phenomenology Through the Eyes of Colaizzi

Colaizzi’s (1978) philosophical stance and subsequent method of interrogation is in keeping

with Husserlian thought in which the structure of lived experience is explicated through

description and interpretation of a selected phenomenon. From the perspective of Colaizzi,

human experience has an influence on everything people do. It involves the everyday world

– a world inextricably intertwined with the person. Such sentiments are in keeping with

Husserlian thought. In relation to research, Colaizzi (1978) has constructed an eight-step

approach to analysis for exploring the essential nature of a particular phenomenon. These

steps although listed in a sequential manner are meant to be a guide allowing for ease and

flexibility of analysis. The actual process of analysis will be discussed in more detail in the

following chapter. In light of the consistency of thought between Husserlian

phenomenological thought and that of Colaizzi’s approach to analysis is considered by this

researcher to be an appropriate choice of method for this study.

The question that now needs to be asked is, “In what way is phenomenological inquiry an

appropriate means by which the world of nursing practice can be explored?”

3.10. Phenomenology and Nursing

Phenomenology and nursing is rooted in the Human Sciences (Dzurek, 1994). As a human

science, nursing’s main concern is with the person within the context of health-illness

experiences. Benner (1994) suggests that “health and illness are lived experiences and are

accessed through perception, beliefs, skills, practices and, expectations” (p. 1). “The

meaning of health as well as illness is unique to the individual” (Allen & Jensen, 1990, p.

252) and therefore, understanding the meaning of health as well as illness as experienced by

the individual is important to nursing.

Phenomenology and nursing are viewed as related as they share a concern with people’s

experiences in their everyday lives (Taylor, 1993). The endorsement of this philosophical

‘marriage’ is evident in the phenomenological grounding of three foundational nurse

theorists: Parse’s (1981) theory of human becoming, Paterson and Zderad’s (1976) theory

of Humanistic Nursing and Watson’s (2001) theory of Caring (cited in Burns, 2001).

Patterson and Zderad (1976) were the first to introduce the philosophical notion of

31

phenomenology into their research. Since then, phenomenology has been generally

considered to be a valid human science approach for nursing research (Munhall, 2001;

Annels, 1996; Stommel & Willis, 2004).

Taylor (1993) believes that “nursing viewed from a phenomenological perspective provides

an illumination of the world of nurses and patients as entities or beings of ‘being’” (p. 175).

More recently Schneider, Elliot, Wood and Haber (2003) suggest that “phenomenology and

nursing share basic premises related to beliefs about individuals and their relationship to the

environment” (p. 196). Phenomenology provides nursing with a rich and appropriate

philosophical basis for understanding a broad range of human experiences relating to

health, illness, or disability, including strategies for coping, recovery, and endurance when

confronted with long-term problems (Husserl, 1938; Madjar, 1998). Such beliefs are

supported by Walters (1994) in positing “phenomenology, as a philosophy, has great

applicability to nursing, particularly when… phenomena of interest to nursing are about the

everyday lives of people…usually coping with some form of illness” (p.135). The merit of

working with a phenomenological research process was noted by Oiler (1982) who

proposed that a phenomenological approach to inquiry is consistent with the science and art

of nursing practice.

As a profession, nursing is enmeshed in human life experiences and so phenomenology

appears to be a suitable research method to investigate particular phenomena. In this

instance the experience of post-traumatic stress following a motor vehicle accident as

described by accident victims in Jordan.

3.11. Phenomenology and the Experience of Post-traumatic Stress Disorder

As previously indicated the central focus of this study is to explicate the phenomenon of

the experience of post-traumatic stress following a motor vehicle accident as described by

accident victims in Jordan. The experience of post-traumatic stress is a human response

related to exposure to physical and psychological trauma manifesting a range of symptoms

including anxiety, avoidance, re-experiencing the event, and having feelings of detachment

and estrangement (Bisson & Andrew, 2007).

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The very nature of experiencing post-traumatic stress is therefore a human response to a

traumatic event lived out in the everyday lives of the victims. Given that such an experience

is for these victims part of the fabric of everyday experience and in being human, a

phenomenological methodology is an appropriate research approach for exploring the

phenomenon of the experience of post-traumatic stress within the context of this study.

The philosophical underpinnings of phenomenological thought are consistent with the

values of nursing practice, the uniqueness of the person, the importance of personal

discovery, acceptance of life situations, the need for exploration of meaning, constructed

reality and the potential for person growth. In this context, phenomenology as a

philosophical framework and research methodology can provide knowledge about aspects

of a person’s life in health and illness which cannot be accessed by observation alone.

3.12. Conclusion

This chapter examined the theoretical framework of phenomenological research as applied

to this study. The chapter primarily discussed the philosophical foundations of

phenomenological thought followed by an explication of empirical existential

phenomenology as articulated by Colaizzi (1978) the process of analysis used for this study.

The next chapter provides a discussion of the methodology employed for this study.

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CHAPTER FOUR

METHOD

4.1. Introduction

This chapter provides a discussion of the methods employed for this study. The chapter

begins with a description of the processes involved in participant selection, method of

accessing potential participants, information gathering processes, ethical considerations and

how a rigorous approach to inquiry was maintained throughout this study.

4.2. Focus of the Study

As previously discussed, the purpose of this study was to explore the life world of people

who have experienced post-traumatic stress disorder following a MVA in Jordan. The

overarching question that gave focus to this inquiry was:

What is the lived experience of post-traumatic stress disorder (PTSD) as

articulated by motor vehicle accident victims in Jordan?

4.3. The Process of Participant Selection

The primary mode of participant recruitment for this study was through the process of

purposive sampling. The purposive sampling method has been singled out as the most

appropriate means of participant recruitment as it provides an opportunity for the researcher

to select potential participants who are best positioned to provide rich descriptions of their

experiences (Clifford, 1997; Polit & Beck, 2008). Such a mode of participant recruitment is

an acknowledged method for a qualitative study (Minichiello, Sullivan, Greenwood &

Axford, 1999; Munhall, 2001).

4.4. Criteria for Participation in the Study

Potential participants who met the inclusion and exclusion criteria (Table 4.4.1) were

invited to be a participant in this study. The inclusion and exclusion criteria for

participation in the study are presented in Table 4.4.1 below.

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4.5. Number of Participants

It was anticipated that a purposive sample of 10-15 participants would be required for this

study. The actual number of participants after completion of the recruitment process was

15, the point at which data saturation occurred. The term data saturation refers to the point

in the data collection process where no additional knowledge about the phenomenon being

studied emerges (Marshall, 1996; Ploeg, 1999; Tuckett, 2004, 2005). At the point of data

saturation the researcher needs to make a determination that no further information will be

forthcoming and therefore, the information gathering process is completed. Within the

context of this study the researcher believed that she reached data saturation after

interviewing participant 14, however, to ensure this was the case an additional participant

was interviewed. The information shared by the 15th participant confirmed data saturation

which brought the interview process to a point of conclusion.

4.6. Accessing the Participants and the Recruitment Process

The process of accessing participants for this study involved the following processes. The

researcher initially contacted the Director of Amera Basma Hospital in writing to arrange

an appointment to discuss the possibility of conducting a research study at that facility. An

appointment was arranged at which the purpose of the study was discussed and a request to

access potential participants were made. After receiving verbal permission to conduct the

Table 4.4.1. Selection criteria for the study

Inclusion criteria:

Men and Women who have been involved in a MVA Have, as a consequence of their accident developed PTSD Over the age of 18 years Willing to share their experiences of PTSD Able to converse in English Exclusion criteria: Unduly distressed (meaning unable to control one’s emotions; reacting to the memories of the initial trauma) Exhibit florid/severe symptoms of PTSD Present as overtly vulnerable

35

study, the means by which invitations could be extended to potential participants was

explored. The outcome of the discussion was to arrange a further meeting with the Director

of the hospital, the Director of Nursing, and this researcher to set in place the process by

which potential participants would be invited to be part of this study. The process agreed on

by all parties attending the meeting was as follows.

The Director of Amera Basma Hospital would introduce the researcher to the medical and

nursing staff assigned to the orthopaedic unit to inform them of the study and to illicit their

support. All staff expressed enthusiasm for the study and offered any assistance required.

The only request of the researcher was that a meeting of the staff be arranged for the

purpose of informing them of the intent of the study, and to seek their assistance in the

recruitment process. The agreed on process involved the researcher and Nurse Unit

Manager reviewing patient files to ascertain which patients met the inclusion and exclusion

criteria for the study. The addresses and telephone numbers of those patients who met both

criteria were noted. The Nurse Unit Manager then contacted those potential participants by

phone to inform them of the study and to ascertain their interest in being a participant.

Those who expressed initial interest in being involved in the study were asked to provide

their contact details to the researcher.

Follow-up phone contact with each participant was made by the researcher at which time

further information about the purpose of the study and level of participation required was

discussed. Those potential participants who continued to express interest in being involved

in the study were invited to attend a meeting with the researcher at which time a full

explanation of the study was presented both verbally and in writing (Appendix I). At the

conclusion of the meeting each person was informed that the researcher would be in contact

in a week to see if they still wished to be part of the study. The time lapse between the

informal meeting and obtaining permission was intended to provide potential participants

the space to think through what it would mean for them to be involved in the study and to

make a decision without coercion. All those approached consented to be part of the study.

On receiving verbal acceptance a mutually acceptable time and place for interview was

arranged.

36

4.7. Location of Information Gathering

Of the 15 participants, 11 preferred to be interviewed in their own homes. The remaining

four preferred to be interviewed at the hospital. To ensure that these participants were not

inconvenienced this researcher arranged to transport the participants to and from the

hospital and provided them with a food voucher for a meal after the interview and before

being transported home.

4.8. Information Gathering Process

Information was collected through the process of unstructured in-depth digitally recorded

interviews. Each participant was involved in two interviews – the first for information

gathering at which participants were asked to describe their experience of PTSD and to

share their metaphor and/or pictorial representation (which they were asked to bring to the

interview), and the second to provide the participants with an opportunity to review the

transcribed transcript of their respective experiences and the findings (the structure of the

phenomenon) undertaken by this researcher. The first interview with participants lasted

approximately 60 minutes. The second follow-up interview lasted approximately 30

minutes.

4.9. The Interview Process

As part of ensuring researcher integrity, prior to commencing the formal interview process

this researcher conducted two pilot interviews under the supervision of her principal

supervisor in order to acquire expertise and feedback in this method of information

gathering. This process proved extremely valuable providing this researcher with a critique

of her interview style and her level of competency in conducting a phenomenological

interview. After gaining approval from her principal supervisor the researcher returned to

Jordan to commence information gathering.

Prior to each initial interview with participants a time was set aside to obtain written

informed consent. The information provided at this time included:

The nature and aims of the study

37

That the participants would be involved in two digitally recorded interviews

potentially lasting between 30-60 minutes.

That participants have the right to withdraw from the study at any time without

prejudice;

That names and places mentioned in the course of the interview will not be

identified in the study report;

That the duration of the two interviews would be approximately one hour each;

That the content of the digital recording would be kept under lock and key with

only the researcher and her supervisors having access during the conduct of the

study after which, all information will be archived at the university for a period of

five years and then destroyed in accordance with University policy for destruction

of confidential information;

That their respective transcript of interview along with the thematic analysis

would be given to participants to judge if the findings of the study reflected their

experiences (Appendix II).

Once written informed consent was obtained the researcher engaged the participant in an

informal conversation as a means of allaying any anxiety that the participant may be

experiencing about sharing their experiences on tape. In each case engaging participants in

an informal discussion prior to the commencement of the formal interview proved effective

in alleying any initial sense of discomfort. When the participants indicated they were happy

to proceed, the interview commenced.

The central question which gave focus to the interview was:

What is it like to experience living with post-traumatic stress disorder?

Prompts used to encourage the participants to elaborate on their experiences included:

Tell me about your thoughts and feelings relating to these experiences?

Tell me more about that?

Is there any metaphor or artistic representation that you would like to share

that sums up your experience of post-traumatic stress disorder?

38

The purpose of using such an open-ended approach to the interview process was to avoid

having question-answer sequences and to allow the participants the opportunity to verbalize

their ideas in an un-incumbent manner as if in an informal conversation (Cutcliffe &

McKenna, 2002; Minichiello, Aroni, Timewell & Alexander, 1990, 1995).

4.10. Information Analysis

Information analysis was informed by Colaizzi’s (1978) eight-step phenomenological

method plus two additional steps as outlined below. Colaizzi (1978) eight step framework

for analysing qualitative data includes (1) transcribing all the participants’ descriptions; (2)

extracting significant statements; (3) creating formulated meanings, (4) Aggregating

formulated meanings into theme clusters (refer these clusters back to the original protocols

to validate them, note discrepancies among or between various clusters, and avoiding

temptation of ignoring data or themes that do not fit); (5) Developing an exhaustive

description of the phenomenon; (6) Formulating the exhaustive description into an

unequivocal statement of identification of the structure: (7) Validating the findings (the

structure) with the participants; (8) Integrating information from the validating interview

into the final description. Two additional steps were included: participants sharing their

metaphors and/or pictorial representations of their experiences and a review of literature in

relation to the findings of the study making it a 10 step approach to analysis.

The Following provides an outline of the ten-step approach to analysis in this study:

4.10.1. Transcribing the participants’ transcripts

The interviews which were digitally recorded were transcribed by the researcher. A copy of

the transcript of interview was returned to the respective participant within a week after the

interview to identify any inaccuracies in the transcript and to add additional material if

deemed necessary by the participant prior to commencement of the analysis process. The

participants were provided with a pre-paid envelope addressed to the researcher for return

of the transcription of interview and their comments. Reflections on the interview process

which were documented by the researcher immediately after each interview were attached

to the reviewed transcript of interview of each participant in preparation for the process of

analysis.

39

4.10.2. Extracting significant statements

Each transcript of interview and the researcher’s reflections on the interview process for

that interview were reviewed twice in conjunction with listening to the interview recording.

The initial review was to gain a general sense or gestalt of the participant’s story. The

second review was to extract significant statements from the transcripts. Significant

statements are comments/descriptions by the participant that directly relates to the

phenomenon under study – in this case the experience of PTSD. The significant statements

were then numbered and numerically entered into a list (e.g., 1, 2, 3…) for each participant.

4.10.3. Participant symbolic and/or pictorial representations of their experience of post-

traumatic stress disorder.

The rationale for the inclusion of this additional step stemmed from the concern by the

researcher and her supervisors that rich descriptions of the participants’ experiences have

the potential to be compromised because of linguistic concerns – for both the participants

and the researcher. As English was the second language for both participants and researcher

- the first language for the participants was Arabic while the first language for the

researcher was Filipino. In addition, it was thought by both the researcher and her

supervisors that including another source of information could enhance the participants’

actual descriptions.

All participants responded in a positive manner to sharing a metaphor and/or pictorial

representation that reflected their experience. However, of the pictorial representations

provided by participants only seven were able to be included in this study because of

difficulty in obtaining copyright permission. Three participants brought with them their

own pictures taken by them which did not require copyright permission. During the course

of the interview participants were asked to talk about their respective metaphors and/or

pictorial representations concerning their experience of PTSD which provided rich

insightful comments that complemented their descriptions of their experiences. Such a

process especially in the circumstances of this study where linguistic barriers existed was in

keeping with the intent of phenomenological research where the central focus of inquiry is

the explication of the structure or essence of the phenomenon under study (Husserl, 1956;

40

Merleau-Ponty, 1956). The metaphors are presented in chapter five, and the pictorial

representations form part of the discussion of the explicated themes in chapter six.

4.10.4. Creating formulated meanings

Colaizzi (1978) recommends that the researcher attempts to formulate more general re-

statements or meaning for each significance statement condensed from the participants’

narratives. The process of creating formulated meanings for this study involved the

following processes. The researcher commenced this process by first reflecting on her own

assumptions and pre-conceptions of what it would be like to experience PTSD. Insights

gleaned through this process were documented in her reflective journal which acted as a

point of reference throughout the analysis process providing a point of reference for

ensuring that her personal views and perceptions were kept in abeyance during the analysis

process. Such an activity is consistent with what Husserl (1965) and Colaizzi (1978) term

phenomenological reduction or ‘bracketing’ which they consider an essential requirement

in phenomenological research. The formulated meanings explicated by the researcher

formed the basis for the development of theme clusters.

4.10.5. Aggregating formulated meanings into theme clusters

Colaizzi (1978) suggests that formulated meanings can be organised into similar groups or

themes clusters. In keeping with Colaizzi’s (1978) analysis process the significant

statements explicated from the participants’ transcripts of interview were then arranged into

theme clusters. This was achieved by the researcher taking time to review each formulated

meaning as a separate entity followed by engaging in a process of comparing the meaning

units with each other to identify common elements or potential themes. This process

involved configuring and reconfiguring the theme clusters by moving the formulated

meanings between themes, and renaming themes to clearly identify theme clusters that

reflected the participant’s experiences underpinned by the formulated meanings allocated to

a specific theme providing evidence of how the theme clusters were generated. The theme

clusters formed the basis of the discussion of themes in chapter five of this study.

41

4.10.6. Developing an exhaustive description of the phenomenon

An exhaustive description of the phenomenon is a comprehensive description of the

experience of post-traumatic stress disorder (PTSD) as articulated by participants and

interpreted by the researcher. The exhaustive description is located at the end of chapter six.

4.10.7. Formulating the exhaustive description into an unequivocal statement of

identification of the structure of the phenomenon.

This process involved identifying the essential nature of the experience of the phenomenon

that clearly indicates the core elements and dimensions of the phenomenon. The

unequivocal statement is located in chapter six.

4.10.8. Validating the findings (the structure) with the participants.

This process involved returning the transcripts of interviews and the completed analysis to

the participants for comment and validation. Participants were given a week to review their

respective transcripts and the completed analysis after which the second interview was

arranged. The second interview involved spending time with participants in clarifying any

concerns or points of analysis that seemed to the participants to lack clarity. In the main the

majority of participants felt that the findings of the study were clearly described and were

consistent with their experience of PTSD. Two participants sort clarification of some of the

terms used in the presentation of findings which were addressed by the researcher to their

satisfaction. Both of these participants also confirmed that the findings of the study

represented their experiences of PTSD.

4.10.9. Integrating information from the validating interview into the final description.

All participants indicated that the analysis of findings was an accurate representation of

their experiences, and therefore, no adjustments to the findings were required.

4.10.10. Reviewing the literature for understandings of the phenomenon.

The findings of the study were reviewed in relation to the literature on the topic (see chapter

42

seven). This additional step to Colaizzi’s (1978) method of analysis was introduced by

Edwards (2007) as part of her doctoral dissertation. This step was undertaken to achieve a

deeper understanding of the phenomenon in this study and to compare the findings of this

study with extant knowledge concerning the phenomenon under study.

The process of information analysis began immediately after each interview as advised by

Colaizzi (1978). Streubert and Carpenter (2002) support such an approach in suggesting

that analysis begins with the initial interview and continues as an on-going process until the

analysis component of the study is completed (Holloway & Wheeler, 2002).

4.11. Ethical Considerations

Prior to commencement of this study research ethics approval was obtained through

Queensland University of Technology Research Ethics Committee.

Ethical considerations identified in the conduct of this study were:

4.11.1 Confidentiality/anonymity

The identities of participants were kept in strictest confidence throughout the study. Any

personal and/or identifying information, such as names on the consent forms were kept

separate from the data. Code numbers were used to identify each interview transcript and

recordings of the interview. The only persons to have access to the original transcripts with

participant identification were the researcher and the respective participant. The

researcher’s supervisors had access to the coded transcripts of interview for the purpose of

reviewing the work of the researcher. In the presentation of participant profiles particularly

attention has been given to ensuring that there is no identifying information that could lead

to the recognition of participants.

4.11.2. Informed consent

Prior to the commencement of interviews participants were provided with a detailed

explanation both verbally and in writing of the purpose of the study, the manner in which

information would be gathered including digital recording of interviews, their level of

43

involvement, assurances of confidentiality and anonymity, and the rights of participants to

discontinue their involvement in the study at any time without prejudice (Appendix I & II).

The participants were also informed that if any difficulties surfaced for them during the

course of the information gathering process there would be opportunities to discuss their

concerns and negotiate continuing consent. Considering the nature of the study and the

cultural background of participants – their reluctance to assert themselves in such situations

for fear of offending, the researcher periodically inquired throughout the interview about

how they were feeling, whether there were concerns, and whether they were happy to

continue in the study. The method of ‘process consent’ or ‘consensual decision-making’ is

widely used in qualitative research (Munhall, 1988; Munhall & Boyd, 1993; Munhall,

2001). No participants expressed a need to either stop the interview or to discontinue the

interview and withdraw from the study.

4.11.3. Level of risk

Participants were asked to share health sensitive and personal information in relation to

their experiences. Given the personal nature of the information, it was the belief of this

researcher that potential existed for participants to experience some level of discomfort

while reflecting on their experiences. In consideration of such a situation occurring, a

number of strategies were set in place as contingencies:

Participants were informed and reminded prior to and at periods during the

interview that they could withdraw from the study at any time without prejudice.

Debriefing was offered if required by the participant, or otherwise, indicated by

the researcher.

If ongoing debriefing or counselling was required by participants, the researcher

was in a position to link the individual with a qualified mental health clinician

with expertise in PTSD counselling. A referral process was set in place prior to

commencement of the study.

In addition, the moral, ethical and cultural norms of the participants were also respected

throughout the interview process. This included avoiding asking questions that could

produce and encourage emotional pain. If the participant indicated that they were not in a

position to discuss a particular question, the view of the participant was respected, and that

44

particular question was not pursued any further. Throughout the interview process

participants were monitored by the researcher for any sign of discomfort or apprehension

when responding to the interview questions or points of clarification. Apart from the

normal anxious moments at the commencement of the first interview and sharing some

personal moments of frustration, anger, and uncertainty about the future none of the

participants expressed reluctance or where perceived by the researcher to be uncomfortable

about sharing their experiences.

4.11.4. Storage of information

All information was kept under lock and key when not in use for the duration of the study.

During the course of the study all information was retained by the researcher in her office at

the university. During the period of information gathering, all information was retained in a

locked cabinet at the home of the researcher as the study was conducted in Jordan. All

information will be retained by the university for a period of five (5) years after completion

of the study, and then destroyed in accordance with university policy for the destruction of

sensitive and confidential information.

4.11.5. Occupational Health and Safety Considerations

The proposed study was reviewed by the Research Health and Safety of the School of

Nursing and Midwifery, Queensland University of Technology, Brisbane, Australia. All

issues pertaining to research health and safety were addressed to the satisfaction of the

Occupational Health and Safety Officer.

4.12. Rigour of the Study

Evaluation of the quality of data collected is one of the most important methodological

challenges for qualitative research (Stommel & Willis, 2004). In quantitative research,

terms such as reliability and validity are used to describe the quality of data collected.

Reliability and validity also refer to the consistency with which the instrument produces the

results if administered in the same circumstances and to the degree to which an instrument

measures what it is intended to measure (Burns & Groove, 2001). However, in qualitative

research, the quality of data collected is assessed in a different manner. Guba and Lincoln

45

(1985) established operational techniques to ensure the trustworthiness of a study by

proposing four tenets: credibility, dependability, confirmability and transferability. This

study adhered to these tenets as discussed below.

4.12.1. Credibility

Credibility is concerned with establishing the match between the constructed realities of

participants and those realities as represented by the researcher. To achieve this, the

researcher provided the participants with the opportunity to review their transcripts and the

presentation of findings to ensure that a 'true' account of their experiences was captured

(Miles & Huberman 1994). Furthermore, the researcher engaged in a process of reflection

concerning her assumptions and pre-conceived ideas about the phenomenon, and made

every effort not to contaminate participant information during the processes of information

gathering and analysis. This was achieved by maintaining a journal of my thoughts and

activities throughout the research process (Cutcliffe & McKenna, 2002).

4.12.2. Dependability

One of the criteria for measuring trustworthiness in qualitative research is that of

dependability of the study. Dependability refers to stability of information over the duration

of the study. Stability is concerned with ensuring the information is not altered in any way

which may distort the original intent of what was initially communicated by participants. If

any alterations are made in pursuit of clarity of information, those changes and associated

decisions need to be documented. In other words, the supervisors to this study scrutinized

each stage of the research process to ensure that a clear audit trail was maintained. The

researcher and her supervisors met regularly for discussions and to monitor any alterations,

changes to participant information, and associated decisions in terms of their

appropriateness (Stommel & Willis, 2004).

4.12.3. Transferability

Transferability is dependent upon the degree of similarity between two contexts (Guba &

Lincoln, 1989). It occurs when the findings can fit into the contexts outside the study

investigated, and when individuals not involved in the study view the findings as

46

meaningful and applicable in terms of the reality of their personal experience (Sandelowski,

1993, 1986). To enhance the transferability of the findings of the study, independent people

were asked to review the findings. The independent people were two persons who had

suffered from PTSD as a result of being involved in MVA. They were asked to review the

findings to ascertain whether the findings reflected their own personal experience. The two

people indicated that the findings of this study were consistent with their experiences of

PTSD.

4.12.4. Confirmability

Confirmability “may be thought of as parallel to the conventional criterion of objectivity”

(Guba & Lincoln, 1989, p. 242). It is concerned with ensuring that all research processes

are clearly described and that the actual findings of the study are an accurate reflection of

the participants’ descriptions of the phenomenon free of personal bias and prejudice of the

researcher. Confirmability was achieved in this study by the researcher documenting all

elements of the research process including her reflections on the research process.

4.13. Conclusion

This chapter discussed the research methods applied to this study. The chapter began by

outlining the focus of the study followed by a description of the various processes involved

in information gathering including, the criteria for involvement in this study, recruitment

and access processes, information gathering processes, and Colaizzi’s (1978) method of

data analysis with additional steps. The chapter concluded with a discussion of ethical

considerations and rigour was maintained throughout the study. The next chapter begins the

presentation of findings for this study.

47

CHAPTER FIVE

FINDINGS OF THE STUDY

5.1. Introduction

This chapter begins the presentation of findings. The chapter commences by presenting

demographic information about the participants. The significant statements explicated from

the transcripts of participants’ interviews are then presented. The formulated meanings of

the significant statements are presented in diagrammatic form. The seven themes explicated

from the significant statements and the formulated meanings conclude the chapter.

5.2. Demographic Description of the Participants

The participants were described in terms of age, gender, and marital status. Eight (8) out of

fifteen (15) participants were female and seven (7) were male. The age of participants

ranged from 18 to 60 years. Seven (7) participants were aged between 30 and 49 years, five

(5) participants were aged between 50 and 60 years, and three (3) participants between 18

and 29 years (see table 5.2.1).

In terms of marital status, eleven (11) of the participants were married, two participants

were widowed, and two had never married.

Table 5.2.1. Demographic characteristics of the participants.

Gender

Total Age Marital status

18-

29

30-

49

50 -

60

Married Widow Single

Female

Male

Total

8

7

15

2

1

3

4

3

7

2

3

5

6

5

11

1

1

2

2

0

2

48

5.3. Participant Significant Statements

Significant statements refers to those statements contained in the participants’ transcripts of

interview which are explicitly stated or implicitly inferred that relate to the phenomenon

under study, in this instance, the lived experience of PTSD. The significant statements are

presented under each participant.

Participant 1 –Significant Statement

1. I feel my strength just slipping away with each day. I no longer have the strength

to do what I used to do…I have no energy left. I just wish that my strength would

return.

2. It was that stage when I have no strength to move freely because of the accident. I

would have wished that my strength had not gone.

3. But now I need a stick to move around because of that accident. I was walking and

crossing the street when a car crashed on another car and hit me without knowing, and

I was hospitalised for one month.

4. I used to prepare breakfast for myself, now I have lost that ability. To lose one’s

independence is a terrifying experience. It is a constant struggle not to give in and not

having to rely on others. I want to regain my independence, but it is so difficult.

5. [Being patient with post traumatic stress disorder], you lose your independence and

you became totally dependent on others. I can’t concentrate; I have lost my ability to

think clearly.

6. I have no energy to continue to maintain myself and I have relied on others for

assistance. Yes, people can do things for you, but in most cases I do not have the

energy to do things, like in the morning I used to prepare breakfast for myself. Now, I

have to depend on others to do things for me. I’m not able to do for myself, like

before when I had normal health.

7. [Post traumatic stress disorder is] having bad dreams, I felt I was going out of my

mind. I kept having dreams about what happened in the accident.

8. I realised what the doctor said while I was in the hospital that I’m suffering from [post

traumatic stress disorder], which I have no idea what it is all about?

9. I had these memories that kept coming back. I tried to ignore them but I couldn’t. I

asked my doctor and he explained to me what to do.

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10. I guess I have to adapt to having this [post traumatic stress disorder] and pray to God

that I get well again and get back to a normal life.

11. I think this [post traumatic stress disorder] is just hopeless, no life. People don’t like

me because I am useless.

12. I think it is very difficult for me to accept that I’m not able to work anymore.

13. Sometimes I’m quiet; suddenly I laugh or cry without any reason. I feel I do not

belong to this world, I feel I’m alone.

14. My family suffers too. They don’t know what to do to help me.

15. The government is not helping me, although I get free consultations, I have to pay my

hospital bills. I thought I felt better but I have become sicker.

16. They referred me to the community mental health services for more follow up, but I

can’t go because it is too far from my home. I can’t afford to get treatment from the

hospital because I have no money to pay for my bills. I lost my job because of this

disability. You know… I have to depend on my parents financially.

17. I just need to stay at home and wait until God will take me. It will be better for me and

my family.

18. I have to accept this condition no matter what happens.

Participant 2 –Significant statement.

1. My health was good until I had the car accident. I can no longer think clearly and my

physical health is now poor. I feel frustrated that I cannot do what I used to.

2. I am disabled both physically and mentally. I am unable to even help myself. I feel

there is no hope and I am unable to care for myself. At times I just want to die

3. Sleeping is a problem. Every time I fall asleep I am plagued by memories of the

accident. I can still hear the screams and noises of the accident. People’s voices

screaming all at once.

4. I think I became more irritable when I could not sleep. I just screamed and stayed in

the room by myself.

5. Every night I always remember what happened to me. I could not forget that time. It

is always on my mind.

6. At times I feel that people don’t care what happens to me. The hospital staff payed

little attention to my needs. They just ignored me as if I was responsible for my own

situation. Their lack of concern was very distressing. I just felt that no one was taking

me seriously.

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7. You know… I faced a lot of problems not only as a result of my condition, but also

from others…my friends, neighbours, and relatives. I feel isolated from the world.

8. I think people don’t like me. I didn’t get any attention from them especially the

nurses. The hospital service was generally poor. I felt more stressed because of them.

Staff attitudes are very bad in this institution; nurses just don’t care about those with

PTSD.

9. I think having this condition [post traumatic stress disorder] I just want to die because

there is no reason to live. Anyway, I have no money to pay my hospital bills and

medication. I need to have further consultations in the city, but I can’t afford it.

10. I think I will be burdened with this disability...I am [disabled physically and

mentally] and have no hope for the future.

11. It [post traumatic stress disorder] was difficult for me to accept and to go on living

with this condition.

12. Being placed inside a box that I am not allowed to get out of. It is a terrible

experience.

13. I had lots of friends, family, and relatives to help me but now nobody is around. They

all disserted me since I developed this condition [post traumatic stress disorder].

14. I try to accept my situation even though I have no money or income. It is very

difficult for me because there is no support from my family or the government either.

15. When you are ill or in need of family support such as in my situation you expect

them to be there for you. That did not happen to me. When I needed them most they

just turned their backs. It was as if they were scared or didn’t understand what was

happening to me. I had lost the capacity to look after myself because of my illness but

had no one to care for me. I was left to survive on my own.

16. Dehumanising, unwanted, and alone. I feel there is no hope of recovery as there is no

one to care for me.

17. I think people can help if they want to especially the government. On paper it seems

the government is helping… but in reality… that is not the case. I feel that if I don’t

get any help I will die. What will become of me?

Participant 3 –Significant statement

1. I just feel depressed because I don’t know why this has happened to me [post

traumatic stress disorder]. People think I am crazy and I feel I will always be disabled

because of this condition.

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2. In the beginning it was hard to adapt to my diagnosis of PTSD. It was like a

nightmare. People laughed at me all the time because they thought I am crazy. You

know… when you have a mental illness they talk about you and they isolate you. You

feel marginalised and pushed aside as if you are no one. I just want to recover so that

people will stop laughing at me.

3. You know…our society is very un-accepting of people with PTSD. Even my family

finds it difficult and often complains that they feel embarrassed when my name is

mentioned in conversation with neighbours and friends. I just feel no one wants to

know me because of my condition. You just feel pushed aside by everyone.

4. I didn’t begin to feel these symptoms until I went home. Once home I began to feel

lonely, crying all the time, and sometimes scared about what was happening to me.

5. At times I am unable to sleep at night. If I sleep I begin to have these terrible dreams

which keep coming back about the accident.

6. At times I feel I just want to run away from home.

7. I had a lot of friends around me , but now they are [ avoiding me] I’m alone and no

one wants me, I don’t have anybody to support me.

8. You know… our society tries not to accept this kind of condition; even my family,

they feel embarrassed.

9. I have struggled with this condition but now I have to accept what I am.

10. Suffering from PTSD has been a nightmare. People laughed at me all the time

because they said I was crazy. You know…when you have a mental illness they talk

about you and they isolate you by not involving you.

11. The experience of PTSD has been for me feeling like a lost bird. You are out there on

your own and not belonging to any group. It is a lonely existence. You feel as if there

is no one there for you not knowing where to fly to.

12. I try [to cope] with everything so I can get back my life – my life before developing

PTSD.

13. Having no family to care for you and being left to find your own way is very

distressing.

14. I feel like a small person having this condition [post traumatic stress disorder].

However, I live with hope that I will be able to work again.

15. If I am to survive and get through this ordeal it will be because of Allah. Each day I

pray to Allah that I will recover. He is my only source of hope and comfort in this

52

difficult time. He is my strength. I believe He will come to my aid and be my

protector.

16. I realise now you have to be strong enough to accept what you have got. What has

happened to me is God’s will and I have to accept it. I continue to pray that God will

help me to recover.

Participant 4-Significant statement

1. They don’t know anything; I wonder how they became nurses.

2. I had no idea what happened to me. I thought I am going crazy. I couldn’t speak and

my body was numb. It is like being in a daze wondering what is happening to you.

3. At times I have these panic attacks which come out of no where. When these happen I

am unable to concentrate. It is a frightening experience because you feel alone… no

one understands what you are going through.

4. Many times I become cold and clammy with palpitations when the memory of the

accident returns.

5. I think I’m losing my mind. I don’t know where I’ll get help, and I don’t know what

to do.

6. My life since becoming ill has left me imprisoned, separated from everything precious

to me. No matter how you try to escape from your fears and confusion you cannot.

7. I think having this post-traumatic stress disorder I need to have someone to depend on

to care for me. It is very difficult to be alone with no one to care and love me.

8. The longer I am sick, I feel there is no future for me, I just don’t know what to do.

9. I think love and affection are what helped me [to cope] from this disorder.

10. I try [to adapt and to cope] with my situation.

11. I can’t avoid thinking about what happened to me but I realised no one can help me

except myself.

12. It is very difficult to be alone with no one to care or love you. My family no longer

wants anything to do with me because of my illness. They just left me to look after

myself with no support. Without them I am lost.

13. I worked so hard to escape from my [depression] without any help.

14. I was happy when I had this support group. These people helped me to [to recover]

go on with my life.

15. Talking with people there gave me an opportunity to live again.

53

16. I think to myself, I now have another life and I don’t want to experience such things

again.

17. Having faith in Allah helped me to accept that I may never be the same. That I could

never go back to the way I was before my accident and illness. Once I accepted that I

could no longer do the things I once did, I felt much lighter of heart. I could let go the

anger, hurt, and frustrations at being ill. Fear of not having a future went away. I was

no longer afraid of the future. Gradually I began to think that my life is not over.

There are still many things I can do and will do with the blessing of Allah.

18. I think I am ready for a new life.

Participant 5 –Significant statement

1. I have nothing to look forward too. I was feeling good prior to the accident. I had all

the support I needed from family but since the accident and diagnosed with post-

traumatic stress disorder my life has changed. My life has fallen apart and the family

have distanced themselves from me.

2. The memory of the accident keeps coming back.

3. I already have diabetes and now post-traumatic stress disorder. Living with both

conditions is at times overwhelming.

4. Before the accident I had everything to look forward to. Even after the accident and

being told I had a disorder, I thought I would still get through this nightmare. Now I

am having doubts. I am gradually losing hope that I have a future.

5. I continue to suffer from stress and anxiety. I never know when the symptoms will

return.

6. I have problems in getting to sleep. I wake up at night with bad dreams. I can only

sleep on one side because of my injuries. When I sleep on the other side, I experience

severe pain and develop a headache. Between the physical pain and the nightmares

there is no respite.

7. I don’t want to see anybody, even my family. I want to be alone to try to work out

what is happening with my life.

8. I sometimes feel that someone will hurt me. I was so scared, frightened day and

night. I always close the curtains in my room. I want the place dark and quiet and no

one is allowed to enter my room because I don’t trust anybody.

9. It has been very hard without anyone to help me. I can’t do anything…I have no

strength to do the things I like doing.

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10. I have to rely on others for assistance. I have lost my independence and have become

totally dependent on others. My family can do things for me but I have to do for

myself. Sometimes I have no energy to do things. Even to wash myself is extremely

difficult.

11. It was very hard without anyone helping me as I couldn’t do anything for myself…I

felt as if I was paralysed, no strength to do the simplest of things like having a

shower. Living like this is so frustrating.

12. I have panic attacks and I don’t know what to do. I can’t concentrate. If my sister is

with me I grab her hands very tightly to the point I sometimes hurt her.

13. As a consequence of the accident, and developing post-traumatic stress, I now have

to rely on others for assistance. I lost my independence and became totally dependent

on others. I know my family can do things for me but I want to do things for myself.

I want some control over my life. The struggle to be independent is constant. All I

can do is to keep trying.

14. I was unable to keep my consultation appointment for treatment in the city because I

had no money to even pay for transport let alone the consultation. Although my

family kept insisting I go despite my financial situation I said I cannot afford to.

Anyway, up till now the medication hasn’t helped. I keep asking myself will I ever

recover? If I don’t what is my future?

15. I feel neglected; the nurses were mean to me as well as other patients who were

seeking treatment for post-traumatic stress disorder.

16. All I received from the hospital staff was neglect and rudeness. The way they spoke

to me and looked at me was as if there was something odd about me, as if I was not

human. They didn’t seem to care or have any idea what I was going through nor did

they even try to understand. I just wanted to leave and never come back, even if it

means not getting over this condition.

17. I think the government needs to help patients like me who are suffering from [post

traumatic stress disorder].

18. As usual nurses were very rude. They have no idea what it is like to suffer from this

disorder. Nurses don’t care about their patients. They treated us poorly.

19. I felt I’m not human because of this condition and the way they treated me in the

hospital. When I saw the Mental Health Centre, I thought to myself am I crazy? I

cried and felt sorry for myself. I asked my family to take me home because I’m not

crazy. Although I am ok now they diagnosed me with post-traumatic stress disorder.

55

20. I refused to be hospitalised. I went home with my family and on my way home, I was

thinking I [can cope] without help from the doctors or nurses.

21. I encouraged myself to fight this disorder [post traumatic stress] by being with

friends, relatives and other people.

22. I think after a month I saw myself improving. I am now able to do some of the things

I used to do before the accident and illness.

23. I think I learned to be independent.

24. I accepted what happened to me. Thank God I’m back to my old myself. I have faith

and hope that one day I will be able to be normal again.

Participant 6 –Significant statement

1. The experience of [post traumatic stress disorder] has been difficult to cope with. I

can’t accept it and the thought that I may never recover.

2. I think the government should help and support me through this illness. My life is

now one of being ignored with no one to help. I can’t afford to buy my medicine or

even pay my bills. How I can feel better if I am so angry for what has happened?

3. After my ordeal and the way I was treated in hospital, I promised myself I would

never return. All I wanted to do was to get out of there. I didn’t care where I would go

I just wanted to be as far away from that place as possible. I am still asking myself

why did they treat me that way? Why did they not treat me like others?

4. My condition is becoming worse. My quality of life is poor and I don’t know how to

get out of this situation.

5. I won’t ever forget what it is like. After the accident I kept having frightening dreams

in which I kept recalling the accident. I have great difficulty sleeping. My illness is

affecting every part of my life.

6. I screamed a lot even when at home. At times I become very irritable without any

apparent reason. I just seem to explode.

7. It has been a difficult time in my life. I lost my independence to do for myself and I

need to depend on others. I have no strength to do for myself, I have to depend on

others

8. I cannot forget what it was like – the accident was like a nightmare which recurs again

and again in sleep. I am at times afraid to sleep because of what may happen. My

inability to sleep affects every aspect of my life. I feel very weak all the time, no

energy. I just want to get my old life back.

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9. I still perform the daily rituals required of a religious person. My constant prayer is

that God will help me to get back to my normal life. I thank God that I am alive.

10. It was a difficult time in my life. Losing my independence and having to rely on my

family was extremely difficult. A thing I have always been reluctant to do. Each day

was a struggle not to depend on others.

11. I have [to accept] what happens to me. God gave me this condition to see if I can deal

with it.

12. There was a time when I couldn’t sleep because of the flashbacks to the accident. I

turned to the Quran for help to forget the accident.

13. When I was in the hospital, my family were the only help I got. I couldn’t count on

the nurses because they ignored me when I needed their help.

14. At times I feel hopeless and helpless.

15. I felt as if I was dead and my life was over - no life to look forward to because I lost

my job as a result of this disability. I need support and monthly income to provide and

maintain myself. Nobody is helping me because I have no money now, and am also

disabled.

16. For me, the experience of PTSD is to feel that you don’t belong, an outcast. You feel

like a stranger in your own community.

17. I thought that the government would help me to survive from this disorder. For all that

I have done for my community I have received nothing in return.

18. I considered myself a dead man, no life to look forward to. I lost my job because of

this disability. I need support and monthly income to provide for my family and

maintain myself in good health in order to fight this disorder. No body wants to help

me because I have no money and no future. What will become of me?

19. I felt angry not only because of my illness but also about how society has responded.

20. I think it’s time for society and the government to recognise that post-traumatic stress

disorder is a real disorder rather than thinking we are making it up. It is very hard to

deal with no being believed.

21. In the beginning I couldn’t accept that I had post-traumatic stress disorder.

22. I started to help myself [to cope] from depression, denial and anger.

23. I have been able to improve because of the help of my children and relatives.

24. It makes me feel good that there are people who care about me.

25. I think if I didn’t have any help from my family, I would be more depressed than I am

now.

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26. You have to have self confidence, you have to encourage yourself, you have to have a

strong faith in God, and you have to give yourself the strength to fight for life.

27. It [post traumatic stress disorder] is a challenge requiring you to hope that you will get

through it. You have to believe in yourself and believe in others that they’ll be there

to support you and help when you are in need.

28. I think it is time to be happy in my life and accept whatever happened.

29. It is time to accept my situation if I want to be happy once again and get on with my

life. There are many things I cannot change but there are things I can. It is Allah’s will

what has happened to me and I must accept it. I have faith in Him to guide my future.

Participant 7 –Significant statement

1. Although the doctor diagnosed me with [post traumatic stress] which I have little

knowledge of, I feel that life will continue and I will get through this period.

2. I feel that I can still do some work at home and I am still as strong as anyone else,

although the accident and the illness has been difficult to cope with.

3. I have energy to sing around the house, be happy with my children, and whoever

comes here. I put on a good face and smile no matter what I am feeling inside.

4. As happy as I am, I also fear seeing myself like other patients who are suffering from

[post traumatic stress disorder] who are totally dependent on others.

5. The sad part of my coping is having financial problems. My salary is very small so I

allow it to accumulate throughout the year. However, the yearly sum is not enough to

pay for my expenses for treatment.

6. Sometimes there is the issue of property grabbing when you are very ill. They the

family] think you will never need your property again. But this is the time I need the

money to maintain myself; especially because I have no financial support from

anyone.

7. I have to be wise in spending my money to afford my medication. Although I have

access to free consultation, I have to pay my own expense going to the hospital. I feel

ignored by society who seems to not realise that people suffering from post-traumatic

need better care and treatment.

8. I had these nightmares, sweating; cold feelings, and palpitations like I’m nervous and

I couldn’t sleep at night.

9. I lose my trust in others.

10. I have faith that I will feel better and become healthier.

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11. I accepted and followed what the doctor told me to do and took my medication on a

regular basis.

12. I have learned how [to cope] with everything with the help of my family and doctors

who treated me.

13. When I was ill my family supported me [to cope] and how to become a better person.

14. It is Allah who gives me the strength to continue. Without Him I would not have

been able to keep going against the overwhelming difficulties that have resulted from

my condition [PTSD]. Allah is has been my constant source of comfort. I have faith

in Him to heal me.

15. I have to accept everything that God has given me…it is God’s blessing.

16. I have come to accept my disabilities and my inability to do many things as a result

of my illness with the help of Allah. I have come to realise that accepting Allah’s will

is what is important as He knows what is best for me. I have learnt to be happy in

doing the simple thing around the home that are meaningful to me and that makes a

contribution to family life.

Participant 8 –Significant statement

1. In this society we never had any help from the government, which made me angry. I

have to cope with this disorder by myself.

2. Every so often I have these nightmares about the accident which are terrifying.

3. I couldn’t sleep. I try to take a nap during the day but the dreams kept returning.

4. I had body aches especially my back, hurts me so much. I asked the doctor about this

and he said it was only a part of the accident.

5. I was upset about everything. I am not comfortable at all because of my feelings of

anger, shame and hopelessness.

6. I had no support from anybody, I feel they abandoned me. No one is helping me.

7. As a result of my illness no one wants to know you or be around you. Even my wife

has stopped caring about me. My family has always been my world now they have

disserted me. What do I do? Where do I go?

8. I felt there is no place for me in this world.

9. My experience of PTSD is being on the fringe of everything. At times I feel I am no

longer apart of anything. My mind is just hanging in there. At times you tell yourself

to hang on and not let go for if I do there is no coming back. It is a frightening place

to be.

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10. I met this person who told me he’ll help me [to cope] with this disorder. He was kind

and helpful; he took me to the small health centre and get referral from the doctor.

11. I had a consultation and understood everything about this post [traumatic stress

disorder].

12. I [cope] little by little with the help of this person who encouraged me to be a person

again.

13. I can’t go back again to that miserable life, I have to fight this [post traumatic stress]

condition.

Participant 9 –Significant statement

1. The nightmares continue whether I sleep at night or during the day.

2. I had trouble sleeping after the accident. I often wake up in lather of perspiration and

with palpitations.

3. I had a hard time after the accident and my illness because I had no money to support

myself.

4. You know…if you live with children or relatives whom you are able to support

financially; they are more willing to look after you [however] your chances of being

neglected or abandoned are higher if you are not able to support them. Family can be

fickle at times especially when you become a burden. I thought they would be there

for me but they weren’t.

5. If I had to change things, I want to be a survivor, not to expect money from my

children or other relatives. I would like to be an independent person so I can get more

respect from others.

6. The doctor said that I have this condition [post traumatic stress disorder], which

usually develops after a traumatic event.

7. I think I need more attention and affection from people, especially from my children.

My children and relatives left me alone; they ignored me because they thought I ‘m

mental illness.

8. It makes you feel terrible when there’s no one helping you or giving you supports in

times of trouble.

9. Being a person with post-traumatic stress is like being a beggar always asking for

help. It makes you feel terrible to ask or receive help from others even if they are

family and friends. It is quiet humiliating but what else can I do? Without help I fear I

will never recover.

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10. I need my family to stay and be with me whatever happens…I’m not happy right now

because I think my family will walk out on me because of my disorder… post-

traumatic stress disorder. No one will help me and that’s what hurts me.

11. I desperately need my family to stay and be with me whatever happens. I fear each

day that will not happen. It is only a matter of time till they leave me because of my

illness. There have already been signs that they are preparing to leave. Without them I

have no life or hope for a future.

12. I think only God can help me to survive.

Participant 10 -Significant statement

1. Being a [post traumatic stress disorder] patient is terrible.

2. I try to sleep but I can’t. I just get tired, irritable and angry.

3. I went to a private doctor and he told me what was happening to me. Before this I

didn’t know what was happening to me.

4. I thought I was going crazy. You know…it is very hard to be accepted in this society

if you are crazy.

5. My family were the ones who supported me during this difficult time. They helped

me [to cope] and understand what was happening to me and what I needed to do to

get well.

6. When I asked for help from my friends and relatives they just looked the other way

because they think I am crazy. They didn’t want to talk or see me, they just avoided

me. Society is much the same.

7. No matter what you do you feel confined. It is like everyone wants to keep you in a

box and away from them.

8. Having to deal with all the issues of my condition leaves you feeling angry, and

depressed. The future sometimes seems hopeless. It is only with the love and support

of family that you can survive.

9. It was my family that helped me to accept that I have PTSD. Accepting what you

have is the beginning of getting well again.

10. There have been times when I just wanted to avoid others because of my shame and

guilt about having PTSD.

11. It is difficult to receive treatment because of the expense. I expected the government

to help but as yet they haven’t.

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12. I don’t have enough money to pay my hospital bills, medication or even food to eat. I

worry about what will happen to my family if there is no money to buy food?

13. There is little assistance from the government for people like me with PTSD.

14. I have a small income from my government pension, enough for daily expenses to

feed my family, but not for treatment of my condition. I want to feel well again but

when? I sometimes I get anxious that I will never recover, never again have a normal

life.

15. It is unfair, I was paying monthly from my salary and I’m not allowed to get any help

from the government service especially with this [post traumatic stress disorder]

illness.

16. It is about time the government found a solution to help people in their needs, like

me, suffering from [post traumatic stress disorder]. They should find a solution to

help us.

17. I think I have enough support from my family but still need money to survive. That’s

why I try to become stronger so I will not need the government’s help.

18. I am gradually learning how to cope with my condition.

19. I have accepted myself for what I am now.

Participant 11 –Significant statement

1. I had to depend on my family to take care of me while I was in hospital, not on the

nurses. They seemed to have no idea about what I was suffering from. Each time I

asked for help to move because I had no energy they just ignored me. Being ignored

is a terrible feeling.

2. Being [post traumatic stress disorder] patient was terrible; I felt as if I was an alien.

3. As a result of this condition I have experienced a range of emotions including

depression, anger, and self pity. At times I feel helpless to do anything about it.

4. During nights are difficult with the recurring nightmares.

5. I keep remembering that event which is distressing. My family is also suffering

because of what I am going through.

6. I am suffering from [post traumatic stress disorder] which means crazy. It’s not easy

to say this word or accept in this society. People will talk about you and put you in

embarrassing situation.

7. I have had to keep my illness [post traumatic stress disorder] a secret. The only

people who know are my family. If others found out I would be rejected.

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8. I feel like society just wants to ignore you as if you don’t exist because of this

condition.

9. I thought I was dying from it [post traumatic stress disorder] and I would not survive.

10. I worked so hard to change my behaviour and there was no result. I tried to ignore

everything but I couldn’t do it. I told to myself just leave it for a while. If this is

God’s will I will have to accept it.

11. I attended a group session with people who have PTSD. The experience has been

helpful in helping come to terms with my life.

12. I pray to God for help and guidance to get through this difficult time.

13. It is only Allah who can heal me, make me well. Throughout each day I reflect on

His goodness and His power to heal me. During times when praying to Allah I ask for

His blessing help to be a normal person again. It is through Him that I will be healed.

14. Having faith in God helps you to cope.

Participant 12 Significant statement

1. The nightmares are frightening. I often wake up screaming.

2. The nurse who was taking care of me was so mean. I complained to the head nurse

but she don’t do anything. You feel so humiliated.

3. It is very disturbing when you are ill such as I was and the staff just thinks you are

making it up.

4. My dreams are always about the accident. You wake up in a terrible state and you are

afraid to go back to sleep.

5. I thought it was real, I was screaming according to my wife. I was sweating, had

palpitations and a cold sweat.

6. I thought I was going to die because I had no idea what was happening to me. My life

had fallen apart and my health had gotten worse.

7. For me, the experience of PTSD is to feel as if there is something wrong with you, as

if you are deformed or mentally disturbed. Everyone shuns you and looks at you with

suspicion and fear.

8. When hospital staff treat you as if there is nothing wrong with you, treat you as if you

are not ill, don’t respond to your requests for assistance, you start to think what is

wrong with me? Am I making all this up? Is this the type of person I am? At one stage

I was really afraid that I was going mad.

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9. My life has changed forever because of the accident and now my illness. I feel

responsible for what has happened and I can’t do anything about it. Everything I

loved and cherished especially my family have moved away from me. Left me to look

after myself, disowned me. I have lost everything that is important to me

10. Living with this illness is a lonely existence, no one understanding and few people to.

You are on your own.

11. I need to have people around me who are willing to help and understand what I am

going through. That is the only way I am going to survive.

12. The Government is useless. I can’t get any help from them.

13. I have lost my independence and I am totally dependent on my family.

14. It is hard to accept this situation [with post traumatic stress disorder].

15. Each day I live hoping I will get well again, and fear that it may never happen.

16. I have no strength or energy to move on and maintain myself. I need to rely on others.

17. I had to be patient hoping that the government will help to support me in coping with

this situation. I hope that the government will acknowledge my suffering from post-

traumatic stress so that they can give me some assistance to survive.

Participant 13 –Significant statement

1. Suffering from what you call…[post traumatic stress disorder], wasn’t easy for me.

2. As a result of my accident and later developing PTSD I am unable to concentrate on

my studies. My mind just wonders.

3. When the doctor told me I’m suffering from [post traumatic stress disorder]; I

couldn’t accept it. It took a long time to come to a point of accepting that I had this

condition.

4. I asked myself if this condition continues do I have a future?

5. Attending a small support group for people with PTSD, I met friends that were in the

same situation and I realised that I was not the only one.

6. I have to learn to accept what has happened if I want to get well.

7. Accepting your situation is important to moving on with your life.

Participant 14 -Significant statement

1. The night times are the worst when those terrifying dreams about the accident keep

recurring.

2. I try to put all memories of the accident out of my head but I just can’t.

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3. At times I feel I’m going crazy, losing my mind. I can’t think clearly. I don’t know

what to do.

4. The panic attacks at night as a result of the dreams are frightening. You never know

when they will occur.

5. Living with this condition [post traumatic stress patient] is at times overwhelming.

6. I thought it was the end of my life. I think I was in totally out of control. My friends

avoided me, my relationship with my family was destroyed, and they no longer want

to talk to me.

7. Trying to adapt to living with this condition is very difficult. It is a daily struggle.

8. I blame myself for what has happened. Because of the accident I have lost everything

– my job, my friends, my health, and my family. Because of my illness I have lost

everything. I am so sorry for what has happened.

9. I think one day I will be able to cope with this situation [post traumatic stress

disorder patient].

10. I have lost my independence and I have to depend on others. My body strength is so

weak; I can’t do anything for myself. I can’t even wash myself. I need somebody to

assist me in my daily routine.

11. I try to adapt and accept what is happening to me.

12. I try to be happy. Just to listen to the Quran gives me happiness. Thank God He gave

me another life to move on.

13. I realised I needed to cope and help myself if I was to survive.

Participant 15 -Significant statement

1. Living with [post traumatic stress disorder] has been hard. I have lost my

independence and it is hard having a disability.

2. I can no longer provide for my family. Because of my illness and physical disability

as a result of the accident I am no longer able to work or even to the jobs around the

house that I used to. I now have to depend on the good will of others.

3. At times I get overwhelmed by feelings of self pity, loneliness, and hopelessness.

4. When I recall the accident and all the friends I have lost because of my illness I get

depressed.

5. All my friends have abandoned me because of this [post traumatic stress disorder].

They think I am crazy… even my family they can’t accept what has happened to me.

Society is no better.

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6. The nights are often long. The nightmares frequent.

7. My life at the moment is a lonely existence. If I am to survive I need help from

others.

8. Because of this condition [post traumatic stress disorder] I am in a difficult situation. I

can no longer work and therefore have to take leave without pay because this is the

policy of the company for which I work. I can’t depend on government assistance for

treatment either.

9. I can’t manage myself or afford to pay my hospital bills and medication. I wish the

government could support me by giving me a free monthly consultation and free

medicine. Without government assistance I will not be able to continue having

medical care. Without that help the chances of getting well again are poor.

10. What will become of me?

11. I thought this was the end for me. There’s no one to look after me. I don’t know what

to do? There is no one out there to care for me.

12. I feel as if life has no future. I am at the end of my strength. All around me is

darkness. I feel there is no hope and no way out of this nightmare I am experiencing.

13. I sometimes think this is the end for me. I have no one to look after me, no family or

friends to care for me. I am in constant pain.

14. Since the accident and developing this illness [PTSD] everything in my life has gone

wrong. No one wanted to listen to my calls for help. No one wanted to understand

what I was going through. I was left to fend for myself, abandoned by the very ones I

trusted and depended on. All my dreams for a wonderful life just seemed to shatter.

Have you ever felt so rejected and abandoned that life no longer had any meaning? I

was this person. There have been many times that I said to myself, “give up, don’t

fight it any more, your strength has gone, no body cares, what is the use of fighting to

get well when it is not going to happen”. There were many times I just wanted to give

up but my faith in Allah to bring me back from giving into despair rescued me, My

faith in Allah was my only strength. He did not leave me in my time of need.

15. I have [to cope] no matter what…I need to survive.

16. I have to say that post-traumatic stress disorder patients like me need have a lot of

care and attention nothing else. I think love and affection are what we need from

people to survive with this condition.

17. I believe that I have accepted my lot in life and am now at peace with myself and the

world. I accept myself as having a disability and I pray to Allah to give me the

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strength to move on with my life. I thank Allah for giving me another chance to live

and to enjoy His continuing blessings. Life for me is once again full of opportunities.

5.4. Created Formulated Meanings from the Significant Statements.

Each significant statement explicated from the participants’ transcripts of interview were

then re-read several times to obtain a sense of their respective meaning. The fundamental

question asked by the researcher was: “What is the meaning of the experience of PTSD

inherent in each significant statement?” Formulated meanings were developed from each

significant statement and then sorted into theme clusters. The significant statements,

formulated meanings were reviewed by the researcher’s supervisors. The following table

provides a succinct explication of the formulated meanings in relation to the significant

statements.

Table 5.4.1. Formulated Meanings and Relative Significant Statement

FORMULATED MEANINGS PARTICIPANT NUMBER (P) AND SIGNIFICANT STATEMENT

The experience of PTSD limits a person’s capacity to care for self.

P1-1,2,4,5,6,9

P2-2,10

P3-1,13

P4-7,8,11,12

P5-9,10,11,13

P6-7

P12-16

P15-2 The experience of PTSD is to live with the frustration of not being able to do things for yourself.

P1-1

P2-1,15

P5-11

P6-8,10

The experience of PTSD engenders

feelings of hopelessness, helplessness and

dependence on others.

P2-2,8,10,16

P3-14

P4-8,12

P5-11,12,13

P6-7,10,14

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P7-4

P9-11,10

P11-1

P12-13

P14-10

P15-3,12 The experience of PTSD trying to keep a balance and fear of failing.

P4-3

P5-5,14

P8-9

P9-11

P12-15

P13-4

The experience of PTSD is a constant struggle

P3-9,10

P6-10

P8-5

P9-9

P11-5

P15-3,4 The experience of PTSD is fear of losing

control.

P4-5

P11-3

P14-6

P15-14 The experience of PTSD is not knowing what the future holds

P3-11

P5-14

P6-4,18

P13-4

P14-4

P15-10,11 The experience of PTSD is being laughed at and ridiculed

P2-7,12

P3-2,3,7

P4-6

P6-20

P10-6,7

P11-6

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P12-7

P14-6

P15-5,14 The experience of PTSD is to be rejected

by society.

P3-3,7

P4-6

P7-7

P8-1

P10-4

P6-7,8

P15-5 The experience of PTSD is a process of gradually dying.

P10-4

P11-9

P12-6 The experience of PTSD is to be invisible. P2-6,8

P9-10,12

P11-6,11,13

P12-11

P13-5

P15-9

The experience of PTSD is being lonely

and alone.

P1-13

P2-4

P3-7

P4-12

P8-10

P12-10

P15-3,7 The experience of PTSD is feeling lost. P3-9

P4-12

P8-8

P12-9

P13-5

P15-9

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From the significant statements in relation to the formulated meanings seven themes

emerged: Frustrated at a diminishing health status; Struggling to Maintain a sense of

Independence; Harbouring fears that they may never recover; Feeling discriminated against

and marginalised by society; Feeling ignored and neglected by health care professionals;

Feeling abandoned by family; Moving toward acceptance through having faith in Allah.

Significant statements that best reflected the participants’ experiences of each of these themes

were explicated as below.

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The Explicated Themes from the Participant Significant Statements

The Lived Experiences of PTSD as Described by People in Jordan

Theme One

1. Frustrated at a diminishing health status

I feel my strength just slipping away with each day. I no longer have the strength to do what I used to do…I have no energy left. I just wish that my strength would return.

1-1

It was very hard without anyone helping me as I couldn’t do anything for myself…I felt as if I was paralysed, no strength to do the simplest of things like having a shower. Living like this is so frustrating.

5-10

My health was good until I had the car accident. Since then I can no longer think clearly and my physical health is now poor. I feel frustrated that I cannot do what I used to do.

2-1

The experience of living with PTSD is like going over a water fall - you have no control. No matter how much you struggle against the current you cannot win. You are at the mercy of the water and the rocks and you have no strength. The pressure of the water forces you in directions you don’t want to go. I feel much like this all the time and it is frustrating.

5-16

I have problems in getting to sleep. I can no longer sleep like before. I wake up at night with bad dreams. I can only sleep on one side because of my injuries. When I sleep on the other side, I experience severe pain and develop a headache. Between the physical pain and the nightmares there is no respite.

5-5

I cannot forget what it was like – the accident was like a nightmare which recurs again and again in sleep. I am at times afraid to sleep because of what may happen. My inability to sleep affects every aspect of my life. I feel very weak all the time, no energy. I just want to get my old life back.

6-8

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Participant Significant Statement Theme Two

2. Struggling to maintain a sense of independence

I used to prepare breakfast for myself, now I have lost that ability. To lose one’s independence is a terrifying experience. It is a constant struggle not to give in and not having to rely on others. I want to regain my independence, but it is so difficult.

1-4

It was a difficult time in my life. Losing my independence and having to rely on my family was extremely difficult. A thing I have always been reluctant to do. Each day was a struggle not to depend on others.

6-10

As a consequence of the accident, and developing post-traumatic stress, I now have to rely on others for assistance. I lost my independence and became totally dependent on others. I know my family can do things for me but I want to do things for myself. I want some control over my life. The struggle to be independent is constant. All I can do is to keep trying.

5 -12

Normally I used to help the family with jobs around the house, but now, because of this condition I can’t even help myself. Every day is a struggle to do things for myself, to be independent. Although it is a struggle, if I don’t attempt to do them myself I will lose all independence which I cannot afford to do

15-4

When you no longer have the energy or the strength to continue to fight, you just feel like giving up. Everything, every attempt to do things without asking family to help was so difficult. At times it seemed easier just to let go and give up.

12-12

I have always been in control of my life. Now everything is such a struggle. I want to be my old self not having to rely on others. At times I feel so tired I just want to give up trying.

9-11

Life for me can be likened to being a blind person. Like the blind person I have lost my independence and I struggle with not knowing what is ahead of me. I now have to rely on others. It is like searching in the dark.

7-11

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Participant Significant Statement

Theme Three

3. Harbouring feelings of not being able to recover

I was unable to keep my consultation appointment for treatment in the city because I had no money to even pay for transport let alone the consultation. Although my family kept insisting I go despite my financial situation I said I cannot afford to. Anyway, up till now the medication hasn’t helped. I keep asking myself will I ever recover? If I don’t what is my future?

5-14

I have a small income from my government pension, enough for daily expenses to feed my family, but not for treatment of my condition. I want to feel well again but when? I sometimes get anxious that I will never recover, never again have a normal life.

10-18

My salary is very small and so I let it accumulate over the year and then withdraw it to pay my expenses. It is never enough and the bills keep mounting up. Without the ability to pay for treatment I am doomed. I will never get better.

7-7

If I have a chance to change anything it would be my current situation. I want to recover and not be dependent on others. I want to be like others again – independent and in control of my life – but I fear that is not going to happen.

9-9

I considered myself a dead man, no life to look forward to. I lost my job because of this disability. I need support and monthly income to provide for my family and maintain myself in good health in order to fight this disorder. No body wants to help me because I have no money and no future. What will become of me?

6-18

Being a person with post-traumatic stress is like being a beggar always asking for help. It makes you feel terrible to ask or receive help from others even if they are family and friends. It is quiet humiliating but what else can I do? Without help I fear I will never recover.

9-13

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I can’t manage myself or afford to pay my hospital bills and medication. I wish the government could support me by giving me a free monthly consultation and free medicine. Without government assistance I will not be able to continue having medical care. Without that help the chances of getting well again are poor.

15-12

Before the accident I had everything to look forward to. Even after the accident and being told I had a disorder, I thought I would still get through this nightmare. Now I am having doubts. I am gradually losing hope that I have a future.

5-4

The longer I am sick I feel there is no future for me I just don’t know what to do. 4-9

I am disabled both physically and mentally. I am unable to even help myself. I feel there is no hope and I am unable to care for myself. At times I just want to die.

2-2

What will become of me? 15-13 I feel as if life has no future. I am at the end of my strength. All around me is darkness. I feel there is no hope

and no way out of this nightmare I am experiencing. 15-15

Each day I live hoping I will get well again, and fear that it may never happen. 12-19

Participant Significant Statement Theme Four

4. Feeling discriminated against and marginalised by society

You know…our society is very un-accepting of people with PTSD. Even my family finds it difficult and often complain that they feel embarrassed when my name is mentioned in conversation with neighbours and friends. I just feel no one wants to know me because of my condition. You just feel pushed aside by everyone.

3-3

Being a person with PTSD is like being a prisoner. No one wants to know you or be associated with you. They avoid you as if there is something wrong with you.

4-7

My life since becoming ill has left me imprisoned, separated from everything precious to you. No matter how you try to escape from your fears and confusion you cannot.

4-8

Being placed inside a box that I am not allowed to get out of. It is a terrible experience. 2-12 When I asked my friends and neighbours for help because of my condition they turned their backs and walked

away. They think I’m crazy and don’t want anything to do with me. Society is much the same. Society just laughs at you and wants nothing to do with you. It just wants you to keep out of sight.

10-9

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Suffering from PTSD has been a nightmare. People laughed at me all the time because they said I was crazy. You know…when you have a mental illness they talk about you and they isolate you by not involving you

3-11

Participant Significant Statement Theme Five

5. Feeling ignored and neglected by health care professionals

At times I feel that people don’t care what happens to me. The hospital staff payed little attention to my needs. They just ignored me as if I was responsible for my own situation. Their lack of concern was very distressing. I just felt that no one was taking me seriously.

2-6

I had to depend on my family to take care of me while I was in hospital not on the nurses. They seemed to have no idea about what I was suffering from. Each time I asked for help to move because I had no energy they just ignored me. Being ignored is a terrible feeling.

11-5

After my ordeal in the way I was treated in hospital I promised myself I would never return. All I wanted to do was to get out of there. I didn’t care where I would go I just wanted to be as far away from that place as possible. I am still asking myself why did they treat me that way? Why did they not treat me like others?

6-4

All I received from the hospital staff was neglect and rudeness. The way they spoke to me and looked at me was as if there was something odd about me, as if I was not human. They didn’t seem to care or have any idea what I was going through nor did they even try to understand. I just wanted to leave and never come back even if it means not getting over this condition.

5-17

When hospital staff treat you as if there is nothing wrong with you, treat you as if you are not ill, don’t respond to your requests for assistance, you start to think what is wrong with me? Am I making all this up? Is this the type of person I am? At one stage I was really afraid that I was going mad.

12-11

Being a person with post-traumatic stress disorder is like a dying flower, no one looks at it. No attention is given to it. It is ignored and neglected just like me.

10-10

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Participant Significant Statement

Theme Six

6. Feeling abandoned by family Dehumanising, unwanted, and alone. I feel there is no hope of recovery as there is no one to care for me.

2-17

I desperately need my family to stay and be with me whatever happens. I fear each day that will not happen. It is only a matter of time till they leave me because of my illness. There have already been signs that they are preparing to leave. Without them I have no life or hope for a future.

9-15

I sometimes think, this is the end for me. I have no one to look after me, no family or friends to care for me. I am in constant pain. What will become of me?

15-16

It is very difficult to be alone with no one to care or love you. My family no longer wants anything to do with me because of my illness. They just left me to look after myself with no support. Without them I am lost.

4-15

As a result of my illness no one wants to know you or be around you. Even my wife has stopped caring about me. My family has always been my world now they have disserted me. What do I do? Where do I go?

8-11

Having no family to care for you and being left to find your own way is very distressing. At times I feel like a bird with no nest and no place to go.

3-14

I blame myself for what has happened. Because of the accident I have lost everything – my job, my friends, my health, and my family. Because of my illness I have lost everything. I am so sorry for what has happened.

14-14

My life has changed forever because of the accident and now my illness. I feel responsible for what has happened and I can’t do anything about it. Everything I loved and cherished especially my family have moved away from me. Left me to look after myself, disowned me. I have lost everything that is important to me.

12-14

You know…if you live with children or relatives whom you are able to support financially; they are more willing to look after you [however] your chances of being neglected or abandoned are higher if you are not able to support them. Family can be fickle at times especially when you become a burden. I thought they would be there for me but they weren’t.

9-8

When you are ill or in need of family support such as in my situation you expect them to be there for you. That did not happen to me. When I needed them most they just turned their backs. It was as if they were scared or didn’t understand what was happening to me. I had lost the capacity to look after myself because of my illness but had no one to care for me. I was left to survive on my own.

2-16

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Participant Significant Statement

Theme Seven

7. Moving toward acceptance through having faith in Allah

If I am to survive and get through this ordeal it will be because of Allah. Each day I pray to Allah that I will recover. He is my only source of hope and comfort in this difficult time. He is my strength. I believe He will come to my aid and be my protector.

3-16

It is Allah who gives me the strength to continue. Without Him I would not have been able to keep going against the overwhelming difficulties that have resulted from my condition [PTSD]. Allah is has been my constant source of comfort. I have faith in Him to heal me.

7-18

Since the accident and developing this illness [PTSD] everything in my life went wrong. No one wanted to listen to my calls for help. No one wanted to understand what I was going through. I was left to fend for myself, abandoned by the very ones I trusted and depended on. All my dreams for a wonderful life just seemed to shatter. Have you ever felt so rejected and abandoned that life no longer had any meaning? I was this person. There have been many times that I said to myself, “give up, don’t fight it any more, your strength has gone, no body cares, what is the use of fighting to get well when it is not going to happen”. There were many times I just wanted to give up but my faith in Allah to bring me back from giving into despair rescued me, My faith in Allah was my only strength. He did not abandon me in my time of need.

15-17

It is only Allah who can heal me, make me well. Throughout each day I reflect on his goodness and His power to heal me. During times when praying to Allah and asking for His blessing and help to be a normal person again. It is through Him that I will be healed.

11-19

It is time to accept my situation if I want to be happy once again and get on with my life. There are many things I cannot change but there are things I can. It is Allah’s will what has happened to me and I must accept it. I have faith in Him to guide my future.

6-30

I have come to accept my disabilities and my inability to do many things as a result of my illness with the help of Allah. I have come to realise that accepting Allah’s will is what is important as He knows what is best for me. I have learnt to be happy in doing the simple thing around the home that are meaningful to me and that makes a contribution to family life.

7-20

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Having faith in Allah helped me to accept that I would never be the same. That I could never go back to the way I was before my accident and illness. Once I accepted that I could no longer do the things I once did I felt much lighter of heart. I could let go the anger, hurt, and frustrations at being ill. Fear of not having a future went away. I was no longer afraid of the future. Gradually I began to think that my life is not over. There are still many things I can do and will do with the blessing of Allah.

4-20

I believe that I have accepted my lot in life and am now at peace with myself and the world. I accept myself as having a disability and I pray to Allah to give me the strength to move on with my life. I thank Allah for giving me another chance to live and to enjoy His continuing blessings. Life for me is once again full of opportunities.

15-21

Living with this condition is like crawling you way through thick bush, deep ravines, deep shadows and sometimes darkness. However, even in the darkest of times there is always hope that things will change. Having faith in Allah was for me the most important part in accepting your situation. Only then can you get on with life.

7-21

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5.5. Conclusion

This chapter presented some demographic data of the participants followed by the significant

statements explicated from the participants’ transcripts of interview. A formulated meaning

of each significant statement of participants was then presented. The seven themes explicated

from the significant statements of participants and the formulated meanings were then

presented. The next chapter presents a discussion of the explicated themes and participant

metaphors of their experience of PTSD are presented.

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CHAPTER SIX

PRESENTATION AND DISCUSSION OF FINDINGS

6.1. Introduction

This chapter presents a discussion of the findings of this study. The chapter begins with a

discussion of the seven themes explicated from the significant statements of participants.

Pictorial representations of the experience of PTSD provided by a number of the

participants are included in each of the themes. The chapter concludes with a discussion of

participant metaphors which provided a synthesis of their experiences.

6.2. Discussion of Findings

The analysis of the participants’ transcripts explicated seven themes:

Each of these themes are discussed supported by the inclusion of significant statements of the

participants.

The lived experience of 

post‐traumatic 

stress disorder

Feeling frustrated at a diminishing health status

Struggling to maintain a sense of independence

Harbouring feelings of not being able to  

recover

Feeling discriminated against and 

marginalised by society

Feeling ignored and neglected by 

health care professionals

Feeling abandoned by 

family

Moving toward acceptance 

through having faith in Allah

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6.2.1. Theme one: Feeling frustrated at a diminishing health status.

A number of the participants expressed feelings of frustration at their diminished health

status as a consequence of experiencing post-traumatic stress. Being witness to what

seemed to them to be an imploding personal world characterised by physical pain, sleep

disturbance, lack of energy, flash-backs, and tormenting nightmares, engendered in the

participants a sense of deep frustration at no longer being able to care for self and re-take

control of their daily lives. For participant 1, the sense of diminishing health was one of a

slow insidious loss of energy eroding his capacity to do normal everyday activities: I feel

my strength just slipping away with each day. I no longer have the strength to do what I

used to do…I have no energy left. I just wish that my strength would return. The feeling of

having no strength to do the simple things of life such as being able to attend to activities of

daily living was described by participant 5 in stating: It was very hard without anyone

helping me as I couldn’t do anything for myself…I felt as if I was paralysed, no strength to

do the simplest of things like having a shower. Living like this is so frustrating. Similar

sentiments were expressed by participant 2 in discussing the aftermath of her accident and

subsequently developing PTSD: My health was good until I had the car accident. Since

then I can no longer think clearly and my physical health is now poor. I feel frustrated that

I cannot do what I used to do. Participant 5 spoke in pictorial terms in describing her

experiences of anger and frustration at witnessing her health deteriorate. The pictorial

representation that she brought to interview was that of a waterfall. In describing her

experience in light of the picture she stated:

Plate 1: Going over a water fall

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The experience of living with PTSD is like going over a water fall - you have no control. No matter how much you struggle against the current you cannot win. You are at the mercy of the water and the rocks and you have no strength. The pressure of the water forces you in directions you don’t want to go. I feel much like this all the time and it is frustrating.

For Participant 5, the inability to meet the challenges of daily living as a result of

diminishing health surfaced feelings of annoyance and frustrating disquiet. Alterations to

the health status of participants extended to disturbance in sleep patterns and consequential

tiredness and lack of energy. For participant 5 the experience of having disrupted sleep was

a source of significant stress and frustration:

I have problems in getting to sleep. I can no longer sleep like before. I wake up at night with bad dreams. I can only sleep on one side because of my injuries. When I sleep on the other side, I experience severe pain and develop a headache. Between the physical pain and the nightmares there is no respite.

The intrusion of flashbacks and nightmares into an already disturbed sleep pattern was

experienced by a number of participants conveyed in the description of participant 6:

I cannot forget what it was like – the accident was like a nightmare which recurs again and again in sleep. I am at times afraid to sleep because of what may happen. My inability to sleep affects every aspect of my life. I feel very weak all the time, no energy. I just want to get my old life back.

6.2.1.1. Researcher interpretation of theme 1

For each of the participants the experience of PTSD was one of frustration at a diminishing

health status. A gradual waning of strength exacerbated by sleep deprivation, flashbacks,

and nightmares coupled with feelings of loss of control over one’s life surfaced feelings of

anger and frustration. However, amid the frustration of diminishing strength and inability to

care for self, participants spoke of their struggles to maintain a sense of independence.

6.2.2. Theme two: Struggling to maintain a sense of independence

A number of the participants spoke of their personal struggle to maintain a sense of

independence in the face of diminishing health as a consequence of developing PTSD. For

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these participants, losing one’s independence was a shattering experience which drilled

down to the core of their sense of self and personal identity. The thought of having to rely

on others was, for these participants was often untenable, and therefore, each day was a

struggle to fight off a need to depend on others coupled with a strong unflinching desire to

regain their independence. The need to be independent was described by participant 1 in

stating:

I used to prepare breakfast for myself, now I have lost that ability. To lose one’s independence is a terrifying experience. It is a constant struggle not to give in and not having to rely on others. I want to regain my independence, but it is so difficult.

Reticence to rely on others and compromise their personal sense of independence was

conveyed in the words of participant 6 who said: It was a difficult time in my life. Losing my

independence and having to rely on my family was extremely difficult. A thing I have

always been reluctant to do. Each day was a struggle not to depend on others. Similar

sentiments were expressed by participant 5 who spoke of the need to regain personal

control of her life:

As a consequence of the accident, and developing post-traumatic stress, I now have to rely on others for assistance. I lost my independence and became totally dependent on others. I know my family can do things for me but I want to do things for myself. I want some control over my life. The struggle to be independent is constant. All I can do is to keep trying.

For a number of the participants the struggle to regain a sense of independence was

primarily concerned with performing simple tasks such as showering or attending to small

jobs around the home which, prior to developing PTSD was part of the daily routine. Not

being able to make such simple contributions to everyday family life was a constant source

of distress. Participants spoke of a hankering desire to be independent once again. Such

notions were captured in the words of participant 15 in describing her experience:

Normally I used to help the family with jobs around the house, but now, because of this condition I can’t even help myself. Every day is a struggle to do things for myself, to be independent. Although it is a struggle, if I don’t attempt to do them myself I will lose all independence which I cannot afford to do.

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At times the struggle for independence became overwhelming to the point of some of the

participants contemplating giving up as described by participant 12:

When you no longer have the energy or the strength to continue to fight, you just feel like giving up. Everything, every attempt to do things without asking family to help was so difficult. At times it seemed easier just to let go and give up.

Similar sentiments were expressed by participant 9 in relating his experiences: I have

always been in control of my life. Now everything is such a struggle. I want to be my old

self not having to rely on others. At times I feel so tired I just want to give up trying.

The need to regain a sense of independence and direction was vividly captured in the words

of participant 4 in stating: life for me can be likened to being a blind person. Like the blind

person I have lost my independence and I struggle with not knowing what is ahead of me. I

now have to rely on others. It is like searching in the dark.

Participant 7 also provided a pictorial representation of his sentiments concerning his

struggle for independence.

Plate 2: A walking blind person

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6.2.2.1. Researcher Interpretation of theme 2

For the participants of this study the struggle for independence was thwarted with

difficulties which encompassed feelings of extreme tiredness, lack of energy, a reluctance

to rely on others, and a strong desire to regain control over one’s life. However, at times the

struggle to once again be independent became overwhelming to the point that some

participants expressed the thought of wanting to give up.

6.2.3. Theme three: Harbouring feelings of not being able to recover

Although some of the participants at times entertained the thought of wanting to give up,

others harboured fears that they may never recover. The thought that recovery from PTSD

may never happen engendered in a number of the participants feelings of anxiety and

apprehension that there would never be a return to what was once a happy and productive

life. For a number of the participants the possibility of recovery was eroded by a lack of

money to pay for medical consultations and purchase the required medications prescribed

for the treatment of PTSD. For participant 5 the burden of having limited financial income

impacted on receiving treatment for her condition:

I was unable to keep my consultation appointment for treatment in the city because I had no money to even pay for transport let alone the consultation. Although my family kept insisting I go despite my financial situation I said I cannot afford to. Anyway, up till now the medication hasn’t helped. I keep asking myself will I ever recover? If I don’t what is my future?

Similar sentiments were expressed by participant 10 in sharing his thoughts about his

future:

I have a small income from my government pension, enough for daily expenses to feed my family, but not for treatment of my condition. I want to feel well again but when? I sometimes get anxious that I will never recover, never again have a normal life.

In reflecting on his possibility of recovery against the backdrop of financial insecurity,

participant 7 spoke of his attempt to make ends meet:

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My salary is very small and so I let it accumulate over the year and then withdraw it to pay my expenses. It is never enough and the bills keep building up. Without the ability to pay for treatment I am doomed. I will never get better.

The fear of not recovering from PTSD interlaced with yearnings to turn back the clock was

articulated by participant 9 in stating:

If I have a chance to change anything it would be my current situation. I want to recover and not be dependent on others. I want to be like others again – independent and in control of my life – but I fear that is not going to happen.

For participant 6, fear of not recovering echoed feelings of quiet desperation as described

by him:

I considered myself a dead man, no life to look forward to. I lost my job because of this disability. I need support and monthly income to provide for my family and maintain myself in good health in order to fight this disorder. No body wants to help me because I have no money and no future. What will become of me?

A number of the participants spoke of the importance of having financial support during

such difficult times. Although many of the participants appreciated the financial support

provided by their parents, adult children, and relatives, receiving such assistance for these

participants was akin to being a beggar - having to rely on the good will of others. Without

the ability to be financially solvent, the possibility of regaining one’s independence

appeared slim. Such sentiments were shared by participant 9 in both word and picture:

Being a person with post-traumatic stress is like being a beggar always asking for help. It makes you feel terrible to ask or receive help from others even if they are family and friends. It is quiet humiliating but what else can I do? Without help I fear I will never recover.

The pictorial representation depicts a man who is counting his meager earnings for the day.

The man’s facial expression conveys a sense of quiet despondency as he appears to

contemplate how he will survive. For this man the future appears dim as tomorrow will be

much the same as today – that relies on the generosity of others.

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Plate 3: A Beggar

Feelings of desperation were also described by other participants captured in the words of

participant 15 in stating:

I can’t manage myself or afford to pay my hospital bills and medication. I wish the government could support me by giving me a free monthly consultation and free medicine. Without government assistance I will not be able to continue having medical care. Without that help the chances of getting well again are poor.

Harbouring doubts that recovery may never occur led to feelings of increased helplessness

and hopelessness. For a number of the participants the possibility of recovery seemed to

diminish with each passing day as hope gave way to feelings of hopelessness as described

by participant 5: Before the accident I had everything to look forward to. Even after the

accident and being told I had a disorder, I thought I would still get through this nightmare.

Now I am having doubts. I am gradually losing hope that I have a future. The gradual loss

of hope was also expressed by participant 4 in stating: the longer I am sick I feel there is no

future for me, I just don’t know what to do. Similar sentiments were expressed by

participant 2 who viewed herself as totally incapacitated and therefore, unable to visualise a

future free from illness and disability: I am disabled both physically and mentally. I am

unable to even help myself. I feel there is no hope and I am unable to care for myself. At

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times I just want to die. Disquieting desperation and feelings of hopelessness reverberated

in the self-questioning words of participant 15: What will become of me? The pictorial

representation, a painting by Rob provided by participant 15 further illustrates those

sentiments. The lone figure projects an image of desolation as he ponders what to do. The

platform in front of him appears to be partly submerged by lapping water cutting of any

chance of moving forward. The landscape is empty and isolated which conveys a sense of

hopelessness.

Plate 4: An empty vessel by Rob

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Participant 15 provided his own interpretation of living with PTSD in the following words:

I feel as if life has no future. I am at the end of my strength. All around me is darkness. I

feel there is no hope and no way out of this nightmare I am experiencing.

Feelings of fear and hopelessness were not only experienced by participants as an insidious

process eroding self-confidence. The paradoxical nature of the participants’ experience of

PTSD which reverberated through the accounts of a number of participants was succinctly

articulated by participant 12 in stating: Each day I live hoping I will get well again, and fear

that it may never happen.

6.2.3.1. Researcher interpretation of theme 3

The very thought that recovery may never be a reality engendered in a number of the

participants feelings of fearful apprehension. Inability to pay for hospitalisation, medical

and psychiatric consultation, and medication surfaced questioning uncertainty about what

seemed to them to be an unknown future about the possibility of recovery. As time passed

hope of recovery gradually dwindled only to be replaced with a growing sense of

hopelessness and desolation.

Compounding the participants’ experiences of fearing they may never recover from PTSD,

was the added stress of feeling discriminated against and marginalised by society.

6.2.4. Theme four: Feeling discriminated against and marginalised by society

A number of participants expressed feeling discriminated and marginalised by society as a

consequence of developing PTSD. Already suffering from low-self esteem and feelings of

helplessness and hopelessness, participants were faced with what appeared to them as an

onslaught of social rejection, marginalisation, and further disempowerment as described by

participant 3 in stating:

You know…our society is very un-accepting of people with PTSD. Even my family finds it difficult and often complain that they feel embarrassed when my name is mentioned in conversation with neighbours and friends. I just feel no one wants to know me because of my condition. You just feel pushed aside by everyone.

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Being pushed aside and marginalised was expressed by participant 4 as being incarcerated

in a world devoid of social interactions with friends: Being a person with PTSD is like

being a prisoner. No one wants to know you or be associated with you. They avoid you as if

there is something wrong with you. Participant 4 also provided a pictorial representation of

being a prisoner. The picture depicts a man behind bars, separated from society. The

expression on the partly revealed face is one of deep despondency as he looks longingly to

the world on the other side of his barred window. The grasping fingers suggest a sense of

desperation to be free from his incarceration, to once again be part of society. When asked

to share her thoughts about what this pictorial representation meant for the participant she

stated: My life since becoming ill has left me imprisoned, separated from everything

precious to you. No matter how you try to escape from your fears and confusion you

cannot.

Plate 5: A prisoner

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The notion of being incarcerated or restricted in being part of the local community was also

expressed by participant 2 in describing her experience as being placed inside a box that I am

not allowed to get out of. It is a terrible experience.

For other participants the experience of being discriminated against was one of being

shunned and rejected by once loved friends, neighbours, and the local community as captured

in the words of participant 10:

When I asked my friends and neighbours for help because of my condition they turned their backs and walked away. They think I’m crazy and don’t want anything to do with me. Society is much the same. Society just laughs at you and wants nothing to do with you. It just wants you to keep out of sight.

Similar sentiments were expressed by participant 3 who spoke of her pain at being rejected

and marginalised by society:

Suffering from PTSD has been a nightmare. People laughed at me all the time because they said I was crazy. You know…when you have a mental illness they talk about you and they isolate you by not involving you.

6.2.4.1. Researcher interpretation of theme 4

Feeling discriminated and marginalised by society was, for a number of participants a

disquieting and humiliating experience that engendered feelings of rejection, dejection, and

a sense of imprisonment. Seeking support in once close friends, and neighbours was met

with suspicion, fear, and distance. The loneliness of feeling marginalised was exacerbated

further by being ignored and neglected by health professionals.

6.2.5. Theme five: Feeling ignored and neglected by health care professionals

A number of the participants told of their experiences of being ignored and neglected by

health care professionals. Receiving appropriate care and treatment for their condition was

an initial expectation. However, confident expectations that they would receive appropriate

quality care and treatment evaporated in the face of being ignored and neglected by hospital

staff. For participant 2, such an experience was described in the following words:

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At times I feel that people don’t care what happens to me. The hospital staff payed little attention to my needs. They just ignored me as if I was responsible for my own situation. Their lack of concern was very distressing. I just felt that no one was taking me seriously.

The level of neglect by staff resulted in one of the participants seeking help from the family

to take care of him as described by participant 11:

I had to depend on my family to take care of me while I was in hospital not on the nurses. They seemed to have no idea about what I was suffering from. Each time I asked for help to move because I had no energy they just ignored me. Being ignored is a terrible feeling.

A number of participants vowed never to return once discharged because of the way they

were treated by hospital staff. For these participants suffering from PTSD had its own

stresses, discomforts, and vulnerabilities in attempting to make sense of what was

happening to them. The stress of being ignored and neglected by health care professionals

at this time of crisis only served to amplify their situation to the point of wanting to

‘escape’ and never return. Such sentiments were conveyed in the words of participant 6:

After my ordeal in the way I was treated in hospital I promised myself I would never return. All I wanted to do was to get out of there. I didn’t care where I would go I just wanted to be as far away from that place as possible. I am still asking myself why did they treat me that way? Why did they not treat me like others?

Similar feelings were echoed by participant 5 who found the experience of hospitalisation

dehumanizing:

All I received from the hospital staff was neglect and rudeness. The way they spoke to me and looked at me was as if there was something odd about me, as if I was not human. They didn’t seem to care or have any idea what I was going through nor did they even try to understand. I just wanted to leave and never come back even if it means not getting over this condition.

Being ignored and neglected by health care professionals left participant 12 questioning his

sense of self and the legitimacy of her illness (PTSD):

When hospital staff treat you as if there is nothing wrong with you, treat you as if you are not ill, don’t respond to your requests for assistance, you start to think

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what is wrong with me? Am I making all this up? Is this the type of person I am? At one stage I was really afraid that I was going mad.

Feeling ignored by health care professionals was described by participant 10 as being

similar to a dying flower in stating: Being a person with post-traumatic stress disorder is

like a dying flower, no one looks at it. No attention is given to it. It is ignored and neglected

just like me.

Participant 10 also contributed a pictorial representation of his experience of being ignored

and neglected by health care professionals.

Plate 6: A dying flower by Geraldine Dukes

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6.2.5.1 Researcher interpretation of theme 5

Feeling ignored and neglected by health care professionals engendered in a number of the

participants a sense of vulnerability at not receiving what they believed to be appropriate

quality care. In the face of neglect and being ignored, some of the participants resorted to

asking their families to take over their hospital care and provide the emotional and physical

support expected to be provided by hospital staff. The stress of being treated in this manner

left some participants in an emotional and psychological state of wanting to ‘escape’ from

the hospital, and never to return. Being ignored and neglected by health care professionals

led to self-doubt and questioning the legitimacy of their illness.

Although a number of participants spoke of relying on family for support and care while in

hospital, other participants spoke of being abandoned by family as a consequence of having

PTSD.

6.2.6. Theme six: Feeling abandoned by family

Feeling abandoned by family engendered in a number of the participants fear of being left

to fend for themselves at a time when their life seemed to be imploding. At a time when

family were meant to be their anchor and support, the antithesis was taking place –

withdrawal of support coupled by emotional and physically distancing. For participant 2,

the very thought of being left to fend for self by family amid the turmoil and confusion of

trying to cope with PTSD was expressed as dehumanising, unwanted, and alone. I feel

there is no hope of recovery as there is no one to care for me. The sense of abandonment

was further exacerbated by the participants need for family support as described by

participant 9 in stating:

I desperately need my family to stay and be with me whatever happens. I fear each day that will not happen. It is only a matter of time till they leave me because of my illness. There have already been signs that they are preparing to leave. Without them I have no life or hope for a future.

Similar sentiments were expressed by participant 15 who shared his thoughts of living

moments of quiet desperation: I sometimes think, this is the end for me. I have no one to

look after me, no family or friends to care for me. I am in constant pain. What will become

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of me? Feelings of quite desperation were also echoed in the words of participant 4 in

saying:

It is very difficult to be alone with no one to care or love you. My family no longer wants anything to do with me because of my illness. They just left me to look after myself with no support. Without them I am lost.

Feeling lost as a result of family abandonment and subsequent dislocation from loved ones

at a time of needing their loving support was also expressed by participant 8 in sharing his

experiences:

As a result of my illness no one wants to know you or be around you. Even my wife has stopped caring about me. My family has always been my world now they have disserted me. What do I do? Where do I go?

The feeling of having no where to go or what to do was also expressed by participant 3:

Having no family to care for you and being left to find your own way is very distressing. At

times I feel like a bird with no nest and no place to go. The following is the pictorial

representation provided by participant 3 to conceptualise his experience of being abandoned

by family.

Plate 7: A lost bird by Colin Turvey and Sue Turvey

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A part from feeling lost at being abandoned by family, a number of the participants shared

their experiences of suffering multiple losses. For participant 14, the experience of multiple

losses surfaced feelings of deep remorse for what had occurred:

I blame myself for what has happened. Because of the accident I have lost everything – my job, my friends, my health, and my family. Because of my illness I have lost everything. I am so sorry for what has happened.

Similar sentiments were expressed by participant 12 in conveying his remorse and distress

at his current plight as a result of suffering multiple losses after developing PTSD:

My life has changed forever because of the accident and now my illness. I feel responsible for what has happened and I can’t do anything about it. Everything I loved and cherished especially my family has moved away from me. Left me to look after myself, disowned me. I have lost everything that is important to me.

The tenuous nature of family support for some of the participants was described by

participant 9 in sharing his experience of family abandonment:

You know…if you live with children or relatives whom you are able to support financially; they are more willing to look after you [however] your chances of being neglected or abandoned are higher if you are not able to support them. Family can be fickle at times especially when you become a burden. I thought they would be there for me but they weren’t.

Similar thoughts were echoed by participant 12 in sharing his experience:

When you are ill or in need of family support such as in my situation you expect them to be there for you. That did not happen to me. When I needed them most they just turned their backs. It was as if they were scared or didn’t understand what was happening to me. I had lost the capacity to look after myself because of my illness but had no one to care for me. I was left to survive on my own.

6.2.6.1. Researcher interpretation of theme 6

Feeling abandoned by family engendered in the participants moments of quiet desperation

and at times fearful apprehension that the very fabric of daily living – family love and

support - had dissipated to the point of being non existent. Loss of family support was

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exacerbated by multiple losses including diminishing health, loss of employment, financial

insecurity, and physical incapacity. Belief that family would be there in times of need

eroded in the face of family fears, and misunderstanding about the nature of the

participants’ illness. Family support was tenuous which was reliant on the ability of the

participant to contribute to daily financial family needs.

Despite the overwhelming difficulties encompassing feelings of helplessness, hopelessness,

self-doubt, social rejection, and family abandonment, participants also spoke of living in

hopeful expectancy of a future free from illness and misunderstanding through having faith

in Allah.

6.2.7. Theme seven: Moving toward acceptance through having faith in Allah

For a number of the participants, having faith in Allah provided an anchor amid what

appeared to them to be, overwhelming physical and emotional difficulties as a result of

PTSD leading to frustrations, uncertainties, self-doubt, family abandonment, and social

rejection. Belief that Allah would see them through this traumatic and uncertain time was a

source of personal strength and spiritual comfort as elucidated by participant 3 in stating:

If I am to survive and get through this ordeal it will be because of Allah. Each day I pray to Allah that I will recover. He is my only source of hope and comfort in this difficult time. He is my strength. I believe He will come to my aid and be my protector.

Faith in Allah was also a sustaining force that gave the participants the strength to endure

the many tribulations confronting them as described by participant 7:

It is Allah who gives me the strength to continue. Without Him I would not have been able to keep going against the overwhelming difficulties that have resulted from my condition [PTSD]. Allah is has been my constant source of comfort. I have faith in Him to heal me.

Similar sentiments were expressed by participant 15 who spoke of the traumatic impact of

PTSD, living quiet moments of desolation, and having faith in Allah which brought him

back from the brink of despair.

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Since the accident and developing this illness [PTSD] everything in my life went wrong. No one wanted to listen to my calls for help. No one wanted to understand what I was going through. I was left to fend for myself, abandoned by the very ones I trusted and depended on. All my dreams for a wonderful life just seemed to shatter. Have you ever felt so rejected and abandoned that life no longer had any meaning? I was this person. There have been many times that I said to myself, “give up, don’t fight it any more, your strength has gone, no body cares, what is the use of fighting to get well when it is not going to happen”. There were many times I just wanted to give up but my faith in Allah to bring me back from giving into despair rescued me, My faith in Allah was my only strength. He did not abandon me in my time of need.

For participant 15, having faith in Allah was expressed through engaging in the daily rituals

of praying and in reading passages from the Quran. The daily prayer rituals provided

moments of connection with Allah through quiet contemplation on His goodness and

personal supplications to be made well again. It was at such moments amid the apparent

chaos and uncertainty of what the future may hold that the participants found an anchor of

hope that one day they would once again be well and able to resume a normal life. Such

sentiments were expressed by participant 11 in stating:

It is only Allah who can heal me, make me well. Throughout each day I reflect on his goodness and His power to heal me. At times of pray to Allah asking for His blessing and help to be a normal person again. It is through Him that I will be healed.

Having faith in Allah was also a source of personal strength in coming to a point of

acceptance of their condition and the life changes that had resulted as a consequence of the

accident and the subsequent development of PTSD. For participant 6, acceptance of her

situation involved being pragmatic about what had happened and what life now had to

offer:

It is time to accept my situation if I want to be happy once again and get on with my life. There are many things I cannot change but there are things I can. It is Allah’s will what has happened to me and I must accept it. I have faith in Him to guide my future.

The pragmatics of accepting and learning to live with a reduced capacity to engage with life

as before the onset of PTSD was also echoed by participant 7 who spoke of the need to face

one’s limitations in order to re-engage with life in new and self-affirming ways:

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I have come to accept my disabilities and my inability to do many things as a result of my illness with the help of Allah. I have come to realise that accepting Allah’s will is what is important as He knows what is best for me. I have learnt to be happy in doing the simple thing around the home that are meaningful to me and that makes a contribution to family life.

For participant 4, reaching a point of accepting that life had forever changed as a result of

developing PTSD was a liberating experience that gave birth to new possibilities for living

with one’s limitations:

Having faith in Allah helped me to accept that I would never be the same. That I could never go back to the way I was before my accident and illness. Once I accepted that I could no longer do the things I once did I felt much lighter of heart. I could let go the anger, hurt, and frustrations at being ill. Fear of not having a future went away. I was no longer afraid of the future. Gradually I began to think that my life is not over. There are still many things I can do and will do with the blessing of Allah.

The sentiments expressed by participant 4 were similar to those shared by participant 15

who spoke of the internal peace that came with reaching that moment of acceptance:

I believe that I have accepted my lot in life and am now at peace with myself and the world. I accept myself as having a disability and I pray to Allah to give me the strength to move on with my life. I thank Allah for giving me another chance to live and to enjoy His continuing blessings. Life for me is once again full of opportunities.

Participant 7 presented a pictorial representation of moving toward acceptance through

having faith in Allah.

Plate 8: Moving toward acceptance

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In reflecting on the above pictorial representation about his experience of living with PTSD participant 7 stated:

Living with this condition is like crawling you way through thick bush, deep ravines, deep shadows and sometimes darkness. However, even in the darkest of times there is always hope that things will change. Having faith in Allah was for me the most important part in accepting your situation. Only then can you get on with life.

6.2.7.1. Researcher interpretation of theme 7

Having faith in Allah was an anchor amid overwhelming physical and emotional

difficulties, frustrations, uncertainties, self-doubt, family abandonment, social rejection,

quiet moments of desolation and despair. Belief that Allah would be their raft through

turbulent and uncertain seas of living with PTSD provided a much needed buffer and a

source of strength and resolve to ‘survive’ these traumatic times. Having faith in Allah was

also a source of strength for the participants in coming to a point of accepting their illness

and associated disabilities and limitations. Reaching the point of acceptance that life had

forever changed as a result of their accident and subsequent illness surfaced feelings of

personal liberation which gave rise to being able to look at the future in new and affirming

ways within the context of their disabilities.

6.3. Exhaustive Description of the Phenomenon

For each of the participants the experience of PTSD was one of frustration at a diminishing

health status. A gradual waning of strength exacerbated by sleep deprivation, flashbacks,

and nightmares coupled with feelings of loss of independency and control over one’s life

surfaced feelings of anger and frustration. However, amid the frustration of diminishing

strength and inability to care for self, participants spoke of their struggles to maintain a

sense of independence.

For the participants of this study the struggle for independence was thwarted with

difficulties which encompassed feelings of extreme tiredness, lack of energy, a reluctance

to rely on others, and a strong desire to regain control over one’s life. However, at times the

struggle to once again be independent became overwhelming to the point that some

participants expressed the thought of wanting to give up.

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The very thought that recovery may never be a reality engendered in a number of the

participants feelings of fearful apprehension. Inability to pay for hospitalisation, medical

and psychiatric consultation, and medication surfaced questioning uncertainty about what

seemed to them to be an unknown future about the possibility of recovery. As time passed

hope of recovery gradually dwindled only to be replaced with a growing sense of

hopelessness.

Compounding the participants’ experiences of fearing they may never recover from PTSD,

was the added stress of feeling discriminated against and marginalised by society.

Feeling discriminated and marginalised by society was, for a number of participants a

disquieting and humiliating experience that engendered feelings of rejection, dejection, and

a sense of imprisonment. Seeking support in once close friends, and neighbours was met

with suspicion, fear, and distance. The loneliness of feeling marginalised was exacerbated

further by being ignored and neglected by health professionals.

Feeling ignored and neglected by health care professionals engendered in a number of the

participants a sense of vulnerability at not receiving what they believed to be appropriate

quality care. In the face of neglect and being ignored some of the participants resorted to

asking their families to take over their hospital care and provide the emotional and physical

support expected to be provided by hospital staff. The stress of being treated in this manner

left some participants in an emotional and psychological state of wanting to ‘escape’ from

the hospital, and never to return. Being ignored and neglected by health care professionals

led to self-doubt and questioning the legitimacy of their illness.

Although a number of participants spoke of relying on family for support and care while in

hospital, other participants spoke of being abandoned by family as a consequence of having

PTSD.

Feeling abandoned by family engendered in the participants moments of quiet desperation

and at times fearful apprehension that the very fabric of daily living – family love and

support - had dissipated to the point of being non-existent. Loss of family support was

exacerbated by multiple losses including diminishing health, loss of employment, financial

insecurity, and physical incapacity. Belief that family would be there in times of need

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eroded in the face of family fears, and misunderstanding about the nature of the

participants’ illness. Family support was tenuous which was reliant on the ability of the

participant to contribute to daily financial family needs.

Despite the overwhelming difficulties encompassing feelings of helplessness, hopelessness,

self-doubt, social rejection, and family abandonment, participants also spoke of living in

hopeful expectancy of a future free from illness and misunderstanding through having faith

in Allah.

Having faith in Allah was an anchor amid, overwhelming physical and emotional

difficulties, frustrations, uncertainties, self-doubt, family abandonment, social rejection,

quiet moments of desolation and despair. Belief that Allah would be their raft through

turbulent and uncertain seas of living with PTSD provided a much needed buffer and a

source of strength and resolve to ‘survive’ these traumatic times. Having faith in Allah was

also a source of strength for the participants in coming to a point of accepting their illness

and associated disabilities and limitations. Reaching the point of acceptance that life had

forever changed as a result of their accident and subsequent illness surfaced feelings of

personal liberation which gave rise to being able to look at the future in new and affirming

ways within the context of their disabilities.

6.4. Fundamental Structure of the Phenomenon from the Participants’ Transcripts of

Interview as Interpreted by the Researcher

The lived experience of PTSD is struggling to maintain a state of independence in the face

of diminishing health while having to rely on others for assistance with daily needs amid

harbouring fears that you may never recover. Dependence on others while struggling to

resume control over one’s life gives way to feelings of anger and frustration. Moving

toward acceptance through having faith in Allah occurs against the backdrop of family

abandonment, social discrimination, and being ignored and neglected by health care

professionals.

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6.5. Participants’ Pictorial Representations

At the commencement of this study each of the participants was requested by the researcher

to bring to the interview a symbolic representation of their experience of PTSD. The

rationale for the inclusion of symbolic representations was to complement participants’

descriptions and to provide a different and enhancing dimension to what can be articulated

in word. The following are the participants’ symbolic representations as presented at

interview accompanied by the researcher’s interpretation.

Participant 1 – Walking a tightrope

Living with PTSD is like walking a tightrope. It is always trying to keep your balance.

Trying to get across to the other side without falling. You are always conscious of falling

and never being sure of anything.

Researcher interpretation of symbolic representation of participant 1

The experience of PTSD is living moment-by-moment with unsure footing never knowing

what lies ahead.

Participant 2 – Feeling like a baby

The experience of PTSD for me is feeling like a baby. Someone who is helpless and

therefore, you have to depend on everyone else just to do the simple things such as caring

for yourself.

Researcher interpretation of symbolic representation of participant 2

The experience of PTSD is feeling disenfranchised and powerless to be independent.

Participant 3 – A lost bird

The experience of PTSD has been for me feeling like a lost bird. You are out there on your

own and not belonging to any group. It is a lonely existence. You feel as if there is no one

there for you not knowing where to fly to.

Researcher interpretation of the symbolic representation of participant 3

The experience of PTSD is feeling lost, alone, and lonely.

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Participant 4 – Being a prisoner

The experience of PTSD is like being a prisoner, confined and unable to get free. There is

no way out of your situation. All you can do is accept where you are.

Researcher interpretation of the symbolic representation of participant 4

The experience of PTSD is debilitating and disempowering with no vision of a future

devoid of feeling incarcerated in one’s body and mind.

Participant 5 – Going over a waterfall

The waterfall for me represents a force that you cannot fight against. You are at the mercy

of the water as it drags you over the edge. You don’t know whether you will be dragged

under and die or live through the experience.

Researcher interpretation of the symbolic representation of participant 5

The experience of PTSD is to live in that moment of free fall where the security of the past

is no longer and the future is uncertain.

Participant 6 – A foreigner

For me, the experience of PTSD is to feel that you don’t belong, an outcast. You feel like a

stranger in your own community.

Researcher interpretation of the symbolic representation of participant 6

The experience of PTSD is feeling estranged from family, friends, and the local

community.

Participant 7 – Walking blind

For me living with PTSD is like fumbling in the dark. You never know what is in front of

you. You turn to feeling your way by trying to sense what is ahead. It is at times frightening

not knowing what is there.

Researcher interpretation of the symbolic representation of participant 7

The experience of PTSD is seeking, searching for a way forward not knowing what is

ahead.

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Participant 8 – Living on the edge

My experience of PTSD is being on the fringe of everything. At times I feel I am no longer

apart of anything. My mind is just hanging in there. At times you tell yourself to hang on

and not let go for if I do there is no coming back. It is a frightening place to be.

Researcher interpretation of the symbolic representation of participant 8

The experience of PTSD is being tenacious and never giving up.

Participant 9 – A beggar

My experience of PTSD is like being a beggar, depending on others for everything. It is an

awful feeling not being able to do things for yourself, and always asking for help.

Researcher interpretation of the symbolic representation of participant 9

The experience of PTSD is having to rely on others for daily needs.

Participant 10 – A dying flower

For me the experience of PTSD is to feel that you are gradually dying – not all at once but

petal by petal until there is nothing left except dead, lifeless leaves. The purpose for which

you existed is no longer.

Researcher interpretation of the symbolic representation of participant 10

The experience of PTSD is a process of gradual decline into nothingness

Participant 11 – A nondescript painting

The experience of PTSD is like being a nondescript painting. No one notices you. It is as if

your do not exist in the eyes of others or they simply do not want to recognise you.

Researcher interpretation of the symbolic representation of participant 11

The experience of PTSD is to feel ignored by others.

Participant 12 – A monster

For me, the experience of PTSD is to feel as if there is something wrong with you, as if you

are deformed or mentally disturbed. Everyone shuns you and looks at you with suspicion

and fear.

Researcher interpretation of the symbolic representation of participant 12

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The experience of PTSD is dehumanising.

Participant 13 – Climbing never ending stairs

The experience of PTSD is like climbing stairs that never seem to end. They simply go on

and on with no end in sight. You try to claw you way to the top but with each step you

become increasingly tired with no energy to continue.

Researcher interpretation of the symbolic representation of participant 13

The experience of PTSD is an exhausting.

Participant 14 – Carrying a heavy stone

For me the experience of PTSD is carrying a heavy stone. Where ever you go you feel the

weight. No matter what you do to get rid of the stone it won’t go away. At times the weight

becomes too much and you just want to give in.

Researcher interpretation of the symbolic representation of participant 14

The experience of PTSD is a burdensome yoke from which the individual struggles to be

free.

Participant 15 – An empty vessel

The experience of PTSD is to feel like an empty vessel with nothing to offer, nothing to

contribute. I have nothing to contribute. I just feel empty inside.

Researcher interpretation of the symbolic representation of participant 15

The experience of PTSD is to live with an abiding sense of emptiness.

6.6. Exhaustive Description of the Pictorial Representations provided by Participants

The experience of living with PTSD is like walking a tightrope. Continually it is always

trying to keep your balance. Trying to get across to the other side without falling. You are

always conscious of falling and never being sure of anything. It is living moment-by-

moment with unsure footing never knowing what lies ahead. Feeling like a lost bird. You

are out there on your own and not belonging to any group. It is a lonely existence. You feel

as if there is no one there for you and not knowing where to fly. It is like being a prisoner,

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confined and unable to get free. There is no way out of your situation. All you can do is

accept where you are. It is like being caught in a waterfall - a force that you cannot fight

against. You are at the mercy of the water as it drags you over the edge. You don’t know

whether you will be dragged under and die or live through the experience. I am to feel that

you don’t belong – you are an outcast. You feel like a stranger in your own community. It is

like being a beggar, depending on others for everything. It is an awful feeling not being able

to do things for yourself, and always asking for help. It is to feel that you are gradually

dying – not all at once but petal by petal until there is nothing left except dead, lifeless

leaves. The purpose for which you existed is no longer. It is like being a nondescript

painting. No one notices you. It is as if you do not exist in the eyes of others or they simply

do not want to recognise you. It is to feel as if there is something wrong with you, as if you

are deformed or mentally disturbed. Everyone shuns you and looks at you with suspicion

and fear. It is like climbing stairs that never seem to end. They simply go on and on with no

end in sight. You try to claw you way to the top but with each step you become increasingly

tired with no energy to continue. It I like carrying a heavy stone. Where ever you go you

feel the weight. No matter what you do to get rid of the stone it won’t go away. At times the

weight becomes too much and you just want to give in. It is to feel like an empty vessel

with nothing to offer, nothing to contribute. I have nothing to contribute. I just feel empty

inside.

6.7. Fundamental Structure of the Pictorial Representations provided by Participants

as Interpreted by the Researcher

The experience of PTSD is living moment-by-moment with unsure footing, seeking and

searching for what lies ahead but not knowing. Not having a sense of the future engenders

feelings of debilitating disempowerment which is further exacerbated by having to rely on

others for daily needs in the presence of a gradual decline into nothingness, and despair.

Abandonment by family, friends, and the community leads to feelings of incarceration,

estrangement, aloneness, and loneliness. Life feels like it is continually in free fall where

the security of the past is no longer and the future remains uncertain. However, amid an

abiding sense of desolation, emptiness, and feeling exhausted and dehumanised, tenacious

endeavours surface coupled with a personal resolve not to give in.

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6.8. Conclusion

This chapter provided a discussion of the analysis of the 15 participant transcripts of

interview concerning their lived experience of PTSD. The seven explicated themes were

presented supported by extracts from the participants’ interview transcripts and

participants’ pictorial representation of their experiences. The chapter concluded with a

presentation of an exhaustive description of the phenomenon under study explicated from

each of the seven themes followed by a description of the fundamental structure of the

phenomenon. The next chapter provides a discussion of the findings of this study in

relation to contemporary literature on the topic.

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CHAPTER SEVEN

A REVIEW OF LITERATURE IN RELATION TO STUDY FINDINGS

7.1. Introduction

This chapter presents a review of literature in related to the explicated themes from the

participant transcripts of interview. The themes and related literature are sequentially

discussed. Within each theme a brief overview of this study’s findings are initially

presented followed by a discussion of contemporary literature pertaining to the theme.

7.2. Review of the Literature Related to the Themes

As discussed in the previous chapter, seven themes were explicated through the process of

analysis. The explicated themes were: feeling frustrated at a diminishing health status,

struggling to maintain a state of independence, harbouring feelings of not being able

to recover, feeling discriminated against and marginalised by society, feeling ignored

and neglected by health care professionals, feeling abandoned by family, and moving

toward acceptance through having faith in Allah.

7.2.1 Theme One: Feeling frustrated at a diminishing health status

For each of the participants the experience of PTSD was one of frustration at their

diminishing health status. Each day witnessed further decline in being able to meet the

challenges of daily living. A gradual waning of strength exacerbated by sleep deprivation,

flashbacks, and nightmares coupled with feelings of loss of control over one’s life surfaced

feelings of anger and frustration. Anger and frustration fed into a negative cycle in which

there appeared to be from the participants’ perspectives a downward spiral into a world of

disability, restriction, and reliance on others.

In a review of literature pertaining to this theme a number of studies were located. Quale,

Schanke, Froslie and Roise (2009) in their study of the impact on post-traumatic stress

symptoms in 79 severely injured patients admitted to the Department of Multi-trauma and

Spinal Cord Injury at Sunnaas Rehabilitation Hospital in Norway found that the participants

of their study described similar experiences to those of this study in which being physically

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and emotionally restricted because of PTSD engendered feelings of frustration and anger.

For these participants, the gradual loss of physical strength to attend to their normal daily

activities, lack of energy, and unrelenting sleep disturbance and nightmares only increased

their yearning to return to a life before PTSD. Similar findings to both this present study

and that of Quale et al. (2009) were explicated in a study by Lauterback, Vora and Rakow

(2005) concerning the relationship between PTSD and self-health problems among six

groups of PTSD patients in US. The findings revealed that, the traumatic impact of the

vehicle accident impacted directly on their physical and psychological sense of well-being

and health status, significantly impeding their capacity to care for self. Studies by

Lauterbach et al (2005), Karatzias and Chouliara (2008), and McNutt and Postmus (2002)

found a similar relationship between exposure to trauma and the health status of

individuals. One example provided by Lauterbach et al. (2005) suggested that mistreatment

from the family or carer of people with PTSD have been linked to poorer health behaviours

such as poor diet and reduced levels of daily physical activity. However, the study by

Karatzias and Chouliara (2008) suggests that the diminished health status of individuals

experiencing PTSD can be a catalyst to engaging in health-enhancing behaviours.

The experience of loss of control over one’s life surfacing feelings of anger and frustration

explicated in this current study were also found in a number of other studies. De Jong et al.,

(2005) study on patients suffering from PTSD using multi random sampling in three

different regions of the world (North Africa, East Africa & Middle East) found that they

were exposed to a range of stresses associated with a diminished health status, in particular,

diminished physical capacity to care for self, struggling to adjust to their circumstances, and

a loss of social status and self-esteem. Having to deal with a range of stress points resulted

in participants feeling that their sense of well-being had been compromised while surfacing

feelings of anger and frustration. Similar findings were explicated in studies by Lauterback

et al. (2005) and Beck, Palyo, Winer, Schwagler and Ang (2007) which posited a direct

relationship between the physical health status of individuals who have experienced trauma

(PTSD), and the trauma itself among two African Americans and six Caucasians. The

findings of both of these studies suggest that trauma exposure impacts significantly on a

person’s physical health status to the extent that the ability of individuals to perform their

daily activities are severely compromised leading to feelings of frustration. The findings of

Fontaine’s (2009) study supports the findings of Lauterback et al’s (2005) and Beck et al’s

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(2007) studies in which they found that the psychological response to a diminished

capacity to care for self has the potential to result in frustration and anger.

Giarratano’s (2004) phenomenological study of patients with PTSD after three months

post-discharge from hospital in Australia also identified frustration as a major theme

experienced by participants at having to depend on others as a result of a compromised

health status. The findings by Giarratano (2004) are supported by a study by Blanchard and

Hickling (2007) who undertook a similar study of patients with PTSD post-discharge from

hospital after a motor vehicle accident in the USA which identified the need to depend on

others was an issue of great concerns to the participants.

The findings of this current study were consistent with the findings of a number of studies

concerning the experience of PTSD.

7.2.2. Theme Two: Struggling to maintain a state of independence

For the participants of this study the struggle for independence was thwart with difficulties

which encompassed feelings of extreme tiredness, loss of energy, a reluctance to rely on

others, and a strong desire to regain control over one’s life. However, at times the struggle

to once again be independent became overwhelming to the point that some participants

expressed the thought of wanting to give up.

In a review of literature relating to this theme, struggling to maintain a state of

independence, there was a noticeable paucity of literature. A study by Lauterback et al.

(2005) concerning health related problems of people diagnosed with PTSD found that the

participants in their study exhibited symptoms of loss of energy, diminished physical

strength, and an inability to perform activities of daily living without some form of

assistance.

Although not directly related to the experiences of PTSD as a result of a MVA, a study

conducted by Zeilani (2008) which explored the lived experience of 16 Jordanian women in

Critical Intensive Unit (ICU) who developed PTSD as a consequence of the traumatic

experiences in the ICU found that the participants expressed feeling guilty at not being able

to take care of themselves and having to rely on others for assistance. Their desire to

resume taking care of their children against the backdrop of physical disability and

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emotional vulnerability surfaced feelings of frustration. The findings of Zeilani’s (2008)

study were similar to the findings of this current study although the focus was different.

Therefore, struggling to maintain a state of independence constitutes new knowledge

concerning the phenomenon under study.

7.2.3. Theme Three: Harbouring feelings of not being able to recover

The very thought that recovery may never be a reality engendered in a number of the

participants feelings of fearful apprehension. Inability to pay for hospitalisation, medical

and psychiatric consultation, and medication surfaced questioning uncertainty about what

seemed to them to be an unknown future about the possibility of recovery. As time passed

hope of recovery gradually dwindled only to be replaced with a growing sense of

hopelessness.

A review of contemporary research concerning the theme: harbouring fears that they may

never recover surfaced a number of studies. Layne, Waren, Shalev and Watson (2007)

identified a number of factors impacting on PTSD patients’ recovery. Factors cited by

Layne et al. (2007) that has relevance to the findings of this study included, lack of regular

income which led to financial insecurity, and difficulties in accessing health care services.

The lack of financial security during this time of illness exacerbated fears that they may

never recover. Similar findings were identified in Grundy’s (2010) review concerning

PTSD. The findings indicated a direct link between rate of recovery and the family’s

financial status at the time.

A meta analytic review conducted by Olatunji et al. (2007) about the quality of life in 32

PTSD patients taken from 23 separate studies found that fear of not recovering in

conjunction with feeling vulnerable as a result of developing PTSD delayed the recovery

process. De Jong et al. (2005) and Mason (2006) in their studies relating to recovery in

individuals with PTSD found that the level of trauma, the person’s perception of the

severity of their condition, and the duration of their hospitalization had a direct relationship

to the person’s fear that they may never recover.

Olff, Langeland and Gersons’ (2005) work concerning the impact of cognitive factors on

people with PTSD found that the ongoing and unrelenting nature of PTSD and their

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negative beliefs about recovery engendered in them fear that recovery may never be a

reality. A review of contemporary research conducted by Science Daily (2007) relating to

recovery among 33 veterans with PTSD who had returned from Iraq and Afghanistan had

similar findings to that of Olff et al.’s (2005) study. The findings of both Science Daily

(2007) and Olff et al. (2005) suggest poor health as a result of the traumatic event, coupled

with fear of never recovering increased the possibility of poor recovery.

Scarpa, Haden and Hurley (2006) provided insight into the PTSD experience of 372 men

and women aged 18 to 22 years being fearful about the possibility of never recovering. For

the participants in their study, the continuing recurrence of symptoms of PTSD including

nightmares, flashbacks, and inability of the person to forget the incident engendered fears

of not recovering from their condition.

7.2.4. Theme Four: Feeling discriminated against and marginalised by society

Feeling discriminated against and marginalised by society was, for a number of participants

a disquieting and humiliating experience that surfaced feelings of rejection, dejection, and a

sense of imprisonment. Seeking support in once close friends, and neighbours was met with

suspicion, fear, and distance.

In a review of literature relating to the theme of feeling discriminated against and

marginalised by society, a number of studies were located. Andermann’s (2010) study

reviewed patient’s explanatory models of illness from the perspectives of traditional and

Western beliefs among men and women with PTSD with the aim of developing a program

of education to reduce social isolation and discrimination of people with PTSD. The

findings of Andermann’s (2010) study highlighted the significant needs of people suffering

from mental illness. Of Andermann’s (2010) participant cohort one-third of survivors of

trauma injury and PTSD spoke of being discriminated against by society. Andermann

(2010) suggested that it is the responsibility of society to redress issues of discrimination

because of mental illness such as PTSD. Bryant, O’Donnell, Creamer, McFarlane, Clark

and Silove’s (2010) cohort study of patients with PTSD from four major trauma hospitals

across Australia found that isolation and discrimination were important considerations in

early intervention and management. The findings of Bryant et al’s (2010) study supported

the findings of Andermann’s (2010) study by suggesting that the best approach to reducing

discrimination, marginalisation, and therefore social isolation of people with a mental

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illness including PTSD is to ensure prompt early interventions maximising the potential for

optimal recovery.

Carlson, Greenberg, Rubin and Mujica-Parodi’s (2010) recent study found that social

isolation that is not self-imposed can result in significant anxiety for the person being

isolated. Similar findings to those of Carlson et al. (2010) were located in a study by Sayce

(2001) who found that social attitudes and responses toward individuals with a mental

illness in USA and Britain have a significant element of stigma and discrimination attached

leading to rejection of the people involved. Enggerman’s (2010) and Andermann’s (2010)

studies which examined the relationship between fighting discrimination and a reduction in

public stigma of the mental ill found that the effective protest against discrimination is

generally useful and therefore, can stem the flow of continuing stigmatization and

discrimination of the mentally ill including people suffering from PTSD.

Studies by Sellers and Shelton (2003), and Laffaye et al.’s (2008) found that losing one’s

social status and social connections can be extremely isolating leaving the person feeling

abandoned and marginalized. Turner and Avison (2003) suggested that the victim may also

feel that nothing will ever be the same – precluding the use of the past to build the future.

However, Carlson et al. (2010) suggest that when victims feel betrayed by individuals in

their social support network, feelings of self-blame and blame of others may contribute to

feelings of isolation and marginalisation.

Ford’s (2008) study about PTSD among ethnoracial majority and minority groups in the

USA found that the females in the group with PTSD were more likely to experience feeling

discriminated against by society because of disparities in access to social resources such as

education, income, political pressure, and health care. Similar findings to both this current

study and that of Ford (2008) were explicated in a study by Laffaye et al. (2008) concerning

being discriminated against and marginalised by society among 128 male veterans with

chronic PTSD. The findings revealed that the impact of PTSD from a traumatic event can

break the victim’s perceived sense of stability and social connection.

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7.2.5. Theme Five: Feeling ignored and neglected by health care professionals

Feeling ignored and neglected by health care professionals engendered in a number of the

participants a sense of vulnerability at not receiving what they believed to be appropriate

quality care. In the face of neglect and being ignored some of the participants resorted to

asking their families to take over their hospital care and provide the emotional and physical

support expected to be provided by hospital staff. The stress of being treated in this manner

left some participants in an emotional and psychological state of wanting to ‘escape’ from

the hospital, and never to return. Being ignored and neglected by health care professionals

led to self-doubt and questioning the legitimacy of his illness.

A review of contemporary research concerning the theme: feeling ignored and neglected by

health care professionals surfaced a number of articles. Litz (2008) explored challenges for

researchers, decision makers, and care providers in providing health care interventions for

patients with PTSD. The findings indicated that patients felt ignored by nurses as they

became the subject of inflexible routines which made no allowances for individual

differences or special health care needs such as PTSD sufferers. The study also found that

participants became increasingly frustrated at not receiving appropriate care. The

participants in this current study expressed similar views when describing their experiences

of the health care delivery services in Jordan.

A study by Maercker and Muller (2004) investigated two samples – one of 178 former

prisoners of war in East Germany who had developed PTSD and 151 recently traumatized

crime victims who developed PTSD. The findings indicated that the impact of health care

professionals’ uncaring behaviours toward patients with PTSD was a significant predictor

of emotional and psychological strain. Maercker and Muller (2004) also suggest that the

survivors of a traumatic event who develop PTSD are likely to be in “extreme need of

support from health care professionals” (p. 345). Similar findings by Laffaye et al. (2008)

indicated that the extent to which the experience of PTSD are consensually validated or

invalidated by society, particularly by health care professionals, may have a significant

effect on the person’s psychological adaptation and ability to cope. One example provided

by Hobfoll et al. (2008) suggested that positive reactions from health care delivery services

such as showing appreciation of the victim’s unique state and acknowledging the patient’s

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difficult condition can be instrumental in helping the patient with PTSD in the recovery

process.

Blanchard and Hickling’s (2007) study found that poor social health care services have the

potential to have a negative psychological impact on people suffering from PTSD. Their

findings also suggested that the majority of motor vehicle accident (MVA) victims who

developed PTSD depend on the health care delivery system for survival. The absence of

such a system in Jordan and the impact on the person and his/her family is significant as

described in this thesis. Similar findings to both this present study and that of Blanchard

and Hickling (2007) were explicated in studies by Vranceanu et al. (2007), Laffaye et al.

(2008) and Beck et al. (2009) in which poor health care delivery was identified as a

significant contributor to the development of behavioural changes among PTSD patients.

The findings revealed that behavioural changes impacted negatively on the person’s pattern

of daily living.

7.2.6. Theme Six: Feeling Abandoned by Family

Feeling abandoned by family engendered in the participants moments of quiet desperation

and at times fearful apprehension that the very fabric of daily living – family love and

support - had dissipated to the point of being non-existent. Loss of family support was

exacerbated by multiple losses including diminishing health, loss of employment, financial

insecurity, and physical incapacity. Belief that family would be there in times of need

eroded in the face of family fears, and misunderstanding about the nature of the

participants’ illness. Family support was tenuous which was reliant on the ability of the

participant to contribute to daily financial needs of the family.

In a review of literature pertaining to this theme, a number of studies were located. Adams

and Boscarino’s (2006) study which used a baseline survey to identify the prevalence of

family support in individuals with PTSD found that there was a strong relationship between

the level of economic security of the family and level of family support. In low socio-

economic families who were struggling to make ends meet, having a family member with

PTSD who is not only unable to contribute to the financial stability of the family but

becomes a financial burden can lead to family stress and family disintegration. Similar

findings to both this current study and that of Adams and Boscarino (2006) were explicated

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in a study by Norris, Friedman, Watson, Byrne, Diaz and Kanasty (2002) concerning the

relationship between, family stress, PTSD, and family abandonment. The findings indicated

that family stress as a result of a family member developing PTSD can lead to the person

being abandoned by family. Kasdan et al.’s (2006) study about experiential avoidance as a

generalised psychological vulnerability and comparisons with coping and emotion

regulation strategies by using a quantitative method among 382 undergraduate volunteers

recruited from the University at Albany, found a similar correlation between family

relationship, trauma, and abandonment by family of the person with PTSD. These findings

are further corroborated by Jordan Ministry of Health (2007) in positing that changes to the

Jordanian family situation as a result of a family member being involved in a traumatic

event and subsequently developing PTSD leads to family stress and may lead to family

disintegration or the abandonment of the family member.

Clapp and Beck (2009) in their study suggested that the multiple losses sustained by the

person with PTSD and the consequent adjustments which need to be made both by the

individual and the family have the potential to lead to significant stress and family

abandonment or family disintegration. The findings of Clapp and Beck’s (2009) study

supports the findings of Laffaye et al’s (2008) study in which dependence on the family by

the family member with PTSD can increase family stress, and lead to either family

disintegration or being abandoned by family. The findings of these studies reflect the

findings of this study in which participants spoke of their experience of feeling abandoned

by family.

An interpretative phenomenological study conducted by Ray and Vastone (2009) of ten

contemporary peacekeepers aged 37-46 from Canada about their experiences of PTSD

identified feeling abandoned by family. Some of the responses of participants follow:

I’ve seen how PTSD affected my wife and kids. My wife can understand it at one level but still I am not doing anything. Why don’t I go out? It really had a profound effect on my oldest son because when I shut down then the relationship with him changed. He has a lot of anger and hurt. He was basically abandoned… unable to understand why I have these mood swings and anger. It changed the family dynamic, around him. My interaction with the psychiatrist revolved around how my wife, my other son and the youngest two are dealing with my oldest son and his treatment (p.842.)

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The findings of Ray and Vastone’s (2009) study are similar to those in this current study in

which participants described:

When you are ill or in need of family support such as in my situation you expect them to be there for you. That did not happen to me. When I needed them most they just turned their backs. It was as if they were scared or didn’t understand what was happening to me. I had lost the capacity to look after myself because of my illness but had no one to care for me. I was left to survive on my own.

Marcia’s (2009) study found that abandonment by family begins with a disability of a

family member due to a traumatic event. Bisson and Andrew’s (2006) systematic review

about randomised controlled trials of a psychological treatment among adults suffering

from traumatic stress symptoms found that any significant loss makes most people feel

fearful and anxious and that life changes in the family can be positive or negative, intended

or unforeseen, and some family changes occur without caution such as abandoning a family

member. However, Miller, Dunn and Patel (2010) suggest that a significant concern is the

anticipatory anxiety and apprehension about the future and what is not known about the

illness, disease entity, or disability. Similar findings in Clark’s (2009) study concerning

family relationships during illness found that a period of suffering is essential for the person

who is disabled and for the family members. During this period the person with a disability

often feels trapped, isolated, and even abandoned by the family. Moser and Dracup (2004)

suggested that numerous transitional experiences and disturbances in life such as PTSD can

cause stress and lead to abandonment by the family.

7.2.7. Theme Seven: Moving Toward acceptance through having faith in Allah

Having faith in Allah was an anchor amid, overwhelming physical and emotional

difficulties, frustrations, uncertainties, self-doubt, family abandonment, social rejection,

quiet moment of desolation and despair. Belief that Allah would be their raft through

turbulent and uncertain seas of living with PTSD provided a much needed buffer and a

source of strength and resolve to ‘survive’ these traumatic times. Having faith in Allah was

also a source of strength for the participants in coming to a point of acceptance of their

illness and associated disabilities and limitations. Reaching the point of acceptance that life

had forever changed as a result of their accident and subsequent illness surfaced feelings of

personal liberation which gave rise to being able to look at the future in new and affirming

ways within the context of their disabilities.

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In a review of literature relating to this theme, moving toward acceptance through having

faith in Allah, located a number of studies. Chen and Koenig (2006) reviewed empirical

studies and examined the association between religion and adaptation after a traumatic

event. Their study findings revealed that faith in God has often been perceived as a source

of comfort, purpose, and meaning for those experiencing extreme difficulty and negative

life events. Similar findings were explicated by Exline, Smyth, Gregory, Hockemeyer and

Tulloch (2005) in their study of 15 participants with PTSD concerning religious framing in

writing about traumatic experiences. The findings revealed a direct connection between

faith and acceptance of traumatic events.

The notion of faith as a human experience has been the focus of many disciplines. One

example provided by a sufferer of PTSD (Murphy & Bradley. 2010) described faith as

being the anchor through difficult times and a source of strength in her recovery. Faith was

the impetus to moving on: I want my work to please me as well as others, but if my spirit

isn’t pleased with it, I’m not finished. I go home and pray on it, I ask God to give me that

feeling of satisfaction. Then I can put my name to it (Murphy & Bradley, 2010). Similar

sentiments were expressed by three participants of this current study in stating: I accept

what happened to. Thanks to Allah [God] I have faith and hope that one day I will be

normal once again (Participant 5). Participant 10 and Participant 14 also expressed

experiences in stating: I have to accept everything that Allah [God] has given me. My

illness is Allah’s blessing (Participant 10). Just to listen to the readings of the Quran gives

me peace and happiness. Thanks to Allah who gave me another life to move on (Participant

14).

Similar findings to those of Murphy and Bradley (2010) and this current study were

identified in Tan et al.’s (2008) study about the experience of motor vehicle accident

victims among six orthopaedic patients in which the notion of optimism in PTSD sufferers

as a consequence of a MVA was explored. The findings suggest that one of the ways in

coming to terms with and overcoming their illness experience was through their Christian

faith. God was their source of strength in moving toward acceptance and hope of recovery.

At times of feeling they were loosing control of their lives; they asked God to take control

as they moved to accepting God’s will. Zielani (2008) suggests that moving toward

acceptance is essential for continued existence.

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The findings of the above mentioned studies are consisted with this current study in which

the participant’s spoke of having faith in Allah helped them to come to a moment of

acceptance of their condition despite fears that they may never recover.

7.3. Conclusion

This chapter provided a review of research literature in relation to the findings of this study.

Chapter eight provides this researcher’s reflections on the PhD Journey of this study.

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CHAPTER EIGHT

REFLECTIONS ON THE PhD JOURNEY

Plate 9: Reflection

8.1. Introduction

This chapter describes the researcher’s personal reflections of her journey in undertaking

Doctoral studies. In the domain of qualitative research, providing a transparent account of

the research process – the decision pathways, moments of illumination, and moments of

doubt and self-searching - adds to researcher credibility and the overall integrity of the

study. According to Corbin and Strauss (2008) providing a reflective account of the

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researcher’s journey contributes an additional dimension to simply presenting the findings

of a study in accordance with the chosen ontological and epistemological stance, and the

methodology and method underpinning the study.

8.2. The Research Journey

8.2.1 Making the decision to undertake doctoral studies

The decision to embark on a pathway of doctoral studies has its origins in my clinical

practice after completing a Master of Nursing at Victoria University, Melbourne,

Australia. After completing my Master’s degree I returned to the Kingdom of Jordan

where my family resides and recommenced clinical practice in the areas of orthopaedic

and surgical nursing at Amera Basma Hopsital. During this period I was involved in the

care and management of a number of patients who had sustained injuries as a result of

MVAs. As time progressed I became increasingly aware that many of these patients were

also experiencing psychological trauma. The name given to this condition was post-

traumatic stress disorder. I was not familiar with this condition as were many of my

professional nursing and medical colleagues who seemed to ignore the patient’s

emotional plight. I also became aware of tensions with family who could not understand

the change in their loved one. It was at this time that I began to take a particular interest in

the psychological health status of these patients and their manner of coping with such a

situation. I had contemplated undertaking doctoral studies to advance my professional

career in nursing academia and, therefore, began to think about the possibility of making

the experience of PTSD the focus of my intended studies.

My Principal supervisor from my Master’s program was not in a position to take the

principal supervisory role again but knew of Dr Anthony Welch who had acted as her

mentor over a number of years. The end result of a three-way conversation was my

enrolment in the doctoral program, School of Nursing and Midwifery, Queensland

University of Technology, Brisbane, Australia with Dr Anthony Welch acting as principal

supervisor.

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8.2.2 Year 1: The beginning of the research journey

The beginning of any research journey involves moments of excitement, anticipation,

hopeful expectancy, and a strong desire to achieve which is often coupled with quiet self-

examination about one’s ability to meet the exacting requirements of undertaking PhD

studies. Such was my experience. My research journey began with my enrolment into a

Doctorate in Health Science as I had limited experience of research during my Master of

Nursing program and was required to demonstrate my ability to articulate to PhD studies

after one year of full-time enrolment.

At the outset of my studies I was relatively clear about the focus of the intended research

– the experience of PTSD from the perspectives of victims of MVAs – however, the

appropriate research design remained unclear. During discussions with my principal

supervisor, he suggested that the first task to be undertaken was to develop a researchable

question that I wished to investigate. He emphasised that it is the research question that

drives the methodology (theoretical framework) and method of the research. His advice

was to read widely but selectively keeping in mind the focus of the study, and the

research question. At this point of the research journey, there was significant pressure to

present to the university a 20 page research proposal within the required timeframe of

three months. The submitted proposal is then reviewed by two academics conversant with

the area of study and the methodology as a quality assurance measure and to provide

feedback on the strengths and limitations of the proposal outlining the intended study.

This milestone was termed stage two. This was an arduous task as I not only had to

complete coursework requirements but simultaneously develop a proposal that

demonstrated my understanding of the topic, knowledge of contemporary research on the

topic, and the theoretical framework that would underpin the study. Such requirements

and associated stresses were further compounded by my need to improve my English

competency and gain beginning mastery of the language of phenomenology which I had

not encountered previously.

This was an extremely testing time as I felt under siege from a range of perspectives.

Questions kept flooding in as to what I should do first, what should be my priority, how

do I make sense of all this material in a limited time? I was full of fear and apprehension

about whether the task ahead would be too much for me. I felt overwhelmed with

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expectations from my family, my university in Jordan at which I teach, and QUT

requirements for pursuing doctoral studies. However, amid the mounting uncertainty and

internal turmoil, I found solace in my principal supervisor who encouraged me to express

how I was feeling and to think in positive terms about my studies. Having the opportunity

to talk with him, I gradually began to relax and allow the turmoil to pass. This was a

watershed moment along the road to completing my doctoral studies. Having the time to

talk about my personal doubts and fears provided a much needed space to be able to

review what was happening and to regain a sense of confidence where there was once

self-doubt, develop a sense of clarity where there was once confusion, and what seemed

to me to be chaos, and regain a sense of direction about how my studies would proceed.

Regaining a sense of direction gave me a renewed faith in myself that I had the necessary

ability to succeed along with a change in attitude from one of being the victim of

circumstances to being in control of my life situation. At this point in my journey I came

to the realisation that in order to achieve my goals I needed to saturate myself in any

activities that related to research. This involved attending research seminars, conferences,

discussion groups, talking with colleagues, and presenting my work-in-progress at

different research forums for critique. I also needed to enhance my computer skills for the

compilation of large amounts of research material which would be required for my

research. In order to achieve these tasks I sort the guidance of my principal supervisor

who mentored me through this stage of my dissertation.

After completing stage two of my dissertation which I have previously described, the next

hurdle was to prepare for confirmation of candidature which takes place after 12 months

full-time study. The candidate was required to submit evidence that he/she has developed

a sound understanding of the topic to be explored, a comprehensive review of literature

about what is known on the topic, a well developed rationale for why the proposed study

should be undertaken, and an informed understanding of the methodology and method to

be used for the study. The candidate is required to present to the university at what is

termed ‘The Confirmation Panel’ which consists of approximately four academics who

are required to make an evaluation of the substantive nature of the proposed study and the

candidate’s competency and ability to successfully complete the course of study. The

process of reaching this point involved a steep learning curve particularly in the area of

grasping a competent and coherent understanding of phenomenology as a philosophical

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movement as well as a research approach. My naïve understanding of phenomenology at

stage two of my research study became glaringly apparent as I revisited what I had

initially written in comparison to completed dissertations using phenomenology as their

theoretical framework. Rather than attempt to synthesize views presented by different

contemporary authors concerning phenomenology, I felt the need to explore the

movement’s origins and how it has developed overtime. However, I was not prepared for

what this involved. Working my way through the different schools of thought and the

different periods of thought development left me feeling disempowered, confused, and

uncertain about how to move forward. It was only after seeking guidance from my

principal supervisor who listened to my dilemma and provided sound counsel about how

to undertake a review of the material from an historical perspective that I began to gain

some confidence about re-engaging with the phenomenological literature.

The way forward for me was to start at the beginning with the works of Brentano and

Husserl, followed by a review of works by such notable phenomenologist as Heidegger,

Sartre, and Merleau- Ponty to name a few. In order to achieve my goal of gaining a

coherent sense of the essential nature of phenomenological thought I had to remain

focused and avoid being distracted by interesting pathways of thought that were not

directly connected to what I was pursing. I decided to take a sequential approach by

reviewing the works of each author and how each author built or challenged previous

authors in the development of knowledge. I then began identifying what were the key or

shared understandings of the various authors that constituted the essential nature or core

of phenomenological thought. Reaching this point was an ‘aha’ experience for I began to

put together the various pieces of the puzzle that made sense to me. Although I feel that I

have developed a working understanding of phenomenology, I realise I am only at the

beginning of that understanding and therefore, have much to learn.

My confirmation seminar took place in July 2008. Feedback from the confirmation panel

was extremely valuable in providing me with further direction and flagging potential

pitfalls for me to consider as my thesis progressed. I was given approval to articulate to

PhD leaving me only ethics approval to obtain before embarking on the process of data

collection in Jordan. Ethics approval was granted and I left for Jordan soon after to spend

time with family and commence data collection.

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8.2.3. Year 2: Data collection in Jordan

The process of data collection was not as straight forward as outlined in my initial

proposal and confirmation document. Accessing potential participants that met the

inclusion criteria for the study was a major concern. The crux of the concern was that of

language. The inclusion criteria stated that participants needed to be able to converse in

English, however, for the normal Jordanian English was a second language as the national

language was Arabic. Finding suitable participants who had a reasonable grasp of English

that would allow them to share their experiences of PTSD posed significant difficulty.

The issue of language was further compounded by my level of language competency.

Originally from the Philippines, I moved to Jordan after marrying my husband who is

Jordanian. My native tongue is Filipino. English is my second language and Arabic my

third. In view of the fact that my dissertation would be in English, I felt that the most

appropriate means of data collection would be in English thus removing the many

difficulties associated with transcription and translation of interview texts. However,

conducting interviews in English where both the researcher and participant spoke English

as a second language was an onerous task. I explored alternatives with my principal

supervisor but eventually after considerable reflection on what would be best, I decided to

remain with the original decision that English was the best medium for conducting

interviews given the abovementioned scenario.

I entered the interview setting with mixed emotions. On the one hand I was excited and

felt privileged to be given the opportunity to share the lives of the participants especially

given their circumstances and vulnerability as victims of a MVA and, as a consequence,

suffering with PTSD. On the other hand, I began questioning my competence to conduct

interviews of such a personal nature and at such a sensitive time in the participants’ lives.

After a period of personal reflection in which I found myself weighing up the pros and

cons of the situation, I knew that there was only one decision – that of moving forward

with the interviews.

As each interview progressed I became increasing comfortable and confident in what I

was doing. I reviewed the initial interviews to ascertain whether there were any

discrepancies in the way they were conducted and the quality of the content in relation to

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later interviews. At the time I was comfortable about the consistent nature of the

interviews given individual differences, variations in participant responses, and my

capacity to elicit the participants’ experiences in their own time and manner of

expression. However, on later reflection the earlier interviews were not as robust as

initially thought as a result of my nervousness and inexperience. As a means of rectifying

the situation, I made available extra time during the review of these participants’

transcripts of interview to either add to their initial descriptions or to clarify statements

that they believed did not convey the intended meaning. Only minor additions were made

by participants. Once I felt confident that the transcripts of interviews were as complete as

possible – reflecting the participants’ experiences of PTSD – the process of analysis was

commenced.

Adhering to the format of analysis stipulated by Colaizzi (1978) I first read all the

participant transcripts to gain a general overview of the various dimensions of their

experiences. The initial read of the transcripts left me feeling overwhelmed with the range

of participant experiences and what appeared to me to be confusing and contradictory

descriptions. At this point in the analysis process I began to panic and question my

capacity to proceed. I contacted my principal supervisor and informed him of my

dilemma and uncertainty about how to continue with the process of analysis. His

reassurance that what I was going through was an experience shared by many students

helped to dispel my anxiety and to refocus on the task ahead. He reminded me that I was

only at the first stage of analysis and, that if I continued to follow Colaizzi’s steps of

analysis I would gradually unravel the participants’ descriptions and be able to identify

common experiences or central themes.

I returned to the participants’ transcripts of interview and began to read and re-read each

one in combination with the interview tapes. This process allowed me to systematically

work through each transcript, identify and extract significant statements – statements that

directly related to the experience of PTSD – and numerically list them. Each numerical

list of statements were then reviewed with the aim of clustering the significant statements

into formulated meanings and then themes. This proved a difficult task for me.

Attempting to move from the language of the participants to the language of the

researcher required an ability to think in abstract terms in a language which was not my

original tongue. This process consumed considerable time with many moments of

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frustration and self-doubt. However, persistence won the day. This experience taught me

that unless you are able to take someone’s writing or statement, and reconfigure it in your

own language without losing the essential meaning of what has been written,

comprehension of what is being shared by the author is limited. Completion of this stage

of the analysis process was an important landmark in my study as I felt I had developed a

level of competency in analysing and synthesising a large amount of data into a

meaningful and coherent presentation of themes.

After completing the initial analysis of data I return to Queensland University of

Technology to continue with the analysis process and writing up of my thesis. I met

regularly with my principal supervisor to review my initial analysis. These regular

meetings proved valuable in clarifying and justifying the processes by which significant

statements of participants were explicated, and how theme clustering was undertaken. As

English was the second language for both the participants and myself as previously

mentioned, my principal supervisor and I together reviewed each participant’s significant

statements to ensure that each statement was an accurate reflection of their intended

meaning. This process involved reading each statement, and discussing the meaning of

each. At the completion of this exercise, the actual explicated themes and the significant

statements underpinning each theme were reviewed for accuracy and appropriateness.

Given the number of significant statements of the 15 participants, those statements which

best represented the experience of the phenomenon were used in the presentation of

results.

8.2.4 Year 3: Completing my dissertation

My final year of study has been thwart with difficult times which has involved attempting

to complete my studies against the backdrop of family illness, death of a family member,

and having to cope with living apart from my husband and children who remained in

Jordan, resisting the pressures by family to return home, and carrying the burden of

financial concerns. Soon after returning to Australia my father-in-law who had been

diagnosed with cancer suffered a relapse. As a daughter-in-law and being a nurse, much

of the responsibility to care for him and the family in general during this period fell to me.

I was required to return to Jordan and take over the management of my father-in-law.

This meant having to take a leave of absence from my studies. I applied for, and was

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granted leave of absence from the university for a period of four months which later had

to be extended because of my father-in-laws deteriorating health. This was an extremely

difficult time as I felt caught between a rock and a hard place. The needs of my family

commanded by attention and commitment, however, my studies for which I had

sacrificed much, was not progressing and time was running out. Tension within myself

mounted as my father-in-law’s illness continued and there seemed no resolution in sight,

while pressure from the university to meet completion deadlines continued. I was at a loss

about what to do – if I returned to studies the family would lose out, however, if I stayed

with the family my studies would be compromised to the point of not completing. The

decision was a difficult one, but one that had to be made.

In March 2010, I returned to QUT to complete my studies. Since my return my father-in-

law has died which has been a significant loss for me. These last few months with my

dissertation have been difficult but life goes on. I have now reached a point of completion

in relation to this research journey and therefore, at such times questions surface about

what have I learnt and what wisdom do I have to communicate to other neophyte

researchers commencing graduate research studies? As I reflect on my research journey a

number of insights have been gleaned which I would like to share with you.

In order to enter a program of study – in this case graduate research - knowledge

of contemporary thought on the area of interest is essential in defining the broad

parameters of the area of inquiry that will inform the research question.

Refinement of the focus of the study can then take place in collaboration with the

supervisory team once the candidate is formally enrolled in the program of study.

Lack of clarity and direction early in the research process has the potential to

unnecessarily consume valuable time and thus impede progress.

A solid beginning knowledge of the methodology and method which will underpin

the study prior to data collection is essential in having the correct philosophically

stance and conceptual lens for guiding the research method.

If an international student whose first language is not English, and who is

engaging in qualitative research of which he/she has limited knowledge,

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familiarisation with the nomenclature of the research methodology is imperative.

Failure to do so has the potential to significantly restrict or hamper ‘access’ to the

world of phenomenological thought and diminish the candidate’s capacity to work

in the selected philosophical framework.

Choice of supervisor/s is critical in maximising the potential for successful

completion of a dissertation. Time spent in this decision-making process is

essential to ensure that there is a meeting of ‘like minds’ at the commencement of

the study as the journey is long and arduous.

8.3. Conclusion

This chapter presented this researcher’s personal reflections on the research process in

undertaking doctoral studies. Moments of uncertainty, anxiety, apprehension, lack of

clarity, personal doubts about completing the dissertation, and family burden coupled with

moments of illumination, confident expectancy, self-affirmation, and personal achievement

were presented. The chapter concluded with insights cleaned form the experience of

undertaking research at doctoral level. The following chapter provides a summary of

conclusions, implications and recommendations for future research, education, and clinical

practice.

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CHAPTER NINE

SUMMARY, CONCLUSION, IMPLICATIONS AND RECOMMENDATIONS FROM

THE STUDY

9.1. Introduction

This chapter provides a summary of this study’s findings and the associated implications

and recommendations for future nursing practice, research, education and policy

development. A brief summary of findings is presented followed by a discussion of what

this study adds to contemporary knowledge concerning the experience of post-traumatic

stress disorder. Limitations of the study are then discussed. Implications and

recommendations for practice, teaching, policy development are addressed. The chapter

concludes with a brief summary of the chapter.

9.2. Summary of Findings

A descriptive phenomenological study of the experience of PTSD as described by victims

of MVAs in Jordan was undertaken with the following aims: (1) To provide an

explication of the lived experience of what it is like to experience PTSD within a

Jordanian context. (2) To make a substantive contribution to extant knowledge about

living with post-traumatic stress disorder. (3) To disseminate findings of the study to

health care practitioners working in the specialty area of post-traumatic stress, health care

policy makers in Jordan, and the wider Jordanian population for their self-reflection,

knowledge enhancement, and affirmative action if, when and where appropriate.

Seven themes were explicated from the participants’ transcripts of interview: Feeling

frustrated at a diminishing health status; Struggling to maintain a state of

independence; Harbouring feelings of not being able to recover; Feeling

discriminated against and marginalised by society; Feeling ignored and neglected by

health care professionals; Feeling abandoned by family; Moving toward acceptance

through having faith in Allah.

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9.2.1 Theme one: Feeling frustrated at a diminishing health status.

The participants in this study spoke of the frustrations they felt at their inability to attend to

the simple everyday tasks of caring for themselves and their families as a result of a gradual

decline in their physical strength and mental capacity. Disturbed sleep patterns fuelled by

flashbacks and nightmares exacerbated the situation. In the absence of no tangible

improvement in their health status participants became increasingly angry and frustrated.

Anger and frustration fed into a negative cycle in which there appeared to be from the

participants’ perspectives a downward spiral into a world of disability, restriction, and

reliance on others. In a review of literature pertaining to this theme a number of studies

were located in which the findings were consistent with the findings of this current study

including feeling physically and emotionally tired (Johansen et al., 2009), feeling frustrated

and angry at a diminished capacity to care for self and others (Lauterback et al., 2005;

Karatzias & Chouliara, 2008; McNutt & Postmus, 2002), and feeling a loss of control (De

Jong et al., 2005)

9.2.2. Theme Two: Struggling to maintain a state of independence

For the participants of this study the struggle to maintain a state of independence was

thwarted with difficulties which encompassed feelings of extreme tiredness, loss of energy,

a reluctance to rely on others, and a strong desire to regain control over one’s life.

However, at times the struggle to once again be independent became overwhelming to the

point that some participants expressed the thought of wanting to give up. In a review of

literature relating to this theme a number of studies were located with similar findings

including struggle for independence (Ray & Vanstone, 2009; Zeilani, 2008; Jonsson &

Segesten 2004).

9.2.3. Theme Three: Harbouring feelings of not being able to recover

The very thought that recovery may never be a reality engendered in a number of the

participants feelings of fearful apprehension. Inability to pay for hospitalisation, medical

and psychiatric consultation, and medication surfaced questioning uncertainty about what

seemed to them to be an unknown future about the possibility of recovery. As time passed

hope of recovery gradually dwindled only to be replaced with a growing sense of

hopelessness. Reviews of literature a number of studies concerning this theme were

132

identified: a lack of financial support (Layne et al., 2007) harbouring fears that they may

never recover (Grundy, 2010; Olatunji et al., 2007) in PTSD experience surfaced a number

of articles (Layne et al., 2007).

9.2.4. Theme Four: Feeling discriminated against and marginalised by society.

Feeling discriminated against and marginalised by society was for a number of participants

a disquieting and humiliating experience that engendered feelings of rejection, dejection,

and a sense of imprisonment. Seeking support in once close friends, and neighbours was

met with suspicion, fear, and distance. In a review of literature similar findings were

located to the findings of this study (Andermann, 2010; Bryant et al., 2010; Maercker and

Muller, 2004).

9.2.5. Theme Five: Feeling ignored and neglected by health care professionals

Feeling ignored and neglected by health care professionals engendered in a number of the

participants a sense of vulnerability at not receiving what they believed to be appropriate

quality care. In the face of neglect and being ignored some of the participants resorted to

asking their families to take over their hospital care and provide the emotional and physical

support expected to be provided by hospital staff. The stress of being treated in this manner

left some participants in an emotional and psychological state of wanting to ‘escape’ from

the hospital, and never to return. Being ignored and neglected by health care professionals

led to self-doubt and questioning the legitimacy of their illness. Similar findings were

located in a review of literature on the theme (Hobfoll et al., 2008; Maercker & Muller,

2004; Laffaye et al., 2008).

9.2.6. Theme Six: Feeling abandoned by family

Feeling abandoned by family engendered in the participants moments of quiet desperation

and at times fearful apprehension that the very fabric of daily living – family love and

support - had dissipated to the point of being non existent. Loss of family support was

exacerbated by multiple losses including diminishing health, loss of employment, financial

insecurity, and physical incapacity. Belief that family would be there in times of need

eroded in the face of family fears, and misunderstanding about the nature of the

133

participants’ illness. Family support was tenuous which was reliant on the ability of the

participant to contribute to daily financial needs of the family.

In a review of literature pertaining to this theme a number of studies were located the

findings of which were consistent with this current study (Adams & Boscarino, 2006;

Kasdan et al., 2006; Clapp and Beck, 2009; Laffaye et al., 2008).

9.2.7. Moving toward acceptance through having faith in Allah

Having faith in Allah was an anchor amid, overwhelming physical and emotional

difficulties, frustrations, uncertainties, self-doubt, family abandonment, social rejection,

quiet moment of desolation and despair. Belief that Allah would be their raft through

turbulent and uncertain seas of living with PTSD provided a much needed buffer and a

source of strength and resolve to ‘survive’ these traumatic times. Having faith in Allah was

also a source of strength for the participants in coming to a point of acceptance of their

illness and associated disabilities and limitations. Reaching the point of acceptance that life

had forever changed as a result of their accident and subsequent illness surfaced feelings of

personal liberation which gave rise to being able to look at the future in new and affirming

ways within the context of their disabilities. In a review of literature relating to this theme,

a number of studies were located that explored the relationship between having faith in God

as a source of strength in moving toward recovery (Chen & Koenig, 2006; Exline et al.,

2005; Murphy & Bradley, 2010).

9.3. The Uniqueness of the Study: What this Study Adds to Extant Knowledge

Each of the themes explicated in this current study were supported by current research

literature and expressions of life through the Arts. However, what was not found in the

literature was the combination of themes in one study which provides a unique insight into

the life world of Jordanians concerning the experience of PTSD adding to extant knowledge

on the topic. Two themes of this study which have had little attention in the literature are

feeling abandoned by family and struggling to maintain a state of independence.

In relation to the theme being abandoned by family, the findings of this study suggest that

such an occurrence is not uncommon especially when tied to financial insecurity or poverty.

134

Given the importance of the family in Jordan, being abandoned by the very ones you love

and on whom you rely for support at a vulnerable point in life is significant. In relation to

the theme struggling to maintain a state of independence, there was a noticeable absence of

discussion in the literature. Although from an anecdotal perspective this issue has been

discussed, no research on the theme seems to have been undertaken.

The contributions of this study to extant knowledge have the potential to be an instrument

of change in Jordan not only in the domain of health care delivery, but also in the areas of

clinical practice, policy development, education, and research.

9.4. Limitation of the Study

Given that this was a descriptive phenomenological study concern about generalisability

from a quantitative perspective is not an issue of concern. However, from the perspective

of this researcher, the study was limited in two ways – conducting a study in English

when English is the second language of both the researcher and participants, and

restricting the study to one site. In relation to English language competency, difficulty

was experienced in not only the data collection phase of this study, but also in the analysis

phase. In an attempt to ensure that thick rich descriptions were obtained from

135

participant’s additional time at interview and follow-up with participants was necessary.

The inclusion of metaphors and artistic representations was an addition to Colaizzi’s

(1978) analysis process to enhance the participants’ description of their experiences.

However, the potential to lose meaning as a result of not being able to understand or

capture the nuances of communication is high.

In relation to the study being conducted on one site, opportunities to work with

participants who are at different stages of trauma recovery has the potential to add

different dimensions to the study.

9.5. Implications and Recommendations Arising from the Study

A number of implications and recommendations are put forward for consideration and

future application.

9.5.1. In view of the findings of this study there is an urgent need to address issues of

concern through targeting specific problem areas including: the health status of people

with PTSD, the health care providers, the health care services, and community attitudes

toward people with PTSD.

It is therefore recommended that:

9.5.1.1. Recommendation One: A program of education be developed which targets

community attitudes concerning PTSD.

9.5.1.2. Context of the recommendation

Jordanian society is not yet ready to give recognition to the legitimacy of PTSD as an

illness. One of the main barriers to recognition of this condition is the population’s

attitude to mental illness. Mental illness is still generally regarded as something to be

feared and therefore, people with a mental illness are in the main marginalised by society.

Therefore, any form of community education or raising public awareness of PTSD must

be approached in a sensitive and gradual manner.

136

Specific recommendation:

Develop a program of public education to raise community awareness of PTSD.

This can take the form of distributing pamphlets on PTSD through health care

organizations; profile PTSD through the media, and conducting workshops for

families of people with PTSD. Focus of the workshops should include symptom

management, self-care practices, and rights to access quality health care. Particular

attention needs to be given to educating people living in rural Jordan about PTSD as

access to education and appropriate facilities is significantly lacking.

9.5.1.3. Recommendation Two: Develop educational programs targeted at health care

professional about PTSD.

9.5.1.4. Context of the recommendation

Shortages of nurses are an escalating phenomenon in Jordan because of their cultural and

religious beliefs towards the nursing profession. Small numbers of the population attend

nursing colleges and universities; in Jordan, nursing is a profession that is not highly

valued especially for women. Many of those entering nursing have similar attitudes to

that of the general community. Apart from knowledge gained in the undergraduate

program of study nurses in the main present as being disinterested in furthering their

professional career through education. The end result is a lack of concern for their

patients, particularly those with a mental illness of which they have little or no

knowledge. However, there are beginning moves to make changes to the health care

system and to health care education.

Specific recommendations:

Undergraduate preparation for nurses should include units on mental health and

mental health nursing.

In-service training, seminars on PTSD nursing care, treatment, and management

should be offered to nurses, and other health professionals attending the PTSD

patients.

137

Post-graduate education in mental health should be developed for nurses working in

the area of mental health.

9.5.1.5. Recommendation Three: The development of health care policy that addresses

access and equity issues for people with PTSD.

9.5.1.6. Context of the Recommendation

The current social services policies of the Jordanian Health Care System have given little

credence to the health care needs of people with PTSD. As a result of this inattention

there is a noticeable lack of processes and protocols concerning care of the mentally ill

and people with PTSD. The lack of policy direction has also led to a lack of health

resources in this area including specialised clinics. Access to the limited services

continues to place patients in vulnerable situations. Lack of policy direction has also

impacted on access to health benefits.

Specific recommendations:

A policy review should be undertaken by government. Revision to policy changes

need to include provision of legislation, governance, financial and material

resources, and service access.

The existing Pension scheme and social security policies, which favours those in

formal sector employment, should be reviewed, though having a pension is no

guarantee for financial security.

9.5.1.7. Recommendation Four: New ways of extending the social network of the PTSD

patients should be investigated.

9.5.1.8. Context of the recommendation

Support of people with PTSD primarily falls to the family within Jordanian culture.

Social support includes not only helping with physical and emotional recovery, but also

has a practical dimension such as family members taking care of sick family members

through financial support. The traditional reliance on family members as the primary

138

source of support is no longer relevant due to social economic changes. Given the

changes in the family structure, and loss of the cohesiveness of the extended family, care

of the family member with PTSD should now be considered a public health issue.

Specific recommendations:

The prevailing economic powerlessness of people with PTSD needs not to be seen

as a familial burden but a shared responsibility with the community and

stakeholders such as health care professionals, and community organisations. The

family should only operate as a safety net, providing the basic necessities of life.

Support groups for people with PTSD should be established within the different

local communities. These support groups will offer the PTSD patient the

opportunity to share their problems, work with members of the group in moving

toward recovery, provide mutual support, and be a resource for others.

Links need to be forged between government and non-government organizations

along with community groups to establish a network for referral and interventions

for people with PTSD and their families.

9.5.1.9. Recommendation Five: Undertake further research in the area of PTSD in Jordan.

9.5.1.10. Context of the recommendation

There is a noticeable absence of research concerning PTSD in Jordan. Further research

therefore is needed not only to advance knowledge about PTSD but to use such knowledge

for future education, clinical practice, and policy initiatives. Areas for further research

include:

Effect of family abandonment on the individual with PTSD

The impact of a lack of financial resources for individuals with PTSD and their

families.

Exploration of the lived world of women suffering from PTSD

Effective PTSD treatment and management strategies

139

Exploration of PTSD women’s voices in relation to the impact of culture and

tradition.

A comparative study of different groups of PTSD in the Middle East for example

Saudi Arabia, UAE, Syria, and Lebanon.

Exploration of attitudes in the community towards PTSD.

Exploration of PTSD experience among men involved in MVAs.

9.6. Conclusion

This chapter presented a discussion of the outcomes of this study including a summary of

the seven themes in relation to extant literature on the topic, what this thesis adds to

knowledge development, limitations of the study and recommendations for future practice,

education, policy development, and research.

140

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APPENDICES Appendix I…...Invitation to Participate in a Research Project Appendix II…..Consent Form Appendix III….Demographic Questions Appendix IV… Ethics Approval Appendix V..... Dept. of Orthopaedic Unit Amira Basma Hospital Appendix VI.....Copyright Permission Appendix VI-1. Copyright permission from Faginandpagan 1@binternet.com

Appendix VI-2. Copyright permission from Info, Concierge [Info@concierge.com]

Appendix VI-3. Copyright permission from Geraldine Dukes [zonezeb@yahoo.co.uk]

Appendix VI-4. Copyright permission from colin turvey crete-birding@hotmail.co.uk

Appendix VI-5. Copyright permission from Michele Rosenthal [healmyptsd@gmail.com] Appendix VII......Frameworks of Lived Experiences of PTSD patients of Jordan Appendix VIII.....Framework of the meaning attached to the experience being PTSD patients of Jordan Appendix IX........Framework of understanding the lived experience of PTSD patients of Jordan Appendix X.........Participant Profiles

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APPENDIX I

Information for Potential Participants Involved in Study on “The Lived Experience of Post Traumatic Stress Disorder as Described by Motor Vehicle Accident Victims in Jordan Principal Supervisor: Dr. Anthony Welch Faculty of Health and Sciences – School of Nursing Queensland University of Technology Phone: anthony.welch@qut.edu.au Second Supervisor: Dr. Meng Lim School of Nursing & Midwifery St. Albans, Victoria University Phone: (03) 93652222 meng.lim@vu.edu.au Researcher : Lilibeth Al-Kofahy Phone: 7102137 alkofahylilibeth@yahoo.com.au You are invited to participate in a study to share your experiences and reflections of post-traumatic stress disorder after your motor vehicle accident. As a person who has experienced post-traumatic stress, the researchers would welcome an opportunity to talk with you about your experience. The purposes of this study are to explore and to describe the experiences of motor vehicle accident (MVA) victims who have as a consequence of the traumatic event developed post-traumatic stress disorder PTSD. The aims are: firstly, to make a substantive contribution to existing knowledge about living with PTSD. Secondly, to provide opportunities of victims of trauma to give voice to their lived world and finally, to disseminate findings of the study to health care practitioners working in the specialty area of PTSD for personal reflection in relation to their current understandings of the phenomenon and, where appropriate, utilize such knowledge to guide professional practice. Therefore, this study seeks to understand the following: 1. What are the experiences of motor vehicle accident victims who have as a consequence of the traumatic event developed post-traumatic stress disorder? Participation in this study will require the participants to be involved in two one-hour interviews. During the interviews, questions will be asked regarding your trauma experience including the way you have coped and the support you have received from family, and hospital staff, including nurses. The interview(s) will be arranged at a time and location agreed to suit you. The interview, which will be conducted in an informal manner, will be audio taped and later transcribed for analysis. Given the nature of the interview if at any time you experience any discomfort talking about your experience,

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APPENDIX I the interview will be stopped immediately and an opportunity for you to discuss your concerns will be provided. If you wish not to continue with the interview your decision will be respected and the interview will cease. If you wish to postpone the interview a further time will be mutually arranged. Your participation is voluntary and therefore, you may withdraw from the study at any time without jeopardizing yourself in anyway. If you feel the need for further support after the interview a list of recommended counselors will be given to you at the time of interview. If you need to speak to a counselor, the researcher will arrange the meeting for you. The information shared by you will be strictly confidential and no person’s name will be mentioned in the report. The information on the audiotape and transcripts of the tape will be stored in a locked and secured place. The transcripts and the summarized report will be given to you so that you can clarify whether the information truly reflects your experience. If you have any questions, please contact one of the researchers listed below. If you are interested to participants in the study, please contact: Student researcher: Lilibeth Al-Kofahy Principal investigator: Dr. Anthony Welch Second Supervisor: Dr. Meng Lim If you have any concerns arising from the conduct of this study, please contact the: Human Research Ethics Committee Office for Research, Level 3 O Block Podium, Gardens Point Campus http://www.research.qut.edu.au/ethichs/ I 07 3138 2340 I ethichscontact@qut.edu.au Thank you for you assistance. Yours Sincerely _________________ Lilibeth Al-Kofahy (Researcher) Dr. Anthony Welch (Principal investigator) Dr. Meng Lim (Second Supervisor)

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APPENDIX II

Queensland University of Technology School of Nursing Consent Form for Participants Involved in a study on “The Lived Experience of Post traumatic Stress Disorder as Described By Motor Vehicle Accident Victims in Jordan” INFORMATION TO PARTICIPANTS: We would like to invite you to be part of a study to share your experiences of post-traumatic stress disorder from a Motor Vehicle Accident CERTIFICATION BY SUBJECT I, __________________________________________________of_______________________ certify that I am at least 18 years old and that I am voluntarily giving my consent to participate in the study entitled: The Lived Experience of PTSD as Described by Motor Vehicle Accident Victims in Jordan. being conducted by Mrs. Lilibeth Al-Kofahy of Queensland University of Technology. I certify that the objectives of the study, together with any risks to me associated with the procedures listed have been fully explained to me by Lilibeth Al-Kofahy and that I freely give my consent to participate this study. My participation in this study includes interviews that will be conducted at least two times and each interview will last about one hour. During the interview, questions will be asked regarding my traumatic experience. The interview(s) will be arranged at a time and location agreed to suit me. The interview will be audiotaped with my permission and conducted informally. I understand that there is no physical risk to me, but at any time of the interview(s), if I feel upset or angry or any kind of discomfort during the reflection of my experience, I may stop the interview and choose whether to postpone it, continue or withdraw from the study. I certify that I have had the opportunity to have any questions answered and that I understand that I can withdraw from this study at any time and that this withdrawal will not jeopardize me in any way. I have been informed that the information I have provided in the interview will be kept confidential. Signed: ………………………….. Witness other than the researcher: Date: …………………….. …………………………………

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APPENDIX III Demographic Questions

1. General Information

Age in years

Gender Male Female

Marital Status Widow Divorce Married Single Others

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APPENDIX IV

University Human Research Ethics Committee

HUMAN ETHICS APPROVAL CERTIFICATE NHMRC Registered Committee Number EC00171 Date of Issue:30/7/09 (supersedes all previously issued certificates) Dear Dr Anthony Welch A UHREC should clearly communicate its decisions about a research proposal to the researcher and the final decision to approve or reject a proposal should be communicated to the researcher in writing. This Approval Certificate serves as your written notice that the proposal has met the requirements of the National Statement on Research involving Human Participation and has been approved on that basis. You are therefore authorised to commence activities as outlined in your proposal application, subject to any specific and standard conditions detailed in this document. Within this Approval Certificate are: * Project Details * Participant Details * Conditions of Approval (Specific and Standard) Researchers should report to the UHREC, via the Research Ethics Coordinator, events that might affect continued ethical acceptability of the project, including, but not limited to: (a) serious or unexpected adverse effects on participants; and (b) proposed significant changes in the conduct, the participant profile or the risks of the proposed research. Further information regarding your ongoing obligations regarding human based research can be found via the Research Ethics website http://www.research.qut.edu.au/ethics/ or by contacting the Research Ethics Coordinator on 07 3138 2091 or ethicscontact@qut.edu.au If any details within this Approval Certificate are incorrect please advise the Research Ethics Unit within 10 days of receipt of this certificate. Project Details Category of Approval: Approved From: 29/07/2010 Approval Number: 0900000339 The lived experience of post traumatic stress disorder as described by motor vehicle accident victims in Jordan Human - Committee Project Title: 29/07/2009 Approved Until: (subject to annual reports) Chief Investigator: Dr Anthony Welch Other Staff/Students: Mrs Lilibeth Al Kofahy , Dr Meng Lim Experiment Summary Explore the impact on the physical, emotional, and psychosocial patterns of daily living after a motor vehicle accident. Participant Details Participants:

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Approximately 10 Location/s of the Work: Jordan Conditions of Approval Specific Conditions of Approval: RM Report No. E801 Version 3 Page 1 of 2

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University Human Research Ethics Committee HUMAN ETHICS APPROVAL CERTIFICATE NHMRC Registered Committee Number EC00171 Date of Issue:30/7/09 (supersedes all previously issued certificates) No special conditions placed on approval by the UHREC. Standard conditions apply. Modifying your Ethical Clearance: Requests for variations must be made via submission of a Request for Variation to Existing Clearance Form (http://www.research.qut.edu.au/ethics/forms/hum/var/var.jsp) to the Research Ethics Coordinator. Minor changes will be assessed on a case by case basis. It generally takes 7-14 days to process and notify the Chief Investigator of the outcome of a request for a variation. Major changes, depending upon the nature of your request, may require submission of a new application. 5. Stop any involvement of any participant if continuation of the research may be harmful to that person, and immediately advise the Research Ethics Coordinator of this action; 6. Advise the Research Ethics Coordinator of any unforeseen development or events that might affect the continued ethical acceptability of the project; 7. Report on the progress of the approved project at least annually, or at intervals determined by the Committee; 8. (Where the research is publicly or privately funded) publish the results of the project is such a way to permit scrutiny and contribute to public knowledge; and 9. Ensure that the results of the research are made available to the participants. Audits: All active ethical clearances are subject to random audit by the UHREC, which will include the review of the signed consent forms for participants, whether any modifications / variations to the project have been approved, and the data storage arrangements. Standard Conditions of Approval: The University's standard conditions of approval require the research team to: 1. Conduct the project in accordance with University policy, NHMRC / AVCC guidelines and regulations, and the provisions of any relevant State / Territory or Commonwealth regulations or legislation; 2. Respond to the requests and instructions of the University Human Research Ethics Committee (UHREC); 3. Advise the Research Ethics Coordinator immediately if any complaints are made, or expressions of concern are raised, in relation to the project; 4. Suspend or modify the project if the risks to participants are found to be disproportionate to the benefits, and immediately advise the Research Ethics Coordinator of this action; End of Document RM Report No. E801 Version 3 Page 2 of 2

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APPENDIX V

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APPENDIX VI COPYRIGHT PERMISSION APPENDIX VI-1. Faginandpagan 1@binternet.com

Re: Message from...Faginandpagan 1@binternet.com

Sent: Tuesday, December 07, 2010

To: LILIBETH AL-KOFAHY

Blessings, You are very welcome to use the depression image. Thank you for asking. Please recommend my site if possible anywhere that you have an opportunity to. I wish you love and luck Pagan www.paganshop1.com ----- Original Message ----- From: "Lilibeth Al-Kofahy" <faginandpagan1@paganshop1.com> To: <faginandpagan1@paganshop1.com> Sent: Tuesday, December 07, 2010 5:56 AM Subject: Message from Paganshop1.com > From: Lilibeth Al-Kofahy > Email: lilibeth.alkofahy@student.qut.edu.au > > ------------------------------------------------------ > > To whom it may concern, > > I would like to request a permission to use this image (depression) as > part > of my PhD thesis related to Posttraumatic stress disorder. > > Hope for your kind consideration. > > Yours Sincerely, > Lilibeth Al-Kofahy > PhD Candidate > QUT School of Nursing & Midwifery > Brisbane,QLD. 4059 > Australia > > ------------------------------------------------------ > > Office Use Only: > From: Lilibeth Al-Kofahy > Email: lilibeth.alkofahy@student.qut.edu.au > Login Name: Not logged in > Login Email: Not logged in > IP Address: 131.181.251.10 - 131.181.251.10 RE: General Feedback

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APPENDIX VI–2. Info, Concierge [Info@concierge.com]

From: Info, Concierge [Info@concierge.com] Sent: Wednesday, December 01, 2010 12:37 AM To: LILIBETH AL KOFAHY Subject: RE: General Feedback Hi Lilibeth, You may use our content and/or photos, provided that you credit us with the specific URL (as well as any photographer or external source used). Warm regards, -the concierge.com team ________________________________ From: lilibeth.alkofahy@student.qut.edu.au [mailto:lilibeth.alkofahy@student.qut.edu.au] Sent: Thu 11/25/2010 5:43 PM To: Info, Concierge Subject: General Feedback Lilibeth Al-Kofahy has sent the following feedback: Email: lilibeth.alkofahy@student.qut.edu.au Message: To whom it may concern, I would like to request a permission to use one of your images in Google web site (Blind Man in Kashban Morocco)as part of my PhD thesis about post-traumatic stress disorder. Hope for your kind consideration. Yours sincerely, Lilibeth Al-Kofahy PhD Candidate QUT, School of Nursing & Midwifery Brisbane, QLD 4059 Australia Connection Speed: URL where problem occurred: Country: Australia State: Zip: ENVIRONMENT VARIABLES --------------------- HTTP_USER_AGENT: Mozilla/5.0 (Windows; U; Windows NT 5.1; en-US; rv:1.9.2.12) Gecko/20101026 Firefox/3.6.12 (.NET CLR 3.5.30729) REMOTE_ADDR: 131.181.251.10 ------------------------------------------------------------------------------------------------ This e-mail, including attachments, is intended for the person(s) or company named and may contain confidential and/or legally privileged information. Unauthorized disclosure, copying or use of this information may be unlawful and is prohibited. If you are not the intended recipient, please delete this message and notify the sender.

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APPENDIX VI–3.Geraldine Dukes [zonezeb@yahoo.co,.uk]

Re: Enquiry from your website Geraldine Dukes [zonezeb@yahoo.co,.uk] Sent: Wednesday, November 24, 2010 5:47 pm To: LILIBETH AL-KOFAHY Hi Lilibeth, Thank you for requesting permission. I would be very happy for you to use my image for your thesis. All good wishes for achieving great marks in your PhD. Kind regards, Geraldine

Sent: Tue, 23 November, 2010 21:49:50 Subject: Enquiry from your website START SUBMITTED INFORMATION --------------------------- First_name: Lilibeth Last_name: Alkofahy E-mail: lilibeth.alkofahy@student.qut.edu.au Address: QUT, School of Nursing & Midwifery, City: Kelvin Grove, Victoria Park Road State: Brisbane, QLD ZIP: 4059 Country: Australia Phone: 0404145935 Best_time_to_call: Message: To whom, it may concern, I would like to request a permission to use one of your images (Dying flower 367x 550 -214k - jpg) to use as part of my PhD thesis about post traumatic stress disorder (PTSD). Hope for your kind consideration. Yours sincerely, Lilibeth Al-Kofahy PhD Candidate QUT, School of Nursing & Midwifery Kelvin Grove, Brisbane, QLD 4059 Australia --------------------------- END SUBMITTED INFORMATION

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APPENDIX VI–4. colin turvey crete-birding@hotmail.co.uk

Date: Mon, 22 Nov 2010 23:00:04 -0800 RE: Query - Permisssion

Wednesday, 24 November, 2010 10:23 AM From: "Lilibeth Al- Kofahy" <alkofahylilibeth@yahoo.com.au> Add sender to Contacts To: "colin turvey" crete-birding@hotmail.co.uk Hi Colin, Thanks for letting me to use one of your images. This is the image to be used in my thesis (Little Egret/lost bird and flower/ Linnet Carduellis Cannabina). It would be great and you are very welcome to read my thesis as soon it will be online. Let you know soon. Kind regards, LIlibeth Alkofahy --- On Wed, 24/11/10, colin turvey <crete-birding@hotmail.co.uk> wrote: From: colin turvey <crete-birding@hotmail.co.uk> Subject: RE: Query - Permisssion To: alkofahylilibeth@yahoo.com.au Received: Wednesday, 24 November, 2010, 3:25 AM

Hi Lilybeth Thank you for your email. Yes that would be OK to use the images, thank you for asking. Would you please tell me which ones you actually require, they are numbered at the top of the page when enlarged, I will then send in a better image quality if you require it. May I wish good luck with your thesis, will it go online when you have finished ? I would be very interested in reading your research. Kind regards Colin Turvey

Date: Mon, 22 Nov 2010 23:00:04 -0800 From: alkofahylilibeth@yahoo.com.au Subject: Query - Permisssion To: crete-birding@hotmail.co.uk

To whom it may concern, I would like to request in your company to have a permission to use one of your images (Little Egret/lost bird and flower/ Linnet Carduellis Cannabina to use as part of my PhD thesis about post traumatic stress disorder. I am a PhD candidate at Queensland University of Technology in the School of Nursing & Midwifery. Hope for your kind consideration. Yours sincerely, Lilibeth Al- Kofahy PhD Candidate QUT, School of Nursing & Midwifery Kelvin Grove, QUT, Brisbane, QLD, Australia

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APPENDIX VI-5. Michele Rosenthal [healmyptsd@gmail.com]

Re: Blog Related Topics

Michele Rosenthal [healmyptsd@gmail.com]

Sent: Monday, November 22, 2010 3:19 pm

To: LILIBETH AL-KOFAHY

I would love to give you permission; I don't know whom to credit as my designer bought the images for my site. I think if it's just for your dissertation and not for commercial use it would be ok for you to borrow it. :)

On Mon, Nov 22, 2010 at 12:01 AM, LilibethAl-Kofahy <lilibeth.alkofahy@student.qut.edu.au> wrote: Dear Sir/Madam, I would like to ask or request a permission to use one of the PTSD image from your website (PTSD Healing). This image is really good to be part of my thesis about PTSD. I am a PhD candidate in Queensland University of Technology, brisbane, QLD. Australia. Hope for your kind consideration

-- Michele Rosenthal, Self-Empowered Healing Coach Trauma ~ Stress ~ PTSD Helping clients shift from powerLESS to powerFUL! Certified Life Coach Certified Hypnotist Certified Neuro-Linguistic Programmer HEAL MY PTSD, LLC www.healmyptsd.com A site for PTSD awareness, education, treatment & self-empowered healing.

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APPENDIX VII Framework of lived experiences of the PTSD patients of Jordan Emerged Themes: -Feeling frustrated at a diminishing health status -Struggling to maintain a state of dependence -Harbouring fears that they may never recover -Feeling discriminated against and marginalised by society -Feeling ignored and neglected by health care professionals -Feeling abandoned by family

Descriptive meaning: A gradual waning of strength exacerbated by sleep deprivation, flashbacks, and nightmares coupled with feelings of loss of independency and loss of control over one’s life surfaced feelings of anger and frustration. For the participants of this study the struggle for independence was thwart with difficulties which encompassed feelings of extreme tiredness, lack of energy, a reluctance to rely on others, and a strong desire to regain control over one’s life. The very thought that recovery may never be a reality engendered in a number of the participants feelings of fearful apprehension. Feeling discriminated and marginalised by society was, for a number of participants a disquieting and humiliating experience that engendered feelings of rejection, dejection, and a sense of imprisonment. Feeling ignored and neglected by health care professionals engendered in a number of the participants a sense of vulnerability at not receiving what they believed to be appropriate quality care. Feeling abandoned by family engendered in the participants moments of quiet desperation and at times fearful apprehension that the very fabric of daily living – family love and support - had dissipated to the point of being non existent.

Essence of the meaning of the lived experiences:

The lived experiences of the PTSD patients’ compromise human responses to PTSD emerging from their feeling frustrated at a diminishing health status, struggling to maintain a state of dependence, harbouring fears that they may never recover, feeling discriminated against and marginalised by society, feeling ignored and neglected by health care professionals, feeling abandoned by family.

Figure 1: Framework of the lived experiences of PTSD patients of Jordan

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APPENDIX VIII Framework of meaning attached being PTSD patients in Jordanian context

Emerged Theme: -Moving toward acceptance through having faith in Allah

Descriptive meaning: PTSD is defined by the PTSD patients of Jordan, by having faith in Allah was an anchor amid, overwhelming physical and emotional difficulties, frustrations uncertainties, self-doubt, family abandonment, social rejection, quiet moment of desolation and despair. The PTSD patients of Jordan believes that Allah would be their raft through turbulent and uncertain seas of living with PTSD provided a much needed buffer and a source of strength and resolve to ‘survive’ these traumatic times.

The essence of the meaning: For PTSD patients, PTSD is the situation or condition that God’s gave to them and by having faith as an anchor in life, a satisfying period of life that is lived with the need for acceptance in moving toward to their recovery.

Figure 2. Framework of the meaning of being PTSD patients of Jordan

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APPENDIX IX Framework for understanding PTSD patients of Jordan Lived Experiences A gradual waning of strength exacerbated by sleep deprivation, flashbacks, and nightmares coupled with feelings of loss of independency and loss of control over one’s life surfaced feelings of anger and frustration. For the participants of this study the struggle for independence was thwart with difficulties which encompassed feelings of extreme tiredness, lack of energy, a reluctance to rely on others, and a strong desire to regain control over one’s life. The very thought that recovery may never be a reality engendered in a number of the participants feelings of fearful apprehension. Feeling discriminated and marginalised by society was, for a number of participants a disquieting and humiliating experience that engendered feelings of rejection, dejection, and a sense of imprisonment. Feeling ignored and neglected by health care professionals engendered in a number of the participants a sense of vulnerability at not receiving what they believed to be appropriate quality care. Feeling abandoned by family engendered in the participants moments of quiet desperation and at times fearful apprehension that the very fabric of daily living – family love and support - had dissipated to the point of being non existent. Meaning attached to the experiences

Figure 3. Framework for understanding PTSD amongst the PTSD patients of Jordan

Exhaustive description: The PTSD patients of Jordan are frustrated because of their unrelieved PTSD symptoms restrict their physical mobility and autonomy; and they are interacting with feeling frustrated at a diminishing health status, struggling to maintain a state of dependence, harbouring fears that they may never recover, feeling discriminated against and marginalised by society, ignored and neglected by health care professionals and feeling abandoned by family.

Exhaustive description: Having faith in Allah was also a source of strength for the participants in coming to a point of acceptance of their illness and associated disabilities and limitations. Reaching the point of acceptance that life had forever changed as a result of their accident and subsequent illness surfaced feelings of personal liberation which gave rise to being able to look at the future in new and affirming ways within the context of their disabilities.

PTSD is defined by the PTSD patients of Jordan, by having faith in Allah was an anchor amid, overwhelming physical and emotional difficulties, frustrations, uncertainties, self-doubt, family abandonment, social rejection, quiet moment of desolation and despair. Belief that Allah would be their raft through turbulent and uncertain seas of living with PTSD provided a much needed buffer and a source of strength and resolve to ‘survive’ these traumatic times.

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APPENDIX X

Participant Profiles

A brief profile of each of the participants is presented in order to provide a background for

the presentation of findings. As a means of ensuring confidentiality, each participant has been

assigned a fictitious name.

Participant 1 (Murad’s) Story

Murad is 30-years of age and married with three children – two girls and one boy. The eldest

is 9 years of age, the second is 8 years, and the youngest is 7 years. Murad was married at the

age of 18 years. He is the second youngest in a family of five children. Murad and his family

live on the same property as his parents but in a separate dwelling. Prior to his accident

Murad worked at a University in Jordan where he was employed as a maintenance man.

Murad discontinued his university studies at the age of twenty because of financial

difficulties, and inability to provide for his immediate family and his parents. Murad was hit

by a motor vehicle which was involved in a two car collision. One of the cars involved in the

collision continued through the pedestrian crossing at the same time that Murad was

attempting to cross the road. He was admitted to hospital in an unconscious state. He

sustained significant injuries which have left him with permanent physical disabilities. At the

time of interview Murad was living at home and in part-time employment.

Participant 2 (Nasrine’s) Story

Nasrine is a 38 year old mother, living with her husband and four children – three boys and

one girl. Her three sons are 17, 15, and 13 years of age. Nasrine’s daughter is 10 years of age.

Nasrine and her family live with her parents together with her brother’s family in one

apartment in Irbid City. Nasrine was driving her car when another car suddenly crashed on

her car. She was in semiconscious when the paramedics, policemen and firemen arrived and

transported her to hospital. Nasrine was hospitalised for one month. Before the accident

Nasrine was employed as a clerk in a government department. Since her discharge from

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hospital, Nasrine has been unable to return to employment because of the disabling impact of

the accident and subsequent development of PTSD.

Participant 3 (Fatima’s) Story

Fatima is a 40 year old mother, living with her husband, two daughters, and three sons. Her

two daughters are aged 18 and 17 years both of whom are enrolled at University. Fatima’s

three sons aged 12, 14 and 15 years are in high school. Fatima and her family reside in their

own home. Prior to the accident Fatima worked as a secretary however, since the accident

she has resigned from her position. The accident was the result of Fatima panicking at a

change of lights at an intersection which caused her to lose control and crash into on-coming

traffic. The impact of the accident left Fatima unconscious and she was subsequently

admitted to hospital. Fatima also sustained significant bruising and lacerations to the left side

of her face which has left some scaring. Her recovery from her physical scaring and PTSD

has been slow and arduous. At the time of interview Fatima presented as anxious and self

conscious about her appearance and her mental state.

Participant 4 (Noor’s) Story

Noor is a 35 year old mother living with her husband and four children – one boy aged 15

years and three girls aged 13, 12, and nine. The family live in a rental apartment. Noor has

completed a Bachelor of Education and was employed as an elementary teacher in a private

school in Irbid city. Prior to her accident Noor was made redundant from her teaching

position and is now working as a medical secretary in one of the medical clinics in Irbid city.

Noor’s accident was a result of her losing control of her vehicle. She was unconscious at the

scene of the accident and was subsequently hospitalised. After regaining consciousness Noor

discharged herself from hospital against medical advice because of what she perceived as

poor treatment by nursing staff. Since being discharged Noor has not attended follow-up

appointments. As a consequence of her accident Noor sustained a number of physical injuries

and was being treated for PTSD which has left her emotionally and psychologically unable to

care for herself. Noor’s sister provides daily assistance. At the time of interview Noor had not

returned to work but hoped to do so soon.

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Participant 5 (Reem’s) Story

Reem is 49 years of age, married with six children - four sons and two daughters. The

children are aged between 23 and 16 years. Reem is the fifth daughter in her family who has

assumed responsible for the care of her parents who live in the same apartment building.

Apart from caring for her own family and her parents, Reem also works full-time as an

assistant bank manager in an inner city branch. Reem was travelling to Aqaba by bus when

the bus in which she was a passenger attempted to overtake without indicating, resulting in a

collision with another bus. All the passengers sustained major injuries requiring them to be

hospitalised. Reem was concussed and had bruising to all parts of her body. The

psychological impact of the accident resulted in Reem becoming fully dependent on her

husband and children. She received psychiatric treatment for PTSD in Amman, the capital

city of Jordan. Reem is starting to recover and has plans to go back to work. She continues to

receive treatment for her condition.

Participant 6 (Miriam’s) Story

Miriam is a 55 year old widow with seven adult children. She has five sons and two

daughters. Five of her children are married and have their own families. Miriam lives by

herself with her two youngest children, Rami and Ramsi. Rami is a third year college student

and Ramsi is in the 12th grade of secondary school. Miriam lives in a rental apartment near

her eldest daughter. Since her retirement as a public elementary school teacher, she has been

working as a part-time tutor to support her two sons. Miriam was hit by a speeding car while

attempting to cross a pedestrian crossing. She was knocked unconscious, treated at the scene

by paramedics, and transferred to Amera Basma hospital where she underwent surgery for a

fracture of her left leg. Miriam is a religious woman. Recitation of the Quran is an important

part of her daily life which has become a great source of comfort and hope since her accident

and subsequent diagnosis of PTSD. As a result of her accident Miriam lost her part-time

position, the only source of income for the family. She is currently living with her eldest son.

Miriam is hopeful that she will be given government financial support as she has contributed

to a superannuation fund since commencing work at an early age. Miriam presented as a

highly motivated person whose one desire is to recover from PTSD.

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Participant 7 (Mohammad’s) Story

Mohammad is a 45 year old male living with his wife and three sons aged 20, 19, and 17. He

owns a small house away from the city. He is employed as a manager in a telephone company

in Irbid. Although he has a good position, his salary is insufficient to meet the financial

commitments of the family. He has subsequently had to take on a second job as an electrical

service man. Mohammad’s wife is not working and his children are all attending college.

Mohammad, as the eldest son is also responsible for looking after his parents. Mohammad

was a passenger in a taxi which collided with another vehicle. As a result of the collision both

Mohammad and the driver were hospitalised and treated for minor bruising. Her was placed

under observation for a number of hours and eventually discharged from hospital.

Mohammad has returned to work but unable to maintain both jobs which has resulted in a

financial burden for the family. As a result of his condition (PTSD) and physical disability,

Mohammad has not been able to function at his pre-accident capacity. During the period of

his recovery Mohammad has also had to contend with relatives who have attempted to claim

ownership of his property. At the time of interview Mohammad continues to work toward his

recovery.

Participant 8 (Ahmad’s) Story

Ahmad is a 40 year old male, living with his wife and four sons aged 15, 13, 10, and 7 years.

Ahmad and his family live in their own house with his parents. Ahmad’s parents live in an

adjoining room to the main house. Ahmad has assumed primary responsibility for the care of

his parents supported by his siblings who help with their everyday needs. Ahmad was

awarded a Bachelor of Business Administration; however, due to the socio-economic state of

the Jordanian economy Ahmad has not been able to obtain a position commensurate with his

qualifications. The only alternative for him at the time was to leave Jordan for work overseas

which he did for a three-year period. Since his return he has opened his own small business –

a clothing boutique for women. Ahmad was hit by a car at a pedestrian crossing on his way

home from work. He sustained multiple injuries including being knocked unconscious and

sustaining a fracture of his right arm. He was attended to by Paramedics at the accident scene

and transferred to a local hospital for treatment. Ahmad remained in hospital for six weeks

where he was treated for PTSD. Since his accident Ahmad has been struggling to come to

terms with his situation which has included bouts of anger, feeling ashamed about his mental

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health issues, and having little support from family, friends, and the government. At the time

of interview Ahmad was receiving treatment and is improving.

Participant 9 (Mohammoud’s) Story

Mohammoud is 55 years of age. He is married with four children - one girl and three boys, all

of whom are married. Mohammoud was employed as an administrative officer at a Jordanian

University but has now retired. He is now the manager of a small restaurant (second job after

his retirement) which provides him and his wife sufficient income for their daily needs.

Mohammoud’s wife also works part-time as a cashier in one of the supermarkets in Irbid. All

Mohamoud’s children and their respective families live in the same apartment building of a

small town some distance from the city. Mohammoud was parked at a local shopping centre

when a driver of a car lost control of the vehicle and slammed into the back of

Mohammoud’s car. He was rendered unconscious at the scene and taken by ambulance to

Amera Basma hospital where he received treatment for his condition. Mohammoud remained

in hospital for a number of weeks for his physical injuries. After being discharged he was

referred to another institution for treatment of PTSD. Unfortunately, the institution was

situated some distance from where Mohammoud and his family lived making it impossible to

attend. As a result of his accident and subsequent physical and mental health status

Mohammoud was unable to work and therefore, found himself in financial difficulties. He

received some financial support from the government but insufficient to pay for expenses

incurred as a result of hospitalisation and treatment. At the time of interview Mohammoud

was on the way to recovery.

Participant 10 (Ibrahim’s) Story

Ibrahim is a 60 year old widower and grandfather who has seven adult children all of whom

are married. He lives with his youngest son and daughter-in-law. Ibrahim retired at age 58 as

a postman. After his retirement he took up a position as a security guard in one of the malls in

Irbid which allowed him to contribute to the financial expenses of the family. Ibrahim was

involved in a car accident on his way home from work when he swerved to miss an animal in

the middle of the road and subsequently hit a tree. As it was night there was no traffic and

therefore, no one to render assistance. Ibrahim was forced to crawl to the roadside where he

gained the attention of a passer-by who took him to the local hospital. Ibrahim only sustained

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minor injuries and was discharged from hospital to recuperate at home. While at home

Ibrahim increasingly became irritable, and angry at not being able to contribute to the family

and struggled to accept that he had been diagnosed with ‘a mental illness’ (PTSD) and

became increasingly agitated about what other people would think. Ibrahim was also

concerned about his financial situation; his pension was inadequate to support his treatment

and daily expenses, although his children provided some financial assistance. He received no

support from the government. At the time of interview Ibrahim presented as a man who was

struggling to accept his situation and expressed doubts that he would ever recover. Ibrahim

remains at home in the care of his son and daughter-in-law.

Participant 11 (Mousa’s) Story

Mousa is a 29 year old father, living with his wife and two sons – the eldest is 5 years old and

the youngest is 3 years of aged. Mousa and his family live in their own flat with Mousa’s

parents. Mousa graduated from the University of Jordan with a degree in English and was

looking forward to a career in teaching, however, because of the high number of applicants

for such positions he was placed on a waiting list. Realising that he may not get a position in

teaching Mousa found employment as a mail delivery man at a local post office. After he

graduated he married his first cousin. While at work Mousa was involved in a motor vehicle

accident when one car crashed into him. He was knocked unconscious. When he regained

consciousness he found that he was in hospital with cast on his left leg. Mousa sustained

some bruising to his face and parts of his body. He spent one month in the hospital after

which he was discharged with a referral to his doctor. As a result of the accident Mousa

developed depression. He was subsequently diagnosed with PTSD. Since his accident Mousa

has isolated himself from family, friends and relatives because of his condition and

appearance. After some time his wife persuaded him to seek help and receive treatment in

Amman. After a few months of receiving treatment Mousa believes he is on the road to

recovery. Devotion to Allah has became an important daily activity in helping him cope with

his illness and disability.

Participant 12 (Saddam’s) Story

Saddam is a 28 year old father, living with his wife and two sons in a small town far from

Irbid city. His eldest son is three years of age and the youngest son is one and half years old.

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They share an apartment with his eldest brother, his wife and three sons. Saddam works as a

public elementary teacher in Irbid. He also has a part-time position as a tutor every weekend.

His wife is unemployed electing to remain at home to take care of their two children. Saddam

was involved in an accident while taking his family on a picnic. The accident occurred when

a small boy attempted to cross the road in front of Saddam’s car. In an attempt to avoid the

young boy Saddam swerved and lost control of his vehicle crashing into an on-coming car.

None of the family were injured except for Saddam who sustained minor lacerations. He was

admitted to hospital for treatment. While in hospital Saddam began to exhibit symptoms of

PTSD and was subsequently diagnosed with the condition. He was discharged from hospital

four days later on medication for anxiety and depression. After returning home Saddam was

fully reliant on his wife and sister-in-law. With support and encouragement from his family

Saddam began to show signs of recovery. The family continues to have financial difficulties

as a result of Saddam’s illness and inability to work.

Participant 13 (Mai’s) Story

Mai is an 18 years of age. She attends a Jordanian University. She lives with her parents and

her two brothers. Her eldest brother is 19 years of age and also a student at the same

University. Her other brother is 15 years of age. Mai was involved in a motor vehicle

accident as a result of speeding and losing control of her car. At the time of the accident Mai

was not wearing a seatbelt and therefore, sustained major injuries. She was admitted to

hospital in an unconscious state with fractures to her right arm. She was hospitalised for one

month after which she was discharged from the orthopaedic unit and continued her treatment

at home. After two months convalescing at home Mai returned to University to continue her

studies. Soon after her return to university Mai became depressed and her physical health

began to deteriorate. Mai asked her parents to arrange for her to see a doctor about her

condition. She was referred to a psychiatrist for assessment and was subsequently diagnosed

with PTSD. At the time of interview Mai had returned to her university studies.

Participant 14 (Kholoud’s) Story

Kholoud is a 58 year old mother, living with her husband and eight daughters, five of whom

are married and lived with their husbands. However, Kholoud, her husband and the four

unmarried daughters aged 19, 20, 22, and 23 are still living together near her husband’s

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parents. Kholoud works as a secretary in a company in Irbid. She plans to retire after her four

daughters are married. Kholoud was involved in a motor vehicle accident which involved a

collision while she was making a U turn. Kholoud was hospitalised and treated for minor

injuries. After discharge from hospital everything seemed to return to normal, however,

Kholoud began to exhibit symptoms of anxiety, flashbacks to the accident, and depression.

She was referred by her local doctor for a full psychological assessment and was diagnosed

with PTSD. Since the accident and developing PTSD Kholoud has become fully dependent

on her husband and children physically and financially. At the time of interview Kholoud

spoke of her hopes for a full recovery sometime in the future.

Participant 15 (Eman’s) Story

Eman is a 29 year old single lady living with her parents and youngest brother who is 24

years old and also single. Eman also has a second brother who lives overseas. Eman and her

brothers live in a duplex house which was built and is owned by her eldest brother who is

working overseas. Eman was hit by a car while crossing an intersection. The impact of the

collision rendered Eman unconscious. She was subsequently taken to hospital by ambulance

where she was treated for her unconscious state and cuts and abrasions sustained by the

accident. After regaining consciousness Eman remained in hospital for observations and

psychological assessment. She was diagnosed with PTSD and referred on to a specialist for

treatment. Eman was discharged to the care of her family because of her inability to look

after herself. She did not follow up with her specialist consultation. After a lengthy period of

physical recovery Eman returned to her position as a secretary at the university. Soon after

her return to work, Eman began to exhibit behaviours consistent with PTSD. Colleagues

found out that she had been diagnosed with a mental illness and ostracised her from social

activities in the workplace. Eman’s only source of consolation was her faith in Allah. At the

time of interview Eman was still living with her parents and had leave of absence from work.