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
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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
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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.
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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).
Appendix VI-5 Copyright permission from Michele Rosenthal [[email protected]]........................................................................................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
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
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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.
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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
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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
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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
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
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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
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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.
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).
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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
28
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
29
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
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).
32
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 &
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
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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
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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.
56
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.
57
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.
58
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.
59
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
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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 [email protected]
Appendix VI-2. Copyright permission from Info, Concierge [[email protected]]
Appendix VI-3. Copyright permission from Geraldine Dukes [[email protected]]
Appendix VI-4. Copyright permission from colin turvey [email protected]
Appendix VI-5. Copyright permission from Michele Rosenthal [[email protected]] 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: [email protected] Second Supervisor: Dr. Meng Lim School of Nursing & Midwifery St. Albans, Victoria University Phone: (03) 93652222 [email protected] Researcher : Lilibeth Al-Kofahy Phone: 7102137 [email protected] 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 [email protected] 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 [email protected] 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 [email protected]
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" <[email protected]> To: <[email protected]> Sent: Tuesday, December 07, 2010 5:56 AM Subject: Message from Paganshop1.com > From: Lilibeth Al-Kofahy > Email: [email protected] > > ------------------------------------------------------ > > 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: [email protected] > Login Name: Not logged in > Login Email: Not logged in > IP Address: 131.181.251.10 - 131.181.251.10 RE: General Feedback
From: Info, Concierge [[email protected]] 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: [email protected] [mailto:[email protected]] Sent: Thu 11/25/2010 5:43 PM To: Info, Concierge Subject: General Feedback Lilibeth Al-Kofahy has sent the following feedback: Email: [email protected] 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.
Re: Enquiry from your website Geraldine Dukes [[email protected],.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: [email protected] 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
Wednesday, 24 November, 2010 10:23 AM From: "Lilibeth Al- Kofahy" <[email protected]> Add sender to Contacts To: "colin turvey" [email protected] 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 <[email protected]> wrote: From: colin turvey <[email protected]> Subject: RE: Query - Permisssion To: [email protected] 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
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
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 <[email protected]> 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.