Running Head: TRAUMA AND RESILIENCE
Why Don’t All Trauma Survivors Develop Post-traumatic Stress Disorder?
A Multi-method Exploration of Resilience.
RESEARCH PAPER
Author: Vivien Le Fort
Supervisors: Dr Anke Karl and Dr Janet Smithson
Nominated journal: Journal of Traumatic Stress
This manuscript has been submitted in partial fulfilment of a Doctoral degree in Clinical Psychology.
Word count: 7963 (excluding tables, references and appendices; 13,248 with appendices).
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TRAUMA AND RESILIENCE
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Contents
1. Title page……………………………………………………………………………………….….25
2. Contents…………………………………………………………………………………………....26
3. Abstract………………………………………..………………………………….……………..…27
4. Literature overview……………………………………………………………………………..….28
5.1 Method 1: Psychophysiological Feasibility Study……………………………………...…….….32
5.2 Results 1: Psychophysiological Feasibility Study…..…………………………………………….38
6.1 Method 2: IPA Study..………………………………………………………………….………..43
6.2 Results 2: IPA Study..……………………………………………...…………………………….46
7. General Discussion……...………………………………………………………………………….54
8. Concluding comments……………………………………………………………………………...61
9. References………………………………………………………………………………………….62
10.Appendices…………………………………………………………………………………………66
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Why Don’t All Trauma Survivors Develop PTSD? A Multi-method Exploration of Resilience.
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Abstract
The role of factors which influenced individual differences in post-trauma outcome were
explored using a multi-method design, in response to recommendations in the literature that self-report
data should be incorporated into studies of post-traumatic stress disorder (PTSD). In part 1, a
psychophysiological study with process interviews was tested for feasibility and acceptability with a
small-scale sample (n = 17) and found individual differences between how participants described
responding to trauma-related picture stimuli. Five primary response types were identified: avoidance,
acceptance, increased attendance, dismissal and confrontation.
In part 2, resilient and recovered individuals (n = 11) were interviewed in depth about their
experiences of coping with trauma and transcripts were analysed using an interpretative
phenomenological approach. Themes identified were attitudes and beliefs, emotion regulation,
narrative development, support and safety and recovery. Some resilient participants described initial
use of avoidance as a coping strategy but moved from this position towards acceptance of their trauma
in their recovery journey. Therefore avoidance may play a more helpful role than has previously been
thought. The importance of specific attributes of factors positively associated with recovery from
trauma and potential interactions between these factors was discussed.
Keywords: Post-traumatic stress disorder, resilience, coping, trauma, emotion regulation.
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Literature Overview
Post-traumatic stress disorder (PTSD) can develop in response to exposure to severely traumatic
events, such as threatened or actual death or serious injury, or threat to the physical integrity of the self
or others, which inspire feelings of helplessness, fear or horror (American Psychological Association,
2000). It is a highly disabling condition (Elsesser, Sartory & Tackenburg, 2005), affecting functioning
across domains and producing symptoms of intrusive recollections, avoidance and numbing, and hyperarousal (APA, 2000).
Many trauma exposed individuals do not go on to develop PTSD, even following extreme
stressors such as incarceration in the Holocaust concentration camps (Barel, Sagi-Schwartz, Van
Ijzendoorn & Bakermans-Kranenburg, 2010) and war trauma or torture (Johnson & Thompsen, 2008).
Latent growth mixed modelling statistical techniques have identified several post-trauma trajectories of
symptomatology and functioning: chronic PTSD, delayed onset PTSD, PTSD followed by recovery,
and resilience (Bonnano, 2004). The resilient pathway, in which people showed some initial symptoms
before quickly resuming baseline functioning, was the most common response to trauma (Bonnano,
Westphal & Mancini, 2011; Norris, Tracy & Galea, 2009).
Researchers have examined the variables that distinguish resilient individuals, or those who
successfully recover, from those who develop chronic PTSD (Elwood, Hahn, Olatunji & Williams,
2009). A range of significant individual vulnerabilities and social and demographic variables have
been identified, but these have failed to explain more than a low proportion of the variance (Elwood et
al., 2009).
Psychophysiological research has been a useful methodology to explore some variables because
findings have provided an opportunity to reconsider the pathophysiology of PTSD (Pole, 2007). In his
meta-analysis of 122 psychophysiological studies, Pole (2007) concluded that the ability to regulate the
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body following trauma exposure, measured through skin conductance habituation to startle sounds,
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rather than the initial startle response researchers had previously concentrated on, had the most robust
effect size and therefore was the most promising variable in potentially discriminating resilient and
PTSD individuals.
However, Pole (2007) suggested the variance within these findings might reflect a sub-group of
PTSD participants utilising numbing or dissociation strategies when confronted with the trauma-related
stimuli. Therefore participants may have used different emotion regulation strategies, an area requiring
further research.
The importance of emotion regulation was supported by Mancini and Bonnano’s (2006) two
year follow-up of survivors of the 9/11 terrorist attacks, where the strongest predictor of resilience was
flexibility on emotion regulation, measured as the ability to engage in emotional expression or
suppression when instructed to do so. These researchers argued that given the complexity of the
phenomenon of resilience, psychological studies must examine actual outcomes after a potentially
traumatic event, and not simply focus on characteristics globally associated with resilience.
These findings support emotion dys-regulation models of PTSD (e.g., Lanius, Frewen,
Vermetten & Yehuda, 2010), which explain PTSD development as a failure to manage unwanted
emotional experiences following stress sensitization, resulting in individuals alternating between overand under-modulation. This model therefore accounts for both the hyper-arousal and hypo-arousal
symptoms of PTSD, a challenge which has eluded some alternative theories.
It would therefore be useful to explore the differences between trauma exposed individuals with
and without current PTSD in terms of emotional regulation when exposed to trauma-related stimuli.
Schaubroeck, Peng, Riolli & Spain (2011) have called for a study of how people respond during the
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period they are exposed to trauma related stimuli and both Pole (2007) and Bonnano et al. (2011) have
suggested that self-report data should be examined alongside psychophysiological measures, filling a
gap in the existing literature. The phenomenological psychopathology approach, in which self-report
data are combined with neurological or physiological data to better understand an experience, has
recently gained popularity in neuroimaging research (e.g., Lutz & Thompsen, 2003) and would be
appropriate.
This proposed design would be novel and might therefore be tested in a small-scale feasibility
and acceptability study to identify whether different data could be usefully combined in order to
enhance understanding of individual differences in psychophysiological reaction to trauma-related
stimuli.
However, a comprehensive understanding of resilience to trauma would need to consider how
the individual responded to their trauma experience, as well as how they behave in the laboratory when
presented with a traumatic stressor (Pole, 2007; Mancini & Bonnano, 2006). Given the heterogeneity
of the trauma resilient population and the wide variety of potential factors associated with resilience
including personality, interpersonal and stressor variables (see, for example, Elwood et al, 2009),
qualitative methods which enable a detailed, idiographic description of the experience would give a
more comprehensive insight than self-report measures based on a specific concept or theory driven
qualitative methodologies.
Interpretative phenomenological analysis (IPA; Smith, 2004), a qualitative research approach
that examines how people make sense of their major life experiences (Smith, Flowers & Larkin, 2009)
has been employed in recent studies with topics related to PTSD and resilience, such as the experience
of being a family member of a veteran with PTSD (Ray & Vanstone, 2009), exploration of young
offenders’ responses to traumatic experiences (Paton, Crouch & Camic, 2009) and examination of the
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experiences of people living in risky and disadvantaged circumstances (Stanley, 2011). Given the
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focus on developing a better understanding of the experience of an individual who has undergone a
major life event, IPA would be an appropriate method for the exploration of the coping strategies and
recovery process undergone by participants after their real-life trauma.
Aims and Research Questions
Review of the literature has concluded that psychological study of variables associated with
resilience, of which emotional regulation appears promising, should include self-report data
corresponding to the psychophysiological symptom under investigation, as well as exploration of actual
resilience after a potentially traumatic event. The aim of this research project is test both of these
recommendations: firstly, by conducting a feasibility study to examine whether combining
psychophysiological and self-report data is a useful and acceptable design when applied to this research
topic; and secondly, by using a phenomenological qualitative method to explore how recovered or
resilient individuals responded to actual traumatic events.
1. To ascertain whether the combination of psychophysiological data (heart rate response) and selfreport data (process interviews) in a phenomenological psychopathology design is feasible and
acceptable as a novel methodology to address the research question of whether trauma survivors with
PTSD show slower heart rate habituation to trauma-related stimuli in comparison to survivors without
PTSD.
2. To explore through self-report data how the participants responded to or coped with the traumarelated picture stimuli.
3. To explore how trauma-resilient individuals experienced and responded to their trauma experiences
through interpretative phenomenological analysis of semi-structured interviews.
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Method 1: Psychophysiological Feasibility Study
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Design
This feasibility and acceptability study combined cross-sectional psychophysiological data with
process interviews.
Pre-study Power Calculation
Pole’s (2007) meta-analytic review did not report an effect size for heart rate habituation slope
(HRHS) to trauma cues due to a lack of existing studies. However, his meta-analysis reported medium
effect sizes, with significant heterogeneity, for heart rate reaction to both standardized and idiographic
trauma cues. Therefore assuming as a starting point a potential medium effect size for HRHS (r = 0.5),
this study design which predicted the direction of the difference between means for two independent
groups would need to recruit 51 participants per group to achieve acceptable statistical power (0.8).
Participants
Figure 1 outlines the participant recruitment process. All applicants met the following inclusion
criteria: aged 18 years or over; direct experience or witnessing at least one traumatic event in their
lifetime which fulfilled criterion A for PTSD diagnosis (DSM-IV-R; APA, 2000); and ability to attend
the study site in the South West of England within the four moth testing window. None met the
exclusion criteria which comprised currently taking prescribed cardiac medication, having a pacemaker
fitted, having a history of cardiac surgery that would influence heart rate response, or currently taking
prescribed psychotropic medication for any mental health condition which might influence heart rate
(e.g. medications for anxiety or depressive conditions).
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31 individuals expressed an
interest in participating in the
study in response to community
advertising and were sent the
participant information sheet
(see Appendix 5).
21 individuals booked an
appointment to take part in the
study.
17 individuals took part in the
psychophysiological study.
10 individuals did not proceed
further with the study despite
follow-up email contact.
4 individuals were unable to
attend or reschedule their
appointments due to ongoing
illness and new work
commitments.
Figure 1. Flowchart Outlining Recruitment Process.
The participant group comprised seven men and ten women and were aged between 20 and 70
years (mean = 44 years). The vast majority described themselves as White British (88%) with the
remaining two participants reporting White European (n=1) or Chinese (n=1) ethnicity. Six reported
formal psychiatric diagnoses, primarily depression (n=6), PTSD (n=4), anxiety (n=4), mental fatigue
(n=1) and agoraphobia (n=1).
Measures
Life events checklist (Blake, Weathers, Nagy et al., 1995). This screening measure lists 16
potentially traumatic events known to result in PTSD or other post-traumatic difficulties (Gray et al.,
2004) and an item inquiring about inordinately stressful events not captured by the other items. It has
adequate reliability and stability as a screening measure of direct trauma experience and strong
convergence with measures of psychopathology associated with trauma exposure (Gray et al., 2004).
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Participants completed a 5-point scale to indicate their level of exposure to the trauma and were scored
two points for each event that had happened to them and one point for each event that they had
witnessed.
PTSD checklist – civilian version (PCL-C; Weathers, Litz, Huska & Keane, 1994). This
17-item self-report instrument parallels diagnostic criteria B, C and D for PTSD, as specified in the
DSM-IV (APA, 1994). The PCL-C has been found to have strong internal consistency and good testretest reliability, as well as convergent and discriminant validity (Ruggiero, Del Ben, Scotti & Rabalai,
2003). For each PTSD symptom the participant indicated on a 5-point Likert scale the extent to which
they have been bothered by that problem in the last month. Participants were scored between one and
five points for each response with higher scores indicating greater symptomatology and were scored
against the diagnostic criteria to identify the presence of PTSD or sub-threshold PTSD (APA, 2000).
Table 1.
Participant Total Group, PTSD Group and Non-PTSD Group Responses to Questionnaire Measures
Sample
Trauma typeᵃᵇ
Sex (N)
Measure
Mean
SD
Total participants
Male = 7
Age
44.24
14.85
(N=17)
Female = 10
LEC
12.35
8.43
PCL-C
34.59
14.28
PTSD group
Interpersonal violence = 5
Male = 2
Age
45.17
17.94
(N=6)
Accident = 4
Female = 4
LEC
12.67
5.85
PCL-C
43.33
14.33
Life threatening injury = 4
Sudden death = 4
Disaster = 3
Other = 3
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Non-PTSD group Accident = 9
Male = 5
Age
43.73
11
13.83
(N=11)
Female = 6
LEC
12.18
9.82
PCL-C
26.55
4.70
Interpersonal violence = 7
Sudden death = 6
Other = 5
Disaster = 3
Life threatening injury = 3
Combat = 1
ᵃ “Accident” includes transport, home or work accidents or exposure to toxic substances; “Interpersonal violence” includes
physical assault, assault with a weapon, sexual assault, unwanted sexual experience and captivity; “Life threatening injury”
includes life threatening injuries and illnesses and severe human suffering; “Disaster” includes fire and natural disasters;
“Combat” refers to combat or exposure to a war-zone; “Sudden death” refers to sudden death of a person who was close to
you, homicide, suicide and causing serious harm, injury or death to others..
ᵇ All PTSD participants and eight non-PTSD participants had experienced multiple traumatic events. Multiple event types
within an event category (e.g. physical and sexual assault) were not included.
Process interview for psychophysiological testing. The semi-structured process interview
guide was developed by the researcher and reviewed by a clinical psychologist with significant
psychophysiological and trauma-related research and clinical experience. The process interview took
approximately five minutes to administer and was designed to capture the experience and recollections
of the participant immediately following their viewing of the picture stimuli (see Appendix 6).
Stimulus Material and Paradigm
Forty-eight full-screen coloured pictures were presented sequentially, each presented for
6000ms with a 3000ms white screen gap in between each picture, using Eprime software. The 48
pictures comprised 12 pictures in each of 4 categories: trauma related, neutral, pleasant and unpleasant.
The category order was randomised and within each category picture order was randomised. Pictures
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were taken predominantly from the International Affective Picture System (IAPS; Lang, Bradley &
Cuthbert, 1995). Different versions of the experiment were prepared with various trauma types (natural
disaster, fire, military conflict, car accident, interpersonal violence) to allow for matching between
stimuli and participant trauma experience.
Psychophysiological Data Collection
Heart rate (HR) was determined from continuously recorded electrocardiogram (ECG) using
AcqKnowledge software, version, 4.1.1. ECG was measured using electrodes placed below the
participant’s right collar bone and on their left side underneath the ribcage. The ECG signal was
sampled at 1000 Hz with a low pass filter of 35 Hz and a high pass filter of 0.5 Hz. For HR
determination the data were transformed using a template correlation to remove large artefacts, and R
peaks were identified on the ECG waves. Remaining artefacts from noisy, missing or ectopic beats
were interpolated from the adjacent R-peaks (this was only necessary in one case). The interpolation
procedure was used for less than 5% of the ECG data. HR in beats per minute (bpm) were then
extracted stimulus-locked over a -1 to 6 s time window.
Procedures
Ethical approval was obtained from the Plymouth and Cornwall NHS Research Ethics
Committee and the University of Exeter’s School of Psychology Ethics Committee (see Appendices 2
and 3). Participants gave written informed consent and were not paid for taking part although travel
expenses were reimbursed and a small prize draw was carried out. Participants were recruited through
community advertising and purposive sampling. Participants contacted the researcher by email or
telephone and were sent information about the study and the consent form (see Appendices 4 and 5).
Those who consented completed a screening form and the psychometric battery either at home
themselves or at an appointment with the researcher.
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The psychophysiological experiment took place at a university laboratory. Participants were
seated approximately 60 cm from a computer screen and asked to find a comfortable position and sit as
still as possible for the duration of the experiment, which lasted approximately 8 minutes. Participants
were instructed to simply observe the picture material and advised that they would be asked some
questions about what they thought of the pictures afterwards. The researcher left the room and dimmed
the lights to enhance picture observation. Following presentation completion the researcher re-entered
the room, ended the ECG recording and began the process interview.
Process interviews took place as soon as possible after the participant had viewed the final
picture and removed their ECG recording devices. The researcher used the semi-structured process
interview schedule, omitting any questions that the participant spontaneously discussed and exploring
further any points raised by the participant. These interviews were digitally recorded. Participants who
also took part in study two were offered a short break and refreshments at this stage before starting
their study two procedure whilst other participants were debriefed to ensure they were not in any way
distressed before leaving.
Analysis Strategy
Psychophysiological data. Heart rate analysis was performed using Acqknowledge software,
version 4.1.1 to assist with data cleaning and extraction. The mean and standard deviation of beats per
minute were extracted for the 1000ms prior to each picture presentation in order to establish a baseline
for each participant. Mean, standard deviation, maximum and time of maximum beats per minute were
then extracted for each 1000ms interval from 0 to 6000ms following picture presentation so that a
response wave could be calculated for the entire 6000ms presentation per picture. Category and picture
order for each participant were extracted from Eprime software. This data was transported into Excel
2010 and SPSS version 20 for analysis.
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First baseline HR response was taken from the participant’s HR in the 1000ms window
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immediately prior to the first trauma-related picture presentation. Mean HR response was calculated by
deducting the mean baseline HR response from the mean HR response to each trauma-related picture
presentation for each 1000ms interval of the presentation window. Maximum HR response was
calculated by deducting the mean baseline HR response from the maximum HR response recorded over
the 6000ms presentation per picture.
Process interviews. Each digitally recorded process interview was transcribed by the
researcher. The analysis involved identification of any cognitive or physical coping strategies that
participants used in response to thoughts, feelings or physical reactions to the trauma pictures they had
seen. These reactions and coping strategy responses were coded and a list of strategies produced. Each
transcript was then checked against the code list to ensure that all relevant data had been captured and
that the list accurately reflected the responses given. The responses and strategies for each participant
were summarised (see Appendix 8).
Results 1: Psychophysiological Feasibility Study
Research Question 1.
To ascertain whether the combination of psychophysiological data (heart rate response) and
self-report data (process interviews) in a phenomenological psychopathology design is feasible and
acceptable as a novel methodology to address the research question of whether trauma survivors with
PTSD show slower heart rate habituation to trauma-related stimuli in comparison to survivors without
PTSD.
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Feasibility
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This study required recruitment of 102 participants in total to achieve an acceptable level of
statistical power based on the assumption of a medium effect size. Over the six month recruitment
period 31 individuals contacted the researcher to express an interest in the study but only 17 went on to
take part. Of these participants six met criteria for current PTSD symptomatology and eleven did not
present with PTSD. This would suggest that both groups were difficult to recruit with the PTSD group
especially problematic. Therefore future efforts to achieve full power with this design might require
recruitment from a wider geographical area (either multi-site design or use of portable laboratory
equipment), a longer recruitment period, an enhanced budget in order to provide a more meaningful
incentive for participation and a review of the advertising literature in order to encourage applications
from individuals with PTSD.
Acceptability
None of the participants expressed regret or distress at having taken part in the study. One
participant with PTSD brought her mother with her for support. Another individual reported that
viewing the trauma-related pictures, in this case car crashes, had reminded him of his own accident and
that this memory in turn had reminded him of other traumatic events that he had experienced
(witnessing the murder of a friend as a child). He commented that whilst he had not thought about this
event in a long time, he was not upset to have done so. None of the participants required further
support following the study or contacted the researcher with any concerns
Therefore this study design appeared to have been acceptable to participants, however the
researcher provided generous time allocation per participant (at least 1.5 hours) in order to allow
settling in time, progress through the procedures at the individual’s own pace and plenty of time for
debrief and unhurried conversation at the end. This level of time investment may need to be
maintained in order to also maintain acceptability.
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Group Differences in HRHS Response to Trauma-Related Pictures
The small sample size recruited prevented statistical analyses being carried out on the data set.
Group means are reported in table 3 and presented graphically in figures 2 and 3.
Table 3
Heart Rate Responses to Trauma-Relate Stimuli by Group
Group
PTSD*
N
6
Non-PTSD 11
First baseline HR readingᵃ
Max HR reactivityᵇ
M
SD
M
SD
70.0
7.9
1.0
2.0
76.6
16.1
1.2
2.1
* Participants were assigned to the PTSD group if they met, or scored within one point of meeting
diagnostic criteria on the PCL-C. Participants scoring below this threshold were allocated to the NonPTSD group.
ᵃ Heart rate beats per minute at first baseline reading.
ᵇ Maximum heart rate reactivity obtained for each trauma-related picture over the entire 0-6s exposure
window.
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2
1.5
HR change in bpm
1
0.5
0
0-1s
1-2s`
2-3s
3-4s
4-5s
5-6s
-0.5
-1
-1.5
Time
PTSD
Non-PTSD
Difference between maximum HR in bpm and baseline
Figure 2. Comparison of PTSD and Non-PTSD Group Time Course of HR Reactivity in bpm.
8
7
6
5
4
3
2
1
0
0
1
2
3
4
5
6
7
8
9
10
11
12
13
Trial
PTSD mean
Non-PTSD mean
Figure 3. Graph Showing Habituation Slopes for PTSD and Non-PTSD Groups over 12 Trials.
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Research Question 2.
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To explore through self-report data how the participants responded to or coped with the traumarelated picture stimuli.
Process interviews. Participants reported a variety of cognitive, physical and emotional
reactions to the picture stimuli. With reference to the trauma related stimuli, some participants
described no reaction (n=4). Others described predominantly mild feelings of tension (n=7), concern
(n=3), curiosity (n=3), sadness (n=3), anger (n=2), dislike (n=1) and feeling threatened (n=1). Just over
half of the sample (59%) described a physical response to the images of increased bodily tension.
Cognitive and physiological strategies were employed by some participants in response to the
trauma related stimuli. These are described in Table 4.
Table 4
Coping Strategies Employed in Response to Trauma-related Picture Stimuli
Strategy
Description
Example from transcript
N
Focussing attention elsewhere or
“probably the peripheral stuff, like the girl
5
on peripheral details within the
watching rather than the accident itself. I
image.
noticed she was wearing a red coat” [P12].
Accepting and tolerating
“Just let it impact on me rather than attempt
discomfort provoked by the
to respond”. [P10].
employed
Avoidance
Acceptance
5
image.
Increased
Engaging with and thinking about
“for some strange reason it was more the
attention
the people or events in the image.
violent ones I was paying attention to and
4
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imagining the scene”. [P8].
Reduced
Dismissing the image as
“they were relatively run of the mill and no
attention
uninteresting or unremarkable.
different from anything I’ve seen in twenty
2
odd years”. [P7].
Confrontation Forcing oneself to look at the
image.
“there were a couple which I didn’t want to
1
look at but…I made myself keep looking at
them anyway”. [P1].
Method 2: Interpretative Phenomenological Analysis Study
Design
Interpretative phenomenological analysis of semi-structured interviews was used to explore
participants’ experiences of recovering from a traumatic event.
Participants
Eleven participants expressed an interest in the study and agreed to take part following receipt
of the participant information sheet. Six of these participants had already taken part in the
psychophysiological study. All participants were aged 18 or over and had experienced at least one
traumatic event in their lifetime that they were willing to discuss. They also all described themselves
as having recovered from their traumatic experience.
The participant group comprised five men and six women aged between 26 and 60 years (mean
= 43 years). All participants described themselves as of White ethnicity with 82% stating they were
White British, one participant of White European ethnicity and one participant described their ethnicity
as Welsh.
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Measures
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The participants completed the Life Events Checklist and PCL-C as in study one.
Table 2
Participant Responses to Questionnaire Measures
Sample
Trauma typeᵃᵇ
Sex (N)
Measure
Mean
SD
Total participants
Accident = 9
Male = 5
Age
42.91
8.78
(N=11)
Sudden death = 9
Female = 6
LEC
12.18
5.67
PCL-C
25.64
11.80
Interpersonal violence = 8
Life threatening injury = 6
Disaster = 5
Other = 3
Combat = 1
ᵃ “Accident” includes transport, home or work accidents or exposure to toxic substances; “Interpersonal violence” includes
physical assault, assault with a weapon, sexual assault, unwanted sexual experience and captivity; “Life threatening injury”
includes life threatening injuries and illnesses and severe human suffering; “Disaster” includes fire and natural disasters;
“Combat” refers to combat or exposure to a war-zone; “Sudden death” refers to sudden death of a person who was close to
you, homicide, suicide and causing serious harm, injury or death to others..
ᵇ All participants had experienced multiple traumatic events. Multiple event types within an event category (e.g. physical
and sexual assault) were not included.
Resilience interview. The semi-structured resilience interview guide was developed by the
researcher and piloted with a colleague who had experienced a mildly traumatic event in order to check
comprehension, ease of use, sensitivity and relevance. In accordance with IPA methodology (Smith,
Flowers & Larkin, 2009), the schedule was designed for flexible use with the interviewer exploring
material raised by the participant. Recovery and resilience interviews took around 45 minutes to
administer and were held individually and face-to-face. The schedule can be found in Appendix 7.
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Procedure
Ethical approval was obtained and participant recruitment carried out following the procedure
outlined for study one. Resilience interviews lasted around 45 minutes and were all conducted by the
researcher, either at the laboratory or at the participant’s home or workplace. The investigator was a
final year trainee clinical psychologist with significant experience of conducting sensitive or difficult
interviews. The interview schedule was used flexibly with the researcher following up material raised
by the participant. Given the potentially distressing nature of some of the material raised by
participants the researcher used some supportive or normalising comments throughout interviews as
appropriate. Interviews were digitally recorded. Interviews were spaced generously between
participants to allow time for debrief, small talk and checking the participant’s experience of the
interview and current mood and wellbeing prior to departure.
Analysis Strategy
Resilience interviews. The digital recordings of each interview were transcribed by the
researcher and analysed using the interpretative phenomenological analysis (IPA) method (Smith,
2004; Smith, Flowers & Larkin, 2009). Following transcription initial impressions of the main points
made by the interviewee were recorded. The process of analysis involved several re-readings of a
transcript and coding of key phrases that best captured the point being articulated by the interviewee.
Initial codes were then developed into a coding framework in which similar codes were merged and
overarching themes identified. Each transcript and initial impressions were then re-read against the
coding framework to ensure that the essence of the interviewee’s arguments were fully captured and the
framework was refined during this process. Finally, for each theme, illustrative exemplar extracts were
identified. Nvivo software (v.10) was used to assist with this procedure.
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Maintaining research quality. One resilience interview transcript was analysed by a second
trainee clinical psychologist with experience of using IPA methodology and principles. The initial
impressions, key phrases and themes identified by both researchers were compared in order to explore
whether a similar understanding of the key elements of the participant’s experience had been reached
(see Appendix 9). The final thematic model was discussed with an experienced IPA researcher and the
identified themes were discussed with a group of clinical psychologists experienced in working with
trauma survivors. A reflexivity statement can be found in Appendix 10.
Results 2: Interpretative Phenomenological Analysis Study
How did trauma resilient and recovered individuals cope with and respond to their trauma
experiences?
Qualitative analysis. The experiences discussed by the trauma survivors included traffic
accidents (n=4), domestic violence (n=1), contraction of the life-threatening condition necrotizing
fasciitis (n=1), being attacked by an animal (n=1), unlawful death of a child (n=1) and exposure to
personal high risk and managing situations where people have died in the military, police, fire and
prison service professions (n=3). Some individuals talked about a period of initially developing a
trauma reaction, such as PTSD, heavy alcohol consumption or an eating disorder and then recovering,
whilst others felt they recovered from the event almost immediately.
Five thematic groups were identified as important in recovering from trauma. The first three,
Attitudes and beliefs, Emotion regulation and Developing narrative were classified as internal factors,
predominantly influenced by the individual. Support and Recovery by contrast are more externally
determined. These factors operate most effectively when they are mutually reinforcing, for example
TRAUMA AND RESILIENCE
23
with a social support network encouraging self-care and co-facilitating the development of a narrative
that is consistent with the individual’s positive beliefs. Figure 4 illustrates the dominant thematic
groups and contributory sub-themes.
Figure 4. Model Illustrating Dominant Thematic Groups and Contributing Sub-themes.
Attitudes and beliefs. This thematic group comprised the sub-themes of positivity,
responsibility and a sense of control. Positivity included specific comments about the use of humour to
cope, learning from the dramatic experience and describing oneself as lucky, as well as general positive
beliefs about self and the world. One participant identified humour as the single most important factor
in their ability to cope.
“And I think that’s what I’ve found, if you’ve got a good team around you, I think humour will
get you over it. Er, I think that’s, I think that’s the biggest thing for me, humour. Cause a lot of your
mates will be, ah, you know, if you don’t come back can I have your boots.” [P10].
TRAUMA AND RESILIENCE
24
The positivity sub- theme was also displayed throughout the transcripts, with many participants
laughing at some point when recounting their experience. This was absent for participants who initially
struggled after their trauma when they described that period and then became present when they talked
about their recovery. An element of positivity was found by participants even in the most difficult and
apparently hopeless situations.
“And I try and explain that to the new lads, who, especially with the fire [service], always
remember that you’re helping someone, and you’ll always leave a situation better than you found it.
Erm, regardless of the outcome, it’ll always be, even up to, you know I said about, if you are dealing
with a deceased person, you know, we’ll look after that body until, so we’re always, for peace of mind
you always know that you’ve done the best that you can.” [P9].
Responsibility involved a strong sense of concern for others, which was reflected in some
narratives as an immediate reaction by the participant, despite they themselves being injured or still in
some jeopardy. Some participants also spoke about a sense of responsibility for the traumatic event
empowering their recovery.
“So it, um, the strength I had to get myself through it was, it’s your own fault that this has
happened, now, just carry on and get on with what you’ve got to do.” [P2].
Another participant, who initially struggled to cope with her traumatic experience, resorting to
heavy alcohol use, identified the point at which somebody bluntly pointed out the consequences of their
behaviour on her child as a key moment in beginning her recovery. She identified how her efforts to
cope for her daughter gradually led to a genuine increase in ability to cope.
TRAUMA AND RESILIENCE
25
“well obviously once I got [my daughter] back I had to sort myself out. I couldn’t live the way I
had been living you know? So that was definitely a turning point…’cause it was a case of having to
sort myself out. Or at least pretend I was. And I guess with, over time, I did in a way make myself feel
better. I don’t know.” [P6].
The final sub-theme of the attitude and beliefs theme, sense of control, was cited by participants
as important and, similarly to concern for others as above, a turning point in one participant’s recovery
when she described suddenly realising that she could make a difference as important in developing
resilience.
“And that was the turning point because that was the first time that I ever fought back. And it
suddenly realised, to me, that I do have the power to do something about it and that I’m no longer
willing to put up with this kind of situation anymore.” [P8].
Emotion regulation. The second internal factor was Emotion regulation. Participants
described using distraction from their traumatic experience or subsequent physical pain, such as
curiosity, escapism and the ability to focus on something else, as helpful.
“I remember looking around the ambulance and wondering, ooh, what does some of this
equipment do kind of thing.” [P1].
“But, it wasn’t until I was going down to the theatre when they sort of laid the arm in, not like a
tray but, I was still slightly attached to it, but it was going down there and it’s amazing what goes
through your head. Because I’m a great Formula One fanatic. And all I was thinking about was
who’d won the French grand prix because I’d missed out on that going to the show that day. So I’d
obviously switched right off about what was happening to me there.” [P2].
TRAUMA AND RESILIENCE
26
Participants also expressed their emotions both in terms of describing their behaviour following
their experience and also during the interview, occasionally becoming tearful or showing a change in
vocal tone when recounting an annoyance or irritation. Both of these factors were present but more
extreme in transcripts where participants had struggled initially to cope, with distraction escalating to
denial, avoidance or an extreme preoccupation with other activities in order to block memories of the
traumatic event.
“I thought it would be a really good idea to copy every person’s music CD that I knew and I
ended up literally all day every day just copying CDs. It was really not normal. And it was just
literally to keep me busy. And I did that for a long period of time, before I finally went off sick, it was
I’ve got to keep my brain busy.” [P7].
Similarly, with expressed emotions, some participants who initially struggled after their trauma
reported quite volatile emotions during that period. Rumination was a more clear-cut variable with
participants not dwelling on their experience as they recovered. Finally and perhaps most importantly,
acceptance came across strongly in the transcripts, with participants allowing reminders of the event,
not trying to force themselves to recover more quickly, and not blocking emotional experiences.
Participants described acceptance as being both a cognitive and an embodied process, referring to the
need to accept the facts of the situation as well as the emotions associated with the experience in order
to move forwards.
“And I remember one day thinking well I have two choices here, either accept this or not, and if
I don’t then that’s going to be a massive, er, it’s going to make it all much harder, than if I accept it.
And I think that was the day I said, okay, what’s happened. It was like I really have to start getting
TRAUMA AND RESILIENCE
27
with what’s happened. It’s not a dream, I’m not going to wake up and be in a different place. This is
reality and this is what I kind of need to come to terms with.” [P5].
“With fear, it’s like, the fear is worse than the reality, always. And I think you learn, the more
you have been in that situation… So over time you learn, yeah, to accept it, I don’t want to do it but
actually I know it’s going to be alright…I understand the fear and it’s, that’s the, the reason that I’m
fearing it is that it’s preparing me for something. If I didn’t have it, it’d be wrong. Um, so I use it as a
positive.” [P9].
Developing narrative. The third internal factor was the story, or narrative, the participants
developed around the experience. Participants described having a complete understanding of their
incident as important in helping them close the episode and move forwards.
“I realised very quickly within five minutes oh it’s just an accident, that’s it, done and dusted, I
know what the problem is. Erm, I know the reasons. I’ve got my timeline. There’s nothing else to find
out. No problem there.” [P1].
Participants referred to the importance of understanding the story of the incident and some
described how this was achieved by discussing their experience with friends or, in some cases, people
who had undergone similar experiences, or professionals. One participant explained how simple
repetition was not sufficient for a beneficial effect to occur, the recipient needed to be genuinely
interested and, in all likelihood, help co-construct the narrative by validating and reinforcing key
points. The importance of this theme was also illustrated by its absence in accounts of participants who
had taken a longer time to recover.
TRAUMA AND RESILIENCE
28
“And not knowing [what happened] makes me, upsets me. Like I think if he just said to me, this
is what happened, I didn’t mean it to happen, that would make it better. But it’s the not knowing.”
[P6].
Support. Two external themes were identified: Support and Recovery. Some participants
described an almost immediate and competent response to their situation which resulted in feelings of
comfort as well as practical assistance. It may be that this response reduced the length of time that those
individuals felt alone and highly distressed, and enabled the development of the trauma narrative at an
earlier point, as well as reinforcing positive beliefs.
“I think knowing there were people there that were concerned about me that had never met me
before. It was really nice to know that there was that help there in society. You know, I’ll get out of my
car, be five minutes late for work just to help this chap out.” [P1].
“I remember feeling really, like, happy that someone had because I didn’t know what to do, I
was totally, like, in shock and panic and I think, I feel like I would have just sat there for ages until
someone had done the next step because I didn’t, I didn’t feel like, I knew that I should get out of the
car because of all this traffic as well, and yeah, I felt really relieved that he had taken control of the
situation. Because he’d ring the police and he was very, like, it’s okay, you’re alright and he was being
very, um, calming I suppose, effect, yeah.” [P3].
Some participants described the importance of having people they could access who would
understand the situation they had been in and who held similar beliefs to themselves about that type of
experience. Therefore support was a more subtle and complex construct than simply the availability of
friends or family. Some participants described situations in which partners or family members were
not people they could speak to about their experience. These individuals could feel isolated despite
TRAUMA AND RESILIENCE
apparently having social support structures around them, although this could be mitigated by the
29
presence of an appropriate confidante. Being unable to talk to somebody about the experience was
very negative. Several participants referred to the sense of taboo around their trauma experience as
inhibiting them from feeling able to find a sympathetic listener and a sense of relief when this was
overcome.
“I got involved with a, er, erm, like an abuse group. Where I was with people who were like
minded. And it’s amazing how you suddenly realise you’re not alone…because it’s amazing how, you
talk to somebody but a lot of subjects are taboo subjects. But you talk about it to someone and they say
oh I went through that and then automatically you’ve got a common bond.” [P8].
“I think it was, this is going to sound almost disrespectful for her [counselling] role but I think
it was as much as anything, just someone there that I could, erm, release all this, these thoughts and the
story if you like that I just needed to get out there.” [P7].
Recovery. The environment was an important feature of recovery, either in terms of removing
the participant from places or people associated with the trauma, or by providing access to people and
activities who enabled recovery. Participants used a range of self care techniques to help themselves
heal. Achieving an acceptable quality of life and being able to return to previous activities were
elements of recovery, however participants did not either force themselves to take up an activity
associated with their trauma, such as driving, before they felt ready or decide not to return to it.
“I mean, I’m cycling again now, I couldn’t, I never really cycled properly since I had my
accident. I used to cycle, but, I’ve started cycling now, I’ve got a running blade, which I’m trying to
run on, I’m not fit enough yet to, um, I’m never going to make the Olympic squad but it’s kind of a nice
feeling to know, I can try it again now.” [P4].
TRAUMA AND RESILIENCE
30
General Discussion
This study used a combination of qualitative interviews and psychophysiological measurement
(heart rate response) to explore how trauma survivors with and without PTSD responded to a series of
trauma-related picture stimuli. The study further explored coping by analysing trauma survivors’
accounts of how they either initially responded resiliently or recovered over time from their traumatic
experience. The study revealed two major findings. Firstly, it identified individual differences in the
use of emotion regulation strategies by participants when presented with a series of trauma-related
stimuli. The second major finding was that five thematic groups were identified which participants
described as assisting trauma resilience or recovery. Although some of these have previously been
identified as important, such as social support (e.g., Weiss, 2011), this study indicated that these
variables have particular attributes which determine whether or not the potentially beneficial effect is
realised. This finding potentially explains why some variables which have been associated with
resilience have low explanatory power when measured in general rather than specific terms.
This study explored the feasibility, acceptability and usefulness of a phenomenological
psychopathology multi-method design in PTSD research and concluded that whilst acceptability
seemed good, there were difficulties with feasibility, especially in terms of recruitment of the PTSD
group. Acceptability may have been influence by the researcher using excessive caution in the
selection of trauma-related stimuli given that most participants described the images as invoking mild
or negligible emotional impact. More highly arousing stimuli may also have been considered
acceptable by this group.
The process interview analysis identified individual differences in strategies associated with
emotional regulation reported by the participants following their viewing of the trauma-related stimuli.
Some of these strategies, such as avoidance and acceptance, were discussed by participant interviews in
TRAUMA AND RESILIENCE
31
the IPA study. For example, in some interview accounts, participants who recovered psychologically
from their trauma experiences almost immediately and did not develop PTSD or other reactive
conditions described blocking or avoiding their trauma experience at the time it was taking place.
These participants spoke about how they had distracted themselves with focus on peripheral
detail and turning attention from self to others in the initial phase. However, when the period of crisis
had passed, participants then described a process of accepting both factual and emotional information
about the trauma. Participants who described remaining in the avoidance phase also recollected slower
recovery journeys and early periods of trauma reactions, such as PTSD or a general struggle to cope.
For these participants, the move towards acceptance came later and was associated with their eventual
recovery.
Therefore blocking or avoidance strategies may be protective and helpful in the short term but
become problematic when individuals are unable to move on from that state. These findings
potentially support Mancini and Bonnano’s (2006) suggestion that resilience to adversity may be
achieved by means that are potentially maladaptive under what they term normal circumstances, such
as dismissive coping styles, by suggesting that for some participants in this study, use of such strategies
was initially helpful for them.
These findings have begun to illustrate the complexity of PTSD and trauma recovery, which
may explain some of the difficulties in the literature with the identification of many significant
variables but limited explanatory power of individual variables. Social support, for example, has been
consistently found to be positively associated with recovery (Weiss, 2011). However, participants in
this study were clear that social support in itself was not sufficient to aid their recovery process.
Although social support was very important, it needed to contain particular elements, for example,
access to supportive individuals who would co-facilitate and reinforce a developing narrative in which
TRAUMA AND RESILIENCE
32
the positive beliefs of the individual were encouraged, legitimised and shared. Simply recounting the
trauma to others was not in itself helpful and neither was the presence of supportive individuals if they
were unable or unwilling to understand and empathise with the trauma survivor, or had a different idea
about how the survivor should cope.
This was also an example of how, in fast recoveries, the thematic areas worked together. The
finding that participants often recounted receiving immediate support after their trauma, often from
strangers who witnessed the event and stopped to assist, has been described as a sub-theme in the
support thematic group. However, that experience may also have influenced other themes. The fact of
a stranger demonstrating altruism can also reinforce positive beliefs about the world as fundamentally
safe and supportive and that the individual was not alone. The reassurance provided by the supporter
can assist with emotional regulation by calming and soothing the trauma victim. The relational
interaction between victim and respondent can also be seen as the early development of the trauma
narrative with participants and respondents working out together what just happened and the
respondent emphasising that the victim is now safe and further help is on its way.
The inclusion of participants who recovered over a longer time period and in some cases
initially struggled to cope with their traumatic experience was useful in developing the thematic groups
as often these factors were absent during the initial, difficult period and then started to be spoken about
when the participants described their shift from struggle to recovery. The heterogeneity of trauma
experiences was also useful in developing confidence in themes that were present across different
accounts. Although IPA researchers are generally encouraged to focus on homogenous populations
(Smith, Flowers & Larkin, 2009), a limitation of PTSD literature has been the frequent examination of
atypical groups, such as the military, which does not allow for confidence in generalizability of
findings and results in over-representation of middle-aged males (Pole, 2007).
TRAUMA AND RESILIENCE
Strengths and Limitations
33
The methodology employed in this study has demonstrated the possibility of extending
understanding of psychophysiological research into PTSD and resilience. The inclusion of
qualitatively analysed process interviews resulted in unexpected findings and subsequent generation of
future hypotheses for larger scale quantitative testing. The phenomenological approach can also be
justified given the complexity of the PTSD construct and subsequent difficulties in the literature in
terms of attempting to explain variance through broad concepts such as social support. This study
suggested that social support is an important factor in recovery and resilience but that its usefulness is
determined by specific attributes and perceptions.
Limitations of the research include the lack of statistical power in the psychophysiological study
which prevented multivariate analysis being conducted. Although this element of the research was
intended as exploratory, a larger study may have been able to permit statistical hypothesis testing.
However this was beyond the scope of the current research project. The study was also limited by the
lack of a specific psychometric measure of resilience and reliance instead on lack of current PTSD
symptomatology as indicative of resilience. This was partly due to the concerns about adequacy of
available resilience measures (e.g. Bonnano et al., 2011).
A further limitation was the lack of ethnic diversity in the participant sample, which did not
allow for exploration of ethnicity as a variable, despite calls in the literature for this to be included in
future research due to potential importance (e.g. Pole, 2007, Mancini and Bonnano, 2006).
Limitations of the qualitative analyses were the potential for bias in the process interview
analysis and the reliance in the IPA analysis on retrospective self-report data, with some participants
describing traumas that had taken place many years previously.
TRAUMA AND RESILIENCE
Future Directions
34
This novel study design therefore offers possible hypotheses for future research. The finding
that individuals do appear to use different coping strategies when confronted with trauma-related cues
may help to explain why previous single method studies have produced such mixed outcomes (see
Pole, 2007). Coping strategy style may be a factor which influences psychophysiological response to
such stimuli. The identification of some coping styles in the laboratory which were independently
reported by participants in the IPA study also demonstrates the value of comparing experimental data
with self-report of actual life events.
This integration could potentially be tested in a design where trauma survivors provided
psychophysiological and process interview data in response to idiographic trauma cues and separately
discussed the same traumatic incident in a qualitative study. This would allow comparison of response
to the same trauma both physiologically and in terms of participant recollection.
Given the identification of individual differences in use of emotion regulation strategies when
exposed to trauma cues highlighted in this study, it may be useful for future research to adopt the
methodology piloted here in an appropriately powered study. An improvement to the design might be
to record participants describing out loud their thoughts and reactions to the stimuli during viewing in
order to minimise any loss of data through recall afterwards. It might also useful to increase trauma
stimuli severity, either through use of more highly arousing pictures or video material, in order to
potentially evoke greater use of emotion regulation strategies, being mindful of ethical issues.
The thematic model developed from the IPA study might explored further through similar
analysis of interviews with PTSD sufferers, in order to identify whether their narratives reflect an
absence of the identified thematic groups, either interacting or operating in isolation. Future analyses
TRAUMA AND RESILIENCE
35
may also benefit from recruiting a participant sample where time elapsed since the traumatic incident is
controlled, in order to reduce potential recall errors.
Practical Implications
The IPA analysis has the potential to inform a useful guide for healthcare professionals or
support personnel within an employer such as the police service, responding to individuals who have
experienced a traumatic event. The themes identified could be translated into a checklist as illustrated
in Table 5.
Table 5
Checklist for Healthcare Professionals Developed From Identified Themes
Theme
Checklist for healthcare professionals
Attitudes and beliefs
Does the individual volunteer any positive aspects of their experience
(e.g. describe themselves as “lucky”), do they describe any sense of
control (e.g. ability to prevent repeat of event), do they describe concern
for others?
Emotion regulation
Whilst some greater than usual fluctuation is normal, does the individual
describe feeling very emotionally volatile? Are they engaging in
activities to block out memories or feelings, or spending a lot of time
thinking about the trauma over and over again?
Developing narrative
Can the individual describe the event coherently from beginning to end?
Are any parts of the narrative missing or unknown to them?
TRAUMA AND RESILIENCE
Support and safety
36
Did anybody come to the immediate aid of the individual, and did they
find this supportive? Are they discussing the event with friends or family
and if so are they finding this helpful? Do they feel isolated? Are they in
touch with anybody who has experienced a similar event to themselves?
Are they experiencing pressure, e.g. to return to work before they are
ready?
Recovery
Is the individual generally looking after themselves, resting and not
putting themselves under pressure to recover? Are they still in an
environment where they are regularly reminded of the event or feel it
could re-occur?
This may assist healthcare professionals or employers who come into contact with people or
staff who have experienced a traumatic event in the days afterwards to develop an understanding of
which individuals are likely to require further support and which have the appropriate elements in place
to support recovery.
The analysis also has implications for treatment for individuals who have developed a reaction
to their traumatic experience. Current National Institute of Clinical Excellence guidelines (NICE,
2005) recommend trauma-focussed cognitive behaviour therapy for PTSD and one element of this
treatment is the focus on “hotspots” in the trauma narrative to help the individual re-process these from
sensory to autobiographical memory. This study would support the importance of that intervention.
The study also has implications for narrative therapeutic approaches, such as the potential benefit of
helping the individual to strengthen positive beliefs and sense of control in their identity as well as
TRAUMA AND RESILIENCE
37
working directly with the trauma narrative. Finally the importance of self-care in the recovery theme
might indicate that compassionate-focussed approaches (e.g., Gilbert, 2009) could be helpful.
Finally there are practical implications for people who respond directly to traumatic situations,
such as emergency services personnel, given their potential role in beginning the process of narrative
development for the trauma survivor.
Concluding Comments
PTSD and resilience are complex phenomena. In the same way that models of PTSD have
often been confused by the presence of opposing extremes, hypo- and hyper-arousal, often found
within the condition, so the difficulties in clearly understanding variables which contribute towards
resilience may be explained by the dynamic process of recovery. Furthermore some variables, such as
social support, appear to require quite specific attributes for the beneficial effect to be accessed.
Mixed-method approaches may continue to be useful in developing understanding of these concepts.
TRAUMA AND RESILIENCE
38
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Appendices
1. Journal Instructions to Authors…………………………………………………………67
2. Ethical Approval: NRES Committee South West – Cornwall & Plymouth…………..70
3. Ethical Approval: School of Psychology, University of Exeter……………………….73
4. Participant Consent Sheet v.3…………………………………………………………..76
5. Participant Information Sheet v.3………………………………………………………77
6. Process Interview Schedule…………………………………………………………….80
7. Resilience Interview Schedule………………………………………………………….81
8. Table 5. Summary of Process Interviews………………………………………………82
9. Table 6. Comparison of IPA Analyses…………………………………………………88
10. Reflexivity Statement………………………………………………………………….89
11. Dissemination Statement……………………………………………………………….90
TRAUMA AND RESILIENCE
Journal Instructions to Authors: Journal of Traumatic Stress
43
Author Guidelines
1. The Journal of Traumatic Stress accepts submission of manuscripts online at:
http://mc.manuscriptcentral.com/jots
Information about how to create an account or submit a manuscript may be found online in the "Get
Help Now" menu. Personal assistance also is available by calling 434-817-2040, x167.
2. Three paper formats are accepted. All word counts should include references, tables, and figures.
Regular articles (no longer than 6,000 words) are theoretical articles, full research studies, and reviews.
Purely descriptive articles are rarely accepted. In special circumstances, the editors will consider longer
manuscripts (up to 7,500 words) that describe complex studies. Authors are requested to seek special
consideration prior to submitting manuscripts longer than 6,000 words. Brief reports (2,500 words) are
for pilot studies or uncontrolled trials of an intervention, case studies that cover a new area, preliminary
data on a new problem or population, condensed findings from a study that does not merit a full article,
or methodologically oriented papers that replicate findings in new populations or report preliminary
data on new instruments. Commentaries (1,000 words or less) cover responses to previously published
articles or, occasionally, essays on a professional or scientific topic of general interest. Response
commentaries, submitted no later than 8 weeks after the original article is published (12 weeks if
outside the U.S.), must be content-directed and use tactful language. The original author is given the
opportunity to respond to accepted commentaries.
3. The Journal follows the style recommendations of the 2010 Publication Manual of the American
Psychological Association (APA; 6th). Manuscripts should use non-sexist language. Files must be
formatted using letter or A4 page size, 1 inch (2.54 cm) margins on all sides, Times New Roman 12
point font, and double-spacing for text, tables, figures, and references.
4. The title page should include the title of the article, the running head (maximum 50 characters) in
uppercase flush left, author(s) byline and institutional affiliation, and author note (see pp. 23-25 of the
APA manual).
5. An abstract no longer than 200 words follows the title page on a separate page.
6. Format the reference list using APA style: (a) begin on a new page following the text, (b) doublespace, (c) use hanging indent format, (d) italicize the journal name or book title, and (e) list
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be included as the last element of the reference.
Journal Article
Kraemer, H.C. (2009). Events per person-time (incidence rate): A misleading statistic? Statistics in
Medicine, 28, 1028–1039. doi: 10.1002/sim.3525
Book
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Cohen, J. (1988). Statistical power analysis for the behavioral sciences (2nd ed.). Hillsdale, NJ:
Erlbaum.
44
Book Chapter
Meehl, P. E. (2006). The power of quantitative thinking. In N.G. Waller, L.J. Yonce, W.M. Grove, D.
Faust, & M.F. Lenzenweger (Eds.), A Paul Meehl reader: Essays on the practice of scientific
psychology (pp. 433–444). Mahwah, NJ: Erlbaum.
7. Tables and figures should be formatted in APA style. Count each full-page table or figure as 200
words and each half-page table or figure as 100 words. Tables should be numbered (with Arabic
numerals) and referred to by number in the text. Each table and figure should begin on a separate page.
Only black and white tables and figures will be accepted (no color). Figures (photographs, drawings,
and charts) should be numbered (with Arabic numerals) and referred to by number in the text. Place
figures captions at the bottom of the figure itself, not on a separate page. Include a separate legend to
explain symbols if needed. Figures should be in Word, TIFF, or EPS format.
8. Footnotes should be avoided. When their use is absolutely necessary, footnotes should be formatted
in APA style and placed on a separate page after the reference list and before any tables.
9. The Journal uses a policy of unmasked review. Author identities are known to reviewers; reviewer
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Authors may request blind review by contacting jots@ucsf.edu prior to submission in order to provide
justification and obtain further instructions.
10. Statement of ethical standards: All work submitted to the Journal of Traumatic Stress must
conform to applicable governmental regulations and discipline-appropriate ethical standards.
Responsibility for meeting these requirements rests with all authors. Human and animal research
studies typically require approval by an institutional research committee that has been established to
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program evaluation purposes generally does not require approval by an institutional research
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sources are encouraged to consult with a representative of the applicable institutional committee to
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also usually require written permission from that person to allow public disclosure for educational
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11. Reports of randomized clinical trials should include a flow diagram and a completed CONSORT
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12. Submission is a representation that the manuscript has not been published previously and is not
currently under consideration for publication elsewhere. A statement transferring copyright from the
authors (or their employers, if they hold the copyright) to the International Society for Traumatic Stress
TRAUMA AND RESILIENCE
45
Studies will be required before the manuscript can be accepted for publication. Click on the Copyright
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13. Pre-Submission English-Language Editing: Authors for whom English is a second language may
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Japanese authors can find a list of local English improvement services at
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author, and use of one of these services does not guarantee acceptance or preference for publication.
14. The author(s) are required to adhere to the "Ethical Principles of Psychologists and Code of
Conduct" of the American Psychological Association (visit apastyle.org) or equivalent guidelines in the
study's country of origin. If the author(s) were unable to comply, an explanation is requested.
15. The journal makes no page charges. Author Services – Online production tracking is now
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46
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47
Management permission or approval must be obtained from each host organisation prior to the start of
the study at the site concerned.
Management permission ("R&D approval") should be sought from all NHS organisations involved in
the study in accordance with NHS research governance arrangements.
Guidance on applying for NHS permission for research is available in the Integrated Research
Application System or at http://www.rdforum.nhs.uk.
Where a NHS organisation’s role in the study is limited to identifying and referring potential
participants to research sites ("participant identification centre"), guidance should be sought from the
R&D office on the information it requires to give permission for this activity.
For non-NHS sites, site management permission should be obtained in accordance with the
procedures of the relevant host organisation.
Sponsors are not required to notify the Committee of approvals from host organisations
he Committee receives a copy of any subsequent correspondence
received from MODREC or from King's College.
It is the responsibility of the sponsor to ensure that all the conditions are complied with before
the start of the study or its initiation at a particular site (as applicable).
You should notify the REC in writing once all conditions have been met (except for site
approvals from host organisations) and provide copies of any revised documentation with
updated version numbers. Confirmation should also be provided to host organisations
together with relevant documentation.
Approved documents
The final list of documents
reviewed and approved by
the Committee is as follows:
Version
Document
Advertisement
2
Covering Letter
Covering Letter
Evidence of insurance or indemnity
Investigator CV
Letter from Sponsor
Other: CV - Dr Anke Karl
Other: Leaflet
1
Other: Qualitative Interview
1
Schedule
Other: Process Interview
1
Schedule
Other: Sample Pictures from
1
International Affective Picture
System
Other: Mood Disorders Centre
04/12/09
Risk Protocol
Other: Letter to Chair of MODREC
Other: Letter to Academic Centre for Defence
Mental Health
Other: Certificate of Attendance
Participant Consent Form
2
Participant Information Sheet
2
Protocol
1
Date
30 October 2012
27 September 2012
30 October 2012
01 August 2012
27 September 2012
27 September 2012
04 April 2012
27 September 2012
10 October 2011
10 October 2011
26 September 2012
04 December 2009
30 October 2012
30 October 2012
14 October 2011
30 October 2012
30 October 2012
10 October 2011
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49
Questionnaire: PTSD Checklist - Civilian Version (PCL-C)
Questionnaire: Life Event Checklist
Questionnaire: HADS
Questionnaire: Self Assessment - Dare you say what you think? The Social Desirability Scale
Questionnaire: Peri-traumatic Dissociative Experiences Questionnaire
REC application
3.4
28 September 2012
Referees or other scientific critique report
16 January 2012
Response to Request for Further Information
30 October 2012
Statement of compliance
The Committee is constituted in accordance with the Governance Arrangements for Research Ethics
Committees and complies fully with the Standard Operating Procedures for Research Ethics
Committees in the UK.
After ethical review
Reporting requirements
The attached document “After ethical review – guidance for researchers” gives detailed guidance on
reporting requirements for studies with a favourable opinion, including:
ication of serious breaches of the protocol
The NRES website also provides guidance on these topics, which is updated in the light of changes in
reporting requirements or procedures.
Feedback
You are invited to give your view of the service that you have received from the National Research
Ethics Service and the application procedure. If you wish to make your views known please use the
feedback form available on the website.
Further information is available at National
Research Ethics Service website > After
Review 12/SW/0310
Please quote this number on all
correspondence
With the Committee’s best wishes for the success of this project
Yours sincerely
Canon Ian Ainsworth-Smith
Chair
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50
1. PSYCHOLOGY DEPARTMENT ETHICAL APPROVAL FORM
Tick one box:  STAFF Project  POSTGRADUATE Project
 TRACK A
 UNDERGRADUATE Project
 TRACK B
 ROUTINE EXTENSION TO PRE-APPROVED STUDY
Title Of Project:
Why don’t all trauma survivors develop post-traumatic stress disorder? A multi-method
exploration of resilience.
Name of researcher(s) Vivien Le Fort
Name of supervisor (for student research) Dr Anke Karl & Dr Janet Smithson Date 16.11.12
YES
1
2
3
4
5
6
7
8
N
O
N/A

Will you describe the main experimental procedures to participants in
advance, so that they are informed in advance about what to expect?

Will you tell participants that their participation is voluntary?

Will you obtain written consent for participation?

If the research is observational, will you ask participants for their
consent to being observed?

Will you tell participants that they may withdraw from the research at
any time and for any reason?

With questionnaires, will you give participants the option of omitting
questions they do not what to answer?

Will you tell participants that their data will be treated with full
confidentiality and that, if published, it will not be identifiable as theirs?

Will you debrief participants at the end of their participation (ie. give
them a brief explanation of the study)?
If you have ticked No to any of Q1-8, but have ticked box A overleaf, please give any explanation on a
separate sheet. (Note: N/A = not applicable)
YES
9
N
O

N/A
N
O

N/A
Will your project involve deliberately misleading participants in any
way?

10 Is there a realistic risk of any participants experiencing either physical
or psychological distress or discomfort? If Yes, give details on a
separate sheet and state what you will tell them to do if they should
experience any problems (e.g. who they can contact for help).
If you have ticked Yes to 9 or 10 you should normally tick box B overleaf; if not, please give a full
explanation on a separate sheet.
YES
11
12
Does your study involve work with animals? If yes, and your study is
purely observational, please tick box A. All other studies should tick
box B and provide supporting information.
Do participants fall into any of the School children (under 18 years of
following special groups? If they
age)

TRAUMA AND RESILIENCE
do, please refer to BPS guidelines,
and tick box B overleaf.
Please note that you may also
need to gain satisfactory CRB
clearance or equivalent for
overseas participants.
51
People with learning or
communication difficulties
Patients
Those at risk of psychological
distress or otherwise vulnerable
People in custody



People engaged in illegal activities
(e.g. drug taking)


There is an obligation on the lead researcher to bring to the attention of the Departmental Ethics
Committee projects with ethical implications not clearly covered by the above checklist.
PLEASE TICK EITHER BOX A or BOX B BELOW AND PROVIDE THE DETAILS REQUIRED IN SUPPORT OF
YOUR APPLICATION, THEN SIGN THE FORM.
Please tick:
A. I consider that this project has no significant ethical implications to be brought
before the Departmental Ethics Committee.
In less than 150 words, provide details of the experiment including the number and
type of participants, methods and tests to be used (i.e. the procedure).
This form (and any attachments) should be submitted to the Departmental Ethics committee where it
will be considered by the Chair before it can be approved.

B. I consider that this project may have ethical implications that should be brought
before the Departmental Ethics Committee, and/or it will be carried out with children
or other vulnerable populations.
Please provide all the further information listed below in a separate attachment.
1. Title of project.
2. Purpose of project and its academic rationale.
3. Brief description of methods and measurements.
4. Participants: a) Human research: Recruitment methods, number, age, gender,
exclusion/inclusion criteria.
b) Animal research: location of study site, method of obtaining / marking / identifying
subjects, handling procedures for field experiments.
5. Consent and participant information arrangements, debriefing. (Not relevant for animal
research) Please attach intended information and consent forms.
6. A clear but concise statement of the ethical considerations raised by the project and how
you intend to deal with them.
7. Estimated start date and duration of project.
This form should be submitted to the Departmental Ethics Committee for consideration.
If any of the above information is missing, your application will be returned to you.
I am familiar with the BPS Guidelines for ethical practices in psychological research (and have discussed
them with other researchers involved in the project.)
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Signed……Viv Le Fort…………………………………….…………
Print Name…Vivien Le Fort.………….. Date…16th
November 2012…………
(UG/PG Researcher(s), if applicable)
Email……vl227@exeter.ac.uk…………………………………………..
Signed……………………………………………………. Print Name…Dr Anke Karl……………………………………. Date…16th
November 2012………..
(Lead Researcher or Supervisor)
Email……A.Karl@exeter.ac.uk…………………………………..
STATEMENT OF ETHICAL APPROVAL
This project has been considered using agreed Departmental procedures and is now approved.
Signed…………………………………………….Print Name……………………………………………..Date………………..
(Chair, Departmental Ethics Committee)
52
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53
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54
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What would taking part involve?
55
We will send you some questionnaires to complete so that we can find out some basic information
about you and some details about your traumatic experience(s) and what level of post-traumatic
symptoms you have experienced. When these have been returned, we will contact you to arrange an
appointment for you to take part in our experiment. If you would prefer, you can complete these with
the researcher rather than on your own.
During the experiment, you will be asked to look at some different pictures while we measure how
your body responds to the pictures using a piece of laboratory equipment that measures your heart
rate. Some of the pictures will be of a traumatic nature and the same type of trauma that you
experienced in real life (for example, a car crash scene). We will then ask you some questions about
your experience of looking at the pictures. We will check that you are feeling okay and answer any
questions you have before you leave.
If you are one of the people who has experienced a serious life trauma but had few or no posttraumatic symptoms, we will arrange another appointment to interview you about why you think you
did not suffer these symptoms after your trauma. This interview will take under an hour and will be
recorded so that we can type it up.
How long would the questionnaires take to complete?
The questionnaires that you are sent will take about 45 minutes to an hour to complete in total.
Do I have to take part?
No, the study is completely voluntary.
Can I change my mind?
Yes, you can change your mind at any point up until the results of the study are written up (March
2013). Simply contact one of the researchers and your information will be removed.
What are the benefits and risks if I take part?
The benefit is just the opportunity to contribute to a better understanding of trauma and resilience,
which will hopefully improve support for people who experience serious traumas in future.
The risk is that you may feel upset by reminders of your traumatic experience. We will check with you
that you feel okay before you leave, and if needed put you in touch with agencies who can provide
support.
Do you pay travel expenses?
Yes. Travel expenses will be reimbursed and travel by car is paid at 40p per mile.
TRAUMA AND RESILIENCE
56
What will happen to the information I provide?
You will be assigned a reference number for use during the study so that your identity is kept
anonymous except from the researchers. A confidential document which records personal data and
reference numbers will be kept securely stored at the University of Exeter which can only be accessed
by the researchers. The results you provide will be reported anonymously and you will not be
identified.
Who can I contact if I feel upset after taking part in the study?
Please be reassured that people who agree to participate in this type of research are not usually upset
afterwards. However, in the unlikely event that you do feel upset or distressed, please contact the
researcher.
If you would like support from an external organisation, you can contact the following groups:
Samaritans
08457 90 90 90 (24 hours)
ASSIST (Assistance Support & Self-Help in Surviving Trauma)
01788 560800
Funded prize draw
The University of Exeter will be funding a prize draw at the end of the study to thank participants for
taking part. All participants who wish to be included will be entered into a prize draw with three
prizes of either a £75, £50 or £25 high street voucher. The draw will take place in April 2013 and
winners will be contacted by the researcher with their prize.
Contact details for further information
Please contact the lead researcher Viv Le Fort by emailing vl227@exeter.ac.uk or phoning 0751 054
0194.
TRAUMA AND RESILIENCE
57
Process Interview Schedule
•
What was happening in your mind when you saw the different pictures?
•
Did you do anything to reduce the impact of the pictures?
•
What did you notice happening in your mind when you saw the different pictures?
•
What did you notice happening in your body when you saw the different pictures?
•
What did you think when you saw the different pictures?
•
What aspects of the pictures did you look at?
•
How much attention did you pay to the different pictures?
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58
Qualitative Interview Schedule
1. Can you describe what happened when the traumatic event occurred?
(prompt: what happened next?)
2. What was going through your mind when the trauma happened?/ What were you thinking at the
time of the trauma?
3. How did you respond to the trauma?
(prompts: what did you do? What happened?)
4. What was important in helping you deal with the trauma?
(prompt: what helped you cope?)
5. How did you try and make sense of what had happened?
6. What was supportive or helpful after the trauma?
7. How do you feel about the trauma now when you look back on it?
8. What else was important that I haven’t asked about?
Running Head: TRAUMA AND RESILIENCE
59
Table 5
Participant Responses to Trauma-related Pictures
P.
Thoughts
Feelings
8
Imagined
scene
Very very
sad, quite
angry, very
threatened,
strong
empathy for
victims
7
“I’ve seen that
before”
“Just a Friday
night down
town”.
Thought one
looked staged.
People may
have been
hurt, and
possibly killed.
No great
feelings
6
5
Thoughts of
car accidents
attended (as
breakdown
mechanic)
where whole
Physical
Response
Memories
Coping –
cognitive
Felt relaxed
throughout
Focus
Most attention
Knife
Eye contact
A little bit
upset, it upset
me that
people were
watching
Tried to put it
to the back of
my mind.
Reminded
myself they
were just
pictures.
none
Coping –
physical
Slowed
down
breathing
Reminded of
a couple of
individual
accidents
from 40
years ago
Very quickly
snapped
myself out of
It and
concentrated
on just
Focussed on
the people
watching
rather than the
crash.
Attention
overall
Paid most
attention to the
trauma
pictures.
Dismissed
pleasant
pictures
quickly.
Overall the
same, more
attention to
spider
(unpleasant),
dislike spiders
Strategies
overall
Tried to look at
it from a
psychological
perspective –
why’s that
picture there
The prawn
stood out
(neutral).
Paid more
attention to the
polar bear and
rabbit
(pleasant).
Analysing
severity of
accident from
scene.
When I have
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P. Thoughts
Feelings
Physical
Response
families have
been killed and
there is blood
and children’s
toys around.
Memories
that were
particularly
upsetting.
Coping –
cognitive
looking at the
picture
Coping –
physical
60
Focus
Attention
overall
Strategies
overall
stress, I
immediately
focus on
something else.
Deliberately
looked at
difficult things
in order not to
be avoidant.
Generated ideas
for own
research.
Quite
detailed
memories.
Cued
unrelated
trauma
memory of a
violent death.
4
More men than
women in
pictures.
Differing
levels of
threat.
Interesting to
do eye-tracker
experiment.
Aware of
breath
Had been
squeezing
thumb.
Relaxed grip.
Blood on
knife
If I do feel
fear, it’s a
picture on a
screen, there’s
no actual
threat to me.
People who’ve
been in that
situation might
find picture
upsetting.
3
Breathed as
deeply as I
could.
Anxious?
A bit sweaty,
tense, tighter
around the
chest.
Became very
aware of
breathing.
Tried to look at
whole picture
to check not
missing
anything.
Analysing
experiment
strategy.
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P. Thoughts
Feelings
Physical
Response
Memories
Coping –
cognitive
Coping –
physical
61
Focus
Attention
overall
Strategies
overall
Paid more
attention to
pictures with
people with sad
emotions.
2
1
Okay it’s
another car in
a ditch.
One was
probably
nasty, the rest
quite minor,
probably
walked away
from the
majority of
them.
Urgh, there’s a
knife
None
None
Didn’t like
them, didn’t
want to look.
Instinct was
not to look at
it
Went tense
Vigilance
response
14 What might
have happened
to person,
whether there
was a small
Used to
repair cars.
Trying to
work out what
had happened,
how car had
got there.
Made myself
keep looking
in order not to
screw up the
experiment
Slowed
down my
breathing
a bit
More salient
Thought about
order of
pictures
(assumed
deliberate).
Curious about
experiment and
ethics.
Reflected on,
Oh I’m
feeling quite
sad about that.
Didn’t try to
Clues to
severity, e.g.
airbags.
Tried to pay
equal attention,
didn’t look
away from any.
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P. Thoughts
Feelings
chance they
were injured or
not.
15 Noticed some boredom
number plates
were British
and some
foreign.
17 Judgement call upsetting
about whether
crash was
severe,
moderate or
slight.
16 Measured
them for how
bad they were.
Not
upsetting.
Hope they got
out okay.
shocked
9
Thought for a
moment one
picture was
photo of my
accident.
Trying to
make sense of
pictures
Physical
Response
Memories
Coping –
cognitive
make feeling
go away.
Coping –
physical
Attention
overall
Strategies
overall
Didn’t avoid
any aspects
torpid
Greater sense
of tension in
stomach
(core)
62
Focus
None.
Tense (didn’t
notice at the
time, but
realised
afterwards
more relaxed).
Took a breath
in. Sat up a
little bit,
maybe moved
a bit
Welcome
feelings and
sensations and
then let them
go
Breathed
a bit
more
deeply.
Focussed on
Concentrated
children being on faces
allowed to
watch rescue –
incongruent,
where’s the
cordon?
Analysed the
scene.
Looked for
blood.
Trying to relate
what I was
feeling to what
I was seeing.
Keep it neutral
and just let the
TRAUMA AND RESILIENCE
P. Thoughts
Feelings
Physical
Response
Memories
Coping –
Coping –
cognitive
physical
Said to myself
if people are
watching
can’t be
anything
upsetting
happening.
63
Focus
Attention
overall
Find reasons
why pictures
not upsetting.
10 The more
serious the
crash the
greater
likelihood of
serious injury
or death
Empathy
A slight
impact
Concern and
care
11 Okay, there’s
going to be a
really horrible
one now
Anticipating
No – relaxed
But more
acute
awareness
with more
serious
crashes more
likelihood of
injury.
Tense
No – own
accident was
different
You can’t do
anything
about snow
(icy crash
scene).
Just let it
impact on me,
no strategies,
just looked
passively.
Predicting
patterns of
severity of
pictures
(thought
escalating).
Scanning for
clues about
severity of
accident
Trauma
pictures
provoked
greater degree
of acuity and
cognitive
alertness.
Context –
reactions of
people in
background.
Working out
what
happened in
More attention
to crashes,
trying to
understand the
story of it.
Strategies
overall
pictures get to
me.
TRAUMA AND RESILIENCE
P. Thoughts
Feelings
12 Don’t like it
when people
gawp at
accidents
Annoyed
Physical
Response
No – trying to
sit still.
Felt empathy
with girl
looking
away.
Memories
No
Coping –
cognitive
Coping –
physical
64
Focus
accident ad
impact on
people.
Peripheral
details rather
than accident,
e.g. girl in
accident scene
wearing a red
coat.
Attention
overall
Strategies
overall
Waves of
concentration.
Trying to make
links, analyse
experiment.
Concentrated
on each picture
as a separate
thing.
Very slight
feeling of
worry.
13 What
happened to
the people?
Tension – but
due to
anticipation
not content.
Paid less
attention to
pleasant
pictures.
Running Head: TRAUMA AND RESILIENCE
65
Comparison of IPA Analyses
Transcript 6 was reviewed by the author and a second trainee clinical psychologist who was
familiar and experienced with IPA philosophy and methodology. Transcript 6 was the account of a
female participant who had experienced the unlawful death of one of her children. The participant did
not witness the death but found out about it shortly afterwards and attended hospital with police where
she saw her daughter’s body. The child’s father was later imprisoned for manslaughter. The
participant described struggling to cope in the couple of years following the death and experiencing
alcohol and eating disorder difficulties, before recovering from her traumatic experience.
Table 6
Comparison of IPA Analyses
Author Analysis
Second Analysis
Matter of fact descriptions of traumatic events –
indicative of developed narrative?
Strong sense of shock – but noted use of the term
“pretty awful” by the participant. Minimising?
Sense of control important in Attitudes and Beliefs Sense of an absolute lack of control over the
theme.
situation itself and subsequently.
Taboo subjects make it more difficult to access
social support and co-construct narrative.
How do you talk about something so horrific?
Use of alcohol as a denial/ avoidance mechanism
in early stages – Emotion regulation.
Alcohol. The participant said “you can’t hide
alcohol” – made me wonder what she might be
hiding inside.
Matter of fact in hindsight.
“Just get on with it”.
Evidence of further difficulties in accessing social
support at the time.
Referred to herself as a “fruit” – wondered what
the reactions of others had been and whether she
felt judged.
Difficulty initially in making sense due to absence
of a developing narrative – not aware of facts and
unable to try and establish them as legal process
had taken over. [Did not attend court after giving
witness evidence as too distressed].
Balance between not being believed [by police
initially] and not being able to believe her own
memories – ongoing confusion.
Sense of responsibility in Attitudes and beliefs
theme.
Doing it for others – trying to carry on for her
second daughter.
TRAUMA AND RESILIENCE
66
Reflexivity Statement
The author previously worked in the prison service and met many staff and prisoners who had
experienced significant trauma and showed diverse coping ability. Staff trauma was predominantly
around previous military service or assaults within prison and prisoner trauma frequently involved
childhood abuse and violence in prison. The author herself witnessed various violent incidents during
this time. This interest in responses to trauma was intensified by an incident in which two prison
officers were seriously assaulted with a weapon, which resulted in a rapid and seemingly full recovery
by one officer and deterioration in functioning and development of PTSD by the other, who never
returned to work.
The author is familiar with the different theoretical models of PTSD and variables which
influence resilience and during the interview process attempted to bracket these and set them aside in
order to genuinely consider the participant responses and develop the model from their data rather than
being influenced by top-down theory.
TRAUMA AND RESILIENCE
67
Dissemination Statement
Publications
It is intended that the research paper will be submitted to the Journal of Traumatic Stress for
consideration for publication. The author has been interviewed about the research findings for a feature
article in Mental Health Nursing about resilience following trauma exposure in healthcare
professionals.
Presentations
The IPA research findings have been presented to a group of psychologists working in a
medium secure unit with individuals with extensive trauma histories. A presentation to colleagues,
final year trainee clinical psychologists, at the University of Exeter is planned. A group of service
users associated with the university contributed to the planning and design of the study and it is
intended to present the research findings to them at a convenient date. The author has also been invited
to present the research findings to the King's Centre for Military Health Research (KCMHR) /
Academic Centre for Defence Mental Health (ACDMH).