Citation
Adventurous activities

Material Information

Title:
Adventurous activities a qualitative study of play among OEFOIF veterans
Alternate title:
Qualitative study of play among OEF/OIF veterans
Creator:
Betthauser, Lisa Marie
Place of Publication:
Denver, Colo.
Publisher:
University of Colorado Denver
Publication Date:
Language:
English
Physical Description:
1 electronic file. : ;

Thesis/Dissertation Information

Degree:
Doctorate ( Doctor of Philosophy)
Degree Grantor:
University of Colorado Denver
Degree Divisions:
Department of Psychology, CU Denver
Degree Disciplines:
Clinical Health Psychology
Committee Chair:
Allen, Elizabeth
Committee Members:
Brenner, Lisa
Grigsby, Jim

Subjects

Subjects / Keywords:
Risk-taking (Psychology) ( lcsh )
Operation Enduring Freedom, 2001- -- Veterans ( lcsh )
Iraq War, 2003-2011 -- Veterans ( lcsh )
Veterans -- Recreation -- United States ( lcsh )
Genre:
non-fiction ( marcgt )

Notes

Review:
Individuals who have served in the conflicts in Iraq and Afghanistan have likely been exposed to combat stress. Existing literature has consistently demonstrated the negative impact of combat stress as a risk factor for post-deployment health issues, such as post-traumatic stress disorder (PTSD). One significant, but less studied area that may be affected by the experience of deployment and/or PTSD symptoms is the individual's engagement in pleasurable, leisure activities or "play". Clinical and empirical observations have typically focused on PTSD symptoms of avoidance and emotional numbing, contributing to an individual's loss of interest or participation in pleasurable activities. In contrast, there is literature suggesting that individuals with deployment history or PTSD may actually seek out activities that are risky or that provide an intense level of physiological and psychological arousal. This study qualitatively examined leisure and play among a sample of OEF/OIF Veterans, exploring both possible avoidance and seeking of intense or risky leisure experiences. Findings support the proposed dichotomy, such that there appears to be a subset of this sample that seek to simulate the "rush" experienced in combat by engaging in intense, risky activities, while other Veterans in this sample tend to avoid participation in such activities due to depression or anxiety. Future research could examine whether increased access to safe, affordable leisure activities may address these issues and promote psychological and physical well-being.
Thesis:
Thesis (Ph.D.)--University of Colorado Denver. Clinical health psychology
Bibliography:
Includes bibliographic references.
General Note:
Department of Psychology
Statement of Responsibility:
by Lisa Marie Betthauser.

Record Information

Source Institution:
|University of Colorado Denver
Holding Location:
|Auraria Library
Rights Management:
All applicable rights reserved by the source institution and holding location.
Resource Identifier:
860842860 ( OCLC )
ocn860842860

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Full Text
ADVENTUROUS ACTIVITIES:
A QUALITATIVE STUDY OF PLAY AMONG OEF/OIF VETERANS
by
Lisa Marie Betthauser
B. A.University of Colorado, Boulder2003
M.B. A.University of Colorado, Denver2006
A thesis submitted to the
Faculty of the Graduate School of the
University of Colorado in partial fulfillment
of the requirements for the degree of
Doctor of Philosophy
Clinical Health Psychology
2014


This thesis for the Doctor of Philosophy degree by
Lisa Marie Betthauser
has been approved for the
Clinical Health Psychology Program
by
Elizabeth AllenPh.D.Chair
Lisa Brenner, Ph.D.
Jim Grigsby, Ph.D.
Date March 16, 2012
li


Betthauser, Lisa, Marie (M.A., Clinical Health Psychology)
Adventurous Activities: A Qualitative Study of Play among OEF/OIF Veterans
Thesis directed by Elizabeth Allen, Ph.D.
ABSTRACT
Individuals who have served in the conflicts in Iraq and Afghanistan have likely been
exposed to combat stress. Existing literature has consistently demonstrated the negative
impact of combat stress as a risk factor for post-deployment health issues, such as post-
traumatic stress disorder (PTSD). One significant, but less studied area that may be
affected by the experience of deployment and/or PTSD symptoms is the individuals
engagement in pleasurableleisure activities or play. Clinical and empirical
observations have typically focused on PTSD symptoms of avoidance and emotional
numbingcontributing to an individuals loss of interest or participation in pleasurable
activities. In contrast, there is literature suggesting that individuals with deployment
history or PTSD may actually seek out activities that are risky or that provide an intense
level of physiological and psychological arousal. This study qualitatively examined
leisure and play among a sample of OEF/OIF Veterans, exploring both possible
avoidance and seeking of intense or risky leisure experiences. Findings support the
proposed dichotomy, such that there appears to be a subset of this sample that seek to
simulate the rush experienced in combat by engaging in intenserisky activitieswhile
other Veterans in this sample tend to avoid participation in such activities due to
depression or anxiety. Future research could examine whether increased access to safe,


affordable leisure activities may address these issues and promote psychological and
physical well-being.
The form and content of this abstract are approved. I recommend its publication.
Approved: Elizabeth Allen, Ph.D.
IV


DEDICATION
I dedicate this work to all the brave men and women who have
pledged their lives to preserve, and protect our freedom.
v


ACKNOWLEDGMENTS
I would like to thank Dr. Elizabeth Allen, Dr. Jim Grigsby, and Dr. Lisa Brenner
for their invaluable input and guidance. I would like to thank the research team at the
Mental Illness Research, Education, and Clinical Center at the Denver Veterans Affairs
Medical Center for the assistance and support of this project. I send my gratitude and love
to my husband and family for their love and support throughout my journey and their
acceptance of my passion for this field. Finally, I would like to thank all the dedicated,
brave individuals who have served our country throughout history.
This publication is based on work supported by the Department of Veterans
Affairs, but does not necessarily represent the views of the Department of Veterans
Affairs or the United States Government.
vi


TABLE OF CONTENTS
Contents
CHAPTER................................................................1
I. INTRODUCTION........................................................1
PTSD..............................................................2
PTSD Impacts Leisure Activities...................................3
Models of Risk-Taking and Sensation-Seeking Behaviors.............5
Models of Play and Leisure........................................6
II. QUALITATIVE METHODOLOGY 9
III. ANALYSIS RATIONALE................................................11
IV. METHODS...........................................................14
Participants.....................................................14
Measures and Procedures..........................................15
V. DATA ANALYSIS.....................................................18
VI. FINDINGS..........................................................20
Type of Activities...............................................20
Reasons for Engaging in Adventurous Activities...................21
Accomplishment...................................................21
Arousal..........................................................22
Mood alteration..................................................22
Physical Fitness.................................................23
Bonding..........................................................23
Reasons for Not Engaging in Adventurous Activities...............24
Change in Frequency/Level of Intensity of Adventurous Activities.25
vii


State When Not Engaged in Adventurous Activities.....27
VII.DISUCSSION............................................29
REFERENCES................................................36
APPENDICES.................................................
A: ADVENTUROUS ACTIVITIES INTERVIEW.......................45
B: CODING MANUAL..........................................51
C: CODING SUMMARY FORM....................................54
viii


LIST OF ABBREVIATIONS
DSM-IV-TR Diagnostic and Statistical Manual of Mental Disorders Fourth Edition Text Revision
ECHCS Eastern Colorado Healthcare System
PTSD Posttraumatic Stress Disorder
OEF Operation Enduring Freedom
OIF Operation Iraqi Freedom
VA Veterans Affairs
IX


CHAPTER
I. INTRODUCTION
Since 2001, over 2.3 million individuals have been deployed to serve in the Global
War on Terror (Environmental Health Strategic Healthcare Group, 2011). Operation
Enduring Freedom (OEF; Afghanistan) and Operation Iraqi Freedom (OIF; Iraq) have
been defined as the longest ongoing United States combat conflicts since the Vietnam
War (Tanelian & Jaycox, 2008). These operations have been characterized by increased
frequency of multiple deployments, longer duration of deployments, and shorter post-
deployment periods (Belasco, 2007). An increased likelihood of exposure to combat
stress during OEF/OIF compared to prior wars have been proposed, as the current troops
serving in these operations are experiencing improvised explosive devices, suicide
bombers, frequent mortar attacks, handling of friendly and enemy human remains, and
feelings of helplessness of not being able to stop violent situations (Hoge et al.2004).
Even military personnel deployed for peace-keeping or stability missions are exposed to
the similar stressors as those actively engaged in combat operations (Tanelian & Jaycox,
2008).
Existing literature has consistently demonstrated the negative impact of combat stress
as a risk factor for post-deployment healtn issues, including psychiatric disorders. Of
note, exposure to combat has been shown to increase the likelihood of developing
posttraumatic stress disorder (PTSD; Tanelian & Jaycox, 2008; Hoge et al., 2008; Kulka
et al., 1990; Kessler, Sonnega, Bromet, Hughes & Nelson, 1995). An estimated 10-40%
1


of individuals serving in OEF/OIF have been screened for or report symptoms associated
with PTSD (Hoge et al., 2004; Lapierre, Schwegler, & Labauve, 2007). Seal and
colleagues (2007) looked at OEF/OIF Veterans seeking services at the Department of
Veterans Affairs and found a 13% prevalence of PTSD based on the ICD-9-CM
diagnosis. Furthermore, this group of researchers found a significantly increased risk of
PTSD and mental health diagnoses among the youngest OEF/OIF age group (ages 18-24)
as compared to Veterans 40 years and older. As more of the Soldiers serving in Iraq and
Afghanistan return home and transition out of Active Duty, the psychological impact of
combat exposure is of increasing public concern.
PTSD
Posttraumatic stress disorder is an anxiety disorder that can develop from exposure to
a traumatic event which involves threat, or occurrence, of severe injury or death to
oneself or to others. Common traumatic events that may cause PTSD include accidents,
natural disasters, violent assaults, and military combat. Diagnostic criteria of PTSD
includes: re-experiencing the event, persistent avoidance of things associated with the
event, numbing of emotions, and hyperarousal (DSM-IV-TR, APA, 2000). Symptoms
must persist for more than one month and must cause significant distress and/or
impairment in social, occupational or academic functioning. Studies investigating the
prevalence of PTSD in the Veteran population have typically relied on diagnostic clinical
interviews and screening tools. However, many Veterans returning from combat may not
meet the full DSM-IV-TR criteria for PTSD. Post-deployment Veterans may minimize or
fail to disclose their symptoms in order to facilitate seeing friends and tamily, fear of loss
2


of benefits, and/or stigma associated with having mental health-related symptoms (Bliese,
Wright, Adler, Thomas, & Hoge, 2007). When evaluating returning military personnel, it
is important to consider partial symptoms of PTSD on functioning. In fact, literature has
demonstrated that both PTSD and subsyndromal PTSD affects health and psychosocial
functioning.
Combat-related PTSD has been associated with co-morbid conditions such as
depression, substance use, anxiety and cognitive impairments resulting in negative health
outcomes (Hoge et al.2004, Kang & Hyams2005, Tanielian & Jaycox2008). PTSD
has also been associated with decreased physical functioning and emotional well-being
(Zatzick et al.1997, Erbes et al2007)and impaired social functioning such as
relationship issues and poor family adjustment (Gavloski & Lyons 2004). Furthermore,
having a diagnosis of PTSD has been shown to impact mortality and quality of life
(Pietrzak et al.2010; Tanielian & Jaycox2008). Partial or subsyndromal PTSD also
have been associated with impairment in health and psychosocial functioning (Pietrzak et
al.2009; Jakupcak et al.2004).
PTSD Impacts Leisure Activities
One significant, but less studied area that may be affected by PTSD symptoms is the
individuals engagement in pleasurableleisure activities or play. Clinical and
empirical observations have typically focused on avoidance and emotional numbing
clusters of PTSD symptoms, postulating that individuals with PTSD often demonstrate a
loss of interest or participation in pleasurable activities. In fact, this assessment is
included in the DSM-IV-TR diagnostic criteria and common screening tools used for
3


assessing PTSD symptoms. Individuals with PTSD may avoid activities, places or people
that remind them of the trauma, experience feelings of detachment from others, and have
a limited range of affective responses, such as feeling enjoyment or love. Such
impairment may contribute to the lack of interest and engagement in activities. For
example, Veterans with PTSD may avoid participating in military-related activities with
old military buddies because of the reminder of the loss of a friend during deployment,
or, Veterans may decline invitations to attend social events hosted by civilian friends
because of feelings of estrangement or limited positive affect.
Furthermore, a decreased participation in activities also may be related to PTSD
symptoms of increased arousal, such as hypervigilance and exaggerated startle response.
Veterans have described anecdotal experiences of modifying participation in activities
such as dining in less-crowded restaurants, and avoiding amusement parks, firework
displays, and shooting ranges due to increased startle response from loud noises.
Whereas limited research has been conducted regarding a reduction or loss of interest
in activities due to avoidance, isolation, and/or hypervigilance, there is a body of
literature suggesting that individuals with PTSD may actually seek out activities that are
risky or activities that provide an intense level of physiological and psychological
arousal. Grigsby (1991) proposed a clinical phenomena of combat rush in Veterans
with PTSD. Specifically, he suggested that Veterans experience a heightened state of
arousal within the combat environment and seek to simulate this experience post-
deployment. Additional literature has discussed this phenomena as addiction to trauma
(van der Kolk & Greenberg, 1987; Horowitz & Becker, 1971), where traumatized
individuals seek out experiences analogous to the original trauma event.
4


More recent literature has investigated the association between PTSD and risk-taking
or sensation-seeking behaviors. Risk-taking behaviors among Veterans has been
operationalized by increased negative health behaviors (McFall & Cook, 2006), such as
substance abuse (Begic & Jokic-Begic, 2001; Meisler, 1996), aggression and violence
(Haiti, Rosen, Drescher, Lee, & Gusman, 2005; Taft, Street, Marshall, Dowdall,& Rigs,
2007), and reckless driving (Drescher, Rosen, Burling, & Foy, 2003). Furthermore, such
risk-taking behaviors have resulted in negative outcomes including incarceration
(Greenberg & Rosenheck, 2011; Saxon et al., 2001; Shaw, Churchill, Noyes, &
Loeffelholz1987)deliberate self-harmand/or suicide (Jakupcak et al.2009; Pietrzak et
al., 2009; Sacks, Flood, Dennis, Hertzberg, & Beckham, 2008). As noted above, within
the clinical literature experiences or risk-taking behavior, that is, the elicitation of
combat rush or addiction to trauma wherein the individual may seek dangerous
situations or situations reminiscent of the original trauma to generate an intense level of
arousal has been discussed.
Models of Risk-Taking and Sensation-Seeking Behaviors
Although there is not a consensus in the literature defining the link between PTSD
and risk-taking behaviors, neurobiological, behavioral, affective and personality theories
have been applied to understand this association. Some have proposed an underlying
neurooiological mechanism of arousal triggered by traumatic events that modify broad,
and sustained synaptic function that contribute to the individuals need to seek out a
similar intense rush that mimics the experience of the trauma (van der Kolk & Greenberg
1987; Kolb, 1984). Learned behaviors and physiological arousal via classical


conditioning and intense emotional responses may also be at play in the development of
PTSD (Kolb & Mutalipassi, 1982). Such re-occurring automatic responses may result in
long-lasting neuronal changes (Kandel, 1985; Lynch 1986). PTSD has also been shown
to activate hormonal systems in combat Veterans which have been associated with
affective and cognitive psychological state (Yehuda et al., 1992). Such changes in
hormones have been linked to novel, sensation-seeking behaviors in Vietnam combat
Veterans (Wang et al., 1997). Finally, Zuckerman (1994) proposed sensation-seeking as a
personality attribute, describing such behavior as a tendency to seek diverse, novel,
complex and intense sensations, along with the willingness to accept risks for the
experience. While prior literature has argued that individuals with anxiety disorders
typically demonstrate lower levels of sensation-seeking, both clinical and empirical
observations have demonstrated that Veterans with PTSD show increased ratings on
sensation-seeking behaviors (Wang et al., 1997; Grigsby, 1991; Wilson, Smith, &
Johnson, 1984).
Thus, the literature suggests two common patterns of behavior in combat Veterans:
general avoidance related to PTSD, and risk-taking or sensation-seeking behaviors. The
purpose of the current study was to examine how these patterns manifest in the area of
leisure and play for Veterans.
Models of Play and Leisure
As noted above, the focus of the current study was to examine leisure and play among
Veterans, focusing both on the degree to which leisure and play are avoided, and the
degree to which Veterans seek intense or risky leisure experiences. The evaluation of
6


patterns of play and leisure among Veterans was informed by two existing theories of
play and leisure. These two theories are rooted in family and dyadic systems, proposing
that the value of play is beneficial for both the individual and the broader social system.
Aron and Arons (1986) self-expansion model proposes that an individual is motivated to
expand the self through acquired knowledge, experience, identities and other resources
(Aron & Aron, 1986). One specific method of self-expansion occurs through engaging in
novel, exciting activities. Aron and colleagues (2001) demonstrated that the process of
sharing in new and exciting activities has been associated with feelings of pleasure,
arousal, and excitement.
The importance of both new and expansive activitiesas well as engaging in
common activities are delineated in Johnson and colleagues (2006) Core and Balance
Model of leisure patterns. The Core and Balance Model subsumes two patterns of leisure:
core (common, everyday activities), and balance (novel, less frequent activities). Core
activities consist of common, everyday, accessible, low-cost, and often home-based
activities that one may participate in more frequently. Watcmng movies/television,
cooking dinner, gardening, or playing board games are examples of core activities.
Furthermore, core activities are seen as consistent, safe, and positive to the individual
(Zabriskie, 2000). On the other hand, balance activities consist of engaging in
interactions that are less common and less frequent and typically provide a relatively
novel experience. These activities are usually not considered home-based, and may
require more resources. Outdoor recreation, attending amusement parks, or music
concertsand vacations are examples of balance activities. Balance activities are
unpredictaole and necessitate adaptation to new experiences and challenges (Zabriskie &
7


McCormick, 2001). The Core and Balance model suggests that engagement in both types
of activities promote individual well-being and positive social functioning (Johnson,
Zabriskie, & Hill 2006). Although neither model has been tested in the Veteran or PTSD
population, these models were incorporated in the analysis of the patterns of leisure and
play described by the Veterans in the current study.
8


CHAPTER
II. QUALITATIVE METHODOLOGY
A majority of the literature exploring the impacts of symptoms of PTSD on the
Veteran utilizes quantitative methods. While quantitative methods provide useful
information regarding PTSD symptoms, such methods lack the ability to describe the
individuals personal experience. Qualitative methods provide rich, grounded data rooted
in the individuals personal experience. Other advantages of qualitative methods are the
clarification of less-understood phenomena (Strauss & Corbin, 1990) and the
development of empirically grounded theories derived from the phenomenon of interest
(Glaser & Strauss, 1967). Miles and Huberman (1994) emphasize strengths of qualitative
data including data that are:1)focused on events that occur in everyday life; 2)linked to
a specific situation; 3) explore the individuals experience within a specific context; and
4) data which provides rich descriptions that demonstrate the complexity and tmth of life.
Furthermore, the authors argue the benefits of qualitative data which include assisting in
the development of new hypotheses, may assist in hypothesis testing, and "supplement,
validateexplainilluminateor reinterpret quantitative datap.10) that is gathered
simultaneously (Miles & Huberman, 1994). To this aim, I applied qualitative methods to
explore a conceptual framework of activities in which the Veteran may or may not be
participating.
While there are an abundance of approaches to qualitative methodology, most
relevant to the current study is a phenomenological approach. Phenomenology is often
9


considered both as a philosophical discipline and research method (Geallenos, 1998;
Lopez & Willis, 2004). Phenomenology is the study human consciousness and self-
awareness (Merriam-Webster, 2008). One specific qualitative approach that maintains
phenomenology as a core component is the use of hermeneutics, an interpretive paradigm
(Clark, 1998; Denzin & Lincoln, 1998; Koch, 1995). This branch of interpretation was
named after the Greek god Hermeswhen roughly translated means to interpretLopez
& Willis, 2004; p.728). Hermes role was to interpret, or make clear, hidden or
fragmented messages between the Greek gods. Heidegger, a leader in hermeneutics,
conceptualized this approach as a methodological interpretation of a person5 s experience
of existence (Mackey, 2005). Thus, hermeneutics focuses on the context in which the
human experience occurs. Heidegger (1962) proposed that in order to understand the
human experience one must address the individuals way of being in the world as
integrated with the various contexts that informs their choices and gives meaning to their
life experiences. Furthermore, this approach also considers the individuals5 experiences
and contexts in relation to cultural, political, and social contexts (Campbell, 2001).
Heidegger believed the interpretive process was circular in nature, moving transactionally
between the investigators understanding and the meaning learned from the investigation
(Heidegger, 1962). According to Koch (1995), the investigation leads to a blending of
meanings articulated by the experience of the research and the participants via the data.
Thusthe goal of hermeneutic research is to gather participant-generated experiences and
information, and identify the participants5 meaning of their experience through the blend
of the data collected and the researchers understanding of the phenomena.
10


CHAPTER
III. ANALYSIS RATIONALE
While many other qualitative approaches are available, hermeneutic phenomenology
has been suggested as the most suitable method to examine an individuals experience
from a blend of meaning and interpretation expressed by the participants and
researcher(s) (Benner, 1994; Draucker, 1999; Koch, 1995; Parse, 1999). Additionally,
prior literature has proposed step-by-step frameworks for analyzing the data
(Diekelmann, Allen, & Tanner, 1989; Moustakas, 1994). Such processes provide a
qualitatively rigorous method for examining the Veteran5s experience (or lack) of
activities, interpreted as a blend of the participants5 and researchers5 personal, cultural,
social and political contexts. Thus, hermeneutic phenomenological methods were utilized
to analyze the Adventurous Activities interview, a semi-stmctured interview designed to
elicit OEF/OIF Veteran5s frequency, type, and reasons for participation in activities that
may provide a rushthrillhigh or get them feeling jacked up.
A workshop sponsored by the National Institutes of Health (NIH) Cultural and
Qualitative Research Interest Group provided researcher guidelines for the application of
rigorous qualitative methods (National Institutes of Health Office of Behavioral and
Social Sciences Research, 1999). These include:1)careful and systematic description of
qualitative data methods; 2) clear and supportive rationale for using qualitative methods
to address the research question(s); 3) explicit discussion of the sample variaoles (i.e.,
importance of the sample, sampling plan, timeframes of data collection); and 4) clear and
methodical analysis plan and data interpretation. Chwalisz and colleagues (2008)
11


summarized essential components ensuring the quality of qualitative methodology,
including components of reliability and validity.
PrimarilyLincoln and Gubas (1985) aspects of reliability and validity was utilized
for this study. Reliability in qualitative research should capture aspects of dependability
such as stepwise replication, that is, the use of multiple researchers to analyze data
separately. Triangulation is another form of qualitative reliability. The use of
triangulation as a research strategy ensures the completeness of and confirms research
findings. Specifically, researcher and theoretical triangulation was used for this study.
Researcher triangulation is the process of engaging multiple researchers in the analysis of
the data and includes a consensus process to interpret the data. In essence, this specific
triangulation strategy of using multiple investigators who possess different perspectives
to uncover findings and determine through consensus an outcome of similar findings
contributes to the completeness of the data collected. Three investigators with different
areas of clinical and research expertise in domains associated with the rationale for the
study (relationship functioning, military personnel, military-related posttraumatic stress)
analyzed the data and contribute to the interpretation and discussion of findings.
Theoretical triangulation is the use of a variety of theories used to support or
refute findings uncovered during analysis and interpretation. The use of multiple
theoretical lens assist in deepening the understanding of the experience described by the
participant. Furthermore, theoretical triangulation often contributes to the development
of new hypotheses and theories of the unexplored research phenomena for future studies.
Theoretical triangulation occurred through the development and dissemination of the
rationale for this study as well as the theoretical perspective(s) under which the
12


investigators possess and use in their analysis of the data. As noted, the investigators
were familiar with two theories of play and leisure: Theory of Self-Expansion, and the
Core and Balance Model of Shared Leisure Activities. Additionally, each investigator
possesses differing theoretical perspectives that influenced their analysis and
interpretation of the data.
Validity of data analyses occurred through components of credibility, transferability,
researcher consensus/replication, and reflexive validity. Validity strategies are considered
external checks of the data analysis and interpretation process (Chwalisz et al., 2008).
These components of validity often do not occur in sequence rather the process is
bidirectional that occurs during a consensus meeting. Credibility was addressed by
researcher debriefing of data collection; that is, verbal discussion of the data analysis
process and notation of unique and common findings. In addition, another credibility
technique is the testing and refining of working hypotheses and/or interpretations with
each unique data element noted by the researchers. As such, the investigators openly
discussed each new data element (i.e., quotations from the Veterans) and determined the
fit and relevance of the data to the working themes developed during data
analysis/interpretation. Transferability was obtained by independent researchers
presenting their interpretations as supported by participant data that supports these
interpretations. Consensus/replication and reflexive validity were the processes by which
the researchers collaboratively determined salient interpretations of the participants5
experiences (consensus/replication) in conjunction with how the researcher5s perspective
or hypotheses were affected by data analysis (reflexive validity).
13


CHAPTER
IV. METHODS
Participants
After obtaining approval from the local Institutional Review Board, participants
were recruited from the population of OEF and OIF Veterans seeking or eligible to
receive healthcare within the Veterans Affairs (VA) Eastern Colorado Health Care
System (ECHCS). All participants were recruited in response to flyersmental health
staff meetings, and OEF/OIF clinics. Participants were informed the goals of the
study were to learn more about OEF/OIF Veterans physical and mental health
relationships, and activities through semi-stmctured interviews and self-report
measures. All participants met criteria as an OEF/OIF Veteran, had been in a
romantic relationship for at least one year, and were between the ages of 18 and 50;
no participants were excluded from participation. The final sample included 15 males
and 4 females ranging between the ages of 23 and 49 (M = 32.11 years, SD = 7.68
years). Most of the participants identified as Caucasian/White (N=11)and the rest
were Black/African American (N=4), Hispanic/Latino(a) (N=3), and other (N =1).A
majority of the Veterans served as Active Duty Army (N=9), four Veterans each
served in the Marine Corps and Air Force, one served in the Navy, and one in Army
National Guard. Veterans ranged from 3 years of service to 20 years of service (M =
8.7 years; SD = 6.8 years; Median = 5 years). Eight Veterans deployed once (Iraq N =
5; Afghanistan N = 3), five reported 2 deployments, and four reported 4 or more
14


deployments. Informed consent was obtained prior to any study procedures being
conducted.
Measures and Procedures
Common qualitative methods specify that data are collected until interviews reach
saturation, that is, when additional interviews do not provide any new information (Rubin
& Rubin, 1995). In a previous study by Brenner and colleagues (2008) saturation was
achieved after 16 interviews. Therefore, I predicted that a similar sample size for this
study would be sufficient. Interview transcript review, coding and team consensus was
used to determine if no new themes or information were observed, such that saturation
was confirmed (see more below; Guest, Bunce, & Johnson, 2006).
Two members of the research team (LMBEA) developed a semi-structured
interview to obtain information related to adventurous activities. Adventurous activities
were defined as activities that elicits a rushhighthrill or feeling jacked up. The
interview was initially designed by one investigator (LMB) developing an initial set of
questions and activity descriptions based upon Arons theory of self-expansion
Johnsons model of Core and Balance Activitiesclinical phenomena of combat rush
(Grigsby1991) and addiction to traumavan der Kolk & Greenberg1987)and
Veteran PTSD literature. Items were reviewed with a second team member (EA) to
clarify questions. Revisions were incorporated and reviewed by two of the investigators
(LMB, EA). The final interview includes 9 questions, often with follow up probe
questions. For examplea yes to the question Do you engage in any of these types of
activities (activities that give you a rushhighthrillor get you feeling jacked up)?is
15


followed up by asking the respondent to list examples of these activities, reasons for
engaging in the activitiesi.e.Why do you think you engage in these kinds of
activities?)frequency of engaging in these activitiesand with whom they engage in
these activities. Additional questions elicit information related to change in frequency of
participation in such activities (uDo you participate in more adrenaline-pumping, thrilling
activities now than you did in the past?), emotional state when not engaged in such
activities (When you are not doing something high intensity or riskyhow do you
feel?)expressed level of intensity of these activities (Does it take more intensity or
risk for you to feel a thrill than it did in the past?)loss of interest/avoidance in these
activities (e.g.Have you lost interest in activities that used to get your adrenaline going
or that gave you a thrill?Do you purposefully avoid activities that get your adrenaline
going...?)and a final open-ended question about adventurous activities (Anything else
you can tell us about your current level of adrenaline-surgingthrill-seeking activities?).
Additional probe items often followed these asking for more explanation or details.
Please refer to Appendix A for a complete copy of the interview.
One doctoral-student investigator (LMB) conducted all study interviews and
procedures. This investigator has four years of experience conducting PTSD research in
the Veteran population and ample experience using qualitative methods with this
population. Study procedures lasted approximately 1.5 hours, with the Adventurous
Activities interview ranging from approximately 5 to 20 minutes. All interviews occurred
in person and were recorded by hand by the investigator and then transcribed to
electronic copies. Following the study interviews, participants completed self-report
measures to assess PTSD symptoms, relationship satisfaction, shared activities with their
16


significant other, mental health symptoms, overall health status and suicidal ideation.
These measures are not part of the current study.
17


CHAPTER
V. DATA ANALYSIS
I checked all transcripts for accuracy and completeness before converting the
transcript to electronic copies for data analysis. Prior to data analysis, I created a coding
sheet for the research team. The coding sheet was designed based upon Heideggarian
phenomenological qualitative methodology and related step-by-step frameworks for data
analysis recommended for heuristic qualitative methods (Diekelmann, Allen, & Tanner,
1989; Moustakas1994). Moustakas (1994) suggests a four-step data analysis as
informed by prior literature. These recommendations also address the essential
recommendations for rigor in qualitative methodology suggested by Chwalisz and
colleagues (2008) and described in detail above. Step one requires the researchers to be
aware of and describe their own experience of the elicited phenomena of interest
(theoretical triangulation). Next, the data should be independently analyzed by multiple
researchers considering the data for the richness of the experience, recording salient units
of information, listing unique elements of data, relating and clustering unique themes that
emerge from the data, and synthesizing the themes using verbatim examples (stepwise
replication). Third, steps 1 and 2 should be shared with all members of the research team.
Finally, as a group, the researchers collate, synthesize and achieve consensus regarding
the universal themes discovered from the raw data (researcher triangulation and validity
checks such as credibility, transferability, consensus/replication, and reflection).
Informed by these frameworks, I developed a standardized manual describing the
rationale for Heideggerian phenomenological and heuristic qualitative methods, including
18


detailed specific coding instructions and provide a coding summary packet for each
researcher. An initial coding meeting was conferred to review the manual and coding
summary packet. Feedback from this meeting was incorporated into the final manual
(Appendix B) and coding summary packet (Appendix C).
Researchers independently read and coded all19 interviews. A final coding
consensus meeting was conferred, in which steps 3 and 4 were addressed, using
recommendations to adhere to qualitative rigor. Two members of the research team
(LMB, EA) took notes related to researcher assumptions and biases, salient themes that
emerged from the interviews, and convergence on themes and support for these themes.
In order to maintain data integrity, I integrated both sets of notes, and re-reviewed each
interview prior to the results write-up. Results and discussion were provided to the other
members of the research team (EA, LAB) to additionally check as to consensus on data
interpretation. Feedback from this process was incorporated in this final report.
19


CHAPTER
VI. FINDINGS
Overall, analysis and interpretation of the interviews yielded four unique themes
regarding OEF/OIF Veteran participation in adventurous activities. These themes
included: type of activities, reasons for and against engaging in activities, changes in
frequency/level of intensity, and affective state when not engaged in these activities. Each
theme is presented and illustrated below.
Type of Activities
The interview was designed to elicit examples of activities that gave the Veteran a
rushhighthrillor... feeling jacked up. Expressed activities were all socially
sanctioned, legal, and pro-social in nature. A preponderance of responses included
physically-based activities, which could be furthered grouped into two categories,
extreme sports and physical fitness. In the category of extreme sports, Veterans listed
activities such as whitewater rafting, skiing, mountain biking, rock-climbing, and
kayakingthese activities seemed to represent extreme activities often because of the
intensity and danger of these as described by the Veteran. The most extreme sport listed
was cliff-diving. Others listed physically challenging activities such as hikingrunning
lifting weights, martial arts fighting, and skateboarding. Less often Veterans provided
examples that ranged towards less physically demanding activities such as shooting guns
at a shooting range, four-wheeling, motorcycle riding, and roller coasters. Drawing from
Johnson and colleagues5 (2006) Core and Balance model of leisure activities, it appeared
20


that a majority of the Veterans provided examples of balance activities, that is, activities
that are novel and less frequent. This would be expected from the prompt, where
Veterans were asked about relatively intense activities. In addition, these activity
examples tended to be more expensive and less accessible to the Veteran (e.g.,
whitewater rafting, roller coasters). To a lesser extent, Veterans described core activities,
activities that are more frequent and can occur daily (e.g., laughing, exercise).
Reasons for Engaging in Adventurous Activities
Five distinct sub-themes emerged when Veterans discussed their reasons for engaging
in adventurous activities: accomplishment, arousal, mood alteration, physical fitness, and
bonding.
Accomplishment
Several Veterans indicated that engaging in thrilling activities promoted a sense of
accomplishment or achievement in carrying out the activity. One Veteran commented [1]
achieve more than I could before...it pushes meanother said they participate in the
activity to be able to say Ive done it. One Veteran reported a sense of achievement in
participating in activities such as whitewater rafting and kayaking saying Its a challenge
that I can overcomethough you need to work with the guide and othersand yet another
said Its a challengelike how far can I go?. Others discussed more specific
characteristics related to a sense of accomplishment. For example, one Veteran engaged
in such activities because of the speed and reflexes necessary to complete the activity
and another said once you do itits pretty awesome.. .1 like the bragging rights.
21


Arousal
A second salient reason for why the Veteran participated in adventurous activities
revolved around the level of arousal experienced. This arousal appeared to range from a
seemingly muted description of feeling (fun)to a heightened level of arousalor a
sense of exhilaration or danger. In response to the Veteran5 s specific activity of cliff-
diving, he explained that he does it because it5s "scary as all heck, you don5t know if
youll slip and bounce off the rocksor if youll clear enough to hit water. Another
Veteran commented that mountain biking gave a rush sensation with the uncertainty
principle of when I put on the brakes and engaged in whitewater rafting or kayaking
because the danger aspect is exciting and funnot an over amount of dangerbut enough
to add spice to it.
Mood alteration
Veterans also seemed to engage in these activities to alter their mood, such as
creating enjoyment, happiness, a sense of well-being and a way to relieve stress. For
exampleVeterans stated that these activities makes me feel happymakes me feel
better about myself physically and emotionally and activities brings back good
memories. Four Veterans specifically reported that these activities provide a method to
relieve stresscommenting a good way to blow off steamfor the escapeand gives
me time to think. In additiona close-ended question embedded in the interview
inquiring about participating in such activities with their partner in order to feel emotions
such as happiness yielded several positive responses.
22


Physical Fitness
Analyses also yielded the theme that Veterans were motivated to participate in
adventurous activities to stay physically active and in shapeat times noting these were a
way of staying in shape and it keeps me healthy.
Bonding
A final significant theme noted as a reason for participating in adventurous activities
included the sense of bonding and companionship attained while participating in the
activity. This desire included reasons for activities that were both core (frequent, every
day) and balance (novel, less frequent) activities. This theme appeared in open-ended and
close-ended questions which focused specifically on with whom they engaged in the
activity and bonding functions of the activity. Shared companionship of the activities
varied from romantic partnersto friendsand military buddies. One Veteran noted I
cant explain it; its a really good timesharing with old military buddies to bond with
them. It takes teamwork and it builds trust. It builds trust going mountain bikingyou
have to trust those ahead of you to give a warning if something happens. Another
Veteran discussed participating in an obstacle course race saying it brings people closer
togetheryou have shared misery. Some Veterans talked about how their significant
other got them involved in activityand one Veteran commented if my wife and I
participated in something togetherI would want to do that activity again
23


Reasons for Not Engaging in Adventurous Activities
During the course of coding all three team members independently noted common
themes related to why some Veterans did not engage in these types of activities. Veterans
described reasons that prevented them from participating in adventurous activities in
response to a variety of questions. The most frequent questions in which these topics
arose during questions about change in frequency of activity, level of intensity to feel a
thrill, whether or not they lost interest in such activities, and in the final open-ended
question that allowed the Veteran to discuss any further ideas related to their current level
of thrill-seeking activities.
Lack of participation seemed to be related to internal and external barriers. The most
salient external barrier appeared to be a lack of resources. Veterans reported a lack of
financial means, limited opportunities to participate in activities, and a lack of time.
Another secondary external barrier seemed to be related to getting older, including a
sense of maturity, physical constraints of getting older, and protection of family. For
instancein the following quote one Veteran included lack of money and maturity as
factors related to lower involvement in these types of activities:
So many things that used to be fun arent anymore. I want to go mountain
climbingkayakingbut I cant because of money. I think its also because Ive
matured, [I] used to like it a lot more, like childish things. More focused on family
thingsnot myselfanymore... some of them [activities] werent good for menot
appropriate for a family man and fatherso Ive grown to let things go.
Internal barriers appeared to fall into two categories. There were Veterans who
indicated an anhedonic/depressive response to activities and others who described an
24


anxious or avoidant relationship to such activities. Several Veterans expressed a loss of
interest, motivation and a lack of energy and noted how this affected their ability to or
enjoyment of participating in adventurous activities. These themes emerged throughout
the course of the interview and did not seem to be tied to a specific question. For some
Veterans, this loss of energy and lack of motivation was distressing, as one Veteran
stated:
I did a lot when I first got out, I climbed mountains, drove fast, I wanted to do
things to the max. Now I have no motivationI couldnt handle it. I either have no
energy or I lost interest. I would give anything to be like before.
Others seemed to note this loss of interest as being related to a general sense of lack
of interestas one Veteran noted I lost interest in most things regardless of if it gave me
a thrill.
On the other hand, some Veterans talked more about feelings of anxiety or avoidance
that contributed to non-participation. Such themes were noted in statements like I have
some anxietyoften I just want to shut down and I avoid itI avoid when things involve
other people, avoid social situations or having to do new things but I work myself
through it until its over. In additionsome Veterans reported that they became avoidant
or anxious about activities which occur in large crowds or where sudden noises might
occur, such as firework displays.
Change in Frequency/Level of Intensity of Adventurous Activities
In response to a question regarding change in the frequency of participation in
adventurous activities, some participants discussed the idea that combat was the ultimate
25


experience, and no activity stateside could compare to the level of thrill experienced
while deployed. Rich descriptions were provided to describe this change:
'Cause there5s nothing that gets me excited, 'cause after dodging bullets and
feeling the heat of bombs and rocks flyingwhat else is going to get your
adrenaline up. Im gonna have to take up sky-diving or something
and the risk of being blown up every day is adrenaline pumpingnow its not that big of
a deal....whatever. This desensitization was noted as the Veterans described combat as
high intensity all daythat being deployed was hard to topit was pretty exciting. Yet
another said Getting into combat was a great feelingstill the fear factorit keeps you
motivatedaggressiveand excited. In order to attain a semblance of the same
adrenaline-pumping experiences at home, a few Veterans reported adding new elements
to activities to generate a greater thrill. One Veteran stated I add new elements to things
because I know how it is, for example, Til go rafting when it is stormy because it makes
it more exciting.
Other Veterans seemed to feel that the deployment experience had dampened their
interest in adventuresome activitiesnot because of the inability to reach the same high
of combat, but because combat had instilled in them a greater sense of caution and
realities associated with dangerous activities. One Veteran in response to a query
regarding frequency of participating in such activitiescommented Probably lessI have
no interest in thingsI guess its a dullness from deployment of having seen the aftermath
of what can happenIm cautious now. Another Veteran stated Ive seen what happens
like in the military.. .1 guess it could be from deployment. I was patient security, so I saw
the aftermath of war, men, women, children.. .Fve seen the worst of what could happen. I
26


avoid conflict and a lot of stuff. Some Veterans discussed an appreciation of the risk
associated with extreme activities. Veterans realized the significance of potential negative
consequences of engaging in such activities. Similar to themes noted under reasons for
not participating in adventurous activities, some Veterans were aware that participating in
such activities may cause harm to their families or reflect poorly upon their role as a
family man. Physical consequences also were notable. These responses varied from
wanting to avoid body aches caused by more intense activities to the chance that
serious physical damage may occur. For instance, a couple Veterans described being
discouraged from participating in risky activities (e.g.sky-diving) for the l-2/ chance
of things going wrong and the 99.9% chance that I would be paralyzed.
State When Not Engaged in Adventurous Activities
Veterans were asked to describe how they felt when they were not doing something
high intensity or risky. Common responses were feelings of boredom and restlessness.
Some felt sad, or anxious. Others indicated they felt fine. For those Veterans who
described feeling bored, the valence of the emotion appeared to be quite strong, for
exampleboredveryvery bored and bored stiffOften this was connected to
feelings of restlessnessas one participant noted Boredbut I always feel like I have to
keep myself busy. Feel like I should have something to doand yet another reported
feeling fidgety. Occasionallyaspects of anxiety were describedsome anxietyjust
want to shut down and feelings of being cautiousirritableon edge. Others expressed
feelings of sadness using phrases melancholy and downwhen in my depression
time. One Veteran expressed sadness as a component of missing out and feeling limited
27


in their ability to participate in adventurous activities. A smaller number of Veterans said
they felt normal or fine in response to this question.
28


CHAPTER
VII. DISUCSSION
Veterans deployed in service of the Global War on Terror may have encountered
extreme situations, requiring psychological and physical capabilities exceeding those
needed in day-to-day life. This exposure has been discussed in the literature as combat
stress. Combat stress is proposed to hold implications for re-integration concerns, health,
and psychological well-being. The literature has demonstrated that combat stress can lead
to psychiatric disorders, including mood and anxiety disorders, such as PTSD. However,
not all Veterans meet full criteria for PTSD, often exhibiting subthreshold or partial
symptoms. Regardless, empirical, clinical and popular observations have noted
impairment of functioning from symptoms of emotional numbing, avoidance and
hyperarousal in the OEF/OIF Veteran population. These symptoms may influence aspects
of the Veterans5 life, such as their participation in leisure activities. PTSD symptoms
have been postulated to affect leisure in two distinct ways:1)emotional distancing,
avoidance, and heightened startle response may inhibit participation in activities that
would remind the individual of the traumatic event or 2) individuals may seek out risky
behaviors or activities that simulate combat rush to generate a level of arousal and
intensity experience during combat. In addition, Veterans without PTSD may be more
likely to seek this combat rush simply because the intensity of their military
experiences may raise the bar for what they consider fun and exciting.
The current study used interviews with a small sample of Veterans to qualitatively
explore their personal experiences of leisure activities that generate a rushhighor
29


thrill to investigate these two frameworks. These Veterans predominantly discussed
participation in activities that are generally considered pro-social, socially sanctioned
activities. Most of these activities included some component of physical fitness or
activity. These activities tended to fit within Johnsons (2006) balance activities
characterized by the unpredictability of elements within the activity, activities that require
adaptation to new challenges, and activities that required more resources, such as money
and time. Activities reported by these Veterans also fit with Aron and Arons (1986)
model of self-expansion. That is, participants reported finding pleasure in activities that
elicited increased arousal and excitement. This finding does reflect the manner in which
the interview questions were asked and the information the questions were designed to
elicitas items prompted the participants to describe activities that were adrenaline-
pumping.
Reasons for participation and reasons inhibiting participation in activities yielded five
distinct themes: accomplishment, arousal, mood alteration, physical fitness, and bonding.
Some activities reflected more than one theme. For example, whitewater rafting or
mountain biking were generally group activities, require some physical stamina, and
require teamwork for communication and safe completion of the activity. It is interesting
to consider the degree to which these themes align with military service. The sense of
accomplishment, heightened arousal, and physical fitness reflects military values and
requirements of service. All of the Veterans who participated in this study had prior
deployments to either Iraq and/or Afghanistan. As such, success during training and
missions, frequent encounters with stressful situations, and the need for sustained
physical stamina were all requirements of their experience on deployment. Comradeship
30


and community in the military life could promote bonding with others in relation to these
activities.
It is important to note that not all of these Veterans felt the need to participate in
activities that generated a msh or a thrill. Furthermore, even the individuals who did
describe participating in adventurous activities identified reasons that limited their
engagement in such activities. Reasons for not engaging in adventurous activities seemed
to differentiate by internal and/or external barriers. External barriers described by these
Veterans included limitations of time, resources, and opportunity to seek out participation
in thrill-seeking activities. Some of these Veterans appeared frustrated with the inability
to participate in adventurous activities due to lack of finances, indicating they would like
to engage in more activities if they had the monetary means. Veterans in this study also
expressed internal barriers reflecting emotional states of depression or anxiety. Such
internal barriers appear to be clinically relevant, in that understanding these types of
psychological or affective states may inhibit participation in activities that would
potentially elicit higher intensity emotions or intense physiological arousal.
An additional theme was that combat was an ultimate adrenaline experience. While
some of this study5 s participants appeared to express a desire to engage in activities that
would elicit the same feelings as combat rushothers appeared to be inhibited by
combat experiences, such as a sense that they now had a tme understanding of the
mortality and damage that they could experience (and thus avoided danger), or by
depressed or anxious mood perhaps secondary to combat.
Overall, findings support the proposed dichotomy, such that there appears to be
subsets of this group of Veterans; one subset seeks to simulate the rush experienced in
31


combat by engaging in intense, risky activities, while another subset tends to avoid
participation in such activities due to more depressed or anxious state of being. Theories
such as combat rush and addiction to trauma appeared to be substantiated to a degree
based upon some of these Veterans who described a sense of boredom and need to
challenge themselves to a higher level of intensity in their leisure activities. In terms of
combat rushVeterans who participated in this study may be attempting to regulate
their internal physiological and emotional state by simulating the msh experienced on
deployment.
In terms of addiction to traumathese Veterans may be attempting to balance their
physiological state through the psychological component of re-living the arousal
experienced during the traumatic event. That is, the re-creation of the experience of
trauma may be more rooted in the re-experiencing symptoms of PTSD compared to a
pure physiological need to generate the arousal and excitement. On the other hand, some
Veterans in this study also demonstrated potential impacts of combat stress, such as
symptoms of anxiety disorders or depression, on their pursuit of leisure activities. This
has been supported in clinical and empirical observations in populations of Veterans
diagnosed with these disorders. Avoidance of or loss of interest in participating in
adventurous activities may serve as a coping strategy to remain distanced from the
traumatic memories associated with combat.
Beyond the implications for mental health, this sample of OEF/OIF Veterans who
seek activities that simulate combat rush may be more at risk of physical harm
substance abuse, and reckless behaviors. Consequences of engaging in activities that
place this sample of OEF/OIF Veterans at an increased risk may result in increased
32


healthcare utilization, loss of productivity, and may contribute to negative effects on
social relationships. However, in this particular sample, Veterans portrayed their
engagement in thrilling activities as pro-social and even pmdent, expressly avoiding
activities where there was real perceived high risk of harm, injury, or death.
While these findings provide implications for leisure and play activity patterns in this
group of individuals, this initial study had a number of limitations. This was only a small
sample of the larger OEF/OIF Veteran population and the interview questions and format
may have inhibited full expression (including not acknowledging more illicit thrills). At
the same time, these methods allowed an initial exploration of these issues with this
sample; an exploration which provided insights into how this sample of OEF/OIF
Veterans view and represent these experiences.
In additionthe larger study included specific recruitment selection factors. For
example, the study targeted OEF/OIF Veterans who had been in a romantic relationship
for at least one year. Thus, these may have been a relatively stable group with lower
levels of risk taking behavior, perhaps more likely to even be inhibited due to obligations
to these relationships. Additional demographic or availability factors may have
influenced the sample of OEF/OIF Veterans ability to participate in the research study.
As the study was conducted during VA business hours, only OEF/OIF Veterans able to
attend and complete research procedures were included. Variables such as employment
status and clinical populations may have contributed to the convenience sample. Another
sample selection limitation is the sole inclusion of Veterans who served in support of the
Global War on Terror, compared to a general inclusion of Veterans across multiple
theaters of deployment (e.g., Vietnam, Gulf, etc).
33


Most of the individuals that have served in the current war operations have
voluntarily enlisted or joined officer candidate school, as compared to prior wars that
have utilized draft methods for increasing the military population. Veterans who have
voluntarily joined the military may possess characteristics that are distinct from prior
Veteran populations. Such characteristics may specifically confound findings in this
study as the Veterans who participated in this study may be more inclined to seek
activities that generate a msh or a thrill. Hence, findings from this study may not be
generalized to the larger Veteran population. These findings should be considered
preliminary or pilot data from which larger quantitative studies could be planned which
would allow analysis of variability in patterns of thrill-seeking.
Because of the importance of leisure/playcombat rushand thrill-seeking
behaviors as a factor related to individual and relationship functioning, more research on
tms issue in this population are warranted. Further research into the implication of leisure
and play may be beneficial in the determination of potential models of risk, resiliency,
and recovery from combat stress in this population. Early identification of OEF/OIF
Veterans that may engage in risky behaviors may decrease potential negative outcomes of
such thrill-seeking behaviors, instead promoting safe and enjoyable activities to promote
well-being. Increased knowledge regarding activities to which OEF/OIF Veterans are
interested in participating may assist in clinical interventions. Inclusion of these types of
activities in clinical practice may promote OEF/OIF Veterans5 personal growth and well-
being, healthy relationships, and increase quality of life. In addition, a focus using a
positive approach to engaging OEF/OIF Veterans after their exposure to combat stress
34


may facilitate posttraumatic growth and recovery from stressors experienced while
deployed.
Veterans in this sample appear to have experienced relatively high adrenaline during
their military careers. As these Veterans adapt back to a normalcivilian life
discrepancies between their military values and culture may interact with their ability to
modulate their mood, seek healthy, safe activities, and build relationships. Future
research to incorporate safe, affordable leisure activities may promote psychological and
physical well-being.
35


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APPENDICES
APPENDIX A: ADVENTUROUS ACTIVITIES INTERVIEW
We are interested in knowing if there is anything you do now that gets your
adrenaline going, that is, activities that give you a rush, high, thrill, or get you
feeling jacked up.
1.Do you engage in any of these types of activities?
____________YES ____________NO
IF YES: Please list some examples of these activities (note to interviewer: please list all
activities stated below. If more than one response please query each activity for the
questions below: 2) why they engage in this activity (if necessary), 3) frequency of
activity including whom they participate in this activity with, etc) :
a.
b.
c.
d.
2. Why do you think you engage in these kinds of activities?
Do you participate in {note to interviewer: list activities from above here) for any
other reasons that you did not already say?
________a.______________________________________________________________________________
________b,______________________________________________________________________________
________c,______________________________________________________________________________
________d_______________________________________________________________________________
45


3. How often do you do something that gives you a rush, thrill, etc?
a. Activity:

At least daily
At least weekly
At least monthly
At least annually
For a )out how long per time?
< 1 hour 1-2 hrs 2-3 hours
3-4 hours 4-5 hours 5-6hours
o- / hours 7-8 hours 8-9 hours
9-10 hours >10 hours > 1 day
In general, who do you do these kinds of things with? (select all that apply)
Aloneby myself With military buddies With civilian friends
I I With members of my family With my partner
I I With another romantic partner
{Note to interviewer: If they answer with Yes to either partner or another
romantic partner please query the following)
Do you do these activities with your partner in order to feel emotions such as
intimacy, closeness, happiness or love?
What is your best guess about how your partner would feel about you engaging in these
kinds of activities?
I I Approve Disapprove Other (please explain):_____________________
Would you ever want your partner to share these kinds of activities with you?
Yes No Maybe (please explain): ____________
How many of these activities do you think could really cause harm to yourself or to
others?
I I None Some All
Is the risk that you 1 1 Not at all or others might get hurt part of the thrill of the activity or activities? A little Mostly Completely
For a )out how long per time?
At least daily < 1 hour 1-2 hrs 2-3 hours
At least weekly 3-4 hours 4-5 hours 5-6hours
At least monthly 6-7 hours 7-8 hours 8-9 hours
46


At least annually
b. Activity
9-10 hours >10 hours > 1 day
In general, who do you do these kinds of things with? (select all that apply)
Aloneby myself With military buddies With civilian friends
I I With members of my family With my partner
I I With another romantic partner
What is your best guess about how your partner would feel about you engaging in these
kinds of activities?
I I Approve Disapprove Other (please explain):____________________
Would you ever want your partner to share these kinds of activities with you?
Yes No Maybe (please explain): ____________
How many of these activities do you think could really cause harm to yourself or to
others?
I I None Some All
Is the risk that you or others might get hurt part of the thrill of the activity or activities?
I I Not at all A little Mostly Completely
c. Activity:
For a )out how long per time?
< 1 hour 1-2 hrs 2-3 hours
3-4 hours 4-5 hours 5-6hours
o- / hours 7-8 hours 8-9 hours
9-10 hours >10 hours > 1 day

At least daily
At least weekly
At least monthly
At least annually
In general, who do you do these Kinds of things with? (select all that apply)
I I Alone, by myself With military buddies With civilian friends
I I With members of my family With my partner
I I With another romantic partner
What is your best guess about how your partner would feel about you engaging in these
kinds of activities?
47


I I Approve Disapprove Other (please explain):_____________________
Would you ever want your partner to share these kinds of activities with you?
Yes No Maybe (please explain): ____________
How many of these activities do you think could really cause harm to yourself or to
others?
I I None Some All
Is the risk that you or others might get hurt part of the thrill of the activity or activities?
I I Not at all A little Mostly Completely
d. Activity:
For a )out how long per time?
< 1 hour 1-2 hrs 2-3 hours
3-4 hours 4-5 hours 5-6hours
o- / hours 7-8 hours 8-9 hours
9-10 hours >10 hours > 1 day

At least daily
At least weekly
At least monthly
At least annually
In general, who do you do these kinds of things with? (select all that apply)
_| Alone, by myself With military buddies With civilian friends
I I With members of my family With my partner
I I With another romantic partner
What is your best guess about how your partner would feel about you engaging in these
kinds of activities?
I I Approve Disapprove Other (please explain):____________________
Would you ever want your partner to share these kinds of activities with you?
Yes No Maybe (please explain): _____________
How many of these activities do you think could really cause harm to yourself or to
others?
I I None Some All
Is the risk that you or others might get hurt part of the thrill of the activity or activities?
I I Not at all A little Mostly Completely
48


4. Do you participate in more adrenaline-pumping, thrilling activities now than
you did in the past?
______YES _________NO
Please explain:
{note to interviewer: If response is query the following):
When you are not doing something high intensity or risky, how do you feel?
5. Does it take more intensity or risk for you to feel a thrill it did in the past?
YES _________________NO
If so, why?
6. Have you lost interest in activities that used to get your adrenaline going or
that gave you a thrill?
_______YES __________NO
If so, why?
7. Do you purposefully avoid activities that get your adrenaline going, that is,
activities that give you a rush, high, thrill, or get you feeling jacked up?
49


YES ______NO
If so, why?
8. Do you specifically avoid activities that would generate a thrill or get you
jacked up because it reminds you of an event you had in the past?
______YES _________NO
If so, why?
9. Do you avoid any activities that would give you a thrill because you feel that
something bad will happen if you do it?
______YES __________NO
If so, why?___________________________________________________________
10. Anything else you can tell us about your current level of adrenaline-
surgingthrill-seeking activities?______________________________________
50


APPENDIX B: CODING MANUAL
This qualitative data analysis is based upon phenomenological research methods
to examine concepts that arise from the Adventurous Activities interview. The
Adventurous Activities interview was designed to elicit OEF/OIF Veterans frequency
type, reasons and social supports when engaging in activities that may provide a umsh,
thrillhigh or get them feeling jacked up. SpecificallyI will utilize hermeneutic
phenomenological methods to analyze these data.
Hermeneutics is one branch of an interpretive paradigm, to which phenomenology
is a central component (Clark, 1998; Denzin & Lincoln, 1998; Koch, 1995).
Phenomenology, often considered both as a philosophical discipline and research method
(Geallenos, 1998; Lopez & Willis, 2004), is the study human consciousness and self-
awareness (Merriam-Webster, 2011). Hermeneutics (interpretive) phenomenology is one
branch of such study/description that focuses on the context in which the human
experience occurs. Heidegger (1962), the leader in hermeneutics, proposed that in order
to understand the human experience one must address the individuals way of being in
the world as integrated with the various contexts that informs their choices and gives
meaning to their life experiences. Furthermore, this approach also considers the
individuals5 experiences and contexts in relation to cultural, political, and social contexts
(Campbell, 2001). Thus, to understand the Veteran5 s experience (or lack) of activities, we
must interpret the experiences in light of their personal, cultural, social and political
contexts. For example, we must consider the effects of mental health conditions,
influences of significant others, and financial means, among other contexts, on the
experience of thrilling, adrenaline-pumping activities.
51


In addition to considering the individuals experience and contextsthe researcher
must also be aware of their own preconceptions, biases, and expectations that may
influence the analysis (Koch, 1995). Hermeneutic phenomenologists, assumptions
subsumed in Heideggers practice of hermeneuticsrecommend that the researcher reflect
on their own preconceptions so that during the interpretive processes such assumptions
are accounted for (Benner2004) and included in the rigor of the analysis.
For the process of this hermeneutic analysis, team members will be assigned
transcripts for review, coding and analyses; all team members will review each transcript.
Detailed instructions for analysis are included below. I have included the summary
coding form, however, it is expected that these drafts may be adapted as part of the
qualitative process. Likewise, the coding process may evolve as the team members code
the transcripts.
From the interview transcript(s), guided by your own phenomenological experience,
complete the following steps:
1st reviewfor each transcript (e.g.participant):
Read each transcript with a clear and open mind. Being aware of any
preconceived notions or biases that may be arising. Read each transcript, allowing the
participants experience to emerge naturally from the text.
Highlight relevantmeaningful text that expresses the participants experience as
elicited by the interview.
(note: spontaneous questions asked by the Interviewer will be noted with an 1:
responses by participants will be noted with an S:
2nd review, using all transcripts simultaneously:
52


Utilizing the summary coding formlist all unique (non-repetitive and non-
overlapping) statements or units of meaning in each respective section including:
Type of Adventurous Activities
Reasons for engaging in Adventurous Activities
Change in frequency of Adventurous Activities
State (emotional, physical, behavioral) when not engaged in Adventurous
Activities
Expressed level of intensity to feel the thrilletcof the activity
Synthesize/summarize the themes based upon your own description, including
clear documentation of preconceived notions/expectations/biases.
Group review
Bring all assigned transcripts and completed summary coding forms.
Team will review unique units and themes and obtain consensus.
Team will discuss each transcript, one at a time, to:
Identify any additional units or themes
Identify quotations of interest
Achieve triangulation/quality assurance of data analysis
Team will review and discuss the synthesis of themes and summary of data
constructed by each team member.
53


APPENDIX C: CODING SUMMARY FORM
Type of Adventurous Activities (List the Activities)
___(e.g.Interview Question 1 abcd and/or 10)
Examples & Quotes:
Study ID Line # Quotation
54


Reasons for Engaging in Adventurous Activities
(e.g., Interview Question 2 and 2 a, b, c, d,: Why do you think you engage in these kinds
of activities?; and/or 10)
Examples & Quotes:
Study ID Line #
Quotation
55


Change in Frequency of Adventurous Activities
_(e.g.Interview Question 4, 6, 8, 9 and/or 10_
Examples & Quotes:
Study ID Line #
Quotation
56


State When not Engaged in Adventurous Activities
(e.g., Interview Question 4b: When you are not doing something high intensity or risk,
_________________________how do you feel?; and/or 10)_____________________
Examples & Quotes:
Study ID Line # Quotation
Expressed Level of Intensity to Feel Thrill of Activity ______
57


(e.g., Interview Question 5: Does it take more intensity or risk for you to feel a thrill it
did in the past?', and/or 10; or information gathered from direct questions related to each
activity [3 a-e])
Examples & Quotes:
Study ID Line # Quotation
Synthesis or Summary of Themes Identified_________________________
58


Illustrative Examples & Quotes:
Study ID Line # Quotation
59


Full Text

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ADVENTUROUS ACTIVITIES: A QUALITATIVE STUDY OF PLAY AMONG OEF/OIF VETERANS by Lisa Marie Betthauser B.A., University of Colorado, Boulder, 2003 M.B.A., University of Colorado, Denver, 2006 A thesis submitted to the Faculty of the Graduate School of the University of Colorado in partial fulfillment of the requirements for the degree of Doctor of Philosophy Clinical Health Psychology 2014

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ii This thesis for the Doctor of Philosophy degree by Lisa Marie Betthauser has been approved for the Clinical Health Psychology Program by Elizabeth Allen, Ph.D., Chair Lisa Brenner, Ph.D. Jim Grigsby, Ph.D. Date March 16, 2012

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iii Betthauser, Lisa, Marie (M.A., Clinical Health Psyc hology) Adventurous Activities: A Qualitative Study of Play among OEF/OIF Veterans Thesis directed by Elizabeth Allen, Ph.D. ABSTRACT Individuals who have served in the conflicts in Ira q and Afghanistan have likely been exposed to combat stress. Existing literature has consistently demonstrated the negative impact of combat stress as a risk factor for post-d eployment health issues, such as posttraumatic stress disorder (PTSD). One significant, but less studied area that may be affected by the experience of deployment and/or PTS D symptoms is the individual’s engagement in pleasurable, leisure activities or “p lay”. Clinical and empirical observations have typically focused on PTSD symptom s of avoidance and emotional numbing, contributing to an individual’s loss of in terest or participation in pleasurable activities. In contrast, there is literature sugges ting that individuals with deployment history or PTSD may actually seek out activities th at are risky or that provide an intense level of physiological and psychological arousal. T his study qualitatively examined leisure and play among a sample of OEF/OIF Veterans exploring both possible avoidance and seeking of intense or risky leisure e xperiences. Findings support the proposed dichotomy, such that there appears to be a subset of this sample that seek to simulate the “rush” experienced in combat by engagi ng in intense, risky activities, while other Veterans in this sample tend to avoid partici pation in such activities due to depression or anxiety. Future research could examin e whether increased access to safe,

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iv affordable leisure activities may address these iss ues and promote psychological and physical well-being. The form and content of this abstract are approved. I recommend its publication. Approved: Elizabeth Allen, Ph.D.

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v DEDICATION I dedicate this work to all the brave men and wom en who have pledged their lives to preserve, and protect our fr eedom.

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vi ACKNOWLEDGMENTS I would like to thank Dr. Elizabeth Allen, Dr. Jim Grigsby, and Dr. Lisa Brenner for their invaluable input and guidance. I would li ke to thank the research team at the Mental Illness Research, Education, and Clinical Ce nter at the Denver Veterans Affairs Medical Center for the assistance and support of th is project. I send my gratitude and love to my husband and family for their love and support throughout my journey and their acceptance of my passion for this field. Finally, I would like to thank all the dedicated, brave individuals who have served our country throu ghout history. This publication is based on work supported by the Department of Veterans Affairs, but does not necessarily represent the vie ws of the Department of Veterans Affairs or the United States Government.

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vii TABLE OF CONTENTS Contents CHAPTER ........................................... ................................................... ............................ 1 I. INTRODUCTION ...................................... ................................................... .............. 1 PTSD .............................................. ................................................... ...................... 2 PTSD Impacts Leisure Activities.................... ................................................... ..... 3 Models of Risk-Taking and Sensation-Seeking Behavio rs .................................... 5 Models of Play and Leisure ........................ ................................................... ......... 6 II. QUALITATIVE METHODOLOGY .................................................. ..................... 9 III. ANALYSIS RATIONALE .................................................. .................................... 11 IV. METHODS .................................................. ................................................... .......... 14 Participants ...................................... ................................................... ................... 14 Measures and Procedures ........................... ................................................... ........ 15 V. DATA ANALYSIS .................................................. ................................................. 1 8 VI. FINDINGS .................................................. ................................................... ........... 20 Type of Activities ................................ ................................................... .............. 20 Reasons for Engaging in Adventurous Activities .... ............................................. 21 Accomplishment .................................... ................................................... ............ 21 Arousal ........................................... ................................................... .................... 22 Mood alteration ................................... ................................................... ............... 22 Physical Fitness .................................. ................................................... ................ 23 Bonding ........................................... ................................................... ................... 23 Reasons for Not Engaging in Adventurous Activities .......................................... 24 Change in Frequency/Level of Intensity of Adventuro us Activities .................... 25

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viii State When Not Engaged in Adventurous Activities .. .......................................... 27 VII. DISUCSSION .................................................. ................................................... ...... 29 REFERENCES ........................................ ................................................... ...................... 36 APPENDICES ........................................ ................................................... ........................... A: ADVENTUROUS ACTIVITIES INTERVIEW ............... .......................................... 45 B: CODING MANUAL .................................. ................................................... ............... 51 C: CODING SUMMARY FORM ............................ ................................................... ..... 54

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ix LIST OF ABBREVIATIONS DSM-IV-TR Diagnostic and Statistical Manual of Men tal Disorders Fourth Edition Text Revision ECHCS Eastern Colorado Healthcare System PTSD Posttraumatic Stress Disorder OEF Operation Enduring Freedom OIF Operation Iraqi Freedom VA Veterans Affairs

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1 CHAPTER I. INTRODUCTION Since 2001, over 2.3 million individuals have been deployed to serve in the Global War on Terror (Environmental Health Strategic Healt hcare Group, 2011). Operation Enduring Freedom (OEF; Afghanistan) and Operation I raqi Freedom (OIF; Iraq) have been defined as the longest ongoing United States c ombat conflicts since the Vietnam War (Tanelian & Jaycox, 2008). These operations hav e been characterized by increased frequency of multiple deployments, longer duration of deployments, and shorter postdeployment periods (Belasco, 2007). An increased li kelihood of exposure to combat stress during OEF/OIF compared to prior wars have b een proposed, as the current troops serving in these operations are experiencing improv ised explosive devices, suicide bombers, frequent mortar attacks, handling of frien dly and enemy human remains, and feelings of helplessness of not being able to stop violent situations (Hoge et al., 2004). Even military personnel deployed for peace-keeping or stability missions are exposed to the similar stressors as those actively engaged in combat operations (Tanelian & Jaycox, 2008). Existing literature has consistently demonstrated t he negative impact of combat stress as a risk factor for post-deployment health issues, including psychiatric disorders. Of note, exposure to combat has been shown to increase the likelihood of developing posttraumatic stress disorder (PTSD; Tanelian & Jay cox, 2008; Hoge et al., 2008; Kulka et al., 1990; Kessler, Sonnega, Bromet, Hughes & Ne lson, 1995). An estimated 10-40%

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2 of individuals serving in OEF/OIF have been screene d for or report symptoms associated with PTSD (Hoge et al., 2004; Lapierre, Schwegler, & Labauve, 2007). Seal and colleagues (2007) looked at OEF/OIF Veterans seekin g services at the Department of Veterans Affairs and found a 13% prevalence of PTSD based on the ICD-9-CM diagnosis. Furthermore, this group of researchers f ound a significantly increased risk of PTSD and mental health diagnoses among the youngest OEF/OIF age group (ages 18-24) as compared to Veterans 40 years and older. As more of the Soldiers serving in Iraq and Afghanistan return home and transition out of Activ e Duty, the psychological impact of combat exposure is of increasing public concern. PTSD Posttraumatic stress disorder is an anxiety disorde r that can develop from exposure to a traumatic event which involves threat, or occurre nce, of severe injury or death to oneself or to others. Common traumatic events that may cause PTSD include accidents, natural disasters, violent assaults, and military c ombat. Diagnostic criteria of PTSD includes: re-experiencing the event, persistent avo idance of things associated with the event, numbing of emotions, and hyperarousal (DSM-I V-TR, APA, 2000). Symptoms must persist for more than one month and must cause significant distress and/or impairment in social, occupational or academic func tioning. Studies investigating the prevalence of PTSD in the Veteran population have t ypically relied on diagnostic clinical interviews and screening tools. However, many Veter ans returning from combat may not meet the full DSM-IV-TR criteria for PTSD. Post-dep loyment Veterans may minimize or fail to disclose their symptoms in order to facilit ate seeing friends and family, fear of loss

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3 of benefits, and/or stigma associated with having m ental health-related symptoms (Bliese, Wright, Adler, Thomas, & Hoge, 2007). When evaluati ng returning military personnel, it is important to consider partial symptoms of PTSD o n functioning. In fact, literature has demonstrated that both PTSD and subsyndromal PTSD a ffects health and psychosocial functioning. Combat-related PTSD has been associated with co-mor bid conditions such as depression, substance use, anxiety and cognitive im pairments resulting in negative health outcomes (Hoge et al., 2004, Kang & Hyams, 2005, Ta nielian & Jaycox, 2008). PTSD has also been associated with decreased physical fu nctioning and emotional well-being (Zatzick et al., 1997, Erbes et al, 2007), and impa ired social functioning such as relationship issues and poor family adjustment (Gav loski & Lyons 2004). Furthermore, having a diagnosis of PTSD has been shown to impact mortality and quality of life (Pietrzak et al., 2010; Tanielian & Jaycox, 2008). Partial or subsyndromal PTSD also have been associated with impairment in health and psychosocial functioning (Pietrzak et al., 2009; Jakupcak et al., 2004). PTSD Impacts Leisure Activities One significant, but less studied area that may be affected by PTSD symptoms is the individual’s engagement in pleasurable, leisure act ivities or “play”. Clinical and empirical observations have typically focused on av oidance and emotional numbing clusters of PTSD symptoms, postulating that individ uals with PTSD often demonstrate a loss of interest or participation in pleasurable ac tivities. In fact, this assessment is included in the DSM-IV-TR diagnostic criteria and c ommon screening tools used for

PAGE 13

4 assessing PTSD symptoms. Individuals with PTSD may avoid activities, places or people that remind them of the trauma, experience feelings of detachment from others, and have a limited range of affective responses, such as fee ling enjoyment or love. Such impairment may contribute to the lack of interest a nd engagement in activities. For example, Veterans with PTSD may avoid participating in military-related activities with old military buddies because of the reminder of the loss of a friend during deployment, or, Veterans may decline invitations to attend soci al events hosted by civilian friends because of feelings of estrangement or limited posi tive affect. Furthermore, a decreased participation in activitie s also may be related to PTSD symptoms of increased arousal, such as hypervigilan ce and exaggerated startle response. Veterans have described anecdotal experiences of mo difying participation in activities such as dining in less-crowded restaurants, and avo iding amusement parks, firework displays, and shooting ranges due to increased star tle response from loud noises. Whereas limited research has been conducted regardi ng a reduction or loss of interest in activities due to avoidance, isolation, and/or h ypervigilance, there is a body of literature suggesting that individuals with PTSD ma y actually seek out activities that are risky or activities that provide an intense level o f physiological and psychological arousal. Grigsby (1991) proposed a clinical phenome na of “combat rush” in Veterans with PTSD. Specifically, he suggested that Veterans experience a heightened state of arousal within the combat environment and seek to s imulate this experience postdeployment. Additional literature has discussed thi s phenomena as “addiction to trauma” (van der Kolk & Greenberg, 1987; Horowitz & Becker, 1971), where traumatized individuals seek out experiences analogous to the o riginal trauma event.

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5 More recent literature has investigated the associa tion between PTSD and risk-taking or sensation-seeking behaviors. Risk-taking behavio rs among Veterans has been operationalized by increased negative health behavi ors (McFall & Cook, 2006), such as substance abuse (Begic & Jokic-Begic, 2001; Meisler 1996), aggression and violence (Hartl, Rosen, Drescher, Lee, & Gusman, 2005; Taft, Street, Marshall, Dowdall, & Rigs, 2007), and reckless driving (Drescher, Rosen, Burli ng, & Foy, 2003). Furthermore, such risk-taking behaviors have resulted in negative out comes including incarceration (Greenberg & Rosenheck, 2011; Saxon et al., 2001; S haw, Churchill, Noyes, & Loeffelholz, 1987), deliberate self-harm, and/or su icide (Jakupcak et al., 2009; Pietrzak et al., 2009; Sacks, Flood, Dennis, Hertzberg, & Beckh am, 2008). As noted above, within the clinical literature experiences of risk-taking behavior, that is, the elicitation of “combat rush” or “addiction to trauma” wherein the individual may seek dangerous situations or situations reminiscent of the origina l trauma to generate an intense level of arousal has been discussed. Models of Risk-Taking and Sensation-Seeking Behavio rs Although there is not a consensus in the literature defining the link between PTSD and risk-taking behaviors, neurobiological, behavio ral, affective and personality theories have been applied to understand this association. S ome have proposed an underlying neurobiological mechanism of arousal triggered by t raumatic events that modify broad, and sustained synaptic function that contribute to the individual’s need to seek out a similar intense rush that mimics the experience of the trauma (van der Kolk & Greenberg, 1987; Kolb, 1984). Learned behaviors and physiologi cal arousal via classical

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6 conditioning and intense emotional responses may al so be at play in the development of PTSD (Kolb & Mutalipassi, 1982). Such re-occurring automatic responses may result in long-lasting neuronal changes (Kandel, 1985; Lynch 1986). PTSD has also been shown to activate hormonal systems in combat Veterans whi ch have been associated with affective and cognitive psychological state (Yehuda et al., 1992). Such changes in hormones have been linked to novel, sensation-seeki ng behaviors in Vietnam combat Veterans (Wang et al., 1997). Finally, Zuckerman (1 994) proposed sensation-seeking as a personality attribute, describing such behavior as a tendency to seek diverse, novel, complex and intense sensations, along with the will ingness to accept risks for the experience. While prior literature has argued that individuals with anxiety disorders typically demonstrate lower levels of sensation-see king, both clinical and empirical observations have demonstrated that Veterans with P TSD show increased ratings on sensation-seeking behaviors (Wang et al., 1997; Gri gsby, 1991; Wilson, Smith, & Johnson, 1984). Thus, the literature suggests two common patterns o f behavior in combat Veterans: general avoidance related to PTSD, and risk-taking or sensation-seeking behaviors. The purpose of the current study was to examine how the se patterns manifest in the area of leisure and play for Veterans. Models of Play and Leisure As noted above, the focus of the current study was to examine leisure and play among Veterans, focusing both on the degree to which leis ure and play are avoided, and the degree to which Veterans seek intense or risky leis ure experiences. The evaluation of

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7 patterns of play and leisure among Veterans was inf ormed by two existing theories of play and leisure. These two theories are rooted in family and dyadic systems, proposing that the value of play is beneficial for both the i ndividual and the broader social system. Aron and Aron’s (1986) self-expansion model propose s that an individual is motivated to expand the self through acquired knowledge, experie nce, identities and other resources (Aron & Aron, 1986). One specific method of self-ex pansion occurs through engaging in novel, exciting activities. Aron and colleagues (2 001) demonstrated that the process of sharing in new and exciting activities has been ass ociated with feelings of pleasure, arousal, and excitement. The importance of both new and “expansive” activiti es, as well as engaging in common activities are delineated in Johnson and col leagues’ (2006) Core and Balance Model of leisure patterns. The Core and Balance Mod el subsumes two patterns of leisure: core (common, everyday activities), and balance (no vel, less frequent activities). Core activities consist of common, everyday, accessible, low-cost, and often home-based activities that one may participate in more frequen tly. Watching movies/television, cooking dinner, gardening, or playing board games a re examples of core activities. Furthermore, core activities are seen as consistent safe, and positive to the individual (Zabriskie, 2000). On the other hand, balance activ ities consist of engaging in interactions that are less common and less frequent and typically provide a relatively novel experience. These activities are usually not considered home-based, and may require more resources. Outdoor recreation, attendi ng amusement parks, or music concerts, and vacations are examples of balance act ivities. Balance activities are unpredictable and necessitate adaptation to new exp eriences and challenges (Zabriskie &

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8 McCormick, 2001). The Core and Balance model sugges ts that engagement in both types of activities promote individual well-being and pos itive social functioning (Johnson, Zabriskie, & Hill 2006). Although neither model has been tested in the Veteran or PTSD population, these models were incorporated in the a nalysis of the patterns of leisure and play described by the Veterans in the current study

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9 CHAPTER II. QUALITATIVE METHODOLOGY A majority of the literature exploring the impacts of symptoms of PTSD on the Veteran utilizes quantitative methods. While quanti tative methods provide useful information regarding PTSD symptoms, such methods l ack the ability to describe the individual’s personal experience. Qualitative meth ods provide rich, grounded data rooted in the individual’s personal experience. Other adva ntages of qualitative methods are the clarification of less-understood phenomena (Strauss & Corbin, 1990) and the development of empirically grounded theories derive d from the phenomenon of interest (Glaser & Strauss, 1967). Miles and Huberman (1994) emphasize strengths of qualitative data including data that are: 1) focused on events that occur in everyday life; 2) linked to a specific situation; 3) explore the individual’s e xperience within a specific context; and 4) data which provides rich descriptions that demon strate the complexity and truth of life. Furthermore, the authors argue the benefits of qual itative data which include assisting in the development of new hypotheses, may assist in hy pothesis testing, and “supplement, validate, explain, illuminate, or reinterpret quant itative data” (p. 10) that is gathered simultaneously (Miles & Huberman, 1994). To this ai m, I applied qualitative methods to explore a conceptual framework of activities in whi ch the Veteran may or may not be participating. While there are an abundance of approaches to quali tative methodology, most relevant to the current study is a phenomenological approach. Phenomenology is often

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10 considered both as a philosophical discipline and r esearch method (Geallenos, 1998; Lopez & Willis, 2004). Phenomenology is the study h uman consciousness and selfawareness (Merriam-Webster, 2008). One specific qua litative approach that maintains phenomenology as a core component is the use of her meneutics, an interpretive paradigm (Clark, 1998; Denzin & Lincoln, 1998; Koch, 1995). This branch of interpretation was named after the Greek god Hermes, when roughly tran slated means “to interpret” (Lopez & Willis, 2004; p.728). Hermes role was to interpre t, or make clear, hidden or fragmented messages between the Greek gods. Heidegg er, a leader in hermeneutics, conceptualized this approach as a methodological in terpretation of a person’s experience of existence (Mackey, 2005). Thus, hermeneutics foc uses on the context in which the human experience occurs. Heidegger (1962) proposed that in order to understand the human experience one must address the individual’s way of being in the world as integrated with the various contexts that informs t heir choices and gives meaning to their life experiences. Furthermore, this approach also c onsiders the individuals’ experiences and contexts in relation to cultural, political, an d social contexts (Campbell, 2001). Heidegger believed the interpretive process was cir cular in nature, moving transactionally between the investigator’s understanding and the me aning learned from the investigation (Heidegger, 1962). According to Koch (1995), the in vestigation leads to a blending of meanings articulated by the experience of the resea rch and the participants via the data. Thus, the goal of hermeneutic research is to gather participant-generated experiences and information, and identify the participants’ meaning of their experience through the blend of the data collected and the researcher’s understa nding of the phenomena.

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11 CHAPTER III. ANALYSIS RATIONALE While many other qualitative approaches are availab le, hermeneutic phenomenology has been suggested as the most suitable method to e xamine an individual’s experience from a blend of meaning and interpretation expresse d by the participants and researcher(s) (Benner, 1994; Draucker, 1999; Koch, 1995; Parse, 1999). Additionally, prior literature has proposed step-by-step framewor ks for analyzing the data (Diekelmann, Allen, & Tanner, 1989; Moustakas, 1994 ). Such processes provide a qualitatively rigorous method for examining the Vet eran’s experience (or lack) of activities, interpreted as a blend of the participa nts’ and researchers’ personal, cultural, social and political contexts. Thus, hermeneutic ph enomenological methods were utilized to analyze the Adventurous Activities interview, a semi-structured interview designed to elicit OEF/OIF Veteran’s frequency, type, and reaso ns for participation in activities that may provide a “rush, thrill, high” or get them feel ing “jacked up”. A workshop sponsored by the National Institutes of Health (NIH) Cultural and Qualitative Research Interest Group provided resear cher guidelines for the application of rigorous qualitative methods (National Institutes o f Health Office of Behavioral and Social Sciences Research, 1999). These include: 1) careful and systematic description of qualitative data methods; 2) clear and supportive r ationale for using qualitative methods to address the research question(s); 3) explicit di scussion of the sample variables (i.e., importance of the sample, sampling plan, timeframes of data collection); and 4) clear and methodical analysis plan and data interpretation. C hwalisz and colleagues (2008)

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12 summarized essential components ensuring the qualit y of qualitative methodology, including components of reliability and validity. Primarily, Lincoln and GubaÂ’s (1985) aspects of rel iability and validity was utilized for this study. Reliability in qualitative research should capture aspects of dependability such as stepwise replication, that is, the use of m ultiple researchers to analyze data separately. Triangulation is another form of qualit ative reliability. The use of triangulation as a research strategy ensures the co mpleteness of and confirms research findings. Specifically, researcher and theoretical triangulation was used for this study. Researcher triangulation is the process of engaging multiple researchers in the analysis of the data and includes a consensus process to interp ret the data. In essence, this specific triangulation strategy of using multiple investigat ors who possess different perspectives to uncover findings and determine through consensus an outcome of similar findings contributes to the completeness of the data collect ed. Three investigators with different areas of clinical and research expertise in domains associated with the rationale for the study (relationship functioning, military personnel military-related posttraumatic stress) analyzed the data and contribute to the interpretat ion and discussion of findings. Theoretical triangulation is the use of a variety o f theories used to support or refute findings uncovered during analysis and inter pretation. The use of multiple theoretical lens assist in deepening the understand ing of the experience described by the participant. Furthermore, theoretical triangulatio n often contributes to the development of new hypotheses and theories of the unexplored re search phenomena for future studies. Theoretical triangulation occurred through the deve lopment and dissemination of the rationale for this study as well as the theoretical perspective(s) under which the

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13 investigators possess and use in their analysis of the data. As noted, the investigators were familiar with two theories of play and leisure : Theory of Self-Expansion, and the Core and Balance Model of Shared Leisure Activities Additionally, each investigator possesses differing theoretical perspectives that i nfluenced their analysis and interpretation of the data. Validity of data analyses occurred through componen ts of credibility, transferability, researcher consensus/replication, and reflexive val idity. Validity strategies are considered external checks of the data analysis and interpreta tion process (Chwalisz et al., 2008). These components of validity often do not occur in sequence rather the process is bidirectional that occurs during a consensus meetin g. Credibility was addressed by researcher debriefing of data collection; that is, verbal discussion of the data analysis process and notation of unique and common findings. In addition, another credibility technique is the testing and refining of working hy potheses and/or interpretations with each unique data element noted by the researchers. As such, the investigators openly discussed each new data element (i.e., quotations f rom the Veterans) and determined the fit and relevance of the data to the working themes developed during data analysis/interpretation. Transferability was obtain ed by independent researchers presenting their interpretations as supported by pa rticipant data that supports these interpretations. Consensus/replication and reflexiv e validity were the processes by which the researchers collaboratively determined salient interpretations of the participantsÂ’ experiences (consensus/replication) in conjunction with how the researcherÂ’s perspective or hypotheses were affected by data analysis (refle xive validity).

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14 CHAPTER IV. METHODS Participants After obtaining approval from the local Institution al Review Board, participants were recruited from the population of OEF and OIF V eterans seeking or eligible to receive healthcare within the Veterans Affairs (VA) Eastern Colorado Health Care System (ECHCS). All participants were recruited in response to flyers, mental health staff meetings, and OEF/OIF clinics. Participants w ere informed the goals of the study were to learn more about OEF/OIF VeteranÂ’s ph ysical and mental health, relationships, and activities through semi-structur ed interviews and self-report measures. All participants met criteria as an OEF/O IF Veteran, had been in a romantic relationship for at least one year, and we re between the ages of 18 and 50; no participants were excluded from participation. T he final sample included 15 males and 4 females ranging between the ages of 23 and 49 (M = 32.11 years, SD = 7.68 years). Most of the participants identified as Cauc asian/White (N=11), and the rest were Black/African American (N=4), Hispanic/Latino( a) (N=3), and other (N = 1). A majority of the Veterans served as Active Duty Army (N=9), four Veterans each served in the Marine Corps and Air Force, one serve d in the Navy, and one in Army National Guard. Veterans ranged from 3 years of ser vice to 20 years of service (M = 8.7 years; SD = 6.8 years; Median = 5 years). Eight Veterans deployed once (Iraq N = 5; Afghanistan N = 3), five reported 2 deployments, and four reported 4 or more

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15 deployments. Informed consent was obtained prior to any study procedures being conducted. Measures and Procedures Common qualitative methods specify that data are co llected until interviews reach saturation, that is, when additional interviews do not provide any new information (Rubin & Rubin, 1995). In a previous study by Brenner and colleagues (2008) saturation was achieved after 16 interviews. Therefore, I predicte d that a similar sample size for this study would be sufficient. Interview transcript rev iew, coding and team consensus was used to determine if no new themes or information w ere observed, such that saturation was confirmed (see more below; Guest, Bunce, & John son, 2006). Two members of the research team (LMB, EA) develope d a semi-structured interview to obtain information related to adventur ous activities. Adventurous activities were defined as activities that elicits a “rush, hi gh, thrill or feeling jacked up”. The interview was initially designed by one investigato r (LMB) developing an initial set of questions and activity descriptions based upon Aron ’s theory of self-expansion, Johnson’s model of Core and Balance Activities, cli nical phenomena of “combat rush” (Grigsby, 1991) and “addiction to trauma” (van der Kolk & Greenberg, 1987), and Veteran PTSD literature. Items were reviewed with a second team member (EA) to clarify questions. Revisions were incorporated and reviewed by two of the investigators (LMB, EA). The final interview includes 9 questions often with follow up probe questions. For example, a “yes” to the question “Do you engage in any of these types of activities (activities that give you a rush, high, thrill, or get you feeling jacked up)?” is

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16 followed up by asking the respondent to list exampl es of these activities, reasons for engaging in the activities, (i.e., “Why do you thin k you engage in these kinds of activities?”), frequency of engaging in these activ ities, and with whom they engage in these activities. Additional questions elicit infor mation related to change in frequency of participation in such activities (“Do you participa te in more adrenaline-pumping, thrilling activities now than you did in the past?), emotiona l state when not engaged in such activities (“When you are not doing something high intensity or risky, how do you feel?”), expressed level of intensity of these acti vities (“Does it take more intensity or risk for you to feel a thrill than it did in the pa st?”), loss of interest/avoidance in these activities (e.g., “Have you lost interest in activi ties that used to get your adrenaline going or that gave you a thrill?”, “Do you purposefully a void activities that get your adrenaline going…?”), and a final open-ended question about ad venturous activities (“Anything else you can tell us about your current level of adrenal ine-surging, thrill-seeking activities?”). Additional probe items often followed these asking for more explanation or details. Please refer to Appendix A for a complete copy of t he interview. One doctoral-student investigator (LMB) conducted a ll study interviews and procedures. This investigator has four years of exp erience conducting PTSD research in the Veteran population and ample experience using q ualitative methods with this population. Study procedures lasted approximately 1 .5 hours, with the Adventurous Activities interview ranging from approximately 5 t o 20 minutes. All interviews occurred in person and were recorded by hand by the investig ator and then transcribed to electronic copies. Following the study interviews, participants completed self-report measures to assess PTSD symptoms, relationship sati sfaction, shared activities with their

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17 significant other, mental health symptoms, overall health status and suicidal ideation. These measures are not part of the current study.

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18 CHAPTER V. DATA ANALYSIS I checked all transcripts for accuracy and complete ness before converting the transcript to electronic copies for data analysis. Prior to data analysis, I created a coding sheet for the research team. The coding sheet was d esigned based upon Heideggarian phenomenological qualitative methodology and relate d step-by-step frameworks for data analysis recommended for heuristic qualitative meth ods (Diekelmann, Allen, & Tanner, 1989; Moustakas, 1994). Moustakas (1994) suggests a four-step data analysis as informed by prior literature. These recommendations also address the essential recommendations for rigor in qualitative methodolog y suggested by Chwalisz and colleagues (2008) and described in detail above. St ep one requires the researchers to be aware of and describe their own experience of the e licited phenomena of interest (theoretical triangulation). Next, the data should be independently analyzed by multiple researchers considering the data for the richness o f the experience, recording salient units of information, listing unique elements of data, re lating and clustering unique themes that emerge from the data, and synthesizing the themes u sing verbatim examples (stepwise replication). Third, steps 1 and 2 should be shared with all members of the research team. Finally, as a group, the researchers collate, synth esize and achieve consensus regarding the universal themes discovered from the raw data ( researcher triangulation and validity checks such as credibility, transferability, consen sus/replication, and reflection). Informed by these frameworks, I developed a standar dized manual describing the rationale for Heideggerian phenomenological and heu ristic qualitative methods, including

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19 detailed specific coding instructions and provide a coding summary packet for each researcher. An initial coding meeting was conferred to review the manual and coding summary packet. Feedback from this meeting was inco rporated into the final manual (Appendix B) and coding summary packet (Appendix C) Researchers independently read and coded all 19 int erviews. A final coding consensus meeting was conferred, in which steps 3 a nd 4 were addressed, using recommendations to adhere to qualitative rigor. Two members of the research team (LMB, EA) took notes related to researcher assumpti ons and biases, salient themes that emerged from the interviews, and convergence on the mes and support for these themes. In order to maintain data integrity, I integrated b oth sets of notes, and re-reviewed each interview prior to the results write-up. Results an d discussion were provided to the other members of the research team (EA, LAB) to additiona lly check as to consensus on data interpretation. Feedback from this process was inco rporated in this final report.

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20 CHAPTER VI. FINDINGS Overall, analysis and interpretation of the intervi ews yielded four unique themes regarding OEF/OIF Veteran participation in adventur ous activities. These themes included: type of activities, reasons for and again st engaging in activities, changes in frequency/level of intensity, and affective state w hen not engaged in these activities. Each theme is presented and illustrated below. Type of Activities The interview was designed to elicit examples of ac tivities that gave the Veteran a “rush, high, thrill, or…feeling jacked up”. Express ed activities were all socially sanctioned, legal, and pro-social in nature. A prep onderance of responses included physically-based activities, which could be further ed grouped into two categories, extreme sports and physical fitness. In the categor y of extreme sports, Veterans listed activities such as whitewater rafting, skiing, moun tain biking, rock-climbing, and kayaking—these activities seemed to represent “extr eme” activities often because of the intensity and danger of these as described by the V eteran. The most extreme sport listed was cliff-diving. Others listed physically challeng ing activities such as hiking, running, lifting weights, martial arts fighting, and skatebo arding. Less often Veterans provided examples that ranged towards less physically demand ing activities such as shooting guns at a shooting range, four-wheeling, motorcycle ridi ng, and roller coasters. Drawing from Johnson and colleagues’ (2006) Core and Balance mod el of leisure activities, it appeared

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21 that a majority of the Veterans provided examples o f balance activities, that is, activities that are novel and less frequent. This would be exp ected from the prompt, where Veterans were asked about relatively intense activi ties. In addition, these activity examples tended to be more expensive and less acces sible to the Veteran (e.g., whitewater rafting, roller coasters). To a lesser e xtent, Veterans described core activities, activities that are more frequent and can occur dai ly (e.g., laughing, exercise). Reasons for Engaging in Adventurous Activities Five distinct sub-themes emerged when Veterans disc ussed their reasons for engaging in adventurous activities: accomplishment, arousal, mood alteration, physical fitness, and bonding. Accomplishment Several Veterans indicated that engaging in thrilli ng activities promoted a sense of accomplishment or achievement in carrying out the a ctivity. One Veteran commented “[I] achieve more than I could before…it pushes me”, ano ther said they participate in the activity “to be able to say I’ve done it”. One Vete ran reported a sense of achievement in participating in activities such as whitewater raft ing and kayaking saying “It’s a challenge that I can overcome, though you need to work with t he guide and others”, and yet another said “It’s a challenge, like ‘how far can I go?’”. Others discussed more specific characteristics related to a sense of accomplishmen t. For example, one Veteran engaged in such activities because of the “speed and reflex es” necessary to complete the activity, and another said “once you do it, it’s pretty aweso me…I like the bragging rights”.

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22 Arousal A second salient reason for why the Veteran partici pated in adventurous activities revolved around the level of arousal experienced. T his arousal appeared to range from a seemingly muted description of feeling (“fun”), to a heightened level of arousal, or a sense of exhilaration or danger. In response to the Veteran’s specific activity of cliffdiving, he explained that he does it because it’s “ scary as all heck, you don’t know if you’ll slip and bounce off the rocks, or if you’ll clear enough to hit water”. Another Veteran commented that mountain biking gave a “rush sensation with the uncertainty principle of when I put on the brakes” and engaged in whitewater rafting or kayaking because “the danger aspect is exciting and fun, not an over amount of danger, but enough to add spice to it”. Mood alteration Veterans also seemed to engage in these activities to alter their mood, such as creating enjoyment, happiness, a sense of well-bein g and a way to relieve stress. For example, Veterans stated that these activities “mak es me feel happy”, “makes me feel better about myself physically and emotionally” and activities “brings back good memories”. Four Veterans specifically reported tha t these activities provide a method to relieve stress, commenting “a good way to blow off steam”, “for the escape”, and “gives me time to think”. In addition, a close-ended quest ion embedded in the interview inquiring about participating in such activities wi th their partner in order to feel emotions such as happiness yielded several positive response s.

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23 Physical Fitness Analyses also yielded the theme that Veterans were motivated to participate in adventurous activities to stay physically active an d in shape, at times noting these were “a way of staying in shape” and “it keeps me healthy”. Bonding A final significant theme noted as a reason for par ticipating in adventurous activities included the sense of bonding and companionship att ained while participating in the activity. This desire included reasons for activiti es that were both core (frequent, every day) and balance (novel, less frequent) activities. This theme appeared in open-ended and close-ended questions which focused specifically on with whom they engaged in the activity and bonding functions of the activity. Sha red companionship of the activities varied from romantic partners, to friends, and mili tary buddies. One Veteran noted “I can’t explain it; it’s a really good time, sharing with old military buddies to bond with them. It takes teamwork and it builds trust. It bui lds trust going mountain biking, you have to trust those ahead of you to give a warning if something happens”. Another Veteran discussed participating in an obstacle cour se race saying “it brings people closer together, you have shared misery”. Some Veterans ta lked about how their significant other got them involved in activity, and one Vetera n commented “if my wife and I participated in something together, I would want to do that activity again”

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24 Reasons for Not Engaging in Adventurous Activities During the course of coding all three team members independently noted common themes related to why some Veterans did not engage in these types of activities. Veterans described reasons that prevented them from particip ating in adventurous activities in response to a variety of questions. The most freque nt questions in which these topics arose during questions about change in frequency of activity, level of intensity to feel a thrill, whether or not they lost interest in such a ctivities, and in the final open-ended question that allowed the Veteran to discuss any fu rther ideas related to their current level of thrill-seeking activities. Lack of participation seemed to be related to inter nal and external barriers. The most salient external barrier appeared to be a lack of r esources. Veterans reported a lack of financial means, limited opportunities to participa te in activities, and a lack of time. Another secondary external barrier seemed to be rel ated to getting older, including a sense of maturity, physical constraints of getting older, and protection of family. For instance, in the following quote one Veteran includ ed lack of money and “maturity” as factors related to lower involvement in these types of activities: So many things that used to be fun aren’t anymore. I want to go mountain climbing, kayaking, but I can’t because of money. I think it’s also because I’ve matured, [I] used to like it a lot more, like child ish things. More focused on family things, not myself, anymore…some of them [activitie s] weren’t good for me, not appropriate for a family man and father, so I’ve gr own to let things go. Internal barriers appeared to fall into two categor ies. There were Veterans who indicated an anhedonic/depressive response to activ ities and others who described an

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25 anxious or avoidant relationship to such activities Several Veterans expressed a loss of interest, motivation and a lack of energy and noted how this affected their ability to or enjoyment of participating in adventurous activitie s. These themes emerged throughout the course of the interview and did not seem to be tied to a specific question. For some Veterans, this loss of energy and lack of motivatio n was distressing, as one Veteran stated: I did a lot when I first got out, I climbed mountai ns, drove fast, I wanted to do things to the max. Now I have no motivation, I coul dn’t handle it. I either have no energy or I lost interest. I would give anything to be like before. Others seemed to note this loss of interest as bein g related to a general sense of lack of interest, as one Veteran noted “I lost interest in most things regardless of if it gave me a thrill”. On the other hand, some Veterans talked more about feelings of anxiety or avoidance that contributed to non-participation. Such themes were noted in statements like “I have some anxiety, often I just want to shut down” and “ I avoid it, I avoid when things involve other people, avoid social situations or having to do new things but I work myself through it until it’s over”. In addition, some Vete rans reported that they became avoidant or anxious about activities which occur in large cr owds or where sudden noises might occur, such as firework displays. Change in Frequency/Level of Intensity of Adventuro us Activities In response to a question regarding change in the f requency of participation in adventurous activities, some participants discussed the idea that combat was the ultimate

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26 experience, and no activity stateside could compare to the level of thrill experienced while deployed. Rich descriptions were provided to describe this change: ‘Cause there’s nothing that gets me excited, ‘cause after dodging bullets and feeling the heat of bombs and rocks flying, what el se is going to get your adrenaline up. I’m gonna have to take up sky-diving or something and “the risk of being blown up every day is adrena line pumping, now it’s not that big of a deal….whatever”. This desensitization was noted a s the Veterans described combat as “high intensity all day”, that “being deployed was hard to top, it was pretty exciting”. Yet another said “Getting into combat was a great feeli ng, still the fear factor, it keeps you motivated, aggressive, and excited”. In order to at tain a semblance of the same adrenaline-pumping experiences at home, a few Veter ans reported adding new elements to activities to generate a greater thrill. One Vet eran stated “I add new elements to things, because I know how it is, for example, I’ll go raft ing when it is stormy because it makes it more exciting”. Other Veterans seemed to feel that the deployment e xperience had dampened their interest in adventuresome activities, not because o f the inability to reach the same “high” of combat, but because combat had instilled in them a greater sense of caution and realities associated with dangerous activities. One Veteran in response to a query regarding frequency of participating in such activi ties, commented “Probably less, I have no interest in things, I guess it’s a dullness from deployment of having seen the aftermath of what can happen, I’m cautious now.” Another Vete ran stated “I’ve seen what happens, like in the military…I guess it could be from deplo yment. I was patient security, so I saw the aftermath of war, men, women, children…I’ve see n the worst of what could happen. I

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27 avoid conflict and a lot of stuff”. Some Veterans d iscussed an appreciation of the risk associated with extreme activities. Veterans realiz ed the significance of potential negative consequences of engaging in such activities. Simila r to themes noted under reasons for not participating in adventurous activities, some V eterans were aware that participating in such activities may cause harm to their families or reflect poorly upon their role as a “family man”. Physical consequences also were notab le. These responses varied from wanting to avoid “body aches” caused by more intens e activities to the chance that serious physical damage may occur. For instance, a couple Veterans described being discouraged from participating in risky activities (e.g., sky-diving) for the “1-2% chance of things going wrong” and the “99.9% chance that I would be paralyzed”. State When Not Engaged in Adventurous Activities Veterans were asked to describe how they felt when they were not “doing something high intensity or risky”. Common responses were fee lings of boredom and restlessness. Some felt sad, or anxious. Others indicated they fe lt fine. For those Veterans who described feeling bored, the valence of the emotion appeared to be quite strong, for example, “bored, very, very bored” and “bored stiff ”. Often this was connected to feelings of restlessness, as one participant noted “Bored, but I always feel like I have to keep myself busy. Feel like I should have something to do”, and yet another reported feeling “fidgety”. Occasionally, aspects of anxiet y were described, “some anxiety, just want to shut down” and feelings of being “cautious, irritable, on edge”. Others expressed feelings of sadness using phrases “melancholy” and “down, when in my depression time”. One Veteran expressed sadness as a component of missing out and feeling limited

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28 in their ability to participate in adventurous acti vities. A smaller number of Veterans said they felt “normal” or “fine” in response to this qu estion.

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29 CHAPTER VII. DISUCSSION Veterans deployed in service of the Global War on T error may have encountered extreme situations, requiring psychological and phy sical capabilities exceeding those needed in day-to-day life. This exposure has been d iscussed in the literature as combat stress. Combat stress is proposed to hold implicati ons for re-integration concerns, health, and psychological well-being. The literature has de monstrated that combat stress can lead to psychiatric disorders, including mood and anxiet y disorders, such as PTSD. However, not all Veterans meet full criteria for PTSD, often exhibiting subthreshold or partial symptoms. Regardless, empirical, clinical and popul ar observations have noted impairment of functioning from symptoms of emotiona l numbing, avoidance and hyperarousal in the OEF/OIF Veteran population. The se symptoms may influence aspects of the Veterans’ life, such as their participation in leisure activities. PTSD symptoms have been postulated to affect leisure in two disti nct ways: 1) emotional distancing, avoidance, and heightened startle response may inhi bit participation in activities that would remind the individual of the traumatic event or 2) individuals may seek out risky behaviors or activities that simulate “combat rush” to generate a level of arousal and intensity experience during combat. In addition, Ve terans without PTSD may be more likely to seek this “combat rush” simply because th e intensity of their military experiences may raise the bar for what they conside r fun and exciting. The current study used interviews with a small samp le of Veterans to qualitatively explore their personal experiences of leisure activ ities that generate a “rush, high, or

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30 thrill” to investigate these two frameworks. These Veterans predominantly discussed participation in activities that are generally cons idered pro-social, socially sanctioned activities. Most of these activities included some component of physical fitness or activity. These activities tended to fit within Joh nson’s (2006) balance activities, characterized by the unpredictability of elements w ithin the activity, activities that require adaptation to new challenges, and activities that r equired more resources, such as money and time. Activities reported by these Veterans als o fit with Aron and Aron’s (1986) model of self-expansion. That is, participants repo rted finding pleasure in activities that elicited increased arousal and excitement. This fin ding does reflect the manner in which the interview questions were asked and the informat ion the questions were designed to elicit, as items prompted the participants to descr ibe activities that were “adrenalinepumping”. Reasons for participation and reasons inhibiting pa rticipation in activities yielded five distinct themes: accomplishment, arousal, mood alte ration, physical fitness, and bonding. Some activities reflected more than one theme. For example, whitewater rafting or mountain biking were generally group activities, re quire some physical stamina, and require teamwork for communication and safe complet ion of the activity. It is interesting to consider the degree to which these themes align with military service. The sense of accomplishment, heightened arousal, and physical fi tness reflects military values and requirements of service. All of the Veterans who pa rticipated in this study had prior deployments to either Iraq and/or Afghanistan. As s uch, success during training and missions, frequent encounters with stressful situat ions, and the need for sustained physical stamina were all requirements of their exp erience on deployment. Comradeship

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31 and community in the military life could promote bo nding with others in relation to these activities. It is important to note that not all of these Veter ans felt the need to participate in activities that generated a rush or a thrill. Furth ermore, even the individuals who did describe participating in adventurous activities id entified reasons that limited their engagement in such activities. Reasons for not enga ging in adventurous activities seemed to differentiate by internal and/or external barrie rs. External barriers described by these Veterans included limitations of time, resources, a nd opportunity to seek out participation in thrill-seeking activities. Some of these Veteran s appeared frustrated with the inability to participate in adventurous activities due to lac k of finances, indicating they would like to engage in more activities if they had the moneta ry means. Veterans in this study also expressed internal barriers reflecting emotional st ates of depression or anxiety. Such internal barriers appear to be clinically relevant, in that understanding these types of psychological or affective states may inhibit parti cipation in activities that would potentially elicit higher intensity emotions or int ense physiological arousal. An additional theme was that combat was an ultimate adrenaline experience. While some of this study’s participants appeared to expre ss a desire to engage in activities that would elicit the same feelings as “combat rush”, ot hers appeared to be inhibited by combat experiences, such as a sense that they now h ad a true understanding of the mortality and damage that they could experience (an d thus avoided danger), or by depressed or anxious mood perhaps secondary to comb at. Overall, findings support the proposed dichotomy, s uch that there appears to be subsets of this group of Veterans; one subset seek s to simulate the “rush” experienced in

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32 combat by engaging in intense, risky activities, wh ile another subset tends to avoid participation in such activities due to more depres sed or anxious state of being. Theories such as “combat rush” and “addiction to trauma” app eared to be substantiated to a degree based upon some of these Veterans who described a s ense of boredom and need to challenge themselves to a higher level of intensity in their leisure activities. In terms of “combat rush”, Veterans who participated in this st udy may be attempting to regulate their internal physiological and emotional state by simulating the rush experienced on deployment. In terms of “addiction to trauma”, these Veterans m ay be attempting to balance their physiological state through the psychological compo nent of re-living the arousal experienced during the traumatic event. That is, th e re-creation of the experience of trauma may be more rooted in the re-experiencing sy mptoms of PTSD compared to a pure physiological need to generate the arousal and excitement. On the other hand, some Veterans in this study also demonstrated potential impacts of combat stress, such as symptoms of anxiety disorders or depression, on the ir pursuit of leisure activities. This has been supported in clinical and empirical observ ations in populations of Veterans diagnosed with these disorders. Avoidance of or los s of interest in participating in adventurous activities may serve as a coping strate gy to remain distanced from the traumatic memories associated with combat. Beyond the implications for mental health, this sam ple of OEF/OIF Veterans who seek activities that simulate “combat rush” may be more at risk of physical harm, substance abuse, and reckless behaviors. Consequenc es of engaging in activities that place this sample of OEF/OIF Veterans at an increas ed risk may result in increased

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33 healthcare utilization, loss of productivity, and m ay contribute to negative effects on social relationships. However, in this particular s ample, Veterans portrayed their engagement in thrilling activities as pro-social an d even prudent, expressly avoiding activities where there was real perceived high risk of harm, injury, or death. While these findings provide implications for leisu re and play activity patterns in this group of individuals, this initial study had a numb er of limitations. This was only a small sample of the larger OEF/OIF Veteran population and the interview questions and format may have inhibited full expression (including not a cknowledging more illicit thrills). At the same time, these methods allowed an initial exp loration of these issues with this sample; an exploration which provided insights into how this sample of OEF/OIF Veterans view and represent these experiences. In addition, the larger study included specific rec ruitment selection factors. For example, the study targeted OEF/OIF Veterans who ha d been in a romantic relationship for at least one year. Thus, these may have been a relatively stable group with lower levels of risk taking behavior, perhaps more likely to even be inhibited due to obligations to these relationships. Additional demographic or a vailability factors may have influenced the sample of OEF/OIF Veterans ability t o participate in the research study. As the study was conducted during VA business hours only OEF/OIF Veterans able to attend and complete research procedures were includ ed. Variables such as employment status and clinical populations may have contribute d to the convenience sample. Another sample selection limitation is the sole inclusion o f Veterans who served in support of the Global War on Terror, compared to a general inclusi on of Veterans across multiple theaters of deployment (e.g., Vietnam, Gulf, etc).

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34 Most of the individuals that have served in the cur rent war operations have voluntarily enlisted or joined officer candidate sc hool, as compared to prior wars that have utilized draft methods for increasing the mili tary population. Veterans who have voluntarily joined the military may possess charact eristics that are distinct from prior Veteran populations. Such characteristics may speci fically confound findings in this study as the Veterans who participated in this stud y may be more inclined to seek activities that generate a rush or a thrill. Hence, findings from this study may not be generalized to the larger Veteran population. These findings should be considered preliminary or pilot data from which larger quantit ative studies could be planned which would allow analysis of variability in patterns of thrill-seeking. Because of the importance of leisure/play, “combat rush”, and thrill-seeking behaviors as a factor related to individual and rel ationship functioning, more research on this issue in this population are warranted. Furthe r research into the implication of leisure and play may be beneficial in the determination of potential models of risk, resiliency, and recovery from combat stress in this population. Early identification of OEF/OIF Veterans that may engage in risky behaviors may dec rease potential negative outcomes of such thrill-seeking behaviors, instead promoting sa fe and enjoyable activities to promote well-being. Increased knowledge regarding activitie s to which OEF/OIF Veterans are interested in participating may assist in clinical interventions. Inclusion of these types of activities in clinical practice may promote OEF/OIF Veterans’ personal growth and wellbeing, healthy relationships, and increase quality of life. In addition, a focus using a positive approach to engaging OEF/OIF Veterans afte r their exposure to combat stress

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35 may facilitate posttraumatic growth and recovery fr om stressors experienced while deployed. Veterans in this sample appear to have experienced relatively high adrenaline during their military careers. As these Veterans adapt bac k to a “normal”, civilian life, discrepancies between their military values and cul ture may interact with their ability to modulate their mood, seek healthy, safe activities, and build relationships. Future research to incorporate safe, affordable leisure ac tivities may promote psychological and physical well-being.

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36 REFERENCES American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text revised). Washington, DC: Author. Aron, A., & Aron, N.E. (1986). Love as the expansion of self: Understanding attrac tion and satisfaction New York: Hemisphere. Aron, A., Norman, C.C., Aron, N.E., McKenna, C., & Heyman, R.E. (2000). CouplesÂ’ shared participation in novel and arousing activiti es and experience relationship quality. Journal of Personality and Social Psychology, 78, 273-284. Begic, D., & Jokic-Begic, N. (2001). Aggressive beh avior in combat veterans with posttraumatic stress disorder. Military Medicine, 166 671-676. Belasco, A. (2007). The cost of Iraq, Afghanistan, and other global war on terror operations since 9/11 Washington, D.C.: Congressional Research Service. Benner, P. (1994). Hermeneutic phenomenology: A met hodology for family health and health promotion study in nursing. In P. Benner (Ed .), Interpretive phenomenology: Embodiment, caring and ethics in hea lth and illness (pp. 71-72). Thousand Oaks, CA: Sage. Bliese, P.D., Wright, K.M., Adler, A. B., Thomas, J .L., & Hoge, C.W. (2007). Timing of postcombat mental health assessments. Psychological Services, 4(3), 141-148. Brenner, L. A., Gutierrez, P. M., Cornette, M. M., Betthauser, L. M., Bahraini, N., & Staves, P. J. (2008). A qualitative study of potent ial suicide risk factors in returning combat veterans. Journal of Mental Health Counseling, 30 211-225.

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37 Campbell, R. (2001). Heidegger: Truth as Aletheia. In R. Small (Ed.), A hundred years of phenomenology: Perspectives on a philosophical trad ition (pp. 73-89). Burlington, VT: Ashgate. Chwalisz, K, Shah, S.R., & Hand, K.M. (2008). Facil itating rigorous qualitative research in rehabilitation psychology. Rehabilitation Psychology, 53(3), 387-399. Clark, A. (1998). The qualitative-quantitative deba te: Moving from positivism and confrontation to postpositivism and reconciliation. Journal of Advanced Nursing, 27 1242-1249. Denzin, N.K., & Lincoln, Y.S. (1998). Introduction: Entering the field of qualitative research. In N.K. Denzin & Y.S. Lincoln (Eds.), Strategies of qualitative inquiry (pp. 1-35). Thousand Oaks, CA: Sage. Diekelmann, N.L., Allen, D., & Tanner, C. (1989). The NLN criteria for appraisal of baccalaureate programs: A critical hermeneutic anal ysis New York: National League for Nursing. Dindia, K., & Baxter, L.A. (1987). Strategies for m aintaining and repairing marital relationships. Journal of Social and Personal Relat ionships, 4, 143-158. Draucker, C.B. (1999). The critique of Heideggerian hermeneutical nursing research. Journal of Advanced Nursing, 30, 360-373. Drescher, K.D., Rosen, C.S., Burling, T.A., & Foy, D.W. (2003). Causes of death among male veterans who received residential treatment fo r PTSD. Journal of Traumatic Stress, 16 535543. Environmental Health Strategic Healthcare Group. (2 011). Analysis of VA health care utilization among Operation Enduring Freedom (OEF), Operation Iraqi Freedom

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38 (OIF), and Operation New Dawn (OND) veterans. Power Point presentation. Veterans Health Administration Department of Vetera ns Affairs. Erbes, C., Westermeyer, J., Engdahl, B., & Johnson, E. (2007). Post-traumatic stress disorder and service utilization in a sample of ser vice members from Iraq and Afghanistan. Military Medicine, 172 359-363. Galovski, T., & Lyons, J.A. (2004). Psychological s equelae of combat violence: A review of the impact of PTSD on the veteranÂ’s family and p ossible interventions. Aggression and Violent Behavior, 9 477-501. Geallenos, R. (1998). Hermeneutic philosophy. Part I: Implications of its use as methodology in interpretive nursing research. Nursing Inquiry, 5 154-163. Glaser, B., & Strauss, A. (1967). The discovery of grounded theory Chicago: Aldine. Greenberg, G.A., & Rosenheck, R.A. (2011). Incarcer ation among male veterans: Relative risk of imprisonment and differences betwe en veteran and nonveteran inmates. International Journal of Offender Therapy and Comparative Criminology, published online April 18, 2011, retri eved from: http://ijo.sagepub.com/content/early/2011/04/15/030 6624X11406091 Grigsby, J. (1991). Combat rush: Phenomenology of c entral and autonomic arousal among war veterans with PTSD. Psychotherapy, 28(2), 354-363. Guest, G., Bunce, A., & Johnson, L. (2006). How man y interviews are enough?: An experiment with data saturation and variability. Field Methods, 18, 59-82. Hartl, T.L., Rosen, C., Drescher, K., Lee, T.T., & Gusman, F. (2005). Predicting highrisk behaviors in veterans with posttraumatic stres s disorder. Journal of Nervous and Mental Disease, 193 464-472.

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39 Heidegger, M. (1962). Being and time (J. Macquarrie & E. Robinson, Trans). New York: Harper & Row. Hoge, C.W., Castro, C.A., Messer, S.C., McGurk, D., Cotting, D.L., & Koffman, R.L. (2004). Combat duty in Iraq and Afghanistan mental health problems, and barriers to care. New England Journal of Medicine, 351, 13-22. Hoge, C.W., Terhakopian, A., Castro, C.A., Messer, S.C., & Engel, C.C. (2008). Association of posttraumatic stress disorder with s omatic symptoms, health care visits, and absenteeism among Iraq war veterans. American Journal of Psychiatry, 164(1), 150-153. Horowitz, M.J., & Becker, S.S. (1971). The compulsi on to repeat trauma. Journal of Nervous and Mental Disease, 153 32-40. Jakupcak, M., Conybeare, D., Phelps, L. Hunt, S., H olmes, H.A., Felker, B.,Â…& McFall, M.E. (2004). Anger, hostility, and aggression among Iraq and Afghanistan War veterans reporting PTSD and subthreshold PTSD. Journal of Traumatic Stress, 20 945-954. Jakupcak M., Cook, J., Imel, Z., Fontana, A., Ros enheck, R., & McFall, M. (2009). Posttraumatic stress disorder as a risk factor for suicidal ideation in Iraq and Afghanistan War veterans. Journal of Traumatic Stress, 22 303-306. Johnson, H.A., Zabriskie, R.B., & Hill, B. (2006). The contribution of couple leisure involvement, leisure time, and leisure satisfaction to marital satisfaction. Marriage and Family Review, 40 69-91.

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40 Kandel, E.R. (1985). Cellular mechanisms of learnin g and the biological basis of individuality. In E.R. Kandel and J.H. Schwartz (Ed s.), Principles of neural science (2nd ed.). New York: Elsevier. Kang, H.K., & Hyams, K.C. (2005). Mental health car e needs among recent war veterans. New England Journal of Medicine, 352 1289. Kessler, A., Sonnega, A., Bromet, E., Hughes, M., & Nelson, C. (1995). Posttraumatic stress disorder in National Comorbidity Survey. Archives of General Psychiatry, 52 1048-1060. Koch, T. (1995). Interpretive approaches in nursing research: The influence of Husserl and Heidegger. Journal of Advanced Nursing, 21 827-836. Kolb, L.C. (1984). The post-traumatic stress disord ers of combat: A subgroup with a conditioned emotional response. Military Medicine, 149 237-243. Kolb, L.C., & Mutalipassi, L.R. (1982). The conditi oned emotional response: A sub-class of the chronic and delayed post-traumatic stress di sorder. Psychiatric Annals, 12 979-987. Kulka, R.A., Schlenger, W.E., Fairbank, J.A., Houfh R.L., Jordan, B.K., Marmar, C.R., & Weiss, D.C. (1990). Trauma and the Vietnam war generation: Report of findings from the National Vietnam Veterans Readjus tment Study New York, NY: Brunner/Mazel. Lapierre, C.B., Schwegler, A.F., & Labauve, B.J. (2 007). Posttraumatic stress and depression symptoms in soldiers returning from comb at operations in Iraq and Afghanistan. Journal of Traumatic Stress, 20 933-943. Lincoln, Y.S., & Guba, E.G. (1985). Qualitative inquiry Beverly Hills, CA: Sage.

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41 Lopez, K.A., & Willis, D.G. (2004). Descriptive ver sus interpretive phenomenology: Their contributions to nursing knowledge. Qualitative Health Research, 14(5), 726-735. Lynch, G. (1986). Synapses, circuits, and the beginnings of memory Cambridge, MA: MIT Press. Mackey, S. (2005). Phenomenological nursing researc h: Methodological insights derived from HeideggerÂ’s interpretive phenomenology. International Journal of Nursing Studies, 42 179-186. McFall, M., & Cook, J. (2006). PTSD and health risk behavior. PTSD Research Quarterly, 17 1-8. Meisler, A.W. (1996). Trauma, PTSD and substance ab use. PTSD Research Quarterly, 7 1-8. Merriam-WebsterÂ’s collegiate dictionary (11th ed.). (2008). Springfield, MA: MerriamWebster. Miles, M.B., & Huberman, A.M. (1994). Qualitative data analysis (2nd ed.). Thousand Oaks, CA: Sage Publications, Inc. Moustakas, C. (1994). Phenomenological research methods Thousand Oaks, CA: Sage Publications, Inc. National Institutes of Health Office of Behavioral and Social Sciences Research. (1999). Qualitative methods in health research: Opportuniti es and considerations in application and review. Bethesda, MD: Author. Retri eved February 26, 2012, from http://obssr.od.nih.gov/pdf/qualitative.pdf

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42 Parse, R.R. (1999). Nursing science: The transforma tion of practice. Journal of Advanced Nursing, 30 1383-1387. Pietrzak, R.H., Goldstein, M.B., Malley, J.C., Rive rs, A.J., Johnson, D.C., & Southwick, S.M. (2010). Risk and protective factors associated with suicidal ideation in veterans of Operations Enduring Freedom and Iraqi F reedom. Journal of Affective Disorders, 123 102-107. Pietrzak, R.H., Goldstein, M. B., Malley, J.C., Joh nson, D.C., & Southwick, S.M. (2009). Subsyndromal posttraumatic stress disorder is assoc iated with health and psychosocial difficulties in veterans of Operation Enduring Freedom and Iraqi Freedom. Depression and Anxiety, 26 739-744. Rubin, H., & Rubin, I. (1995). Qualitative interviewing: The art of hearing data Thousand Oaks: Sage Publications, Inc. Sacks, M.B., Flood, A.M., Dennis, M.F., Hertzberg, M.A., & Beckham, J.C. (2008). Selfmutilative behaviors in male veterans with posttrau matic stress disorder. Journal of Psychiatric Research, 42 487-494. Saxon, A.J., Davis, T.M., Sloan, K.L., McKnight, K. M., McFall, M.E., & Kivlahan, D.R. (2001). Trauma, symptoms of posttraumatic stress di sorder, and associated problems among incarcerated veterans. Psychiatric Services, 52(7), 959-964. Seal, K.H., Bertenthal, D., Miner, C.R., Sen, S., & Marmar, C. (2007). Bringing the war back home: Mental health disorders among 103,788 US veterans returning from Iraq and Afghanistan seen at Department of Veterans Affairs facilities. Archives of Internal Medicine, 167 476-482.

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43 Shaw, D.M., Churchill, C.M., Noyes Jr., R., & Loeff elholz, P.L. (1987). Criminal behavior and post-traumatic stress disorder in Viet nam veterans. Comprehensive Psychiatry, 28, 403-411. Strauss, A., & Corbin, J. (1990). Basics of qualitative research: Grounded theory procedures and techniques Newbury Park, CA: Sage Publications, Inc. Taft, C.T., Street, A.E., Marshall, A.D., Dowdall, D.J., & Riggs, D.S. (2007). Posttraumatic stress disorder, anger, and partner a buse among Vietnam combat veterans. Journal of Family Psychology, 21, 270-277 Tanielian, T., & Jaycox, L.H. (2008). Invisible wounds of war: Psychological and cognitive injuries, their consequences, and service s to assist recovery California: RAND Corporation. van der Kolk, B.A., & Greenberg, M.S. (1987). The p sychobiology of the trauma response: Hyperarousal, constriction, and addiction to traumatic reexposure. In B.A. van der Kolk (Ed.), Psychological Trauma Washington, DC: American Psychiatric Press. Wang, S., Mason, J., Charney, D., Yehuda, R., Riney S., & Southwick, S. (1997). Relationships between hormonal profile and novelty seeking in combat-related posttraumatic stress disorder. Biological Psychiatry, 41 145-151. Wilson, J., Smith, K., & Johnson, S. (1984). A comp arative analysis of post-traumatic stress syndrome among individuals exposed to differ ent stressor events. Journal of Sociology and Social Welfare, 11 793-825.

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44 Yehuda, R., Southwick, S.M., Giller, E.L., Xiaowan, M., et al. (1992). Urinary catecholamine excretion and severity of PTSD sympto ms in Vietnam combat veterans. Journal of Nervous and Mental Disease, 180 321-325. Zabriskie, R.B. (2000). An examination of family an d leisure behavior among families with middle school aged children. (Unpublished doct oral dissertation). Indiana University, Bloomington, Indiana. Zabriskie, R.B., & McCormick, B.P. (2001). The infl uences of leisure patterns on perceptions of family functioning. Family Relations, 50 281-289. Zatzick, D.F., Marmar, C.R., Weiss, D.S., Browner, W.S., Metzler, T.J., Golding, J.M., Â…Wells, K.B. (1997). Posttraumatic stress disorder and functioning and quality of life outcomes in a nationally representative sample of male Vietnam Veterans. American Journal of Psychiatry, 154 1690-1695. Zuckerman, M. (1994). Behavioral expressions and biosocial bases of sensa tion seeking Cambridge, MA: University Press.

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45 APPENDICES APPENDIX A: ADVENTUROUS ACTIVITIES INTERVIEW We are interested in knowing if there is anything y ou do now that gets your adrenaline going, that is, activities that give you a rush, high, thrill, or get you feeling “jacked up”. 1. Do you engage in any of these types of activities? YES NO IF YES: Please list some examples of these activiti es ( note to interviewer: please list all activities stated below. If more than one response please query each activity for the questions below: 2) why they engage in this activit y (if necessary), 3) frequency of activity including whom they participate in this ac tivity with, etc ): a. b. c. d. 2. Why do you think you engage in these kinds of activ ities? Do you participate in ( note to interviewer: list activities from above her e) for any other reasons that you did not already say? a. b. c. d.

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46 3. How often do you do something that gives you a rush thrill, etc? a. Activity: In general, who do you do these kinds of things wit h? (select all that apply) Alone, by myself With military buddies With civilian friends With members of my family With my partner With another romantic partner ( Note to interviewer: If they answer with Yes to eit her partner or another romantic partner please query the following ) Do you do these activities with your partner in or der to feel emotions such as intimacy, closeness, happiness or love? What is your best guess about how your partner woul d feel about you engaging in these kinds of activities? Approve Disapprove Other (please explain): Would you ever want your partner to share these kin ds of activities with you? Yes No Maybe (please explain): How many of these activities do you think could rea lly cause harm to yourself or to others? None Some All Is the risk that you or others might get hurt part of the thrill of the activity or activities? Not at all A little Mostly Completely For about how long per time? At least daily < 1 hour 1-2 hrs 2-3 hours At least weekly 3-4 hours 4-5 hours 5-6hours At least monthly 6-7 hours 7-8 hours 8-9 hours At least annually 9-10 hours >10 hours > 1 day For about how long per time? At least daily < 1 hour 1-2 hrs 2-3 hours At least weekly 3-4 hours 4-5 hours 5-6hours At least monthly 6-7 hours 7-8 hours 8-9 hours

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47 b. Activity: In general, who do you do these kinds of things wit h? (select all that apply) Alone, by myself With military buddies With civilian friends With members of my family With my partner With another romantic partner What is your best guess about how your partner woul d feel about you engaging in these kinds of activities? Approve Disapprove Other (please explain): Would you ever want your partner to share these kin ds of activities with you? Yes No Maybe (please explain): How many of these activities do you think could rea lly cause harm to yourself or to others? None Some All Is the risk that you or others might get hurt part of the thrill of the activity or activities? Not at all A little Mostly Completely c. Activity: In general, who do you do these kinds of things wit h? (select all that apply) Alone, by myself With military buddies With civilian friends With members of my family With my partner With another romantic partner What is your best guess about how your partner woul d feel about you engaging in these kinds of activities? At least annually 9-10 hours >10 hours > 1 day For about how long per time? At least daily < 1 hour 1-2 hrs 2-3 hours At least weekly 3-4 hours 4-5 hours 5-6hours At least monthly 6-7 hours 7-8 hours 8-9 hours At least annually 9-10 hours >10 hours > 1 day

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48 Approve Disapprove Other (please explain): Would you ever want your partner to share these kin ds of activities with you? Yes No Maybe (please explain): How many of these activities do you think could rea lly cause harm to yourself or to others? None Some All Is the risk that you or others might get hurt part of the thrill of the activity or activities? Not at all A little Mostly Completely d. Activity: In general, who do you do these kinds of things wit h? (select all that apply) Alone, by myself With military buddies With civilian friends With members of my family With my partner With another romantic partner What is your best guess about how your partner woul d feel about you engaging in these kinds of activities? Approve Disapprove Other (please explain): Would you ever want your partner to share these kin ds of activities with you? Yes No Maybe (please explain): How many of these activities do you think could rea lly cause harm to yourself or to others? None Some All Is the risk that you or others might get hurt part of the thrill of the activity or activities? Not at all A little Mostly Completely For about how long per time? At least daily < 1 hour 1-2 hrs 2-3 hours At least weekly 3-4 hours 4-5 hours 5-6hours At least monthly 6-7 hours 7-8 hours 8-9 hours At least annually 9-10 hours >10 hours > 1 day

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49 4. Do you participate in more adrenaline-pumping, thri lling activities now than you did in the past? YES NO Please explain: ( note to interviewer: If response is “yes” query the following ): When you are not doing something high intensity or risky, how do you feel? 5. Does it take more intensity or risk for you to feel a thrill it did in the past? YES NO If so, why? 6. Have you lost interest in activities that used to g et your adrenaline going or that gave you a thrill? YES NO If so, why? 7. Do you purposefully avoid activities that get your adrenaline going, that is, activities that give you a rush, high, thrill, or g et you feeling “jacked up?

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50 YES NO If so, why? 8. Do you specifically avoid activities that would gen erate a thrill or get you jacked up because it reminds you of an event you ha d in the past? YES NO If so, why? 9. Do you avoid any activities that would give you a t hrill because you feel that something bad will happen if you do it? YES NO If so, why? 10. Anything else you can tell us about your current le vel of adrenalinesurging, thrill-seeking activities?

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51 APPENDIX B: CODING MANUAL This qualitative data analysis is based upon phenom enological research methods to examine concepts that arise from the Adventurous Activities interview. The Adventurous Activities interview was designed to el icit OEF/OIF Veteran’s frequency, type, reasons and social supports when engaging in activities that may provide a “rush, thrill, high” or get them feeling “jacked up”. Spec ifically, I will utilize hermeneutic phenomenological methods to analyze these data. Hermeneutics is one branch of an interpretive parad igm, to which phenomenology is a central component (Clark, 1998; Denzin & Linco ln, 1998; Koch, 1995). Phenomenology, often considered both as a philosoph ical discipline and research method (Geallenos, 1998; Lopez & Willis, 2004), is the stu dy human consciousness and selfawareness (Merriam-Webster, 2011). Hermeneutics (in terpretive) phenomenology is one branch of such study/description that focuses on th e context in which the human experience occurs. Heidegger (1962), the leader in hermeneutics, proposed that in order to understand the human experience one must address the individual’s way of being in the world as integrated with the various contexts t hat informs their choices and gives meaning to their life experiences. Furthermore, thi s approach also considers the individuals’ experiences and contexts in relation t o cultural, political, and social contexts (Campbell, 2001). Thus, to understand the Veteran’s experience (or lack) of activities, we must interpret the experiences in light of their pe rsonal, cultural, social and political contexts. For example, we must consider the effects of mental health conditions, influences of significant others, and financial mea ns, among other contexts, on the experience of thrilling, adrenaline-pumping activit ies.

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52 In addition to considering the individual’s experie nce and contexts, the researcher must also be aware of their own preconceptions, bia ses, and expectations that may influence the analysis (Koch, 1995). Hermeneutic ph enomenologists, assumptions subsumed in Heidegger’s practice of hermeneutics, r ecommend that the researcher reflect on their own preconceptions so that during the inte rpretive processes such assumptions are accounted for (Benner, 2004) and included in th e rigor of the analysis. For the process of this hermeneutic analysis, team members will be assigned transcripts for review, coding and analyses; all te am members will review each transcript. Detailed instructions for analysis are included bel ow. I have included the summary coding form, however, it is expected that these dra fts may be adapted as part of the qualitative process. Likewise, the coding process m ay evolve as the team members code the transcripts. From the interview transcript(s), guided by your ow n phenomenological experience, complete the following steps: 1st review, for each transcript (e.g., participant): Read each transcript with a clear and open mind. Be ing aware of any preconceived notions or biases that may be arising. Read each transcript, allowing the participant’s experience to emerge naturally from t he text. Highlight relevant, meaningful text that expresses the participant’s experience as elicited by the interview. (note: spontaneous questions asked by the Interview er will be noted with an “I:”, responses by participants will be noted with an “S: ”) 2nd review, using all transcripts simultaneously:

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53 Utilizing the summary coding form, list all unique (non-repetitive and nonoverlapping) statements or “units” of meaning in ea ch respective section including: Type of Adventurous Activities Reasons for engaging in Adventurous Activities Change in frequency of Adventurous Activities State (emotional, physical, behavioral) when not en gaged in Adventurous Activities Expressed level of intensity to feel the “thrill”, etc, of the activity Synthesize/summarize the themes based upon your own description, including clear documentation of preconceived notions/expecta tions/biases. Group review Bring all assigned transcripts and completed summar y coding forms. Team will review unique “units” and themes and obta in consensus. Team will discuss each transcript, one at a time, t o: Identify any additional “units” or themes Identify quotations of interest Achieve triangulation/quality assurance of data ana lysis Team will review and discuss the synthesis of theme s and summary of data constructed by each team member.

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54 APPENDIX C: CODING SUMMARY FORM Type of Adventurous Activities (List the Activities ) (e.g., Interview Question 1 a, b, c, d and/or 10) Examples & Quotes: Study ID Line # Quotation

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55 Reasons for Engaging in Adventurous Activities (e.g., Interview Question 2 and 2 a, b, c, d,: Why do you think you engage in these kinds of activities?; and/or 10) Examples & Quotes: Study ID Line # Quotation

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56 Change in Frequency of Adventurous Activities (e.g., Interview Question 4, 6, 8, 9 and/or 10) Examples & Quotes: Study ID Line # Quotation

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57 State When not Engaged in Adventurous Activities (e.g., Interview Question 4b: When you are not doing something high intensity or risk, how do you feel?; and/or 10) Examples & Quotes: Study ID Line # Quotation Expressed Level of Intensity to Feel Thrill of Acti vity

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58 (e.g., Interview Question 5: Does it take more intensity or risk for you to feel a thrill it did in the past? ; and/or 10; or information gathered from direct qu estions related to each activity [3 a-e]) Examples & Quotes: Study ID Line # Quotation Synthesis or Summary of Themes Identified

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59 Illustrative Examples & Quotes: Study ID Line # Quotation