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Veterans' experiences following the violent death of a close comrade Olson , Trevor Ole 2013

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VETERANS’ EXPERIENCES FOLLOWING THE VIOLENT DEATH OF A CLOSE COMRADE  by Trevor Ole Olson  B.A., University of Victoria, 1995 M.Ed., University of Saskatchewan, 1999  A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF  DOCTOR OF PHILOSOPHY  in  THE FACULTY OF GRADUATE STUDIES (Counselling Psychology)  THE UNIVERSITY OF BRITISH COLUMBIA (Vancouver) April 2013  © Trevor Ole Olson, 2013  Abstract A qualitative, phenomenological research design was used to investigate the experience of coming to terms with the violent death of a comrade, for male war veterans who had participated in overseas deployments. The purpose of the study was to describe veterans’ accounts of their experiences in adjusting to, coming to terms with, and making sense of the deaths of their close comrades and friends. Eleven veterans who had experienced the death of a close comrade volunteered to describe their experiences in unstructured, in-depth, audio-taped interviews. A thematic analysis of the essential meaning structures of participants’ experiences of coming to terms with the death of their comrade by violent means, reflected their initial experience of the loss, and how they lived with, and processed the loss over time. The four themes common to their initial experience of the loss included: 1) shock, disbelief and the search for explanations; 2) helplessness, retribution and rage; 3) inhibited grief; and, 4) a sense of responsibility for the loss and for letting their friend down. The four themes common to living with and processing the loss over time included: 1) protracted and unfinished grief; 2) alienation, mistrust, and disconnection; 3) existential reflection; and 4) working through the grief and trauma. These themes were confirmed and refined through validation interviews with the participants. These findings are discussed as they relate to, and expand upon, literature related to bereavement after violent loss, homicide, and in particular, the experience of combat losses for veterans.  ii  Preface This research was conducted with the approval of the University of British Columbia (UBC) Office of Research Ethics Behavioural Research Ethics Board (BREB), certificate number H1101044.  iii  Table of Contents Abstract .......................................................................................................................................... ii Preface ........................................................................................................................................... iii Table of Contents ......................................................................................................................... iv List of Tables .............................................................................................................................. viii Acknowledgements ...................................................................................................................... ix Dedication ..................................................................................................................................... xi Chapter 1: Introduction ...............................................................................................................1 Background to the problem ......................................................................................................... 4 Statement of the problem ............................................................................................................ 6 Significance of the study............................................................................................................. 7 Chapter 2: Literature Review ......................................................................................................8 Bereavement ............................................................................................................................... 8 Criticisms of grief work ........................................................................................................ 15 Alternative models of bereavement .......................................................................................... 16 Loss and trauma ........................................................................................................................ 21 Trauma .................................................................................................................................. 22 Trauma generated by human intent................................................................................... 26 Social support and trauma ................................................................................................. 27 Intervention for trauma ..................................................................................................... 27 Intervention for loss .......................................................................................................... 29 Violent loss ........................................................................................................................... 30 Homicide bereavement ......................................................................................................... 34 iv  Complicated grief.................................................................................................................. 37 Veterans and the deaths of comrades ........................................................................................ 40 Meaning making and violent loss ............................................................................................. 45 Conclusion ................................................................................................................................ 50 Chapter 3: Methodology.............................................................................................................52 Research orientation.................................................................................................................. 52 Outlining presuppositions ..................................................................................................... 54 Procedure .................................................................................................................................. 57 Selection of participants ........................................................................................................ 57 Inclusion criteria ................................................................................................................... 57 Recruitment ........................................................................................................................... 58 Data collection .......................................................................................................................... 61 Interview process .................................................................................................................. 62 Data analysis ............................................................................................................................. 65 Thematic analysis.................................................................................................................. 65 Determining essential themes ........................................................................................... 66 Phenomenological writing ................................................................................................ 67 Data storage and confidentiality ............................................................................................... 68 Trustworthiness ......................................................................................................................... 68 Strengths and challenges of the hermeneutic phenomenological approach .............................. 70 Chapter 4: Results.......................................................................................................................72 Participant profiles .................................................................................................................... 72 Common themes ....................................................................................................................... 96 v  Initial experience of the loss ................................................................................................. 97 Shock, disbelief, and the search for explanations ............................................................. 97 Shock and disbelief ....................................................................................................... 97 Other initial reactions .................................................................................................... 98 Searching for explanations ............................................................................................ 99 Helplessness, retribution and rage .................................................................................. 100 Inhibited grief.................................................................................................................. 105 Delayed grief ............................................................................................................... 105 Compounded loss ........................................................................................................ 109 The impact of trauma .................................................................................................. 110 Military bureaucracy as trauma .................................................................................. 112 A sense of responsibility for the loss and for letting their friend down .......................... 114 Survivor’s guilt ........................................................................................................... 115 Living with and processing the loss over time.................................................................... 118 Protracted and unfinished grief ....................................................................................... 119 Alienation, mistrust and disconnection ........................................................................... 126 Existential reflection ....................................................................................................... 131 A heightened sense of vulnerability............................................................................ 131 Awareness of one’s mortality ..................................................................................... 135 Existential reflection ................................................................................................... 136 Working through the grief and trauma............................................................................ 139 Individual therapy ....................................................................................................... 143 Veterans’ trauma repair groups ................................................................................... 147 vi  Individual work ........................................................................................................... 151 New insights and renewed purpose............................................................................. 153 Honouring their comrades........................................................................................... 157 Summary ............................................................................................................................. 159 Chapter 5: Discussion ...............................................................................................................162 Implications for counseling..................................................................................................... 182 Limitations .............................................................................................................................. 188 Implications for future research .............................................................................................. 190 Researcher’s tribute ................................................................................................................ 191 References ...................................................................................................................................193 Appendix A :Guiding questions and probes ........................................................................... 214 Appendix B :Research study invitation .................................................................................. 215 Appendix C :Information and consent form ........................................................................... 217 Appendix D :Recruitment poster ............................................................................................ 220 D.1....................................................................................................................................... 220 D.2....................................................................................................................................... 221  vii  List of Tables Table 4.1  Themes ..................................................................................................................... 106  viii  Acknowledgements First I would like to thank my wife, Kamla, whose patience, optimism, and unconditional love provided the energy needed to bring this work to life. Both she and my daughter, Charlotte, helped me to complete this research. My father, Chuck, and my mother, Linda, provided much encouragement and support. Among my close friends Dawn Johnston, whose research journey paralleled mine, helped me with numerous conversations about research, moral support and administrative details; and Lucy McCullough gave me solid advice for which I am grateful. Dr. Judith Daniluk’s encouragement and guidance was absolutely vital to the development of this research project. Her enthusiasm for and belief in the importance of this research propelled me forward. She responded promptly, clearly, and specifically to my questions. She drew me back to the research question as the common themes took shape. Her dedication to her students is unparalleled. She went above and beyond what is expected of a committee member and her help was essential to this work. Her loyalty, expert knowledge, and willingness to assist were qualities I valued. In November of 2007 I met Dr. Marv Westwood and initiated a series of research conversations about trauma and grief. These conversations and my involvement in Marv's Veterans' Transition Program laid the groundwork that was important to my entry into this research. Marv's passion for trauma repair and helping traumatized veterans informed and influenced this project. I am grateful for his support throughout the entire doctoral program. Many thanks to Dr. Bill Borgen whose thoughtful questions, suggestions and support came at critical periods during this research project. His support extended beyond this project into the clinical aspects of the program. He brought me back to the research and theory implications for this piece of work. ix  I would like to thank Tony Spiess, a veteran paraprofessional and friend who helped me to understand the idea of brotherhood, loyalty, and authenticity. Thanks to my friend Bob Sutherland, a veteran paraprofessional with a big heart. There would be no study without the support of Tony and Bob. Finally, I am indebted to the veterans who selflessly participated in this research. It is with the utmost respect and reverence that I share their experiences. Their stories changed me in profound ways. Their experiences are at the heart of this research.  x  Dedication For the veterans who have lost and will always remember For my family  xi  Chapter 1: Introduction Nearly every man had missed death by a margin of inches, but those traumas were almost never discussed. Rather, it was the losses in the unit that lingered in men’s minds. The only time I saw a man cry up there was when I asked Pemble whether he was glad the outpost had been named after Doc Restrepo. Pemble nodded, tried to answer, and then his face just went into his hands. (p. 237) (Junger, 2010) In combat or peacekeeping situations, experiencing the death of a comrade by violent means can have a significant impact on service members. As the above quote from Sebastian Junger’s (2010) book War depicts, the loss of a fellow soldier and friend in a combat situation may result in severe distress. Indeed, despite experiencing a variety of war-related traumas, veterans are often most deeply affected by the losses of their comrades. Junger, a journalist, accompanied thirty United States Army soldiers—a single platoon—as they fought their way through a remote valley in Afghanistan. Junger was present during many firefights in which soldiers he knew were killed or wounded, and he himself was almost killed. In his journalistic account of this experience, he noted strong attachments between the soldiers and the indelible impression left upon survivors by a comrade’s death. Despite inquiries directed toward veterans’ experiences of post-traumatic stress disorder (PTSD) (van der Kolk, McFarlane, & Weisaeth 2007; Wilson & Keane, 1997), researchers have yet to fully explore the loss experiences of veterans in relation to violent death (Pivar, 2000). A variety of researchers have investigated post-traumatic stress disorder among veterans, for example, in terms of risk factors (Buckley, Green & Schnurr, 2004; Drescher, Rosen, Burling & Foy, 2003; Orcutt, King & King, 2003), readjustment (Schnurr et al., 2010), treatment models 1  (Benotsch et al., 2000; Cloitre, 2009), and neuropsychological sequelae (Pitman, Orr, Forgue, de Jong, & Claiborn, 1987). Minimal research on the other hand, has investigated how veterans’ experience the death of a close comrade or how grief experiences may interact with experiences of post-traumatic stress (Pivar, 2000; Pivar & Field, 2004). This gap in the research is present even though the connection between veterans’ stress responses and the loss of comrades has been widely acknowledged for some time (Anderson, 1949; Lidz, 1946; Fox, 1974; Pivar, 2000; Pivar & Field, 2004). Due to the violent and high risk nature of a military service member’s work, veterans who lose comrades during deployment, or even after deployment, may struggle to make sense of the experience. Violent or traumatic loss has been defined in objective terms as a sudden and violent mode of death that is characterized by one of three causes: Suicide, homicide, or a fatal accident (Norris, 1992; Currier, Holland, & Neimeyer, 2006). These types of losses are conceptualized as traumatic events that can, in many cases, lead to symptoms of post-traumatic stress (Green, 2000) and other psychiatric symptoms that complicate the grief response (Currier et al., 2006). In contrast to the adaptive trajectories displayed by many individuals who are bereaved (Bonanno, Wortman, & Nesse, 2004), a loss by traumatic means can undermine the survivor’s fundamental beliefs about themselves and the larger world (Currier et al., 2006; Janoff-Bulman, 1992), thereby complicating and protracting the grief process. This study examined the experience of the death of a comrade by violent means for veterans. The research question was: What is the meaning and experience of coming to terms with the traumatic loss of a close comrade for veterans? ‘Coming to terms’ with the loss referred to being able to function and adapt to life following the sudden and violent loss of a close comrade. Veterans who self-identified as coming to terms with the loss believed that they had 2  integrated, assimilated, adjusted to, or made some sense of the death of their comrades. Several guiding questions were established as part of the researcher-participant interview to expand upon the main research question (see Appendix A). In summary, this study captured the lived experiences of veterans who were coming to terms with loss of a close comrade by sudden, unanticipated, and violent means. With the highly personal and profound nature of a violent loss, the need to access veterans’ experiences is clear. This point is important in light of research concerning elevated risk factors for traumatized veterans, such as premature mortality from accidents, substance abuse, and suicide (Buckley et al., 2004; Drescher et al., 2003; Orcutt et al., 2003). The elevated risks outlined in veteran research are mainly concerned with the transition for veterans who have experienced trauma and not focused on the experience of the loss of a comrade. Due to a paucity of research concerning veterans’ experiences after the loss of a close comrade, research knowledge concerning the veterans who have experienced the deaths of their comrades is minimal (Pivar, 2000; Pivar and Field, 2004). A qualitative research orientation was chosen to allow veterans to tell their stories in their own language and voice. The researcher was unable to find any qualitative studies, or studies using a phenomenological orientation to research, that had explored this particular type of bereavement experience. Phenomenological approaches are appropriate for learning about the meanings and experiences of individuals for which a minimal amount is known, or within areas that are laden with assumptions (Colaizzi, 1978; Osborne, 1990; van Manen, 1990). Without hearing from veterans themselves, there is the potential for misinformation or false attributions regarding veterans’ experiences of loss to make their way into the research literature.  3  Background to the problem Survivors who experience suffering following a violent loss endure trauma and stress related-symptoms in addition to grief (Raphael & Martinek, 1997). Having to deal with posttraumatic stress in conjunction with grief can interfere with the grieving process and lead to functional impairment (Raphael & Martinek, 1997). According to Raphael and Martinek, data that exist regarding traumatic loss suggest that mental health outcomes after traumatic loss follow a longer course, are more adverse, and feature both post-traumatic stress and grief phenomenology. Importantly, retrospective and prospective studies consistently show that individuals exposed to human-generated traumatic events carry a higher risk of developing PTSD (Chauvastra & Cloitre, 2008). A variety of researchers have been interested in the overlap between traumatic or violent loss and traumatic stress (Neria & Litz, 2003). The study of trauma and the study of bereavement have typically been considered distinct areas and have mainly been examined separately, with rare exceptions (Green et al., 2001; Neria & Litz, 2003). Although researchers in the area of trauma and bereavement have tended to ignore each other, there is significant overlap between the fields (Parkes, 2009). Loss by violent means is conceptualized as a traumatic stressor that can often lead to PTSD. Bereavement, on the other hand, is viewed as a distinct, individual, social, and relational experience. The intersection between trauma and bereavement has only recently been explored systematically and prior studies of bereavement have not examined post-traumatic stress symptoms (Bonanno & Kaltman, 2003). Bonanno and Kaltman suggest that prior studies of bereavement have neglected to examine PTSD symptoms and the few that have offer unclear findings concerning the role of PTSD symptomatology within the bereavement experience. Similarly, given the large volume of studies concerning the consequences of trauma, little is 4  known about the impact of bereavement on the veteran population (Currier & Holland, 2012). In short, the prominence of grief symptoms among veterans with PTSD has been surprisingly overlooked (Pivar & Field, 2004). According to Neria and Litz (2003), combat “in the war zone provides a laboratory to study the effects of traumatic bereavement on human functioning over the life span” (p. 79). Exposure to violence-related trauma, the loss of fellow combat veterans and friends in battle, and war captivity accounts for significant variance in post-war distress and social functioning (Neria & Litz, 2003). Green, Grace, Lindy, Gleser, and Leonard (1990) evaluated a large group of Vietnam veterans and found that seventy-percent of those with PTSD reported the loss of a “buddy.” In a war zone, concurrent high-intensity demands make it difficult for soldiers to grieve their lost comrades. In some cases, combat veterans are not able to benefit from funeral rituals and their coping resources are drained, due to managing ongoing threat and anxiety in the field (Green et al., 1990; Neria & Litz, 2003). Bereavement-related bio-psycho-social phenomena were not taken into account in conceptualizations of loss by traumatic means until recently (Neria & Litz, 2003). Neria and Litz suggest further examination of the boundaries between traumatic stress, complicated or chronic bereavement, loss by traumatic means, and traumatic grief. The phenomenology, clinical symptoms, clinical needs, and risk factors associated with loss by violent means and the combined influences of loss and trauma-exposure have yet to be systematically studied (Neria & Litz, 2003). Although researchers studied PTSD and depression extensively following the collective trauma due to the terrorist attacks in the United States on September 11th, 2001, few studies examined the interplay between trauma and loss, and their outcomes (Neria & Litz, 2003; Pivar & Field, 2004). 5  Statement of the problem There have been many casualties associated with recent overseas conflicts, particularly with the American and Canadian military involvement in Iraq and Afghanistan from 2001 to the present, and yet little is known about how veterans experience the violent deaths of their comrades. The deaths of service members have a wide-ranging impact and affect “primary grievers” (p. 263) such as spouses, children and parents (Harrington-LaMorie & McDevittMurphy, 2011) as well as fellow service members, such as those included in this study. Service members often return to duty, or return home, with the acute and long term effects of violent loss under-recognized (Harrington-LaMorie & McDevitt-Murphy; Papa, Neria, & Litz, 2008; Pivar & Field, 2004; Currier & Holland, 2012). Despite the attention focused on the diverse effects of trauma among war veterans, the related subject of grief has surprisingly received little attention (Currier & Holland, 2012; Harrington-LaMorie & McDevitt-Murphy, 2011). Losing close comrades in overseas service may be an experience that is more common than people realize. For example, Hoge et al. (2004) found that seventy-five percent of American service members in the field in ‘Operation Iraqi Freedom’ had experienced the death of someone in their immediate unit. Canadian statistics indicate that 136 soldiers have been killed in action from 2002 to 2012 in Afghanistan (National Defence, January 12, 2011). Although these statistics are helpful, they do not include veterans who complete suicide or perish in fatal accidents following their service. The risks for returning veterans are high. Although little is known about untreated grief, untreated combat trauma can has been associated with negative social, physical, and psychological outcomes for soldiers and their families (Rosenheck & Fontana, 1996).  6  As there is such minimal research of veterans experiences with the deaths of comrades (Currier & Holland, 2012; Pivar & Field, 2004; Papa et al, 2008), little is known about how they are able to come to terms with the loss of comrades. This study adds to existing literature aimed at addressing this gap. The study offers rich descriptions of the lived experiences of veterans coping as best as they can after the violent loss of their comrades. There are no other current studies that have explored this subject matter by speaking directly to veterans themselves. Significance of the study This study will explore the embedded meanings in the experiences of veterans who are coping with trauma and grief in relation to the death of a close comrade. The study will serve to further our knowledge of veterans’ experiences with violent loss. This research will provide descriptions of how people are able to make meaning of the combined experiences of loss and trauma for the future benefit of bereaved individuals and the counselling professionals who work with them. An increased understanding of how individuals are able to come to terms with, make sense of, or, in many cases, struggle to make sense of an experience of profound loss will provide new and important knowledge to the field of counselling psychology. The experience of bereavement is very personal and can involve significant feelings of vulnerability. This research will contribute to the field of counselling psychology through an in-depth analysis of the veterans’ experiences of the death of a comrade by violent means.  7  Chapter 2: Literature Review With the exception of one study by Pivar (2000) and a subsequently published article based on its findings (Pivar & Field, 2004), there have been no recent empirical studies concerning veterans’ grief related to the deaths of comrades. There are no current, qualitative studies examining the bereavement experience, or process of coming to terms with this experience for either female or male veterans. Despite the recent and ongoing conflicts in Iraq and Afghanistan, there is a lack of research addressing veterans’ loss experiences in general. The most relevant existing literature addressing veterans’ grief includes studies by Papa, Neria, and Litz (2008), and Currier and Holland (2012) which feature thirty year old retrospective selfreports from veteran samples based on the National Vietnam Veterans Readjustment Study (NVVRS; Kulka et al., 1990). As stated in the introductory section, research with veterans and service members has focused mainly on traumatic aspects of military service (Drescher et al., 2003; Schnurr et al., 2010) rather than grief, or both grief and trauma. This study examines veteran bereavement experiences. To establish a background and context, this literature review will explore traditional models of bereavement, alternative models of bereavement, complicated grief, and violent loss. Literature concerning veterans’ grief experiences will follow, as well as information about trauma and trauma generated by human intent. The literature review will conclude with a focus on meaning making and bereavement. Bereavement As this study is focused on veterans who experienced the deaths of comrades, an overview of traditional models of grief and bereavement will be provided. This will be followed by a brief critique of the traditional bereavement models and a discussion of alternate bereavement theories. 8  The term bereavement is used to describe “the objective situation of having lost someone through death” (Stroebe, Hansson, Schut, & Stroebe, 2008, p. 4). The person lost through death in this study is the comrade or friend of the veteran participant. Grief, according to Stroebe et al. (2008), is described as the primarily emotional reaction to the death of the significant other. Grief is conceptualized as a process rather than a state (Parkes, 1996) and encompasses a broad range of emotions, cognitions, behaviours, and physical sensations that are common after a loss (Worden, 2009). Parkes (1996) further defines grief as a “process of realization, of making real inside the self an event that has already occurred in reality outside” (p. 53). Stroebe et al. (2008) define grief as an internal and personal process, in contrast with mourning which is the public display of grief. Mourning, from this perspective, comprises the social expression or acts of grief that are shaped by beliefs and practices of a society or cultural group (Stroebe et al., 2008). Some researchers define mourning as an active process of coping with and adapting to loss (Rando, 1996; Worden, 2009) and an integration of the loss experience (Rando, 1996). Within the literature, it is sometimes difficult to distinguish mourning from grief or know what exactly researchers may be referring to (Stroebe et al., 2008). Freud’s (1917/1957) seminal paper “Mourning and Melancholia” was the first systematic analysis of bereavement. His theoretical perspective influenced subsequent perspectives regarding healthy and unhealthy adjustment to grief (Stroebe et al., 2008). The function of mourning, or the “work of mourning,” was described as the withdrawal of emotional energy from the deceased or severing of “attachment to the non-existent object” (Freud, 1917/1957, p. 166). “Grief work,” as it came to be known later, was conceptualized to explain the process of withdrawal and reinvestment of emotional energy (Stroebe, 1992; Worden, 2009). Freud (1917/1957) posited that grieving involved an internal, private process where the mourner clung 9  to the lost person and “[turned] away from reality” (p. 153). Freud described how the individual’s instinctual response to the death of a close person is to resist the reality of the loss by holding on to the person. The individual holds the emotional energy invested in the deceased person in spite of the demands of reality that they let go or withdraw energy from the deceased. Over time, the bereaved person gradually reviews each memory and hope connected to the deceased person until a “detachment” (p.154) is accomplished. Normal mourning occurs through a process of repeated reality testing in which the bereaved person gradually withdraws their emotional energy from the deceased individual. Through this process of grief work the person begins to accept the reality of the loss and withdraw energy from the deceased. As per Freud (1917/1957), complicated or “pathological” mourning occurs due to ambivalence that impedes the detachment process. Thus, the “grief work hypothesis” (p. 199) is the notion that a person must confront the experience of bereavement to come to terms with the loss and avoid negative health consequences (Stroebe & Schut, 1999). Although Freud proposed his ideas with caution and they were mainly concerned with the etiology of depression, his theoretical perspectives dominated bereavement literature and were adopted by subsequent theorists, such as Lindemann (1944) (Bonanno & Kaltman, 1999). Lindemann’s (1944) study of the survivors of the Coconut Grove Nightclub fire is one of the most significant early empirical studies of trauma and grief. Approximately 500 people died in the fire and Lindemann (1944) and his colleagues worked with the surviving family members. Lindemann (1944) identified patterns he recognized as manifestations of acute grief from the data he gathered from this experience. These were: (1) Somatic or bodily distress of some type; (2) preoccupation with the image of the deceased; (3) guilt relating to the deceased or circumstances of the death; (4) hostile reactions; and, (5) the inability to function as one had 10  before the loss. Lindemann’s ideas concerning “grief work” involved exposing the person to the reality of the loss (Rando, 1993; Worden, 2009). Although this study makes a very important contribution to the grief literature, Parkes (1996) points out that Lindemann’s (1944) research, which was based on interviews, did not present figures to show the frequency of the symptoms described, neglected to reference the number of interviews conducted, and did not specify the amount of time that had passed between the loss event and the interviews. Lindemann’s (1944) research could be criticized for lacking external generalizability. Attachment theory has been used to shed light on grief since Bowlby (1980) published Loss: Sadness and Depression. Bowlby’s (1969, 1973, 1980) trilogy on attachment and loss offers a theoretical model that provides a way to understand the human tendency to form strong attachments to others, and their powerful reactions to experiences of separation and loss: Disbelief, horror, protest, and despair (Bowlby, 1969; Mikulincer & Shaver, 2008; Worden, 1991). Attachment theory posits that human beings are predisposed, or hard-wired, to create bonds with primary caregivers in infancy and continue to form attachments with significant others in their lives as adults. The death of an attachment figure is therefore a significant event that triggers intense and pervasive distress. The bereaved person has difficulty imagining regaining a sense of security, support, protection, and caring without the attachment figure’s presence (Mikulincer & Shaver, 2008). It follows that the stronger the attachment bonds with the deceased person, the more intense the grief reactions will be (Worden, 1991). In line with Bowlby’s (1980) attachment theory, Pivar (2000) speculates that relationships to comrades may help service members regulate responses to combat trauma. The death of the comrade, on the other hand, may increase feelings of vulnerability. Pivar (2000)  11  speculates that the loss of a comrade may impede the ability to grieve in post-war years and prevent the soldier from investing emotional energy in future relationships. Parkes and Weiss (1983) carried out an extensive longitudinal study of grief with the Harvard Bereavement Project. They interviewed fifty-nine Boston widowers and widows at two weeks, eight weeks, thirteen months, two years, and four years after their spouse’s death. As a result they identified four types of risk factors for the bereaved individual: (1) The personal vulnerability of the bereaved person; (2) the kinship with the deceased person; (3) the events and circumstances leading up to and including the death; and, (4) the social supports and other circumstances after the death. With findings related to attachment, Parkes and Weiss (1983) found that the personal vulnerability of the bereaved person was influenced by the attachment bond to the deceased spouse. Attachment patterns to the deceased person were viewed as giving rise to problematic reactions. In particular, a dependent relationship was found to predict chronic grief, and an ambivalent relationship was found to predict conflicted grief (Parkes and Weiss, 1983; Parkes, 2009). Chronic grief refers to a form of grief that is intense from the outset and continues indefinitely whereas conflicted grief refers to a delayed reaction that is complicated by feelings of anger and guilt (Parkes, 2009). Although grief seemed to be inhibited after trauma in the Parkes and Weiss (1983) study, a later study by Parkes (2009) found that bereavement by traumatic or violent means increased the intensity and duration of grieving. Parkes (2009) found that losses by violent means increased the intensity and duration of grief (Parkes, 2009). In earlier research, Parkes (1971) identified sudden loss as a risk factor for bereavement and studied individuals bereaved by homicide (Parkes, 1993).  12  Stroebe and Schut (1999) assert that Worden (1991) helped redefine the principles of grief intervention with a reformulated model of grief which suggests distinct tasks that the bereaved must undertake. Worden (1991) stated that certain tasks of mourning were essential to re-establish equilibrium and complete the process of mourning. His conceptualization of tasks is derived from developmental psychology and from Freud’s concept of grief work. He cites Havinghurst’s (1953) research as influential, in particular the idea that if a child does not complete a developmental task on a particular level, adaptation may be impaired when the child attempts to complete tasks at higher levels. Worden’s (1991) task theory is often perceived by others as being a stage or phase theory, which assumes relative rigidity and a linear and sequential trajectory (Worden & Winokuer, 2011). However, the tasks he suggests are fluid in that they may be addressed in any ordering and can be revisited and reworked over time (Worden & Winokuer, 2011). The tasks are influenced by mediators of mourning such as: The person who died, the nature of the attachment, the mode of death, the way the loss impacts a person’s identity, previous experiences with loss, how well previous losses were handled, levels of social support, and secondary losses caused by the death (Worden, 2009). The first task in Worden’s (1991, 2009) model is to acknowledge the reality of the loss. Worden states that a person first must believe that the death happened before dealing with the emotional impact. This involves both an emotional and cognitive acceptance of the loss. For example, a person may know that his friend is dead but may still want to speak to him, keep his belongings intact, and may even see him sitting outside. Searching behaviour within Worden’s theory is a quest to confirm that the loss has or has not happened. Wanting to believe the death did not occur may cause some individuals to disbelieve until such time as they can acknowledge the loss emotionally and cognitively (Worden & Winokuer, 2011). The second task in Worden’s 13  model involves processing the pain of grief. Depending on the mediating factors associated with the loss, some deaths are experienced as more painful than others (Worden & Winokuer, 2011). Processing the pain can be difficult and individuals may become stuck in feelings of guilt, sadness, and anger for long periods of time. Difficulty processing the pain can result in displacement of the pain into somatic symptoms or the reappearance of the pain years later in delayed reactions (Worden, 2009; Worden & Winokuer, 2011). The pain of grief can be denied through self-medication with drugs, alcohol or distracting activities. Worden’s (1991) third task is to adjust to a world without the deceased. The adjustments required by task three are divided into external adjustments, internal adjustments, and spiritual adjustments (Worden & Winokuer, 2011). External adjustments involve activities of daily living or roles that change due to the loss of the significant person. Internal adjustments relate to selfdefinitions and personality variables such as self-esteem and self-efficacy. Spiritual adjustments involve the impact that the death has had on the bereaved individual’s assumptive world and the meaning made of the loss. The fourth and final task is to “find an enduring connection with the deceased in the midst of embarking on a new life” (Worden & Winokuer, 2011, p. 65), or to emotionally relocate the deceased (Worden, 1991). Worden and Winokuer state that this accompanies the realization that one cannot keep the deceased person in their life in the same way as when the person was alive. To negate this task is to hold onto the past attachment rather than moving on and forming new ones (Worden, 1991). Accomplishing this task involves emotionally relocating, memorializing or finding a place for the deceased in the bereaved person’s emotional life, while continuing to move forward (Worden, 2011; Worden & Winokuer, 2011).  14  Rando (1993) explored complicated mourning, proposing six processes of bereavement. These bereavement processes bear similarity to Worden’s (1991; 2009) tasks. As per Rando (1993), the bereavement processes are: (1) Recognizing the loss; (2) reacting to the separation; (3) recollecting and re-experiencing the deceased person and the relationship; (4) relinquishing old attachments to the deceased and the old assumptive world; (5) readjusting to move adaptively into the new world without forgetting the old; and, (6) reinvesting. Similar to Worden (1991; 2009), normal bereavement may be complicated when these tasks are not completed. Rando (1993) noted that sudden, unexpected, and traumatic deaths, as well as preventable deaths, were associated with complicated mourning. She suggested that deaths that provoke anxiety (e.g., suicide, mutilation, murder) or embarrassment (e.g., death from friendly fire or fratricide) are likely to cause disenfranchised grief, a concept which will be explored in more depth shortly. Criticisms of grief work More recent research concerning grief has re-examined earlier theories and notions surrounding the resolution of grief, especially the concept of grief work. Researchers call attention to the longstanding endorsement of grief work within the literature despite a lack of empirical evidence (Stroebe & Stroebe, 1991; Wortman & Silver, 1989). Wortman and Silver (1989) identify a number of widely accepted yet unsupported myths, such as the assumption that working through grief is necessary and that people resolve grief (Bonanno & Kaltman, 1999). Wortman and Silver assert that there is a lack of evidence supporting “the issue of ‘working through’” (p. 352), and early efforts at grief work may lead to later difficulty. These conclusions are supported by researchers who also note that grief work had been poorly operationally defined (Stroebe, 1992; Stroebe, van den Bout, & Schut, 1994). Several studies provide results that are inconsistent with the grief work framework (Stroebe & Stroebe, 1991; Bonanno, Keltner, Holen, 15  & Horowitz, 1995). Another criticism of grief work-related models is that there are no adequate definitions distinguishing normal from pathological grief, and little agreement in the literature on this issue (Shucter & Zisook, 1993). Bonanno and Kaltman (1999) suggest that the accumulation of evidence challenging grief work theory has resulted in a “theoretical vacuum” (p. 763), leading to the application of general psychological perspectives of bereavement. Alternative models of bereavement Contemporary researchers have questioned the efficacy of working through grief to come to terms with loss and have initiated alternative models of bereavement (Stroebe & Stroebe, 1991; Stroebe & Schut, 1999). Some of these models have been used to explain behaviour across a range of contexts (Bonnano & Kaltman, 1999). One alternative model proposed by Doka (1989), examines the impact of social factors on bereavement rather than looking specifically at grief through an intrapsychic lens. Alternative models from a cognitive stress perspective and an attachment perspective will be explored in this portion of the literature review. Theories that combine a cognitive perspective, trauma theory, and meaning making will be reviewed later in this literature review following a review of information concerning trauma, violent loss, and homicide. Bonnano and Kaltman (1999) describe applying cognitive stress theory as an alternative to grief work theories of bereavement. The cognitive stress theory emphasizes cognitive appraisal of stressful events and the use of coping strategies to counter the effects of the stress in various ways. The event is psychologically stressful if it is appraised as being stressful by the bereaved person, and appraised as exceeding the bereaved person’s resources and/or endangering their well being (Lazarus & Folkman, 1984). Primary cognitive appraisals assess the degree to which a person may come to harm or benefit, and secondary appraisals assess coping options to 16  prevent harm and improve the prospects for benefit (Bonanno & Kaltman, 1999). When this approach is applied to bereavement, the degree to which the death is stressful depends on the subjective appraisal, or cognitive evaluation, of the bereaved individual (Bonanno & Kaltman, 1999). Some grief-related studies have supported this theory, finding that avoidant coping may serve an adaptive function in bereavement (Bonnano et al., 1995). Support for the role of cognitive appraisal as a mediating factor of grief was found in a study examining bereaved gay men’s appraisals of the death of their partners (Stein, Folkman, Trabasso, & ChristopherRichards, 1997). In contrast with traditional assumptions that grief involves mainly negative states, Stein et al. (1997) found that positive appraisals were associated with positive states of mind, improved morale, and less depression approximately twelve months after the loss. Lending credibility to this finding is a study in which negative appraisals by bereaved middle-aged widows and widowers were associated with increased grief twenty-five months after the death (Capps & Bonanno, 1998). The dual-process model (DPM) of Stroebe and Schut (1999) builds on the cognitive stress theory of coping with bereavement and provides a more systematic application of the cognitive stress perspective to grief (Archer, 2008). Stroebe and Schut (1999) assert that the components of the DPM include the stressors associated with bereavement, the cognitive strategies involved in coming to terms with bereavement, and the dynamic process of oscillation. According to Stroebe and Schut (1999), bereaved individuals “undertake, in varying proportions (according to individual cultural variations),” (p. 212) loss- and restoration-oriented coping. Loss-oriented coping refers to the bereaved person’s focus on appraising and processing an aspect of the loss experience itself, incorporating grief work. It involves experiences at the “heart of grieving” (p. 277) such as painfully dwelling on the loss and searching for the lost person 17  (Stroebe & Schut, 2010). According to Stroebe and Schut (1999), restoration-orientation refers to adjusting to secondary stressors that occur as a consequence of bereavement. Restorationorientation involves reorienting oneself to a changed world without the deceased person; rethinking and replanning one’s life following bereavement (Stroebe & Schut, 2010). A key aspect of Stroebe and Schut’s DPM is the dynamic process fundamental to coping with bereavement called “oscillation”. Oscillation refers to the process of alternating between the loss- and restoration-oriented coping, resulting in a juxtaposition between confronting and avoiding stressors associated with bereavement. The bereaved person will be confronted by the loss at certain points and may attempt to avoid memories or focus on other things for relief (Stroebe and Schut, 1999). Denial, from this perspective is viewed as normal and beneficial as opposed to detrimental, as in more traditional psychoanalytic perspectives (Stroebe and Schut, 1999). Within this model, complicated bereavement is viewed as an absence of oscillation between loss- and restoration-oriented coping (Stroebe and Schut, 1999). Bowlby’s attachment theory model has been viewed by some researchers as aligning with Freud’s (1917/1953) grief work model by holding that “working through” grief involves an attempt to maintain attachment after loss followed by a withdrawal of emotional energy from the deceased (Klass, Silverman, & Nickman, 1996). Later in his career, however, Bowlby (1980) distinguished himself from other grief work theorists by emphasizing the importance of a continued bond with the deceased. Bonanno and Kaltman (1999) pointed out Bowlby (1980) asserted that the pain of grief led to a reshaping of internal “working models” and reorganization of the attachment configuration, which included continuing bonds with the deceased. In his study of widows and widowers, Bowlby (1980) observed persistent feelings of attachment toward the  18  deceased, preserving the bereaved person’s sense of identity and helping to “reorganize their lives along lines they find meaningful” (p. 98). Klass (1987) posited that the resolution of grief involves re-establishing equilibrium, reinvesting energy into new relationships, and incorporating identification with the deceased within the survivor’s self image. Tyson-Rawson (1996) found evidence for ongoing attachments with the deceased in her in-depth interviews with twenty female college students whose fathers’ died. She noted that fourteen of her twenty research participants indicated ongoing attachments and half of the fourteen experienced the ongoing attachment as a welcome presence. Women who reported ongoing attachments were more likely to report that they had come to some resolution regarding the death (Tyson-Rawson, 1996). Rosenblatt (1988) stated that people often sense the ongoing presence of the deceased individuals who were important in their lives. They feel a spiritual nearness to the deceased or have a sense that the deceased is near them. In many cultures, “such spiritual contacts have cultural legitimacy, so they do not seem abnormal” (Rosenblatt, 1988, p. 75). The traditional models of grief (Bowlby, 1980; Lindemann, 1944; Parkes & Weiss, 1983) focus mainly on psychological, biological, and physiological responses to loss. By developing a model of “disenfranchised grief”, Doka (1989) drew attention to the impact of social factors on bereavement. Disenfranchised grief is defined as “grief that results when a person experiences a significant loss and the resultant grief is not openly acknowledged, socially validated, or publically mourned” (Doka, 2008, p. 224). Doka (2008) noted that in some cases, an individual may have an intense and complex grief experience that is not acknowledged by others or by society. Doka asserts that every society has rules and norms that govern behaviour, emotions, and cognition. These rules frame the grieving experience, outlining losses that one may grieve, 19  how one may grieve them, as well as to whom others may respond to with support after a loss (Doka, 2008). Doka (1989) outlines three broad categories of disenfranchised grief. The first occurs when the relationship to the deceased person is not recognized. For example, this may occur when relationship to the deceased is not based on family ties and is not understood or appreciated. He states: While all of these studies tell us that grief is a normal phenomenon, the intensity of which corresponds to the closeness of the relationship, they fail to take this (i.e., friendship) into account. The underlying assumption is that closeness of relationships exist only among spouses and/or immediate kin. (p. 239) Although friendships may be recognized, mourners may not be offered opportunities to publically grieve. This may be the case with veterans who shared strong friendships with their deceased comrades however do not always have opportunities to grieve, or their grief is not recognized as they are not part of the comrade’s biological family. Another broad category of disenfranchised grief occurs when the loss is not acknowledged or socially supported (Doka, 1989). The loss may not be defined as socially significant or the loss may not be socially validated. For example, others may not perceive the loss to be a cause for grief and may offer limited social support. A third category of disenfranchised grief involves cases where the griever is excluded due to personal characteristics (e.g., young age). In cases such as this, there is no recognition of the person’s sense of loss or need to mourn (Doka, 1989). Doka (2008) also suggests that the circumstances surrounding the death may serve to disenfranchise grief. For example, survivors of suicide may often feel stigmatized and fear that the responses of others may include “isolation, judgement or a morbid curiosity” (Doka, 2008, 20  p.233). Linking this to the experience of veterans, people may be uncomfortable with or not know how to respond to a veteran who is grieving the violent death of a comrade, resulting in further disenfranchisement of their grief. The way that an individual grieves, or style of grief, may also contribute to disenfranchisement (Doka, 2008). Martin and Doka (2011) describe different grieving styles ranging from intuitive to instrumental. Some individuals may experience and express grief as deep feeling whereas others may express grief reactions in a more physical, cognitive, or behavioral way. As counsellors often place a high value on affective response, individuals who grieve in an instrumental, or action based way, may be at risk for disenfranchisement (Doka, 2008). Loss and trauma This study will explore bereavement experiences of veterans which have received considerably less attention than the subject of trauma (Currier & Holland, 2012; HarringtonLaMorie & McDevitt-Murphy, 2011). Much of the current literature concerning combat veterans is not focused on bereavement, however loss by violent means, or traumatic loss, is emerging as an important subcategory of bereavement research that “warrants special attention” (Currier, Holland, & Neimeyer, 2006, p. 403). A loss by violent means bridges areas of both trauma and grief. Although researchers have typically chosen to study trauma and loss separately (Green et al., 2001; Neria & Litz, 2003), the two areas converge when an individual is coming to terms with violent loss. As Raphael & Martinek (1997) stated, survivors who experience suffering following a violent loss are more than likely endure trauma and stress related-symptoms in addition to grief (Raphael & Martinek, 1997). The next section of this literature review will provide an overview of selected trauma literature and define post-traumatic stress disorder. This will be followed by a review of literature addressing loss by violent means, or traumatic loss. 21  Literature highlighting the overlap between these areas and experiences after homicide will be explored. Finally, literature concerning veteran bereavement will be reviewed to conclude this section. Trauma Herman (1997) asserts that the systematic study of trauma has depended on political support. For example, she argues that the study of war trauma was legitimized in a political context in which individuals challenged the sacrifice of young men at war (Herman, 1997). Trauma was brought into public consciousness by Charcot in the 1880s, and then Janet, Breuer, and Freud, as they attempted to demonstrate the cause of hysteria in the late 1890s (Herman, 1997). According to Herman (1997), Freud, in a report on eighteen case studies entitled, “The Aetiology of Hysteria,” put forth the claim that beneath cases of hysteria were occurrences of childhood sexual abuse. The First World War brought trauma into the public consciousness as physicians treating war veterans noted symptoms of fear following war. In the context of war, traumatic symptoms were first described as “shell shock” by Myers (1940), a psychologist to the British armies in France. Kardiner (1941) published a clinical and theoretical study of trauma entitled “The Traumatic Neuroses of War.” Systematic investigation of the long term psychological effects of combat was not conducted until after the Vietnam War (Lifton, 1973). The motivation to study the experience came from the organized efforts of soldiers who were disaffected from war (Herman, 1997). The diagnosis of Post-traumatic Stress Disorder (PTSD) was first included in the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III; American Psychiatric Association, 1980). The inclusion of the PTSD diagnosis in the DSM-III was initially opposed by psychiatrists who argued that the problems of trauma-exposed individuals were 22  already covered by combinations of existing diagnoses. American Vietnam veterans, their advocacy groups, and anti-war psychiatrists organized and rallied for PTSD’s inclusion in the DSM-III (McNally, 2004). The clinical definition of PTSD offers an outline of commonly occurring trauma symptoms. It is defined in the DSM-IV-TR (American Psychiatric Association, 2000) as the development of three types of unrelenting symptoms after exposure to an extreme traumatic stressor (e.g. death, serious injury, or other perceived threat to bodily integrity). The initial exposure to the traumatic stressor produces intense fear, helplessness, or horror in the individual. The three clusters of symptoms that make up the PTSD diagnosis are re-experiencing, avoidance, and arousal symptoms. The individual must have some symptoms from each of these clusters to be diagnosed with PTSD. Re-experiencing the traumatic event is indicated by recurrent recollections, dreams, flashbacks, and psychological/physiological arousal in reaction to cues related to the event. Avoidance symptoms include avoidance of trauma-related cues (possibly experiencing amnesia for aspects of the trauma), and a numbing of responsiveness, which may be experienced as a diminished interest in usual activities, feelings of detachment, restricted range of affect, and a sense of a foreshortened future. Arousal symptoms include difficulty falling or staying asleep, irritability or angry outbursts, concentration problems, hypervigilance, and exaggerated startle response. Symptoms must last at least one month and interfere with adaptive functioning for a diagnosis to be given (American Psychiatric Association, 2000). Psychological trauma has most recently entered into public consciousness due to the Afghanistan and Iraq wars, which followed in the aftermath of the terrorist attacks on the World Trade Centres in on September 11, 2001. These wars have had wide-ranging impacts on multiple 23  levels, ranging from individual to global (Schnurr et al., 2010). Approximately 1.6 million American men and women have served or are currently serving in military operations in Iraq, Afghanistan, or surrounding areas (Seal et al., 2010). Prevalence estimates of deployment-related PTSD for U.S. veterans are 15-percent and will likely increase in the near future as delayed onset cases continue to emerge (Ramchand et al., 2010). PTSD and other adjustment problems resulting from war zone exposure have increased in terms of public recognition (Schnurr et al., 2010). The two aforementioned wars have had a particularly significant impact on the field of traumatic stress studies. As a result, in the United States, more resources are being directed toward helping individuals cope with war-related stress (Seal et al., 2010). For example, the U.S. Departments of Veterans Affairs and Defense have put large-scale surveillance programs in place to monitor veterans’ mental health (Schnurr et al., 2010). Many soldiers are at risk for developing PTSD (Friedman, Warfe & Mwiti, 2003) and are in fact more likely to develop PTSD than to be fired upon, physically injured, or killed in combat (Rosebush, 1998). As part of their active combat duties, soldiers may witness atrocities such as the torture of civilians, be involved in the retrieval and disposal of human remains, and handle human casualties (Lamerson & Kelloway, 1996; MacDonald, Chamberlain, Long, Pereira-Laird & Mirfin, 1998; Westwood, McLean, Cave, Borgen, & Slakov, 2009). In addition to PTSD, other psychiatric disorders, health, and social problems may affect veterans and their families (Herman, 1997). Foa, Keane, and Friedman (2000) state that veterans with PTSD often have co-morbid disorders such as major depression, anxiety disorders, and substance use disorders. Traumatized combat veterans use medical services more frequently and experience more health-related problems in comparison to non-traumatized veterans. In addition, 24  traumatized combat veterans may be at higher risk than their peers for premature mortality from accidents, chronic substance abuse, and suicide (Buckley et al., 2004; Drescher et al., 2003). Untreated combat trauma can become a chronic and debilitating condition associated with negative social, physical, and psychological outcomes for soldiers and their families (Rosenheck & Fontana, 1996). Intimate relationships may suffer as elevated rates of domestic violence and divorce have been noted among veterans with PTSD in comparison with veterans without PTSD (Orcutt et al., 2003; Riggs, Byrne, Weathers & Litz, 1998). In terms of employment, veterans with PTSD are estimated to earn 22-percent less per hour than their veteran peers without PTSD, and are ten times more likely to be unemployed than other veterans (Fairbank, Ebert & Johnson, 1999). Psychological trauma is a complex, multifaceted, and multidimensional concept. Researchers are increasingly emphasizing the emotional components of PTSD and emotional regulation (Greenberg, 2008), as well as the importance of social support and attachment in trauma recovery (Charuvastra & Cloitre, 2008). Trauma recovery is multidimensional and influenced by pre-existing individually-based factors, features of the traumatic event, as well as the peri-traumatic response (Keane, Marshall, & Taft, 2006). In recent years, the therapeutic relationship has also been viewed as being instrumental and a strong predictor of positive outcomes in therapy with trauma survivors presenting with PTSD. Altogether this information illustrates a need for treatment models with the potential to counteract the effects of combat-related trauma, reduce negative outcomes for veterans (Benotsch et al., 2000), and help veterans cope with traumatic loss. It is therefore important to hear from soldiers regarding their recovery experiences after traumatic loss in order to learn from those who are able to reconstruct their lives after trauma. 25  Trauma generated by human intent Traumatic injuries that have been caused by other human beings, or generated by human intent, lead to increased PTSD symptoms and higher rates of PTSD (Charuvastra & Cloitre, 2008). King, King, Gudanowski, and Vreven (1995) report that within the context of combat, witnessing humans being maimed and killed is more subjectively disruptive than exposure to harm only. It involves a violation of the perceived social order, social norms, and basic human conduct, even in war (Charuvastra & Cloitre, 2008). Ozer, Best, Lipsey, and Weiss (2008), in a meta-analysis of risk factors for PTSD, examined the results of 476 studies. They reported that peri-traumatic dissociation was the highest risk factor for PTSD. Peri-traumatic dissociation is defined as experiences occurring during traumatic circumstances that involve the subjective perception of time slowing down or rapidly accelerating, out-of-body experiences, depersonalization, derealisation, or altered pain perception. Ozer et al. (2008) also reported that when a person perceived that their life was threatened during the trauma, risk for PTSD increased. With interpersonal violence, higher levels of subjective distress were associated with fearing for one’s life. Brewin, Andrews, and Valentine (2000), in a meta-analysis of risk factors, found that although the most uniform predictors for PTSD were psychiatric history, reported childhood abuse, and family psychiatric history, factors operating during or after the trauma, such as trauma severity, lack of social support, and additional life stress, “had somewhat stronger effects than pre-trauma factors” (p. 748).  26  Social support and trauma Lack of social support has been found to increase PTSD after peri-traumatic dissociation (Ozer et al., 2008). According to Charuvastra and Cloitre (2008), there is increasing evidence that social support, cognition, and attachment organization contribute to emotional regulation under conditions of traumatic stress. Charuvastra and Cloitre (2008) state that social support helps buffer against psychological distress and, as mentioned, is the strongest correlate of PTSD. It can be a protective factor (presence of social support) and a risk factor (absence of social support). Among Vietnam veterans, social support was the most important mediator of risk postwar (Charuvastra & Cloitre, 2008). Negative reactions from an individual’s social network postwar, or veterans’ dissatisfaction with support, were often predictive of onset and severity of PTSD. The absence of support was associated with negative outcomes, while positive support, depending on who offered the support, was often experienced positively. Thus, risk for and recovery from PTSD appears to be highly dependent on social support (Charuvastra & Cloitre, 2008). Intervention for trauma An extensive and systematic literature base has developed around treatment of trauma. Exploring the knowledge base for the treatment of trauma and grief is important in that it may shed light on processes and factors that may help in the recovery or integration of traumatic loss. Exposure interventions, which emerged from the behavioural approach, were among the first interventions used to treat PTSD and are integral to many modern PTSD treatments (Cloitre, 2009). The learning theory perspective, which is the foundation of the behaviour therapy model, defines PTSD as a fear-based set of symptoms where exposure to a highly threatening event (e.g. accident) or series of events (e.g. combat), lead to a conditioned fear response (Cloitre, 2009). 27  Difficulty with the extinction of fear is echoed within neurobiological literature associated with PTSD (Siegmund & Wotjak, 2006; Francati, Vermetten, & Bremner, 2007). PTSD arousal symptoms are seen as conditioned fear responses resulting from traumatic exposure, and avoidance symptoms are understood as efforts to escape feared stimuli (Cloitre, 2009). Exposure therapy interventions are believed to extinguish conditioned emotional fear responses by exposing individuals to conditioned stimuli in the absence of negative consequences (Foa, Keane & Friedman, 2000). Cognitive stress models focus on how the trauma results in a “shattering” of the person’s belief system (Janoff-Bulman, 1992). Cognitive therapies involve identifying lost or changed beliefs (e.g. “I used to think that I had control over my safety, but I don’t anymore”), and revising the beliefs by contextualizing the individual’s trauma experience and balancing it with other life experiences (e.g. “I have learned self-defense and can control some aspects of my safety”) (Cloitre, 2009). Cognitive approaches focus on the meanings assigned to traumatic events as being more influential in developing and maintaining PTSD, then the objective characteristics of the event (e.g. duration). Revising maladaptive or negative appraisals associated with the experience are effective in resolving PTSD (Cloitre, 2009). Exposure and cognitive therapies are complementary, and with both approaches, emphasis is placed on different aspects of experience. Exposure therapy may focus on the emotion of fear, which is a primary adaptive response to threatening events that endure in PTSD even after danger has passed (Cloitre, 2009; Greenberg, 2008). On the other hand, cognitive therapies may focus on a range of feelings derived from processes related to the post-event appraisal or meaning given to the event and its consequences (Cloitre, 2009).  28  Intervention for loss There has been even less research regarding the efficacy of grief counselling or therapy. It has been stated that most people respond in a resilient fashion to loss; experiencing transitory distress and following an adaptive course to adjustment (Neimeyer & Currier, 2009). In reality, however, ten to fifteen percent of the bereaved struggle to adapt to the loss over a period of many months or years, especially those who experience loss by traumatic means (Currier, Holland, & Neimeyer, 2006). Neimeyer and Currier (2009) have asserted that although various forms of grief therapy have been proposed, there are controversies about the effectiveness of bereavement interventions. Many of the existing studies looking at treatment approaches have been noted to rely on small sample sizes and the findings have reinforced the need for more research to establish the efficacy of therapy for struggling bereaved individuals (Neimeyer & Currier, 2009). Neimeyer and Currier (2009) report that effective interventions for those struggling to adjust to loss have four elements: (a) Included individuals who had displayed intense and prolonged separation distress and related complications in the aftermath of loss, (b) repeated and experientially intense re-telling of the circumstances of the death with associated feelings and reactions, (c) involved a guided encounter with the memory of the loved one (e.g. drafting letters) and, (d) attempted to promote coping such as attending to current relationships and projecting new goals that better fit with the post-loss reality. Interestingly, some of the elements stressed in evidence-based interventions for loss are similar to those stressed in effective treatment for trauma, such as exposure to the trauma through retelling and promoting coping. This information offers insight into some of the factors that may be helpful in processing grief.  29  Violent loss As stated in the introductory section, a violent loss is a sudden and violent mode of death that is characterized by suicide, homicide, or a fatal accident (Norris, 1992; Currier et al., 2006). Literature concerning trauma and loss highlights the intersection of trauma and grief within the experience of violent loss (Green et al., 2001; Neria & Litz, 2003; Rynearson, Schut, & Stroebe, 2013 ). Violent losses are often appraised by the survivor as traumatic and precipitate symptoms of post-traumatic stress (Green, 2000) and other psychiatric symptoms that complicate the grief response (Currier et al., 2006). A violent death often brings together post-traumatic stress and grief, something that has received limited attention in thanatological literature (Rando, 1996). Rando (1996) described factors that made a specific death circumstance traumatic, such as: (1) Suddenness and lack of anticipation; (2) violence, mutilation, and destruction; (3) preventability, and/or randomness; (4) multiple deaths; and, (5) the mourner’s personal encounter with death, where there is a threat to his or her own survival or a massive and/or shocking confrontation with the death and mutilation of others. Rando (1996) adds that in the case of violent loss, the “external situations are such as to engender the disorder psychic and/or behavioral state resulting from mental or emotional stress or physical injury known as ‘trauma’” (p. 144). Raphael and Martinek (1997) state that survivors who experience suffering following a violent loss endure trauma and stress-related symptoms in addition to grief (Raphael & Martinek, 1997). Coping with both post-traumatic stress and grief has been noted to interfere with the grieving process and functioning (Raphael & Martinek, 1997). According to Raphael and Martinek, data that exist regarding traumatic loss suggest that mental health outcomes after traumatic loss follow a longer course, are more adverse, and feature both post-traumatic stress 30  and grief phenomenology. Rando (1996) asserted that experiencing the violent death of a significant person may complicate mourning by: (1) Shattering the assumptive world (e.g., world is orderly predictable and meaningful) creating fear, anxiety and vulnerability; (2) creating a profound loss of confidence in the world that affects all areas of life and increases anxiety; (3) the mourner reconstructing events of the death to comprehend it and retrospectively prepare for it; (4) creating a sense of unfinished business due to the lack of opportunity to say goodbye; (5) increasing anger, ambivalence, guilt, helplessness, death anxiety, as well as strong needs to make meaning of the death and determine blame; (6) creating secondary losses due to the consequences of lack of anticipation; and, (7) provoking a full spectrum of post-traumatic responses including intrusion symptoms, numbing, and increased physiological arousal. There is evidence supporting the premise that violent death has enduring effects on bereavement and grief (Rando, 1993; Rynearson et al., 2013). Violent loss can lead to symptoms of post-traumatic stress (Green, 2000), psychiatric symptoms, and complicated grief for survivors (Currier et al., 2006). Research regarding family members of murder victims has focused attention on the presence of strong intrusive and avoidant thoughts combined with hyperarousal in survivors, suggesting post-traumatic stress symptoms (Rynearson et al., 2013). This kind of loss has also been known to subjectively undermine the fundamental belief systems of the survivor (Janoff-Bulman, 1992; Currier,et al., 2006) and have a deleterious impact on post-loss recovery (Murphy et al., 1999; Murphy, Johnson, Chung, & Beaton, 2003). Violent and unexpected loss results in severe feelings of personal vulnerability and forces the individual to confront the prospect of death, creating intense anxiety; a psychological after-effect common to all traumatic stressors (Neria & Litz, 2003).  31  Green et al. (2001) found that traumatic loss led to more severe intrusive symptoms and greater functional impairment for survivors, suggesting that loss by traumatic means may be more pernicious than direct trauma itself. They compared structured clinical interviews and selfreports of female undergraduates with no reported history of trauma (n=58), a single physical assault as their only trauma (n=34), and a single violent loss as their only trauma (n=32). The average age of the women was 19.3 years and sixty-seven percent of the sample was Caucasian while the remaining percentage of participants were African American, Asian American, or another ethnic identity. Sixteen percent of persons who suffered loss by traumatic means met criteria for PTSD and twenty-two percent of this group met lifetime PTSD criteria. Loss by traumatic means led to more severe intrusive symptoms and greater functional impairment in comparison to a group of individuals who suffered physical assault, suggesting that loss by traumatic means may be more psychologically harmful than direct trauma (Green et al., 2001). It is important to note however that Green et al.’s (2001) research did not explore the nature and extent of the attachment relationship among those who experienced a loss by violent means and did not contrast PTSD as an outcome variable with symptoms of chronic grief. Nonetheless there is an indication that this kind of loss is more closely associated with PTSD and can lead to adverse outcomes, increasing the need to understand how individuals are able to adapt to this kind of loss. Further support for exploring traumatic loss comes from Eth and Pynoos (1994) who discovered that children who were traumatized and bereaved by witnessing their parent’s murders had acute posttraumatic stress reactions that interfered with their ability to successfully grieve. Child survivors tended to regress developmentally, leading to impaired school  32  performance and an inability to trust others and form minimal attachments (Eth & Pynoos, 1994). Two studies found PTSD symptoms and grief symptoms impacted functional adaptation after a major event. The survivors of the 1995 Oklahoma City bombing (168 died, 680 injured) were studied extensively (Tucker, Dickson, Pfefferbaum, McDonald, & Allen, 1997; Pfefferbaum et al., 2001). Tucker et al. (1997) studied eighty-six adults who sought help for distress related to the bombing six months after it occurred. They administered a survey measuring population demographics, level of exposure to the event, symptoms of grief, retrospective reports of reactions to the event, ongoing posttraumatic stress symptoms, and coping strategies. To identify immediate bombing reactions predictive of later distress, retrospective reports of reactions to the trauma were correlated with ongoing posttraumatic stress symptoms. Multiple regression analysis determined which reactions predicted the emergence of posttraumatic stress symptoms. Results indicated that reactions of being nervous and being upset by how other people acted when the bombing occurred accounted for about one-third of the total variation in posttraumatic stress symptom scores, and thus were major predictors of posttraumatic stress. The results varied according to amount of exposure that participants had to the bombing in terms of attachments to people who had died. Some had been injured whereas others were simply exposed to the bombing through the media. In this sense, the study examined trauma to a greater degree than grief reactions. Pfefferbaum et al. (2001), working with the same pool of participants as Tucker et al. (1997), delved further into the range of traumatic loss by examining combined grief and trauma. Forty participants in this study were selected from the larger sample of eighty-six because they knew someone killed in the explosion. This sample included eleven (28 percent) males and 33  twenty-eight (72 percent) females ranging in age from twenty-one to seventy-three years old (MD=40.03, SD=10.98). Two participants (5 percent) lost a close family member, two (5 percent) lost a close family member and a friend, nine (23 percent) lost a friend, and one (3 percent) lost both a friend and an acquaintance. The remaining twenty-six (65 percent) reported that an acquaintance had been killed. Pfefferbaum et al. found that the survivors’ grief responses accounted for a significant portion of the variance in post-traumatic stress symptoms. High grief scores and high self-reported PTSD predicted levels of functional impairment, demonstrating the convergence of post-traumatic stress and loss on post-loss functioning. There are reasons to critique the Pfefferbaum et al. (2001) study however, as similar to Tucker et al. (1997), the self-report instrument was culled together from other instruments. For example, thirteen grief related items were taken from the Texas Inventory of Grief (Faschingbauer, 1981) rather than just administering the actual measures. Pre-existing psychiatric disorders or prior or subsequent trauma was not measured. Additionally, the instruments may not have been very sensitive, considering the overlap of symptoms associated with PTSD and grief, and with other conditions such as depression, which was not measured. In addition, only two participants in the study had lost a close family member and symptoms were not evaluated through clinical interviews or direct observation. Homicide bereavement There are few systematic studies concerning individuals who have experienced homicide (Asaro, 2001a, 2001b; Rynearson, 1994; Spungen, 1998). Although aspects of ‘normal bereavement’ may be generalized to grief experienced by homicide co-victims, there is presently no model in widespread use that encompasses the features and traumatic aspects of homicide bereavement (Spungen, 1998). Spungen posits that such a model should amalgamate information 34  from both the fields of trauma and bereavement. For example, she notes that the same precipitant that leads to a reactivation of trauma for the person bereaved by homicide may simultaneously trigger a subsequent temporary upsurge of grief (STUG) long after the murder (Spungen, 1998). A reaction such as this may be deemed pathological yet may be connected to the loss and uncomplicated mourning (Rando, 1993; Spungen, 1990). Spungen argues that this is an area where grief and trauma intersect, and an area that could be incorporated into a traumatic grief model. Rynearson (1994; 2001) offers a framework for identifying the defining features of violent death that he terms the three ‘V’s: Violence, violation, and volition. He described these as three unique aspects of homicide that differentiate it from other kinds of bereavement (Rynearson, 1994). The three ‘V’s framework can be applied more broadly to violent loss in general (Rynearson, 2001). First, the act of dying is described as ‘violent’; it is forceful, painful, and a sudden act frequently resulting in mutilating injuries. Second, dying is a ‘violation’ or a transgression where the individual rights of the deceased are disregarded. Third, dying can follow from ‘volition’; that is, a voluntary act on the part of the perpetrator (in cases of murder) or victim (in cases of suicide). Rynearson (1994) states that the violence, violation and volition factors are associated with other effects, including: (1) Post-traumatic stress disorder – intrusive re-enactment and avoidance; (2) victimization – feelings of rage and defilement; and, (3) compulsive inquiry – a social and psychological need for investigation and punishment of the murderer. Rynearson (1994) describes the compulsive inquiry as involving a socially mandated response to violent death as well as an involuntary rumination with a need to understand explanations for the death. Rynearson’s three V’s, anchored within the bereavement literature camp, certainly highlight a finding consistent to posttraumatic stress research, namely that 35  individuals exposed to human-generated traumatic events or events precipitated by human intent, carry a higher risk for PTSD and complications (Chauvastra & Cloitre, 2008; King, King, Gudanowski, and Vreven, 1995). Anger is a common initial response after loss, particularly after a violent loss such as a homicide (Parkes, 1993; Rynearson, 1994; Rynearson et al., 2013; Spungen, 1998). The experience of rage and the desire for revenge has been described as being part of the survivor’s experience after a homicide (Rynearson, 2001). The homicide literature has described those close to the victim as commonly wanting to kill the perpetrator(s). As such, Rynearson notes that retaliation, retribution, and punishment are often an “inherent counterstory” (p. 21) to the three V’s (violent, violation, volition). Rynearson et al. (2013) have pointed out that individuals closest to a victim are prone to thoughts of retribution and retaliation after a violent loss. Spungen (1998) described anger as having the function of blocking stress by blocking awareness of emotional or physiological arousal. She states that anger dissipates stress related to: (1) Painful emotions, blocking them so that they are literally pushed out of awareness; (2) painful sensation or muscle tension; (3) frustrated drive; and, (4) perceived threats - the arousal mobilizes and generates a push for stress reduction activity (Spungen, 1998). Although these observations regarding anger seem intuitively plausible, it is not clear what findings or observations Spungen (1998) is basing these hypotheses on. Studies regarding veterans’ experiences of loss do not appear to explore experiences of revenge or anger (Papa et al., 2008; Pivar & Field, 2004).  36  Complicated grief Researchers such as Rynearson et al. (2013) have found few studies that stringently examine complicated grief following violent death. Research has supported a higher intensity of grief following violent causes (Currier, Holland, Coleman, & Neimeyer, 2008; Dyregrov, Nordanger, & Dyregrov, 2003), however, this does not inform about complicated grief (Rynearson et al., 2013). In addition, few complicated grief studies actually look at factors such as the mode or type of bereavement (Rynearson et al., 2013). Although studies have examined the co-morbidity of complicated grief with post-traumatic stress disorder, anxiety, and depression (Morina, Rudari, Bleichhardt, & Prigerson, 2010), studies have not identified the comorbidity of complicated grief with violent versus non-violent deaths (Rynearson et al., 2013). Worden (2009) described complicated grief as the failure to grieve. He described factors surrounding the failure to grieve as relational factors, circumstantial factors, historical factors, personality factors, and social factors. Relational variables refer to the type of relationship the person had with the deceased. Circumstantial factors refer to the circumstances surrounding the loss which are important mediators of the strength and outcome of the grief reaction (Worden, 2009). Although grief theorists such as Worden (1991) have discussed complicated and uncomplicated grief reactions, Horowitz et al. (1997) and Prigerson et al. (1999) have attempted to establish distinct diagnostic categories for complicated bereavement reactions. There have been attempts to define complicated grief in a way in which it can be measured and introduced in the next edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V). These attempts have been spearheaded by Prigerson et al. (1999a;1999b) to develop criteria for diagnosing “severe, prolonged, and maladaptive grief” (Prigerson, Vanderworker, & 37  Maciejewski, 2008, p. 167) and establish that “complicated grief is a distinct and disabling condition” (Boelen & Prigerson, 2013, p. 85). Boelen and Prigerson (2013) argue that there is evidence that complicated grief is associated with sleep disturbances, suicidal ideation, increased substance misuse, reduced quality of life, and health impairments. Prigerson et al. (2008) have attempted to establish diagnostic categories for complicated bereavement reactions. Research is accumulating to support the construct validity of a complicated grief diagnosis, with “expert consensus” (Boelen & Prigerson, 2013). The core features being considered for inclusion in the DSM-V are: 1) Constant longing, yearning or pining for the lost person; 2) intrusive thoughts about the deceased; and, 3) intense feelings of emotional pain, sorrow, or pangs of grief related to separation distress. These core features are accompanied by five of the following symptoms: a) Avoidance of reminders of the loss; b) feeling stunned, shocked or dazed by the loss; c) confusion about role in life or diminished sense of self; d) trouble accepting the loss; e) difficulty trusting others since the loss; f) feelings of bitterness and anger over the loss; g) difficulty moving on (e.g. making new friends, pursuing new interests); h) feeling emotionally numb since the loss; and, i) feeling that life is unfulfilling, empty or meaningless without the deceased (Boelen & Prigerson, 2013). The diagnostic criteria also describe persistent severe grief symptoms that do not remit after the first six months following the loss and interfere with functioning (Boelen & Prigerson, 2013). Although veterans in other grief-related studies (Papa et al., 2008; Pivar & Field, 2004) may display core features of criteria related to a diagnosis of complicated grief (Boelen & Prigerson, 2013), considerable caution should be observed in drawing links to complicated grief diagnoses. There is no data related to the prevalence and impact of complicated grief regarding veterans of the recent Afghanistan and Iraq conflicts. Furthermore, there continues to be a lack of 38  clarity and consensus concerning complicated grief in general, aside from studies related to complicated grief diagnostic criteria (Rando, 2013; Wakefield, 2013; Worden, 2009). Researchers such as Papa et al. (2008) have noted similarities between the proposed diagnostic criteria of complicated grief and experiences such as veteran survivor guilt related to loss. However, since so few aspects of the grief experience for veterans have been explored systematically, drawing a comparison to the complicated grief diagnostic criteria has the potential the brush over unique aspects of experiences for veterans who have experienced violent losses. For example, complicated grief criteria specifying, “inability to trust others since the loss,” (Boelen & Prigerson, 2013, p. 93) may oversimplify the unique aspects of violent loss of a close friend for veterans. Lichtenthal, Cruess, and Prigerson (2004) assert that complicated grief constitutes a distinct psychopathological diagnostic entity and warrants a place in standardized psychiatric diagnostic taxonomies. Although PTSD and complicated grief may have similar precipitating events (e.g. death of significant person by violent means), the criterion stating that the PTSD stressor must involve fear, helplessness or horror is viewed as subjective, or based on the individual’s cognitive appraisal (American Psychiatric Association, 2000; Lichtenthal et al., 2004). These proposed diagnostic categories for complicated grief (Lichtenthal et al., 2004) appear to further establish grief researchers and trauma researchers as distinct from one another (Neria & Litz, 2003). In the last several decades of research, the lasting impacts of combat losses have been mainly included under the PTSD construct (Neria & Litz, 2004). Researchers have noticed that veterans experience chronic problems related to combat losses that endure, are debilitating, and seem distinct from PTSD (Papa et al., 2008; Pivar & Field, 2004). For example, despite the fact 39  that the research participants in Pivar and Field’s (2004) study were veterans with PTSD, the researchers were able to distinguish grief-related symptoms from anxiety or depressive symptoms. They found that unresolved grief played a role in the distress suffered by combat veterans, suggesting that trauma alone cannot account for their experiences. Papa et al. (2008) and Pivar and Field (2004) have noted the similarities between grief-related symptoms and complicated grief. Papa et al. (2008) in particular have aligned with the establishment of complicated grief as a mental health disorder, as proposed by Lichtenthal, Cruess, and Prigerson (2004) and Prigerson et al. (1999b). Veterans and the deaths of comrades Minimal research has systematically explored bereavement as it pertains to veterans (Pivar & Field, 2004), despite the fact that combat stress and grief related to the loss of comrades has been recognized by psychologists and psychiatrists working with soldiers since World War II (Lidz, 1946; Anderson, 1949). Researchers who have studied grief and trauma with military populations have noted that the experiences of grief and mourning have not been placed in perspective beside the diagnosis of PTSD (Pivar, 2000; Pivar & Field, 2004). In addition, it does not appear that any studies have examined the experience of traumatic loss after combat; for example, when a veteran’s friend commits suicide or dies violently after deployment. As will be addressed later in this literature review, the transition to civilian life for veterans can be difficult. As such, PTSD and other readjustment problems resulting from warzone exposure have increased in terms of public recognition (Schnurr et al., 2010). The importance of a soldier’s relationship to his comrades has been documented by several researchers, yet not necessarily studied systematically (Anderson, 1949; Elder & Clipp, 1988; Lidz, 1946). Pivar (2000) noted that soldiers are often in the late adolescent stage of 40  development during involvement in the military sector. The soldier’s comrade may serve as a protector, an object of idealization, and an extension of the self (Pivar, 2000). Elder and Clipp (1989) noted the camaraderie in military units as being related to group formation processes, the formation of attachment bonds within units with a “strong command structure” (p. 179), and by processes of group cohesion among life threatening circumstances. Lidz (1946), speaking about his observations from a psychiatric perspective in the 1940s, observed a correlation between stress symptoms and grief. He viewed the loss of a comrade as contributing to panic reactions due to the dependence on and protection provided by the comrade. Some of the reactions that Lidz observed among soldiers following the loss of a comrade were insecurity, mourning, resentment, retaliation toward the enemy, and guilt. Brende (1983) saw a relationship between loss, grief, and self-destructive symptoms observed in Vietnam veterans. He referred to the relationship of the soldier to his comrades as the development of the “protective self’, a mutually interdependent relationship shielding from the constant threat of death (cited in Pivar, 2000). A variety of other researchers have noted the connection between loss and trauma. Anderson (1949), drawing from psychoanalytic theory, observed a connection between war stress and mourning in British combat veterans. He observed severe grief reactions with those who suffered trauma. Anderson (1949) stated, “The external battlefield had been swallowed up and was now an internal battlefield” (p. 50). Likewise, Scurfield (1985), while assessing and treating PTSD symptoms in veterans, noted the centrality of loss to their experience. Scurfield (1985) classified loss reactions and symptoms characteristic of PTSD into two categories, bereavement and personal injury, noting that the combat veteran often experienced both. Fox (1974) theorized that the experience of rage following the death of a comrade was a reaction to a narcissistic wound and injury to the self, and not the loss of the real person. He 41  theorized that the comrade buddy becomes an extension of the self through the processes of group dynamics and formation specific to the military. Thus the loss of a friend is experienced as an injury to self rather than the loss of a ‘separate’ other. Fox (1974) saw the death of a buddy as a trigger for intense rage reactions leading to acts of mayhem and revenge. He too considered that many soldiers are often in late adolescence, where idealized and intense relationships commonly occur. This research is theoretical and is based on retrospective observations of ‘cases’ of soldiers that Fox worked with and interpreted from the perspective of a psychiatrist. van der Kolk (1985) similarly observed that veterans who developed PTSD after combat were often adolescents during combat and formed intense attachments to others in their units. These attachments were severely disrupted by loss. Haley (1985) viewed the loss of a comrade through a psychoanalytic or object relations lens, referring to the “buddy” as a transitional object. Haley (1985) states the soldier’s friend “served to assuage anxiety, fear, and abandonment panic because of the magical belief—as long as the soldier stayed physically close to him—could protect him and love him enough to endure the dangers around him” (Haley, 1985, p. 58). Again, this theorizing is anecdotal, based on her years of treating Vietnam combat veterans , and includes a case report from the perspective of a social worker treating a Vietnam combat veteran. Junger (2010), an embedded journalist who travelled with soldiers engaged in heavy combat in the Korengal valley in Afghanistan, has a different, less psychodynamic take on the affective bonds between service members. He writes: Combat obscures your fate—obscures when and where you might die—and from that unknown is born a desperate bond between men. That bond is the core experience of combat and the only thing you can absolutely count on ... the shared commitment to safeguard one another’s lives is unnegotiable and only deepens with time. The 42  willingness to die for another person is a form of love that even religions fail to inspire, and the experience of it changes a person profoundly (p. 239). Elder and Clipp (1988), in a cohort study examining archival data from longitudinal samples, traced war losses and social bonding across the life span of 149 veterans of WWII and the Korean conflict. They noted that the losses of comrades and friends during war intensified and maintained post-war relationships. The loss of a comrade was described as having a special meaning for mates bound by mutual responsibility, support and protection (Elder & Clipp, 1988). Elder and Clipp state, “when comrades fall in battle, their bonds of mutual obligation and loyalty make survivors especially vulnerable to self-blame and feelings of guilt” (p. 181). They describe how the members of the unit, being mutually dependent, feel responsible for their comrades death even when factors were beyond their control. A comrade’s death, “implies failure to be dependable in the protector role” (Elder & Clipp, 1988; p. 181). Researchers have highlighted the minimal attention given to bereavement by helping professionals treating veterans (Garb, Bleich, and Lerer, 1987; Pivar, 2000). Garb et al. (1987) highlighted the dangers of unresolved grief for the long term adjustment and development of chronic symptoms for combat veterans. The researchers distinguish normal from abnormal grief by describing factors that could contribute to abnormal grief such as the sudden loss, lack of support, trauma symptoms such as dissociation, lack of funeral rituals, and the sudden disposal of the body. A study concerning Israeli war veterans from the Yom Kippur war suggested that exposure to loss was related to grief-like psychopathology (e.g. depressive symptoms, anger, guilt), even two decades after the war (Neria, Soloman, Ginzburg, 2000). Breslau and Davis (1987) found that having a “buddy killed in action” (p. 581) was related with PTSD. They examined the effects of combat stress in a sample of sixty-nine 43  Vietnam veterans who were psychiatric inpatients in a Veterans Administration (VA) hospital. Participants were interviewed with a Diagnostic Interview Schedule related to the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III; American Psychiatric Association, 1980) to gather systematic information about their symptoms. The researchers compared this subset of Vietnam veterans to veterans from a larger pool of 145 inpatient veterans who did not serve in Vietnam. Although this study may have methodological flaws, such as limited information regarding the demographics of the study participants as compared with the control group and the generalizability of the findings, it reveals the intersection between the death of a comrade and PTSD in surviving veterans. Pivar and Field (2004) attempted a more systematic observation of trauma and loss by measuring unresolved grief in a sample of Vietnam veterans diagnosed with PTSD. They noted that previous empirical studies had not focused on the extent and severity of the loss of comrades and the relationship to PTSD, and that grief was often treated “after the fact,” or secondarily to PTSD. Their study demonstrated the prominence of grief-specific symptoms in a sample of veterans being treated for PTSD. The participants were 114 Vietnam veterans being treated for PTSD at a Palo Alto Veterans Affairs inpatient unit. Pivar and Field attempted to differentiate grief symptoms from PTSD and depression with a component analysis. They also assessed the severity of grief-specific symptoms through self-report measures and assessed the extent of attachment to the men in the unit through multiple regression analysis. The results provided support for the existence of grief-related symptoms as distinct from other trauma-related symptoms. The authors concluded that high levels of grief-related symptoms and grief severity were associated with the experience of losing comrades during combat. Higher levels of grief stemmed from the loss of a close comrade during war. Granted, this study does have some 44  limitations to be wary of. For example, it is retrospective and the memories of the soldiers pertain to a time approximately thirty years prior. Also, current levels of symptomatology could confound the reporting of grief symptoms and loss of important attachments. Results may lack generalizability as this study only included Vietnam veterans formally diagnosed with PTSD. In addition, the research methodology did not include clinical interviews or any qualitative information. Despite these limitations however the study recognizes the importance of soldiers’ bonds with other soldiers, and the importance of continuing to address grief and trauma in the treatment process. The research also adds to the observations concerning the significant role that unresolved grief played in the distress suffered by Vietnam veterans (Pivar & Field, 2004). Meaning making and violent loss Several cognitive and trauma theories have helped to provide operational definitions and testable hypotheses, particularly in terms of loss by traumatic means. These theories provide insight into how individuals struggle to make meaning of, or find benefit after a loss by violent means. Taylor’s (1983) cognitive adaptation model proposes that adjustment to threatening events centres around three themes: A search for meaning in the experience, an attempt to regain mastery over the event and over one’s life more generally, and an effort to restore self esteem through self-enhancing evaluations. Taylor (1983) describes the search for meaning as involving the need to understand why a crisis occurred and the impact the crisis has had. She draws from attribution theory (Heider, 1958; Kelley, 1967), proposing that following a threatening event, people make attributions to understand, predict and control their environment. Taylor (1983) states:  45  Meaning is an effort to understand the event: why it happened and what impact it has had. The search for meaning attempts to answer the question, What is the significance of the event? Meaning is exemplified by, but not exclusively determined by, the results of an attributional search that answers the question, What caused the event to happen? ... Meaning is also reflected in the answer to the question, What does my life mean now? (p. 1161) Through understanding the cause of the event, a person may understand the significance of the event and what it symbolizes in terms of one’s life (Taylor, 1983). A threatening event like a violent death can undermine a sense of control over oneself and one’s life. Gaining a sense of mastery is a second way that individuals adapt to threatening events (Taylor, 1983). A third theme in adaptation to threatening events involves an effort to enhance the self and restore self esteem (Taylor, 1983). Janoff-Bulman’s (1989; 1992) “shattered assumptions” theory asserts that the fundamental assumptions individuals hold about themselves, the world, and others may be shattered following a stressful event, such as the death of a significant person (Janoff-Bulman, 1992; Matthews & Marwit, 2003; Currier et al., 2006). Janoff-Bulman’s theory revolves around the premise that our inner worlds are built upon sets of fundamental assumptions that constitute our models of the world and ourselves. Fundamental assumptions are theories built from experiences and are used to plan, perceive people and events, forecast the future, and provide an overall cognitive-emotional guide for navigating the world (Janoff-Bulman, 2006). Cognitive psychology popularized the notion of “schemas” or working models of the world that help us to organize our experiences, help us manage the world, provide us with expectations, and reference new information with our old, familiar schemas (Janoff-Bulman, 2006). The fundamental 46  assumptions proposed by Janoff-Bulman (2006) are our “most general, abstract schemas” (p 83). They provide a sense of safety and security and a sense of our own invulnerability. JanoffBulman (1992) has proposed that our three fundamental assumptions are: 1) The world is benevolent; 2) the world is meaningful, and; 3) the self is worthy. Traumatic events challenge individuals’ basic assumptions and can shatter fundamental assumptions that had “gone unquestioned prior to the traumatizing event” (Schwartzberg & Janoff-Bulman, 1989; p. 271). According to Janoff-Bulman (1992), when there is harm to individuals with whom a person has a strong attachment, the “emotional attachment to these people essentially makes the traumatic event directly felt” (p. 55). Events such as a violent death can force survivors to come face to face with their own mortality, vulnerability, fragility, and they may experience a challenge or “shattering” of their symbolic world (Janoff-Bulman, 1992). Her theory has been referred to frequently within both trauma and loss fields despite more recent evidence suggesting that these effects may not be as strong as claimed (Mancini, Prati, & Bonanno, 2011). In an attempt to find more concrete and specific evidence of the processes involved in meaning-making after a loss, Davis, Nolen-Hoeksema, and Larsen (1998) designed a prospective and longitudinal study with individuals who had experienced the death of a family member in a hospice. The researchers interviewed participants before their family member’s death (pre-loss), one month post-loss, six months post-loss, thirteen months post-loss, and eighteen months postloss. The interview protocol involved several measures of psychological adjustment which were obtained midway through the interview. A measure of optimism and pessimism was also used during interviews. Two open-ended questions about meaning were asked toward the end of the post-loss interviews, and independent coders categorized the responses. Davis et al. (1998) found that both making sense of the event and finding benefit in the experience were at work after the 47  loss, playing roles in the adjustment process. The sense-making process was found to be associated with earlier adjustment after the loss, whereas benefit-finding was found to be strongly associated with adjustment after approximately one year post-loss. Limitations of this study are important to recognize. For example, the participants were recruited through hospices, meaning that the participants were likely anticipating being bereaved as opposed to the experience of losing a loved one suddenly or unexpectedly (Davis et al., 1998). The study does not look at the impact of unexpected, sudden, or violent losses on peoples’ ability to make sense of the loss. Along with this, the study does not differentiate so much between the kinds of anticipated loss people experience and how responses differ due to the different kind of loss. Also, the participants were from non-institutionalized hospices which may yield a different experience than institutionalized hospices. A third limitation of the study is the reliance on single-item variables, rather than multi-item instruments, to assess making sense and finding benefit in the experience. Also, there was a focus on making meaning and this may leave out aspects of the loss that did not make sense (Davis et al., 1998). A recent qualitative study by Johnson (2010) examined the bereavement experiences of African-American teen girls who had mourned the deaths of friends due to homicide. A qualitative methodology was used as there was so little known about the research topic, and the researcher chose grounded theory with themes for data analysis. The study examined the bereavement experiences of twenty African-American teenagers who were 16-19 years old living in a large northeastern U.S. city. The researcher found that these teen girls demonstrated resilience in their ability to adapt to their losses by remaining achievement-oriented, sustaining meaningful relationships with friends and family, and being able to make meaning of the loss. Obviously with qualitative research there are limitations regarding the representativeness of the 48  sample but the point was to gather rich information regarding a minimally studied topic. Also, the girls selected for the study had volunteered to speak about their experiences and may have had the constitutional capacity, supports, and experiences that contributed to their resilience and willingness to participate (Johnson, 2010). Furthermore, the study is retrospective and temporal distance from the experience may increase distortion. Nonetheless the study’s results suggest that positive outcomes following violent, unexpected loss can be mediated by certain factors, including meaning-making. Drawing from earlier models of adapting to life stressors (e.g., Bonanno & Kaltman, 2003; Janoff-Bulman, 1992; Taylor, 1983), Park (2010) proposed an integrated model of meaning-making in the context of stressful life events. Park’s (2010) model included these core tenets: (1) People possess global meaning systems that provide them with frameworks to help interpret their experiences; (2) During situations that challenge or stress their global meaning, individuals appraise the situations and assign meaning to them; (3) The extent to which the appraised meaning is discrepant with their global meaning determines the extent to which they experience distress; (4) The discrepancy produces distress which initiates a process of meaningmaking; (5) Individuals attempt to reduce the discrepancy between appraised and global meaning through meaning-making efforts and restore a sense of the world as meaningful and their own lives as worthwhile; and, (6) this process, when successful, leads to better adjustment to the stressful event (Park, 2010, p. 258). In the current study, the concept of “situational meaning” that Park (2010) described started with the loss of a close friend and continued with the assignment of meaning to this event (“appraised meaning”), assessing discrepancies between appraised and global meaning, meaning making, meanings made and adjustment to the event (Park, 2010, p. 258-259). Like Janoff49  Bulman’s (1992) fundamental assumptions, global meaning refers to a person’s general orienting systems consisting of beliefs, goals, and subjective feelings. Global beliefs are broad views regarding justice, control, predictability, coherence, and so on as well as views toward the individual self. These views form the core schemas through which individuals interpret their experiences of the world. Park (2010) described global goals as internal representations of desired processes, events or outcomes. Goals can be states already possessed that a person seeks to maintain or desired end states such as health or relationships with loved ones. Park (2010) described commonly reported global goals as being relationships, work, religion, knowledge, and achievement. Conclusion Despite the variety of research in the areas of loss and grief, there have been few studies that examine traumatic loss for veterans. Even within studies of veteran populations who have experienced the loss of a comrade (Pivar & Field, 2004), it does not seem that there are any studies that examine the veteran’s experience of a loss of a comrade in his or her own words. There are different conceptualizations of difficult loss such as complicated grief and traumatic grief, yet few studies seem to examine the experience of trauma and loss co-occurring within one experience. What if an individual can experience both trauma and loss reactions at the same time? Is it possible to integrate what we know about trauma and loss rather than viewing these experiences as distinctly separate? Research into veteran’s lived experiences is minimal and there is dearth of rich, descriptive data as they have not been invited to describe the experience of traumatic loss in their own words. A phenomenological study of veterans’ experiences of the loss of a close comrade by violent means will bring trauma and loss experiences together. Using a phenomenological 50  framework, this study will seek to examine the lived experiences of military veteran survivors of traumatic loss and will attempt to reveal the meanings of adaptation to the traumatic loss of a comrade.  51  Chapter 3: Methodology This qualitative study explored the experiences of eleven military veterans who were coming to terms with the violent death of a close comrade. In-depth interviews were conducted to understand the subjective meaning and experience of the loss for each veteran. The research was grounded within a phenomenological orientation. Thematic analysis was conducted to examine the deep meaning structures that characterized the lived experiences of the individual participants (Colaizzi, 1978; Osborne, 1990; van Manen, 1997). Common themes concerning the experiences of living with and making sense of the violent death of a close friend were identified. Research orientation As stated in the introductory chapter, this research sought to answer the question: What is the meaning and experience of coming to terms with the traumatic loss of a close comrade for veterans? The aim of this research was to allow the information provided by each veteran participant to speak for itself (Osborne, 1990). The research was approached from a phenomenological orientation and unstructured, open-ended, in-depth interviews in order to allow veterans to tell their stories using their own voice. The phenomenological approach was undertaken to understand the “lifeworld” (van Manen, 1997), or the experiential world of the veteran participants (Colaizzi, 1978). The goal of phenomenology is to explore the way in which things present themselves, or appear to people in and through their experiences (Sokolowski, 2000). The focus is on the individual’s subjective perceptions of the world and describing the world as it appears to the individual (Langdridge, 2007). The goal is to “contact the phenomena as people experience it” (Colaizzi, 1978, p. 57). The aim with this research was to achieve a highly subjective understanding of the phenomenon 52  of the violent loss of a comrade whereby the voices of veterans themselves could be honoured. A phenomenological approach was selected in order to evoke, connect with, describe, and elaborate upon the qualities and inner meanings of the veteran’s lived experiences (van Manen, 1997). Edmund Husserl is responsible for introducing the philosophical foundations of phenomenology. The foundational concept of phenomenology is intentionality, referring to the idea that whenever we are conscious, we are always conscious of something (Langdridge, 2007). From this perspective, every act of consciousness or experience is correlated with an object (Sokowlowski, 2000). The focus of phenomenology is attending to people’s experiences of how things appear to consciousness, focusing on what is experienced and the way it is experienced (Langdridge, 2007; Sokowlowski, 2000). This study used a hermeneutic phenomenological approach. Although there is no single standardized method for applying the hermeneutic phenomenological philosophy to human inquiry (Gadamer, 2004; Laverty, 2003), this particular study used van Manen’s (1990; 1997) hermeneutic phenomenological approach; an interpretive approach that combines “phenomenology (as pure description of lived experience) and hermeneutics (as interpretation of experience via some ‘text’ or via some symbolic form)” (van Manen, 1990, p. 25). Hermeneutic phenomenology moves from the conscious description of the individual’s lived experience of a phenomenon toward an explication of meanings embedded within descriptions (Allen & Jensen, 1990). Hermeneutic phenomenology suggests that experience and interpretation cannot exist without one another (Heidegger, 1996). Therefore, to understand the lived experience of a veteran coming to terms with such a loss, one must gather the individual’s descriptions of everyday life. Information about their experiences must then be interpreted in accordance with their descriptions. 53  van Manen (1990) stated that the “facts of lived experience are always already meaningfully (hermeneutically) experienced” (p. 18) and conveyed through language, which is an interpretive process. Like Heidegger, van Manen (1990) places emphasis on the sociohistorical context of experiences and recognizes that there can be multiple interpretations of described human experiences. For the current research, the interview method was used to gather rich descriptions of veteran participants’ lived experiences regarding the process of adaptation to traumatic loss. This included stories, anecdotes, and recollections of experiences (van Manen, 1990). Text was then created through the dialogue between the person being interviewed and the interviewer. Themes were developed from careful analysis of each participant’s descriptions and then confirmed with each participant in order to uncover the meaning of coming to terms with the experience of traumatic loss for veterans. Outlining presuppositions The Greek word epoche, or bracketing, describes the process of abstaining from our presuppositions, or ideas regarding the phenomenon that we are investigating (Langdridge, 2007; Osborne, 1990). The idea is to set aside our everyday way of seeing the world. These concepts, particularly the bracketing-off of preconceptions, are debated within phenomenology and tend to be used most frequently with descriptive phenomenological approaches (Langdridge, 2007). While Husserl focused on transcending subjectivity through bracketing in much of his writings (Langdridge, 2007), Heidegger, focused on more ontological concerns such as the nature of being. He did this through his concept of daesin, which translated means the “mode of being human” or “being-in-the-world” (Laverty, p. 7). Heidegger (1962) asserted that to be human is to be interpretive, and that one cannot bracket oneself out of the interpretive process as 54  the interpreter brings certain background expectations and frames of meaning to bear in the act of understanding (Koch, 1996). Heidegger did not believe that it was possible to achieve presuppositionless knowing through bracketing and reduction until pure description revealed the meaning of things themselves (Osborne, 1994). Heidegger (1962) emphasized history and background as being inseparable from a person’s understanding of the world (Laverty, 2003, p. 55). With Heidegger’s perspective, hermeneutic phenomenology occurs within existence, is always contextualized by existence, and not without presuppositions (Osborne, 1994). Although a hermeneutic phenomenological approach of inquiry is derived more from Heidegger’s ‘interpretive’ views, research with a phenomenological orientation is often carried out without discussing the disagreement between Heidegger and Husserl regarding bracketing and reduction (Osborne, 1994). Despite approaching this research from a hermeneutic phenomenological orientation and being aware of the split between these two theorists, I believe that outlining presuppositions is worthwhile. Outlining one’s presuppositions involves selfreflection that makes implicit biases and preconceptions about the phenomenon of interest held by the researcher explicitly known (Osborne, 1990; van Manen, 1990). This process enhances the credibility and confirmability of the researcher’s data analysis (Lincoln & Guba, 1985). Credibility is in essence the faithfulness of the researcher’s depiction of participants’ accounts. Similarly, confirmability serves as a measure of researcher neutrality. The process of outlining one’s presuppositions can aid the researcher in bringing awareness to personal presuppositions as they colour his or her orientation toward the phenomenon of interest (Kvale, 2009; Osborne, 1990). In his hermeneutic approach, van Manen (1997) emphasizes paying close attention to one’s own experiences during interviews, while listening to audio recordings, examining transcripts, and writing and re-writing findings. He places specific emphasis on the importance 55  of self-reflection and urges researchers to be mindful of their feelings, thoughts, and perceptions in order to reveal unknown aspects of the phenomenon under investigation. My presuppositions regarding the military veteran’s experience of violent loss reflect my personal and clinical experiences, as well as my knowledge base regarding loss and trauma. First, I assumed that veterans who experienced the death of a close comrade would experience both post-traumatic stress symptoms and grief symptoms. This overlap was noted in my preparatory review of the literature regarding violent loss (Green, 2000; Green et al., 2001; Neria & Litz, 2003). This was also something that I noted within my personal experiences of loss and my clinical work with clients. Overall, I assumed that veterans who had experienced the death of a close comrade would experience trauma related symptoms in addition to grief (Raphael & Martinek, 1997). Second, I assumed that the grief-related symptoms and the emotional ties to the comrades who died would endure. This was based on my review of literature regarding veteran loss, clinical experience of hearing the stories of veterans who had lost friends, and observing the emotional reactions of my own grandfather who lost a close comrade in World War II. Although my grandfather had experienced trauma symptoms related to his service, he was known to reflect on his friendship with his comrade and the circumstances surrounding his friend’s death into his senior years. At the time of this study my grandfather was ninety-one years old and would speak about his comrade often. Enduring grief-related symptoms for veterans were reflected within an empirical study related to veteran loss (Pivar & Field, 2004) and studies regarding veteran loss based on the theoretical and clinical observations of the researchers (Lidz, 1946; Haley, 1985). Third, through the process of consulting literature exploring adaptation after loss (Currier et al., 2006; Davis et al., 1998; Janoff-Bulman, 1992), I expected that veterans who had 56  experienced the violent loss of their comrades would come to terms with or make sense of it through some process. As I selected participants for this study who self-identified as having come to terms with the loss of a close comrade, I assumed that the participants would have found ways to survive, adapt, and understand their experience. Procedure Selection of participants Selecting participants, or co-researchers, in hermeneutic phenomenology, involves selecting individuals who have lived the experience that is the focus of the study, who are willing to talk about their experience, and who are diverse enough from one another to enhance the possibilities of rich and unique information about the particular phenomenon under investigation (Laverty, 2003). In this study, the veteran participants had diverse military backgrounds and were certainly well-positioned to describe the experience of losing of a comrade because they themselves had lived it (Baker, Wuest, & Noerager Stern, 1992; Osborne, 1990). Participants in this research were selected because of their ability to articulate the phenomenon of interest (Colaizzi, 1978). Inclusion criteria Participation in the study was entirely voluntary. The selection criteria for participation included having been a military service member who participated in overseas military service, having experienced the death of a close comrade by violent means, and having experienced coming to terms with, or self-identifying as coping well within the context of this loss. Coming to terms with the death referred to veteran participants who were coping with the loss and able to function in activities of daily life (e.g. occupation, relationships with others) despite the emotional impact. Participants who had experienced the death of a close comrade and who 57  believed that they were adjusting to the loss, integrating the loss, or making sense of the loss experience were selected. Participants between the ages of twenty to forty-five years who had experienced a death by traumatic means of a close comrade were recruited. Recruitment Criterion-based selection, or purposive sampling, was used to select participants. This kind of sampling is not designed to be representative, rather it is intended to increase the depth of information that is discovered (Guba, 1981). According to Patton (2002), purposeful sampling, “yields insights and in-depth understanding rather than empirical generalizations” (p. 230). This approach to sampling allows the researcher to select description-rich cases to gain an in-depth understanding of the phenomenon under investigation. Patton (2002) asserts, “The validity, meaningfulness, and insights generated from qualitative inquiry have more to do with the information richness of the cases selected and the observational/analytical capabilities of the researcher than with sample size” (p. 245). This study ventured to do exactly that; yield the richest, most descriptive information possible. This research project was subject to the University of British Columbia’s ethical review procedures. Upon obtaining ethical approval, participants were made aware of the opportunity to participate in the study through contact with agencies and organizations. Participants were recruited through contacts with psychologists, physicians, and counsellors who were known to work with veterans. Clinicians were provided with full disclosure regarding the research proposal (Appendix B). They were assured that in the unlikely event that participants needed to access therapeutic services as a result of participation in this research that several sessions addressing any distress would be provided. Prospective participants were contacted by past or present helping professionals or agency representatives and provided with a letter orienting them 58  to the study and researcher’s contact information. Participants who were interested were invited to further explore information regarding the study through informal telephone interviews and email contact with the researcher. Potential participants were asked screening questions to ensure they met the inclusion requirements listed above. After initial contact was made I provided detailed information about the study. I explained the criteria of the study, answered questions related to the study’s purpose, and monitored the suitability of potential study participants. Full disclosure and transparency regarding the study was provided in preliminary conversation with participants and informed consent was gathered at this juncture (see Appendix C). If potential participants expressed an interest in participating they were invited to provide informed consent and participate in the study. In total, eleven participants were recruited over a period of seven months. The participants consisted of predominantly Caucasian males with the exception of one participant of mixed Indian and Italian ethnicity. The time since the loss of a close comrade ranged from two years to twenty years. The time since the loss, before the interview, was: two years (five participants), four years (one participant), five years (one participant), eight years (one participant), and twenty years (three participants). The process of recruitment, described below, was lengthy as participants were often reluctant to speak. Six of the eleven participants in this study were recruited through either psychologists or paraprofessionals (veterans trained to work in a therapeutic setting). The veteran participants spoke with a psychologist or therapist who gave them information about the study, however it was commonly the paraprofessional who assured the prospective participant of the researcher’s credibility and trustworthiness. As the quote below demonstrates, the endorsement from a fellow veteran was important: If he says your intentions are what your intentions are, then I have no qualms with what 59  you're gonna ask. If you ask something offside, I'll tell you it’s offside. I'm not going to lose it and throw you out my window, but, you know what I mean. He’s vetted you. Many participants described the military as a closed subculture with its own set of norms and rules. Veterans described how both those outside and inside—even professionals working within the military—have to gain the trust of service members before they can be seen as credible sources of support. Outsiders wishing to speak with veterans about their experiences are often met with resistance. If professionals or researchers are approved or vouched-for by fellow veterans, the resistance is more likely to disappear and the approval to talk or work with the professional is granted. Without this endorsement, the professional or researcher would have little success in accessing military veterans and research information would end up being second hand or speculative. This is what one veteran refers to when he states that his army friends brought him “into the circle.” I was able to gain the privilege of speaking directly with military veterans by working and having worked with paraprofessional veterans that vetted me after a series of conversations about the goals of this research. They concluded that I was working to benefit participants in this study. I appreciate the confidence and trust that was given to me by the interviewees and consider it a privilege to have interviewed each participant. Four veterans were recruited through professional contacts with trusted helping professionals working with veterans. One additional veteran included in this study was recruited through an online poster campaign circulated via an internet-based newsletter on a counselling website and on a university campus (Appendix D). This brought the number of participants in the study to eleven. An effort was initially made to include participants between the ages of twenty  60  and forty five years. However, one participant who was referred by a psychologist familiar with the inclusion criteria (Appendix B), was sixty-years old. Because this individual met the other inclusion criteria and was very keen to participate in the study, I elected to proceed with a data collection interview. In conducting the interview and analyzing the data, this participant's experiences of loss appeared to resonate with the experiences of the other, younger participants in the study. After a discussion with my supervisor and a member of my committee, it was agreed that this participant's story should be included in the analysis, with any significant differences in his experiences being noted in the findings. Data collection Participants’ verbal accounts of their lived experiences constituted the primary sources of data for this research (Osborne, 1994). The interview is considered the primary method for gathering data within a qualitative study (Kvale, 2009; Osborne, 1994; van Manen, 1997). The goal of this research was to elicit rich descriptions of the phenomenon of coming to terms with violent loss, as experienced by and understood by the veteran participants. According to van Manen (1997), the interview is used as a means for gathering experiential narrative material that serves as a source for “developing a richer and deeper understanding of a human phenomenon” (p. 66) and as a medium for developing a conversational relation with the co-researcher (interviewee) about the meaning of an experience. Personal interviews were felt to be the best and most respectful way to speak to the veteran participants about their experiences. The interviews were minimally structured, in-depth, and audio taped. The aim of these minimally structured interviews was to invite participants to share their experiences in their own words, highlighting details they felt to be the most important. Interview questions were open-ended and the process was facilitated by active listening, reflections, and probes. Participants were 61  encouraged to participate in the interviews at their own pace and articulate their experiences in a way that they felt comfortable. Effort was made to build an atmosphere of respect and trust, and to build rapport with participants. As participants spoke, information that required elaboration or clarification was noted and revisited only after the participant had expressed his thoughts. The goal of the open-ended approach toward the interview was to minimize interviewer interference and to focus on the flow of participants’ thoughts and feelings. Interview process Interviews took place within one month of initial telephone and email contact with potential participants. The eleven participants engaged in one in-person audio-taped interview and a follow-up interview to review and validate each participant’s biographical synopsis and the analysis of common themes uncovered. The duration of each primary interview was between one and a half to three hours. Interviews were scheduled at locations that were decided upon according to the needs of each participant. Three participants preferred to be interviewed in their homes, three participants were interviewed in interview rooms at a counselling agency, and two participants were interviewed in an outdoor park area during the summer months. One participant chose to be interviewed at his work place. One participant was interviewed in a hotel room and another participant was interviewed at a coffee shop. The nature of the study, parameters, and information regarding the study were reviewed at the beginning of the interview with each participant. Confidentiality as well as the possible risks and benefits of participating in the study were reviewed with participants (Appendix C). Participants were reassured about their right to withdraw from the study at any time. Participants were given the opportunity to ask any questions about the study that may have come up since the initial telephone contact. Participants were asked to read and sign copies of the ethical consent 62  form (see Appendix C). One copy was kept by the researcher and one copy was given to participants for their records. The focus for each interview was facilitated by several main questions, probes, and follow-up questions (see Appendix A). Broad initial questions were designed to expand on the research question and elicit each participant’s experience. The aim of probes, active listening, and reflection by the researcher was to let participant know that I was following their experience and invited depth. Participants’ spontaneous verbalizations were followed and follow up questions were used to draw out detailed descriptions of their experiences. Validation interviews were conducted after participants’ accounts had been subjected to thematic analysis and their bio-synopses had been written. It was important that the common themes revealed the essential structures of the lived experience (van Manen, 1997) and matched with participants’ experiences. Participants were asked to review their biographical synopsis and ensure their accounts of the loss of their comrades had been accurately portrayed. The validation interview offered each participant an opportunity to review and verify the common themes that had been drawn from their accounts of coming to terms with the violent loss of their comrade. I spoke with participants via telephone and invited them to examine the common themes and determine whether the themes resonated with or were discrepant from their lived experiences. During these final interviews ranging from ten to fifty minutes, participants were invited to share comments, corrections, or suggestions regarding their bio-synopses or the identified common themes. Participants were asked to verify the accuracy of their profiles and speak honestly about the match between their experiences and the common themes. Conversations with participants were recorded and participants were reassured that suggested changes would be taken into consideration in the final presentation of this research project. 63  Participants confirmed the accuracy of the information in their profiles and the common themes. One participant corrected some family information for accuracy and another clarified that the death of his friend happened on his first tour rather than his second tour. Another participant explained his rationale for serving in Afghanistan in more detail and another participant changed the military terminology in his biography for accuracy. These changes were incorporated into the final presentation of the participants’ profiles. Regarding their biographical synopses and the common themes, participants provided many positive comments. For example, participants stated: “I think it’s great,” “I’m really impressed. I appreciate you doing this project and have really enjoyed reading it,” “It represents what I said and meant to convey” and “it is well done and does reflect my experiences.” Another participant stated: Spent three hours going over the story it is great, had to cry thinking about my [two friends]. It brought back a small flood of memories which today I can deal with. Another veteran reported: I read just through my bio … and instantly became overwhelmed with emotion. I am not sure why … I was also quite anxious. I had just skimmed it and by the time I went upstairs (was at my girlfriend's place) I was in a weird head space. She picked up on it and we ended up having a long talk, was a rough night ... but all good man, all good. Thank you for what you are doing. Several veterans added more information to the themes. One participant added to his descriptions of new insights that he had gained through treatment regarding his loss. He also described his experience of anger in more detail. Overall, veterans’ described the common themes as capturing their journeys and most participants had few changes to suggest.  64  Data analysis The essential themes concerning participants’ lived experiences of coming to terms with the violent deaths of their comrades were discovered through thematic analysis. As described by van Manen (1997), themes “give shape” (p. 88) to the often amorphous and unexamined nature of the lived experience and facilitate reflection and grasping of meanings. van Manen describes themes as stars or points of light that enable us to “navigate and explore” (p. 90) areas of meaning, and as “knots in the webs of our experiences, around which certain lived experiences are spun and thus experienced as a meaningful whole” (van Manen, 1997, p. 90). Validation interviews support the soundness and trustworthiness of the common themes of participants’ accounts. Thematic analysis Phenomenology involves obtaining data (e.g. interviews, life stories, observations) from the participants in the study and analyzing these data for themes. Through thematic analysis, the researcher attempts to create order and elicit meaning from what has been disclosed and to discover the themes that are essential to the experience (van Manen, 1997). According to van Manen (1990), in reflecting on essential themes, meaning is viewed as multi-dimensional and multi-layered, and cannot be grasped in a single reading. Hermeneutic phenomenological reflection occurs during data management, data analysis, and data interpretation. Reflection also happens while transcribing the collected interview data. Researchers attempt to “grasp the essential meaning of something” (p. 77) after transcription through thematic analysis. Researchers examine whether there are emerging themes in the transcripts.  65  Identified themes can become “objects of reflection in follow-up conversations (van Manen, 1990, p. 99), in which the researchers and the participants collaborate. In this process, researchers and informants may “weigh the appropriateness of each theme” (van Manen, p. 99) by asking whether the theme captured “what the experience is really like” (van Manen, p. 99). Because hermeneutic interpretation is a continuous process, researchers and participants may use examination, articulation, re-interpretation, omission, addition or reformulation themes. The hermeneutic phenomenological process continues until participants identify that their lived experiences have been adequately interpreted. Determining essential themes As recommended by van Manen (1997), a selective or highlighting approach was used to determine essential themes. This involved listening to and reading through the interview text several times and asking, “What statement(s) or phrases(s) seem particularly essential or revealing about the phenomenon or experience being described?” (p. 93). Statements were circled, underlined, or highlighted and statements that were particularly revealing about the experience of coming to terms with the death of a comrade were included in the study. Coding was repeated until further readings of each transcript failed to yield new themes. Interviews were analyzed as they occurred and themes were used as a guide for subsequent interviews. As new themes occurred, prior interviews were re-checked for instances of the theme until no new information was revealed. Themes were verified with participants through validation interviews to ensure that the themes capture the meaning that the participant sought to convey. van Manen (1997) noted that the participant and the researcher weigh the appropriateness of each theme by asking “Is this what the experience is really like? (p. 99).  66  Phenomenological writing The process of hermeneutic phenomenological study involves a dialectical process in which the researcher responds to and interacts with text (van Manen, 1997). The goal of this type of research is to put into words experiences that have been pre-reflective or unexpressed. The researcher begins the dialectical process through the process of thematic analysis with the transcribed texts which gives shape to the experiences of the phenomena. As suggested by van Manen, this process continued through writing, re-writing, analysis, and deepening reflection. The text changes and evolves until the finished product is achieved (van Manen, 1997). Field notes were also used to contextualize and clarify themes from interview data during the process of writing and rewriting. In the current study, field notes were recorded after each interview and were re-examined along with the transcripts and audio recorded interviews during the process of analysis. Field notes are “the written account of what a researcher, sees, hears, experiences, and thinks in the course of collecting and reflecting on the data in the qualitative study” (Bogdan & Knopp-Biklen, 2003, pp. 110-111). The field notes offer a way to describe each veteran participant and reconstruct our dialogue and interactions during the session, reflect on the significance of what transpired in the interview, and speculate on connections, emerging themes, methodological difficulties, or reflect on my own subjectivity (Bogdan & Knopp-Biklen, 2003). Both field notes and journal entries allowed me to identify my own subjectivity systematically throughout the course of this research (Peshkin, 1988). Field notes were recorded immediately after interviews and were concerned with the course of the interview whereas journal entries were more focused on my personal process. Laverty (2003) observes that the researcher is called upon on an ongoing basis to reflect on his or her own experiences, and to 67  outline their positionality or “the ways in which their position or experience relates to the issues being researched” (p. 17). My position was clarified and outlined through conversations with my supervisor, committee members, and member checks with the participants. Data storage and confidentiality This study adhered to The University of British Columbia’s guidelines for research with human participants. Confidentiality was strictly maintained. All study documents were kept in a secure locked location and computer files were password protected and encrypted. All paper documents were stored in a locked cabinet. The names of the participants were kept separate from audiotapes and from transcripts of the interviews. Pseudonyms, of the participants’ choice, were used in the biographical synopses. The files for participants were marked with numeric and letter coded symbols rather than names. Following the study, the computer files and paper files associated with this study will be deleted and shredded, and audiotapes will be erased. Trustworthiness According to Marshall and Rossman (1995), “All research must respond to canons that stand as criteria against which the trustworthiness of the project can be evaluated” (p. 142). This study was guided by evaluative criteria proposed by van Manen (1990) that are indicators of rigor for phenomenological studies, in addition to Lincoln and Guba’s (1985) criteria for trustworthiness. van Manen’s (1990) criteria for evaluation of hermeneutic phenomenological research are oriented text, strong text, rich and thick text, and depth. Lincoln and Guba’s (1985) concepts of trustworthiness are credibility, transferability, dependability and confirmability. Lincoln and Guba (1985) suggest that credibility be the criterion against which the truth value of qualitative research be evaluated. With confirmability, the researchers’ interpretation of the participants must be believable. van Manen’s (1990) approach to hermeneutic 68  phenomenology employs Lincoln and Guba’s (1985) recommendations of prolonged engagement, peer debriefing, member checking and triangulation of data. Prolonged engagement with participants is established through creating collaborative relationships with participants through which personal meanings can be accurately clarified. Persistent observation refers to the cyclical process in which the researcher analyzes and re-analyzes the data, teasing out salient information. Triangulation involves verifying research findings through various sources, methods, or investigators. This is accomplished in hermeneutic phenomenological research through field notes noting observations of participants, in-depth and multiple interviews with participants, and the use of a reflexive journal to interpret meaning. Member checking is suggested by Lincoln and Guba (1985) to enhance the credibility of findings and interpretations of data. This involves the dialogue between researchers and participants which gives participants the opportunity to expand their meanings, agree or disagree with the researchers’ perceptions, and add information to the interpretation of the findings which more accurately represents their experiences. For the present study, this was accomplished through the aforementioned validation interviews. Lincoln and Guba (1985) recommend including detailed descriptions of the following: (1) The decision trail that guides research procedures (audit trail), (2) characteristics of the participants and criteria for sample selections, and (3) the selected strategies used to collect, code, and analyze data. This ensures both transferability and confirmability. van Manen’s (1990) aforementioned criteria for evaluation of hermeneutic phenomenological research involve being oriented to text, strong text, rich and thick text, and depth. Orienting to a phenomenon involves approaching the experience with a certain interest. A 69  well oriented text can convey the significance of the study (Cohen & Knafl, 1993). The researcher also has a commitment to strong, rich, and thick text. Geertz (1973) states that that interpretation needs to be based on “thick description”. To clarify this point, he states that when a person winks he or she is “rapidly contracting his/her eyelid” (p. 7) or practicing a burlesque of a friend faking a wink to deceive an innocent into thinking conspiracy is in motion?” (p. 7). This event could have multiple meanings depending on the context, and as the context changes the meaning of the wink changes. Thin description would be a description of the wink itself. Thick description, on the other hand, is text that shows concrete, particular, irreplaceable description and may include anecdotal, story, narrative, or phenomenological descriptions. It engages, involves, and requires a response from those who read the text. The evaluative criterion of richness and thickness can also relate to confirmability. van Manen (1990) referred to text with depth as giving meaning to experiences and explores the meaning structure beyond that which is immediately experienced (van Manen, 1990). The text is a progression through the experienced phenomenon that is compelling and profound van Manen (1990). Strengths and challenges of the hermeneutic phenomenological approach The hermeneutic phenomenological approach is suitable for exploring minimally researched topics, topics that have been explored with positivist, or explanatory methods of inquiry, and topics that have been marginalized or objectified in research. This approach is particularly suitable for the study of violent loss for veterans because this topic has been minimally explored within research literature. It is an approach that began at the start of the twentieth century, has a strong tradition, and has evolved over time.  70  In terms of challenges, the hermeneutic phenomenological approach demands the researcher be able to reflect on their background and assumptions. Written expression and selfreflection is critical to data analysis and interpretation, and requires prolonged engagement and descriptive writing that engages readers through clarification of the meanings drawn from expressed lived experiences (Gadamer, 1998; van Manen, 1990). This approach also uses language and philosophy that is in some cases centuries old (e.g. Ancient Greek expressions). Another challenge to this approach could be over-reliance on field notes and reflexive journals to demonstrate trustworthiness. Moreover, the approach requires a working knowledge of the foundational phenomenological philosophies and takes time to discover deeper meanings. It is not a linear, quick process. An additional criticism levelled by Martin and Sugarman (2001) in a critique of Gadamer’s hermeneutics, is that the approach does not take the issue of power into account when examining the lived experience. In summary, despite the critiques of the hermeneutic phenomenological approach to qualitative research, I found it to be the best suited to the needs of the current study. It was thought to be the approach best suited to understanding the nature of a violent death of a comrade for veterans, and to answer the research question: What is the meaning and experience of coming to terms with the traumatic loss of a close comrade for veterans?  71  Chapter 4: Results An in-depth discussion of the common themes drawn from participants’ accounts of their experiences with the sudden and violent loss of their friends will follow the biographical synopses of the eleven veterans participating in this study. Participant profiles The following bio-synopses are included to highlight important contextual factors and salient aspects of participants’ experiences with the loss of a close comrade. Ken Ken is a forty-one year old United States (U.S.) Marine Corps veteran who lives in the Lower Mainland of B.C. He wore a sleeveless shirt revealing Marine Corps-related tattoos on his shoulders and forearms. The tattoo visible across his back read ‘Semper Fidelis’ (“Always Faithful”). He was born in Canada and grew up in the Lower Mainland of B.C. with his mother, father, a younger brother, and an adopted sister. His maternal family is firmly rooted in the U.S. and his father became a U.S. citizen after marrying his mother. His parents decided to move to Canada before Ken was born. Ken’s mother was killed in a car accident by an impaired driver when Ken was only seven years old: My mom died when I was seven ... my dad and [mom and] ... a close couple of theirs went on Christmas day ... [to] a staff party. And on the way home they had a, got smoked head on by a drunk. Two men in the front seat lived two women in the backseat died. My brother, my sister, and I ... we woke up with a babysitter. His father eventually re-married and Ken has a step-mother and step-sibling. The death of Ken’s maternal grandfather in 2009, a World War II (WWII) U.S. Marine veteran, was significant to him. 72  Ken enlisted in the U.S. Marine Corps in 1988 at age eighteen years old, serving active duty until 1993, and as a Marine reserve until 1996. He deployed to the Middle East in August 1990 with UN-authorized coalition forces for Operation Desert Shield and Desert Storm of the first Gulf War. In a meeting before the operation, Ken’s entire battalion was told to expect an eighty-six percent casualty rate. Ken spent ten months on this campaign and returned home in April 1991. He had earned the rank of Lance Corporal. Ken formed a close relationship with Dave, a comrade and friend who was killed in a friendly fire incident during the first Gulf war. Of his friend, he said: Dave was one of the first guys when I reported to my new unit that kind of took me under his wing. He'd been there a couple of months already. And um, I ended up hanging around, chumming around with the guy quite a bit and we became very close friends ... We had that initial bond. Ken described the qualities such as genuineness and loyalty that he appreciated about Dave: He and I kind of hit it off ... We just kind of hung out together, same core group of guys. You could talk to any of that group and they'll all tell you, you know, Dave is a straight shooter, he's a great guy. You know he's always got your back, and, bit of a mouthpiece ... but you could always count on him to be there when you got in trouble. Ken described being introduced to Dave’s mother after a night of drinking with his fellow Marines. He had passed out and awoken “pretty much tattooed” with a permanent marker by his fellow comrades: Dave called his mom, ‘So, my buddy Ken, you know Ken, how does he get felt pen off him?’ And she goes, ‘What have you guys done?’ Of course, we told her. So she gave us  73  this remedy to get permanent marker off my skin ... So, that's how my introduction to his family happened. Ken and Dave were assigned to the same mission and same vehicle during Operation Desert Storm. They had similar seniority and were vehicle commanders. In the days before Dave’s death, Ken had been ordered to help fill out the crew for a new vehicle that had just come off of a supply ship. Instead of going however, Dave asked Ken to go in his place so that he could reacquaint himself with an old friend who would be part of that crew. Ken has replayed the conversation that he had with Dave in the days before Dave’s death many times: I said, ‘You sure?’ He said, ‘Yeah, I’m sure.’ I said, ‘You positive?’ He said, ‘Yeah.’ I said, ‘I’ll go. I mean, I’m supposed to.’ He said, ‘Well let me talk to the Staff Sergeant ... [who] said, ‘Whatever works, works, I don’t care. I need a body, I need a qualified body’ ... I said, ‘Dave, are you sure?’ He said, ‘Yeah, no everything’s cool.’ Dave was killed on January 29, 1991 in a fratricide, or “friendly fire” incident, during the Iraqi offensive push into Kuwait at Uhm Hujal and Khafji. Confusion and an investigation into the circumstances of the incident ensued. Ken was devastated by the death of his best friend. He felt a sense of responsibility for the loss and thought that he should have been the one who was killed. In the wake of Dave’s death, he wanted to kill the Marine who had “pulled the trigger.” Subsequently, Ken struggled with post-traumatic stress symptoms that had an impact on his relationship with his now ex-wife and his daily functioning in the years following the loss. As he lived with the loss of his friend and PTSD symptoms, Ken admitted to regularly sleeping with a handgun under his pillow and feeling vulnerable without a weapon. He would swing at his ex-wife upon waking up after nightmares. She employed creative methods to wake 74  him up—such as poking his toes with a stick. He would often mix a combination of prescription drugs and alcohol to produce “dreamless coma-like sleeps.” His ex-wife noticed him pulling away, playing online video games and drinking and arranged for initial counselling. Ken was able to let go of a significant amount of survival guilt when, upon the encouragement of a therapist, he called Dave’s mother and spoke to her about the incident. Ken is currently divorced with two adolescent daughters. He has held a variety of jobs since his active service. He worked in construction, for a courier company, and for a Lower Mainland Fire Department. Ken has struggled with PTSD, substance abuse, guilt, self-blame, depression and anxiety since his friend’s death. He has struggled in interpersonal relationships with individuals that display poor leadership qualities, and this has affected his functioning at work. He described having a reputation in the fire department as being a “cynic”, as being outspoken and “very intimidating.” Patrick Patrick is a thirty-eight year old veteran who lives in Vancouver, B.C. and was raised in Saskatchewan. His parents separated when he was seventeen. His father remarried and his mother entered a common-law relationship when Patrick was twenty-two. He has two younger sisters as well as a step-sister. He described feeling close to his uncle who was murdered while Patrick was on his overseas deployment. About his uncle, Patrick shared: My step-dad’s brother ... was the black sheep of the family and there were times where I was really impatient with him ... but thankfully, the last time I saw him ... we connected ... He used to serve in the Navy ... [We] had something in common that no one else in our family did.  75  Patrick decided in his early thirties that serving his country “was something [he] really needed to do.” Always interested in the military, he felt that he was “on a warrior path”, and realized, “it was then or never.” Patrick expressed feeling “anger towards the injustices that had occurred” and was moved to serve in Afghanistan due to violence toward innocent people and due to the terrorist attacks in the United States on September 11, 2001. He started as a military reservist and later became attached to a regular force unit. Patrick described this experience as “harsh” due to some initial discrimination from regular force members toward reservists. He served as a Corporal with the infantry ground forces in Afghanistan in 2009-2010, patrolling through hostile villages, IED grounds, and opium fields. During Patrick’s deployment in 2009 he experienced the loss of his friend, Jack, whom he described as a like-minded, philosophical, and soft spoken person. Patrick shared: I always had a good feeling about him, and ... felt connected with him through our training ... He was very soft spoken, articulate guy ... He was very thoughtful, and you could tell when you talked to him that he was thinking about everything that you were saying ... He was really an awesome listener that people just automatically liked because he had these really kind eyes. Patrick was on his three week vacation leave during his eight month overseas deployment when he found out that Jack had been killed. [On] my leave ... the war just seemed so far away ... I found this little internet cafe and I had set up an iGoogle page ... Right away, I see, it says, ‘Canadian Soldiers Killed,’ and it kind of snapped me back to the moment. I'm like, ‘Oh shit,’ and I clicked on it, and when I opened up the link, there was my friend's face that I'd just seen ... It was like disbelief, especially because like I said, I’d just seen him. 76  At the time of our interview, Patrick worked as a loss-prevention manager at a large store and had just written a fantasy novel that incorporated elements of his overseas experiences in Afghanistan. He lived with his girlfriend and was contemplating moving to Vancouver Island to pursue his dream of writing full time. He had experienced a variety of post-traumatic symptoms related to his service and was also diagnosed with testicular cancer. His cancer was surgically removed but he experienced a recurrence, and it was suspected that the cancer had spread. He continues to deal with a host of serious side effects from the treatment of his cancer. Patrick processed the loss of his friend and his other experiences by reflecting on them and writing about them. He viewed his experiences surrounding the loss of his friend, his uncle, and his cancer as “lessons about mortality.” In addition to writing, Patrick found spiritual contemplation and mindfulness practices helped him to make sense of his cancer and his comrade’s and uncle’s death. Tommy Tommy is a soft spoken, heavily tattooed twenty-five year old veteran who grew up in New Brunswick and now lives in a mid-sized Western Canadian city. His parents are divorced and he has two sisters. Tommy and his sisters were divided by the conflict between his parents growing up. He described experiencing physical and emotional abuse from both sides of his family “until [he] hit puberty ... and could defend [himself].” He connects his experience of PTSD with childhood trauma. Tommy presented as somewhat guarded about his family history and considered himself as an interpersonally cagey person (“That was my way ... I just didn’t get close to people”). Describing his reticence further, he stated: ... Like even my buddies that died, I was close to them but I wasn’t as close as probably other people were because ... I didn’t allow that closeness. 77  Tommy enlisted in the Canadian Army after high school at eighteen- years old. He was posted to a Canadian Forces Base in 2006 and was part of a Combat Engineer Regiment deployed to Afghanistan in 2008. Tommy became a Corporal after returning from his overseas service. He described his job in Afghanistan: Our main job was to find IEDs ... If there was anything suspicious, it was our job to search it. If something ... blew up, it was our job to go and clear up to them to get them out of the vehicle so they could get medical attention, and then to make sure it was safe around the vehicle because they always plant two. Tommy described the bonds that he formed with his comrades during his tour: You become a family ... You become really close ... You can spend two, three months straight in the field at a time and you're always together. Before the deaths of his friends, Tommy described feeling invincible and disconnected due to the surreal nature of his combat experience. His section was the first to respond to a situation where a Canadian vehicle was on fire after detonating an Improvised Explosive Device (IED). He and the other soldiers were unable to get into the vehicle due to ammunition “cooking off” inside the vehicle. He was forced to watch helplessly while the vehicle burned. Tommy described experiencing a “wave of emotion” when he realized that his comrades, including a close friend, were inside the vehicle. Tommy was told by army medical staff that his sleep would improve when he returned to Canada, “but it never did.” As “the romance of being back in Canada disappeared,” he started to use alcohol more frequently. He used alcohol every day and on weekends and noticed he was starting to get more violent, stating, “The part of me that I was pushing down when I was sober came out.” Initially he did not make a connection between his behaviour, his losses, and the 78  things that he had seen within the context of war. When he found that “drinking wasn’t enough,” he used cocaine to return to the “intensity” of his overseas tour. Tommy asked for help and a counsellor referred him to a drug and alcohol program. Through this program he was referred to a veterans’ trauma repair group which he credits as saving his life. The veterans’ trauma repair group was focused on helping veterans actively process trauma and grief related to overseas service. The key element of this group for Tommy was seeing the vulnerability of another veteran group member which somehow permitted Tommy to let go of the grief related to his friends’ deaths. Tommy started to feel connected to others again: “I’m getting there. It’s definitely night and day from before ... [the veterans’ trauma repair group].” He still feels anger toward some of his superiors and would like to distance himself from the army so that it is not part of his identity anymore. At the time of this interview, Tommy had been diagnosed with PTSD and had a permanent medical disability designation. He stated that he did not work with the army anymore, “because [he] wouldn’t be half sane if [he] worked there,” and was glad to be “away from that whole atmosphere.” Despite his views of the army, he found himself bored with the volunteering that he was doing with an animal rescue society and yearned for “high intensity” activities to engage his “body and mind in the present.” Tommy was working toward a medical release from the Army. Brendan Brendan is a thirty-one year old veteran with a bushy beard and a tattoo on his wrist reading, “Lest We Forget.” He was born and raised in Manitoba but now lives in the Lower Mainland of B.C. His parents and older sister still live in Manitoba. Brendan’s sister was hospitalized and diagnosed with a chronic illness when he was a child. Partially due to the 79  family stress his sister’s illness created, Brendan stated that he would often tell his family that things were going well for him, masking any feelings of distress he may have truly been feeling. Brendan became interested in joining the army while working at a bar near an army base and hearing “all the cool [army] stories.” He stated that his army friends brought him “into the circle” and watched out for him while he worked in the bar: They always had their eye on me, which was good ... Civilian friends, you know, they can be great friends right, but ... you don’t know how they’re gonna react in a certain situation whereas military guys, you know, they may not like it but they’ll be there. Brendan enlisted in the Canadian Army at age twenty, the year before the World Trade Centre terrorist attacks of September 11, 2001. He took part in one of the first tours to Afghanistan in 2003 and then went on another tour to Afghanistan in 2005. Although he had been out of the Canadian Forces for a few years at the time of our interview, Brendan maintained his connections to other veterans through a veterans’ motorcycle group and as a paraprofessional in a veteran’s trauma repair group. During his first tour in Afghanistan, Brendan and his driving partner were part of a convoy that drove to a weekly meeting to meet with Afghan village elders. One day he and his partner forgot to attend the weekly meeting. On that particular day the comrade that Brendan believes drove in his place in the convoy was killed. Brendan described experiencing shock after hearing the news that his comrade had been killed. As he lived with the loss, he felt responsible, guilty, and that it was him that should have been killed instead of his comrade. Approximately four years after his second overseas deployment, Brendan was “peppered” by vivid dreams about surviving in a situation where all of his friends had been killed. He was afraid to fall asleep, finding that if he exhausted himself by 80  drinking and staying up late, his nightmares disappeared. A close friend encouraged him to get help. Brendan was “recruited” to attend a veterans’ trauma repair group by another, older, veteran from his veterans’ motorbike group. Through participation in the veteran’s trauma repair group, Brendan let go of some of the guilt related to his friend’s death and retold the story of the loss to other veterans. His disturbing nightmares subsequently became less frequent. Although he had been reluctant to speak to others about his difficulties, he was more open to expressing emotions and exploring the suffering that he experienced in relation to his service following the group. He stated that the veterans’ trauma repair group was “the first time [he] talked about anything.” Tristan Tristan is a twenty-six year old veteran with the initials of two fallen comrades tattooed on his arms. He was born and raised in New Brunswick and now lives in a mid-sized city in Western Canada. A few days before our interview, he had learned about the death of his nineteen-year old cousin. He planned to attend her funeral the following week. Tristan has two younger sisters. When he was thirteen years old his parents separated. His sisters and he stayed with his mother and visited his father every second weekend. He attributed his early teen drug and alcohol misuse to the difficulties he had with his father and step-mother. At the time of our interview, Tristan’s mother had finished a cycle of treatment for breast cancer. He spoke to his mother every day and found that he could share his experience of military-related trauma and loss with her. Tristan enlisted in the Army in 2006 at the age of twenty. He described joining because he needed a job and he felt some pressure from his father to find work. Tristan arrived at a Combat Engineer Regiment in 2007 and deployed to Afghanistan in 2008 after a year of work up 81  training. During military work up training and the leave portion of his overseas tour, Tristan built friendships with the comrades who subsequently died: We hung out there and stuff and we got back from our leave. We talked and stuff and spent a lot of time together there ... Playing road hockey and stuff ... Had a lot in common ... Like I knew [my friend] before, like, we partied together and stuff. Go over to his shack at noon hour and watch TV or something. We both were into hip hop. Tristan felt emotionally detached and withdrawn after several stressful incidents early in his Afghanistan tour. During his first operation, he described “IEDs going off left and right” and four vehicles in his convoy blowing up. He and ten comrades were “jammed” into a small vehicle for eight hours. A superior officer told them that they were going to be ambushed and were unlikely to live through the night. After these early incidents, Tristan emotionally “checked out” and was on “autopilot” for the rest of his overseas tour. He stated that by the time his close comrades were killed near the end of his tour, he was feeling numb and “walking around with no emotions.” At the scene where his friends’ vehicle was destroyed, Tristan picked up his comrades’ personal belongings and saw his friend’s blood on the vehicle. He had difficulty comprehending what had happened and wanted to leave, yet had to stay for two more hours to clean up the site where his friends were killed. Tristan used alcohol and drugs while struggling to cope with the deaths of his friends and trauma related to his military service after returning to Canada. Help started for him when he met a counsellor whom Tristan felt was genuine, caring, and had life experience. Tristan experienced help from this counsellor as well as a veterans’ trauma repair group and a variety of other activities such as meditation, spirituality, and playing the piano. Although he continued to struggle, Tristan improved with help: 82  I started to learn and understand why I was like that. Once you ... understand ... you can control it. It’s not easy to control. You know I have my bad days and my good days. When we met, Tristan was working toward getting a medical release from the Army. He was diagnosed with PTSD and had a medical designation related to this diagnosis. He was limited in terms of what he could do and expressed having no desire to continue with the Army: I’m a civilian. Like mentally, I’ve checked out of the army. I just have to wear a green uniform every day. At the time of our interview, Tristan was hoping to transfer to an East Coast military base to be closer to his family. Nick Nick is a twenty-nine year old Marine Corps veteran who lives in a mid-sized city in Eastern Canada. He was raised in Ontario. He is a dual citizen of Canada and the United States. His parents and his sister live in Eastern Canada. Nick stated that the “constant support from [his] family was huge” in helping him to adapt to the deaths of his four friends who were killed in military-related service. His family was very proud of his service. Despite this support, Nick distanced himself from his family for years after the deaths of his four close comrades. Nearing the end of high school, Nick looked to the U.S. Marine Corps for opportunities for leadership, travel, and to become “a better person.” He enlisted in the Marine Corps in the year 2000 at seventeen years of age and served active duty for four years. During this time, he participated in operations in Egypt and Iraq in 2003. He functioned well during the stress of combat and was awarded a combat meritorious promotion to Corporal. His unit was given a presidential unit citation and Nick received a combat action ribbon for his service. He served the remainder of his active contract back in the U.S.A. and briefly returned to active duty in the latter 83  part of his Marine Corps contract as part of another operation to Afghanistan in approximately 2006. Nick’s friendships with his comrades developed by being in such close proximity to them during his pre-deployment training and spending so much time with them during overseas operations. He described the bonds with his friends as being difficult for outsiders to understand: No one really thinks about the way we live over there I don’t think ... You know like brushing our teeth with each other out of a cup of water ... Being that close with someone under the circumstances for such a long period of time.. There were strong friendships that were built ... I don’t even think I’ll ever have friends like that ever again ... Like, just the bond that we forged, it’s unexplainable ... It really is. Nick experienced the death of his best friend and two close friends while participating in an operation in Iraq. In a separate and more recent operation in Afghanistan, his last friend of the group of four friends was killed. Nick described feeling numb after his best friend was killed beside him in battle. He was unable to communicate with his best friend as he died and, for that moment in time, stopped caring about his own life. He stopped communication with everyone in the days following the deaths of his close friends. After losing his four friends, Nick struggled with friendships. He found it difficult to find the kind of loyalty that he had with his Marine Corps friends. He took time to process his experiences of loss by moving away from what he knew in Eastern Canada and exploring places like Banff, Nelson, and Edmonton. He met new people, worked in managing restaurants and bars, and snowboarded. He stated that a relationship with a girlfriend who introduced him to meditation and spirituality was a pivotal point in his life. This relationship opened up a caring  84  part of Nick, as he had previously been “dead to the world” since returning from his active military service. Nick had powerful healing experiences within a veterans’ trauma repair group and felt connected with the other veterans, therapists, and helping professionals that were part of the group. He described being on a different path after actively grieving the deaths of his friends. He felt connected with others again and improved his communication with his family. Nick stated that he meditated for approximately forty-five minutes daily and found meditation to be helpful in letting go of the deaths of his friends. Well I think that since I started my healing process and I’ve dropped a lot of things, like I’m definitely more emotional and definitely more mindful ... I appreciate the air, like how good it smells, just things I never noticed before because I was so dead to the world ... I’m picking up on even more now. Nick enjoyed success as a bar and restaurant manager and promoter in a mid-sized city in Eastern Canada. He described feeling positive about his current opportunities and future possibilities. He had good rapport with the owners of the bar and restaurant franchise. He was interested in helping and making connections with others in the community through the business. Nick continues to honour his friends by wearing a bracelet made of heavy solid copper engraved with the names of each of his four friends who were killed. George George, a sixty year old man, is married with one adult son and two granddaughters, and lives near a mid-sized city in Atlantic Canada. He was born and raised in Atlantic Canada. His father is still living at eighty-eight years old and his mother is deceased. He described his father as a “real task master” who gave the impression of being infallible. George stated that his family 85  is his priority at this stage of his life and admits that they came second to his career when he was actively working with the military. George enlisted in the Canadian Navy in 1965 when he was sixteen-years old. He described himself as a “bad bastard” who “ran as hard” as he worked and was always keen to learn. He earned the rank of Chief Petty Officer First Class and retired in 2004 after a forty year career in the Canadian Navy. George learned leadership skills during his time in the Navy. He felt that it was important to accept responsibility and lead from “out front.” George aspired to meet his servicemen at their level stating, “Know your men, promote their welfare. Those are basic principles of leadership.” He felt responsible for bringing his comrades back alive. George’s relationships with his comrades and crew were characterized by strong, affective bonds. He described sharing humour and respect with his comrades who died: Bobby’s getting dressed in his diving gear ... and he was laughing. He says, ‘What a beautiful day this is Chief.’ I said, ‘What’s that Bobby?’ He said, ‘I don’t have to listen to your fucking lecture this afternoon.’ I said, ‘You smart ass little bastard. When you come back out the water, you get hold of me, I’ll give you a two hour dissertation just for you.’ And then all the other guys are laughing, right, so. That was the last I seen him alive. George’s two comrades, Bobby and Eddie, died while surface diving around the hull of an American Navy Destroyer to help secure the area from threats. George recounted: Next thing I know, there was panic. Our divers are trapped under the hull ... Their re-circ is on. And what the re-circ is, this thing’s about fourteen feet across and it sucks salt water into an intake, used for cooling ... I [used a] megaphone to tell these guys turn off the re-circ, ‘ ... My boys are trapped down there, turn off the re-circ!!!’ It took seventeen 86  minutes to crash-stop. Seventeen fucking minutes. Which is, I’ll tell you right now, it’s fucking three lifetimes. Should have been two, three, four minutes maybe, to crash stop. But the signals got all mixed up ... We tried CPR on the boys but there was nothing ... They were dead. Bobby and Eddie were dead. George also experienced the loss of a close friend, a Senior Chief in the Navy, shortly after the deaths of his comrades. Over the course of these events, which spanned several days, George was unable to sleep. George’s core values regarding leadership, formed through a strong work ethic and years of adversity, were challenged by the deaths of his comrades and impacted him significantly in the years following their deaths. He felt an enormous amount of responsibility for this incident. He was extremely angry at the superior officers on the American ship who deflected blame for the incident onto a low ranking serviceman. After the deaths of his comrades, George threw himself into work for years. After retiring he started to experience movies of the events playing in his mind as if he was there again. He reached a point where he drove to a remote location with a plan to kill himself with a shotgun. A close friend noticed he was not coping well and got him help; first with a social worker, then a psychiatrist, and a psychologist. Following “seven long years” of participating in treatment and working to make sense of the losses, George is now volunteering with cadets and the Navy League of Canada. He has rekindled his relationship with his son that suffered for many years. He has maintained his connections to others in his community and has been validated by the servicemen that he worked with even in his retirement. Despite the length of time it took to get to a healthy place, George clearly expressed that he is thankful for where he is now. 87  Matt Matt is a twenty-six year old Marine Corps veteran who lives in and was raised in the Lower Mainland of B.C. He is a dual Canadian-American citizen. Matt’s mother and father live in the Lower Mainland. He has an older sister and two older brothers. Before joining the military Matt experienced the loss of a close friend and neighbour in grade twelve following a car accident. Matt is close with his family and particularly with his sister who is close to him in age. Matt decided that he wanted to help to effect change in the world through military service. He studied military history throughout his life and his father had a career in the military. Matt enlisted in the Marine Corps in 2005 at age nineteen years old. He served active duty for four years. At the time of our interview he was in the last year of his eight year Marine contract after serving in two tours in Iraq. Matt described the experience of forming close friendships with his comrades due to being in such close proximity to them over a period of several months. In particular, he formed a close friendship with Luis, a Marine who was slightly older, had more combat experience, and who initially acted as a mentor: My really good friend [who] was killed, he was big into weightlifting—actually taught me—He was older than me. He was my mentor for awhile and he essentially taught me how to work out. I was a buck fifty when I went into the Marine Corps right. And he taught me everything about weightlifting ... It became more than that, after ... He had taught me everything and went from mentor to friends. Shortly after finding out Luis and another comrade were killed in an explosion, Matt and his unit had to cordon off the blast site where the deaths occurred. He experienced a sense of  88  disbelief and numbness while “picking up every last scrap of everything that was American out of the blast radius.” He recalled: When you’re finding, you know, pieces of him ... from a guy that was 270 pounds, that could bench press 500 pounds, it really hits you. You know he’s gone, he’s decimated, he was destroyed, right? ... It was an atrocious site, it was just utter destruction, right? ... And I remember at the end ... I remember just looking at it ... Like that’s what’s left of my mentor and my friend. Matt described the experience of losing his friend through violent means as being qualitatively different than other losses he had experienced in his life: It was so much more personal and ah, and destructive then I’ve ever seen before ... [The death] was out of the scope in what we had been conditioned in ... I realized that after my friend was killed, right, by another human being ... those two things never connected. Like the idea of civilian death, and combat death, right? Matt had difficulty adjusting to being back in Canada as he experienced trauma symptoms related to the loss of his friend and other experiences during his tours. He isolated himself from others, experienced hyper-vigilance that he believes will never go away, and experienced intrusive thoughts. He thinks about his comrade and the horrific incident that claimed his life every day. Like many of the other veterans, Matt was helped by reading the books “On Killing” and “On Combat” (Grossman, 1996; Grossman & Christensen, 2008): It’s really good because it’s a mix of dealing with it, dealing with trauma, preparing for trauma. Preparing to, like, be able to perform within the scope of trauma and aggressive environments, and then being able to ... decompress and get that sense of civilian back.  89  Matt saw his family’s reactions to his behaviour as well as the reactions of his wife and took them into account as he adjusted back to civilian life. He was able to heal by working through difficulties around communication with his wife, educating himself with regard to his trauma symptoms, and informing himself by reading biographies of veterans who had successfully integrated back into society. His decision to shift out of a construction job into his own business and to take courses at university helped him turn his life around. He experienced a renewed sense of purpose and meaning, and felt in control of his destiny. By focusing on his dream of having a career in international relations and developing his business he felt he was honouring his Marine Corps friends who thought highly of him. Karl Karl is a forty-three year old Canadian Army veteran who lives in the Lower Mainland of B.C. He is one of five siblings. He has two younger brothers, an older brother, and sister. His older brother died in a car accident when Karl returned from military service in Somalia. Karl’s father died of cancer when Karl was fourteen years old. He started using alcohol and drugs shortly thereafter. At the end of our interview he shared that he was about to have his first sober Christmas in approximately twenty-five years. Karl described “going nowhere,” feeling directionless, and starting to get a “taste” of drugs before enlisting in the Canadian Army at approximately age twenty-one years old. He joined the Royal Canadian Regiment and was posted to Gagetown for approximately one year. He deployed with the Canadian Airborne Regiment to Somalia in 1992 as part of a humanitarian effort with the United Nations. He subsequently deployed to Rwanda as a Canadian Peacekeeper in 1994. Karl continued to work for the Canadian Military in a variety of roles until 2008.  90  Karl lost two friends during his overseas tours—Frank and “Jonesy.” During his tour in Somalia in 1992 his friend Frank was accidentally shot by a comrade: His best friend shot him ... They were playing games I guess they were goofing around ... All we heard was a bang and a pop, and then we heard screaming and started to run next door. And there was ... [a comrade] standing above him with his gun which obviously he had a round in there. Like how do you? Take off your mag, right? Clear a weapon, right? I guess none of that was done or something. It was a mistake. Compounding this first experience of loss, on another tour in Rwanda, his friend “Jonesy” committed suicide on Christmas. When offered the chance to talk to a psychologist about his friend’s death, Karl recalled just trying to “tough it out.” These two events, along with the dead bodies and stress of his tours—Rwanda in particular—come up in the “slides” that Karl reexperienced over time. Karl has been married for eight years and lives with his wife in the B.C. Lower Mainland. He has two step-daughters and grandchildren. He now receives disability benefits through Veterans Affairs. In addition to the deaths of two comrades, Karl witnessed a variety of horrific experiences such as the aftermath of human genocide. He described persistently re-experiencing the aforementioned “slides,” experiencing “night terrors,” and being sensitive to certain smells and textures related to his overseas service. Karl admitted to using alcohol to cope with the stressors that he faced in relation to his service. He described it as an accepted panacea within military culture and a “pill that [he] could take.” Two weeks before our interview, Karl plead guilty to impaired driving charges and lost his driver’s licence. He stated that if he did not keep himself busy, he would be drunk. He reported, “If my wife ever left me ... because of drinking, I’d be screwed. I’d be dead. I guarantee that.” 91  Karl found weekly visits and monitoring by a clinical care manager from Veteran’s Affairs to be helpful. He also met with an individual from a veteran’s group and is planning to start a trauma treatment program in the near future. He described the importance of having structure in his week and his network of friends and family who were concerned about his welfare. He stated that he had been sober for several months since attending a west coast based substance abuse treatment program. William William is a thirty-three year old Canadian Army veteran who lived in the Lower Mainland in B.C. He was raised on a farm in Saskatchewan and then his family moved to a rural area in the Lower Mainland in his early teens. His parents are divorced and each has remarried. He has one sister, one half-brother, and one step-brother. Although William’s interest in the army may have started with playing with G.I. Joe action figures as a child, his desire to be a part of the army extends “as far back as [he] can remember,” and may be “hard-wired” within him. As he became increasingly disenchanted by high school, William’s thoughts returned to the Canadian Forces recruitment poster that he had taken off the wall of his school and put in his pocket. At age sixteen, having reached a point where he felt he needed a change, he drove into a Canadian Forces recruitment centre in Vancouver with his father and passed all of the requisite tests. He joined the Canadian Army in 1996 and was able to successfully navigate between the reserve and regular forces throughout his tenure. Aside from the years of 2006 to 2008 where he decided to pursue work as a paramedic, he worked for the Canadian Army. William worked as a radio operator and instructor. He deployed to Bosnia in 2003 and to Afghanistan in 2009. He had a variety of roles while in Afghanistan including working as a medic. 92  William developed a friendship with one of the first people he met during his early years in the military. Of his friend, he shared: He’s one of the first guys I remember meeting and commuting together with from the valley ... I remember meeting his parents. You’re just young guys and you’re making money so you’re partying and being crazy and wild, and whatever else. Similar to other veterans in this study, William has experienced cumulative losses. He lost the aforementioned friend he had met during his early years in the military before his first tour of Afghanistan. His Afghanistan tour in 2009 was filled with loss and unpredictability and included the deaths of multiple comrades. William turned to a veteran’s trauma repair group after a friend told him that he should get some help for his frequent expressions of anger. He received support for the loss of his closest friend and the cumulative losses that he experienced. William described receiving help from a therapist from the group who was following him on an outreach basis after the group concluded. At the time of our interview William was taking a Business Management diploma through the Canadian Legion-supported BCIT skills conversion program. He was married and reported that regular exercise and help from therapists in a therapeutic veterans group were helpful in his adjustment. William was extremely upset by the suicide of a comrade who had who had been attending the BCIT skills conversion program with him, and had significant difficulty making sense of his friend’s suicide. He shared: I really don’t know what to make of it. I can’t wrap my head around it. I don’t know. He was doing fine in school and knew why he wanted to be there and whatever else so ... I don’t get it ... School’s gonna suck up ‘til June when we graduate without him there. 93  Dennis Dennis is a twenty-three year old Canadian Army veteran who was raised in a mid-sized city in the interior of B.C. Although he travels frequently, he currently lives near his parents, younger sister and older brother in the mid-sized city where he was raised. Dennis joined a reserve regiment in 2006. He was initially eager to go on tour as soon as possible. He was a reservist and was determined to serve Canada overseas. Dennis submitted memos, spoke to as many people as possible, and repeatedly informed his reservist Sergeant about his interest in an overseas tour. He eventually joined a regular force platoon. Dennis experienced discrimination as a reservist joining the regular forces. When he arrived at his infantry unit, his new Sergeant, a former reservist himself, said, “What the fuck are you here for?” Dennis slowly made friends with members of his new unit during his deployment. He became close to and spent a significant amount of time with Scott “Smitty” Smith, who was the driver in Dennis’ vehicle. Dennis described how being in close proximity to Scott and dependent on one another within their specific roles increased the closeness of their bond: So Scott Smith, that was his name. Here I’ll show you a picture so you know [shows a picture on cell phone]. That’s me and him. So he, he was my driver. So, as driver or gunner, whichever vehicle we’re in. It’s kind of like this relationship where they’re sort of your left hand, or your right hand ... So we were always together. Dennis described how Smitty was out on a foot patrol when he stepped on an IED and was horrifically injured. He described the event in excruciating detail. He remembered experiencing a mixture of initial reactions and wanting revenge following Smitty’s death. He explained how tense it was while patrolling for suicide bombers and how difficult it sometimes 94  was to differentiate civilians from Taliban fighters. At the time of our interview Dennis was still struggling with his grief over the death of his comrade, depressive symptoms, and suicidal ideation. He was being followed at a stress injury clinic for service members and had met with a psychiatrist. He had not found the process of speaking about what had happened, or counselling, particularly helpful. Dennis thought he would get better in “six or seven months” yet was feeling “the same if not worse” two years later. More recently, he came up with a plan to commit suicide but spoke with his mother and an army chaplain who arranged for help before he could make any attempts. Dennis experienced the suicide-related death of a friend whom he had trained with just two months prior to our interview. He described his experience of intense suicidal ideation as, “Like being incredibly thirsty and all you want is a cup of water ... and that water is death.” Dennis described feeling disconnected from friends who had what seemed like a “breaker switch” that would shut off when he tried to speak about what he was feeling. He stated that in Afghanistan he felt closer to what was meaningful. Since returning from home he had tried to “manufacture that closeness to death,” and had gone to the border of Somalia (“the most dangerous place I could”) to help Somali refugees, and to “funnel this lack of fear of death into something useful.” He also helped at an orphanage in Mexico and described going into the wilderness without food in order to experience life with “vividness.” Fortunately, Dennis was open to help at the time of our interview and felt supported by his family, particularly his mother. He was open to trying different forms of support to increase his ability to cope.  95  Common themes The participants shared their experiences. Their accounts were reviewed and read. The common themes concern their experiences of living with, and their coming to terms with, the loss of a close friend/comrade. The themes are divided into two parts: the initial experience of the loss, and living with and processing the loss over time. Phenomenological themes specific to these two parts are described below. The themes common to their initial experience of the loss include: (1) shock, disbelief and the search for explanations; (2) helplessness, retribution and rage; (3) inhibited grief; and, (4) a sense of responsibility for the loss and for letting their friend down. The themes common to living with and processing the loss over time included: (1) protracted and unfinished grief; (2) alienation, mistrust, and disconnection; (3) existential reflection; and, (4) working through the grief and trauma (see Table 4.2 below). Table 4.1 Initial experience of the loss  Themes 1) Shock, disbelief and the search for explanations  a) Shock and disbelief b) Other initial reactions c) Searching for explanations  2) Helplessness, retribution and rage 3) Inhibited grief  4) A Sense of responsibility for the loss and for letting their friend down Living with and processing the loss over time  a) b) c) d) a)  Delayed grief Compounded loss The impact of trauma Military bureaucracy as trauma Survivor guilt  1) Protracted and unfinished grief 2) Alienation, mistrust, and disconnection 3) Existential reflection  a) A heightened sense of vulnerability b) Awareness of one’s mortality c) Existential reflection  4) Working through the grief and trauma  a) b) c) d) e)  Individual therapy Veterans’ trauma repair groups Individual work New insights and renewed purpose Honouring their comrades 96  The themes will be described below, with quotes from the participants being used extensively throughout to highlight their lived experiences of loss and their attempts to live with and reconcile that loss. Initial experience of the loss Shock, disbelief, and the search for explanations The participants in this study described experiencing emotional reactions of shock, disbelief, numbness and tearfulness after learning of or witnessing the loss of their comrade. These initial reactions took place within the context of overseas service, where participants were often with fellow service members conducting operations and missions. The search for explanations of the violent loss was also a common part of the initial reaction immediately following the loss. In searching for explanations, participants explored reasons for the loss, thought about aspects of the loss, and re-experienced the events surrounding the loss. Shock and disbelief Participants experienced shock after hearing about or witnessing their friend’s death. After receiving news of his friend’s death, one participant described how everything else “drowned right out.” Veterans described being stunned by the news and having difficulty expressing themselves upon receiving word of/witnessing the loss. In some cases, participants felt paralyzed by shock and detached from their physical and emotional reality. One participant described being in a daze as he cleaned up his deceased friend’s belongings. Similarly, another participant described experiencing shock and disbelief after hearing the news of his friend’s death:  97  We were all just kind of in shock ... he was just like always there ... it’s kind of like, “Well no, he was right here. How do you mean he’s dead?” You could just like walk out and see him sitting there—or smoking a cigarette ‘cause he smoked all the time. And so it was kind of like this shock of it. In addition to shock, disbelief was another common reaction to the loss for all of the participants. One participant could not believe that his mentor and friend who had seemed “invincible” could die. Another participant, who had been on leave when the death of his comrade occurred, described finding it difficult to believe his friend was dead after having spoken to his friend only a few days prior. One veteran described feeling numb and experiencing disbelief after his friend was killed beside him during a battle. He held his friend as his friend died in his arms. He described not caring about his own life even though he was being shot at in the moments following the loss. Similarly, another veteran experienced a sense of disbelief and numbness while retrieving the remains of his friend and fallen comrades. He and his unit had to cordon off the blast site where the deaths had occurred. Another participant described not being emotionally present, or feeling “checked out” as he witnessed the deaths of his friends and later went to retrieve their gear. Other initial reactions Although feelings of shock were pervasive among participants, alternatively one participant described feeling disconnected from his experience during his tour and experienced a “wave of emotion” and tearfulness after finding out that a friend and some other military acquaintances were killed. He tried to suppress his emotional responses “because there was a job to do,” and was unable to contain his sadness.  98  In addition to experiencing shock, participants described sleep disturbances and physical sensations such as shortness of breath and nausea in the initial weeks following the loss. One participant was unable to sleep for almost four days after the loss as he thought about the circumstances surrounding the deaths of his comrades. He experienced anger and feelings of responsibility for the loss. Another veteran described experiencing feeling physically ill on hearing the news of his friend’s death stating, “I just wanted to vomit.” Searching for explanations The participants searched for explanations for the deaths of their friends. The search was a process that was initiated after hearing about or witnessing the loss. A component of searching for an explanation involved attempting to understand the sequence of events leading up to the loss, problem solving, and analyzing causal factors related to the loss. The experience of searching for explanations involved reliving and returning to the circumstances of the loss. As one participant lamented: ‘Cause it just plays over in your head man. Maybe it’s human nature to try and rationalize ... you want to make sense of this stuff ... if there is a reason or purpose, well what the hell is it? Participants described being unable to stop thinking about the images of violence that accompanied the losses—such as the sight of a friend’s blood on a gun turret—and reexperienced these images repeatedly in their minds. One participant who retrieved the remains of his deceased friend stated that the loss experience was “so much more personal and ... destructive” than any other loss he had experienced before. In describing their search for explanations, participants described needing to explain what had happened, go over the moments leading up the loss, review the critical details concerning the seemingly random nature of the 99  event, and attribute blame for the event to themselves and others for the event. As well, there were often “what if” questions associated with the loss and participants played out alternative scenarios: This is one of the things that I always run through in my head. I’m like well what if the ... airstrike didn’t happen, and we didn’t catch those Taliban, and then [he] had gone out on this patrol. And then he would have been okay. And it would have been somebody else’s turn to go on the next patrol. One participant described going over the events surrounding the loss and thinking about how he had survived and his friend had died only because of random situational factors. Another participant described searching for an explanation regarding the decisions made by superior officers leading up to his friends’ deaths. Repetitive thoughts about the loss started immediately and in many cases continued indefinitely post-loss. Helplessness, retribution and rage A sense of helplessness to protect or save friends, a desire for retribution, and feelings of rage were described across participants’ accounts of the violent loss of a comrade. A feeling of being helpless to save or protect their friends who were killed was described by participants. For example, a navy officer veteran described feeling helpless to save his comrades for 17 minutes as they drowned. One veteran experienced feelings of helplessness and questioned his responsibility after learning his best friend was killed in a fratricide incident involving a vehicle he had just switched out of. The violent deaths of friends happened quickly, involved confusion, and were unexpected. Participants described feeling a sense of helplessness and feeling powerless to intervene and control the outcomes of these rapid, chaotic events. This sense of helplessness was  100  common across all participants’ accounts and was commonly paired with rage and a desire for retribution. Beneath their anger, as described above, veterans expressed feeling helpless to save their friends. In many cases, the death of a comrade was viewed as more upsetting than the prospect of one’s own death. The death of a comrade was akin to their own death, as one participant said, “Part of me died that day.” Participants described living in close proximity to their comrades and forging strong affective bonds over time within the parameters and pressures of the military and overseas deployment. One’s inability to protect a comrade resulted in a disruption to the inherent commitment to safeguard their friends’ lives. In cases where participants’ comrades had been murdered, the wish to kill the perpetrator was a common reaction. Retribution was viewed as an acceptable solution for a number of reasons. Participants indicated that the act of retribution could counter their sense of helplessness, could restore a sense of order and fairness, and seemed acceptable within the context of a deployment in an area of conflict or war zone. Revenge by taking the life of an enemy was viewed as a way to restore balance after experiencing a sense of powerlessness due to the loss. One veteran described grappling with his desire for retribution after his close comrade was killed: An Iraqi soldier surrendered to me ... I was yelling commands to him and he wasn’t complying ... At about 10-15 feet he finally got on his knees ... crawled towards me not understanding my verbal commands. I had the stock of my M16 in my arm, one hand on pistol grip, safety ‘off’ and selector on ‘burst’ and my finger resting on the trigger. I recall looking around ... thinking that if I hiccupped, burped, tripped, twitched, I could end this guy’s life and it would be easy to explain ... I really wanted to kill this fucker ... I 101  wanted some fucker to answer to [my friend’s] death. I wanted to kill this asshole for [my friend] ... I just wanted something to ‘legitimize’ [my friend and comrades] sacrifice. Participants who were involved in operations in Afghanistan indicated that the Taliban were difficult to find and would strike indirectly through IEDs that tended to hit Afghan civilians and children more often than they hit Coalition soldiers. One participant described embarking on his overseas tour with “revenge in mind” on behalf of one of his closest friends who was killed during a tour. Another participant viewed retribution as a “driving factor” and swore he would “find the fuckers that did this.” A “deep desire” for revenge was expressed by another participant who felt it would demonstrate that his friend’s life “meant something.” This veteran previously spent long periods of time in close proximity to his friend as their jobs were interdependent within the vehicle they shared. He wanted to honour his friend by exacting revenge on his killer. He described how he felt that his friend had saved his own life and the lives of other comrades with his skillful driving in a situation where the vehicle behind them blew up. He described the difficulty with finding a target for his revenge due to the unseen enemy: For me there was like an intense hatred, like this deep, deep desire to kill. And I think that’s something here that people don’t understand ... The hatred that comes over you ... you wanted to get revenge. It’s almost like I wanted to show [him] like if he could see that, that he meant something to me, like I cared about him ... I wanted to ... get revenge for him. And we couldn’t find the enemy ... we never saw them and so it’s just the worst feeling ever ... They’re everywhere and you just don’t know. He described how having experienced this desire for retribution helped him to understand why soldiers might commit acts that civilians may deem atrocious. By experiencing combat in a place where his friends were killed, he gained insight into the intent behind such acts: 102  That’s what people here don’t really get ... This thing about the guys pissing on bodies. Um, and here that was like this big scandal ... I don’t think it’s right at all, but when you’re there and when they’ve killed your friends, just the amount of hatred that you have is so, it’s so, insatiable ... That’s why that stuff happens and that’s what war is ... That’s why war can’t be filmed and then shown on TV at home. Like true war. Another participant described wanting to kill the service member responsible for the fratricide of his friend and three others. His desire for retribution was complicated by the perpetrator being a fellow serviceman: We were given specific instructions to stay away from [the perpetrator]…cause he was the guy that dropped the hammer … They said, ‘you guys stay away from him you get caught even talking to him we'll court-martial you.’ And I remember sitting there with about four of us…Saying, ‘If I ever see that guy I swear I’ll drop a round in him.’ And, you know, everybody was dead serious. The desire for retribution followed the loss for most participants, and the intensity of the desire faded over time. Many participants, however, continued to experience anger toward the individuals that they believed were responsible for the deaths of their friends. It was common for participants to experience rage and it was not unusual for participants to project their anger onto others. One participant directed his anger toward superior officers who had committed an error resulting in his comrades’ deaths. His anger was also directed towards a variety of other individuals, including hospital staff who did not respond to the incident in a respectful manner, senior officials who did not feel that it was important to repatriate his friends’ remain in a timely manner, and two military psychologists that he felt were invasive and not attuned to the needs of his servicemen. This participant stated: 103  They sent over the first traumatic stress debriefing team ever deployed to see us ... And two of the fucking guys they sent were fucking utter idiots. They said, ‘We know how you feel.’ Don’t fucking tell me how I feel. Don’t tell my men how they feel ... I had the one ... by the fuckin’ throat. The [executive officer] had two arms on my arm to get me off and I was gonna strangle the son of a bitch ... he was a psychologist. Military, a young guy, no experience and he just pissed me off. During an inquiry into the death of his comrades this same participant expressed rage at the executive officer of the United States destroyer escort boat who claimed the servicemen had not been asked to dive around the hull of the destroyer. Instead, the blame for the incident was placed on a lower ranking “ordinary seaman.” This veteran admits that his anger simmered for years due to the lack of accountability surrounding the incident that claimed his comrades’ lives. When a single person could not be blamed for the death of his comrade, one veteran of the Afghanistan war directed his anger more generally toward the Taliban. Illustrating this, he stated: They’re not warriors. They’re not walking that warrior path … So it’s like … you know, a slippery enemy you can’t get your hands on. I would have liked to, especially after that … I would definitely still like the opportunity to exact a certain amount of revenge. One participant described experiencing anger related to what he perceived as the unfairness of the deaths of friends whose service, he felt, was noble and for the greater good. He commented: The people I know who had wives and kids, or had degrees, took time off school to do a tour they believed in before going back to finish their degrees ... How much better the world would have been with them in it and other people not.  104  Inhibited grief In addition to the themes of “Shock, Disbelief and the Search for Explanations” and “Helplessness, Rage, and Retribution” that were to common to participants’ initial experiences, grief responses were also disabled and delayed by their military duties in the context of war. Their grief was further complicated by the multiple successive losses many participants experienced and ongoing traumas surrounding them. Delayed grief Grief reactions were often deferred until later due to the demands of overseas deployment. Participants recalled delaying their grief due to an intense focus on their duties during their overseas deployments, the multiple losses they experienced, and exposure to a variety of traumatic experiences. A constant focus on their deployment-related duties needed to be maintained, taking priority over thoughts and feelings related to the loss. It was only during down-time that participants tended to let thoughts of their friends’ deaths trickle into their consciousness. Despite participating in funeral rituals or impromptu memorials, participants’ attention returned quickly to their jobs, staying alive, and protecting their remaining comrades. The experience of losing a close friend, as well as other comrades, complicated the grieving process. Several veterans described the necessity for extreme concentration during overseas deployment. One participant reported: Your whole world revolves around that one thing ... You can’t be distracted with other things, right? ‘Cause then you’re not going to be doing your job the way you need to be doing it.  105  Being out in the field during deployment requires constant focus without reprieve. Participants recalled being “pretty beat” after getting home from tour as there were no days off except during leaves. Of this constant focus, one veteran stated: There is no quitting time. You’re either on a patrol or you’re on a road check searching vehicles, or you’re out searching culverts or moving a convoy or a patrol or whatever. Or you’re responding to an IED. Or you’re doing guard on the machine gun on the tower, or doing radio watch. You’re doing vehicle maintenance. You’re trying to get some sleep, or you’re trying to grab your first ... bath in a week, or you’re washing some laundry. Participants stated that their adrenaline and hyper-vigilance was “way up” during overseas deployment. The intensity of their experience increased when comrades were hurt or in trouble. As stated by one participant, “I think you’re already way up there...When you know it’s people potentially ... that you know it becomes personal. So now that sense of urgency becomes even more urgent.” As a result of the intensity required for duty normal grief processes were delayed as service members continued to engage in their jobs. Participants relayed stories of having to continue to focus on their duties even after learning or witnessing their friends’ death. It was not easy for participants to stop their thoughts from drifting back to the violent loss of their friends. One Marine described this intensity and his limited time to focus on the loss of his best friend: I could only deal with it for five minutes and then I never saw his body after that ... We didn’t ... have time to deal with it because we were so busy. And then it kind of, like the war stopped and it kind of ... things kind of slowed down but we never really talked about it with each other.  106  As thoughts and feelings about his comrade continued to “come back” to his attention following the loss, one veteran suppressed his grief to maintain his focus on his duties for the rest of his tour: It just keeps coming back. It just keeps revisiting, right? It just kept popping back up, and ... It got to a point where I was like, “Okay, I've got to push this to the back of my mind until I finish the rest of my tour.” Participants described “shoving down” their emotions following the death of a friend and continuing with duties in spite of exhaustion and grief. In some cases, veterans had additional duties because of the gap left by their friends’ death, adding even more pressure. Veterans did their best to support one another after losses in spite of not experiencing reprieve from their duties. One veteran described how members of his unit improvised a memorial for his comrade by keeping his friend’s name plate above an empty spot where his gear had been. Caught off guard by tears during a brief supply run, a bereaved veteran was offered a brief gesture of support from a comrade: And he just looks at me and he bursts into tears. And just starts crying and I just give him a big hug ... We’re both like so broken over it ... It brought us closer but only really in that moment ... After, it was kind of like back to things as normal ... It seemed like after that we just didn’t talk about it. Like nobody really talked about him. Some participants described helping each other out in small ways after the loss. After his unit sustained two sudden and violent losses, one veteran helped other members of his unit out by “shepherding” them away when they needed time away from the group: We had a couple guys it was, get them out of the way shepherd them away, you know, comfort them as best as possible ... none of us were really great at that ... we were ... “A” 107  type personalities ... guys needed—once a break down would happen—some space. So we’d get them where they wouldn’t be seen [by a] ... higher officer ... You know, he’d yank him out of the line and say he’s got PTSD or combat stress ... that would be devastating to that guy ... We protected him ... get them out of the way and tell ‘em where we are, where you can see us and take ten ... And in my experience, a lot of times guys would ... just gather themselves. Thus, veterans made their best efforts to honour their fallen comrades while continuing to do their jobs at a high level. Veterans occasionally touched on their grief during overseas funeral ceremonies. For some Canadian veterans honouring fallen comrades required fighting through bureaucracy to be part of an overseas ramp ceremony. One veteran described his experience with this: We were their friends so we wanted to carry them ... The people in charge of us gave it to people that didn’t even know them to carry them. So, you know we had to fight up ‘til like the last hour to carry our friends, to carry their caskets, to take the positions of people that didn’t even know them. One soldier described the symbolic representation of an unfamiliar fallen soldier while attending an overseas ramp ceremony: I attended the ramp ceremony for a fallen Canadian soldier and that, I mean in a sense, he wasn’t [my friend], but in a sense he was … He represented every soldier. As helpful as these ceremonies honouring fallen soldiers may have been, they only allowed for partial processing of the grief experienced by bereaved veterans.  108  Compounded loss All of the participants in this study experienced multiple losses. They endured the loss of other comrades in addition to the close comrade who was the focus of this study. Each participant described losing other comrades to suicide or fatal accidents during their tours or on previous or subsequent overseas deployments. Altogether, multiple loss experiences were common for participants. One participant described several such losses. Before he left on a tour of Afghanistan, he experienced the death of one of his best friends. Subsequently, while on tour, his company was “hit hard” with casualties. He was affected by the deaths of comrades and of a platoon commander who was a “likeable, likeable dude.” Sadly, after returning home, the same participant was bewildered when a friend with whom he was attending a military skills conversion course with killed himself. He shared: There’s been other companies hit hard but you know we lost five guys just in that company. But prior to that I lost one of my best friends. He was killed over there in 2007. ... And recently, like, we’re talking 6 weeks ago, I just had a friend of mine who I’m going to school with kill himself...And my first tour in Bosnia...I didn’t know the guy, but you’re not expecting it, guy shot himself around Christmas Day over there. So as long as I’ve been in the army there’s either been somebody who’s killed themselves or ... somebody who’s been killed overseas. I guess it comes with the job, getting killed overseas ... It just kinda’ wears on you after a while. Further illustrating the experience of multiple losses, a Marine participant lost all four of his closest friends during back-to-back deployments. These were friends with whom he had become close during the latter parts of his pre-deployment training and during his deployment. 109  He lost his best friend and two close friends on one tour to Iraq. He lost his remaining friend of this group and “grieving partner” on a tour of Afghanistan. Another participant recalls his experience of finding out about yet another friend who died shortly after returning home: ... And you come back and you find out other friends have been killed—people you know that are over there ... while you’re back. I was good buddies with a guy named Joe. We hung out when I first joined the army ... we did our ... course together ... we’d hang out on weekends and stuff ... And then he uh, yeah he was killed by an IED ... When I heard about that, like I broke down. You know that was rough man, like, he was just a ... wicked guy. The experience of multiple losses complicated and added to veterans’ grief. The impact of trauma In addition to multiple losses, veterans described being affected by traumatic incidents as part of war. Trauma experiences, whether related to the loss or not, complicated the loss, added to the difficulty in grieving. The intersection of trauma and grief played a role in the loss experience for each participant, and made it more difficult to grieve the loss of their friend. Traumatic experiences impaired the more reflective demands of grieving and adjusting to the loss. One participant recalled an event in the weeks after his friend’s death that he experienced as traumatic. He describes how the event stayed with him for years: The sound of fighter aircraft is really unnerving for me, to a point of if I cannot anticipate it, it drives my anxiety through the roof and I get very agitated ... Not too many weeks after the loss ... I was on patrol on the border. I had just told my gunner that I was going 110  to rest my eyes ... I awoke what seemed like two seconds later to that sound, a blur of an aircraft against the sky and the world exploded ... a U.S. Navy F-18 on its way back to its base, had misidentified us as Iraqis and dropped a cluster bomb ... Once daylight hit, they discovered that we had bomblets as close as 50-75 feel from our position, some exploded, others intact ... Needless to say, I now understand my innate fear and anxiety around the sound of fighter aircraft. Another veteran recalled the constant barrage of war zone-related stressors he experienced: I don’t remember ever turning off ...You just couldn’t...We would never go more than— never ever, that I could think of—go more than two days without there being ... an explosion or gunfire, or a casualty ... one of our guys wounded or one of our guys killed. Some participants described stressors such as being shot at by Rocket Propelled Grenades (RPGs) or the “constant stress from suicide bombers” after the losses they experienced. Participants in Afghanistan and Iraq commonly faced the stress of suicide bombers who were often difficult to discern from civilians. Incidents that veterans minimized or perceived as having less of an impact would stay with them and complicate their bereavement and eventual adjustment to returning home. . I was walking through a market on patrol, looking around and saw this little guy ... maybe four years old, just a regular Afghan kid. You know, kind of smiled at him and he just had that blank look on his face. Then he pulls up a gun and points it at me...by the time I got my rifle up ... the kid he’s gone. It was a really crowded area. I thought nothing of that experience ... It ends up that I’ve had a lot more issues from that than I realized. Participants described the vivid images of death and destruction. One participant described witnessing an Afghan civilian shot after being warned several times to stop coming 111  toward the area around a base. Other participants described “cordoning off” areas for investigations or cleaning up areas where service members had been killed. In some cases the areas were “devastated” by explosions, people were dead, and there were pieces of blown up vehicles. One veteran recalled the image of a little girl shot through the spine as being one of the many things he re-experienced after returning from battle. They brought her into this little hospital ... a girl shot through the spine and she’s trying to breathe but it was small and like I didn’t think it would really bother me. But as I come back and that memory just like grows and I see her eyes and like I see, and then it just gets worse and worse. One participant experienced detachment, or dissociation, from his emotional and physical experience, referring to this as “checking out”: My body couldn’t handle the stress ... My mind couldn’t. So my brain checked out for me. And I was kind of on autopilot for the remainder of the tour. I still did stuff and I was still around but I just wasn’t scared ... really ... ever. Like if I had to look for bombs, I wouldn’t worry about them blowing up. I wasn’t terrified or nothing anymore. Military bureaucracy as trauma Post-deployment questionnaires and interviews administered by mental health professionals following overseas service were perceived as another stressor that interfered with grief and trauma experiences by some participants. Participants recognized this experience as military bureaucracy failing to recognize the deeper needs of service members. Participants described being dishonest within post-deployment questionnaires and interviews. They concealed their experiences due to not wanting to speak to “shrinks”, being worried about being  112  “shipped off” for psychological examination, fears of having limits placed on their military careers, and not wanting to be labelled. As one participant stated: You know the answers they want to hear. And it’s like bang, bang, bang, bang, done. Let’s go from here ... Nobody takes it seriously ‘cause you know they don’t want to get labelled. You know especially when you’re in the military. You don’t want to be ... the guy that’s fucked up. During post-deployment sessions, veterans were asked questions related to their mental and emotional health. Another participant explained his reasoning for being guarded during a post-deployment interview: The other aspect was the fear amongst the guys you know where we’ve just spent ten months over here. If I hint that there might be something wrong with me, these fucking assholes are gonna keep me here and all I want to do is go home ... All anybody wanted to do was get the fuck home … I don’t think that there was a single guy that said, ‘Yeah I’m having some huge psychological issues right now’… I think you just convince yourself that you’re better off to say, ‘Fuck it, I’m fine. Whatever, let’s move on, let’s get out of here.’ Many Canadian soldiers were confronted with military bureaucracy during their overseas deployments. Canadian veterans of Afghanistan stated that soldiers were sometimes treated with disrespect by “administrative” service members when they returned to the larger operations base (KAF) after being in the field. This angered participants and inhibited their normal reactions to grief and trauma. One veteran knew a comrade who was yelled at by an officer for having “blood on his shoe” after returning from battle. He described an incident he witnessed:  113  I was there when guys got jacked up for not having their beret on … just crossing the road, and already there's an officer there yelling and stuff ... these types of things ... don't sit well ... people in officer positions who speak down to you or speak harshly to you and they're not soldiering. Another participant described the “disparity” between elements of military bureaucracy and soldiers who were out in field: The thing that bugs me the most...disparity...that exists...between elements of the military ... Sometimes when you’d come in, and you’d have been out there and it’s been tough or challenging or your tired and dirty or you’ve had a guy get killed and then you come into to a bigger base and the stupid stuff they focus on ... It’s a systemic problem ... and causes anger and stress, frustration ... you’ll get Sergeant Majors who will yell at you ... Canadians are some of the worst going in KAF for being uptight or being over the top. As illustrated, a variety of factors mediated, complicated, and delayed grief following the violent deaths of comrades. Grief was deferred, delayed, and inhibited because of the intense focus required for duties during overseas operations, and complicated due to multiple losses and experiences that participants perceived as traumatic. A sense of responsibility for the loss and for letting their friend down Most participants experienced a profound sense of guilt and felt responsible for the violent deaths of their friends. This sense of responsibility and sense of having let their friends down followed the loss, and in many cases extended over time. Participants felt that perhaps it was supposed to be them that died, and felt guilty for surviving. Some participants felt they let their friends down by being unable to protect or save them. Participants often identified so closely with their friends that their deaths felt like their own. 114  Survivor’s guilt One veteran described experiencing profound guilt for his friend’s death starting immediately after and for many years following the loss. Not only had he developed a strong attachment to his comrade, he had worked in the same vehicle with him for five-months in the context of a war zone. His interdependence with his friend and his crew was heightened by the pervasive threat of the enemy and fear of mass casualties. This participant ran through the circumstances surrounding the loss—which involved switching vehicles—in the days and years after his friend’s death. His sense of responsibility, guilt, and feeling he had let his friend down continued for thirteen years until it was addressed with a clinical intervention. Recalling this, he stated: You know that survivor’s guilt part is part of that. I was supposed to go. That was supposed to be me on that vehicle ... That’s where I was supposed to be. There’s nothing more than [my friend’s] ... desire to reacquaint himself with a buddy that prevented me from being scraped up in a ziploc bag and sent home to my parents. That’s it, that’s the reality of it. It should have been me ... I shouldn’t have let him take my spot. Other participants articulated similar experiences of guilt, feelings of responsibility, and of having let their comrade down. Not surprisingly, the depth of guilt and sense of responsibility increased with the closeness of the relationship with the friend who died. Like the aforementioned participant, participants frequently thought they could have done something more to prevent the death, and carried a sense that it should have been them that died. A participant who worked closely with his friend as part of a crew in a vehicle described wishing he had been there when his friend had been killed by an IED. Like other participants, he went back over the scenario and searched for an explanation in the events leading up to the death 115  of his friend. As he had stayed behind that day, he reflected on how he felt he should have died rather than his friend: ... And then there’s just like this feeling like, we wish that we were there. Like, I felt so bad ... Just even like to have been there or maybe it should have been me if, you know, with the last time maybe it would have been my turn to go on the patrol. This participant reflected more deeply on the experience and recalled a moment where his friend had saved his life as well as the lives of the other men in his vehicle. He felt indebted to his friend for this event, yet now unable to re-pay him for saving his life: To feel like you owe somebody your life, it’s a heavy debt that you wish you could pay ... Because he did his job well, um, I’m alive. I never thanked him for that. Like I tried once but he just, he was like, ‘Whatever’, you know? Another participant described feeling responsible for his friend’s death, and feeling that it should have been him that died in his place. In his mind, if he had not made a scheduling error, he would have been dead rather than his friend. He shared: Even to this day it still bugs me. Like, by all rights, if I hadn’t forgotten what day it was I probably wouldn’t be here right now. Just because I forgot the day ... and then you know, it’s like, ‘Wait a second, that was supposed to be where I was ... that was really supposed to be me.’ This participant also shared that a “really good friend” and fellow Afghanistan veteran was in a situation where his vehicle was “blown up” and he was the sole survivor. He described what happened to his friend after this event:  116  He killed himself a year and a half ago. He had pretty bad survivor’s guilt because like, why is he the only one that survived? ‘Like why am I alive, why am I here still, like what the fuck?’ He did not feel that he deserved to exist when his comrades had died. Adding to this, he described feeling guilty because he was “a single guy” whereas his friends who died had wives and children: You know these guys are leaving behind wives, kids, you know...Kids are growing up without even knowing their dad. A single guy living by myself, you know like, why? Another participant, who was in a leadership position, was haunted by feelings of responsibility for the loss of his friend. Even though it was unlikely that he could have prevented the loss, he felt responsible for the deaths of two of his closest comrades. He did everything in his power to save the men and was unable to sleep for days after the loss. He accompanied their bodies to the hospital and ensured they were respected even in death. He made extra efforts to make sure the men’s bodies were shipped home and that there were proper memorials for them in the field. The measures taken by this participant are symbolic of the responsibility he felt for his comrades’ deaths. One participant described being unable to function after the deaths of his friends. He had held his best friend in his arms as he died. His friend had tried to say something to him but was unable to speak. As they were in the middle of a fire fight there was no closure to the situation for this participant. Over the years following the loss, he described feeling “dead to the world,” and turning away from family and friends. For him, losing this friend and others left him frozen. He described playing scenarios over in his head about how he might have prevented their deaths. Before receiving clinical intervention, his guilt was concerned with surviving while his friends 117  had been killed. Later, his guilt shifted to wondering if he was doing enough with his own life. He said: Guilt issues revolve around me, like me coming home, my friends not. Well at first it was like maybe I could have done something different or more ... Now it’s like, am I doing enough with my life because I was granted something that like should have been taken away from me? Participants also described feeling guilt for not communicating more sincerely or making a stronger connection with their friends in the days before their deaths. One participant described regret after holding back when he saw his friend on the boardwalk at the KAF base: We were really excited to see each other and we were talking, but at the same time we were very aware of everybody else that's around … That not only is that the last time I saw him, it was only a couple days before he passed away, so it really brought into perspective, into the present, my relationship with him and the bonds I felt with him...I think that's why it kind of hit me harder just because his face was so fresh in my mind and his voice was so fresh in my mind ... I always feel kind of guilty I couldn’t talk to him more. Living with and processing the loss over time The participants in this study wanted to avoid painful feelings and intrusive thoughts about their friend’s deaths. They described living with a sense of alienation and mistrust, and the sense that others did not understand their experiences. Furthermore, following the deaths of their friends, participants experienced an increase in existential reflection, a heightened sense of vulnerability and an awareness of their mortality. All of the veterans in this study were aware that a change was needed at some point as they struggled to live with and process their grief 118  experiences. This became apparent as their friends, intimate partners, or relatives helped them to recognize that they were struggling. Confronted with the observations of their relatives and the consequences of their own behaviour, participants attempted to adjust to lives without their deceased friends and make sense of the losses. Those who were able to live with and successfully process their loss experiences described actively learning more about how the loss was affecting them, processing their experiences in some way, and participating in formal treatment. Veterans who processed the losses and who were able to make some sense of them were able to set goals for themselves and focus on their futures. Many participants made commitments to developing and maintaining legacies for their fallen comrades. Protracted and unfinished grief Participants described experiencing protracted grief, or grief lasting longer than expected, as they lived with the deaths of their comrades. Participants described their grief experiences as being unfinished or unresolved for years after their losses. Although length of time since the death varied among participants, they all described experiencing a combination of grief and trauma-related symptoms beyond six months post-loss. They described enduring post-traumatic stress symptoms that interfered with their grieving and led to difficulty in daily functioning. For example, participants described difficulty managing their emotions in work-related settings, with close family and partners, and with friends. Many participants described attempting to distance themselves from thoughts and feelings related to the loss by numbing themselves with alcohol, drugs, video games, and working long hours. Several participants described experiencing symptoms related to depression, such as depressive thoughts, hopelessness, difficulty sleeping, and poor appetite. Some participants admitted to struggling with suicidal thoughts. Two participants disclosed that they had come 119  close to attempting suicide by firearm. All of the participants described experiencing posttraumatic symptoms after their service including arousal, avoidance, and intrusive thoughts. Furthermore, participants struggled with distressing dreams related to the loss, intrusive thoughts, and wanting to avoid others. One participant described his experience of protracted grief as he started to come face-to-face with the death of his comrade: When you’re there like you see a lot of stuff ... with (my friend) dying, you can’t process it, really, so it’s almost like burying it in snow ... You’ve got all this garbage and you’ve just got to chuck it in snow and bury it and like move on you don’t have time to think about it. While you’re there it’s sort of easy to do that because there’s so much focus, you know, on just trying to live the next few days ... When you come home and that focus is gone, it’s like that snow begins to melt. What you’d buried there begins to rot. In your mind these things bounce around and they get more and more amplified, like, you see it … worse than when you actually saw it. Participants described re-experiencing the deaths of their friends with intrusive and distressing images, and perceptions. They continued to experience intrusive, distressing recollections of their losses and sometimes felt as if the losses were recurring. For some veterans, intrusive recollections and re-experiencing the loss occurred years afterwards. One participant described re-experiencing the loss as if it was recurring. He described these episodes as movies or “out of body experiences” that were impossible to stop until they were over. For this participant, the re-experiencing occurred thirteen years after the loss, during his retirement. Finally, after coming close to committing suicide, he got some help: I retired in the spring of 2004 ... By Christmas time, in my mind, I was a fuckin’ basket case. Really bad shape..I sat in the woods with a fuckin’ shot gun in my mouth. Gonna 120  kill myself. I started getting these fucking nightmares. I call them out of body experiences ... It’s like seeing the whole frigging movie from me talking to [my friend who died], to going up top, to the megaphone, to yelling and screaming at the guys to being on the jetty trying to give these guys CPR, to being in the goddarn ambulance, to finding ‘em on the floor of the hospital, to the critical incident stress guys just rotating this ... and once it started I couldn’t stop it. There was no stopping ‘til it was over. It was like, you wanted to stop it…I kept saying to myself, ‘I gotta stop this thing’ ... It’d come on at different times. Something might trigger it. I couldn’t read the obituaries in the paper. Some participants described being upset by triggers that were symbolically associated with the deaths of their peers. A participant described being surprised by his emotional response to a movie with military themes featuring two service members on a notification team that informed family members about the death of a service person. He recalled: I was watching a … movie. It was about two guys that were on the notification team ... I think I barely got half way into that and before I knew it, I was just fucking wrecked. I couldn't watch it. I had to turn it off. I had a couple of drinks and uh ... I just had these fucking awful, awful, like emotional roller coaster-type feelings. I flipped up my pictures, I'm looking at, you know, I'm looking at [my friend’s] pictures and all the good times we had, and it just fucked me right up ... For whatever reason [it was] a … trigger for me. Another participant reported that the memory of his friend’s death seemed unaffected by the passage of time. He reported using alcohol to cope with feelings related to the loss. He shared: It happened three years ago. It felt it could have happened 20 minutes ago. I can’t comprehend that I was there three years ago. It could have happened yesterday … It 121  doesn’t affect me negatively like it used to. I don’t have to drink not to numb the feelings … It kicks in when I see a movie because I’m more visual because it would bring that feeling up again. Distressing dreams of the loss event were described by participants. In some cases these were frightening dreams without recognizable content. In other cases, the dreams were laden with themes of survivor guilt or a replay of the events surrounding the losses. One participant described experiencing “nightmares” related to his feelings of guilt associated with surviving while his friend died. He also described the difficulty with speaking to others about his experiences: I just started getting nightmares ... out of nowhere. Just like wham, waking up just like cold sweat and everything, it’s like, ‘What the fuck is going on?’ ... Basically, like all my buddies dying around me and I’m the only one walking out. They started coming frequently, like at least every other night. This participant described that his way of coping with his nightmares was to drink with his friend. He did not speak to his friend about the content of the nightmares yet they shared a common understanding: I never had nightmares ‘cause when we drank, we drank together so that was pretty much my guarantee of not having a nightmare. If I was drunk then guaranteed I would not have a nightmare. I wouldn’t dream at all. I’d just pass out ... He could relate ‘cause he was having some too ... We never talked to each other about our actual experiences ... You don’t talk about your feelings. There’s really none of that. Another participant described how his disturbed sleep impacted his relationship with his wife. Although he was not aware of the content of his dreams, he found them to be distressing 122  and accompanied by feelings of dread. He recalled that his wife resorted to creative ways of waking him up due to his propensity for violent reactions when awoken. Like the participant above, he exhausted himself so he would not dream: I would wake up screaming … If she had to wake me up, she’d poke me with a stick or she’d grab my toes because I would come out swinging at her. Um, I would wake up screaming. I would wake up in cold sweats. I would wake up heart pounding...Most of the times I couldn’t remember the … content of my dreams … I would just get a feeling of dread … If I could get myself to a point where I was either loaded or exhausted, I would sleep dreamlessly. I wouldn’t sleep well, but I would sleep dreamlessly. Many participants found alcohol, drugs, video games, and working long hours to be at least temporarily helpful in creating some distance between themselves and their experiences related to the violent deaths of their comrades. Participants described how they were able to “escape” and cope—to a degree—with these behaviours. One participant described using alcohol and video games to escape: ... Just played video games because it made me escape. It was a form of escaping— alcohol and video games. And then when the weekend came, blackout drunk and then get fucked up. That was my life. One participant described using alcohol to avoid dealing with problems he was experiencing. Despite being able to push away problems temporarily, he struggled to cope with witnessed images of the death of a friend who had been accidently shot in the neck, the suicide of a close comrade, and the experience of dealing with human remains encountered in the field. His memories of these tour experiences were fragmented and he would see them in the form of a  123  “slide show.” In addition, he described struggling with the memories of the smells and textures related to his tours. Describing his attempts to escape with alcohol, he stated: It was a pill that I could take and it could take care of the problem right now kind of thing. It was a right here, right now kind of thing. I could drink a bottle—glug, glug, glug—couple minutes later I’d be right out of it. I wouldn’t think of anything. Nothing would bother me ...Why go see the medic? Go to the bar. Another veteran worked excessively to avoid dealing with his experiences of loss. He was able to “work” through sleep difficulties, and by focusing on work he distracted himself from re-experiencing elements related to the loss: No, I didn’t have problems dealing with this for years afterwards. But now I know why I didn’t ... What I did instead of, of dealing with it, I just worked harder. I worked, my wife would tell you, eighteen to twenty hours a day. Every day ... As long as I was working, and bustin’ my ass, I could ... goddamn work so hard that I didn’t have to worry, that when I finally did go to sleep, I slept. Interestingly, this participant acknowledged re-experiencing the deaths of his comrades once he retired and no longer had work demands to distract himself with. One participant stated that despite the emotional stress that he and his comrades experienced, they avoided speaking about their friend’s death unless under the influence of alcohol. This participant described how alcohol and a relaxed atmosphere helped to facilitate an environment where his comrades were able to “let their guard down a little bit” and express some of their feelings. Being emotional about the loss was a sign of weakness to other servicemen, and being a “tough guy,” in control of one’s emotions, was more acceptable:  124  I guess for years … we never really talked about, amongst my buddies and stuff, about [my friend’s] death …We all remained friends but we never just brought it up ... [Anniversary date] we’d always have a, a bit of a party with the boys and have a couple of drinks … But we never really discussed it. It never really was talked about…I don’t think anyone wants to come to grips with it. I think it’s avoidance ... [He’s] not with us but if we don’t talk about it, maybe it didn’t happen. Veterans had difficulty acknowledging and expressing their feelings of distress. This tendency to internalize and repress feelings was attributed to the culture of the military and their identification of emotional expression as weakness, and controlled emotions. As one participant put it: Before I was just bottling everything up ... You know ‘suck it up soldier on’ ... That was the attitude before ... ‘I’m fine you know’ ... I can understand why guys turn to booze so much and drugs ... I mean it is hard to deal with when you’re on your own dealing with it ... A lot of guys they’ll just self destruct ... It’s the only thing that’ll shut off the voices so to speak—the dreams and the thoughts. In summary, participants experienced protracted and unfinished grief in relation to their losses in large part due to the accompanying post-traumatic symptoms they experienced. Participants described experiencing problems related to the deaths of their friends for years before processing their emotional responses or grieving through some form of treatment. The three oldest veterans in this study experienced grief and trauma symptoms for many years before initiating treatment. Participants were upset by their vivid memories of the loss and overseas experiences. Participants recalled difficulty understanding their fluctuating emotional and physical states. They often struggled to articulate and describe what they were experiencing. 125  Many participants struggled in areas that they had previously mastered, looking at the world differently and not feeling safe. Their experiences of loss, and the overseas service, left some participants in “pieces,” feeling fragmented, and struggling with negative views of themselves. Some participants engaged in dysfunctional ways of coping with their grief and trauma until they were able to “put the pieces” of their lives back together. Alienation, mistrust and disconnection Emotional distance between the veterans and others was a common theme. This distance emerged due to a combination of their intra- and interpersonal experiences. One participant described the distance he felt from others: As high as Mt Everest is, 29, 006 feet, there’s a deeper place in the ocean. It’s called the Marianas Trench. It’s over 35, 000 feet deep. I was there at the bottom of that son-of-a bitch with nowhere else to go. There was nowhere else to go. Like other participants, this veteran wanted to protect family and friends from what he was experiencing (e.g., intrusive memories of the loss, intense anger, and guilt for not being able to save his friends). His wife noticed something was wrong but he kept a “lid on things” so he would not upset her. She noticed that he had not wanted to go anywhere, make love to her or spend time with her. He was reluctant to tell her what was happening as he did not want her to “suffer or have her worry” about him. He was more forthcoming with a close friend who was also a veteran and had noticed something was wrong. He stated: You keep things locked up more and more inside but Jesus, the harder you try to friggin’ keep the lid on things, sometimes it doesn’t work that way ... I was pretty sick, and one of my buddies saw me ... And he said ‘What the fuck’s wrong?’ I said, ‘Man I’m losing it.’ I  126  said ‘There’s days here, man, I gotta fight for every frickin’ breath that I take to get out of bed without wanting to write myself off.’ Another participant reported withdrawing from his family and friends after the death of four comrades. He cut off emotional contact with others: I just didn’t care ... I just didn’t care about myself. I didn’t care ... Yeah, I don’t know, like I was just frozen I guess. Not ‘frozen.’ Frozen’s a typical word to say, but, ah, yeah like I was dead. Like people would talk to me and I wouldn’t even pay attention ... It felt normal. It felt normal. This participant had experienced a closeness and loyalty with his comrades that he felt he would never experience again. He felt guilt, shame, and sense of responsibility for having let his friends down. His family and friends were well-meaning and celebrated him as a hero while he was struggling to make sense of the deaths of his friends. He moved away from his friends and family so he could process his losses in solitude. He found that he felt different from others due to being young and having experienced such profound loss of friendships. He would often compare new friends to his friends who died. Reflecting on this, the participant said: ... I just think that because I am still pretty young that a lot of people don’t understand everything that you’ve been through. It’s hard to connect with people sometimes ... when you go through a traumatic event I just think you look at life a bit differently ... I think about them all the time. New friends that I start relationships with I’ll always compare it to the relationships that I had. That’s a kind of, I think that’s a negative thing ... I don’t even think I’ll ever have friendships like that ever again ... the bonds that we forged, it’s unexplainable, it really is.  127  When participants returned home, they described feeling “emotionally stretched” and disconnected from others. One participant described being physically present yet emotionally withdrawn from others. He described himself as a “vegetable” during that time. Another participant described feeling similarly disconnected but was met with avoidance from others when he did attempt to communicate: I feel ... so emotionally stretched by it ... I feel an inability to talk to people here ... Like my family, I sort of feel a deep void and separation from them ... My friends too, it’s like they have a breaker switch ... and if you get too heavy or deep ... their switch just breaks ... I was talking to one guy and, and I told him I was having some trouble and he’s like ... ‘Oh hold on I just got to go do something,’ and he goes, he turns up the TV ... A lot of people can’t, can’t handle something ... so they just switch off. Most participants were guarded and found it difficult to let others get emotionally close. They struggled to let people in and allow themselves to open up to others and form intimate, close attachments. Participants struggled to maintain control of their emotions and, in many cases, equated emotional expression with weakness. To speak to others about a personal and highly emotional experience required a significant amount of interpersonal trust. One participant, who was in a new relationship, described his struggle to form close attachments to others. He noticed a “shield” between himself and others since his service. He found deep attachments to family and his girlfriend “scary”: I definitely feel kind of like a shield … Not wanting to allow myself to love people completely for the sense that moments are temporary and preserve against loss…In moments where I feel a lot of love for my girlfriend, or even when I think about my mom and I feel a deep sense of love, that’s scary ... It’s a protective thing and I’m a little bit 128  detached. I feel myself a bit detached from a lot of people now … People I felt closer to before I went over, or before all this, it’s not as close. Participants described censoring themselves around others. One participant described his disconnection from others as emerging from a sense of shame and failure: If I were to say to you, you don’t understand ... What you wouldn’t understand is like, the shame and the failure ... that’s what people don’t understand. ‘Cause people see you come back ... People are like, ‘Oh you went to Afghanistan, you’re so brave, you’re a hero’ and it’s just like I didn’t do anything ... (my friend) gave everything ... He gave everything and I gave nothing and people are saying that I’m brave. So it’s like this incredible shame ... That’s why we don’t like to talk about it because it’s like I’m not who you think I am but I don’t want you to know that I’m not who you think I am. In articulating his feeling that his friend gave everything and his shame and failure, this veteran described something that other veterans certainly felt. It is related to the theme of responsibility and letting their friends down. It highlights the participants’ beliefs that perhaps they should not exist because their friends were dead. In addition to disconnection from family and friends, participants perceived that their loss and tour experiences were beyond the scope of what most people could fathom. They sometimes experienced critical and unsupportive opinions about their service and felt their experiences were at odds with the political climate. Participants described how the concerns and political views of others would often overshadow and invalidate their experiences and the losses of their friends. In a sense, their losses felt socially unspeakable. One participant reported that he did not even bother to speak to people about his experiences due to polarized political views about Canada’s  129  involvement in overseas conflict. Participants described remaining silent about their losses for this reason: It’s hard to talk to people outside of the circles, just ‘cause, explaining more than we’re used to explaining. You know, a lot of people are very opinionated about why we’re over there and everything so it could be hard to talk about why you’re even in the military. Another participant described limiting what he shared about his experience with others: With friends dying ... a lot of people have the perspective ... like, ‘Oh well it’s war and that’s what happens.’ ‘Cause they play video games or they see movies, and, and so they don’t understand, like, how it affects you and all this stuff. And so that’s kind of frustrating. One participant did not try to explain the experience of losing his friend because he felt that others would not understand: There isn’t really anyone I have explained it to or tried to, simply because of the fact that people in Canada or the U.S. don’t really understand the idea—most don’t—understand the idea of someone being violently killed. Overall, participants felt others did not really understand their experiences. One veteran described that others are largely ignorant to loss: That stuff still bothers me. Ignorant people that don’t fuckin’ ... just don’t know ... what it’s like to lose a friend and don’t know what it’s like to be there when your friends die. You know, and you can’t do anything to save them and shit. Not a lot of people know about that, man. The perception that others could not understand what they endured pervaded participants’ experiences following the loss of a friend. 130  Existential reflection Following the losses, participants experienced a heightened sense of vulnerability and vigilance, and an awareness of their own mortality. Participants no longer believed that they were invincible as they previously had. The deaths lead to participants questioning their own mortality, safety, and experiencing vulnerability. They struggled to make sense of what had happened to their friends and described difficulty putting the events together with what they knew about themselves and the world. These sub-themes are described in further detail below. A heightened sense of vulnerability Regardless of training or previous losses, participants were unprepared for the violent deaths of their friends. All participants prepared for the stress of their overseas deployments, yet admitted that they were ill-prepared for the losses of comrades. The violence of each death was described as shocking and unlike anything that participants had experienced before. One participant described: You come into that culture knowing at some point you’re going to be put in harm’s way ... That’s what you’re there for. That’s the deal. But nowhere does it ever, you know, cross your mind that you’re not going to come home. Or that your buddies aren’t. I mean it’s there but it’s not real. Participants did not think that their friends would die. Despite being in very dangerous places during their overseas tours they still had a sense that they would be protected from misfortune; a sense of safety. There was a sense that by being prepared, being good servicemen, and engaging in the “right” kind of behaviours, participants would maximize their chances of protecting their comrades and maintaining control over the outcomes. At a rational level, participants described having awareness that bad things could happen to them and their comrades 131  during their tours; however at an emotional level, among their deeper assumptions, participants’ did not expect tragedy to happen to them or their close comrades. Speaking to this phenomenon, one participant stated: I didn’t have that sense of vulnerability. Ever. Even when rounds are snapping and banging off the vehicle, I wasn’t vulnerable. I was vulnerable but I didn’t have that feeling or that sense of vulnerability. I was still invincible ... Even when they told us, you know, ‘You guys are gonna’ be suffering an eighty-six percent casualty rating.’ Even at that point, you know, I don’t think it really registered. I said ‘Holy shit, eighty-six percent, fuck, this sucks.’ You ... still knew that, maybe they’re wrong. Veterans heightened sense of vulnerability manifested in different ways. One veteran connected his need to have control in situations to a sense of vulnerability related to the violent deaths of his friend and comrades in an explosion: I knew who they were and I knew they were dead ... I knew that we couldn’t get close to them because it was unsafe, because of the fire and bullets going off inside of the vehicle ... We were first on the scene ... We couldn’t get in ... Not having control of the situation ... I always have to have control of the situation now, no matter what it is ... Otherwise I’ll feel uncomfortable. Participants first noticed feeling more vulnerable after returning home with increased hyper-vigilance. A piece of wire sticking up from the ground became an IED for some veterans. One veteran stated that it took several months for his nervous system to calm down. He described the hyper-vigilance that followed after returning home: Back to the base where I was posted. Get dropped off and it’s winter and my walkway isn’t shovelled ... Just spent six months in a country where if you step off the hard pack 132  there’s probably land mines and it’s like, ‘Ahhhhh.’ I stood there quite a bit just looking at the walkway ... Some family meet me on base ... surprised me ... The kids just go running up to the front door and I’m ... freaking out a little bit, it’s like, ‘DON’T GO THERE it’s not safe, it’s not been cleared!’ Feeling vigilant in situations where they had little control, such as public spaces, was a common expression of vulnerability. One participant described “fighting for the chair in the back of the bar” with his friends so he could feel safe. He stated: My ex-wife said, ‘Can you ever just sit in some place and relax?’ And it’s almost like you’re doin’ threat assessments on everything you see. I go into a bar, ‘Where’s my exit? Where am I sitting? What’s in the room in front of me?’ Somebody approaches, ‘Is this person a threat, yes or no?’ ... It becomes so obsessive that you can’t really focus on enjoying yourself. Another participant stated, “I’ll never have my back to someone unless I absolutely have to,” and reported that he was “always checking” over his shoulder. Most of the participants described feeling more vulnerable in crowded places. Although many veterans noticed that their hypervigilance decreased over time some veterans continued to experience increased arousal. One participant described finding a sense of comfort and safety in having a weapon near him: There’s nights when I will pull my Glock (semi-automatic pistol) out. I will tuck it underneath my pillow. And I will not sleep unless that’s there ... I can’t put a finger on why. Something happened during the day, some sort of mood, some sort of trigger. I’ll toss and turn ... I won’t be able to sleep. I’ll pull it out of the case. I’ll tuck it under. I  133  won’t even put a magazine case in it for Christ’s sake ... I don’t know what it is, I don’t think we like that feeling of being vulnerable. This participant’s feelings of vulnerability had started after his friend’s death. He attempted to understand his sense of vulnerability with a psychologist, noting that it emerged from a combination of the loss of his friend, the death of a key caregiver, and increased arousal symptoms after his service. To illustrate his experience of feeling vulnerable, one participant described an incident he witnessed when he was helping at a hospital when a group of American soldiers were brought in after their helicopter crashed. He alluded to the difficulty admitting to vulnerability as a veteran: They brought in this one guy ... I remember he was screaming ... They put him on the operating table and he’s pretty much naked. He’s there exposed in front of all these people. I remember thinking how terrifying that would be. ‘Cause he’s like a soldier, you know, he’s tough ... and then all of a sudden he’s naked and pretty much exposed to all these people looking at him and poking him. And, and that’s almost what it feels like when you have to admit that you’re this close to suicide ... in the same way it’s necessary for this soldier to get help from all those people. In summary, feelings of vulnerability followed the deaths of comrades and continued as participants lived with their losses. Participants described how it was difficult to live with heightened vulnerability as the experience of being in the military had provided a sense of safety, invincibility, belonging, and control. As the participants returned home and lived with grief and trauma symptoms, they coped with feelings of vulnerability.  134  Awareness of one’s mortality Participants’ described a change in their sense of safety and security after their friends’ deaths. One participant described the realization of combat’s mortal threat: With that one IED I saw, nobody was really hurt. So it was kind of like just bring it on, like we can handle it, whatever you guys got. It’s almost fun, you know? When ... [my friend’s death] happened ... it was just a lot harder to deal with. Following the losses of their comrades, participants described having heightened awareness of their own mortality and the fragility of life. Experiencing the death of their comrades caused them to confront these realities. One participant described how his increased awareness of his own mortality started to “wear” on him after witnessing the deaths of his friends. He became more aware that he could be killed thereafter and the combat experience became “real”: After I saw what happened, thinking it wouldn’t happen to me or anyone I knew kind of disappeared and it became real. Like, before I didn’t really feel like it was there ... I wasn’t present until then and then I became present and it started to wear on me, the last month and a half [of tour]. Having experienced the death of his comrade (in addition to the murder of his uncle, and a diagnosis of testicular cancer) another participant confronted his own mortality. He referred to each of these experiences as “lessons about mortality”: I’d gotten to a point where I felt like it was okay if I died. I’d already made that peace … Kind of the acceptance of the inevitability of death. The end of mortality ... All of these lessons about mortality that came up, and between all of them, it thrust me back into a very spiritual, reflective state where I felt like it was really important for me to get back 135  onto my path, my connection to, my interpretation of the divine, and my reconnection with nature. This same participant reflected further on the “lessons about mortality.” He described his experience of loss as information that gave him a healthier perspective on mortality in general: Seeing how it affected me, the last meetings with them [comrade and uncle]…It’s like when you’re at the edge of a cold stream and you splash a little bit of that cold water on your face and chest to prepare yourself for jumping in. You know it’s going to be damn cold, so it’s kind of like what it feels like…I look around. Everyone that’s important to me, they’re going to be gone some day, whether I’m first or they’re first … Especially with the prolonged experience with the cancer and stuff, it’s something that I think about a lot. Existential reflection As participants experienced heightened vulnerability and awareness of their mortality, they began to question themselves, others and the world. As a result, participants’ reflected on existential issues and the meaning of their loss experiences. One participant would often think about the event and wonder why he had been spared and what this meant: I think it will always be there. It’s one of those ultimate questions, it’s one of those ultimate, ‘What ifs,’ you know? ‘What if I didn’t forget what day it was?’ You know? ‘What if? What if?’ You can what if it to death but I mean. It’s happened, it’s done. This participant continued to struggle with his friend’s death and had difficulty understanding how his friend died and he lived. The violent loss of his friend challenged his sense of stability and continued to be a difficult experience for him to understand.  136  Some participants struggled to make sense of their comrades’ deaths and this seemed to contribute to their difficulty adjusting to and making meaning of the loss. One participant in particular struggled to make sense of the loss and experienced depressive symptoms. He was at high risk for committing suicide when interviewed. He described struggling with making sense of his friend’s death: I want to be able to make sense and say that he died for something. And I think like, that the guys from WWII, they were like able to say, ‘He died but we defeated Nazism,’ and there was purpose to it ... With [my friend] every time I read an article that’s saying it’s a lost cause in Afghanistan ... that just like feels like such a stab in the back ... I haven’t made sense of it and I think that’s what also contributes to my depression. So, it’s like what did he die for. It’s like nothing really. And that just breaks my heart. Another participant described how he was struggling to make sense of the many deaths of his comrades. He experienced severe casualties in his unit, not only from battle but also when a soldier from his company was on leave. At the time of our interview he had also experienced the death of a comrade by suicide: The more I just sit and think “I’ll remember the guy on (leave) from my company who was off on holidays and he was killed in a car accident. He was supposed to be on his holiday; supposed to be safe, you know? And a taxi he gets in rolls over ... and he gets killed and he’s twenty-one and on his first tour. And you just start thinking, there’s just so many people who are gone. You’re like, ‘Well, what the hell?’ He found it especially difficult to understand how his friend would commit suicide after his military service. He was unable to make sense of this and worried that making sense of it might put him “on the same road”: 137  It’s almost like it’s as if it’s a gift that I don’t understand ... Why would you want to understand how they got there, and some of the things that made sense to them that put them there might start making sense to you and you might put yourself in the same road. I would rather make no sense at all ... I hope that never makes sense to me ... I don’t think ... that’ll ever make any sense. One participant described being irrevocably changed after his overseas service and the death of his comrade. After his comrade died, he described experiencing moments that he “thought ... never would happen” where he questioned whether his military service had purpose. He reflected on how his friend, who was violently killed, was doing a routine “night patrol with no one around in a random field.” He proclaimed that the violence of his friend’s death was unlike anything he had ever experienced before. He thought about the loss every day and felt changed by the experience: You’ll never ever, ever, get back to who you were before ... You just won’t. It’s just that simple ... I just know it. I’ve already spent two years doing everything imaginable to assimilate back into the society that I should know very well. But it took four years just for it to completely alter it. And no matter what I will never be the same or even close. As participants lived with and processed the loss over time they had many questions about the deaths of their friends, experienced a heightened awareness of their own mortality and increased sense of vulnerability. They found the violent losses of their friends difficult to understand. Participants experienced shifts in the way they viewed themselves, the world and others. Participants described experiencing more ambiguity within the world and experiencing a world in which things no longer seemed straightforward, controllable and logical. The  138  experiences of the violent losses of their friends created dissonance and challenged their fundamental beliefs Working through the grief and trauma Participants became increasingly aware of the impact that the losses of their comrades had on them over time. Many participants found their relationships with family and friends invaluable in increasing their awareness. In some cases, participants were not aware that anything was wrong until family members or friends brought it to their attention. In other cases, participants started to see that something was wrong when their attempts to modulate their emotions through drinking or anger resulted in negative consequences for them and their relationships. Participants described being generally open to helping themselves or receiving help from others when they recognized that they were experiencing difficulties related to loss or trauma. One participant recalled recognizing that his behaviour was “getting out of hand” after one year of being back in Canada. Eventually, he asked his counsellor on a Canadian Forces Base for a referral to alcohol and drug rehabilitation: I asked to go because it was getting out of hand, you know? Getting drunk and going to hockey games, and getting furious. And getting kicked out of everywhere I went…I would like spill a drink on someone by accident and then they’d get mad and I’d take on whoever wanted to go ... Just embarrassing myself…I was really angry and unhappy with myself so I’d take it out on anyone who I could, and after the anger then I’d start crying. So I checked myself in.  139  A veteran of the First Gulf War described how he was initially reluctant to address the loss of his friend. He and his fellow Marines touched on the death of his friend during a reunion twelve years after the loss: We had some very emotional nights sitting around that pool half shitfaced. You know guys would let their guard down a little bit ... You’re starting to see the same ... feelings you had about this particular incident or thoughts ... Other guys were harbouring ... some of the same guilt, some of the same feelings. It was not until “shortly after the reunion” that his ex-wife encouraged him to get help, noticing that he was avoiding family and friends, drinking, and escaping with an online video game: My ex had started to encourage me to seek some kind of counseling. She was noticing me pulling away ... spending too much time drinking, and probably found bottles hidden around the house in various locations. Um, I did the escape, typical, classical escape thing. I got hooked on one of those online video games and I would play it until two, three in the morning until I was so exhausted ... She noticed obvious changes in my behaviour and stuff like that, and she started encouraging me maybe to think about counselling. A veteran threw himself into work in the years after the loss of his comrades, working sixteen to eighteen hour days. After his retirement from the military he found himself reexperiencing the day of the loss and he avoided others. Another comrade that he had worked closely with and trusted saw that he needed help: I was in a cage. I’d see people come down the street and I’d go down the back. I didn’t want to talk to people ... I didn’t want to have to explain to people why I wasn’t feeling good and I was having a hard time explaining to [myself] ... Once you start going fucking 140  downhill you don’t know how bad you really are. I mean you may think you’re doing alright so it’s the other people that see you ... My buddy got a hold of [my family doctor] and said, ‘Listen, someone’s gotta’ see him because he’s all fucked up.’ Many participants described how it was their friends that recognized their need for help. One veteran recalled how a close friend organized help for him: ... And you know my buddy, you know, like he was the one I could talk to. He ended up talking to [another veteran] ... They saw something was wrong. This participant was wary of therapeutic interventions and afraid to be vulnerable. His energy was focused on protecting himself emotionally within a competitive, “testosterone-filled environment”: The military is like the big hockey locker room. It’s just one giant pissing contest; who’s the tough guy ... Don’t cry ... You know, it’s a very testosterone-filled environment. You don’t want to be the weak one, right? It’s a pack of dogs ... You don’t want to be the runt of the litter. He reluctantly agreed to attend a workshop focused on trauma repair for veterans. He described being ready to go home before the workshop even started: I never heard about [the veterans’ group] ‘til [an older veteran] got me onto it ... He put me in a headlock and dragged me into it. He talked to me about it once and I said, ‘Ah, no that’s for crazy guys. I’m not crazy.’ You know, it was that machismo attitude coming through, ‘Fuck I’m fine I don’t need this shit’, you know? ... The first point is admitting you could use a little help. Another participant noticed changes in a friend who had been attending treatment.  141  [My friend] ... He started to see a counsellor on base, addictions counsellor. I started to see the improvement from him and how he was totally changing, you know? And here I was, drinking an eight pack of Guinness every night. Playing video games all day. I had a girlfriend but I didn’t talk to her. She just lived here ... Was goin’ nowhere ... So I saw how he was doing it and he recommended me to go see ... a counsellor on base. A meaningful relationship with a girlfriend after many years of avoiding family and friends helped one veteran to reflect on his loss and begin his “healing process”: Definitely having someone in my life that cared about me and that I actually started to care about. I think that helped me to think about my future. Thinking about like having a family one day ... I knew that I couldn’t have any of those things until I started to forgive myself and to love myself basically ... My healing process could begin ... Addressing what was actually going on inside. And that was having four people that I loved dearly taken away from me and like having abandonment issues still there. So, that definitely, having ... [someone like that] in my life helped me. After his overseas service, another participant described feeling as if his best years were behind him. He experienced many difficult months feeling as if “[he] had shot [his] bolt in life.” With this metaphor, he was referring to feeling as if his life was over. He realized he had to “pick up the pieces” within himself: They were rough, rough months. I was perpetually angry. Disappointed ... I was looking for everywhere to rejoin [active duty] ... [My relationship] was going down the tubes quickly ... I hated what I was doing ... I was so far away from my [military] friends ... That’s where I started to realize I can’t live my life like this. I’m not going to just say, ‘Alright I’m done, my life’s over. I’ll just write myself off. I got my four years and that’s 142  it.’ And I started to feel like, ‘No, I do have a lot more left in me and ah, I have to pick up the pieces within myself.’ Veterans started to get help after becoming aware that help was needed. One participant described his recognition of the impact of the loss and highlighted the importance of receiving help: I see a future…Without the help I received I would have been dead. I thought about committing suicide a bunch of times. I almost did it when I was in rehab. A doctor walked in when I was about to do it. I was gonna take x-amount of pills to just stop my breathing ... I didn’t care if I lived. After [getting help] ... I could see that I had a future. Participants who were able to come to terms with their loss experiences took an active role in adapting to their losses. Processing the loss, or grieving the loss, was “work.” Some participants worked through their losses themselves by practicing mindfulness, meditation, writing, and reading extensively about loss and trauma. Some participants found individual therapy to be helpful in making sense of their loss experiences. Five participants actively worked through their grief in veterans’ trauma repair groups. Taking an active role in their grieving— through individual work, individual treatment or group therapy—helped veterans to integrate and make sense of the loss. Individual therapy Several participants stated that they confronted and worked through their losses and trauma with individual therapy. A strong therapeutic relationship was essential to this process. As indicated by the sense of alienation that participants’ described, it was difficult for them to trust anyone. A key aspect of seeking help was finding a professional that they perceived as  143  legitimate and trustworthy. For all of the veterans, regardless of the form their processing took, having a good working relationship with the helping professional was vital. One participant described the crucial importance of trusting the professionals he worked with. He had been very cautious about speaking to anyone about his experience of loss. He trusted a social worker and “could talk to her because [they] had some talks in the past”: With this stuff man … Until you get to a point where you feel good about it you gotta’ have somebody you trust. You don’t want to trust a lot of people. You don’t trust a lot of people with how you feel in your heart. This participant described how individual treatment was more comfortable for him as opposed to group treatment. He indicated that he had been reluctant to speak to the researcher. He said, “I was a little apprehensive last couple days to come here, to meet you.” It was difficult for this participant to feel vulnerable and trust others to discuss his experiences related to loss. He explained the process of treatment that helped him. So, like I said, I went and got help; [A psychologist]…You know what was helpful? It’s a slow thing … You’ve gotta be able to start to let go, right? And, and you gotta be able to teach or explain to somebody what happened. You shouldn’t be ashamed of yourself. You did the best you could ... I felt responsible. Those were my guys. For this participant, retelling the story of loss with people that he trusted was what helped him to come to terms with, integrate, and make sense of the loss. Reluctant to trust anyone, especially helping professionals, another participant described how it was the genuineness of the therapists he met convinced him “they were for real”: I came in there like I didn’t trust anybody. I’m thinking, ‘Who the fuck are these doctors, like, why do they care?’… I didn’t trust anybody. Then they started sharing stories and 144  being vulnerable and you can see like, oh these guys are pretty decent. Any other doctor …they know everything about you, but you know nothing about them, so it’s lopsided ... [Knowing] something about them helped to ease my mind. The therapists that helped these veterans showed vulnerability, were genuine, and shared life experience. One soldier described how he was able to differentiate between helping professionals who cared, had experience, and were genuine, from helping professionals who did not possess these qualities. He described his favourite therapist: She genuinely cared ... I’ve had psychologists and doctors and stuff talk to me who I can tell don’t really give a shit. They’re just kind of going through the motions ... [My counsellor] was a civilian. She had a hard life growing up ... She comes from experience. So that’s the difference between her and someone who just fuckin’ went to university and came out ... You want to talk to people that have been through it before, you know? Just because there’s that bond ... a connection. Many participants described coming to terms with their friend’s death by actively processing their profound guilt with a trusted therapist. One participant stated that after he was able to relieve his guilt, he could begin grieving. A psychologist helped him to articulate his experience of guilt, labelling it “survivor’s guilt.” His psychologist suggested he “tackle” the survivor’s guilt by calling the mother of his deceased friend and telling her about his experience of guilt. He resisted this idea initially (“I can't do that!"). He described his motivation for eventually making the phone call to his friend’s mother: I think it was just, ‘I'm sick and tired of living with this. I'm sick and tired ... I gotta do something about it because it's killing me. I don't like the person I'm becoming. I don't like the guilt ... It's not going to fix itself. So if I don't work on fixing it, it's not going to 145  go away’ ... So if that's what it takes, what's it going to hurt to try, I guess? He got some buy-in with me, you know ... ‘Ok, well let's give it a shot.’ In making the phone call, he learned that his friend’s mother did not hold him accountable for her son’s death and this brought him a sense of relief: I think a lot of it is relief ... What happened for me was that at that point, the guilt part went away and then the actual grieving part could start ... And you know, I had a couple of ... rough years ... I think I just missed my friend ... I'm upset with myself for taking on this responsibility…or this guilt that I had no reason to take on and had been carrying. This participant was able to let go of some of his guilt. He was able to shed some of the weight of the responsibility for his friend’s death: I'm kinda going, 'Okay ... Alright, they're not holding me accountable. So who's holding me accountable?’ And that realization that,‘Yeah, you know what? You're right. The only fuckin' person that's holding me accountable for this is me. And why the hell am I doing that?’ So, I mean, do I still feel guilty? Sure, now and then I feel guilty but I don't obsess over it ... I feel sadness that my friend and a bunch of other guys are dead. He described being able to process other aspects of the loss too, such as his feelings of sadness related to his friend’s death. Another participant, through individual treatment and his own insights, one participant was able to come to terms with the losses of his close comrades: To understand that no matter what I did or what I’d done, I couldn’t have prevented this from happening. But what your heart tells you is the other side of the coin ... Where did you fail somewhere along the line to allow this to fucking transpire? And if you care and if you’re genuine inside ah, it’s, somebody took a piece of your heart that day. Somebody 146  stole a piece of my heart that day and ah…I can talk about it now. I mean I got a little teary-eyed here a couple times ... I suppose two years ago I started really coming out of it ... [My psychologist] and I, my psychiatrist said I didn’t need to see her anymore. I went off the medication that she’d given me. Veterans’ trauma repair groups Several veterans participated in a group-therapeutic approach. These trauma repair groups involved a group-based therapeutic approach where participants re-enacted and reexperienced the loss, were exposed to the pain of the loss, and actively re-storied the loss experience in a healthy way. They described feeling less isolated and more connected to fellow veterans after these groups. Participants stated that the groups helped them to describe the experiences of their losses of their friends. In some cases, they had not shared these stories with anyone. Some veterans described their participation in the groups as being the first time they had expressed their emotions concerning the deaths of their friends. Veterans’ described the groups as helping to alleviate the burden of the responsibility for the loss and for letting their friends down. The groups helped these veterans to make sense of their losses and understand how their losses had impacted their lives. Many of the veterans who participated in these groups expressed a sense of relief, connectedness to others, and increased control over their daily functioning. Despite feeling connected to other veterans in different contexts, the participants noted that there was something qualitatively different about being with veterans within a therapeutic setting. They attributed this to the structure, format, and facilitators (e.g., veteran paraprofessionals) of the groups. One participant described how the time spent with group was different from the way he would normally spend time with his friends. The group format offered him something new: 147  There was a format to it because I hung out with my buddies who were all soldiers but…we’d drink and we’d kind of talk about it, but it didn’t do anything ... This way there was a structure to it and a plan. So, you’d be with soldiers again but…you wouldn’t be drinking and just kind of shooting the shit. You’d be getting down to it and connecting … It wasn’t easy at first … I resisted. Veterans described their initial experiences within the group. As one participant previously described, veterans often entered the group with some resistance and a focus on protecting themselves emotionally. One participant described withdrawing and judging others before participating in the group. I had terminal uniqueness before, like no-one’s story was the same as mine…Yeah you were overseas but you didn’t do this or that … It was always an ego competition and maybe that was a protection to not let anybody in. He described how guarded he was as he entered the group: I’m a master of just not allowing (myself) to feel. And yeah, when I first showed up I couldn’t feel. I had no empathy whatsoever. The only thing I could feel was anger. Another participant described his anxious anticipation for a veterans’ trauma repair group, echoing the mistrust and caution that other participants expressed about therapeutic encounters: I knew it was gonna be heavy shit. You know, your defences are up. You don’t really know what’s going on and you don’t know what’s gonna happen. You know, I kinda had a basic idea but it’s like, I’m going in with a group of guys I don’t fucking know. Are we gonna sit around a campfire singing Kumbaya? What’s going on here? It’s just that  148  testosterone attitude of, “I’m fine, just give me a bottle of beer I’ll be fine.” I ended up going. Veterans participated in enactments within the trauma repair groups. These involved carefully acting out their loss experiences with group facilitators. Other veterans in the group played key roles of individuals who were part of the loss experience. Group members witnessed enactments of loss. Typically, when the enactment ended, group members discussed what they had observed and how the enactment affected them personally. All participants in these groups described experiencing increased group cohesion after the enactments. As one participant described: I just felt alone still. And that’s when I came into contact with like the [veterans’ trauma repair group]. Obviously like meeting [a new friend] was like a huge, we had a huge connection. His enactment helped me a lot ... When I did my enactments ... He was experiencing what I was experiencing ... He would break down. Like he broke down a couple times and when he did his enactment it was almost like I was letting all his emotion go for him ... It was probably one of the most powerful things I’ve ever experienced. As this participant enacted his experience of the death of his best friend, he was able to say things that he was not able to say to him in the midst of the former high stress combat situation: My enactment helped me with that ... I got to say a lot of things to him that I didn’t get to say before ... so that really helped me a lot. Because I’ve obviously had dreams about that scenario a lot ... and just letting go of telling the story that I’ve never told anyone, about [my comrade].  149  Another participant described the experience of enactment that is unique to the veterans’ trauma repair group: [It] was definitely the first time that I actually expressed deep kind of emotions. Witnessing that and doing it. It was kind of something that we did at [drug] rehab but we didn’t go deep, so it was a real connection to another person. So I hadn’t had that in a while, I shut that off. Another veteran described how he became frustrated and struggled to express himself during his enactment until he tapped into his anger: It wasn’t working for me. So they decided that anger would be a better emotion to use. So they set up Taliban against the wall and I would just yell at the Taliban ... I just started getting mad at the [Taliban], just yelling. [A group facilitator] started yelling along with me at them. And that’s when I broke down and started crying. All participants described the communication skills component of the veterans’ transition group as helpful in enhancing their relationships with their girlfriends or coping with difficult relationships with co-workers or bosses. Participants described the group dynamic as shifting from loss-focussed to future-focussed by the end of the group. Participants generated and discussed life and career goals during the last part of the group. Group members also found the post-group network of communication with one another to be very helpful. One participant described a strengthened support network that developed from his group experience and described how his friendships grew closer after the group: ... A little more positive outlook on things. Like being able to talk about it you know and having a network of people I can talk to things about is huge…Like having one of my  150  best friends go through it with me ... if he’s having a bad time he can give me a call I can be over there ... And vice versa. Another participant described how his nightmares related to the death of his friend decreased after the veterans’ trauma repair group: The [veterans’ repair group] helped a lot. The nightmares went from every other night to maybe once a month. So you know they’ve, they’ve calmed down quite a bit. But you know, I mean, you still get the thoughts every once in a while. Individual work Participants’ worked through their grief and loss in a variety of ways. In addition to group and individual therapy, participants described various independent activities, such as, reading memoirs of loss and trauma, writing about the loss, practicing mindfulness, and processing the loss with other veterans, to be helpful. Not all of the participants found therapy helpful or even participated in therapy. One participant described how he would rather speak to other veterans about his loss and tour experiences. One of the veterans that he spoke with almost daily had been very close to the comrade who died: I talked once to a Veteran’s Affairs counsellor ... He was good, he listened, and I ... kind of vented a little bit it. It was like an hour session ... it was good. A lot of it I came to terms with myself and with my friends who had been there ... And so talking with my friends was the best thing for me. Better than finding some guy with, no offense, but a PhD ... I would rather talk to the guys who’ve got the sweat and blood on their boots as well, right? So that was always the best thing for me.  151  One participant found that the writing process helped him to explore his thoughts, emotionally process, and develop a coherent narrative of his loss experience. Writing served to help him not only come to terms with the death of his friend, but also his own mortality: The writing process is therapeutic and it also helped me…explore my own beliefs regarding certain things…I just think writing is…there’s so much going on even beneath the surface. Like a lot of times when I’m writing, I feel like almost I’m channelling something and it’s not necessarily even me writing ... It just feels so therapeutic, right? It just feels like you get so much out that you’d never be able to get out otherwise. He believed writing helped him to put many aspects of his life together and become more connected with the “lessons of mortality” that helped him to understand his “path”: [Writing] involves … a complete gathering together of my whole life experience…It was like everything that had happened before was like lessons to help me understand my path. I tried to use the negative things that happened as positive as far as like keys to help me understand what’s behind certain doors, or to help me kind of make sense of life as I see it, and that works for me. I mean, it’s my own metaphor. Everybody’s got their own beliefs, but this is what worked for me. Mindfulness was described as important after the loss by one participant: In the moment, I’m fine. In the moment, I’m healthy. In the moment, nobody’s threatened. In the moment, my [family] they’re all okay … If I’m a little bit cold, I sit with it for a moment. If I’m sweating a little bit, I sit with it for a moment. You know, I appreciate that glass of water. It’s not every moment, but I try to be mindful, you know?  152  New insights and renewed purpose Participants described emerging with new insights and being able to, for the first time in years, experience their lives without the weight of their grief and trauma. One of the older veterans in the study described his change in perspective after participating in different forms of treatment and letting go of guilt and grief: The 10, 000 foot view ... I know I have it. I know that I have lived a fairly normal life in the 20 years since. I know that I can live a better 20 plus years with the tools and resources to manage it. I relapse, absolutely. I have good days, and days I rather be dead. I still self medicate but with enough control that it doesn’t affect my life. I still feel distracted, not part of the world, different, like I have nothing in common with ninetynine percent of the people I am around but I am aware. Another veteran was transformed by the help he received to cope with his loss and overseas trauma: A year and a half ago my life wasn’t meaningful at all. Just didn’t give a shit. I was in the fuck-it-zone. Fuck it. It’s different now. I wake up with a fuckin’ smile. You know and I look forward to each day. I really take advantage of nice days ... I get a feeling inside, like a warmer feeling when it’s a nice day out. Even when it’s raining, I like it when it’s raining. Another veteran described how the death of his friend has lead him to value his relationships more: You never know when those relationships could end. I mean I could lose my wife, so you put in 110 percent ... You deal with, and love, and enjoy because it might be gone. And  153  those are things I don’t take for granted anymore ... so I enrich my relationships, and so I try to put 110 percent into them. A participant who retired from the Navy stated that he is thankful for where he is now and “glad to be alive”: To be where I’m at today is a wonderful, wonderful thing. I’m glad to be alive. I got two granddaughters. I love ‘em with all my heart and soul. Um, love my wife ... Be in the woods hunting tomorrow. Going rabbit hunting, got a beautiful old, big old dog. You know I don’t have many cares in the world but it took a long time to get there and that’s, that’s the sad thing. Most of the participants expressed a changed worldview. They were able to be positive about where they were, despite having had their assumptions about the world changed. Although the world was not wholly comprehensible, predictable, or controllable, participants realized that living could no longer be taken for granted: Right now the future feels pretty good but at the same time I know how mortal we all are ... I could get t-boned leaving the parking lot tonight ... Or we could have an earthquake right now and this building could collapse. It really helps enjoy moments a lot more just knowing how mortal we are. Another participant described feeling different after actively grieving the loss of his comrades: I had my eyes. My counsellor noticed and other people…colour in my face and I was kind of happier…I had more empathy. Being every day in rehab, people talking about their problems, I could understand it and connect with them … Had none of that before ... I still have a long way to go because I don’t let people in easy. And like, empathy is the 154  first thing to go. So I still have a lot of work to do there right, but I’ve seen that I can do it. I know how to. Other participants spoke about how their life philosophy shifted due to their loss experiences: If I can use the term ‘the universe,’ it seems the universe is screaming at me…It’s my willingness to look at it and explore it, and understand it, that has helped me deal with everything ... from the death of [my comrade], to the death of my uncle, to my own … mortality. So it’s some big stuff to embrace sometimes but I try to look at it as a positive. You know, ‘What am I learning from this? What do I have to learn from it?’ One veteran explained that his comrade’s death and other aspects of his tour—such as being in a position where the members of his unit and he were almost killed—helped him to put life into perspective. Reflecting on these experiences contributed to an overall shift in terms of appreciating life, relating to others, and even spiritual growth. He described making peace with his existence and not taking life for granted: This guy opened up with a machine gun … [machine gun] rounds were cracking over our heads…In that moment I just felt a surrendering like, ‘This is it, I’m going to die.’ And I felt like if I would have lifted my head, even a little bit, that a bullet would have hit me … There was kind of a feeling of peace that came over me and I just kind of had…some very strange thoughts about my life and things I didn’t do…It seemed to alter the course of my life afterwards … it was a tense moment and … I just kind of felt really thankful … I just felt, you know, I shouldn’t squander my life and if there are dreams in my heart, they’re there for a reason and I should at least try to fulfill them.  155  Another participant who witnessed the death of his friend reflected on being faced with life and death situations in his overseas tour of Afghanistan. You’re faced with life and death situations ... Everything’s stripped away. It’s all stripped away when you get in circumstances like that. When you think you’re gonna die or you could die at any moment, you know, all the little bullshit just doesn’t matter anymore. One participant described how thinking about how his fellow service members might view him if he were to follow a path that was less than his potential helped him to motivate himself. He described being motivated by not wanting to let his comrades down. He said: I remember thinking when I was working construction, ‘I’m letting these guys down who expected so much more from me’ ... that idea of not letting my [comrades] down and calling them in 10 years and being like ‘Yeah I just, I’m 250 lbs of lard and I work construction and I’ve got like 3 kids that I can barely afford and that’s it.’ They would have been like, ‘Wow, I expected so much more’ ... the idea of not letting them down is what got me going again. After experiencing a difficult adjustment to his life back home, he described coming to terms with the loss of his friend by “picking up the pieces” within himself; harnessing his internal locus of control and finding purpose. He recalled: First I quit construction. Started my own business ... I started taking a few classes ... to get back into school ... and start to learn and remember why I loved politics/international relations so much right and history. And so I started to do well in them I put a tonne of effort. I used the skills I learned in the [military] ... You know, getting the job done, doing it right. All those things and I slowly brought it together.  156  He described how setting goals that he believed in, developing his own business and reflecting on his military service values helped him to adjust to the loss of his friend and civilian life. I feel that when I’m on this path. When I’m in this stream going towards my goals that I value, that I can deal with anything and I’m never going to revert. Honouring their comrades Participants spoke of wanting to maintain and honour the memories of their deceased friends. Some participants organized reunions and memorial services. Other participants described the importance of funerals for their fallen comrades and were part of, or organized, memorials for their friends. One participant kept pictures of his overseas service with his friend and developed a web page devoted to his comrades in the Marine Corps. A participant who was a veteran of Afghanistan described how he attempted to trigger positive memories and keep things in perspective by displaying a picture of his friends: I’ve never been a big guy to have pictures of myself anywhere, but one thing that’s been very important to me is to have a couple of pictures of me and my buddies in Afghanistan by my front door…I try and take a moment when I’m walking out my door to just kind of look and just remember ... The more I can trigger those memories in a positive way, the better … just to remember. Put things in perspective. One veteran put together a twentieth anniversary memorial that was held on the day that his comrades died. He stated that his comrade’s son asked him many questions about his father and it pleased him to be able to help answer these questions. Another participant described a connection that he made with a fellow Marine through his grandfather’s funeral: My grandfather, when he passed away, he had none of his ribbons from WWII ... I made it my mission to expedite a set of medals for him. I pinned ‘em on him in his casket ... I 157  turned around…my aunt has re-married…a Marine…a former Captain, Company Commander of an infantry unit in Vietnam…This was the first time I ever met the guy… He walks up to me … Gives me this big hug and he goes, ‘That by far has been one of the most touching things I've ever seen’…Watching me pin my grandfather's medals on his jacket in the casket…it's that kind of stuff that guys'll do for each other. You can't ... I don't think you can describe that. Many participants had tattoos that symbolized their military service. One marine had many tattoos representing his service including a tattoo in his best friend’s memory. Another veteran had a tattoo with the initials of his friend. The participant who had experienced the death of his best friend in addition to three very close friends wore a metal bracelet around his wrist as a memento reminding him of his fallen friends. Describing it, he said: It has all their names on it and the date that they died and I can never take it off. It’s ... called a Spartan bracelet, it’s made for this purpose ... The symbolism is that you can never forget them. You’re going to have to pretty much cut off my wrist to take it off ... It’s kind of cool, it’s a constant reminder ... [A therapist] actually helped me realize ... that it helps me to open up to people ... when people ask about it ... I lost four friends and this is why I wear it, so like I can’t really ignore the question like I used to. Remembrance Day in Canada, or Veteran’s Day in the U.S.A., was described as a particularly difficult day for many veterans as they paid tribute to their fallen comrades. It was an important day for each veteran as an ongoing remembrance of their comrades. One veteran shared: Remembrance Day is always an emotional day. Everything comes flooding back on that day just because, it’s just everyone ... It’s their day obviously, those that we’ve lost. And 158  you know you get a drink and you’re, everybody’s talking about it. By the time you go home at the end of the night ... sitting there with ... the girlfriend. And all of a sudden ... crying, you know just crying ... Those thoughts start coming back again. Summary Findings revealed the life-changing impacts of the sudden and violent loss of a fellow comrade and friend on veterans. As participants described their losses, it was clear that they had formed strong emotional attachments to the person who died. The interpersonal connections with deceased comrades are reflected in each theme and in the biographical introductions of each veteran. The veterans perceived that few military outsiders understood the situational demands and experiences that they encountered over the course of their overseas deployments. Within the context of overseas conflict, participants described coming to depend heavily on their comrades for emotional, psychological and physical support. The emotional attachments between service members served to provide support, protection, and prevent isolation. Participants described forming familial bonds with their comrades in their tight knit groups. This, along with the severity and intensity of combat, is what participants portrayed as making the loss of a fellow veteran and close friend so powerful and painful. Veterans’ had to delay grieving the violent and sudden losses of their comrades in order to carry on with the demands of their service duties. Following each loss, participants described grappling with a heavy sense of responsibility for the deaths of their friends and a sense that they had somehow let their friends down by being unable to protect them. These experiences often manifested in the form of guilt for surviving and continuing to live after their friends had died. Common to participants’ experiences was the sense of feeling helpless to protect the friend who 159  died and extreme anger toward individuals and circumstances that contributed to the friend’s death. In addition, each participant described experiencing multiple losses, something that may be unique to research concerning overseas military service due to the nature of this highly dangerous work. All participants described the deaths of their comrades as having lasting impacts on their lives. Participants described yearning for the lost friend and distancing themselves from reminders of their death in a variety of ways. Participants described feeling emotionally numb, angry, shocked, unable to move on, and ultimately, being unable to make sense of the loss. Participants described experiences which seemed to exist outside of, yet were related to the loss, such as depressive symptoms and symptoms of trauma (e.g., avoidance and intrusive thoughts about the loss). Participants often perceived increased arousal as something that remained with them as part of their overseas service but not necessarily related to the violent losses of their friends. When participants returned home after their overseas service they often struggled with a sense of disconnection, alienation, and mistrust of others. Participants commonly distanced themselves from their families and others in order to cope with their own processing of grief/trauma, to protect others from what they had witnessed, and because of their sense of responsibility/guilt concerning the deaths that they often felt. Following the death of a comrade, participants described experiencing a heightened sense of vulnerability, an increased awareness of their own mortality, and a sense of being changed irrevocably by the loss. Participants described how increasing their subjective awareness of the impact of the loss was crucial for taking steps toward working through their grief. With each  160  participant, this awareness was facilitated by a friend or family member who helped them realize how the suffering from the loss was affecting them. Within this study, coming to terms with the loss commonly occurred after finding people that participants trusted to speak to about their experiences. Those who worked through the loss individually, wrote about their experiences, practiced mindfulness, reflected on lessons of the loss, and found purpose. Therapeutic relationships built around trust were essential to helping veterans, who were wary of the intentions of others after their losses. Through these relationships and their own processes, some participants were able to grieve and emotionally process their losses. Participants emerged with new insights and some participants were able to experience themselves, others and the world without feeling the heavy weight of their guilt, anger, and feelings of responsibility that had once been associated with the deaths of their comrade(s).  161  Chapter 5: Discussion The experience of the violent death of a close comrade for veterans is complex and has the potential to create distress that is unknown to, and commonly misunderstood by others. The purpose of the current study was to understand this experience by hearing directly from bereaved veterans whose comrade friends had succumbed to violent and sudden loss. The research question addressed in this investigation was: What is the meaning and experience of coming to terms with the traumatic loss of a close comrade for veterans? Veteran participants were interviewed regarding their experiences and analysis of the interview content was conducted according to a phenomenological methodology (van Manen, 1997). Beyond the information gleaned from the current study, little is actually known about how veterans experience the violent death of a close comrade due to the current paucity of empirical research on the topic. This is rather shocking since there have been many casualties associated with recent overseas conflicts, particularly in Afghanistan and Iraq. The impact of trauma on war veterans has received considerably more research attention in comparison to the subject of bereavement (Currier & Holland, 2012; Harrington-LaMorie & McDevitt-Murphy, 2011). The trauma research has focused primarily on killing, atrocities, fighting, and stressors that may occur during combat (Currier & Holland, 2012; King et al., 1995). However, losing close friends in overseas service is a common experience for service members. For example, in analyzing the statistics based on the National Vietnam Veterans Readjustment Study (NVVRS; Kulka wt al, 1990), Papa et al. (2008) found that more than half of the Vietnam veterans surveyed had lost a close comrade. More recently, Hoge et al. (2004) found that seventy-five percent of American service members in the field from the 2003 Invasion of Iraq (March 19-May 23, 2003) had experienced the death of someone in their immediate unit. Given the prevalence of 162  violent loss among comrades in recent world conflicts, the bereaved veteran’s experience is a worthy topic of study. For the purposes of discussion here, where commensurate research is unavailable, findings from the homicide and other violent death literature are extracted and compared to the findings from this study. The initial responses described by the bereaved veterans in this study share characteristics with general grief responses detailed in the bereavement literature (Bowlby, 1980; Lindemann, 1944; Parkes, 1996; 2009; Worden, 2009), and the literature concerning those bereaved by homicide (Goodrum, 2005; Parkes, 1993). Participants in this study described a range of emotions after finding out about or witnessing the loss of their close comrade(s). Initial feelings of numbness, shock, disbelief were prominent in veterans’ accounts. In particular, the initial emotional responses of shock and numbness have been observed in previous research. Shock is an especially common initial response to loss and is believed to be more common in the case of sudden loss (Worden, 2009). Numbness, another common reaction often experienced early on in the grieving process, has been described as a protective response preventing an overwhelming flood of feelings, blocking sensations and defending against what would otherwise be highly distressing emotional pain (Parkes & Weiss, 1983; Worden, 2009). The numbing reaction is described as protective, allowing the reality of the loss sink “into… consciousness bit by bit” (Silverman, 1997, p. 392). Interestingly, findings from the current study indicate that the initial numbness experienced by veterans in response to their loss, endured for months, and even years, after the death of their close comrade. There was little opportunity to acknowledge their loss, much less allow themselves to feel the emotions associated with the loss. Veterans inhibited their grief as they were still in combat situations and given the way that the  163  military dealt with the circumstances surrounding the losses by quickly “cleaning up” and getting back to work. Participants’ reports of searching for explanations in the wake of their comrades’ deaths are supported by the literature as a common reaction to sudden loss, including homicide. Worden (2009) suggests that especially in cases of sudden loss, there is a strong interest in explaining the death. He noted that when sudden death occurs, the search for explanations is related to the need to find meaning, to understand, and to determine the cause. The veterans in the current study reported expressing a strong desire to know about the cause and details surrounding their comrade’s death. In most cases, they provided detailed and extensive explanations concerning the circumstances surrounding the deaths of their comrades. For example, one veteran’s process of searching for explanations focused on a discussion he had with his friend about who should fill a spot in a vehicle in the days before his comrade’s death. He continued to ask himself whether he had made the right decision by letting his comrade go in the vehicle after his comrade was in the vehicle when he was killed. Another veteran spoke about thinking about the details of the day his friend was killed by an insurgent and all of the situational factors leading up to his comrade’s death. Rynearson (1994) describes this phenomenon as compulsive inquiry and, “involuntary pathological rumination of the death” (p. 342). In the case of homicide, for example, he asserts that there is a need to know how and why the tragedy happened—a need which may persist long after the crime has been solved and the perpetrator has been punished. Rando (1996) suggests that it is the perception of death as preventable which increases the duration and severity of mourning, and motivates people to search for explanations, affix responsibility, and carry out punishment whenever possible. This certainly fits for the participant who experienced his friend killed through “friendly fire” (accidental shooting by a member of 164  the section), the participant whose best friend took his spot in the vehicle that was destroyed, and the participant whose friend was killed after taking his spot in a convoy of vehicles attending a meeting in a village. The search for explanations after the loss appears to be part of the larger process of existential reflection, or meaning making, which is considered among bereavement researchers to be part of the adjustment to stressful events (Currier et al., 2006; Gillies & Neimeyer, 2006; Davis et al., 1998). Taylor (1983) suggests that this search for meaning is an attempt to answer questions concerning the significance of the event. She states, “Meaning is exemplified by, but not exclusively determined by, the results of an attributional search that answers the question, what does my life mean now?” (p. 1161). Janoff-Bulman’s (1989; 1992) “shattered assumptions” research, as described in Chapter 2, asserted that the fundamental assumptions individuals hold about themselves, the world, and others may be shattered following a violent loss (JanoffBulman; Matthews & Marwit, 2003; Currier, Holland, & Neimeyer, 2006). Furthermore, the bereaved veteran’s quest for explanations may be part of the process of meaning-making proposed by Park (2010), whereby people attempt to resolve the distress they experience due to discrepancies in their appraised meaning of the event in contrast with their global assumptions or beliefs about life. Participants’ search for explanations, within the context of Park’s (2010) model, would be attempts to reduce discrepancies and restore a sense of the world as meaningful and their lives as worthwhile. The search for explanations for participants started shortly after the death of a comrade as participants sought causal explanations for, relived, and returned to the circumstances of the loss. The results of this study are aligned with research regarding homicide and violent death. Anger is a common initial response after loss (Worden, 2009), particularly after a violent loss 165  (Parkes, 1993; Rynearson et al., 2013). However, the few studies specific to veterans’ bereavement experiences did not explore experiences of helplessness, revenge and anger (Papa, Neria, & Litz, 2008; Pivar & Field, 2004). Specifically, participants’ accounts of rage and desire for retribution reflected similarities compared with the literature concerning a survivor’s experience of homicide (Parkes, 1993; Rynearson, 1994; Rynearson, 2001; Rynearson et al., 2013). Homicide-related literature has described those close to the individual as having frequent thoughts of killing those responsible for contributing to the violent death of the person that they cared about. Rynearson (2001) notes that a desire for retaliation, retribution, and punishment are commonly experienced by individuals who survive the loss of significant others by homicide. All of the bereaved veterans in the current study spoke of wanting retribution for their friends at the time of their death, particularly if the death occurred due to a hostile encounter (e.g., enemy), yet also in cases of non-hostile death (e.g., fratricide, fatal accident). One veteran described a “deep, deep desire” for retribution that partially stemmed from wanting to show his friend that he meant something. He went on to state that his friend’s murder left him with an “insatiable” amount of hatred toward the enemy. Another veteran, who had experienced the death of a comrade by friendly fire, echoed this sentiment. He initially directed his desire for retribution toward the service member who had taken the shot that had killed his friend and comrades, however, his desire for retribution generalized to other individuals. For example, he stated that he considered killing an Iraqi soldier to legitimize his comrade’s sacrifice. Revenge was something that participants in the current study thought about frequently. It was viewed as a mechanism for meeting emotional needs within a narrow set of available options in the context of their overseas deployment. Enacting revenge, if only in their minds, upon those who contributed to their friend’s death was viewed as an acceptable solution; a way to fulfill 166  emotional needs in the context of battle, and an instrumental way to express grief. Although participants spoke of wanting to kill the person or group responsible for contributing to the deaths of their comrades, most participants acknowledged, with considerable frustration, that it was difficult to find out who the actual perpetrator was. Although he is not speaking specifically about violent death, Worden (2009) describes sudden death as an assault on the survivor’s sense of power and orderliness. This results in feelings of helplessness and rage. It is common for the survivor to want to project their anger on others to defend against the pain and distress of reality (Rynearson, 1994). Retribution may be considered by the survivor as a way to restore order or a sense of equilibrium. Rage and retribution may be ways that veterans adjust to the loss of a comrade and gain “a feeling of control over the threatening event so as to manage it or keep it from occurring again” (Taylor, 1983, p. 1163). Even in cases where the violent death was the result of an accident, participants experienced rage toward the individuals that they believed were responsible for the deaths of their friends. One veteran projected his anger toward senior officers who he believed were responsible for the death of his comrades and whom he believed had “tried to cover it up” by blaming it on a service member of low rank. The findings here are similar to those described by Rynearson (1994), who states that, even in cases where the violent death was not intentionally caused, there is a presumption that the perpetrator was somehow negligent and inadvertently to blame. In many cases, participants’ experiences of anger continued to endure for years after the death, even in cases where the time since the loss was twenty years. A central part of all participants’ experience of the violent death of their close comrade involved living with a profound sense of guilt. Participants’ described several components of 167  their guilt, including: a sense of responsibility for not having prevented the loss, a sense of guilt for not having protected their comrade, the feeling of having let their comrade down, and a sense of guilt for existing or being alive while their friend lost his life. One participant struggled with the decision to let his friend take his place in a vehicle that was destroyed. Another participant perceived that his losing track of time had resulted in his comrade’s death as his comrade was killed in the spot he was “supposed” to be. The depth of guilt and sense of responsibility experienced by each veteran appeared to be proportional in intensity to the closeness of their attachment to the lost friend, and the circumstances around their friend’s death. Participants who spoke of strong affective bonds with their fallen comrades appeared to experience more guilt and responsibility-related feelings that endured over a longer period of time. All of the participants reported that the sense of guilt continued in the years following the loss, until participating in some form of treatment (e.g., group, individual) or doing individual work related to the loss. The existing literature at the time of this study was based on research focused on veterans’ experiences with loss more than thirty years ago, for example, during the Vietnam War. Links between survivor guilt and poor post-deployment adjustment have been highlighted within literature related to Vietnam War veterans (Glover, 1984; Henning & Frueh, 1997; Opp & Samson, 1989; Papa et al., 2008). This literature is not focussed primarily on veteran’s bereavement experiences. Rather, the primary focus of this dated literature concerns guilt as it relates to military service (Glover, 1984; Opp & Samson, 1989), PTSD (Henning & Frueh, 1997), and the suicidal behaviour of Vietnam veterans (Hyer, McCranie, Woods, & Boudewyns, 1990). The present study uncovers a deeper understanding of the experience by highlighting the meaning underlying each veteran’s feelings of guilt and sense of responsibility for their friend’s death. 168  An Opp and Samson (1989) article, based on their own clinical practice and a review of the literature, posits a taxonomy of guilt specifically for combat veterans. One of the types of guilt related to combat trauma that they identify is survivor guilt. Survivor guilt, as defined by Opp and Samson’s study, is the veteran’s sense that he or she should have died, that he or she did not deserve to live, and that somehow his or her survival has cheated someone else out of living. A principle experience of survivor guilt is unworthiness. Many participants in the present study described living with the sense that it should have been them that died rather than their friends. Some participants questioned whether they deserved to live when their friends had “given everything.” Some participants described being troubled by the idea that the men who died were more worthy or had more reason to live because they had wives, children, and a sense of purpose. One of the thoughts of another participant was that his friend’s relatives would be angry at him for living while his friend died. Several participants also described feeling guilt for not doing enough with their lives in the years following the deaths of their close comrades. The results of this study also join with the existing literature related to attachment and loss (Bowlby, 1980). Findings are consistent with research that has documented the importance of service members relationships to their comrades (van der Kolk, 1985; Papa et al., 2008; Pivar & Field, 2004). The present findings underscore the closeness of veteran relationships and consequently, the significant impact of their loss. Detailed descriptions offered by each veteran participant in this study indicated a high degree of attachment between them and their comrades. They described forming incredibly trusting relationships and family-like bonds with their fallen comrade. In fact, the affective bonds formed between these veterans appeared to serve as their primary attachment system leading up to, during, and following deployment.  169  Loss researchers have documented the significance of service members’ relationships to each other (Papa et al, 2008; Pivar & Field, 2004). Relationships serve multiple functions but are known to be particularly important in protecting against the development of mental health problems during and after combat (Charuvastra & Cloitre, 2008; Iverson, Nikolaou, & Greenberg et al., 2005). As the military setting is highly relational, the loss of a close comrade is a precipitant of significant grief reactions with the potential to interfere with military duties and long term functioning (Neria, Solomon, & Ginzburg, 2000). Demonstrating the long term impact of the death of one’s comrade, Pivar and Field (2004) found that a sample of Vietnam veterans had high levels of grief symptoms comparable to bereaved individuals following the death of a spouse, thirty years after their military experience. This finding not only validates the significance of the attachment between comrades but also the long term impact of this type of loss. Similarly, participants within the present study—whose time since the loss ranged from two years to twenty years—expressed significant attachments to their comrades. Participants who experienced the deaths of comrades twenty years before this study continued to experience very strong attachments to their fallen comrades and unresolved grief for years after their losses. Participants formed incredibly trusting relationships and “families” with their comrades/friends. One participant stated “If one of my guys called me up today and said, ‘I'm in trouble,’ I'd be on a plane tomorrow morning.” Friendships endured and mattered more to participants than other aspects military service. Veterans’ grief is often addressed by military protocols (e.g. memorial services) and the widely-held perception is that the grief process is expected to be resolved at that point (Harrington-LaMorie & McDevitt-Murphy, 2011). However, service members often return to duty with the acute and long term effects of grief lingering and under-recognized (Harrington170  LaMorie & McDevitt-Murphy, 2011; Papa et al., 2008; Pivar & Field, 2004; Currier & Holland, 2012). Participants in the current study confirmed this when they described delaying their grieving indefinitely, or at least until returning home from deployment. The intensity and ongoing nature of their overseas duties, along with the fear of being stigmatized, led them to suppress their grief reactions. Some participants described turning to substance abuse to keep from experiencing their grief while others turned those feelings into more acceptable outlets, such as anger. Participants’ descriptions of protracted and unfinished grief are comparable to observations of grief-related distress suffered by veterans decades after war and conflicts (Neria et al., 2000; Pivar and Field, 2004). The time since the loss for veterans in the present study ranged from approximately two to twenty years, yet there was evidence for continued grief and trauma related symptoms even twenty years post-loss. Although participants were able to speak about their losses, they described experiencing a combination of grief and trauma-related symptoms beyond six months post loss. These studies are consistent with empirical literature reporting enduring and continued grief and trauma-related suffering after violent loss (Green, Grace, & Gleser, 1985; Neria et al 2007; Pynoos, Nader, Gonda, & Stuber, 1987; Rynearson et al, 2013). The present research adds to the observations concerning the significant role that unresolved grief played in the distress suffered by Vietnam veterans (Pivar and Field, 2004). Several studies concerning Israeli war veterans from the Yom Kippur war suggested that exposure to loss was related to grief-like psychopathology (e.g., depressive symptoms, anger, guilt) even two decades after the war (Neria, Soloman, Ginzburg, 2000). These studies are consistent with reports among civilians suggesting that violent loss is one of the most pernicious 171  human experiences (Neria, Gross, Litz, et al 2007; Pfefferbaum et al; 2001; Rynearson & McCreery, 1993). The findings also substantiate findings concerning violent loss by Green, Grace, and Gleser (1985) who observed continued suffering after life threat, injury, and interpersonal loss following a nightclub fire and Pynoos, Nader, Gonda, and Stuber (1987) who identified PTSD and grief symptoms in children after a sniper incident. Participants described initial reactions that did not appear to deviate from “normal” initial bereavement reactions (Worden, 2009), yet many of their symptoms continued to affect their functioning within family relationships, interpersonally, and across other areas of their lives such as work. For example, some participants described difficulty finding meaningful work after their service and being affected by trauma and grief-related symptoms at work. Similar to the description provided by Rynearson et al. (2013) for survivors of violent loss, participants in this study described: (1) experiencing separation distress with feelings of longing for their friends, and; (2) traumatic distress in reaction to the manner of dying. In addition to grief, participants described: re-experiencing the loss in the form of intrusive and distressing images and perceptions; experiencing distress related to external triggers that somehow symbolized the loss and dream content/feelings regarding the loss; dissociative episodes, described by one participant as “out of body experiences”; and avoidance of others. In order to numb their responsiveness and cope with their experiences the participants described working, playing video games, using drugs, and using alcohol excessively. After the loss experience, participants emerged with an increased sense of their own mortality, a decreased sense of safety, and, in general, increased existential reflection. They admitted to being unprepared for the violence and violation of the losses and for the intensity of their own grief reactions (Rynearson et al., 2013). Similar to Janoff-Bulman’s (1992) 172  descriptions of changes within the assumptive world after trauma or loss, the participants described: feelings of increased vulnerability, a sense of their own fragility, and confronting their own mortality after the deaths of their friends. They began to question their beliefs about themselves, others and the world. They could not reconcile the inexplicable loss of their close comrades with their former beliefs about the world—beliefs that had previously provided them with a sense of stability and coherence. As a result, participants’ found themselves faced with existential questions and reflections, following the deaths of their comrades. Participant’s experiences appear to fit with models focused on adapting to life stressors (e.g., Bonanno & Kaltman, 2003; Janoff-Bulman, 1992; Taylor, 1983). Park (2010) proposed an integrated model of meaning making in the context of stressful life events. Park’s (2010) model included these core tenets: (1) people possess global meaning systems that provide them with frameworks to help interpret their experience; (2) during situations that challenge or stress their global meaning, individuals appraise the situations and assign meaning to them; (3) the extent to which the appraised meaning is discrepant with their global meaning determines the extent to which they experience distress; (4) the discrepancy produces distress which initiates a process of meaning making; (5) individuals attempt to reduce the discrepancy between appraised and global meaning through meaning making efforts and restore a sense of the world as meaningful and their own lives as worthwhile; and (6) this process, when successful leads to better adjustment to the stressful event (Park, 2010, p. 258). Thus, global meaning refers to a person’s general orienting systems consisting of beliefs, goals, and subjective feelings. Global beliefs are essentially the same as Janoff-Bulman’s (1992) fundamental assumptions. There is evidence within this study to suggest that the more discrepant the appraised meaning toward the situation (e.g., “I did not protect my friend”) was with the participants’ global beliefs (e.g., “I will be there 173  to protect my friend”), the more difficulty the participant appeared to have in adjusting to the death of his comrade. All participants admitted to being unprepared for the violence and violation of the losses (Rynearson, 2013), regardless of their training. Similar to Janoff-Bulman’s (1992) descriptions of changes within the assumptive world after trauma or loss, participants described: feelings of increased vulnerability, a sense of their own fragility and confronting their own mortality after the deaths of their friends. Participants questioned the meaning of the loss and the comprehensibility of the world and struggled to make sense of what had happened to their friends. The deaths of their friends challenged their sense of fairness and seemed incomprehensible. Participants described difficulty assimilating the events with their prior knowledge. They described intrusive thoughts about the loss, re-experiencing of the loss and avoidance. Their new experiences after the loss did not match with participants’ previous experiences and assumptions which had provided them with a sense of stability and coherence. As a result, participants’ described experiencing a sense that they had been changed by the loss. In the working through process for violent loss, participants reported that a sense of trust was very important. Veterans who did not engage in formal treatment reported that they preferred to speak to fellow veterans, who had “blood and sweat on their boots,” or process the loss on their own terms (e.g., through writing). A significant finding was that those participants who did engage in mental health treatment were not likely to engage in any kind of treatment without first building a strong therapeutic alliance. Some of the participants within this study described treatment as a necessary part of their healing and reconciling the loss. Many of the veterans sought treatment for issues that they did not realize were connected to the loss of their friend, such as substance abuse, nightmares, post-traumatic stress symptoms, 174  relationship problems, suicidality and depressive symptoms. Veteran’s who participated in treatment described feeling anxious and noncommittal about initiating treatment. Most participants’ engaged in treatment only after receiving recommendations from fellow veterans. In some cases, the fellow veterans who had recommended treatment had gone through the treatment themselves. Another key aspect of participating in treatment was finding a person that they perceived as trustworthy. Several participants described their reluctance to trust helping professionals, however, they felt more comfortable with helping professionals who were genuine, experienced, vulnerable and caring. Processing the sense of responsibility for the loss, failure to prevent the loss and survivor guilt feelings were an important part of the working through the violent loss for the veterans in this study. For some veterans, the process of letting go of this responsibility and guilt for the violent loss their friend/friends took place through individual therapy. One participant described being encouraged by a psychologist to speak to his deceased friend’s mother. He described this process as being very helpful in letting go of his guilt for his friend dying instead of him. It was only after making this call that his grieving could begin. For some veterans, letting go of the responsibility and grieving the loss took place within the supportive group context of veterans’ trauma repair groups. Participants reported that these groups alleviated the sense of responsibility for the loss and for letting their friends down. Participants descriptions of the veteran’s trauma repair groups indicate that the groups helped to reduce their sense of alienation and disenfranchised grief (Doka, 1989). Participants stated that the veterans’ trauma repair groups involved retelling the loss (Herman, 1997; Neimeyer & Currier, 2009). For example, one participant described how he was able to tell the story of the death of his comrade that he had never told anyone. They described the veterans’ trauma repair 175  groups treatment as oscillating between a focus on loss and restoration, similar to Stroebe and Schut’s (1999) dual process model. For example, participants described grieving the loss and letting go of their profound sense of responsibility for the loss as well as reorienting to the world, learning communication skills, and setting future goals. Although research has started to focus on the interplay between trauma and bereavement (Papa et al., 2008) delayed grief due to the demands of military service, or because of the culture of the military, has not been explored extensively within the literature (Currier & Holland, 2012; Pivar & Field, 2004). The unstructured, experiential nature of the present study provided the opportunity to explore the multi-faceted experience of violent loss for veterans. Grief experiences due to the violent loss of a comrade were delayed, deferred or inhibited due to the demands/stressors of overseas service. Participants described having to maintain a strong focus on their duties and protecting their remaining comrades. The duties were often ongoing throughout the tour and there was little down time. Although one participant claimed that he and his unit normalized the losses by covering for other members of the unit by “shepherding” them away when they needed time to grieve, this was not the experience of most participants. Participants described inhibiting or delaying grief due to: (1) the extreme stressors and operational demands they experienced during their overseas service; (2) their survival within the military structure that they inhabited as part of their service; and (3) the interplay between trauma and loss. In his model of grief, Worden (2009) has described delayed grief reactions as following experiences where grieving is not adequately accomplished at the time of the loss and carried forward. The present findings support theory concerning delayed grief and can inform models of bereavement. According to participants in the current study, staying composed and in control of 176  their emotions was important to surviving within the military culture. Participants described inhibiting their grief due to fears of breaking down and not appearing in control, the lack of social acknowledgement of grief (other than through funeral rituals), and the existence of social norms within the military, which focus on being in control. Furthermore, participants described masking their emotions and resisting honest expression of grief during military post-deployment/ decompression due to a desire to return home and reunite with family and friends, to avoid being stigmatized or labelled, and for fear of admitting to ‘psychological issues’ which could affect future advancement within the military. Despite being an important facet of their experiences with violent loss, the impact of the military culture on the veteran’s grieving process was significant for the men in this study, and has not been explored within bereavement or trauma literature specific to military losses. The traumatic aspects of the death of a comrade and traumatic stressors within the midst of overseas service impaired and inhibited the reflective demands of grieving and adjusting to the loss. Participants described experiencing traumatic stress after witnessing close comrades’ deaths, cleaning up comrades’ body parts and personal items, and imagining the circumstances of their comrades’ deaths in cases where they were not present. Participants described many traumatic events such as witnessing the suffering of women and children, witnessing civilian deaths, and disposing of human remains at blast sites. Participants described maintaining extreme levels of vigilance and a variety of events. Often participants were not aware of how these events had affected them until they were able to unpack and differentiate these experiences within treatment or through individual work. These experiences inhibited and complicated grief experiences for participants, as described within literature concerning violent loss (Green, 2000; Neria & Litz, 2003; Raphael & Martinek, 1997; Papa et al., 2008). 177  Multiple losses also inhibited grief and complicated the grieving process for the participants within this study. All of the participants in the present study described multiple losses: friends/comrades who had been killed during their overseas deployments, friends/comrades who had been killed on subsequent or prior deployments, friends or acquaintances who had completed suicide, or individuals who had died in a fatal accident. Many participants acknowledged that they had not processed the deaths of their close comrades before experiencing the losses of other comrades. The experience of multiple losses during and after service has been noted but not explored extensively within bereavement literature. Papa, Neria, and Litz (2008), for example, in examining the National Vietnam Veterans Readjustment (NVVRS) database in the United States, found that increased numbers of close friends killed increased the risk for complicated grief. A significant finding in the current study involved participants’ descriptions of a sense of alienation, mistrust, and disconnection from others. Participants described many moments, prior to their healing process, when they withdrew from others. Many participants were still quite wary of people “outside” of their circles and preferred to keep to themselves regarding their tour experiences/losses. These shifts coincided with attachment struggles with family members, friends, intimate partners and the wider communities that participants had been part of before their losses/overseas service. Participants described distance between themselves and others due to difficulties related to emotional regulation, intrusive thoughts/feelings, and avoidance. Participants struggled to modulate arousal levels following their losses and overseas service. They had difficulty describing their losses and overseas experiences to their families and friends and adjusting to their own intensely emotional memories. Participants often needed time and space to get a handle their raw emotional experiences to the loss and overseas service. Some 178  participants described well-meaning efforts of friends and family as helpful whereas other participants kept their families and friends at a distance. Several participants in the present study described the origin of their disconnection from others in the shame and a sense of failure that they experienced in relation to their tours. This has not been explored extensively within bereavement literature related to veterans. One participant stated that despite civilian perceptions that he might be a “hero”, he felt that it was his friend who died and “gave everything.” He wanted to avoid others because of an internal sense of incongruence between the “incredible shame” he felt on the inside and how others perceived him from his outward appearance as a veteran who had returned from a tour of Afghanistan. Although disconnection has been explored in terms of avoidance related to trauma symptoms in studies regarding veterans with PTSD (Charuvastra & Cloitre, 2008; Herman, 1997; Orcutt et al., 2003; Riggs, Byrne, Weathers & Litz, 1998; Rosenheck & Fontana, 1996), there are few studies that have addressed or examined the sense of alienation or disconnection that veterans who have experienced a violent loss of a comrade may experience. Some support for alienation after loss is linked to literature regarding bereavement following violent death (Asaro, 2001a; Dregrov et al, 2003; Parkes, 1993) and disenfranchised grief (Doka, 1989). Charuvastra and Cloitre (2008) have noted the power of social support as a protective factor against psychological distress. According to Charuvastra and Cloitre social support can be a protective factor (presence of social support) and a risk factor (absence of social support). There were no studies concerning social support and bereaved veterans, specifically. The findings in this study revealed that participants believed that their loss and tour experiences were beyond the scope of what most people had experienced. Some participants experienced critical and unsupportive views toward their service. For example, one participant reported that he did 179  not speak to people about his experiences due to polarized political views regarding his country’s military involvement in an overseas conflict. Others found that their friends had difficulty tolerating hearing about their loss experiences. Thus, participants pushed down their need to communicate their grief and experienced silence. After trust and safety had been established with a mental health provider or in a veterans’ trauma repair group, several participants described the process of retelling the story of their loss as being particularly helpful. Four participants accomplished this through individual therapy. Five participants were able to do this within a veterans’ trauma repair group. One of the veteran’s described the telling of his story as an experience of “letting go.” Participants who had been involved in a veterans’ trauma repair group described the value of telling their stories through therapeutic enactments of the violent losses of their friends (see Westwood, McLean, Cave, Borgen, & Slakov, 2010). The veterans described how fragmented components of their stories were reassembled into a verbal account that was more oriented in time. This healing process is consistent with Herman’s (1997) description of the importance of reconstructing the trauma story including a systemic review of the meaning of the event to the person who experienced the traumatic loss and to the important people in the person’s life. Participants described enactments, retelling, and reconstructing the story of the death of their comrade as being helpful in being able to acknowledge and process their grief. Participants described experiencing deep emotions during the retelling process in some cases for the first time. According to Herman (1997), mourning is “the most necessary and the most dreaded task” in the synthesis of trauma. The importance of retelling the story of the violent loss has been viewed by researchers as a restorative way to come to terms with such losses and re-establish coherence and comprehensibility (Neimeyer & Currier, 2009; Rynearson, 2001; Rynearson & Salloum, 2011). 180  The finding regarding the critical importance of building trust in treatment with veterans is something that has not been specifically mentioned within literature addressing veteran bereavement. Just as trust was an important part of the relationships between the veterans and their comrades, trust was described as an important part of treatment. In working through grief and processing traumatic experiences, trust in others was important to the veterans in this study. All of the participants in this study experienced a sense of alienation as they lived with and processed their grief on their own. They sometimes did not even know that their unprocessed grief and guilt were the underlying source of their other problems (e.g., nightmares, anger, depression). Participants were extremely cautious about speaking to others regarding their experiences. There is some evidence for the importance of building trust within group-based treatment (Rozynko & Dondershine, 1991; Yalom, 1995). Building trust with veterans engaged in group work has been addressed more specifically in a study by Westwood et al. (2010). The findings of this study revealed that building trust and rapport with veterans was essential to any kind of grief or trauma support offered by professionals. It was foundational to any kind of treatment that followed. Participants also emphasized the importance of maintaining the memories of their friends. This occurred through organizing reunions, memorial services, keeping pictures, developing web pages, participating in Remembrance Day/Veterans Day, and tattoos and other symbols that related to their fallen veterans. This was reiterated during validation interviews by two participants. One participant described how helpful it was for him to take part in a memorial service for his fallen comrades twenty years after the event. The other, described getting a tattoo symbolizing his connection to his friend. Yet another wore a bracelet with the names of his fallen  181  comrades so that he could always keep their memory close. The continuing bonds of veterans and their fallen comrades is an area of research that warrants further exploration. In summary, the value of this study is in the unique nature of the sample of coresearchers; veterans who themselves had engaged in the process of coming to terms with the violent deaths of their close comrades. The themes that emerged from their insights reflect an effort to faithfully reveal what the veterans shared about their experience of coming to terms with violent loss. As such, the research findings contribute important insights for counsellors working with service members and veterans who have experienced the violent loss of close comrades. Exploring the meaning underlying the experience of grief for this population has implications for counsellors and mental health professionals in conceptualizing, engaging with, and helping veterans who have experienced loss. As the findings of the current study suggest, the experience of coming to terms with such a traumatic loss is challenging and complex. Participants in the current study integrated their loss experiences in a variety of ways. Some found a veterans’ trauma repair group very helpful whereas others were able to process their grief and were more comfortable with individual treatment. Participants also processed their loss experiences through individual work, such as writing about their loss experiences, mindfulness, and speaking to veteran friends. Implications for counseling The findings of this study reveal the many aspects and challenges that veterans may face in trying to come to terms with the violent loss of a close comrade. For the veterans in this study, responses to the trauma, and feelings of intense anger and grief, were delayed or inhibited during deployment. Consequently, for many of these veterans, it was months or years later before they were able to acknowledge and process their grief. In some cases, their unresolved grief and 182  feelings of guilt were masked by other feelings, actions and behaviours (e.g., anger, substance abuse, depression). Counsellors working with veterans need to be aware that unresolved losses may affect the lives of veterans for years after they return from deployment, and that the grief from these losses may be masked by other symptoms. In working with veterans, after safety and trust have been established, mental health professionals should provide opportunities for veterans to reflect back on their deployment experiences, and carefully probe for significant losses such as the violent death of a close comrade. Following the loss of a comrade, participants found that their grief was inhibited due to operational demands, military bureaucracy, and trauma experiences. Two veterans described situations where they attempted to support their surviving comrades after the deaths of their friends. One veteran described “shepherding” away his comrades following losses to give them some time to “gather themselves,” away from the group and away from others, such as superior officers. This allowed others to grieve the losses in small doses. Another veteran described being caught off guard by the tears of his surviving comrade and giving his comrade a hug during a brief supply run following the death of his close comrade. It will be helpful for deployed senior officers to acknowledge the grief of service members in a genuine way following the death of a comrade. The long term health, ability to function, and the return to duties will be best served by normalizing the grief process and validating the experiences of those affected by the loss. The resiliency of service members would be increased by: a) reducing stigma surrounding grief reactions; b) acknowledging the normal somatic, emotional, cognitive, and behavioural expressions of grief after the death of a comrade; and, c) allowing fellow comrades to express their grief symbolically (e.g., memento of friend). Post-deployment phases of military service can be improved through increased education concerning grief experiences after a violent loss 183  for Canadian and American forces support staff. Support staff can be helpful in the postdeployment phases of service by providing education about, responding to, and normalizing grief experiences. A central part of the participants’ experiences of the violent death of a close comrade involved living with a profound sense of guilt. It is important that counsellors understand that veterans may be experiencing feelings of responsibility for not having prevented the death of their comrades, feeling as if they had let their comrades down, and feeling guilty in some cases for being alive. Counsellors and mental health professionals can turn to literature concerned with working through and processing survivor guilt to assist veterans in this necessary part of the healing process. There is literature related to grief counselling (Stroebe & Schut, 1999; Worden, 2009), trauma (Bisson & Andrew, 2009; Cloitre, 2009; Foa, Keane, Friedman, & Cohen, 2009, Herman, 1997), and working with victims of violent loss that may be of help (Rynearson, 2001; Rynearson, & Salloum, 2011). There is less literature concerning veteran bereavement. Hoge (2010) has written a book specifically for veterans containing suggestions for coping with grief and survivor guilt related to major losses in combat. Within the current study, one veteran was able to let go of his guilt after speaking with his fallen comrade’s mother and being “forgiven” by her. Making contact with close family members and friends of fallen comrades may be one way for veterans to come to terms with their profound sense of guilt. This process may be healing in providing some closure and a way for the veteran (and family/friends) to share memories of an individual who they cared deeply for. Counsellors may recommend that the veteran write a letter to his fallen comrade or to family members, as a way of expressing his grief or letting go of his guilt (the letter would not necessarily need to be sent to be therapeutic). With both of the above suggestions it would be 184  very important to be attentive to the family members/friends needs and not to provide information that was not desired or asked for. One veteran stated that he made himself available for questions from his comrade’s son after a memorial that he organized for his fallen comrades. Veterans may also let family members know that if they have questions, or if there is something that the veteran can help them with, to let them know. It would be important in this situation for both parties to communicate clearly about and be comfortable with the information shared. As previously stated, many of the participants’ experiences of grief were protracted and unresolved over time. There was evidence for continued grief and trauma related symptoms for many years after the loss. Mental health professionals should be aware of the interplay between trauma and loss with this kind of violent loss, as well as the many complicating and concurrent difficulties that veterans face in being able to acknowledge and process such traumatic losses. For example, veterans described struggling with alcoholism, substance misuse, depressive symptoms, and trauma symptoms in addition to, or as part of, their loss experience. Consistent with the research of Raphael and Martinek (1997), the current study underscores the reality that survivors of violent loss often cope with trauma and stress in addition to death and grief. Counsellors should be mindful that dealing with post-traumatic stress as a result of the loss can interfere with grieving and lead to functional impairment. Furthermore, mental health outcomes after violent loss follow a longer course, are more adverse, and feature both post-traumatic stress and grief phenomenology (Raphael & Martinek, 1997). Disentangling the phenomena of grief and trauma may be a challenge for counselors—one that is necessary to fully appreciate and successfully reach and support veterans struggling after loss. Another key implication for counselling practice stems from the current finding that many veterans were isolated, disconnected, wary of trusting others, and struggled with feelings 185  of alienation. Counsellors should be aware that, in the transition back to North America and especially in cases of the violent loss of a close comrade, veterans have often lost valuable social resources and significant attachment systems. Studies have documented the buffering role of positive social support during and after exposure to combat, in buffering the development of mental health problems (Charuvastra & Cloitre, 2008; Iverson et al., 2005). It is important when working with veterans, that counsellors assess the social support network of the veteran and ensure adequate supports are in place before proceeding with helping the veteran express and process the violent death of a close comrade. The bereaved veterans in the current study describe experiencing changes in their assumptions about themselves and the world. They emerged from their loss experiences with a heightened sense of their own mortality and vulnerability. Veterans may have been unprepared for the violence and violation of their loss experiences (Rynearson et al., 2013). Mental health professionals should be aware that veterans may be struggling with issues concerning their mortality, a decreased sense of safety, and generally struggling to make sense of the loss. Helping veterans make sense of the death of their comrades, and being aware of the possibility that their fundamental assumptions about themselves, the world, and others, may have been shattered, is critical (Janoff-Bulman, 1992). The participants in this study, who engaged in formal treatment, explored issues of meaning, mortality, and vulnerability only after a trusting therapeutic alliance and safety was established. Similarly, participants who did not engage in formal treatment needed to establish stability before examining fundamental assumptions. Restoring control, or establishing safety, involved directing attention toward issues of basic health, such as the regulation of sleep, management of post-traumatic stress, and control of selfdestructive behaviors (e.g., substance misuse, suicidal behavior). Establishing a sense of safety 186  with others by considering support networks was also described as important. Participants were able to retell the story of violent loss, explore meaning, mortality and vulnerability only after safety and stability had been established. After building trust, establishing a sense of safety, ensuring adequate supports are in place, counsellors may wish to help veterans with remembrance and mourning, and to construct a coherent narrative of the loss in order to help them make sense of the loss. It may be useful for counsellors to ask their veteran clients to bring in remembrances of their fallen comrades, as a way to begin to identify and explore these losses. Importance should also be placed on helping the veteran to honour their fallen friend in symbolic ways such as memorials, anniversary days, and Remembrance Day/Veterans Day. The findings of the current study indicate the critical importance of building trust and establishing a strong therapeutic alliance when working with veterans. As the bereaved veterans in this study stated, trust was a very important part of their training and their relationships with each other. The men were unlikely to engage in any kind of treatment without the therapist first building trust. In most cases, veterans described feeling more comfortable with the assurance of another veteran before “trusting” a mental health professional or seeking help. Veterans were more likely to establish therapeutic alliances with helping professionals who expressed genuine reactions to their experiences. Participants integrated their loss experiences in a variety of ways and the counsellor should be aware that their services may be only one of the ways that this occurs. Some veterans preferred to engage in individual therapy while others engaged in individual work. On the other hand, some veterans reported benefitting in many areas of their life (e.g., communication, processing their grief, feeling less alone) due to veterans’ trauma repair groups. All of the veterans who participated in veterans’ trauma repair groups reported forming positive bonds with 187  other veterans, something that was described as extremely valuable after experiencing a sense of alienation, mistrust and disconnection with others. One veteran stated that he told his story of the loss of his best friend for the first time within the context of the safety and camaraderie he felt within the veterans’ trauma repair group. The participants described developing a positive community of support and healthy relationships with other veterans through the veterans’ support groups that extended beyond the veterans’ repair groups. This study shows that a group based approach (e.g., Veterans’ Transition Program) is an antidote for the alienation, mistrust, and disconnection that veterans experience after the violent loss of a close comrade Westwood et al., 2010). Veterans described reinvesting in supportive and positive relationships with other veterans from the groups. These findings inform bereavement theory, particularly theory concerning delayed grief (Worden, 2009). Veterans’ describe being unable to process their grief in the field, during postdeployment questioning, and because of concurrent trauma experiences. Inhibiting grief during the critical period after the loss was found to delay and complicate grief for veterans. Limitations At this point it is important to recognize some of the limitations of the current study and points of caution. This research was confined to participants who fit specific inclusion criteria and random sampling was not employed. The results were therefore derived from the experiences of a small, homogenous group of male participants. Although female participants were recruited, the individuals in this study were male, limiting the study findings. Due to the qualitative nature of the study, the context in which it took place, and the small, purposefully selected sample, the results cannot be generalized to all military personnel who have experienced the violent loss of a comrade. This limitation is acceptable however, as the purpose of the 188  research was to develop a foundational understand of the meaning and experience of coming to terms with violent loss for veterans; a unique human experience (van Manen, 1997). Also, the goal of qualitative research is transferability rather than generalizability. By using phenomenological methodology, “internal meaning structures” (van Manen, 1997, p. 10) were discovered through retrospective analysis of interview data. The qualitative method of this research allowed for entry into the research free of theorizing. Without prior theorizing, the veterans’ subjective experiences were more likely to remain at the centre of focus. However, it must be acknowledged however that as the researcher and primary research instrument, my subjective perspectives and interpretations inevitably coloured the research to some degree. While I attempted to limit researcher bias through the process of bracketing (Osborne, 1990) the findings inevitably are a co-construction of my experiences and interpretations as well as those of the participants. Additionally, participants approved their individual bio-synopses and validated that the themes that emerged from the data analysis process resonated with, and accurately reflected, their experiences of the violent loss of their close comrades. Finally, social desirability may be an additional limitation of this study. This refers to the tendency of participants to respond in a way that they think may be desirable to the researcher, thereby potentially reducing the rigor of the research findings. The researcher attempted to guard against this by reassuring participants that the goal was to, understand their experiences of coming to terms with loss as authentically as possible. That said, it is impossible to tell the extent to which information was over- or under-reported, based on participants’ desire to please me or avoid social taboos, and on the extent to which I was able to create a trusting non-judgemental space within which they could share their stories. 189  Implications for future research This qualitative, exploratory study contributes valuable information about veterans’ experiences with the sudden and violent loss of a close comrade and fellow service member, a topic that warrants further study. Further research will add to and enhance this preliminary investigation. Future research should attempt to include larger, more diverse samples of veterans selected via random sampling methods in order to enhance future findings and increase generalizability. Although both female and male veterans were sought for this study, the eleven participants in the sample were male. Further research should make concerted efforts to include female veterans’ experiences in addition to veterans representing more diverse ethnic groups to illuminate the role of cultural values and beliefs as mediators of the loss experience. As this study was undertaken with a retrospective design, it relied on the veteran’s abilities to recall past experiences. Although participants spoke of their experiences as they happened at different times in their lives, future efforts to produce longitudinal studies could yield valuable insights. Given the protracted and unresolved grief that veterans described, longitudinal data could provide very helpful information about the processes and impacts of complicated and unresolved grief over time. Given the greater potential for veterans to experience loss while serving overseas, it could be possible to design a prospective study with baseline measures and grief-related measures post-deployment. Two participants in this study described experiencing earlier losses that may have affected their ability to cope with, and process, the loss of a friend. Veterans also described adverse early experiences such as physical abuse and parental conflict that may have affected their ability to cope with losses. Veterans also described experiencing multiple losses prior to, 190  during, and following their overseas service. For example, one veteran described experiencing the death of a close friend before his tour, the deaths of multiple comrades in his company during his tour, the death of a comrade who was on a leave from tour, and the completed suicide of a comrade with whom he was attending a university-based skills conversion after his tour. Future research could also explore the impact of prior losses or multiple losses on the veteran’s experience. As the findings highlighted, the role of early attachment experiences may also be an important element on which to focus future inquiries. Veterans within this study described participating in formal treatment such as individual therapy and veterans’ trauma repair groups. Future studies could explore veterans’ experiences with group treatment versus individual treatment. Furthermore, our understanding of the veteran’s experience could be enhanced by focusing future research on one aspect of the loss experience, such as the process of therapy for veterans receiving group therapeutic support, as there is currently such limited information regarding the mechanisms of change in this form of treatment. Veterans’ repair groups, more specifically the Veterans’ Transition Program, showed considerable promise in helping the veterans within this study. In conclusion, the findings of this study confirm that the violent loss of a close comrade impacts the veteran in many ways and has both short- and long-term implications. The current study fills an important gap in the literature, examining the role of grief in the veteran’s experience which is more commonly described in terms of trauma. Researcher’s tribute Participants in this study described their participation as a positive experience and found that by articulating their experiences of violent loss, they gained a greater understanding of themselves and their experiences. These participants’ experiences offer a testimony to the power 191  of phenomenological research; an approach purposefully chosen to faithfully reveal veterans’ experiences of loss. The men in this study set aside their time to describe some of their most personal experiences to this researcher and you, the reader. They shared their stories in the interest of helping other veterans who are suffering. 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How would you explain/describe/interpret the experience of making sense of/coming to terms with/understanding the loss? c. What has your everyday experience been like since the loss? What was it like before the loss? d. What helped you in your experience of coming to terms with the loss? Can you think of anything in particular that stands out for you? e. What was happening at the time that you were making sense of the loss (at home, with family, with your job)? f. How would you describe your social relationship(s) since the loss? What were they like before the loss? Impact of loss on relationships with others? 2. What is life like for you now? a. Have you experienced any changes as a result of this experience (feelings, beliefs ... self, relationships, philosophy)? Has your understanding of this experience changed over time? b. Are there ways that you experience the loss that that affect your day-to-day life? c. Have your feelings about yourself, the way you see yourself or the ways you treat yourself or your body changed in any way? Have your relationships with others changed? d. Are things different, or are they the same? What is the same? What is different? Is there anything you do differently? e. Does life feel meaningful to you? Does it ever feel meaningless? 3. What do you feel about the future? What do you think your life will be like in the future? a. What will it be like to move on? How will you understand the experience of the loss of your friend? b. Have there been any changes in your future expectations? c. What future challenges do you think that you will face? Probes and Prompts: 1. Tell me more about that .... 2. Tell me more about what that means to you .... 3. What stands out for you? 4. What was most difficult/ most satisfying for you? 5. Can you give me an example of this? 6. Is there anything more you would like to add?  214  Appendix B :Research study invitation  THE UNIVERSITY OF BRITISH COLUMBIA Department of Educational and Counselling Psychology, and Special Education The University of British Columbia Faculty of Education 2125 Main Mall Vancouver BC Canada V6T 1Z4 Tel 604-822-0242 Fax 604-822-3302 www.ecps.educ.ubc.ca  Research Study Invitation Dear Colleague: My name is Trevor Olson. I am requesting your assistance for a research study that I am conducting in partial fulfillment of a doctoral degree in Counselling Psychology at the University of British Columbia. The title of my study is Veterans’ Experiences Following the Traumatic Loss of a Comrade and I have attached the Information and Consent form for prospective participants. The purpose of this study is to create further understanding regarding veterans’ lived experiences of recovery following the loss of a close friend by traumatic means. For the purposes of this study I would like to hear from veterans who have been recovering from the traumatic loss of a close comrade that occurred during their deployment or after they return home. Due to the nature of a soldier’s work, veterans who lose a friend during deployment, or even after deployment, are most likely experience a loss by violent means. Violent or traumatic loss has been defined as a sudden and violent mode of death characterized by one of three causes: suicide, homicide, or a fatal accident. These types of losses are conceptualized as traumatic events and often lead to symptoms of post-traumatic stress (Green, 2000) and other symptoms that complicate the grief response (Currier et al., 2006). Individuals who are ‘coming to terms’ with this kind of loss would include veterans who believe that they are doing well with, integrating, or making sense of the loss following the traumatic loss. To research this topic, I would like to interview several veterans who have had this experience. Please find attached an Information and Consent form for participants which provides more information regarding the study. I have established a set of guidelines that may be helpful for you in deciding which of your clients may be appropriate to refer. I will be sharing information regarding this study with each participant. The process will include reviewing each of the questions below to make sure participants are aware of the voluntary commitment involved, as well as reviewing confidentiality and gaining full informed consent. I request that participants in this study meet the following requirements:  215    Participants are between the ages of 20 to 45 years and have experienced a death by traumatic means of a close comrade and are approximately two to six years from this experience    The participant has reached a level of emotional regulation that allows him or her to discuss the event. The participant self-identifies as coming to terms with this loss.  216  Appendix C :Information and consent form  THE UNIVERSITY OF BRITISH COLUMBIA  Department of Educational and Counselling Psychology, and Special Education The University of British Columbia Faculty of Education 2125 Main Mall Vancouver BC Canada V6T 1Z4 Tel 604-822-0242 Fax 604-822-3302 www.ecps.educ.ubc.ca  Information and Consent Form Title: Veterans’ Experiences Following the Traumatic Loss of a Comrade Principal Investigator: Dr. Marvin Westwood, Department of Educational & Counselling Psychology, and Special Education. Phone number: ###-###-####. Co-Investigator: Trevor Olson, M.Ed. Department of Educational & Counselling Psychology, and Special Education. Phone number: ###-###-#####. This information and consent form is intended to provide information regarding research that is part of a thesis for a graduate degree so that you can make an informed decision regarding your participation. At our request, the professional that you have been in contact with has forwarded this letter to you and will not be aware of whether or not you contact the researchers. This research has no impact on your relationship with this professional or any support you are receiving. Purpose: The purpose of this study is to explore veteran’s experiences of coming to terms with and making sense of the experience of having a close friend die. The goal of this research is to develop a better understanding of how veterans, such as yourself, have experienced your life following the traumatic loss of a comrade. A loss by traumatic means has been defined as a sudden and violent mode of death characterized by one of three causes: suicide, homicide, or a fatal accident. This area is in need of further exploration and the stories of veterans living this experience may help other veterans who face this type of loss as well as help professionals better understand how to work with them.  217  Specifically, the researcher is interested in speaking to veterans who have experienced the loss of a close comrade and who believe that they are adjusting in a positive way to the loss, integrating, or making sense of the loss experience. The researchers would like to speak to veterans who:  have experienced the loss of a friend or close comrade by traumatic means;  have identified themselves as coming to terms with this loss. By ‘coming to terms’ with the loss the researcher is referring to persons who self-identify as doing well within the context of a traumatic loss of a close comrade.  are between the ages of 20 to 45 years old and have experienced the death of a close friend who was also a soldier either during or after deployment  have experienced this loss at least 1 year and not longer than 6 years prior to beginning the study.  Participation is entirely voluntary and the hope is that veterans will share their experiences and describe what has been significant in their recovery. Procedure: As part of the study you will be asked to participate in two individual interviews and review summaries of our conversation following the first interview. Each of the interviews will be audio-taped. While the length of each interview will be determined by you I expect they may last approximately 1 to 2 hours. Potential risks and benefits: Participating in this study may pose some risks and benefits to you. In our conversations you will be asked to discuss your personal experiences related to the death of a close friend. This may bring forth emotions and new understandings of yourself and your experience. You may find value as well as difficulty in exploring the meanings of your experience. The researcher’s role will be to try to understand what this experience has been like for you and to listen to your story. If any concerns arise from these interviews a qualified ounselin will be provided for you to speak with. Your participation in this research project is completely voluntary and you may refuse to answer any of the questions or withdraw from the study at any time. The refusal to answer a question or a decision to withdraw from the study will not affect your right to access a professional, qualified ounselin should you consider such ounseling necessary as a consequence of participating in this study. Confidentiality: All information that you provide is of a confidential nature. To keep information confidential and to ensure your anonymity, audio-tapes and transcripts will be assigned a pseudonym and identifying details changed. All field notes, including journal entries, as well as audiotapes and transcripts, will be fully safeguarded and stored at the University of British Columbia for the required 5 year period. The study findings may be presented to a larger audience or as a published article in the future. Contact for information about the study: If after reading this information and consent form you have any questions, require further information or would like to participate in this study please contact the Principal Investigator, Dr. Marvin Westwood at ###-###-####, or his Co-Investigator, Trevor Olson, at ###-###-####. If 218  you are interested in participating we can arrange for an interview at a time and place that is convenient for you. Consent Your participation in this research project is entirely voluntary and you may refuse to answer any of the questions and have the right to withdraw from the study at any time. If after reading this consent you are still interested in participating in this study, please contact Trevor Olson Your signature below indicates that you have received a copy of this consent form for your own records. Your signature indicates that you consent to participate in this study.  Signature of research participant  Date  Printed name of participant signing above  219  Appendix D :Recruitment poster D.1 UBC Study – We Would Like To Interview Veterans Who Have Experienced the Loss of a Close Comrade We are interested in speaking to male and female veterans who are willing to participate in a private, confidential interview with a UBC researcher about their experiences of the death of a close friend during or following deployment. The purpose of this study is to understand how veterans make sense of, and come to terms with, the loss of a close friend. We are interested in speaking with veterans who meet the following criteria: -20 to 45 years of age and have served their country as a soldier or peacekeeper. -have experienced the loss of a close comrade during, or after deployment/involvement in service. -feel they have come to terms with this loss. If you know a veteran who has experienced the loss of a friend and may be willing to speak about this experience please have him or her contact us for more information at: ubc.veteran.study@gmail.com  220  D.2  Are you a veteran who lost a comrade during or after deployment? Would you like to share your experience of coping following the death of your friend? We want to understand how veterans make sense of the loss of a close comrade. Sharing your experience may help other veterans facing loss. We would like to invite you to share your experiences with a UBC researcher in a confidential interview. This research study on veterans’ experiences with coping with the loss of a close friend is being conducted by Trevor Olson, a doctoral student in Counselling Psychology at UBC, under the supervision of Dr. Marvin Westwood (604.###.####). If you are interested in learning more about this study: PLEASE CONTACT Trevor Olson ###-###-#### or ubc.veteran.study@gmail.com 221  

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