CALIFORNIA STATE UNIVERSITY, NORTHRIDGE Women Veterans with PTSD and Deep Breathing Meditation A graduate project submitted in partial fulfillment of the requirements For the degree of Master in Social Work By Jacqueline Galang-Chavez May 2016
The graduate project of Jacqueline Galang-Chavez is approved: Dr. Jodi Brown Dr. Allen Lipscomb Dr. Amy Levin Chair Date Date Date California State University, Northridge ii
Acknowledgements This paper and journey would not be possible without the support and help of many individuals. I would like to extend my sincere thanks to all of them. I would like to express my sincere gratitude to my advisor, Dr. Allen Lipscomb, for all his support, guidance, and wisdom. I am so grateful for the privilege to be a part of the MSW program. Thank you to the staff for their support during this endeavor. I would like to give a special thanks to my English professor Philip Lopez, who encouraged me to further my education, and gave excellent advice. Thank you to my supportive husband, Freddy Chavez, who is always there for me when I need him and continues to encourage me to believe in myself. To my grandparents, who continue to be my source of strength throughout my life and my guardian angels. My deepest appreciation and gratitude for my parents, who taught me everything I know, you both are my inspiration. I am grateful to my brothers and sisters, who continue to encourage and support me. Thank you to my aunts, for their generosity and kindness. Thank you to my dear uncle, I will miss you. I appreciate everything you have done for me. My thanks and appreciation also goes to the United States Marine Corps. I would not be the person I am today had I not enlisted, and I am eternally grateful for that experience. iii
Dedication This paper is dedicated to: The memory of my beloved grandparents, Elisa and Jaime Galang. My best friend and brother, Chuy My amazing husband, Freddy Chavez. And my parents Rogelio and Dalia Galang Without them, nothing would be possible iv
Table of Contents Signature Page Acknowledgment Dedication Abstract ii iii iv vi Chapter One: Introduction 1 Chapter Two: Background 2 Chapter Three: Methods 4 Participant 4 Measures 4 Research Design 6 Chapter Four: Results 9 Content Analysis 9 Individual Interviews 9 Chapter Five: Discussion 12 Important Findings 12 Limitations 13 Conclusion 14 References 15 Appendix A 17 v
Abstract Women Veterans with PTSD and Deep Breathing Meditation By Jacqueline Galang-Chavez Master of Arts Social Work Post Traumatic Stress Disorder (PTSD) is a very serious mental health condition that is associated with an anxiety disorder (U.S Department of Veterans Affairs, 2015). This disorder can emerge after someone has witnessed or experienced a traumatic event, although it is still unclear why some people develop PTSD and others do not (U.S Department of Veterans Affairs, 2015). Veteran women are reported to have more psychological distress than men among those who have deployed to Iraq (Seppala et al, 2014). The purpose of this qualitative research paper is to analyze the results that compare and contrast the experience of veteran women with PTSD using deep breathing meditation and how this type of exercise helps them live with the disorder. The objective of this paper is to evaluate the effectiveness of this type of exercise while living with the disorder. This paper measures the efficiency of deep breathing meditation. The results suggest that mind-body interventions, such as deep breathing meditations showed a vi
significant reduction in symptoms of PTSD. The study of this small population of veterans with PTSD, especially women suffering from PTSD can further help improve their quality of life. vii
Chapter One: Introduction Veterans returning from Operation Iraqi Freedom (OIF) and/or Operation Enduring Freedom (OEF), which took place in Afghanistan, have symptoms of Posttraumatic Stress Disorder (PTSD), according to a study done by Hoge (Hoge et al, 2015). This paper explores how deep breathing meditation affects women veterans who suffer from PTSD. Veteran women who practiced deep breathing meditation have been found to be a viable intervention to improve PTSD (Hawn Kim et al, 2013). The evidence in recent studies have shown that mind-body interventions have had a positive impact on the quality of life for people living with PTSD (Price et al, 2013). Interventions such as: yoga, gyro kinesis, Pilates, tai chi, and deep breathing meditation have been shown to reduce stress-related disorders. According to Seppala (2014), in any given year, 7.7 million Americans over the age of eighteen are diagnosed with PTSD. There is a concern for soldiers who are consistently deploying to Afghanistan and other war zones. The current areas that are not being addressed are women coming back from deployment(s), because most of the studies are done on male soldiers returning from war zones. It is critical to find out if deep breathing mediation is effective for women veterans. Additionally, being able to apply mind-body exercises (such as: yoga, pilaties, tai chi, etc.) can benefit women veterans that are suffering from PTSD. The ability to offer more choices in treatment for this small population who might not have access to a Veterans Affairs (VA) clinic or do not qualify for VA benefits, this exercise can be applied from the comfort of their own homes. 1
Chapter Two: Background One in every five female veterans who seek Veterans Affairs (VA) services screens positive for PTSD and many have a lifetime history of sexual trauma (Price et al, 2007). A recent review in health research for female veterans pointed to the lack of experimental studies with this population, specifically treatment approaches for women with PTSD related to sexual trauma (Price et al, 2007). The importance to continue more research for female veterans is in high demand What does the field know about this topic? Women veterans have significantly more somatic distress, medical conditions, comorbid psychiatric problems, and substance abuse compared to other women veterans without PTSD (Price et al, 2007). As of today, more than 2.7 million United States Military personnel have deployed to Iraq or Afghanistan since the start of military operations in 2001, and more than half have been deployed more than once (Hoge et al, 2015). It is crucial to invest time and research into interventions for returning military men and women. How successful was the research and what strategies have been tested? In previous literature there have been mind-body practices that have increasingly employed treatment of PTSD and have a positive impact on stress-induced illnesses such as depression and PTSD (Hwan Kim et al, 2013). A growing body of evidence has suggested that meditation based interventions have the potential to reduce the symptoms of PTSD and improve the well-being (Seppala et al, 2014). Deep breathing exercises is designed to be comfortable and does not require the purchase of fancy equipment or a lot of space when implemented. Deep breathing meditation can be practiced anywhere the 2
participant is and where they feel most comfortable. Breathing-based practices are particularly beneficial for PTSD and can help with the difficulties of regulating emotion (Seppala et al, 2014). What knowledge is missing in published research? The knowledge that is missing in published research in terms of PTSD symptoms among veterans of the Iraq war is a lack of gender differences (Hoge et al, 2007). The studies in PTSD among veterans are more focused on the frequency of deployments and the intensity of the combat experience, rather then that of gender. There are different variables that are not included during previous research, as to why women veterans get PTSD. Most research pertaining to veterans with PTSD is the nature of their combat experience that has lead to PTSD and nothing more than that, especially for women. Why is this study important to the social work field? This paper is hypothesizing, that there would be reductions in the symptoms of PTSD as a response to deep breathing meditation. This study on deep breathing meditation has demonstrated that after participating in a four-week mind-body intervention exercise, the subjects in this study have shown a reduction in PTSD symptoms compared to those who did not implement the exercise. According to the Department of Veteran Affairs National Center for PTSD, the trauma is common; about six of every ten U.S adults experience at least one trauma in their life. This paper looks at a small sample of how deep breathing meditation has considerably reduced symptoms of PTSD for women veterans, and the importance of continued exploration and research to support social workers who are currently treating returning veterans with PTSD, especially women retuning with the disorder. 3
Chapter Three: Methods The California State University Northridge Institutional Review Board approved this paper on February 19, 2016. Participants The inclusion requirement for this study includes women who are receiving veterans benefits from the Department of Veterans Affairs for PTSD, served in any branch of the military (active or reserve), lives in Southern California, and eighteen years or older. The subjects in this study have met all of the criteria and agreed to sign a consent form. The initial contact was made with a phone call, used from the flyer posted to advertise the study. The snowball sample consisted of a total of five women. The sample was divided up between two different groups, 3 women implementing deep breathing meditation and 2 women not doing the daily exercise. All the participants remained until the end of the study. All the women recruited in the study were of a variety of different nationalities. The ages of the women were between 30-35. All the participants in this study have been deployed to Iraq and/or Afghanistan during their military enlistment. All the women were same branch of the military and served active duty. Measure The design of this study is a qualitative approach, which was used during the sampling, collection, and analysis. The type of data collection implemented was in-depth interview of the participants. Individual interviews were conducted for privacy. The researcher is looking for patterns, themes or common categories among the participants. The subjects were given open-ended questions during the interview, and the data was 4
compared at the end of the study. Deep breathing meditation was the intervention, and analyzing the content of the interviews was used to distinguish if the hypothesis was effective or not. The sampling method used for this qualitative study is a non-probability snowball sampling technique. This type of sampling will be used because this type of population is not easily accessible for the researcher. The purpose is to provide an in-depth study, to provide individual information and the participant s personal experience with PTSD, by determining what has helped and what has not. Being able to assess the patterns, themes and analyzing the complexity of the situation. The paper used only a qualitative method of ground theory to inductively generate and explanatory theory of deep breathing meditation and its effects on women veterans. A weakness in the study is the sample size is small, and the time implementing deep breathing mediation took place for the duration of only four weeks. A longer period of time might determine the long-term effectiveness of deep breathing meditation. Another weakness of the study is some personal biases influenced by the interviewer. This study might not be diverse enough since the sample size is small. The analysis from this study will also provide an understanding of the veteran s experience once women leave the military for civilian life. This study can be used to advance veteran s services, and address the issues about how veteran women have handled PTSD since leaving the military. Using the qualitative approach gave the interviewer an in-depth look by asking open-ended questions to examine a range of different areas that might not otherwise be discovered using a different method. 5
The participants were able to reveal more about their experience with PTSD, since the researcher is a female and the subjects were able to choose the location of the interview, including the option to not answer any questions. Participants chose to conduct the interview in the comfort of their own home. The reason for this was to provide flexibility, confidentiality, and comfort for the participant. This method is a significant strength in this paper, which gave the participants control and was a comfortable atmosphere to speak openly about their experience with PTSD. One group was implementing deep breathing mediation for a minimum of 10 minutes on a daily basis. The subject was asked to sit comfortably with their eyes closed. The subject was asked to take a few moments to be in a relaxed state. The subject was asked to focus their attention on their breathing and just let their body breathe automatically without altering their breathing rhythm. Doing this will allow the subject to clear their mind and focus only on breathing blocking out all of their surroundings. The other group will not be doing anything. The results were collected to find patterns and themes. Research Design The open-ended questions used (see Appendix A) were designed to allow the subjects to speak freely about their experience with PTSD. The interviewer used the jotting method, which consisted of hand written notes during the interview. The interview write-ups were organized and then analyzed in detail, looking for similar content. The data was used to find any themes, patterns, and differences among participant responses to the questions given. There were no instruments used during this study. Conclusion validity was used to measure any relationship found between variables. Open-ended 6
questions were asked and the responses were later analyzed to find common themes and patters. The individual interviews consisted of a series of questions for a duration of up to 30 minutes. The open-ended questions (see Appendix A) during the initial interview were categorized in three sections. Participants were able to take their time to answer questions and talk freely to provide comfort and flexibility. The questions were interactive in nature. The questions were structured so the participants provided a deeper and fuller understanding of what they are feeling while exploring their experience with PTSD. The explanatory evidence is essential in this qualitative study. Debriefing included a $10 Starbucks gift card for compensation, thanking them for their time and participation in the study, while answering any questions the participants may have afterward. The study consisted of two interviews, one at the beginning of the study and one at the end, over the course of four weeks. All of the participants were asked in-depth qualitative questions about their experience with PTSD. Three of the participants were selected randomly to implement deep breathing mediation daily, and were asked four weeks later additional questions about their experience doing the exercise during the second interview. All the participants were given a second interview, even the two participants that did not implement the intervention. A number was assigned to identify the participant to protect their identity. All the subjects were not aware of what number they were given. The interviewer evaluated, sorted, and analyzed the data collected to find patterns and themes between the two 7
groups. Once the study is competed, the researcher will destroy all notes and information. The evaluated data will be discussed in the next chapter. 8
Chapter Four: Results Content Analysis The data compiled during the study searched for patterns and themes during the interview. The use of common words and phrases was used to find similarities when analyzing the data. The participant s age, race, years of service, and branch they served were analyzed for common patterns. Their results were divided up in three main categories: 1) a general description about the participant, 2) the first interview, what the participants have done so far to reduce the symptoms of PTSD before any intervention, and 3) the second interview, the participants feelings from both groups four weeks later. The findings of the study are discussed below. Individual Interviews General description about the participants There are some common themes that all the participants shared. The participants were all women in their early 30 s (ages 30-35). All the women served in the same branch of the military, the United States Marine Corps. All the participants served four or more years, active duty in the military. The participants reported to all have deployed to Iraq and/or Afghanistan during their enlistment. A difference in the participants was their nationality. Participant #1 was Asian; Participant #3 was Caucasian, and Participant #2, # 4, and #5 were Hispanic. The first interview-what the participants have done to reduce symptoms All five of the participants are on medication to reduce the their symptoms of PTSD. The participants found some sort of satisfaction when taking medication. Participant #1 said, I am a little satisfied with taking medication, it only helps 9
sometimes. Participant # 2 said, Currently I am taking medical marijuana, it satisfies me and helps with my anxiety, Participant #3 said, Going to the gym is what I try to do regularly, I like working out. Another common theme among the participants was their negative sentiments about the Department of Veteran Affairs. Participant #5 said, The VA is so slow processing a claim, and it took longer than six months to see anyone, Participant #3 said, I don t like the doctors at the VA, they don t know what they are doing. Participant #4 said, I deployed four times to Iraq, and barely qualified to get PTSD! I was denied for everything else I filed a claim for, Participant #1 said, The VA is okay [long pause].but if can have a choice, I would rather see a private doctor, Participant #2 said, I don t like that its run like an HMO, you have to get a referral to see a specialist and the nurse has denied me that referral. Four out of the five participants had feelings of anger, anxiety, irritability and depression most days. Participants #4 and #5 re-enlisted and served a total of eight years each, they both had patterns of severe symptoms of PTSD. Participant #5 stated, Most days, I feel angry and isolated. I have a short fuse and it is hard to deal with people without snapping. Participants #4 and #5, had a pattern of severe symptoms of PTSD due to multiple deployments to Iraq and/or Afghanistan. The theme of longer enlistments correlates with multiple deployments, increasing the chances of PTSD. Second interview- Participants feelings from both groups four weeks later Participants #3, #4, and #5 were chosen randomly to conduct deep breathing medication. The group that was asked to not do anything were Participants #1 and #2. All the participants were asked if they had done anything since the researcher last spoke to 10
them four weeks ago. Participants #3, #4 and #5 reported that they had done their deep breathing meditation for at least a minimum of ten minutes a day. Participants #1 and #2 had not done anything, but still continued to take medication, reported no changes in their sentiments. Participant #3 mentioned, I started taking yoga and Zumba, its different than what I m used to doing. All three of the participants that implemented deep breathing exercises mentioned the experience as, satisfied, helpful, and easy to do. Participants #4 and #5 reported to have only implemented the exercise once a day. Only Participant #3 had reported to have done the exercise more than once a day. All the participants found it had reduced anxiety the most of all the symptoms reported. Participant #4 stated her thoughts about the intervention by saying, I would continue doing this when I start to feel irritable or angry, it helped clear my mind, Participant #4, I found it more relaxing than anything, I usually feel overwhelmed and anxious, and it helped keep me focused. Overall, the results suggested that deep breathing meditation had positive effects in dealing with PTSD. 11
Chapter Five: Discussions The results indicate that the participants have experienced some relief from PTSD when implementing deep breathing meditation. The findings have shown that is type of exercise has been consistent by other previous studies. One of the most compelling similarities was that all of the participants are on medication for PTSD. The women all felt that they had little to no support from the VA. The differences they had were the symptoms of PTSD. Some of the women were more affected than others. Important Findings This study had demonstrated that the four-week intervention had decreased symptoms of PTSD. The reduction of PTSD symptoms was sustained for the duration of four weeks, and no participants reported an increase. Further comparison shows that practicing deep breathing meditation provides relief and the longer the duration of the exercise; the more positive the outcome would be. The length of time served in the military has proven an increase in deployments to Iraq and Afghanistan, therefore increases the chances of PTSD. Consequently, being put at higher risk of PTSD with multiple deployments. According to Price (2007), 222,620 Army and Marine service members (10.6% were women) that completed the assessment after returning from Iraq, 24% of the women reported a mental health issue when compared with 19% of the men. In this study, the reduction of PTSD symptoms was associated with deep breathing meditation. During the duration of the four-week intervention, the participants reported to have decreased anxiety, irritability, and anger. Two out of the three participants had expressed their desire to continue the exercise. According to Hawn Kim (2013), slow and 12
deep breathing stimulates stretch-induced inhibitory signals, leading to synchronization of neural elements in the heart, lungs, limbic system and cortex and its association with reduced PTSD symptoms severity (Hawn Kim, 2013, pp 2990). Limitations This study was limited due to a small number of participants, making it difficult to compare both groups. The literature available on veterans with PTSD focuses on mostly men, and very few include only women veterans. The interviewer remained discreet to not reveal their own experience as a veteran to the participants in the study. A limitation can be the specific nature of their combat experience. There are other variables that need to be studied surrounding the area of how women veterans get PTSD. Other experiences such as sexual harassment or abuse during enlistment, and mental heath status prior to deployment are at higher risk for severe PTSD when getting out of the military. Another limitation is the age group, using a younger group might have had a different pattern due to maturity. 13
Conclusion More studies will be needed to replicate this studies finding, but overall this study has successfully demonstrated that deep breathing medication had reduced symptoms of PTSD. The researcher has demonstrated that after participation in the four-week deep breathing exercise intervention, participants reported an improvement in their quality of life. Participants are able to incorporate this type of mind-body exercise into their individualized self-care treatment plan. This paper could further our understanding about treating PTSD, and become a part of a treatment plan. 14
References Hawn Kim, S., Schneider, S. M., Bevans, M., Kravitz, L., Mermier, C., Qualls, C., Burge, M. R. (2013). PTSD Symptoms Reduction with Mindfulness-Based Stretching and Deep Breathing Exercise: Randomized Controlled Clinical Trial of Efficacy. The Endocrine Society.98(7):2987-2992. doi:10.1210/jc.2012-3742 Hawn Kim, S., Schneider, S. M., Kravitz, L., Mermier, C., Burge, M. R. (2013). Mind- Body Practices for Posttraumatic Stress Disorder. National Institutes of Health. 61(5). 827-834. doi:10.231/jim.0b013e3182906862 Hoge, W.C., Clark. C. J., Castro, C. A. (2007). Commentary: Women in Combat and the Risk of Post-Traumatic Stress Disorder and Depression. International Journal of Epidemiology, 36, 327-329. doi:10.1093/ije/dym013 Hoge, W.C., McGurk, D., Thomas, J. L., Cox, A. L., Engel, C. C., Castro, C. (2015). Retrieved on November 1, 2015. Mild Traumatic Brain Injury in U.S. Soldiers Returning from Iraq. The New England Journal of Medicine. 328(5). 453-463 Retrieved from http://www.dtic.mil/dtic/tr/fulltext/u2/a479403.pdf Price, C. J., McBride B., Hyerle, L., Kivlahan, D. R. (2007). Mindful Awareness in Body-Oriented Therapy for Female Veterans with Post-Traumatic Stress Disorder Taking Prescription Analgesics For Chronic Pain: A Feasibility Study. National Institute of Health. 13(6), 32-40. doi:10.1016/j.jsat.2011.09.016 Seppala, E. M., Nitschke, J. B., Tudorascu, D. L., Hayes, A., Goldstein, M. R., Nguyen, D.T.H., Perlman, D., Davidson, R. (2014). Breathing-Based Meditation Decreases Posttraumatic Stress Disorder Symptoms in U.S. Military Veterans: A Randomized Controlled Longitudinal Study. Journal of Traumatic Stress. 27, 397-405. doi:10.1002/jts.21936 15
U.S. Department of Veterans Affairs. (2015). Retrieved November 1, 2015, PTSD: National Center for PTSD. Retrieved from http://www.ptsd.va.gov/public/ptsdoverview/basics/what-is-ptsd.asp 16
Pseudo Name Given: Participant #1 Participant #2 Participant #3 Participant #4 Participant #5 Interview Questions Appendix A Interview Questions Women Veterans and PTSD and Deep Breathing Meditation The general questions for both groups in the research will be: Age? Race? Years served in the military? What branch did you serve in? The In-depth qualitative questions will be: What have you done to reduce your symptoms of PTSD? How satisfied are you with your current method? What are your thoughts about the current services provided for veterans dealing with PTSD? How have you been feeling most days? The group doing daily deep breathing meditation will be asked these additional questions at the end of the study in the second interview: Second interview will include Have you done anything to reduce your symptoms since we last spoke? How satisfied have you been since we last spoke? How have you been feeling since we last spoke? How often are you doing deep breathing meditation exercise? (Meditation group only) What are your thoughts about deep breathing meditation? (Meditation group only) 17