Several occupational groups are exposed to a combination of acute stress, which is severely demanding by nature, and accumulated everyday stress, which is milder but occurs more frequently (Marmar et al., 1999; Michel, 2005). Examples of such groups are firefighters, military personnel, paramedics, and police officers. (These professional groups are henceforth called “first responders.”) Lately, this issue has gained much attention as many veterans returning from deployment in Afghanistan and Iraq have developed post-traumatic stress disorder (PTSD). A high number of suicides, violence within the family, other criminality, and substance abuse have been reported (Britt, Castro, & Adler, 2006).
Research on psychological effects among first responders has been dominated by a focus on PTSD, its prevalence and duration, and the outcome of various treatment regimens. However, this focus may entail limitations. One of them is that other stress-related reactions that fall outside the well-defined symptom picture are at risk of being neglected. For example, cumulative “wear and tear” stress reactions related to daily hassles are not adequately encompassed in current conceptions of PTSD (Drescher et al., 2011; Nash & Litz, 2013; Nilsson et al., 2015; Rosner & Powell, 2009).
Research on stress and health took on a new direction in the 1980s based on the accumulated effects of daily hassles (see e.g., DeLongis, Coyne, Dakof, Folkman, & Lazarus, 1982; Gruen, Folkman, & Lazarus, 1988; Kanner, Coyne, Schaefer, & Lazarus, 1981; Lazarus, 1984). Lazarus defined daily hassles as “experiences and conditions of daily living that have been appraised as salient or harmful or threatening to the endorser’s well-being” (Lazarus, 1984, p. 376). More simply put, Stefanek, Strohmeier, Fandrem, & Spiel (2012) define daily hassles as “minor negative experiences which occur quite frequently on a regular basis” (p. 202). This means that a potential hassle becomes a hassle only if it is appraised as a hassle, not simply because it occurs. The appraisal process reflects the meaning and significance the individual ascribes to the situation (DeLongis et al., 1982; Ruffin, 1993).
A core finding across various study groups is that accumulated daily hassles show stronger relationships with physical and psychological symptoms than major stressful episodes or chronic stressors, as clearly shown in a recent literature review (Larsson, Berglund, & Ohlsson, 2016). However, many writers also note that major events and daily hassles are often linked. A minor hassle such as misplacing things might, for example, be symptomatic of a persistent preoccupation with some larger issues in one’s life (Lu, 1991). A biphasic process between daily hassles and symptoms has also been observed, meaning that repeated hassles can lead to symptoms. This tendency, in turn, may increase the likelihood of appraising more daily events as hassles (Searle & Bennett, 2001).
Regarding health outcomes, most studies on daily hassles have focused on physical and psychological symptoms rather than illnesses (Gruen et al., 1988; Larsson et al., 2016). This inclination is in line with Folkman’s (1985) idea on the importance of what she labeled transient symptoms. The argument is that general health status changes slowly and is influenced by a range of variables, including genetic dispositions, normal aging, and environmental agents, which have little or no relationship to stress. This points to the importance of including assessments of milder stress reactions rather than focusing on more severe reactions only, such as PTSD, suicide rates, criminality, substance abuse, etc.
In the early writings on daily hassles, Lazarus and colleagues also pointed to potential favorable effects of daily uplifts, the latter referring to positive or satisfying experiences (e.g., DeLongis et al., 1982; Kenner et al., 1981). However, while the research evidence is quite conclusive regarding negative effects of accumulated daily hassles, the findings are mixed when it comes to daily uplifts. Positive buffering effects have been observed (Lu, 1991), whereas other studies failed to show such effects. In contrast, they related resistance stress to more optimistic personality dispositions, rather than to positively perceived daily events (Lazarus, 1984). It should also be noted that most studies have looked at relationships between health outcomes and daily hassles and between health outcomes and daily uplifts separately (Larsson et al., 2016). Knowledge of their interplay and its effects is still missing.
The increased focus on transient symptoms rather than end-stage diseases (see above) makes sense from a stress research point of view. However, given this tendency, there is still a temporal process between stress exposure and the onset of symptoms. Thus, there is a need for further process-oriented studies (cf., Pedlar & Thompson, 2011).
Returning to first responders, despite ample research on stress and health, and in particular on PTSD in the military profession, the interplay among daily hassles, daily uplifts, and transient stress-related symptoms is relatively unexplored. Given this propensity, it was concluded that qualitative in-depth interviews could be a fruitful approach in uncovering these processes and their development across time. The aim of the study was to gain a deeper understanding of how daily hassles and daily uplifts interact with each other and with stress reactions over time in military personnel.
Informants were selected on the basis of a grounded theory approach (Glaser & Strauss, 1967; Starrin, Dahlgren, Larsson, & Styrborn, 1997). In this case, that meant the ambition was to obtain a wide variety of experiences and hierarchical levels from Swedish officers and soldiers who had participated in international military missions during the last five years.
The interview process started out with just a few informants. Additional names were then provided with the help of the already selected people. Thus, the selection could be described as a convenience sample (Morse, 2007).
The informants were initially contacted by email and were informed about the project’s aim and the use of data. Communicating with the informants by email was a conscious strategy to give them time to reflect on whether to provide us their informed consent. The email was followed up and a meeting was arranged. (All contacted veterans agreed to participate.) All dealings with study informants were conducted according to the ethical guidelines of the Swedish Research Council. The study has been subjected to ethical review and vetting and was approved by the Swedish Regional Ethics Committee of Stockholm (Protocol EPN 2016/5:3).
A total of 15 informants (13 men and two women) participated in the study. At the time of the mission, their ages spanned 19 to 45 years and their ranks ranged from soldier to colonel. Most informants reported experiences from service in Afghanistan but the United Nation’s operation in Mali was also represented. The mission duration was six months for all participants and the time since the end of the mission ranged from three to five years.
Data were collected by qualitative semi-structured interviews following a prepared interview guide, which had previously been tested in a couple of pilot interviews. The interviews consisted of open-ended questions and individually adapted follow-up questions. They followed a chronological structure with questions related to the time before the mission, during the mission, and after the mission. All informants were specifically asked to consider the following themes:
- Background questions (age, education, position, domestic and international military experiences)
- Characteristics of everyday life before, during, and after the mission
- Daily hassles on duty and in private life
- Daily uplifts on duty and in private life
- Reactions and coping efforts related to daily hassles
Ten of the informants were interviewed individually at their present places of work. For practical reasons, five interviews were conducted on the telephone. The interviews took place during the period spanning February 2016 to June 2016. They lasted about 45 minutes to 120 minutes and were all recorded. All interviews were conducted and analyzed by the authors.
The interviews were transcribed verbatim and were analyzed consecutively according to the constant comparative method (Glaser & Strauss, 1967). The first step is known as “open coding.” That means data are examined line by line to identify not only participants’ descriptions of actions related to the themes mentioned in the interviews but also thought patterns and feelings associated with these actions. After that, codes are formulated in words resembling those used by the participants. To illustrate:
so of course you feel ”what the hell, we’ll manage this, we’ll turn it around, we’re bloody unbeatable,” it’s a great feeling, it is and that we’re doing it together with an infantry platoon, each individual soldier won’t win a battle but together when we’re united and know what we’re doing and that’s when it goes well
This excerpt was coded as “Feeling unbeatable.” The second step was to sort the codes into different categories. The previous example was sorted into the category “Positive group-related factors” and finally into the superior category “Daily uplifts” (see Results below). This process of analysis was conducted by making constant comparisons among the interview transcriptions, codes, and categories. Both codes and categories were also analyzed with respect to the selection criteria, meaning that comparisons were made between the different participants and their positions in terms of hierarchical level. Finally, the third step consisted of creating a model by fitting the categories together into superior categories using the constant comparative method. A proposal to such a model is illustrated in Figure 1 (below).
In practice, the steps of analysis were not strictly sequential. That is because we constantly moved back and forth in re-examining interview data, codes, and categories—a working procedure that is in line with the iterative process of the grounded theory method. The interviewing continued until the data appeared to have reached a point of saturation or, in other words, the point at which the most recent three interviews did not seem to make any substantial contribution to the model, which had successively been generated on the basis of earlier data. In the following section, the model is presented first, followed by a presentation of its categories. This particular order is used to give parts their meanings when understood in relation to the whole model. Within the different parts of the figure, the most illustrative examples will be presented.
The results section will commence with a presentation of the final product of analysis, i.e., the theoretical model which merges the informants’ reports into a wholeness. Using the model as a point of departure, this will be followed by a presentation of the superior categories of the model related to each of the following six periods of time: (1) Before the mission, (2) Early on in the mission, (3) Near the end of the mission, (4) Homecoming, (5) The year after homecoming, and (6) Today. The subdivision of the three time periods used in the interview guide (before, during, and after the mission (see Method above)) into six time periods followed from the rich database obtained in the interviews.
A summarizing theoretical model
The model in Figure 1 (below) consists of the following four superior categories: (1) Daily Hassles, (2) Daily Uplifts, (3) Coping Strategies, and (4) Stress Reactions. Within each of these, the categories that build up the superior category are shown. In the following results presentation, the codes underpinning the categories are presented. This means that each superior category has a hierarchical structure with interview responses at the bottom, followed by codes and categories adding up to the superior category at a higher level of abstraction.
According to the model, there are two arenas of interplay. In one of them, the superior categories Daily Hassles, Daily Uplifts, and Coping Strategies interact with each other. An illustration: A source of irritation occurs (a daily hassle), it is handled a bit clumsily with problem-focused coping efforts, a colleague jokes about it (emotion-focused coping), and the whole group begins to laugh (a daily uplift).
The “product” of this interplay forms the basis for the second arena of interplay, wherein this product interacts with the superior category Stress Reactions. The dominating form of interplay is that stress reactions occur as a consequence. However, the dotted arrow in the figure shows that there can also be interplay where stress reactions constitute a source. As an example, repeated nights with sleeping problems and days with concentration difficulties can be perceived as hassles in themselves and can contribute to more daily events being appraised as hassles.
The model is designed to be generic and is intended to function as a roadmap when different time periods and contexts are analyzed. As will be seen in the following time-specific presentations, the actual content of the model looks different in different time periods. Each of the six time periods presented below, using a summary table, is based on the theoretical model. These tables contain most of the codes identified in the analysis process.
Before the mission
Table 1 shows inter alia that a conflict of loyalty to the family prior to the mission is a significant source of worry and irritation. Positive experience felt by the military group and higher leadership are uplifting. All the reported coping strategies seem to be functional. Although there are significant stress reactions, they do not dominate existence.
Early on in the mission
Table 2 shows that the family’s anxiety continues to be a source of worry and irritation. More of these hassles are now connected to the job. Most of the uplifts come from the people who are closest to the informants on the job. The increase in cumulative stress is clear in the description of stress reactions.
Near the end of the mission
Table 3 shows that diverse job-related daily hassles are now dominant. Once again, both uplifts and coping strategies are closely connected to people in the informants’ proximity. Mixed stress reactions are observed but many emphasize exhaustion in this phase.
Table 4 shows that family’s and friends’ inability to fully understand what was experienced constitutes a worrying and irritating moment. The same applies to the reactions of people to everyday life in Sweden. Problems encountered are easily perceived by those who have been on missions abroad as being trivial “industrialized country problems.” The fact that families are together again, feelings of pride, and time for reflection are uplifts and coping strategies. At the same time, stress reactions are strong and include exhaustion and difficulties in relaxing, a feeling of emptiness, and difficulty readjusting to everyday Swedish life.
The first year after homecoming
Table 5 shows that typical daily hassles are people not listening and the fact that everyday life seems boring and meaningless. An uplift is increased self-knowledge. Coping strategies like justification, psychotherapy, and achieving acceptance are described. There are still strong stress reactions.
Table 6 shows that daily hassles are now less intense and that uplifts and coping strategies are now more related to everyday Swedish life. Stress reactions are significantly lower than in the previous five phases.
The aim was to gain a deeper understanding of how daily hassles and uplifts interact with each other and with stress reactions over time in military personnel. The study showed that three to five years after an international peace enforcement mission, none of the 15 interviewed officers and soldiers had been diagnosed with PTSD or suffered from mental problems requiring professional help. Given previously reported post-mission problems (Britt et al., 2006), this finding is notable and will be discussed in the following paragraphs.
Each of the six mapped time periods was characterized by severe daily hassles. At the same time, our interpretation is that the combined effect of daily uplifts and functional problem- and emotion-focused coping strategies contributed to limiting the stress reactions. The physical, cognitive, and emotional stress reactions did not take over and dominate one’s everyday life. Despite strong stress reactions at times, they appeared to be time-limited. There are obviously individual differences regarding these patterns within and between the different time periods. Yet the fact remains that three to five years after the mission, none of the informants reported serious mental problems or a need for professional support.
We suggest that there are three major causes underlying the result. The first factor is selection. This was not directly addressed in the study but lies as an underlying antecedent condition. In order to serve in this kind of military mission, one has to pass several selection steps, which means that psychologically more vulnerable individuals are not included (Michel, 2014).
A second potential explanatory factor behind the outcome is the intensity of the stress dose the informants were exposed to. Although it was high, as can be seen in the six summary tables, it could not be regarded as extreme. Within the studied group there was not, for instance, anybody who lost several close friends or who was severely physically wounded him/herself. Thus, it is possible that a dose-response relationship exists here (see e.g., Michel, 2014; Wahlström, Michélsen, Schulman, & Backheden, 2008) and that none of the 15 participants reached a critical stress dose level.
A third possible explanation for the favorable long-term results draws on the everyday conditions that were the point of departure of the study. Thus, if there are enough daily uplifts and effective coping strategies for the daily hassles, then the stress reactions will be limited. The result is partly consistent with the picture that emerged in a recent systematic literature review based on personnel in different first responder professions (Larsson et al., 2016). However, we suggest that the present study contributes to new theoretical knowledge. Previous research has mostly treated daily hassles and daily uplifts separately. By focusing on their relationship to each other, and their interplay with coping strategies, a new picture regarding stress reactions emerges. The results also support the positive buffering hypothesis of daily uplifts suggested by Lu (1991).
Contributing factors to the favorable outcome of this interplay as reported in the interviews were social support from colleagues, leaders, family, and friends. Being part of a well-established organizational structure is an obvious asset in these kinds of circumstances (Brede, 2012; Nilsson et al., 2015; Pickering & Holton, 2011; Ray & Salverson, 2012).
Conceptually, we consider the applicability of the suggested theoretical model across six different time periods as a strength. Although the indicators varied over time, the four superior categories and their postulated interplay held up during all time periods. According to Glaser (2011), theoretical concepts should be stable enough to remain, even if some underpinning indicators change. This is equivalent to stable factors in quantitative research. Underlying structures should ideally remain, even if some single items are changed.
We will now turn to some methodological aspects. First, the study is based on interview responses from only 15 individuals. Thus, nothing can be said about the generalizability of the results. This limitation is inherent in the chosen qualitative method. The approach was adopted to obtain a deeper understanding, and the results need to be tested on a larger scale.
A second weakness related to the study group is the selection procedure used, whereby new informants were suggested by active participants. This approach entails the risk that individuals similar to each other were recruited, or at least individuals who were socially active. Considering that some long-term reactions, including depression and anxiety, often co-exist with withdrawal from others, the selection procedure may have led to some problems not being detected. On the other hand, the ambition to obtain a wide variety of experiences and hierarchical levels, in agreement with the grounded theory method (Glaser & Strauss, 1967), also affected the selection process, and the final sample included a wide range of ages and military ranks with informants taking part in different missions.
A third weakness is the time that had passed between the military missions and the interviews. It is quite likely that the informants did not remember as much as they would have had they been followed and interviewed longitudinally. It could also be assumed that the myriad events and situations occurring after the mission may have affected the informants’ retelling of their experiences. However, the respondents’ narratives (both live and telephone interviews) were rich in detail and consisted of a number of potentially psychologically testing topics, and we did not get the impression that they had a personal interest in providing a false picture of their experiences.
A fourth methodological weakness is the broad framework of each of the chosen six time periods. It is obvious that the everyday experiences will vary considerably during a timeframe such as the first year after the mission. This means that our interpretations represent overall patterns in a given time period.
A final methodological aspect we would like to mention is that the superior categories of the suggested model are obviously colored by our theoretical preconceptions. We argue that the initial analytical steps from interview responses to codes and from codes to categories were in line with the grounded theory method ideal (Glaser & Strauss, 1967). Further studies will show whether the continued abstraction process can be handled differently.
Daily uplifts, and effective coping strategies for the daily hassles, may limit stress reactions.
Potential practical implications include education and training interventions directed at individual, front-line leaders, strategic-level leaders, and professionals in occupational health care. Interventions focusing on daily hassles, uplifts, and coping efforts have an intuitive appeal since these aspects, in contrast to uninfluential major traumatic events, can be affected.
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