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Application: Evidence-Based Practice Interventions
Cognitive-behavioral therapy (CBT) includes a variety of approaches and therapeutic systems, the most well known of which include cognitive therapy, behavior therapy, rational emotive behavior therapy, and multimodal therapy. Multimodal therapy is a type of CBT that is based on the idea that humans are biological beings who think, feel, act, sense, imagine, and interact. Each of those “modalities” should be addressed in psychological treatment. The multimodal therapy acronym “BASIC I D” signifies behavior, affect, sensation, imagery, cognition, interpersonal relationships, and drugs/biology and is the basis for treatment. Various types of cognitive behavior therapies such as Trauma-Focused CBT are valuable when working with child and adolescent disaster survivors. Relaxation training is a cognitive behavioral adjunct that is helpful for anxiety reduction.
Interpersonal Therapy (IPT) is time-limited and employs homework, structured interviews, and assessment tools. It focuses on the interpersonal context (rather than intrapsychic) and on building interpersonal skills. IPT may change the client’s interpersonal behavior by promoting adjustment to current interpersonal roles and conditions. Similar to other counseling and psychotherapy, crisis interventions include assessment that is ongoing throughout the intervention process. The dissimilarities of crisis interventions, however, include the persistent emphasis on problem-solving techniques as well as safety assessment.
To prepare for this assignment:
Review Chapter 7 in your course text, Crisis Intervention Strategies, and think about the potential scope of impact a crisis may have on people suffering from PTSD.
https://bookshelf.vitalsource.com/books/9781305888081/pageid/166
Review Chapters 10 in your course text, Crisis Intervention Strategies,and think about how special populations and/or substance abuse might require additional attention when PTSD is involved.
https://bookshelf.vitalsource.com/books/9781305888081/pageid/307
Review the types of responses to trauma, including but not limited to responses to PTSD.
Review this week’s media, During a Crisis-Counselor Interventions and Strategies, paying particular attention to Dr. Berger’s presentation on differences between military and civilian trauma reactions.
Review the article, “Responsive Therapy and Motivational Interviewing: Postmodernist Paradigms,” and consider the benefits of motivational interviewing.
Review the article, “Best Practices for Counselors Who Treat Posttraumatic Stress Disorder,” and think about ways these best practices could fit into the implementation of CBT and IPT.
Review the article, “The Treatment and Prevention of Depression: Implications for Counseling and Counselor Training,” and consider how you might teach this information to make it useful for counselor educators and in crisis training.
Review the article, “Psychosocial and Moral Development of PTSD-Diagnosed Combat Veterans,” and think about whether this information transfers to civilian populations too.
Review the literature to support CBT and IPT techniques for use with survivors of crises suffering from such illnesses as PTSD, depression, anxiety, suicidal ideation, and substance abuse.
The assignment: (4 page paper )
Briefly describe two CBT and two IPT evidenced-based practice strategies that may be applied to working with crisis survivors.
Then explain how these strategies might be changed if the crisis survivor was diagnosed with PTSD prior to the current trauma.
Finally, provide a brief analysis of how your intervention strategies for persons with PTSD might differ if you were working with military personnel rather than civilians. Give specific examples.
Support your Application Assignment with specific references to all resources used in its preparation. You are required to provide a reference list and to appropriately cite, APA style, all references used within your assignment.
Center for the Study of Traumatic Stress: Resources for Recovery
http://www.cstsonline.org/resources/
WAL_COUN8145_08_A_EN-CC.mp4
Journal of Counseling & Development ■ Summer 2007 ■ Volume 85364
© 2007 by the American Counseling Association. All rights reserved.
Posttraumatic stress disorder (PTSD) is a malady that has
been known by many names for centuries (Dean, 1997). For
example, Homer noted behavioral changes in participants in
the Trojan Wars that would likely meet the current definition
of PTSD (Shay, 1994). However, causation has been poorly
understood, and agreement about reasons for symptom onset
has been at wide variance (Dean, 1997).
Currently, PTSD is listed as an anxiety disorder in the
Diagnostic and Statistical Manual of Mental Disorders (4th
ed., text rev.; DSM-IV-TR; American Psychiatric Association
[APA], 2000). The DSM-IV-TR also describes PTSD cases as
being acute (symptom duration of less than 3 months), chronic
(symptoms at least 3 months or longer), or with delayed onset
(at least 6 months have passed between the traumatic event
and the onset of symptoms).
Much of what is known about combat-induced PTSD is
oriented to the American experience in Vietnam because con-
siderable research has been conducted with veterans of that war
(Kulka et al., 1990; Lifton, 1992; Wilson, 1980). Meichenbaum
(1986, 1994) attempted to treat PTSD via cognitive-behavioral
therapy, emphasizing that clients must recognize disordered
behaviors or thoughts prior to having potential for change.
Another approach to treating PTSD is offered by Figley
(1995), who included the veteran’s family members in the
treatment process via grief and family therapy. The therapy is
preceded by an accurate evaluation of the veteran and each fam-
ily member accompanied by crisis intervention when needed.
On the basis of interviews of veterans experiencing PTSD,
Wilson (1980) concluded that the social-personality arena has
the best potential for helping veterans experiencing PTSD.
According to Dean (1997), it is common if not normal
for veterans to experience dread, guilt, or sadness when
recollecting their combat experiences. Combat veterans
from various wars report similar feelings, mood swings,
temporary inability to relate to noncombatants, and cyni-
cism at calls to arms from the “unblooded” (i.e., those who
have not seen combat). Why then do some of these combat
veterans become dysfunctional?
One pathway to resolving this dilemma may be enhanced
understanding of the psychosocial and moral development
stages of combat veterans when exposed to war trauma.
Specifically, in Vietnam, the average age for combatants was
approximately 19 years, a time when forming a coherent
personality structure is the predominant developmental task
(Erikson, 1963). Wilson (1980) pointed out that a complex
mixture of social, political, and moral factors the young Viet-
nam combatants faced may have undermined the period of
psychosocial moratorium for some of them that society usually
provides. Thus, their opportunity to unify critical elements of
ego identity may have been interrupted, perhaps leading to
arrested psychosocial and moral development.
Erikson (1963) conceived of human development as a
psychosocial process consisting of conflicts and challenges
occurring at each developmental stage. In his Eight Ages of
Man model, Erikson viewed humans as proceeding through
stages, each of which presents special crises or challenges
related to basic elements of society. Successful mastery of the
challenge for each stage enhances the transition to the next
stage. Failure to meet the crisis successfully leads to continued
ego challenges regarding that crisis even though one moves on
chronologically to face the crises of the future stages. Erikson
believed that individuals, although having passed through
earlier stages unsuccessfully, can learn to meet the chal-
lenges of earlier stages successfully later in life. On the other
hand, some individuals do not meet the challenges of earlier
stages successfully and continue to experience psychosocial
problems associated with those crises. For example, they may
experience role confusion because they did not successfully
achieve psychosocial identity. In the present studies, we refer
to that unresolved attempt to meet those challenges of a stage
as arrested development.
Our focus in the present study is on three stages—Stage
5: Identity Versus Role Confusion (late adolescence), Stage
6: Intimacy Versus Isolation (early adulthood), and Stage 7:
Generativity Versus Stagnation (adulthood). It appears that
most combat veterans experience war in their late adolescence.
John G. Taylor, U.S. Department of Veterans Affairs; Stanley B. Baker, Counselor Education Program, North Carolina State Univer-
sity at Raleigh. Correspondence concerning this article should be addressed to John G. Taylor, U.S. Department of Veterans Affairs,
Vocational Rehabilitation and Employment, Box 4360 (MCAS), Jacksonville, NC 28540 (e-mail: ADJJTAYL2@vba.va.gov).
Psychosocial and Moral Development of
PTSD-Diagnosed Combat Veterans
John G. Taylor and Stanley B. Baker
Two related studies were conducted in order to investigate whether psychosocial and moral development appeared to
have been disrupted and arrested in veterans diagnosed as having posttraumatic stress disorder (PTSD). Study 1 was
devoted to developing a measure of late adolescence, early adulthood, and adulthood stages of psychosocial devel-
opment. In Study 2, a sample of 32 PTSD-diagnosed and 32 PTSD-free veterans participated. The PTSD-diagnosed
participants presented evidence of arrested psychosocial and moral development.
Journal of Counseling & Development ■ Summer 2007 ■ Volume 85 365
Development of PTSD-Diagnosed Combat Veterans
A concern in the present studies was whether veterans diag-
nosed with PTSD may have experienced challenges to their
psychosocial development at or before the late adolescence
stage that may not have been resolved successfully. If so,
failure to resolve the crises associated with early stages of
psychosocial development may be related to the symptoms
or PTSD, and Erikson’s (1963) paradigm may offer recom-
mendations for treatment.
Erikson (1963) believed that the challenge for adolescents
is to achieve true identity amid the confusion of playing many
different roles for expanding audiences in an expanding social
world. This is an ideological time. The ideological outlook
of society that speaks most clearly to adolescents is rituals,
creeds, and programs that define what is evil, uncanny, and
inimical. Shay (1994) suggested that the dissonance between
these developmental ideals and the brutality of war may lead to
a sense of betrayal. Focusing specifically on Vietnam veterans,
LeLieuvre (1998) supported the contention that those who
experienced PTSD never successfully resolved the psychoso-
cial tasks associated with Erikson’s late adolescence and early
adulthood stages. Additional research with Vietnam veterans
with PTSD indicates that they cannot share experiences, lead-
ing to relationship difficulties (Kulka et al., 1990).
Building on the work of Piaget (1932/1965), Kohlberg
(1976) posited that moral judgment is developmental in na-
ture. He stated that humans proceed through the same stages
of moral judgment/development in the same order. However,
the rate of development varies, and all do not achieve the same
developmental endpoints. The theory suggests six levels of
moral development that are classified into three categories:
pre-conventional, conventional, and post-conventional.
Although Kohlberg’s (1976) theory is not age specific, and
keeping in mind that the average age of American combatants
in Vietnam was 19 years, it seemed reasonable to speculate that
most veterans were at the conventional stages when involved in
combat. Also, research by Rest (1986) suggests that age may
be related to levels of moral development. Characteristics of
these stages are experiencing conventions, rules, obligations,
and expectations as part of oneself and adherence to authority.
One might speculate that Kohlberg’s conventional levels of
moral development correspond to Erikson’s (1963) psychoso-
cial development Stage 5 (late adolescence). Thus, information
gleaned from the theories of Erikson and Kohlberg suggested
that the average combat veteran, particularly in the Vietnam
War, should have been engaged in addressing the challenges
of late adolescence psychosocially while having achieved con-
ventional levels of moral judgment/development.
In combat, one’s social and moral horizons have been known
to shrink (Shay, 1994). Could the combat experience in late
adolescence have caused the veterans, later diagnosed as having
PTSD, to have experienced arrested psychosocial and moral de-
velopment? Could treating PTSD-diagnosed veterans for arrested
psychosocial and moral development by helping them to master
the challenges associated with those psychosocial development
stages and achieve higher levels of moral judgment/development
be a way to help them? Seeking answers to these questions led us
to undertake the present studies. Specifically, the purpose of the
present studies was to investigate whether psychosocial develop-
ment, as described by Erikson (1963), and moral development,
as defined by Kohlberg (1976), appeared to have been disrupted
and arrested in veterans who were diagnosed as having PTSD.
Achieving this goal required a two-stage process that is described
herein as Study 1 and Study 2.
Study 1
A search of the professional literature and consultation with
a nationally known scholar in the field led to deciding that we
would need to develop an objectively scored instrument with a
diverse norms group in order to assess Erikson’s (1963) Stages
5 (late adolescence), 6 (early adulthood), and 7 (adulthood).
Wilson’s (1977) instrument is interview based and was too
time-consuming for the setting in which the present study
was to take place. Marcia’s (1964) instrument measures only
Erikson’s Stage 5 and possesses a scoring system that was
difficult to use in the present study. Constantinople (1965)
developed an instrument that included Erikson’s Stage 6;
however, it was designed for college undergraduates. Con-
stantinople’s instrument served as a model for the scaling of
the instrument in the present study. The goal of Study 1 was to
develop a paper-and-pencil, objectively scored, theory-based
instrument for assessing psychosocial development across
Erikson’s Stages 5, 6, and 7.
Study 2
To achieve our primary goal of investigating the psychosocial
and moral development of PTSD-diagnosed veterans once an
instrument for assessing Erikson’s (1963) Stages 5, 6, and 7
had been developed, we established the following research
questions: (a) What is the psychosocial development level of
PTSD-diagnosed participants? (b) What is the moral devel-
opment level of PTSD-diagnosed participants? (c) How do
veterans diagnosed as having PTSD compare with PTSD-free
veterans regarding level of psychosocial development? and
(d) How do veterans diagnosed as having PTSD compare with
PTSD-free veterans regarding level of moral development? A
secondary goal was that findings from the present study might
lead eventually to suggestions for clinical and educational
treatments for veterans with PTSD.
Study 1
Method
Participants. Ninety-two students enrolled in undergraduate
and graduate courses at a southeastern land grant university
agreed to participate. Sixty of the participants were under-
graduates between the ages of 17 and 19, and they represented
persons in Erikson’s (1963) Stage 5 (late adolescence). Four-
Journal of Counseling & Development ■ Summer 2007 ■ Volume 85366
Taylor & Baker
teen were graduate students between the ages of 21 and 29, and
they represented Erikson’s Stage 6 (early adulthood). Eighteen
of the graduate students were between the ages of 30 and 54.
They represented Erikson’s Stage 7 (adulthood). There were
30 men and 30 women in the 17- to 19-year-old cohort, 4 men
and 10 women in the 21- to 29-year-old cohort, and 4 men
and 14 women in the 30- to 54-year-old cohort.
Procedure. A careful reading of Erikson (1963) led to
identifying primary themes for Stages 5, 6, and 7. Ten phrases
representing the themes were either paraphrased or quoted for
each of the three stages. The 30 phrases were then converted
to 60 sentences, 2 for each phrase. In each dyad of sentences,
one was stated positively and depicted successful resolution
of the crisis for that stage, and the other sentence was stated
negatively, representing failure to resolve the crisis.
The 60 items were randomly ordered and presented to five
judges for a content validity study. The judges had graduate
degrees in counseling or a related field. The judges indepen-
dently determined whether each of the 60 sentences adequately
represented the definitions of the three stages that were also
provided in the instrument. In order for an item to remain
in the scale, 60% of the judges had to be in agreement. The
resultant scale of psychosocial development contained 53 of
the original 60 items. A 5-point Likert scale ranging from
very little to very much was used. A sample item was “My
life seems to have no direction or point.”
The next step was to conduct a construct validity study in
which predictions based on the theory were tested. The 53-
item scale was presented to the 92 participants in the present
experiment, and the data were used to test predictions based
on Erikson’s (1963) theory. The predictions are explicated in
the Results section of this report for Study 1. The data were
submitted to comparisons via analyses of variance (ANOVAs),
with least means squares tests used to follow up on significant
F statistics. An alpha level of .05 was used for all tests. Alpha
reliability estimates for the three stages in the Taylor Scale
of Psychosocial Development (TSPD; Taylor, 2000) were
produced from the scale data for the 92 participants.
Results
In this section, each prediction tested precedes the findings
and is printed in italics.
All participants should have achieved Stage 5 (late adoles-
cence). There were no differences across the three cohorts on
the TSPD total scores for Stage 5, indicating that they seemed
to have all reached that stage of psychosocial development,
F(2, 87) = 2.13, p = .13. This finding seemed consistent with
Erikson’s (1963) theory and indicated that the instrument did
not incorrectly differentiate across the cohorts at this stage.
The participants should have achieved Stage 6 (early
adulthood) differentially. The ANOVA yielded evidence of
significant differences, F(2, 87) = 13.94, p = .003. The follow-up
test indicated that there was a significant difference between
the scores of the 17- to 19- and 21- to 29-year-old cohorts and
between the scores of the 17- to 19- and 30- to 54-year-old
cohorts, indicating that the 17- to 19-year-olds on average had
not yet achieved Stage 6. There were no statistical differences
between the scores of the 21- to 29- and 30- to 54-year-old
cohorts, indicating that, on average, they achieved Stage 6.
This finding indicated that the instrument did seem to differ-
entiate between those who were chronologically at Stage 5
and those who might be assumed to have successfully faced
the challenges of Stage 5. This was viewed as evidence that
the instrument is able to differentiate between individuals in
Stage 5 and those who have moved on to Stages 6 and 7.
The participants should have achieved Stage 7 (adulthood)
differentially. The ANOVA yielded evidence of significant
differences, F(2, 87) = 13.94, p = .0001. The follow-up test
indicated significant differences between the 17- to 19- and
21- to 29-year-old cohorts and between the 17- to 19- and
30- to 54-year-old cohorts. There were no statistical differ-
ences between the 21- to 29- and 30- to 54-year-old cohorts.
These findings were similar to those for the Stage 6 analysis,
indicating that the TSPD was capable of providing evidence
of individuals having achieved Stages 5 and 6. Whether or not
the scale representing Stage 7 has validity remains unclear.
Reliability estimates. The alpha reliability estimates were,
respectively, r = .94 (Stage 5), r = .92 (Stage 6), and r = .86
(Stage 7). These coefficients seemed quite good for a typical
performance measure (Anastasi, 1988).
Discussion
Our primary interest in the reliability and validity of the TSPD
was as a measure for distinguishing between those who had
achieved at least Stage 5 (late adolescence) and those who
had not. There appeared to be sufficient evidence that the
participants who were adolescents chronologically were being
differentiated from the adults in the present study by the TSPD.
Although we were aware that the instrument was relatively
new, the norms were local, and the sample was relatively small
yet diverse, we decided that the psychometric data were suffi-
ciently supportive to move forward with the second study. The
TSPD also appeared ready for further research independent
of the present studies.
Study 2
Method
Participants. Sixty-four participants were selected via a mul-
tistage process presented in the Procedure section. Thirty-two
participants were diagnosed as having PTSD, and 32 had not
received that diagnosis. The 32 PTSD-diagnosed participants
were all over the age of 30. They ranged in age from 30 to 67
(M = 47.46). Sixteen were teenagers when first in combat, 15
were in the 20 to 29 age group at the time of first combat expo-
sure, and 1 had been over 30. The age range at time of combat
was 18–29 (M = 21.4). Twenty were African Americans, 10
Caucasians, 1 Hispanic, and 1 Native American. Twenty-nine
Journal of Counseling & Development ■ Summer 2007 ■ Volume 85 367
Development of PTSD-Diagnosed Combat Veterans
were men, and 3 were women. Their service branches were as
follows: Army = 25, Marine Corps = 5, Air Force = 1, and Navy
= 1. Twenty-eight had their combat experience in Vietnam, and
4 had served in the Persian Gulf War. Six of the PTSD-free
participants were in the 20 to 29 age group, and the remaining
26 were between the ages of 30 and 58. The age range was
23–58 (M = 19.78). Twenty were in their teens when first going
on active duty, and the remaining 12 had been between 20 and
29. Thirteen were African Americans, 18 Caucasians, and 1 a
Pacific Islander. Twenty-four were men, and 8 were women.
Their service branches were as follows: Army = 14, Marine
Corps = 13, Air Force = 3, and Navy = 2. The combat theaters
for the PTSD-free participants were Korean War = 1, Vietnam
War = 5, Persian Gulf War = 11, and Beirut/Panama = 5. The
remaining 10 participants had no combat experience.
Diagnostic screening. Two diagnostic measures were used
in order to screen prospective participants for stress that was
not combat related and for alcoholism. The Davidson Trauma
Scale (DTS; Davidson et al., 1997) consists of 17 items that
correspond to the 17 symptoms of PTSD that are listed in the
DSM-IV-TR (APA, 2000). They are categorized in clusters
of questions that address the following concepts: intrusive
reexperiencing, avoidance and numbness, and hyperarousal.
Participants are asked to rate both frequency and severity dur-
ing the previous week for each item on a 5-point scale. Scores
range from 0 to 136. A test–retest reliability estimate for the
DTS was .86, and convergent and discriminant validity with
three other PTSD rating scales was .78, .64, and .77, respectively
(Davidson et al., 1997). Based on the research of Davidson et
al. and on practices of a regional U.S. Department of Veteran
Affairs medical center screening clinic, a score of 48 was used
as a cutoff for determining presence of a clinical level of PTSD.
Those prospective participants who scored above the cutoff on
the DTS and for whom the stress was not combat related (e.g.,
sexual trauma, auto accident) were not included in the study.
In addition to the DTS, the Michigan Alcoholism Screen-
ing Test (MAST; Selzer, 1971) was used to assess whether
prospective participants abused alcohol, because alcohol
abuse may have affected the results of the two instrumental
measures. The MAST consists of 25 items that describe a
history of alcohol-related problems. Watson et al. (1995)
found that the MAST had an overall hit rate of .91, a positive
predictive power rate of .92, and a sensitivity rate of .97 when
compared with five commonly used alcohol screening instru-
ments. None of the prospective participants were identified
as prospective alcohol abusers.
Instrumental measures. The TSPD (Taylor, 2000) presented
in Study 1 was used as a measure of psychosocial develop-
ment. The short form of the Defining Issues Test (DIT; Rest,
1979) served as a measure of moral development. The DIT is
based on Stages 5 and 6 of Kohlberg’s (1976) theory. This form
consists of three dilemmas: Heinz, Prisoner, and Newspaper.
The DIT challenges respondents to make judgments about
moral problems via requesting information about courses of
action favored and reasons for making the choices. Respon-
dents are requested to rank by number the options presented to
them. In the present study, DIT-P (i.e., DIT Principled Moral-
ity) scores were used. Raw scores range from 0 to 32. The raw
scores are converted to P-scores that can range from 0 to 95.
Rest (1986) reported reliability estimates ranging in the .70s
and .80s. Rest, Thoma, Davison, Robbins, and Swanson (1987)
cited differences among groups of people and evidence that
individuals were unable to fake good decisions as evidence
of criterion-related validity for the DIT.
Procedure. Approval to conduct the study was acquired
from the university’s institutional review board and the
U.S. Department of Veterans Affairs Health Administra-
tion. Participants were recruited from two Veterans Ad-
ministration centers. They were recruited over a period of
3 months as they participated in treatment and services at
the respective centers. Participants were selected randomly
from a pool of volunteers and then screened for evidence
of whether they had experienced known crises in their
lives that could have had the same impact as combat. Upon
agreeing to participate in the study, each veteran received a
packet consisting of the university and the federal informed
consent materials and the MAST, DTS, DIT, and TSPD in-
struments, which the veteran thereupon completed after an
instructional briefing and submitted to the researcher or his
or her representative. An initial screening of the completed
instruments led to eliminating those that were incomplete
or incorrectly done. Data from the MAST were then used
to screen for alcoholism, and the DTS data were used to
assign participants to either the PTSD-diagnosed or PTSD-
free categories. The recruitment process was concluded
when the predetermined number of participants for the two
categories in the study was achieved. The DIT and TSPD
instruments were scored, and the data were analyzed using
the appropriate analyses to test each of the three research
questions stated earlier at the end of the introduction. Each
of the research questions is repeated as a subheading in the
following Results section.
Results
What is the psychosocial development level of PTSD-diagnosed
participants? In this analysis, the group means of the PTSD-
diagnosed participants on the TSPD were compared with the
norms set for Erikson’s (1963) Stages 5, 6, and 7 in the first experi-
ment. The means of the PTSD-diagnosed veterans were all below
the means for the norms groups on all levels, indicating that the
PTSD-diagnosed veterans on average remained at Level 5 (late
adolescence) or possibly lower. See Table 1 for the comparisons.
What is the moral development level of PTSD-diagnosed
participants? The PTSD-diagnosed veterans had a range of
raw scores on the DIT from 2 through 6, with a mean P-score
of 27.39 (SD = 17.98). According to Rest (1986), this P-score
corresponds with the moral reasoning levels found in junior
high school students.
Journal of Counseling & Development ■ Summer 2007 ■ Volume 85368
Taylor & Baker
How do veterans diagnosed as having PTSD compare with
PTSD-free veterans regarding level of psychosocial development?
Students’ t tests were used to conduct the comparisons, and
Cohen’s (1988) d for the effect sizes. The findings indicated sig-
nificant differences between the PTSD-diagnosed and PTSD-free
veterans across all three stages of the TSPD, with the PTSD-free
group means being higher in each instance. An alpha level of .05
was used for all tests. Table 2 presents the summary data.
How do veterans diagnosed as having PTSD compare with
PTSD-free veterans regarding level of moral development? The
average P-score for the PTSD-free participants was 30.52 (SD =
15.75). Rest (1986) indicated that this is at the moral reasoning
level of high school students. As noted earlier, on the P-score,
the PTSD-diagnosed participants had a mean of 27.39 and a
standard deviation of 17.98. Rest (1986) compared this score
with the moral reasoning level of junior high school students.
Discussion
Prior to the data analyses, there were no apparent differences
between the two groups other than the diagnosis of having
or being free from PTSD. The analyses appeared to indicate
that the PTSD-diagnosed veterans indicated lower levels of
psychosocial and moral development across the board. The
effect sizes were quite large.
At the time of the study, all PTSD veterans were over age
30, ranging in age from 30 to 67 years (M = 47.46). However,
their average score on the psychosocial development measure
was below that of college freshmen. In addition, their average
moral development score compared with that of junior high
school students. Together, these findings suggest that veterans
diagnosed as having PTSD may have experienced arrested
psychosocial and moral development.
Conclusion
The findings appear to support contentions of writers and
researchers whose work was cited earlier. For example,
interviews of veterans experiencing PTSD led Wilson
(1980) to conclude that help for them may be found in the
social-personality arena. Arrested psychosocial and moral
development may also explain why, according to Kulka et al.
(1990), veterans with PTSD have difficulty sharing combat
experiences and having successful relationships.
Arrested psychosocial and moral development leading to
relationship difficulties may explain why Figley (1995) found
grief and family therapy useful treatment approaches. In ad-
dition, Meichenbaum’s (1994) focus on cognitive-behavioral
therapy as a treatment mode for veterans with PTSD highlights
the importance of cognitive development. Individuals whose
psychosocial and moral development are arrested at conven-
tional cognitive development stages of early adolescence
possibly lack the necessary capacity to engage in the levels of
reasoning one might need to cope with the trauma, confusion,
emotion, brutality, and fear associated with combat.
One question that arose as the study proceeded, and
which remains unresolved, is whether psychosocial and
moral development was arrested because of combat ex-
perience or was it already arrested before combat experi-
ence. Are these conditions mutually exclusive, or do they
interact? Uncovering answers to this question appears to
be very difficult. In addition, f inding the answer may be
less important than using the present f indings as a foun-
dation for developing treatment programs and enhancing
existing programs.
The findings suggest that treatment programs may ben-
efit from efforts to measure and enhance, if necessary, the
psychosocial and moral development of veterans diagnosed
with PTSD. These efforts may be conducted in combination
with compatible symptoms-related tertiary prevention treat-
ments. With veterans already diagnosed as having PTSD,
stand-alone educational programs that focus on enhancing
psychosocial and moral development, while also including
family members, might serve as helpful secondary preven-
tion programs.
The findings also suggest that programs to prepare military
personnel before they enter combat that focus on preparation
for psychosocial and moral challenges may achieve primary
prevention goals. Such preparatory training might include
elements that are already known to enhance psychosocial
and moral development. Examples are dilemma discussions,
TaBle 1
Comparisons of Posttraumatic Stress
Disorder (PTSD) Participants With Norms Group
Participants on levels of Psychosocial Development
level
Stage 5
Stage 6
Stage 7
PTSD
Participants
73.01
66.35
61.26
39.68
40.81
50.87
Norms Group
17–19
Years Old
20–29
Years Old
77.21
71.71
66.64
30–54
Years Old
78.00
75.55
72.00
Note. Comparisons were made with group means. Stages represent
those of Erikson (1963): Stage 5 = late adolescence; Stage 6 = early
adulthood; Stage 7 = adulthood.
TaBle 2
Summary Data for Psychosocial Development
Comparisons
level
Stage 5
Stage 6
Stage 7
47.46
40.81
50.87
PTSD-Free
Participants
M SD t Test
Note. Comparisons were made with group means. PTSD = posttrau-
matic stress disorder. t = Student’s t-test statistic. Stages represent
those of Erikson (1963): Stage 5 = late adolescence; Stage 6 = early
adulthood; Stage 7 = adulthood. For all levels, p < .0001.
PTSD
Participants
Cohen’s dM SD
13.15
11.89
11.13
76.84
68.93
71.06
9.27
10.10
7.46
10.32
10.19
8.52
2.34
2.37
1.81
Journal of Counseling & Development ■ Summer 2007 ■ Volume 85 369
Development of PTSD-Diagnosed Combat Veterans
reflection activities, perspective-taking simulations and exer-
cises, and enhancement of problem-solving skills.
Limitations and Future Research
The present study identified several avenues for further re-
search. First, the TSPD (Taylor, 2000), being a new instrument,
may foster studies of its psychometric properties or may be
used as a measure of psychosocial development in studies
where that variable is of interest. Second, further tests of the
psychosocial and moral development questions in the second
study of the present article are needed to test the findings in
the present studies. Third, the several recommendations for
tertiary, secondary, and primary prevention interventions, if
implemented, should be evaluated empirically.
Limitations of the present study are that (a) the TSPD is a
relatively new, self-report instrument; (b) only one measure each
of psychosocial and moral development was used; and (c) the
sampling for the experiments was limited to one university and
two veterans centers, all located in the same southeastern state.
The first two limitations are challenges to construct validity, and
the third is a challenge to the external validity of the present
study. We are reminded of the bubble hypothesis (Gelso, 1979),
which states that all research studies have some type of flaw or
weakness. We hope the present set of studies will encourage
others to pursue this line of research and will also support exist-
ing ideas or suggest new approaches for treatment.
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Vietnam veterans. Boston: Beacon Press.
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Journal of Counseling & Development ■ Winter 2005 ■ Volume 83116
Trends
One of the most common disorders facing people today is
depression. By some estimates, roughly 10% to 25% of the
population experiences some form of depression. Accord-
ing to Murray and Lopez (1997), depression is the number
one cause of disability worldwide. It is clearly the most com-
mon disorder experienced by people who see mental health
practitioners (Gilroy, Carroll, & Murra, 2002). Also, it may be
the most common disorder of mental health workers them-
selves (Mahoney, 1997; Pope & Tabachnik, 1994), with re-
search suggesting that from one third to more than 60% of
mental health professionals had reported a significant epi-
sode of depression within the previous year. Depressing? Yes,
but there is hope and good news. Depression, by and large, is
a problem readily amenable to treatment, and there are many
successful approaches, many of which have empirical evi-
dence to support their efficacy. The bad news, however, is that
depression has been increasing in epidemic proportions. Data
reflect that depression is 10 times as prevalent now as it was in
1960! Seligman (2002) provided a provocative paradox on
depression. He stated that while every objective indicator of
well-being in the U.S. has been increasing, every indicator of
subjective well-being is decreasing.
Clearly, the importance of the current knowledge base on
depression is obvious. Counselors, from pre-K to adult men-
tal health workers, need to be well-versed on the current
state of treatment for depression. For counselors, it is quite
likely that for many of their clients, whether they present
with problems of mood disturbance or not, depression may
be involved. For professionals, who are at high risk for mood
disorders by the very nature of their work, the importance of
treatment and prevention in self-care is critical. Thus, this
topic has considerable value because it is quite likely that
counselors will work with clients with depression, and it is
quite likely, given the empirical evidence, that counselors
are experiencing or will be experiencing some form of de-
pression/mood disturbance themselves.
The article “Treatment and Prevention of Depression”
(Hollon, Thase, & Markowitz, 2002) reviews the current state
of research on various treatment modalities, comparing the
effectiveness of the more widely used approaches—psycho-
dynamic therapy, interpersonal psychotherapy, cognitive
behavior therapy, marital and family therapy—to antidepressant
medication therapy. The results of these comparisons are dis-
cussed, together with implications for counselors, counseling,
and counselor training.
Article Review
In a monograph-length article, Hollon et al. (2002) provided
a detailed review of the common treatments for depression,
together with a summary of the available empirical support
for each. They added to that a brief discussion of marital and
family therapy for treating depression, approaches that are
only now starting to receive empirical scrutiny. Specific
research outcomes were presented for medication treatments,
psychodynamic treatments, interpersonal psychotherapy,
cognitive behavior approaches, and marital and family ap-
proaches. The authors discussed the relative effectiveness of
Louis V. Paradise and Peggy C. Kirby, Department of Educational Leadership, Counseling, and Foundations, University of
New Orleans. Correspondence concerning this article should be addressed to Louis V. Paradise, Department of Educational
Leadership, Counseling, and Foundations, University of New Orleans, New Orleans, LA 70148 (e-mail: Louis.Paradise@uno.edu).
The Treatment and Prevention of
Depression: Implications for
Counseling and
Counselor Training
Louis V. Paradise and Peggy C. Kirby
With depression estimated to exist in as much as 10% of the population, it may be the most prevalent problem
facing counselors today. S. D. Hollon, M. E. Thase, and J. C. Markowitz (2002) reviewed the extensive research
comparing various psychotherapeutic and pharmaceutical approaches to treating depression. They concluded
that certain psychotherapy approaches are as effective as medications, but much remains uncertain about
effective treatment. This article reviews the authors’ analyses and presents implications for the counseling
profession.
Journal of Counseling & Development ■ Winter 2005 ■ Volume 83 117
Treatment and Prevention of Depression
various combinations of these treatments as well. Although
most of the article was concerned with research-based out-
comes for adult outpatients with depressive disorders, the
authors also presented examples from the growing body of
research on the treatment of bipolar disorders.
Hollon et al. (2002) provided a concise primer on the
types of mood disorders. The summary should be very help-
ful for counselors because most will have clients who ex-
hibit some form of mood disorder. The consequences of
depression, beyond the disorder itself, are significant. De-
pression increases the risk of heart disease and diabetes.
Also, mood disorders can increase the risk of substance
abuse and vice versa. Thus, sensitivity to the occurrence of
depression is a critical diagnostic skill for all counselors.
Medication Treatments
The most useful single piece of information presented by
Hollon et al. (2002) was a chart of commonly used medica-
tions. The various types of medications were presented to-
gether with their brand names, common dosage levels, and
prominent side effects. The chart was written for nonmedical
readers, and it could serve as a useful guide to antidepres-
sant drugs. Overall, the authors concluded that antidepres-
sant medications were clearly effective in the treatment of
depression and that the drugs provided some measure of
protection from relapse as long as the person continues to
take the medication.
Noncompliance with medication regimen, over time, is a
very common problem. Motivation, bad side effects, cost,
and so on, all contribute to negative outcomes over time. Side
effects for these medications include insomnia, nausea, vom-
iting, tremors, and memory impairment, to name just a few.
Hollon et al. (2002) concluded that the various types of drug
treatments are generally comparable in efficacy but differ in
terms of side effects, which do vary considerably among
people and can be substantial. Although the empirical evi-
dence presented is clear, in that most individuals will respond
to one or more of the medications, there is no evidence that
any medications will reduce the risk of future depression once
they are discontinued. Furthermore, because of the wide vari-
ability in the effects of antidepressant medications, it may
take some time for the drugs to take effect or for the correct
medication or dosage level to be determined. All these issues
directly affect compliance and outcomes.
To support their assertions on the efficacy of antidepres-
sant medications, Hollon et al. (2002) presented overall sum-
mary research data from a meta-analysis of treatment out-
comes conducted for the Agency for Health Care and Policy
Research (Depression Guideline Panel, 1993) and from an
update of that review by Mulrow et al. (1999). It is interest-
ing that placebo conditions, in general, produced about a
30% response compared with medications at slightly more
than 50% response. These data support the long-held notion
of the powerful effects of placebos in general. Nonetheless,
the medications typically are effective and relatively fast-
acting as a treatment for depression. The authors explained
that the 50% response from medication is reasonable when
one realizes that individuals may need to try several drugs or
combinations of drugs before an effective medication is found.
Therapy Treatments
The authors described the various psychotherapy approaches:
psychodynamic, interpersonal, cognitive-behavioral, and
marital and family. A substantial number of empirical out-
come studies were presented, several of which were meta-
analyses quantitatively summarizing collections of other
studies. The findings suggested that psychodynamic therapy,
although having a long history, lacks adequate empirical
evidence of its efficacy. Based on available data, its results
are just slightly better than placebo medications. The au-
thors lamented this finding given the depth and longevity
of the approach and the number of individuals who receive
this form of treatment.
Interpersonal psychotherapy has demonstrated its effec-
tiveness as a treatment for major depression. Its efficacy, in
comparison studies, shows it is as effective as medication ap-
proaches. The authors concluded that for severe depression, it
seems to produce better outcomes than other psychotherapy/
counseling approaches and may be the treatment of choice. It
is noted that this approach is recommended in practice guide-
lines by the American Psychiatric Association.
Hollon et al. (2002) differentiated the findings from cog-
nitive therapy from those for behavior therapy. However,
they recognized clearly that the most current approaches are
by and large a combination of cognitive and behavioral
strategies. In fact, their conclusions and many of the research
summaries cited by Hollon et al. treated the two approaches
as one, cognitive behavior therapy. As for purely cognitive
approaches, the authors noted that although they often
match or exceed medication results, the level of expertise of
the therapist/counselor makes a greater difference in results
the more severe the depression is to treat. Most important,
the effects of cognitive therapy seem to show enduring ef-
fects beyond the end of treatment, whether the individuals
were on medication or not. The authors reported that behav-
ior therapy interventions have never been as popular as cog-
nitive approaches for treating depression; however, in re-
cent years there has been greater interest in behavioral inter-
ventions. Several studies were cited that reported positive
outcomes for pure behavior interventions. However, there
was greater overall support and more outcomes studies, as
well as wider use by practitioners of cognitive approaches
or cognitive with behavioral intervention than of behavior
therapy alone.
What about combining therapies? The current evidence sug-
gests, according to the authors, that combining cognitive
Journal of Counseling & Development ■ Winter 2005 ■ Volume 83118
Paradise & Kirby
therapy or related cognitive behavioral interventions with medi-
cation appears to provide only modest increments in improve-
ment. Cognitive approaches with medications appear to be
useful for severe/chronic cases of depression. There is also em-
pirical evidence to support the use of cognitive approaches
with medication for the treatment of bipolar depression.
For counselors, many of whom use cognitive behavior ap-
proaches, the news is good. These approaches in the absence of
medication fare well as a depression treatment for all but the
most severe cases. Also, the effects seem to last after treatment.
Because the prime effort behind these approaches is usually to
teach new ways of behaving, relating, and thinking, it makes
sense that the skills learned in treatment can carry forward.
Even for the most severe cases of depression, it seems that
cognitive behavior therapy can be a useful adjunct to medica-
tion treatment regardless of the severity.
Marital and family approaches were briefly discussed by
Hollon et al. (2002). They indicated that although these
approaches are often used to reduce family conflict and to
relieve distress, they are rarely studied in the treatment of
depression. The few studies available suggested that there
may be some value in these approaches, especially from an
educational and family relationship perspective.
In summary, Hollon et al. (2002) concluded that the medi-
cation approaches have the most extensive empirical support
and generally are effective as long as they are continued, but
they do produce troublesome side effects. Treatments such as
interpersonal psychotherapy and cognitive behavior therapy
also are successful in the treatment of depression. Although
they produce effects that are often similar to medication
approaches, they seem to have the added benefit of endur-
ing effects after treatment. The authors did note that depres-
sion is an eminently treatable problem. Furthermore, they
indicated that while considerable progress in treatment has
been made over the years, far too many people go untreated or
do not have access to tested interventions. The authors’ last
comment in the article has substantial implications for all coun-
selors and mental health practitioners: “Most important of all,
the field needs to emphasize efforts at prevention that build on
existing indications that people can learn strategies to reduce
future risk” (Hollon et al., 2002, p. 70).
Implications for the Counseling Profession
With depression being a widespread and growing problem,
it is important for counseling professionals to recognize the
prevalence of the disorder and to be able to provide assis-
tance not only to the clients they serve but to themselves
when necessary. Whereas the Hollon et al. (2002) article
only dealt with outcomes research on clinical depression,
the overall number of individuals with lesser forms of de-
pression is substantial. The profession can play a significant
role in the treatment of this problem. There is ample evi-
dence that interventions for depression are successful and
can benefit individuals with mood disorders. The interven-
tions reviewed by Hollon et al.—interpersonal psycho-
therapy, cognitive behavior therapy, and marital and family
therapy—all prove to be beneficial either with or without
medications. If we counselors extrapolate downward to the
large number of individuals with serious but less severe depres-
sion (nonclinical)—the type most often seen by counselors—we
are faced with a compelling argument that there is much work to
be done. Given that Seligman (2002) believed there is an epi-
demic of depression in America, the counseling profession needs
to provide greater focus on training, research, and practice for
mood disorders in both clinical and nonclinical populations.
For counselors engaged in marital and family counseling,
the evidence is supportive. Hollon et al. (2002) are encour-
aged by the potential of this treatment, and others (Beach,
2003; Gollan, Friedman, & Miller, 2002) provide similar
conclusions. However, much more needs to be done in re-
search and training, especially on documenting the outcomes
of this approach and its unique and added value for treating
depression in the individual with the disorder and for the
other members of that family.
Counselor Implications
Staying current in the field, although important for any pro-
fessional, is critical for practicing counselors. Reviews of
treatment outcomes provide a useful mechanism to inform
the practitioner about which techniques work and under what
conditions they work. Synthesizing years of disparate re-
search findings into a set of omnibus empirically based con-
clusions greatly facilitates counselors’ task of practicing
under state-of-the-art conditions.
On a personal level for the counselor, given the demand-
ing nature of the task, susceptibility to depressive symptoms
is high. Thus, personal issues of self-awareness and self-care
need constant attention. Carroll, Gilroy, and Murra (2003) dis-
cussed the need for counselors to engage in self-care behaviors
for this very reason. Although personal counseling is often
recommended for counselor trainees, practicing counselors
often resist this self-care option.
Counseling Implications
The findings of Hollon et al. (2002) provide validation in that
commonly used approaches in counseling can have signifi-
cant outcomes, even for clinical cases of depression. Using the
many techniques of cognitive behavior therapy—helping
people learn skills to change the way they think, interact, feel,
and so on—can produce positive outcomes with or without
medications for inpatients or outpatients. Counseling’s role in
the treatment of major depression may become more promi-
nent. A study by Chilvers et al. (2001) comparing generic
counseling with the use of antidepressant drugs found es-
sentially no difference in positive outcomes other than
Journal of Counseling & Development ■ Winter 2005 ■ Volume 83 119
Treatment and Prevention of Depression
recovery was faster with the antidepressants, while counsel-
ing was more preferred by the participants.
For the nonclinical populations, Seligman (2002) and
his followers of “Positive Psychology” offer much promise
for improving people’s mood states. Seligman’s book Au-
thentic Happiness provides not only many assessment scales
and techniques but also a complete approach to understand-
ing the positive over the negative aspects of the human con-
dition. Because counseling was founded on such core prin-
ciples as maximizing human potential and positive growth
and development, positive psychology—and its constructs
of learned optimism, authentic happiness, and hope—seems
like an appropriate model for counselors attempting to im-
prove their clients’ quality of life.
Counselor Training
The implications of Hollon et al. (2002) for counselor training
seem obvious. Counselors should receive the necessary educa-
tion in assessing depressive symptoms; making referrals; and
applying techniques, models, and approaches for dealing with
depression, from mild to severe conditions. Approaches that
work with special populations, such as children, adolescents,
and the elderly are important. Occurrence rates for these groups
have been increasing substantially in recent years.
Counselor educators can ensure that counselor trainees
are aware of their own limitations and are sensitive to the
demands of the profession. Counselor training that promotes
a dialogue on self-care, as recommended by Carroll et al.
(2003), is needed and often overlooked in training programs.
Continuing education in depression and the counselor’s role
in effective treatments is necessary for all who practice. With
increasing prevalence of child and adolescent depression,
in-service training for school counselors would be an asset
to the counselor’s armaments. Greater research efforts on
outcomes assessment of counselor-provided treatments are
needed to augment the research base.
Last, counselors from school to mental health settings are
in a unique position to make valuable contributions to help-
ing individuals and their families with depression, whether
through direct intervention or in support of other mental health
professionals. If there is an epidemic of depression, the em-
pirical evidence provided by Hollon et al. (2002) suggests
that counselors have the tools to be effective helpers.
Summary
Hollon et al. (2002) have provided a comprehensive and
insightful review of the extensive research on the thera-
peutic approaches for the treatment of depression. Included
in the review is useful information on the various drug
treatments as well as outcomes research. The authors con-
clude, overall, that antidepressant medications were shown
to be as effective as interpersonal psychotherapy and cog-
nitive behavioral therapy. With depression, in all its forms,
at near epidemic proportions, counselors can play an
important role in its treatment. The evidence shows that the
successful psychotherapy treatments for depression are already
part of the counseling profession’s repertoire. Counselors, from
school to mental health, as well as counselor educators, should
devote considerably more attention to mood disorders.
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