Journal of Counseling and Development

Journal of Counseling and 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.

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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-

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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

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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.