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 PTS

PsychosocialandMoralDevelopmentofPTSD-DiagnosedCombatVeterans.pdf

Home >Social Science homework help >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 PTS

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: [email protected]).

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.

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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

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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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