These notes are from Rachel M. MacNair. Dr. MacNair is a social psychologist, not a therapist, Therefore, these notes from the literature and several year’s worth of conversations and conferences are intended as a starting point for people with much more expertise in therapy than she has.
Understanding the universality of the experience
“I saw many clients come to our inpatient program thinking that they were alone in their pain. They judged themselves uniquely crazy, weak, and/or cowardly for having had problems, such as flashbacks, fearfulness, and rage, in civilian life after their military experience. There was some genuine relief that came from seeing that others had these problems, even if the problems continued.”
Lipke, H. (2000). EMDR and psychotherapy integration. Boca Raton, FL: CRC Press, p. ii
“In the therapy group, especially in the early stages, the disconfirmation of a patient’s feelings of uniqueness is a powerful source of relief. After hearing other members disclose concerns similar to their own, patients report feeling more in touch with the world.”
Yalom, I. (1995). The theory and practice of group psychotherapy. New York: Basic Books
Traditions of Atonement and Bearing Witness
This is one of many references in the literature, but this point has been noted throughout history and confirmed by contemporary therapists:
“alternative strategies . . . [include] exploring ways of making reparations and bearing witness . . . Atonement, repentance and forgiveness, bearing witness, and re-identifying one’s self as a different person than the one who did the killing (as in being “born again”) have been suggested in many verbal discussions with therapists.
These have been some of the responses of the human community in diverse cultures and through many historical periods to the common phenomenon of dealing with killing. They have remained because of extensive experience that they are, in fact, helpful.”
Foa, E. B., Meadows, E. A. (1997). Psychosocial treatments for posttraumatic stress disorder: A critical review. Annual Review of Psychology, 48, 449-480.
For example, veterans join Veterans for Peace, or do service work in the country in which they fought. Former executioners campaign against the death penalty, and so on.
Cognitive Behavioral / Cognitive Processing Therapy
Specifically: “Impact of Killing” Treatment
The Impact of Killing treatment is specifically designed to treat moral injury in combat veterans. It originated in the San Francisco VA Health Care System. Therapists have reported good results for several years. This article lays out the program and discusses it:
Burkman, K. & Maguen, S. (2018, November 9). Impact of Killing (IOK): Expanding our Framework to Help Veterans Heal from War. Trauma Psychology News, American Psychological Association Division 56, https://traumapsychnews.com/2018/11/impact-of-killing/
Eye Movement Desensitization and Reprocessing (EMDR)
“This client said that his worst traumatic experience had to do with the death of some civilians for which he believed he was responsible. As the EMD therapy session unfolded, this veteran first reported decreased anxiety, as had the first veteran. Suddenly, he became upset and asked that we stop treatment. He went out of the therapy room with another staff member to calm down. When he returned he said that, as he became more comfortable with the memory, he got scared. He believed that he had made a “spiritual deal” – that if he stopped suffering, retribution would be taken against his family for the wrong he believed he had done.”
Lipke, H. (2000). EMDR and psychotherapy integration. Boca Raton, FL: CRC Press, p. v)
Time Perspective Therapy
In their book applying a strategy of thinking through past negative, past positive, present (also negative and positive) and future, Phil Zimbardo and colleagues include three cases of combat veterans suffering from PTSD clearly related to killing activity. See pages 110-123 and 129-137.
Zimbardo, P.G., Sword, R. M., & Sword, R.K.M. (2012). The time cure: Overcoming PTSD with the new psychology of time perspective therapy. San Francisco: Jossey Bass.
Concepts from Social Psychology
“Mechanisms of moral disengagement are examined in the literature as a model for understanding complex socio-cognitive processes involved in rationalizing moral transgressions, such as killing. It is proposed that mechanisms of moral disengagement which attempt to protect soldiers from moral culpability while enabling their participation in killing ultimately contribute to negative psychological consequences and trauma.
Particularly, dehumanization processes and the effects of the obedience to authority situation are discussed as elements of the combat context with specific salience to the traumatic impact on soldiers.”
Baalbaki, Zenobia S. (2010). Perpetration in combat, trauma, and the social psychology of killing: An integrative review of clinical and social psychology literature with implications for treatment. Dissertation Abstracts International: Section B: The Sciences and Engineering, Vol 70(10-B), 2010, 6537.
Pharmacotherapy
As yet, nothing is known. The difference between those victimized by trauma and those who participated in causing the trauma still needs to be taken into account in studies.
May be Counter-indicated:
Flooding/Prolonged Exposure/Virtual Reality
People normally have trauma symptoms immediately, then they subside in weeks. The problem with PTSD is that instead they keep having the symptoms. The purpose of this kind of therapy is “systematic desensitization” – to have the symptoms subside as the person acclimates to reminders of the trauma.
This technique is based on extinction of fear, treating PTSD as an anxiety disorder. It may well work when that’s the problem. Experience indicates it may not be workable when killing is the trauma.
Expressive writing
“To their disappointment, researchers found that four months after participating in writing exercises, soldiers in the emotional writing group who had high levels of combat experiences scored higher on an anger scale, compared with soldiers not asked to write . . . The emotional writing exercise seemed to make soldiers angrier than they were before sitting down to write. ‘Overall, it appears that, for soldiers in the high risk condition, those soldiers reporting lots of combat experiences, expressive writing is actually contraindicated,’ [Amy] Adler said. ‘For us, it really underscores that you can’t just take stuff off the shelf from the civilian literature and assume it’s going to work.'”
Munsey, C. (2009, October). Writing about wounds. Monitor on Psychology, 58-59.
While this study didn’t take the killing variable into account, neither checking that the soldiers had done so nor whether this was in the content of what they wrote about, it would seem that because this is commonly associated withhigh levels of combat experience, this might apply and should be explored.
For comments or questions, or to add other sources, please contact Dr. Rachel MacNair at
Rachel_MacNair @ yahoo . com (remove spaces)
Phone:
816-
753-
2057
U.S. Central Time Zone
Other pages:
Home Page: basic explanation.
Personal Stories from biographies and autobiographies throughout history, from a variety of kinds of violence.
Classic Literature shows the cross-cultural observations of keen observers of the human condition.
Moral Injury compares PITS with a related concept that’s become popular in recent years.
Study of Veterans – What an analysis of the U.S. government’s data on 1,638 combat veterans of the American war in Vietnam shows