Killing in war leaves veterans with lasting psychological scars, study finds

December 13, 2016 by Laura Kurtzman, University of California, San Francisco

Killing in war often triggers a moral conflict in veterans that can damage their self-image, relationships and spirituality, according to a study by UCSF researchers at the UCSF-affiliated San Francisco Veterans Affairs Medical Center.

For many of these —some of whom may already suffer from post-traumatic stress (PTSD)—the guilt, shame, anger and isolation they suffer compound psychological trauma related to their war experiences. Shira Maguen, PhD, UCSF associate professor of psychiatry and mental health director of the San Francisco Veterans Affairs Health Care System Integrated Care Clinic, which treats Iraq and Afghanistan war veterans, said these emotional scars sometimes last for decades.

Maguen's earlier research—supported by the Veterans Health Research Institute-NCIRE—has linked killing in combat with PTSD, depression and suicide. The new study, published in the October 2016 issue of Counseling Psychologist, further investigates the moral injury suffered by veterans who have killed and the stigma they carry.

Although not all veterans who have taken a life suffer guilt or mental health consequences, Maguen said the growing number of veterans seeking mental health services suggest that high numbers of veterans are experiencing moral injury. The researchers urged the public and health care workers to allow veterans to express themselves to help them work through these conflicts.

"Civilians, including professionals, have an opportunity and an obligation to better understand veterans' experiences and to join them in confronting difficult truths about the violence of war, its meaning and its consequences," they stated in the paper. "In doing so, we can begin to break through the postwar silence that masks moral injury, sustains isolation and reinforces trauma."

Maguen and the study's first author Natalie Purcell, PhD, who directs the Patient Centered Care Program at the SFVAHCS, have initiated research, outreach and model therapies for veterans with moral injury. These are coordinated with PTSD and general psychiatry programs.

Their Impact of Killing (IOK) treatment program emphasizes self-forgiveness and helping veterans make amends, heal relationships, plan for their future and move forward. Exercises include discussion groups with fellow veterans and writing letters to the person they killed. Veterans and their advocates are also encouraged to build bridges especially to the spiritual community, which is increasingly concerned and sympathetic to the veterans' plight and moral injury.

"It's clear that helping veterans work through their experiences calls for tremendous sensitivity, empathy and patience," said Purcell, assistant adjunct professor of social and behavioral sciences in the UCSF School of Nursing.

The study was based on focus group and individual interviews with 26 war veterans who had killed or believed that their combat actions caused the death of others. Eighteen were Vietnam veterans and eight were deployed in Iraq. They described how they felt after killing in combat and some opened up about hidden agonies.

One veteran put it this way: "All I knew is I hurt inside and I didn't know why, you know? I didn't know why I should feel so bad if I didn't do anything wrong. I was not a baby killer. I was not—I did my job. I did what everybody else did. But always that nagging question, why do I hurt like this?"

Researchers categorized the way that veterans described their experiences across five domains: talking, feeling, identifying, relating and coping.

Most veterans said that killing was the most challenging war experience to talk about, but it was the topic they were asked about most frequently by others.

"Many veterans feared that, if they talked about killing, they would be judged or mischaracterized by other people's notions of what it means to be a combat veteran," Purcell said. "Being asked about killing left many veterans feeling anxious, isolated and even angry because most felt that someone who did not serve in war could not possibly understand what it was like to kill."

She said many veterans also described feeling guilt and shame about their experiences, while others felt numb after being exposed to so much killing and death in combat.

Many described confronting a "dark side" of themselves that they did not know existed before they had killed in combat. Purcell said that for some veterans, this disrupted their sense of identity, making it difficult for them to see themselves as good.

Isolation was a common theme, as many veterans felt civilians could not understand or relate their experiences. Some found it hard to get close to others because they had to hide that they killed in combat.

Commenting on these feelings, one veteran said, "Getting close to people—been a big issue for—caused me to get a divorce, the agitation, irritability through all those years and not really talking to my ex-wife or kids at that time."

Many veterans wanted to avoid any reminders of their combat experience, and they turned to alcohol or isolated themselves from others.

Despite the depths of their wounds, Purcell said that many veterans found, especially when they were able to connect with other veterans, that talking about their experiences eventually became a source of healing, as did volunteering to help others.

Explore further: Study uncovers high prevalence of military sexual trauma among transgender veterans

Related Stories

Study uncovers high prevalence of military sexual trauma among transgender veterans

November 21, 2016
New research found a high prevalence of military sexual trauma (MST) among transgender veterans and an association between the experience of MST and certain mental health conditions.

New survey shows PTSD is big problem, even for noncombatants

September 14, 2016
A recent national survey of 1,484 U.S. military veterans shows that posttraumatic stress disorder (PTSD) remains a major health problem, even for service members who have never seen combat. 

Study suggests feelings of guilt may be a top factor in PTSD

December 6, 2011
A leading cause of post-traumatic stress disorder is guilt that troops experience because of moral dilemmas faced in combat, according to preliminary findings of a study of active-duty Marines.

Killing in war linked with suicidal thoughts among Vietnam veterans, study finds

April 18, 2012
The experience of killing in war was strongly associated with thoughts of suicide, in a study of Vietnam-era veterans led by researchers at the San Francisco VA Medical Center (SFVAMC) and the University of California, San ...

PTSD may negatively affect sex life satisfaction in male and female veterans

June 3, 2016
New research reveals that posttraumatic stress disorder (PTSD) was a strong, negative predictor of sexual satisfaction in both male and female veterans who returned from warzones in recent Iraq and Afghanistan conflicts.

Sexual dysfunction is prevalent among recently deployed veterans

November 4, 2015
In a recent study of 247 US veterans returning from conflicts in Iraq and Afghanistan, almost 18% screened positive for sexual functioning difficulties. Self-reported sexual dysfunction was most strongly linked with depression, ...

Recommended for you

Say cheese! Why a toothy smile makes it easier for you to be identified

June 19, 2018
A fulsome smile in a photo makes it easier for people to identify the individual, say researchers at the University of York.

Videogame loot boxes similar to gambling

June 19, 2018
Adolescents playing video games that offer randomised rewards to increase competitive advantage could possibly be exposed to mechanisms that are psychologically similar to gambling, according to new research just published ...

Mental health declining among disadvantaged American adults

June 19, 2018
American adults of low socioeconomic status report increasing mental distress and worsening well-being, according to a new study by Princeton University and Georgetown University.

Genes associated with infantile forms of schizophrenia identified

June 19, 2018
Scientists at the Montreal Neurological Institute and Hospital (The Neuro) and McGill University have identified novel genes associated with a specific form of schizophrenia.

Kids grasp that you get what you pay for

June 19, 2018
From a young age, children have a nuanced understanding of fairness.

Study on social interactions could improve understanding of mental health risks

June 19, 2018
McLean Hospital investigators have released the results of a study that outlines how age, socioeconomic status, and other factors might contribute to social isolation and poorer mental health. In a paper published in the ...


Please sign in to add a comment. Registration is free, and takes less than a minute. Read more

Click here to reset your password.
Sign in to get notified via email when new comments are made.