Healing from Moral Injury: A Qualitative Evaluation of the Impact of Killing Treatment for Combat Veterans

ABSTRACT

This paper evaluates the Impact of Killing (IOK) treatment—a psychological intervention designed to address moral injury and trauma associated with killing in war. Using qualitative data from interviews with 28 combat veterans, we examine IOK’s impact, how it differs from other trauma-focused treatments, and how it can be improved to better meet veterans’ needs. We found that many veterans processed their killing experiences for the first time in IOK, even though all had previously completed evidence-based treatments for posttraumatic stress disorder. Several described killing in war as the most distressing and transformative trauma of their lives, and all affirmed the value of an intervention focused directly and explicitly on moral injury and killing. IOK helped veterans to acknowledge their grief, shame, and distress; gently but critically examine their thoughts and beliefs about killing in war; and make strides toward acceptance, reconciliation, and forgiveness.

KEYWORDS:

• Combat trauma
• killing
• military veterans
• posttraumatic stress disorder
• treatment evaluation

Notes

¹ There are several reasons why IOK was designed to follow and to build on, rather than to precede or occur concurrently with, existing treatments for PTSD. First, PTSD treatments like PE and CPT are comprehensive, evidence-based treatment models that require intensive engagement. Their focus and treatment goals are not identical to those of IOK. We believe that many veterans would find it challenging to commit to two intensive and substantive treatments at once. Further, not all combat veterans with PTSD struggle with moral injury related to killing, and the psychological challenges attributable to moral injury in particular are not always apparent at the outset of PTSD treatment. For these reasons, we feel it is more appropriate for veterans struggling with posttraumatic stress symptoms to complete a PTSD treatment program before engaging in IOK. Those veterans who continue to experience difficulties after completing PE or CPT can then be offered an additional treatment module (IOK) to address moral injury specifically. Offering IOK after PE or CPT also provides veterans with time to integrate what they have learned in prior treatment and to practice associated skills. Those veterans who feel they need time to take a break from intensive treatment and to consolidate treatment gains will have the opportunity to do so, improving their readiness to commit to and succeed in IOK treatment.

² IOK treatment is designed to be provided by a therapist who has both training in evidence-based treatments for PTSD and significant experience in working with veterans who have PTSD. The therapist should feel comfortable discussing the morally challenging events that come up in war and capable of creating a therapeutic environment in which these topics can be explored without judgment. Some familiarity with military culture and combat experience is important, but a general commitment to the values of cultural humility and sensitivity is more fundamental. Therapists providing IOK should be open to engaging in discussions that touch on spirituality and religious faith with veterans from many different faith backgrounds. At this time, we are exploring the possibility of developing a formal training program for IOK practitioners.

Additional information

Funding

This work was supported by the U.S. Department of Veterans Affairs.