I recently had the opportunity to ask Dr. Craig Bryanfrom the National Center for Veterans Studies at the University of Utah about his experience counseling veterans. Soldiers are trained and disciplined to act appropriately in the violence of war, and are very often surrounded by death and destruction. It is not hard to see, therefore, that the psychological demands placed on those in the armed forces are immense and often result in the need for mental assistance.

Here, Dr. Bryan illuminates the challenges that service women and men face, and the direction of his research to better understand and treat those affected by combat. Here he discusses the fear of killing, moral injury, a crisis of conscience, and cognitive processing therapy.

“In my experience, it’s not very common that service members are unable to overcome the fear of killing. I think this is due in large part to the training provided in the military now, which is explicitly designed to overcome the resistance to killing, especially in the combat arms professions. I also suspect there is a strong self-selection component: those who are most resistant or uncomfortable with killing are highly unlikely to join the military in the first place. So it’s probably a combination of self-sorting and experiential learning.

Now the fact that one has overcome the fear of killing does not necessarily preclude a crisis of conscience after the fact. In my experience, it is not uncommon for service members to regret the decisions they’ve made in combat and to second guess themselves, especially with respect to killing. I’ve treated many service members struggling with such an injury. There is a growing recognition for this type of injury, which has been termed “moral injury” by many. We are currently researching moral injury and its overlap with other forms of mental health issues such as PTSD, depression, and suicide. Our work thus far suggests there are several dimensions of moral injury that are differentially related to these other forms of emotional distress.

I’ve also seen a crisis of conscience from NOT killing. In short, I’ve worked with service members experiencing extreme guilt and shame because they feel they caused the death of a friend or jeopardized the safety of their peers due to inaction in a hostile situation. In each of these cases, their hesitation was due to contextual ambiguity that made it difficult to discern if killing in that situation was justified or not. In essence, they couldn’t figure out if it was a “clean kill” or a “dirty kill” (murder), and therefore froze. The knowledge that one’s response led to the death of a friend (or could have) is often more distressing than the regret that stems from second guessing an actual kill.

From a treatment perspective, I have found it is critical to help the service member understand the difference between killing and murdering, and to focus on contextual variables with respect to psychological reactions/meaning of the event. I’ve found that military personnel very easily grasp the distinction between killing and murdering whereas civilians more often struggle with this. My preferred treatment approach is cognitive processing therapy, which was developed for PTSD but is highly applicable to moral injury. I’ve been collecting some preliminary data from cases I’m treating to test this assumption about CPT.”

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