Veterans’ Perspectives on the Psychosocial Impact of Killing in War

TLDR: Based on focus group and individual interviews with 26 combat veterans, this article examined the psychosocial and interpersonal consequences of killing in war and concluded that the consequences of war can be categorized into two categories: psychological and interpersonal.

Abstract: Based on focus group and individual interviews with 26 combat veterans, this qualitative thematic analysis examines the psychosocial and interpersonal consequences of killing in war. It describes t...

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UCSF
UC San Francisco Previously Published Works
Title
Veterans' Perspectives on the Psychosocial Impact of Killing in War
Permalink
https://escholarship.org/uc/item/6wg5170z
Journal
Counseling Psychologist, 44(7)
Authors
Purcell, Natalie
Koenig, Christopher
Bosch, Jeane
et al.
Publication Date
2016-10-01
Peer reviewed
eScholarship.org Powered by the California Digital Library
University of California

Veterans’ Perspectives 1
Running Head: IMPACT OF KILLING IN WAR
Veterans’ Perspectives on the Psychosocial Impact of Killing in War
Natalie Purcell
1,2
, Christopher J. Koenig
1,2
, Jeane Bosch
3
, and Shira Maguen
1,2
1
University of California, San Francisco
2
San Francisco Veterans Affairs Health Care System
3
St. Louis University, St. Louis, MO
Corresponding Author: Natalie Purcell, PhD, MPA, Office of Patient Centered Care (00-PCC),
San Francisco VA Health Care System, 4150 Clement Street, San Francisco, CA, 94121.
E-mail: Natalie.Purcell@ucsf.edu
1

Veterans’ Perspectives 2
Abstract
Based on focus group and individual interviews with 26 combat veterans, this qualitative
thematic analysis examines the psychosocial and interpersonal consequences of killing in war. It
describes the consequences that veterans identify as most relevant in their lives, including
postwar changes in emotions, cognitions, relationships, and identity. Further, it illustrates the
linked psychological and social dimensions of those consequences—namely, how the impact of
killing in war is rooted in the unique perspectives, actions, and experiences of individual
veterans, as well as the social worlds they confront upon returning from war. We argue that, for
many veterans, killing provokes a moral conflict with a lasting impact on their sense of self, their
spirituality, and their relationships with others. In working with combat veterans, mental health
professionals should be sensitive to the complexities of discussing killing and attuned to the
psychosocial challenges veterans may face after taking a life in war.
2

Veterans’ Perspectives 3
Veterans’ Perspectives on the Psychosocial Impact of Killing in War
As the population of Vietnam veterans ages, and the United States reintegrates over 1.5
million men and women who served in the Iraq War and the War on Terror, mental health
professionals nationwide are called upon to play an evolving role in the counseling, treatment,
and community integration of combat veterans (American Psychological Association Presidential
Task Force on Military Deployment Services for Youth, Families and Service Members, 2007).
The growing need for veterans’ mental health services is well documented; significant numbers
of veterans who served in Afghanistan and Iraq report symptoms related to the stress and trauma
of combat exposure, especially depression (2-10%), post-traumatic stress disorder (PTSD; 5-
15%), and associated problems like substance abuse, relationship issues, and domestic violence
(Tanielian & Jaycox, 2008). Between 2001 and 2015, the number of enrollees in the Veterans
Administration (VA) healthcare system swelled to over 9 million (National Center for Veterans
Analysis and Statistics, 2016), including veterans of different generations who may engage with
mental health clinicians for the first time years or even decades after their deployments. Many
veterans are also seeking guidance or support from private-sector mental health clinicians or
from counselors at their colleges, universities, churches, and local veterans’ organizations
(Danish & Antonides, 2009; Tanielian & Jaycox, 2008). Often, they must turn to clinicians who
have not served in the military, who may know little about military culture, and who seldom
understand the unique experience of serving in a combat zone during war (Danish & Antonides,
2009). This article sensitizes mental health professionals to one part of the combat experience
that can be vital to veterans’ sense of well-being and social integration: the experience of killing
in war.
3

Veterans’ Perspectives 4
At its root, war entails the use of force, and all warriors are trained to kill. Scholars have
debated how many combatants actively kill others during war (Chambers, 2003; Grossman,
2014), but the best estimates suggest that killing is a routine part of the combat experience. For
example, Hoge et al. (2004) found that 87% of U.S. Marines and 77% of U.S. Army soldiers
deployed to Iraq reported directing fire at the enemy, frequently resulting in the death of enemy
combatants (65% Marine, 48% Army) and non-combatants (28% Marine, 14% Army). Despite
the prevalence of killing in war, few researchers have examined its impact on veterans.
Scholarship about the psychological consequences of fighting in war has focused on trauma,
understood largely as a result of experiencing risk and fear, enduring stress, and witnessing death
and suffering. This literature focuses on the violence that fighters are exposed to rather than the
violence that they do, or it considers exposure to combat in toto without differentiating the two
(e.g., American Psychological Association Presidential Task Force on Military Deployment
Services for Youth, Families and Service Members, 2007; Tanielian & Jaycox, 2008).
There is, however, a significant difference between killing and the other exposures of
war: killing requires agential participation in acts that would be condemned in virtually any other
social context; taking action to end a life constitutes the gravest of crimes outside of war. Killing
is thus profoundly incongruous with normal life experiences and shrouded in moral significance
—arguably more so than the other unique and impactful experiences of war. For these reasons, it
is important to examine killing in its own right as a potentially transformative experience.
Studies that have examined the psychological impact of killing in war suggest that the
consequences are significant. Researchers have identified an association between killing in
combat and post-traumatic stress among multiple generations of U.S. military veterans (Breslau
& Davis, 1987; Fontana, Rosenheck, & Brett, 1992; King, King, Gudanowski, & Vreven, 1995;
4

Frequently asked questions

Q1. What are the contributions mentioned in the paper "Veterans’ perspectives 1 running head: impact of killing in war veterans’ perspectives on the psychosocial impact of killing in war" ?

Based on focus group and individual interviews with 26 combat veterans, this qualitative thematic analysis examines the psychosocial and interpersonal consequences of killing in war. Further, it illustrates the linked psychological and social dimensions of those consequences—namely, how the impact of killing in war is rooted in the unique perspectives, actions, and experiences of individual veterans, as well as the social worlds they confront upon returning from war. 

Q2. How many veterans were considered eligible for study?

Veterans who indicated that they had killed others or believed that their combat actions caused the deaths of others, were considered eligible for study participation. 

Q3. How did the authors avoid the marginalization of individual voices?

The authors worked to avoid the marginalization of individual voices by keeping their focus groups small (no more than five participants per group) and diverse, particularly with regard to race and ethnicity, as well as age and era of service. 

Q4. What is the key to avoiding the appearance of curiosity?

Avoiding the appearance of simple curiosity is key, and mental health professionals should exercise patience and garner trust before broaching the topic. 

Q5. What did the veterans experience after prolonged exposure to killing and death?

Whether or not they experienced feelings of moral conflict and guilt, multiple veteransnoted a persistent, generalized emotional numbness in the aftermath of prolonged exposure to killing and death. 

Q6. What can future researchers do to build on the findings of this study?

Future researchers can build on their findings by conducting exploratory qualitative workwith subpopulations of veterans across different locations and cultural contexts, with a particular focus on the experiences of under-represented racial and ethnic groups, as well as women. 

Q7. What are the main reasons for the lack of a coherent postwar identity?

For many, the lessons about self and humanity learned in war are not easily integrated into a coherent postwar identity or worldview, creating a sense of discontinuity, confusion, and loss. 

Q8. What can mental health professionals do to help veterans connect with one another?

Beyond the family, mental health professionals can help veterans connect with oneanother by creating or advocating for venues that bring veterans together to explore the moral and spiritual dimensions of war’s violence. 

Q9. Why did the participants in this study have more time to discuss killing?

Because of their engagement in care, the participants in their study may have been more open to discussing killing than other veterans would be, and they may have done more preparatory work in examining and processing their own thoughts and feelings about war’s violence. 

Q10. Why do many veterans feel that the violence of war undermines their faith in God?

If the violence of combat sometimes undermines their faith in God and humanity, it is because many feel that their prevailing narratives about civilization, morality, and justice fail to account for war’s visceral realities. 

Q11. What questions could be included in future focus groups and interviews?

Future focus groups and interviews might also include questions that more explicitly invite exploration of how race, class, age, and gender shape veterans’ experiences of killing and its aftermath. 

Q12. What are the main reasons for the stigma and isolation of veterans?

The forces of stigma and isolation thus combine to trap veterans in the avoidant coping practices that so many of them rely on— practices that can augment and sustain the feelings of distress and sorrow that they are meant to suppress (Ein-Dor, Doron, Solomon, Mikulincer, & Shaver, 2010; Romero et al., 2015). 

Q13. What did the participants feel was crucial to work through killing experiences?

”To process and work through killing experiences, participants felt it was crucial toconnect with people who have shared that experience. 

Q14. What did the facilitator use to elicit information on participants’ behavior after the war?

the facilitator used probing follow-up questions as needed to elicit information on participants’ behavioral changes, coping strategies, and support systems after the war.