There is mounting evidence that Veterans from multiple eras who kill in war are at increased risk for posttraumatic stress disorder (PTSD), alcohol abuse, general psychiatric symptoms, suicide, and functional difficulties after returning home. Despite high rates of exposure to killing and associated maladaptive responses, the military and VA do not routinely assess exposure to killing, which could assist with prevention and treatment efforts. Furthermore, the impact of killing is not currently addressed as a component of evidence-based treatment (EBT) for PTSD. In fact, in the current system, a Veteran can receive PTSD evaluation and evidence-based treatment without ever being asked about killing and its impact. Some researchers have cautioned against using one type of PTSD treatment, one commonly used in the VA, suggesting that it may be harmful for these patients. Consequently, it is possible that failing to directly treat the mental health impact of killing could result in inappropriate treatment, cause harm to Veterans, and cost lives.
Building on preliminary studies, the goal of this RRP was to pilot test the effectiveness, acceptability, and feasibility of an adjunctive treatment module to be used with existing PTSD cognitive-behavioral therapies (CBT). We developed a six- to eight-session CBT treatment module informed by Veteran focus groups aimed at learning about ways in which they have been impacted by killing. We refer to this new CBT treatment as the Impact of Killing (IOK) module.
Our first aim was to evaluate the effectiveness of a CBT treatment module addressing the mental health and functional impact of killing in the war zone, which would be added onto existing EBTs for PTSD. Our second aim was to gather data on Veteran stakeholders' perceptions of acceptability and feasibility of the CBT treatment module, which was used to further refine the intervention. Our third aim was to gather data on clinician stakeholders' perceptions of acceptability and feasibility of the CBT treatment module, which was used to ensure that the module could be easily integrated into EBTs for PTSD.
We proposed a pilot, cross-sectional Hybrid Type 2 study, given that we added a killing-based treatment module to existing EBTs for PTSD. We conducted a randomized, controlled effectiveness trial to better understand if the six- to eight-week treatment module addressing the impact of killing has added benefit, compared to a control group of PTSD treatment as usual. Veterans needed to endorse having taken a life or felt responsible for the death of another in a war zone context and received some prior trauma-based treatment for PTSD to be included in the study. We used a concurrent design mixed method study to test the perceptions of Veteran stakeholders who received the treatment module, obtaining ratings of acceptability and feasibility through self-report measures and feedback interviews. We also interviewed clinicians who provide EBTs for PTSD, and interviews were guided by Roger's five intrinsic characteristics, as outlined in his Diffusion of Innovations Theory.
Participants ranged from 26 to 80 years (M=60 years); 62% were Caucasian, 50% were Army Veterans, and all were male (N=26). Veterans randomized to IOK treatment (n=12) significantly improved on measures of general psychiatric symptoms, compared to the control group (n=14; p=.022), with significant gains reported in depressive symptoms (p=.029), anxiety symptoms (p=.043), obsessive-compulsive symptoms (p=.011), and phobic anxiety symptoms (p=.028), compared to controls. We also found trends for PTSD symptom improvement, with those randomized to treatment improving at clinically significant rates (greater than five point change), compared to those in the control group. Furthermore, of those completing the treatment (N=23; 11 of control group then completed treatment), pre-post improvement scores on PTSD symptoms were clinically significant (p=.002). The treatment group also demonstrated improvement in multiple killing-related cognitions such as, "I deserve to suffer for killing" (p=.012) and "I can no longer be intimate with a partner after killing" (p=.020), compared to the control group. Ratings of acceptability and feasibility were high with Veterans reporting that the treatment taught them new skills, covered helpful and appropriate content, and was tolerated well. Veterans expressed wishing the treatment had been longer. Veterans completing the treatment self-reported that they were more compassionate, self-accepting, self-forgiving, and that there were specific things that they could continue to do to heal, among other benefits reported. Qualitative feedback interviews with Veterans indicated that our killing module added a novel and important treatment component for Veterans who had killed in war that was highly recommended by those who participated. Trauma clinicians interviewed (N=10) felt the treatment would be helpful, acceptable, and feasible for Veterans with whom they work, and they proposed helpful suggestions to facilitate implementation of this treatment module to be used with EBTs for PTSD.
Given high rates of killing among Veterans, the VA Healthcare System needs to be prepared to deal with the mental health ramifications of such experiences. Given that there are no empirically-validated treatments for helping Veterans cope with the aftermath of killing, the fact that the VA has received national criticism in the media for not helping Veterans deal with the impact of killing, and the fact that those who kill may have the most severe PTSD, as well as a host of other mental health problems, the current study represents an important step towards an examination of this complex and debilitating problem. Through involving Veteran and clinician stakeholders, the main impact of this grant was to obtain information that will assist in revising the CBT treatment module and help prepare for implementing the module in already existing settings, where EBTs for PTSD are provided. Given that we found that IOK was effective, feasible, and acceptable to Veterans, and that clinician stakeholders felt that the treatment would be useful, suggesting ways of integrating it into already existing care, our next step is to continue to collect effectiveness data and make suggested modifications to the existing protocol so that we can better prepare for implementation.
- Maguen S, Burkman K. Combat-Related Killing: Expanding Evidence-Based Treatments for PTSD. Cognitive and behavioral practice. 2013 Nov 1; 20(4):476-479.
- Maguen S, Burkman K. Killing in War and Moral Injury: Research and Clinical Implications. Paper presented at: VA Psychology Leadership Conference; 2014 May 22; San Antonio, TX.