Notes on therapy for
Perpetration-Induced Traumatic Stress
(also known as Participation-Induced Traumatic Stress)

There is also a page on a basic explanation, a page on  PITS in world literature, a page on PITS in personal stories,
and a

Notice: A follow-up book to the 2002 Perpetration-Induced Traumatic Stress is
now being prepared for submission in 2017. If you have experience or know of
studies to improve the chapter on therapy, please send the information to:

admin @

or call Rachel MacNair 816-753-2057 (U.S. Central Time Zone).

Dissertation: Perpetration in combat, trauma, and the social psychology of killing: An integrative review of clinical and
social psychology literature with implications for treatment.
By Baalbaki, Zenobia S.

Dissertation Abstracts International: Section B: The Sciences and Engineering, Vol 70(10-B), 2010, 6537.

Abstract: Conventional cognitive behavioral clinical approaches to combat trauma neglect the significant contribution
of perpetration of violence and killing in combat in the development of combat PTSD and combat stress injuries. The
importance of emotions highly correlated with perpetration induced traumatic stress, such as guilt, are overlooked in
the standard evidence based models of treatment. This critical synthesis of clinical and social psychology literature
identifies these deficits in the current PTSD literature and contrasts alternative perspectives of etiology and treatment
that remedy these deficits. In addition, the social psychology literature presents conceptualizations of psychological
and social processes at work in contexts of organized killing including the combat environment. Mechanisms of moral
disengagement are examined in the literature as a model for understanding complex socio-cognitive processes
involved in rationalizing moral transgressions, such as killing. It is proposed that mechanisms of moral disengagement
which attempt to protect soldiers from moral culpability while enabling their participation in killing ultimately contribute to
negative psychological consequences and trauma. Particularly, dehumanization processes and the effects of the
obedience to authority situation are discussed as elements of the combat context with specific salience to the traumatic
impact on soldiers. The critical synthesis of these literatures advances alternative perspectives on combat trauma.
Implications for clinical applications in treatment with soldiers and veterans are provided.
(PsycINFO Database Record (c) 2012 APA, all rights reserved)

Understanding the universality of the experience

“I saw many clients come to our inpatient program thinking that they were alone in their pain. They judged themselves
uniquely crazy, weak, and/or cowardly for having had problems, such as flashbacks, fearfulness, and rage, in civilian
life after their military experience. There was some genuine relief that came from seeing that others had these
problems, even if the problems continued.”

Lipke, H. (2000). EMDR and psychotherapy integration. Boca Raton, FL: CRC Press, p. ii

“In the therapy group, especially in the early stages, the disconfirmation of a patient’s feelings of uniqueness is a
powerful source of relief. After hearing other members disclose concerns similar to their own, patients report feeling
more in touch with the world.”

Yalom, I. (1995). The theory and practice of group psychotherapy. New York: Basic Books

Knowledge of patterns

Pattern Differences for Those Who Said Yes on Having Killed (from discriminant function analyses)

      Especially high:                                           Also high:
      violent outbursts                                          hyperarousal
      intrusive symptoms                                      alienation
                                                                          sense of disintegration
Information taken from:

MacNair, R. M. (2002).
Perpetration-Induced Traumatic Stress: The psychological consequences of killing. Westport,    
CT: Praeger Publishers

Eye Movement Desensitization and Reprocessing (EMDR)       

“This client said that his worst traumatic experience had to do with the death of some civilians for which he believed he
was responsible. As the EMD therapy session unfolded, this veteran first reported decreased anxiety, as had the first
veteran. Suddenly, he became upset and asked that we stop treatment. He went out of the therapy room with another
staff member to calm down. When he returned he said that, as he became more comfortable with the memory, he got
scared. He believed that he had made a “spiritual deal” – that if he stopped suffering, retribution would be taken
against his family for the wrong he believed he had done.” (Lipke, 2000, p. v)

“I have had many clients who recall engaging in some bloody activity who are dumbfounded about why they would do
such a thing. During the course of treatment, they then recall that their self-mortifying deed followed soon after some
horrible loss of their own, a connection they had not realized since the event occurred.” (Lipke, 2000, p. 53)

Traditions of Atonement and Bearing Witness         

"alternative strategies . . . [include] exploring ways of making reparations and bearing witness" (p. 475)

Foa, E. B., Meadows, E. A. (1997). Psychosocial treatments for posttraumatic stress disorder: A critical review. Annual
Review of Psychology, 48, 449-480.

“Atonement, repentance and forgiveness, bearing witness, and re-identifying one's self as a different person than the
one who did the killing (as in being "born again") have been suggested in many verbal discussions with therapists.
These have been some of the responses of the human community in diverse cultures and through many historical
periods to the common phenomenon of dealing with killing. They have remained because of extensive experience that
they are, in fact, helpful.”

MacNair, R. M. (2002). Perpetration-Induced Traumatic Stress: The psychological consequences of killing. Westport,
CT: Praeger Publishers, p. 92

Time Perspective Therapy

In their book applying a strategy of thinking through past negative, past positive, present (also negative and positive)
and future, Phil Zimbardo and colleagues include three cases of combat veterans suffering from PTSD clearly related
to killing activity. See pages 110-123 and 129-137.   

Zimbardo, P.G., Sword, R. M., & Sword, R.K.M. (2012).
The time cure: Overcoming PTSD with the new psychology of
time perspective therapy
. San Francisco: Jossey Bass.

Therapeutic Stories

I do not know of any studies yet on this, but it seems like a promising area to explore.

May be Counter-indicated:

Flooding/Prolonged Exposure
"In particular, PTSD sufferers whose traumatic memories are about being perpetrators rather than victims may not
benefit from [Prolonged Exposure as a treatment] and perhaps will even deteriorate from such treatment" (Foa and
Meadows, 1997, p. 475).

he article they cite is a set of six case studies which point out times when the flooding technique, involving intense
reminders of the trauma for the purpose of desensitization, seemed to be counterproductive:

Pitman, R. K., Altman, B., Greenwald, E., Longpre, R. E., Macklin, M. L., Poire, R. E.,  & Steketee, G. S. (1991).
Psychiatric complications during flooding therapy for posttraumatic stress disorder.
Journal of Clinical Psychiatry, 52,

Expressive writing
"To their disappointment, researchers found that four months after participating in writing exercises, soldiers in the
emotional writing group who had high levels of combat experiences scored
higher on an anger scale, compared with
soldiers not asked to write . . . The emotional writing exercise seemed to make soldiers angrier than they were before
sitting down to write. 'Overall, it appears that, for soldiers in the high risk condition, those soldiers reporting lots of
combat experiences, expressive writing is actually contraindicated,' [Amy] Adler said. 'For us, it really underscores that
you can't just take stuff off the shelf from the civilian literature and assume it's going to work.'"  

Munsey, C. (2009, October). Writing about wounds.
Monitor on Psychology, 58-59.

While this study didn't take the killing variable into account, neither checking that the soldiers had done so nor
whether this was in the content of what they wrote about, it would seem that because this is commonly associated with
high levels of combat experience, this might apply and should be explored.

For comments or questions, or to add other sources, please contact Rachel MacNair at