The views of some experts on the long-term impact of combat and killing that affects many veterans. Commenting here are Vietnam vet and VA counselor Jim Dooley; VA psychiatrist Andrew Pomerantz; David Grossman, a former Army Ranger who has written extensively about the effects of killing; Matthew Friedman, executive director of the VA's National Center for PTSD; psychiatrist and author Jonathan Shay; Navy psychologist (Ret.) Dennis Reeves; veterans' advocate and former Army Ranger Steve Robinson; and Col. Thomas Burke, director of mental health policy for the Dept. of Defense. These excerpts are from their extended interviews.

Mental health counselor, U.S. Department of Veterans Affairs

…The people that we've spoken to, if they have killed someone, those images in particular are the most haunting, which I thought was a little bit counterintuitive. I thought that seeing your buddy die, or seeing other horrible things that you could imagine happening [would be the most traumatic image], but it is really the act of actually taking another person's life that in the long run had the most emotional strain on them. Have you found this?

I think it is a very important thing to understand that when your friends are wounded or dead, it's a real loss. It's a loss of your friend that you trusted and you loved in a very intense way. When you personally take another life and you go up to that lifeless body with a hole in it and you look down on it, and you say, "I did that," I think it is a loss of yourself at the same time. And I think that [once] they understand that, they can't go back again. They can't say that it didn't happen, or [that] maybe somebody else did it.

The enormous fire power that we are currently expending in our modern wars, from Vietnam onward, blurs the line considerably. Because if there's a massed fire and 2,000 rounds are going out at one time, who knows who shot who? But all we know is there's a lot of people in front of us that are dead. That absolves you of the responsibility of looking at that lifeless body and [seeing that] some mother, some son, some father, some uncle, is now dead. And that's different than not knowing. Knowing, I think, is the Rubicon. And they talk about it with sadness. It's not something that they're prideful of, it's a profound sadness.

But its seems the military doesn't even address it, doesn't even ask about it. On the post-deployment questionnaires they ask questions like, "Did you see dead bodies? Did you see combat? Did you see anyone die?" They don't actually ask about a soldier doing the act of killing, and the kind of emotional impact that would have. What would you say about the military's edict on that? …

Well, I think that the military avoids it. I think the cursory questions that they're asking -- let's call them hallmark questions -- "Are you developing post-traumatic stress disorder?" -- the questions are so vague that if you had images in your head that you didn't want to think about and you didn't want to talk about, it would be very easy to blow past those questions.

A questionnaire is a very impersonal way of doing it. The entire effort of assessment post-deployment is at best cursory. There are a lot of Web sites, there's a lot of literature. There are questionnaires. But there's no live human being sitting in front of you asking the questions. And that really makes the difference. Because who would want to report something that you don't want to have? But if someone asks you directly in front of you -- a live human being -- it's a big difference. I don't think the military is doing that. I think they're avoiding that. It's expensive. It's expensive to have me and tens of thousands of me, and that's what's needed.

At some point, if we're going to go to war, and we value our young people, what better way to help them to be reintegrated into society, to have a positive life? … I say that as a person that came back from war, and that didn't happen to me. And I had to struggle with my own memories and sort it out by myself. It wasn't easy, and I don't think it was fair.

So basically the military just ignores it … the actual subject of killing?

The issue, the after effects of killing -- personal killing -- I believe isn't understood. I don't think the military understands how to deal with it. It is the effects of personal responsibility for taking another life. How do people react to that? How do they look at the spiritual issues? How do they look at the societal issues? How do they look at their family values?

We have been always taught not to hurt others. I know when we go to war, we're taught to kill directly. The current war, in particular, will have a profound effect on people. Because of the very nature of the directness of the killing. We're not talking about distance killing. We're not talking about a firestorm, [like the one] in Dresden that killed 200,000 in a night. We're talking about disintegrating someone in front of you. That needs to be addressed by acknowledging that it does have an affect on people. That is what it means to go to war. But, that person will [need] some support in understanding themselves better and not to have a silence about it.

The silence is really the damaging part, and I would strongly encourage people to talk to people that they trust about it. And if that isn't possible, then they need to figure out who they can begin to trust with [it]. Because they shouldn't just sit on it. They shouldn't just try to make it go away. It won't go away.

Chief of mental health services for the VA in Vermont

…Many soldiers have told us killing the enemy was one of their most haunting memories. Is that usually the case?

I think it's one of the most powerful pieces for most of the people that I've treated who have been in close combat situations. I had one World War II veteran I remember -- to the day he died he could still describe the face of the man he was about to kill. He was that close, that personal, that he felt like he could read the man's entire life just in his eyes, and he was in a situation where he had no choice but to kill him. I hear this frequently.

I think the loss of faith, both in the safety of the world and the loss of faith in one's own humanity, is threatened when people kill other people, which is what we train them to do in war. I mean, it's how you win the war is you kill people, but you take somebody off the street who spent their whole life learning not to kill other people, not to harm other people and put them in a situation where it's his job to kill somebody else. I've not ever met a person who killed others who was not affected by that.

I was hearing a story from a World War II bomber the other day who talked about being able to see the people fleeing and still feeling that today -- you know, "How could I have done such a thing? Where was my sense of reason?" But we know how they did it. There are a lot of military training techniques which are based on dehumanizing the enemy and making people able to kill. I mean, you don't take somebody out of a Sunday school class and try to win a war with that person. You've got to go through some training in between.

What do they tell them in that training?

Very often they will call the enemy by some subhuman name -- you know, "gooks." Who cares about a gook? What's a gook? It's not a person; it's not a human being. Part of the dehumanizing, it's made a lot easier if the person looks different than us, whether it's by names or just firing up "God's on our side; this is our war; we're fighting this, and we should be fighting, and God is proud of us"; a lot of killing is done just with that as the reason. Anything you can do to make a person think this is not the kid next door; this is not the friend that I grew up with that I'm about to blow his brains out; this is some animal; it's not a real person -- simple.

When they get home, they think about it. I had one soldier -- he's long dead now -- who talked about how fearless he was in combat. "I was absolutely without fear," he said, "[and] the day I left, my commander said to me, 'You were a good soldier; you did it like it needed to be done, but you're going to be haunted for the rest of your life.'" Now, this is a World War II commander who is not supposed to know any of that kind of touchy-feely stuff, who's telling this 21-year-old kid that this is going to haunt [him]. And he was indeed haunted by it. He would see faces; he would see people; he would see images. Every night he had nightmares of just killing people. It does not fit. It's a different mentality.

Most veterans that I know have talked about the opening 15 or 20 minutes of Saving Private Ryan as about the only movie that has ever accurately depicted what combat is like, and I've seen that movie, [and] I can't imagine being in the middle of that. Same thing with just reading The Red Badge of Courage. I mean, Stephen Crane was not even a soldier, but somehow [he] had a gift that allowed him to put it into words that people could understand and feel the fear, the chaos and the excitement, all of those things, all in one.

In a different environment, people will do things that they would never think about doing when they're sitting here in Vermont.

How does [the] military deal with the issue of killing?

I don't know. I don't know what the military does with it. I really don't. We were actually one of the first PTSD programs in the country to put a chaplain in our PTSD program. And let me tell you, he was busy. It had a lot to do with "I have killed; I am no longer human. I don't understand; there could not possibly be a God. Everything that I thought was true was not true. Save me from myself. I don't know what to believe in anymore." Those were the kind of things that he would hear from people who had simply lost faith in everything, including in themselves.

What would he tell them?

Well, I remember one phrase he often used: God just looks after the big picture; he doesn't get too involved in the details. The big picture is important. And he used "God" in a very generic sense, kind of referring to just a spirituality that he thought was common to all people. We've worked with a couple of chaplains in that program [who] have had similar approaches. And it takes some time with these people. Many times they're coming to the chaplain looking for somebody who can forgive them for what they've done. But having killed people is a very powerful part of the guilt that a lot of these soldiers feel.

Lt. Colonel, U.S. Army-Ret.

…Take me to the moment where you are faced with a difficult decision and you must kill. Physiologically, what's happening to somebody in that moment?

… [at the moment] the human being looks another human being in the face, a profound and powerful physiological process sets into place. The heart rate goes up; it's a fear-induced heart rate. … Fear-induced heart rate creates vasal constriction. The body shuts down the blood flow to the outer layer of the body. The outer layer of the body becomes a layer of armor. You can suck up significant damage out on the perimeter. As long as you don't hit an artery, there won't be much blood loss.

So this vasal constriction that shuts down the blood flow, your outer layer of the body becomes a layer of armor, but the price you pay... There's always a price. The shut down of the blood flow means the muscles are not getting blood. If the muscles aren't getting blood, that means they stop working. So you begin to lose fine motor control.

One of the most devastating, catastrophic effects of all is forebrain processing shuts down. And the mammalian brain, the mid-brain part of your brain that's the same as your dog, begins to take over.

… So inside the mammalian brain of most healthy human beings is this powerful resistance to killing your own kind. We can see it throughout history.…We saw it in World War II when only 15 percent of the riflemen would fire their weapon at an exposed enemy soldier. In Vietnam, around 95 percent were firing, but there was a lot of spraying and praying.

…And the only way to get the mammalian brain to do the right thing is to train it, train it, train it, train it. … and we do that through various inoculation: paint bullets -- the technology of actually firing real guns with real gunpowder. What comes out the barrel is not a chunk of lead, but a plastic bullet, the marking capsule, and when it hits, it hurts. And we're inoculating you.

A firefighter can't use flickering red lights in his training. A mountain climber can't use a picture of a 1,000-foot drop. He needs a real 1,000-foot drop. A firefighter needs real fire to inoculate them, to teach them that they can deal with this. And soldiers and cops need the same, and we brought them up to that level.

So you see, this physiological phenomenon can be dealt with in several ways. One is to not get into what we call condition black, [but] to remain calm, cool, calculating in the heat of battle. And we're doing that. The other thing is to have a condition reflex in place so that even at the moment of truth, the shot's there -- (snaps fingers) -- and you fire without conscious thought.

And there's a couple of other dynamics in place: the breathing exercise and other tools that make it possible to stay calm. And we're doing all of that. But for the first time in human history, we're actually understanding the physiology of combat. ...we've systematically applied science to combat.

So, in summary, what is the three sentence physiological description of the moment where you need to choose to fire?

Assuming there's no stress inoculation, in a normal human being, at the moment when you want to fire, the forebrain is shut down, the midbrain takes over, and you slam head-on into a resistance to killing your own kind. The only way to overcome that resistance is through operate conditioning, to make killing a condition reflex. And we've done that.

…But if we haven't prepared ourselves emotionally for the act ahead of time, and we just tricked you into killing, the magnitude of the trauma can be significant, because we're having to live with something that your body says is not right, that you didn't want to do, and you were simply tricked into killing.

Now, if you're convinced that what you did was right, if your society says, "But you were right," if everything's peachy keen and you come home, you'll probably be fine. But if there's any doubt about it, if you're killing without conscious thought and there's debate, there's doubt, there's hesitation, to overcome a resistance of that magnitude and to not have [a] support structure on the other end, you've got two strikes against you. The potential's there to be devastated and psychologically destroyed by that act.

What are the systems that need to be put in place to prevent that from happening?

The war needs to be appropriate. Leaders need to be supportive. Atrocities need to be prevented. But when they hone in on the individual, the things that need to be put in place is, number one, stress inoculation ahead of time, mental preparation. We need to have previously faced the stressor and overcome it. We need to embrace the responsibility to kill and accept that this is who we are, this is what we do. ...We need to understand what's going to happen to you in combat -- memory loss, memory distortions.

One out of four cops [who] walks away from a gunfight remembers something that did not happen. And the fact [is] that you've got to get together after the battle and sort out of the pieces. You may not need a debriefing, say, "I don't need no stinking debriefing," but your buddy might have a memory distortion that's going to destroy his life, his family and everything he has. What would you not do to save your buddy's life?

All of these things need to be understood ahead of time. The whole toolbox of coping mechanisms and psychological preparation needs to be given ahead of time.

Exec. Dir. , VA National Center for Post-Traumatic Stress Disorder

…What is the impact on a person of killing another human being? How should we think about this in terms of traumatic impact?

I certainly agree that killing, whether it's another combatant or a civilian, can be for some people the most devastating traumatic experience. [But] there are many different scenarios that for different people are the most devastating. So sure, killing is an important traumatic event that needs to be dealt with, but to single it out ... really distorts the issue. …

For some people, and for police personnel as well, killing can be the most devastating issue. But for other people, the killing isn't. They feel quite justified that it was him or me: "If I didn't kill this individual, so-and-so would have gotten attacked. I was doing my duty." Different people will experience the same event in very different ways based on what their understanding of the event is, what their understanding of the alternatives are, what their past experience is. So it's not a simple question.

Psychiatrist and author of Odysseus in America

…Every war produces its hopeful phrase. In World War II, it was "screening" -- we're going to screen out the people who are vulnerable to breaking down in combat. And guess what? It didn't work.

"Resiliency training" is the hopeful phrase du jour now, [meaning] any military training that makes people genuinely more capable in what they do in a fight increases robustness or increases the resistance to injury. Any training that increases unit skills and increases the tightness, the social and emotional tightness of the unit, increases the psychological protection of all the troops that are tight that way.

So if that's what resiliency training means, well, great. I'm for it, and I think it really works. But if it's some sort of snake oil that is something that somebody gets up and gives a lecture about, I think it's probably not going to have any real effect.

Now, one piece of it that is a puzzle: How much do you want to show people during training what real war wounds look like? What the dead are going to look like? Modern weapons-- actually ancient weapons, too -- do terrible things to the human body. And sometimes people freak out, especially the first time they see it. And so, how much should people be prepared that way? I don't pretend to be an expert in that. But there are people who have thought about it, and I think it deserves to be thought about.

Retired Navy psychologist

…I went into [Iraq] in February [2003], just a few weeks before the war started and then transitioned all the way through, followed the Marines all the way through the very serious battles that they experienced during their 21 days of major fighting. And what I saw was psychologically this great enthusiasm about finally having a chance to do what they had trained to do. The Marines are trained to fight, they're trained to be, [as] we call it, the point end of the spear. You know, go in, kick the door down, destroy the enemy. You do it rapidly, efficiently, precisely, and with a great deal of pride in doing what you've been trained to do. …

… And so the thing that was really sad was when our guys felt or thought that they had maimed or wounded or killed some of the innocent Iraqi civilians. And that was quite devastating to them because they took a great deal of pride in destroying the enemy, but it was very psychologically traumatic for them to believe that they had killed somebody's father or mother or child. …

But the perceptions and the perspectives that we obtained during approximately 120 different groups -- and I think by the end total it was about 5,000 troops that we had heard stories from -- the range was highly, highly personal and highly individual. And if you think about that, that does make sense, because every individual comes from a different kind of family. Some of them don't even have a family. They have different cultures, different cultural values, different religions. Some come from the city; some come from the farm. ... So when we would ask, "What was it like to kill the enemy?," one guy would say [anything] from "It felt like making a touchdown for the home team," to "Well, I was just doing my job."…

What did you tell them about killing?

During our Warrior Conservation sessions, we would explore the morality of war, if you will. It wasn't really exploring morality; it was just talking about what had happened to them. And they did frequently have questions about that. And we would have to explain the differences between what it means to be killing in a war as opposed to killing at home.

I actually had one individual say to me, "Hey, hey, doc, what about the Ten Commandments -- you know, the one about 'Thou shalt not kill'?" Well, fortunately every time we did one of these groups we had a chaplain with us, so I turned to the priest that was with me at the time, and said, "So, Father Joe, what about that?" And he was able to explain, well, actually, that was kind of a literal translation. The scripture actually said, "Thou shalt not murder." If you're in a moral, just war, and if you look at the Old Testament, God supported a lot of wars and warriors, and that is not murder. When you go back home, though, if you kill someone, that is murder, and that's a totally different situation [than] when it's justified, and the other is a criminal act. …

Exec. Dir., National Gulf War Resource Center

What about the emotional impact of killing? How does that affect soldiers?

… We desensitize soldiers to the idea of killing by starting them off with drills and paper targets that don't look like anything, and then ultimately transition to moving targets, pop-up targets and things that are shaped like humans, so that your response is automatic. You don't think. The last thing you want in war while somebody's bearing down with their rifle onto a target is [for them] to think to themselves, I wonder what the consequences are going to be to my long-term psychological health about this act that I'm about to commit. So reflexively, because of drill, they pull the trigger, because that's what they're trained to do.

Unfortunately, there is a reaction that occurs after the fact that they don't spend a lot of time teaching people about. It's the big elephant that's in the room that nobody wants to talk about. Hell, it could be leaning on you, and they still don't want to talk about it. And that is, what are the consequences? There are people that believe that there is no way to train someone to kill and be totally unaffected; that even on a subconscious level, something happens when you commit that act, when you actually pull the trigger. And there are others that believe that by drill and training that they'll get the end result, but they're not really concerned about what happens afterwards. ...

In the post-deployment questionnaires, there's not even one question that has to deal with killing. It's all about what you see and not what you've done. Can you comment on that?

The post-deployment assessment form that the soldiers fill out when they come back lists a bunch of questions about a bunch of different things. They ask you if you have concerns about depleted uranium. Did you see combat? Or did you see dead bodies? They don't collect information on what you did personally. And we think -- the organization thinks and I think; even the VA thinks -- that that's a bad idea. Each soldier's experience is important in understanding the health consequences that will come out of that experience. ...

I think they have acknowledged [killing]. ... We all know there's going to be killing. People in the military aren't stupid. They know that there's going to be killing. But the idea is it's not going to happen to you. ...

There's a whole other side to it that isn't discussed, and that's the part that we're talking about right now, is what happens when you kill, or what happens when you see your buddy killed. How does that affect you? And how do you continue to function? I think that it's something that the Department of Defense would rather not talk about, the ugliness.

Look, war, it's ugly, and it hurts people. And people's legs are going to get lopped up. And people are going to get horribly burned. And some of these soldiers are going to be responsible for inflicting that pain on others that they're fighting. And you would think that you would want them to be able to process this information to have all the tools necessary to do so. But I think in this war, a lot of guys went over -- and girls -- unprepared. I mean, they were told they were going to be met with open arms and flowers, and instead they were met with RPGs and IEDs [improvised explosive devices].

Director of Mental Health Policy, U.S. Dept. of Defense

What effect does the act of killing have on soldiers? Is it a major contributor to PTSD?

Killing is a stressor. It's a traumatic event. People have a natural aversion to killing other human beings. We would consider anybody who didn't have that aversion to be mentally ill. But it is not the only traumatic experience that is present in combat.

The possibility [is] the soldier who killed the civilian because he felt that he was in danger of being killed himself or that somebody else was a danger to one of the other soldiers. The soldiers have to worry [that] perhaps a person who looks like an innocent civilian may be a suicide bomber. I don't believe that you can isolate the issue of killing from the situation that caused the person to kill in the first place.

[But is there a disconnect that happens for our soldiers who are trained to kill, but maybe aren't trained to deal with the consequences of killing?]

[There] is. Some of the stories have tried to portray that the military turns its soldiers into mindless killing machines, and that's just not true. But we are sending these soldiers into situations where they may not have time to go through a long thought process. So what we do is have them go through that thought process before they get into the situation.

It's not that they go in and do these things without any thought. There are rules of engagement that are clearly spelled out for the soldiers, and they're briefed time and again on what the rules of engagement are. That's part of the thinking process that goes on ahead of time so that they have already made the decision to shoot or not to shoot, to kill someone or not to kill someone, before the event happens. Then, when the event happens, they don't have to go through the thought process and perhaps delay that second or two that makes the difference between them being safe and the suicide bomber getting close enough to kill their entire unit.

We do have them think about it, and we do want them to make moral decisions [and be] comfortable with the job that they are going to do and the things that they are going to have to do. But we want them to work through those thought processes ahead of time, so that they don't have to hesitate when the moment comes [and] they have to do something and take some action to save their lives.

[Is the act of killing, and its consequences, addressed during training?]

Killing -- as far as I know -- is not addressed during training as a separate moral and emotional issue. ... It's part of the overall training. And as I talked about before, you do want soldiers to make moral decisions, correct decisions, decisions based on rules, but you want them to go through that thought process ahead of time, before the event happens, so that when the event comes and they have to take some action immediately, they've already made that decision. They don't have to think about it.

[So they are expected to work out their feelings -- their emotions -- about killing before they enter combat?]

Having that emotional exchange is important. You don't want them to have to go through that in the split second when they have to decide to act or not to act. Have them go through that emotional exchange and work out those feelings and work out their decisions beforehand. Then they don't have to do it while they make the decision, while they act.

Afterwards, not all of them are going to have bad reactions. [But] no one goes through that experience unchanged. It will cause more distress for some than it will for others. And we want to have the resources available afterwards to help them to work through the process of recovering and healing and getting back to the selves that they want to be in the future.

[So there is a period of recovery that has to take place after the act of killing?]

That's right. In the case of killing anyone, it's human [to have] the experience of going back, having memories about those events, about your time in combat, about your deployment. There are going to be days when they're going to be sad. Those memories are going to be more vivid than others, and they're going to have bad days. And that's to be expected. That's part of the human experience.

But when those days become more frequent, when those days start to interfere with your ability to get through [the] day and go on with your life, when they interfere with your ability to have relationships with your family, with your children, with your co-workers -- that's when they need to seek some more help. It helps to be able to talk to their families. It helps to be able to talk to other people, to chaplains, their moral, spiritual guides.

But if the distress doesn't get better, that's whenever the mental health community has solutions to offer. We can help, but they have to come and get that help. It can be help of counseling. It can be medication. Group therapy, very often is helpful.

One of the problems that soldiers sometimes complain about is that the people at home can't relate to what they've been through. So that's okay. We can bring people together who have been through that same experience. Veteran's groups, either formal group counseling or support groups, can be very helpful in allowing soldiers to normalize that experience and to talk about it and feel that they're not so alone, that they're not so unique or marked or odd, that this is shared experience and that it's OK.