Case and Commentary
Apr 2023

How Should Clinicians Respond to Patients Experiencing Ongoing Present Traumatic Stress of Industrial Meat Production?

Rachel MacNair, PhD
AMA J Ethics. 2023;25(4):E251-255. doi: 10.1001/amajethics.2023.251.


Slaughterhouse work is traumatizing. Workers experience posttraumatic stress disorder (PTSD) symptoms, especially as dreams of perpetrating violence and as emotional numbing and detachment. Workers’ increased likelihood of committing violence is demonstrated both anecdotally and quantitatively. This commentary on a case considers how clinicians should respond to workers’ PTSD symptoms. Clinical interventions for trauma typically assume that the traumatic experiences are over, in the past—that is, not part of present, everyday work and life experiences of the trauma patient. This article suggests reasons why perpetration-induced traumatic stress should be understood as a continually present, in addition to being a post, traumatic stress disorder. Importantly, interventions for slaughterhouse workers must focus on cultivating their awareness of traumatization and its symptoms in real time. This article also describes the inadequacy of current research and practice for helping patients for whom retraumatization continues as part of their everyday work.


LM is a meat plant worker referred by a primary care clinician to Dr B, a community psychiatrist. LM oversees slaughter protocols at the plant and has experienced recurring sleep disruptions (eg, nightmares about mass killing of nonhuman animals), anxiety, depression, irritability, and emotional volatility since beginning work at the plant months ago. LM tells Dr B that they feel detached from loved ones, noting that things they used to enjoy no longer bring contentment or pleasure. LM also experiences new-onset fatigue and back pain and feels hopeless about alternative job opportunities. LM states, “Where else is someone with my background and skills going to find a job near where we live?”

Dr B diagnoses LM with posttraumatic stress disorder (PTSD). Anxiolytics and antidepressants won’t alleviate key sources of LM’s symptoms, but it seems unreasonable to counsel LM to quit their current means of earning income. Ultimately, this is a challenge to clinical care models that can accommodate posttraumatic stress and present-centered therapeutic means of navigating posttraumatic stress and its symptoms1 but not how to help workers for whom public demand for meat creates ongoing, present, and future exposure to trauma and continual retraumatization.


PTSD is a concept that was first defined for combat veterans and then expanded to all forms of trauma.2 Initially, most PTSD research focused on people as victims of trauma, but the idea that perpetrating violence can also traumatize perpetrators has been mentioned in the fifth and most recent edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5).3 The term perpetration-induced traumatic stress (PITS) can be applied when perpetration is the etiological stressor but PTSD is the official diagnosis. Commonly, the source of trauma that is the etiological stressor is one that is in the past—for example, combat, crimes, domestic abuse that has been escaped, natural disasters, or major accidents. When the trauma itself has ceased, then the patient’s therapeutic needs are easier to provide for. When the patient is still experiencing a trauma, however—for example, combat, crime, or domestic abuse that is still ongoing—then therapeutic needs become more complicated. Ideally, the first step in therapy is to stop the trauma entirely. Cases for which this is not a workable solution—as when first responders experience trauma on the job—have received little research attention. Moreover, there is very little research on PITS, much less on PITS in slaughterhouse workers.

Symptoms of PTSD and PITS

Diagnosis of PTSD is consistent with the symptoms mentioned in the above case and with those observed in slaughterhouse workers. There is some evidence that posttraumatic symptoms can also manifest in people who commit violence not only against humans but also against nonhuman animals. Jennifer Dillard has discussed how slaughterhouse workers suffer: “While the average American will never see the inside of a slaughterhouse and may be able to eat a hamburger without confronting the pain and terror of a beef cow’s final moments, thousands of slaughterhouse workers across the country face that troubling predicament every day, creating an employment situation ripe for psychological problems.”4 She identifies PITS as one of the frameworks for understanding these negative psychological sequelae. Proper large-scale studies are yet to be done, but below I describe some case studies that illustrate the problems of dreams, detachment, and perpetrating other forms of violence.

Dreams. Two examples that illustrate intrusive dreaming about the traumatizing events come from a qualitative study of unstructured interviews with South African slaughterhouse employees.5 One slaughterhouse employee states: “In my dream I see the bleeding line, just the cattle hanging on the line, all whose heads are off. I get this picture often. It’s not nice to dream about blood; you wake up wet with sweat.” However, PITS dreams commonly have not only the standard features of PTSD dreams, but also the added feature of the victims of violence turning around and attacking the attacker within the dream.6 Former US-based slaughterhouse employee Virgil Butler relates his own experience: “Out of desperation you send your mind elsewhere so that you don’t end up like those guys that lose it….  Or the guy they hauled off to the mental hospital that kept having nightmares that chickens were after him. I’ve had those, too (shudder).”7 A South African worker describes surveillance by slaughterhouse animals: “Sometimes I saw myself slaughtering the animals, but you see eyes, I saw, eyes of the animal. It’s like its watching me. That thing, that dream, I didn’t feel well even when I came back to work, but I keep on checking the eyes to see its watching me, because I saw it in the dream.”5

Understanding the universality of one’s experience and that one’s feelings are not unique can be a powerful source of relief. 

Detachment. Butler also illustrates the symptom of emotional numbness: “You find something else to dwell on to try to remove yourself from the situation. To keep your mind from drowning in all those hundreds of gallons of blood you see.”7 Ed Van Winkle put a similar point about his employment in an Iowa slaughterhouse this way: “If you work in the stick pit [where the hogs are killed] for any period of time, you develop an attitude that lets you kill things but doesn’t let you care. You may look a hog in the eye…. You may want to pet it. Pigs down on the kill floor have come up and nuzzled me like a puppy. Two minutes later I had to kill them—beat them to death with a pipe. I can’t care.”4 A worker in South Africa concurs: “As time passes, you get used to it. You feel nothing. You can imagine, if you kill a thing a 1000 times over and over, you wouldn’t have feelings after a while. It kills you on the inside, an abattoir, it kills you. You can be full of blood, it will not bother you.”5

Other forms of violence. Van Winkle also stated: “Every sticker [hog killer] I know carries a gun, and every one of them would shoot you. Most stickers I know have been arrested for assault.”4 Similarly, a worker in South Africa spoke of perpetrating violence on intimates: “What I was having was just to hit. I need to hit, especially my girlfriend. Sometimes, even if you think you can make a mistake[s] you hit him because … you don’t have a heart for him. That is why most people at stunning box, they can do it, they can hit their girlfriends. Say ‘hey, I hit my girlfriend yesterday,’ or ‘I beat my wife yesterday.’”5

Slaughterhouse employees’ perpetration of violence is corroborated by a quantitative analysis of data collected between 1994 and 2002 from 581 US counties in states with right-to-work laws. The study found that, compared with other industries (primarily manufacturing), slaughterhouse employment was associated with increased arrests rates, including arrests for violent crime and rape.8


There is currently remarkably little to be said about treatment. Quantitative and qualitative studies of slaughterhouse workers are sparse and primarily focus on the problem of symptoms rather than solutions. When recommendations are made for amelioration of workers’ situation as a whole, they are mostly for better safety protocols only to help avoid physical injury. For treatment of psychological injury, we can look to the literature on PITS in other groups.

Insight. Understanding the universality of one’s experience and that one’s feelings are not unique can be a powerful source of relief. As one therapist for combat veterans put it: “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…. There was some genuine relief that came from seeing that others had these problems, even if the problems continued.”9 This is the only way of addressing the psychological trauma I have found in the literature to be somewhat effective even when the trauma is continuing.

Behavior therapies. Cognitive-behavioral therapies are common, and eye-movement desensitization and reprocessing has shown some success in mitigating posttraumatic symptoms.9 Two techniques that seem to be contraindicated are prolonged exposure and expressive writing. Prolonged exposure, also called flooding, would be indistinguishable from simply continuing to work in the slaughterhouse. Both of these techniques might work well for victims of trauma, but flooding in particular would seem to bring about more agitation in perpetrators than victims.

Atonement. Most of the therapy techniques for any form of trauma presume that the traumas are in the past. Trying to treat traumatization that is ongoing, such that all progress made is undone by the trauma recurring, is an unusual approach. An analogy might be in treating soldiers so they can be sent back into battle, but normal practice is to pull soldiers out of battle if they need mental health treatment. One of the most effective treatments for PITS is to help undo the damage caused by way of atonement or bearing witness. For example, combat veterans from Vietnam could go back to Vietnam to assist in providing health care for the people there now; those who have done so have reported great relief from symptoms.10 In the case of slaughterhouse workers, perhaps working with animal rights groups or on animal compassion projects would be therapeutic; more research is needed. However, the effectiveness of this technique of helping relies even more than the others on the cessation of the traumatizing circumstances.

It is understandable that a therapist would see it as unrealistic to ask patients to cease doing their job if there is no alternative way of making a living readily available. However, if there are methods that can address the trauma even while retraumatization continues, there is inadequate study to ascertain what those would be, and experience so far does not offer much guidance.


  1. Belsher BE, Beech E, Evatt D, et al. Present‐centered therapy (PCT) for post‐traumatic stress disorder (PTSD) in adults. Cochrane Database Syst Rev. 2019;2019(11):CD012898.

  2. Crocq MA, Crocq L. From shell shock and war neurosis to posttraumatic stress disorder: a history of psychotraumatology. Dialogues Clin Neurosci. 2000;2(1):47-55.
  3. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. American Psychiatric Publishing; 2013.

  4. Dillard J. A slaughterhouse nightmare: psychological harm suffered by slaughterhouse employees and the possibility of redress through legal reform. September 24, 2007. Accessed September 7, 2022.

  5. Victor K, Barnard A. Slaughtering for a living: a hermeneutic phenomenological perspective on the well-being of slaughterhouse employees. Int J Qual Stud Health Well-being. 2016;11:30266.

  6. MacNair RM. Research agenda. In: Perpetration-Induced Traumatic Stress: The Psychological Consequences of Killing. Praeger Publishers; 2002:136-139.

  7. Butler V. Inside the mind of a killer. Cyberactivist. August 31, 2003. Accessed September 7, 2022.

  8. Fitzgerald AJ, Kalof L, Dietz T. Slaughterhouses and increased crime rates: an empirical analysis of the spillover from “the jungle” into the surrounding community. Organ Environ. 2009;22(2):158-184.
  9. Lipke H. EMDR and Psychotherapy Integration. CRC Press; 2000.

  10. Graceffo L. Meet the US veterans returning to make amends in Vietnam. Waging Nonviolence. April 30, 2020. Accessed November 28, 2022.

Editor's Note

The case to which this commentary is a response was developed by the editorial staff. Background image by Samantha Welker.


AMA J Ethics. 2023;25(4):E251-255.



Conflict of Interest Disclosure

The author(s) had no conflicts of interest to disclose.

The people and events in this case are fictional. Resemblance to real events or to names of people, living or dead, is entirely coincidental. The viewpoints expressed in this article are those of the author(s) and do not necessarily reflect the views and policies of the AMA.