Impact of Killing

Domain VI · Brief, integrative, trauma, hypnosis & coaching · Shira Maguen, Kristine Burkman · 2017 · San Francisco

What it is

IOK is a cognitive-behaviourally based individual psychotherapy for veterans distressed by having killed in war, or by feeling responsible for another person's death in a war zone (e.g. a medic who could not save someone). It treats the moral injury that can follow killing (guilt, shame,…

Format

• Session sequence. Two published outlines exist. Burkman & Maguen (2018, Table 1) give an explicit 10-session table with two sessions on common responses to killing (S2 and S3); this guide follows that numbering. Burkman et al. (2022) describe the same modules in the same order but with a single…
• Criteria for moving between phases: the published descriptions are session-scheduled and give no explicit progression criteria. Practical criteria: move from A to B once a written safety plan exists and the veteran can name the killing-related event(s) to be worked on; from C/D to E when the…

Who practises it, and how they are trained or regulated

• Format: 10 weekly individual sessions of 60–90 minutes (the pilot version: 6–8 weekly individual sessions of 60–90 minutes), delivered by a clinician with specialised training in trauma (trial therapists were licensed psychologists or social workers trained in CPT/PE, with weekly consultation and fidelity checklists). The multi-site trial protocol specifies 60–90-minute sessions in person or by video, with…

Evidence status, as the guide reports it

• Who it is for: veterans who killed in war or feel responsible for others' deaths and are troubled by it; as Maguen puts it, "on some level, they struggle with this issue". Not everyone who has killed needs IOK: some veterans feel they did their duty and are not troubled, and killing can be…

Questions to explore with your client

• What drew you to it, and what are you hoping it will change?
• Does it involve any substance, plant preparation, remedy or supplement? Has your doctor or prescriber been told, especially about any medication you take?
• Does it involve intense or unusual breathing? Have you been told about the medical conditions for which that is not advised?
• Does it involve fasting, a special diet or 'detox'? Have you discussed this with your doctor?
• Is it a group, retreat or community? How do they respond if someone wants to leave or raises a concern?
• Who runs it, and what training or registration do they hold?
• What actually happens in a session or meeting, and how often?
• What does it cost, and is there pressure to commit to more?
• How do you feel afterwards, in the hours and days that follow?
• Does it fit with, or clash with, the work we do here?

What practitioners of it watch for

• a plan made entirely of tasks the veteran won't do; keep steps small and owned by the veteran.
• disclosure used as self-punishment, or pressure from family to tell more than the veteran wants.
• reconnecting only as a duty while still feeling undeserving; return to 4.10 and 4.14 if this happens.
• distress about ending; residual PTSD or other conditions that need further treatment (refer or continue care).
• quick agreement without emotional shift (possible pseudo-forgiveness); escalating hopelessness (recheck suicide risk).

Problems the guide addresses

• Suicide risk and self-sabotage
• Socratic questioning feels invalidating
• Hidden ongoing self-condemnation
• Overwhelm or dissociation (especially with letters)
• Not writing the assignments
• "I can't be forgiven" / "only God or the dead can forgive"
• Pseudo-forgiveness
• Therapist reactions and ruptures
• Betrayal and anger at command or country
• Confidentiality and legal concerns about disclosure

When to involve someone else

• New or worsening physical symptoms, or advice to stop or change prescribed medication: involve the client's doctor or prescriber.
• Signs of coercion, isolation from family and friends, escalating costs or secrecy: discuss openly and consider safeguarding.
• A crisis or thoughts of suicide: follow your crisis protocol. In the US, call or text 988; in the UK and Ireland, Samaritans on 116 123.

Drawn automatically from the guide's own sections. Stay curious: neither endorse nor dismiss what the client values, and check anything that matters against the full guide and its sources. Not medical advice.