Impact of Killing

1. Introduction

Version followed: the 10-session, individual Impact of Killing (IOK) protocol developed by Shira Maguen and Kristine Burkman (San Francisco VA Health Care System / UCSF), as published in the developers' session table (Burkman & Maguen, 2018, Table 1; session numbers in this guide follow it) and narrative description (Burkman, Gloria, Mehlman & Maguen, 2022), and tested against Present-Centered Therapy in the multi-site trial (NCT03764033; results in JAMA Psychiatry, Maguen et al., 2026). The earlier pilot version was a 6–8-session weekly module (Maguen et al., 2017, Journal of Clinical Psychology) and was expanded to 10 sessions after veteran feedback. Sources: the session sequence in both published outlines, the Killing Cognition Scale's origin, themes and introduction, the letter types, the pilot design and eligibility, and the multi-site trial's format and comparator come from the developers' texts, the pilot abstract and the trial protocol. Not drawn on [uncertain]: the IOK therapist manual and handouts (not publicly available; no published book edition is known), the developers' chapter in APA's Addressing Moral Injury in Clinical Practice, the KCS items and scoring, and the trial's full exclusion criteria. Step-level wording is therefore paraphrase or marked [synthesis]. [source: Burkman & Maguen 2018; Burkman et al. 2022; Maguen et al. 2017 abstract; NCT03764033 protocol; UCSF 2017 and 2026 news]

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, self-condemnation, self-sabotage, spiritual and moral distress, impaired self-forgiveness) as related to but distinct from fear-based PTSD, and is designed to complement, not replace, Cognitive Processing Therapy (CPT) and Prolonged Exposure (PE). [source: Burkman & Maguen 2018; Burkman et al. 2022]

Core idea of change: veterans first make sense of their reactions to killing (normalising psychoeducation), then use CBT tools to revise killing-related beliefs that are distorted or ignore context; what cannot be changed, including appropriate guilt for real harm, is moved into acceptance. Acceptance is treated as the precursor to self-forgiveness, which is cultivated through self-compassion and perspective-taking (especially letter writing) and made concrete through values-driven action and amends. Therapy is framed as a catalyst or "springboard" for moral repair that continues after treatment, not as resolution. [source: Burkman et al. 2022; Purcell et al. 2018; UCSF 2026 news]

2. Framework

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 Present-Centered Therapy matched for number and length of sessions as the comparator; in practice the trial moved almost entirely to telehealth during COVID-19. Assignments between sessions are both written and behavioural: evaluating killing-related cognitions, writing about the meaning of killing and toward self-forgiveness (including a letter to those killed), and activities that build connection with people and community. Maguen describes the module as built with flexibility so it can be personalised. [source: Burkman & Maguen 2018; Burkman et al. 2022; Maguen et al. 2017 abstract; NCT03764033 protocol; Maguen, CDP guest perspective; VA Research Currents 2013]

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 ambiguous (for example a leader who ordered a killing he did not carry out). Pilot eligibility: combat veterans with PTSD who had already completed trauma-focused psychotherapy and reported distress about killing or feeling responsible for deaths in war [source: Maguen et al. 2017 abstract]. Multi-site trial: veterans aged 18–82 in the continental US, screened by phone and with the SCID-5 and CAPS-5 [source: NCT03764033 protocol]; its exclusion criteria (e.g. for psychosis, acute suicide risk or substance use) are not given in the protocol text [uncertain]. Ideally the veteran has completed an evidence-based PTSD treatment, or at least some prior psychotherapy, because IOK reviews the CBT model only briefly and the emotions involved are intense; the developers place it in a stepped or phase-based model and describe it as an add-on ("something that can be done in addition"). It is especially aimed at veterans with self-handicapping symptoms and functional difficulties such as relationship problems. [source: Burkman & Maguen 2018; Burkman et al. 2022; VA Research Currents 2013; Maguen, CDP guest perspective]

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 common-responses session, so their session numbers from the CBT session onward run one earlier (CBT S3, behaviour as evidence S4, acceptance and moral injury S5, forgiveness S6, letters S7–9, amends in the "final two sessions", which overlap the letter sessions). The likeliest reading is that the 2022 narrative compresses the two common-responses sessions rather than describing a different protocol [synthesis]; if you have the manual, follow its numbering. No published session map for the 6–8-session pilot version is drawn on [uncertain].

Phase / module	Published content	2018 Table 1	2022 narrative	Guide sections
A. Orientation and assessment	Pre-treatment evaluation: expectations, range of emotions, self-care, safety planning against self-harm and self-sabotage, past healing efforts, barriers, coping skills, Killing Cognition Scale	S1	S1	4.1–4.3
B. Common responses to killing	Part 1: physiology, instinctual decisions, initial reactions. Part 2: emotions, behaviours, beliefs. Impact writing assignment (2022)	S2 (Part 1), S3 (Part 2)	S2	4.4–4.5
C. CBT elements	CBT framework, meaning of killing, killing cognitions; Socratic questioning and four-column thought records (2022)	S4	S3	4.6–4.8
D. Becoming unstuck	Maladaptive killing cognitions (cont.), behaviour as "evidence" for beliefs, behavioural activation, introduction to acceptance	S5	S4	4.7, 4.9, 4.10
E. Acceptance and moral injury	Acceptance (cont.), moral injury, role of betrayal, sequelae (survivor guilt, suicidal ideation, self-harm, spiritual disillusionment); self-forgiveness definition assignment set (2022)	S6	S5	4.10–4.12
F. Forgiveness	Part 1: defining forgiveness and self-forgiveness, barriers, introduction to forgiveness plan. Part 2: areas and function of self-forgiveness, forgiveness letters	S7 (Part 1), S8 (Part 2, letters begin)	S6 (definitions, barriers, plan); letters S7–9	4.13–4.18
G. Taking the next step	Forgiveness letters (cont.), amends plan including "living amends", connection to others, preparing for possible disclosure	S9 (amends work continues into S10)	"Final two sessions"	4.18–4.21
H. Maintaining gains	Healing as a process, closing reflection statement, plan to continue work	S10	End of protocol	4.22

[source: Burkman & Maguen 2018, Table 1; Burkman et al. 2022 narrative]

Criteria for moving between phases: the published descriptions are session-scheduled and give no explicit progression criteria [uncertain]. Practical criteria [synthesis]: 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 remaining distress is driven by beliefs that are accurate (real harm, real responsibility) rather than distorted; into F when the veteran can acknowledge what happened and its impact without immediately escalating to self-punishment or minimisation; into G once at least one letter has been written and processed. If the veteran is acutely unsafe, pause the protocol for risk management rather than pushing ahead.

After IOK: the developers expect moral injury to keep healing over months and years, and encourage ongoing connection with faith communities, veteran peers and family, plus further trauma or spiritual care where needed. [source: Burkman et al. 2022; Purcell et al. 2018]

3. Guiding principles

[source: Burkman & Maguen 2018; Burkman et al. 2022; Purcell et al. 2018 unless marked]

Complement, don't replace, PTSD treatment. Assess what fear-based PTSD work has been done; IOK usually comes after it. Maguen frames it as an add-on: "something that can be done in addition" [source: VA Research Currents 2013].
Moral injury is distinct from fear. Target guilt, shame, self-condemnation and loss of meaning, not only fear and avoidance.
Say "killing". Use the word directly; veterans and providers reported that euphemism felt avoidant and stigmatising.
Challenge distortions, accept realities. Use Socratic questioning only on beliefs that ignore context or misjudge responsibility; treat appropriate guilt for real harm as something to accept, not argue away.
Acceptance comes before forgiveness. Don't start forgiveness work until the veteran can hold what happened without denial or minimising.
Compassion without condoning. Offer warmth for the person and their feelings without excusing the act; reassurance that the veteran "did nothing wrong" can make him hide ongoing self-condemnation.
The veteran defines forgiveness. Don't impose a universal definition; explore personal, cultural and spiritual meanings, and respect the right to reject self-forgiveness as a goal.
Forgiveness can't be forced. The developers warn that "false or forced forgiveness is temporary"; watch for pseudo-self-forgiveness that relieves guilt without changed behaviour.
Behaviour generates evidence. Self-sabotage (withdrawal, substance use, undermining relationships) confirms beliefs like "I don't deserve good things"; new values-consistent behaviour builds new evidence.
Moral and spiritual life is in scope. Explore moral and spiritual upbringing and beliefs; collaborate with or refer to chaplains and clergy when that serves the veteran.
Disclosure to others isn't a goal. Letters stay in therapy; sharing killing experiences with family or community is the veteran's choice, and you prepare them for reactions if he chooses it.
Safety first. Veterans who have killed are at high suicide risk; build a safety plan in session 1 and keep monitoring self-harm and self-sabotage.
Tailor to the person. IOK was designed "to leave flexibility, so it could be personalized for each individual" [source: VA Research Currents 2013]; use the KCS profile, prior treatment history, culture and spirituality to decide emphasis; some items or modules may not fit.
Therapy as catalyst. Frame IOK as the start of moral repair, not its completion.
Know your own reactions. Examine your values and reactions to killing, to unfamiliar beliefs and to harsh self-judgements; veterans said the therapeutic connection "can't be an intellectual exercise" [source: Purcell et al. 2018].
Respect the limits of individual repair. Self-forgiveness doesn't undo harm or address the conditions that put soldiers in moral jeopardy; acknowledge betrayal and the collective side of war where relevant [source: Purcell et al. 2018].

4. Intervention inventory

The developers name the components below; the numbered steps are written in my own words from their descriptions, and steps not described in the sources are marked [synthesis]. All example language is illustrative, not from the manual. [source: Burkman & Maguen 2018; Burkman et al. 2022; Purcell et al. 2018]

4.1 Orientation, expectations and safety planning (Session 1)

Purpose / when: Session 1, before any killing-focused work. Prepares the veteran for intense emotions and guards against self-harm and self-sabotage during treatment. [source: Burkman et al. 2022]
Steps: (1) Explain the 10-session structure, weekly writing assignments and the focus on killing, acceptance and self-forgiveness. (2) Say that guilt, grief and anger may rise before they ease. (3) Agree a self-care plan for after sessions. (4) Complete a written safety plan covering suicide warning signs, coping steps, people to contact, crisis lines and lethal-means safety (secure storage or removal of firearms and other means) [synthesis: standard safety-planning content]. (5) Name likely self-sabotage (drinking, skipping sessions, picking fights) and agree what to do if it starts.
Example language (illustrative): "We're going to talk directly about killing, which many veterans have never done. It's common to feel worse for a stretch before feeling better, so let's plan now for how you'll look after yourself between sessions."
Watch for: current suicidal ideation or intent (do a full risk assessment and manage risk before going on); heavy substance use; ambivalence about coming back. It is working if the veteran can name warning signs and at least two concrete coping actions.

4.2 Review of past healing efforts, barriers and coping (Session 1)

Purpose / when: Session 1. Maps what the veteran has already tried (therapy, faith, drinking, isolation, work, volunteering) so you can reinforce what helped and spot self-destructive patterns. [source: Burkman et al. 2022; Burkman & Maguen 2018]
Steps: (1) Ask about previous PTSD treatment (CPT, PE, other), what helped and what didn't. (2) Ask how the veteran has tried to cope with the killing on their own. (3) Sort the strategies together into "moved me forward" and "kept me stuck or hurt me". (4) Note practical barriers to attendance (work, transport, telehealth access).
Example language (illustrative): "Over the years, what have you done to live with what happened? Which of those things helped, and which cost you?"
Watch for: strategies that look like self-punishment (refusing help, sabotaging relationships). Record them; they become material for 4.9.

4.3 Killing Cognition Scale (KCS) (Session 1)

Purpose / when: Session 1. The Killing Cognition Scale is a self-report measure of beliefs about killing in war, developed from focus groups with veterans of several eras (post-9/11, Gulf, Vietnam, Korea, WWII); its themes include guilt and shame, self-betrayal of one's morality, loss of spirituality and self-condemnation. The developers give it in the first session to identify areas of potential cognitive distortion and to individualise the treatment focus. Item content, number of items and scoring are not published in the available sources and are not reproduced here [uncertain]. [source: Burkman & Maguen 2018; Burkman et al. 2022]
Steps: (1) Introduce it: tell the veteran the items were generated by combat veterans of multiple eras and that some may resonate while others may not apply [source: Burkman & Maguen 2018]. (2) Have the veteran complete it in session while you stay nearby [source: Burkman et al. 2022]; it can be distressing, so check in afterwards [synthesis]. (3) Review endorsed themes together. (4) Re-administer at the end of treatment to show change [synthesis].
Example language (illustrative): "Some of these will fit you and some won't. If one hits hard, let's stop and talk about it."
Watch for: strong endorsement of deserving to suffer or of being beyond forgiveness (link to suicide risk); a lower score on such beliefs by the end shows progress (the developers report reduced endorsement of "I deserve to suffer for killing" in the pilot). [source: Burkman et al. 2022]

4.4 Psychoeducation: common responses to killing (Sessions 2–3)

Purpose / when: Early sessions. Reduces shame and isolation by showing the veteran their reactions are shared and understandable. [source: Burkman & Maguen 2018; Burkman et al. 2022]
Steps: (1) Share what other veterans have reported. Part 1: physiological reactions during and after killing, split-second or instinctive decisions, the role of training and unit dynamics, and initial reactions. (2) Part 2: common later emotions (guilt, shame, grief, anger, numbness, and sometimes initial satisfaction or relief that later feels confusing [synthesis]), behaviours (withdrawal, substance use, risk taking) and beliefs about self, others and the world. (3) Ask after each area which parts fit. (4) Use the word "killing" plainly throughout.
Example language (illustrative): "Many veterans describe acting before they had time to think, the way they were trained. Some describe feeling nothing at the time and a lot later. Does any of that fit your experience?"
Watch for: relief ("I thought I was the only one") is a sign it is working. Normalising is not excusing: if the veteran hears it as "it wasn't wrong" and pushes back, acknowledge that the guilt may be pointing to something real (see 4.10).

4.5 Impact writing assignment (after Session 2)

Purpose / when: Homework after the first psychoeducation session. The veteran writes about how killing has changed their view of self, others, meaning and spirituality, and their daily functioning. Responses identify the problem areas for the rest of treatment. [source: Burkman et al. 2022]
Steps: (1) Set the assignment with the four areas named. (2) Suggest a time and place to write, and a calming activity afterwards [synthesis]. (3) In the next session, have the veteran read it or summarise it aloud [synthesis]. (4) Highlight stuck points and themes, and link them to KCS results.
Example language (illustrative): "This week, write about how killing changed the way you see yourself, other people, and what life means to you, and how it shows up in your days now."
Watch for: avoidance (not written, or written about something else); very brief entries (ask gently what made it hard). Useful entries name specific beliefs ("I'm a monster", "I don't deserve my kids").

4.6 CBT model and the meaning of killing (Session 4; Session 3 in the 2022 numbering)

Purpose / when: Gives the shared map for the cognitive work. Reviewed briefly, since most veterans have already done CPT or PE. [source: Burkman & Maguen 2018; Burkman et al. 2022]
Steps: (1) Draw the situation → thought → feeling → behaviour cycle on paper or screen. (2) Fill it in with an example from the veteran's own week. (3) Ask what killing has come to mean about them as a person. (4) List the killing-related cognitions that emerge as targets.
Example language (illustrative): "When your daughter hugged you last week and you pulled away, what went through your mind?"
Watch for: beliefs stated as global identity ("I'm evil") versus about the act ("I did something terrible"); the latter is often more workable.

4.7 Socratic questioning of killing-related cognitions

Purpose / when: Sessions 4–5 (2018 numbering), only for beliefs that are distorted or ignore context (for example overestimated responsibility, hindsight bias, ignoring the threat or orders at the time, global self-condemnation). [source: Burkman et al. 2022]
Steps: (1) Pick one belief. (2) Ask about context: what the veteran knew at that moment, how much time there was, what the rules of engagement and the unit expected, what the options really were. (3) Ask about how responsibility was shared (command, enemy, circumstance, self). (4) Help the veteran write an accurate, balanced version that keeps what was really theirs. [synthesis for steps 2–4, consistent with standard CBT and CPT practice]
Example language (illustrative): "In the seconds you had, what did you actually know? What did you only learn afterwards?"
Watch for: the veteran feeling that you are arguing them out of guilt they believe is deserved; the developers note that Socratic challenging of appropriate guilt can feel invalidating, especially for veterans without prior PTSD treatment. Stop challenging and switch to acceptance (4.10) when the belief is accurate.

4.8 Thought records (between sessions)

Purpose / when: From the CBT session onward. Builds the habit of catching and revising killing-related thoughts in daily life. [source: Burkman et al. 2022]
Steps: (1) Show the four-column form (situation, cognition, emotion, behaviour) [source: Burkman et al. 2022]; adding a revised-thought column once the veteran is practised is optional [synthesis]. (2) Complete one together in session. (3) Assign 3–5 records per week [synthesis: frequency not specified]. (4) Review them at the start of the next session, picking one for in-session work.
Example language (illustrative): "When the 'I don't deserve this' thought shows up this week, write down where you were, what you felt, what you did, and then a more accurate thought."
Watch for: revised thoughts that simply deny responsibility (too easy, unlikely to hold) or that repeat the original (stuck). Working: more balanced revisions and lower emotional intensity ratings.

4.9 Behaviour as evidence and behavioural activation ("Becoming unstuck")

Purpose / when: Session 5 (2018 numbering; Session 4 in 2022). Shows how reactions like withdrawal, substance use and self-sabotage create "evidence" for self-condemning beliefs, and plans new behaviours that support new beliefs. [source: Burkman et al. 2022; Burkman & Maguen 2018]
Steps: (1) Take one self-condemning belief and list the behaviours it drives. (2) Show how those behaviours produce outcomes (isolation, broken relationships) that seem to prove the belief. (3) Choose one or two small values-consistent actions for the week (calling a friend, a family meal, a walk in nature). (4) Review what happened and what it suggests about the belief.
Example language (illustrative): "When you stay away from your family because you feel you don't deserve them, they drift, and that seems to prove the point. What's one small thing this week that would go the other way?"
Watch for: sabotaging the planned activity; shrink it further rather than abandoning it. Working: the veteran notices moments of connection or pleasure without immediately cancelling them out.

4.10 Acceptance work: sorting what to challenge from what to accept

Purpose / when: Introduced in Session 5 and continued in Session 6 (2018 numbering). Separates beliefs that can be revised from painful realities (the act happened, someone died, the veteran played a part) that must be accepted, including appropriate guilt. Acknowledges harm done to self and others and builds compassion for the feelings behind self-destructive behaviour. [source: Burkman & Maguen 2018; Burkman et al. 2022]
Steps: (1) List the main killing-related beliefs. (2) Sort them with the veteran into "distorted, can be revised" and "accurate, needs to be accepted". (3) For accepted items, help the veteran state the reality plainly and stay with the feeling (grief, remorse) rather than escaping into self-punishment or minimisation [synthesis]. (4) Reflect compassion for the feelings driving withdrawal or substance use, without endorsing the behaviour. (5) Introduce the idea that acceptance makes forgiveness possible.
Example language (illustrative): "Some of what you've been carrying isn't accurate, and we've worked on that. Some of it is true: a man died and you were part of that. We're not going to talk you out of that part. The question is how you live with it."
Watch for: confusing acceptance with approval ("accepting means saying it was OK"); clarify. Working: the veteran can speak about the act and its impact with sadness rather than with shame-driven attack on the self.

4.11 Moral injury psychoeducation, betrayal and losses

Purpose / when: Session 6 (2018 numbering; Session 5 in 2022, which also names suicidal ideation and self-harm among the consequences). Defines moral injury and names its consequences, so the veteran can understand symptoms that don't fit fear-based PTSD. [source: Burkman et al. 2022; Burkman & Maguen 2018; UCSF 2026 news]
Steps: (1) Define moral injury in plain language: distress after doing, failing to prevent, or witnessing acts that violate deeply held moral beliefs. (2) Review common consequences: survivor guilt, isolation, spiritual disillusionment, substance use, self-sabotage, suicidality. (3) Explore the role of betrayal (by leaders, institutions, or oneself). (4) Acknowledge other morally injurious events and losses that sit alongside the killing (deaths of comrades, civilian harm, losses since coming home).
Example language (illustrative): "Moral injury is what can happen when something you did or saw goes against what you believe is right. It often shows up as shame and pulling away, more than fear."
Watch for: a betrayal theme that eclipses the killing; note it and decide with the veteran whether it belongs in IOK or in later work [synthesis].

4.12 Exploring moral and spiritual upbringing

Purpose / when: Alongside acceptance and forgiveness work. Understands the moral and spiritual framework the killing violated and the resources it may offer. [source: Burkman & Maguen 2018; Purcell et al. 2018]
Steps: (1) Ask what the veteran was taught about right and wrong, killing, guilt and forgiveness, and by whom (family, faith, culture, military). (2) Ask where they stand with those beliefs now (kept, lost, angry at God, unsure). (3) Note which beliefs fuel condemnation and which could support repair. (4) Offer collaboration with or referral to a chaplain or spiritual leader if the veteran wants it.
Example language (illustrative): "Growing up, what did you learn about what happens after a person does something seriously wrong?"
Watch for: your own discomfort with religious material, or pressure (in either direction) about faith. Stay curious; don't endorse or argue theology. Refer when questions go beyond your competence.

4.13 Defining forgiveness and self-forgiveness (assignment)

Purpose / when: Opens the forgiveness module (Session 7 in the 2018 numbering; in 2022 the definition assignment is set at the end of Session 5 and discussed in Session 6). The veteran defines self-forgiveness in their own terms, identifies where they learned it, and checks whether they hold themselves to the same standard as others. No universal definition is sought. [source: Burkman et al. 2022; Burkman & Maguen 2018; Purcell et al. 2018]
Steps: (1) Assign a short written piece: what forgiveness and self-forgiveness mean, where those ideas came from, and how they apply to others versus to oneself. (2) Review it in session. (3) Compare the standard the veteran applies to a fellow soldier in the same situation with the one applied to self. (4) Agree on a working definition the veteran owns.
Example language (illustrative): "If a buddy told you this story about himself, would you say he can never be forgiven? What makes it different when it's you?"
Watch for: double standards (forgives others, never self; a common pattern in the qualitative interviews); definitions that equate forgiveness with forgetting or excusing.

4.14 Working with barriers to self-forgiveness

Purpose / when: Forgiveness module, whenever a barrier blocks progress. [source: Burkman et al. 2022; Burkman & Maguen 2018; Purcell et al. 2018]
Barriers the developers name: forgiveness means condoning the act or letting oneself off the hook; forgiving could allow it to happen again; justice must come first, so the veteran punishes themselves as judge, jury and executioner; only the person harmed or God can forgive, or self-forgiveness violates one's faith; some acts are unforgivable.
Steps: (1) Name the barrier and validate the value behind it (taking wrongdoing seriously). (2) Explore the evidence and costs: has self-punishment brought justice or helped anyone? (3) Distinguish self-forgiveness from excusing (the developers' framing: acknowledging, learning from and grieving the wrong, then living by one's values). (4) For faith-based barriers, explore what the veteran's tradition says about repentance and repair, and involve a chaplain if wanted. (5) Accept that the veteran may decide self-forgiveness is not their goal, and work on acceptance and amends instead.
Example language (illustrative): "It sounds like punishing yourself has been a way of showing that what happened matters. Has it brought anything back, or helped anyone?"
Watch for: quick agreement without emotional shift (possible pseudo-forgiveness); escalating hopelessness (recheck suicide risk).

4.15 Forgiveness Plan

Purpose / when: Introduced in Session 7 (Session 6 in 2022) and used through Session 9. A veteran-driven plan of exercises and actions addressing their own barriers and the areas of forgiveness that matter (forgiveness of self, of others, and, for some, from God). [source: Burkman & Maguen 2018; Burkman et al. 2022; Purcell et al. 2018]
Steps: (1) List the areas where forgiveness is needed and the barriers for each. (2) Choose exercises for each (letters, reading, conversations with a chaplain, prayer or meditation, pros and cons, values-based actions). (3) Set the order and timing together. (4) Review progress each session and adjust.
Example language (illustrative): "Let's write down what you'd need to do, think about or talk through to move even a little toward forgiving yourself for this."
Watch for: a plan made entirely of tasks the veteran won't do; keep steps small and owned by the veteran.

4.16 Supporting forgiveness activities

Purpose / when: Within the Forgiveness Plan. [source: Burkman et al. 2022]
Activities named by the developers: a pros and cons list on self-forgiveness; reading on forgiveness; consulting chaplains or spiritual leaders; meditation or prayer.
Steps: (1) Match activities to the veteran's beliefs (secular or religious). (2) For pros and cons, list what holding on to self-condemnation does for and against the veteran, and what self-forgiveness might cost and allow [synthesis on structure]. (3) Debrief each activity in the next session.
Example language (illustrative): "What does holding on to this do for you? What does it cost you, and the people around you?"
Watch for: a "pro" of self-condemnation such as "it keeps me from doing it again" or "it honours the dead"; take it seriously and explore other ways to honour that value.

4.17 Perspective-taking and dialogue exercises

Purpose / when: Forgiveness module. Builds flexibility and compassion through dialogue with parts of oneself or with people one has harmed, and through taking another's perspective; the developers list these among IOK's CBT-based tools. [source: Purcell et al. 2018; Burkman et al. 2022]
Steps: The published sources do not describe the procedure [uncertain]. A workable approach [synthesis]: (1) have the veteran write or speak from a named perspective (a trusted mentor, a fellow soldier, their younger self); (2) ask what that person would see that the veteran misses; (3) contrast with the self-condemning voice; (4) note any shift.
Example language (illustrative): "If your grandfather heard the whole story, what do you think he'd say to you?"
Watch for: the veteran being unable to imagine any compassionate perspective; start with a perspective on someone else, then move back to self.

4.18 Forgiveness letters (Sessions 8–9; Sessions 7–9 in the 2022 numbering)

Purpose / when: The central technique of the forgiveness module; veterans described it as both the hardest and the most powerful part of IOK and as a catalyst for change. [source: Burkman et al. 2022; Purcell et al. 2018; Burkman & Maguen 2018]
Letter types described: (a) first letter, to someone the veteran killed, harmed or could not save: states the wrong, its impact, and asks for forgiveness; (b) a letter from the perspective of a trusted person; (c) a letter to the veteran's pre-war or younger self; (d) therapists may also consider letters to the families of enemy soldiers or civilians who were killed, or to loved ones harmed by the veteran's self-destructive or isolating behaviour. Letters are part of the therapy, not a product to share. [source: Burkman et al. 2022] Which letters to write is decided collaboratively.
Steps: (1) Explain the purpose and that letters stay in therapy and are not to be sent or shared. (2) Agree the recipient and timing. (3) The veteran writes between sessions (Maguen lists writing toward self-forgiveness, including a letter to those killed, among the out-of-session assignments [source: Maguen, CDP guest perspective]); suggest a private time, a set limit (for example 30–45 minutes), and a grounding or self-care activity afterwards [synthesis]. (4) In session, the veteran reads or shares the letter (whether letters are read aloud is not stated in the available sources [uncertain]); listen without interrupting. (5) Process: what the veteran felt writing it, what they said, what was hard, what they noticed about responsibility and remorse. (6) Decide the next letter. A letter from the trusted person's perspective often follows a letter of apology [synthesis on order beyond the first letter].
Example language (illustrative): "In this letter, tell him what happened, what it has meant for you, and what you'd want to ask of him. Nobody will ever read this except you and me."
Watch for: strong remorse, grief and despair surfacing (expected); dissociation or overwhelm while reading (pause and ground, see 5.4); avoidance by writing in generalities; a letter in which the veteran grants themselves instant forgiveness without remorse (pseudo-forgiveness). Working: specific acknowledgement of the act and its impact, followed by more compassion toward self and less self-attack in later sessions.
Trauma safeguards: Treat what the veteran writes as their experience and meaning, not as an investigation of historical facts; do not add or suggest details. [synthesis, per brief rules]

4.19 Amends Plan, including "living amends" (Sessions 9–10)

Purpose / when: Final sessions. Turns acknowledgement and remorse into concrete action that reaffirms violated values. Where direct amends are impossible or could cause more harm, use "living amends": a way of living that honours those harmed. [source: Burkman et al. 2022; Purcell et al. 2018; UCSF 2017 news]
Examples the developers report: rituals, volunteering and community service, more time with family, reconciling with estranged adult children or ex-partners, returning to a place of worship, tutoring children, peer support, speaking to others, raising children in those values, and, for one veteran, returning to the country where the killing occurred.
Steps: (1) Ask which values the killing violated. (2) Brainstorm actions that express those values now. (3) Screen each for harm to others or self (unsafe travel, contacting victims' families unprompted, putting legal or safety at risk) [synthesis]. (4) Choose one or two actions with specific dates. (5) Plan for ongoing amends after therapy.
Example language (illustrative): "You can't give him his life back. What could you do with yours that honours what was lost?"
Watch for: amends driven by self-punishment (exhausting, risky) rather than values; grandiose plans that set up failure. Working: actions completed and described with meaning rather than as penance.

4.20 Connection and values-based activities

Purpose / when: From the next-step session onward (and seeded earlier through behavioural activation). Reduces isolation and builds a life that supports new beliefs. [source: Burkman & Maguen 2018; Purcell et al. 2018]
Steps: (1) Identify relationships and communities to reconnect with (family, friends, veteran peers, faith community). (2) Add values-based activities (community service, time in nature, spiritual practice). (3) Schedule and review.
Example language (illustrative): "Who do you want back in your life, and what's one step toward them this week?"
Watch for: reconnecting only as a duty while still feeling undeserving; return to 4.10 and 4.14 if this happens.

4.21 Preparing for possible disclosure

Purpose / when: As needed, late in treatment. Disclosing killing to family or others is not a goal, but if the veteran wants to, you help them prepare for others' possible reactions. [source: Burkman et al. 2022]
Steps: (1) Clarify the veteran's reasons and who would be told. (2) Consider the range of likely reactions, including unhelpful ones. (3) Decide how much to share. (4) Rehearse the conversation and a plan if it goes badly [synthesis for steps 2–4].
Example language (illustrative): "What are you hoping will happen if you tell her? And how would you take care of yourself if she reacts in a way you didn't expect?"
Watch for: disclosure used as self-punishment, or pressure from family to tell more than the veteran wants.

4.22 Maintaining gains and closing reflection (Session 10)

Purpose / when: Final session. Frames healing as ongoing and plans continued work. [source: Burkman & Maguen 2018; Burkman et al. 2022]
Steps: (1) The veteran writes or speaks a final statement on what has changed and what remains unresolved. (2) Re-administer the KCS and other measures to review change [synthesis]. (3) Review the forgiveness and amends plans and what continues after therapy. (4) Encourage connection to faith communities, veteran peers and social supports. (5) Update the safety plan and agree how to get help if things worsen [synthesis]. (6) Note that forced forgiveness does not last and that the process continues.
Example language (illustrative): "Looking back at where you started, what's different? What are you still carrying, and what will you keep doing about it?"
Watch for: distress about ending; residual PTSD or other conditions that need further treatment (refer or continue care).

5. Handling problems

The developers' published descriptions name several difficulties; responses below are tagged by source, and most concrete responses are the writer's [synthesis], since the therapist manual is not publicly available.

5.1 Suicide risk and self-sabotage

Problem: Veterans who kill are at uniquely high suicide risk; suicidality, substance use and withdrawal are named consequences of moral injury, and guilt can rise when killing is first discussed. [source: Burkman et al. 2022; Burkman & Maguen 2018; Purcell et al. 2018]
Response: Safety plan in Session 1; brief risk check each session, more fully after letters and during the acceptance module [synthesis]. If risk rises, pause protocol content, do a full risk assessment using your service's standard procedure, update the safety plan, review lethal-means safety (storage and removal), and increase contact or step up care. Watch for "deserving to suffer" and "unforgivable" beliefs as risk markers [synthesis].

5.2 Socratic questioning feels invalidating

Problem: Challenging guilt that the veteran experiences as deserved can feel dismissive, especially for veterans without prior PTSD treatment. [source: Burkman et al. 2022]
Response: Ask whether the belief is about facts (challengeable) or about having done real harm (accept). Say plainly that you are not trying to remove all guilt. Move that belief into acceptance work (4.10). If many beliefs are fear-based or distorted and the veteran has had no trauma-focused therapy, consider doing CPT or PE first. [synthesis, built on Burkman et al. 2022]

5.3 Hidden ongoing self-condemnation

Problem: Veterans may hide continued self-condemnation from providers who focus on reassurance. [source: Purcell et al. 2018]
Response: Avoid blanket reassurance ("you were just doing your job"). Ask directly what part of them still condemns them, and use the KCS and the impact writing to track it. [synthesis]

5.4 Overwhelm or dissociation (especially with letters)

Problem: Forgiveness letters surface remorse, grief and despair; they were the hardest part of treatment for pilot veterans. [source: Burkman & Maguen 2018; Purcell et al. 2018] What the developers say: prior trauma-focused treatment is recommended partly because of the intensity of emotion in moral injury; therapists rely on clinical judgement, build safety planning into Session 1, assess self-destructive tendencies from the start, and should "offer space to lay out all the pieces contributing to the conflict" [source: Burkman & Maguen 2018; Burkman et al. 2022]. No in-session overwhelm, grounding or dissociation procedure is published in the available sources (the manual may contain one) [uncertain].
Response [synthesis]: Before letter work, check readiness: a current safety plan, at least one reliable grounding skill, no acute substance misuse, and the ability to talk about the killing without losing contact with the room. If the veteran becomes overwhelmed or dissociates in session: stop reading, orient to the present (name date, place, the therapist; feet on the floor; describe objects in the room; slow paced breathing), lower the intensity (summarise rather than read), and resume only when they are present. Close every letter session with a debrief, a check on safety and a planned self-care activity. If dissociation is frequent, return to stabilisation or trauma-focused PTSD treatment before continuing.

5.5 Not writing the assignments

Problem: Writing between sessions is avoided (not specifically addressed in the sources [uncertain]).
Response [synthesis]: Treat avoidance as information: ask what made it hard (shame, fear of the emotion, privacy at home, literacy). Write the first part in session; shorten the task; offer dictation or voice notes; agree a time and place. Keep the expectation, as the letters are central to the protocol.

5.6 "I can't be forgiven" / "only God or the dead can forgive"

Problem: Beliefs that the act is unforgivable, that only victims or God can forgive, or that self-forgiveness would condone or allow repetition. [source: Burkman et al. 2022; Purcell et al. 2018]
Response: Use barrier work (4.14); respect the veteran's right not to adopt self-forgiveness as a goal [source: Purcell et al. 2018]. Offer chaplain collaboration for faith-based barriers [source: Purcell et al. 2018]. Keep amends work going even without self-forgiveness, as values-based action can still reduce self-sabotage [synthesis].

5.7 Pseudo-forgiveness

Problem: Inauthentic self-forgiveness eases guilt without remorse, amends or growth and can coexist with self-destructive behaviour; the developers warn forced forgiveness is temporary. [source: Purcell et al. 2018; Burkman et al. 2022]
Response [synthesis]: Notice fast "I forgive myself" without grief, or with continued drinking or isolation. Return to acknowledgement and acceptance; ask what forgiveness would look like in behaviour, and test it with amends.

5.8 Therapist reactions and ruptures

Problem: Providers may fear their own reactions to killing details or feel uncomfortable with spirituality. [source: Burkman et al. 2022; Purcell et al. 2018]
Response: Examine your values and reactions before and during treatment; get consultation (trial therapists had weekly consultation). If the veteran senses judgement or detachment, name it and repair: acknowledge what you noticed, ask how it felt, and restate your commitment to understanding the whole story. Veterans said they need to see that the therapist really cares. [source: Purcell et al. 2018; synthesis for the repair steps]

5.9 Betrayal and anger at command or country

Problem: Betrayal by leaders or institutions is part of moral injury and can take over sessions. [source: Burkman & Maguen 2018; Purcell et al. 2018]
Response [synthesis]: Validate it and include it in the moral injury formulation (4.11), then return to the killing focus while noting betrayal as a target for further work (other moral injury approaches such as Adaptive Disclosure or spiritually integrated care may suit it).

5.10 Confidentiality and legal concerns about disclosure

Problem: Veterans may fear what will happen if they describe killing, or describe acts they believe may have been unlawful (not addressed in the available sources [uncertain]).
Response [synthesis]: Before detailed disclosure, explain the limits of confidentiality under your jurisdiction's law and your organisation's policy, and get advice from your service's legal or ethics lead if a disclosure may raise reporting questions. Remind the veteran that letters are kept in therapy. Never question for factual or legal detail beyond what the therapy needs.

5.11 Modality fit and adaptations

Problem: The source eligibility is veterans who killed or felt responsible for deaths in war; IOK is not described for other morally injurious events or other populations. [source: Burkman et al. 2022; UCSF 2026 news]
Response [synthesis]: For moral injury not involving killing, consider approaches built for it (the developers mention self-forgiveness workbooks, Trauma-Informed Guilt Reduction Therapy, Adaptive Disclosure and Building Spiritual Strength). Adapting IOK to police, healthcare or civilian contexts is untested; if you do, keep the safety, acceptance and non-disclosure principles and say it is an adaptation.

5.12 Residual PTSD or other conditions

Problem: IOK doesn't fully treat fear-based PTSD, substance use disorder or depression.
Response [synthesis]: Measure symptoms at start and end; refer or continue with CPT, PE, substance use treatment or medication review as indicated. Positioning IOK in a stepped model is the developers' framing [source: Burkman et al. 2022].

Sources

Sources used:

Cited (abstracts or citations only):

Maguen, S., Burkman, K., Madden, E., Dinh, J., Bosch, J., Keyser, J., Schmitz, M., & Neylan, T. C. (2017). Impact of killing in war: A randomized, controlled pilot trial. Journal of Clinical Psychology, 73(9), 997–1012. doi:10.1002/jclp.22471 (abstract). Note: it appeared in the Journal of Clinical Psychology, not the Journal of Traumatic Stress.
Maguen, S., & Burkman, K. (2013). Combat-related killing: Expanding evidence-based treatments for PTSD. Cognitive and Behavioral Practice. (title and journal verified on the UCSF profile; volume and pages not verified [uncertain])
Purcell, N., Burkman, K., Keyser, J., Fucella, P., & Maguen, S. (2018). Healing from moral injury: A qualitative evaluation of the Impact of Killing treatment for combat veterans. Journal of Aggression, Maltreatment & Trauma, 27(6), 645–673. (authors and title verified on the UCSF profile; volume and pages not verified [uncertain])
Burkman, K., Purcell, N., & Maguen, S. (2018). Provider perspectives on a novel moral injury treatment for veterans: Initial assessment of acceptability and feasibility of the Impact of Killing treatment materials. Journal of Clinical Psychology.
Burkman, K., Maguen, S., & Purcell, N. Impact of Killing: A treatment program for military veterans with moral injury. Chapter 11 in J. M. Currier, K. D. Drescher & J. A. Nieuwsma (Eds.), Addressing Moral Injury in Clinical Practice. American Psychological Association (APA lists 2020; the author's profile lists 2021).
Maguen, S., et al. (2026). Psychotherapy for Impact of Killing During War: A Randomized Clinical Trial. JAMA Psychiatry. doi:10.1001/jamapsychiatry.2026.2307.
The IOK therapist manual (San Francisco VA / UCSF) is referred to by the developers but is not publicly available; no published book edition is known. The Killing Cognition Scale items are not published in the available sources [uncertain].

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