Psychotherapy for Impact of Killing During War: A Randomized Clinical Trial.

Authors

Shira Maguen, Rebecca Gloria, Amy Lehrner, Jean C Beckham, Stephanie Y Wells, Laura Pratchett, Jamil Davis, Deborah E Barnes, Kristine Burkman

Published in

JAMA psychiatry. Aug 05, 2026. Epub Aug 05, 2026.

Abstract

Killing in war is associated with multiple adverse outcomes, including posttraumatic stress disorder (PTSD), moral injury (MI), and suicide. Impact of killing (IOK) is an individual psychotherapy developed to treat the mental health impact of killing in war.
To determine whether IOK improves veterans' mental health symptoms and functioning at posttreatment and 6-month follow-up.
This multisite, superiority, randomized clinical trial was conducted from August 2018 to November 2023. Participants were veterans randomized to IOK or present-centered therapy (PCT). Diagnostic assessments were administered at screening and posttreatment by blinded evaluators. Self-report measures were collected at baseline, midtreatment, posttreatment, and 6-month follow-up at 3 Veterans Affairs health care systems in California, New York, and North Carolina via in-person and remote appointments. Participants were a sample of veterans with PTSD who reported distress related to killing in war or feeling responsible for the death of others. Primary exclusion criteria were a psychotic disorder diagnosis, moderate or severe alcohol or substance use disorder, untreated mania, or recent suicidal or homicidal behavior.
IOK, an individual psychotherapy that focuses on killing cognitions, acceptance, self-forgiveness, and moral repair, and PCT, which addresses current functional issues due to moral distress with related problem-solving.
The primary outcomes were psychosocial functioning assessed by the World Health Organization Quality of Life Scale-Brief (WHOQOL-BREF) and the Sheehan Disability Scale (SDS). Secondary outcomes included PTSD and MI measures.
A total of 100 individuals (98 male; mean [SD] age, 48.4 [13.7] years) were randomized. Linear mixed models revealed that psychosocial functioning improved for both groups at posttreatment (WHOQOL-BREF and SDS) and the IOK group had a significantly greater improvement than those in PCT on the SDS (-3.50; z score, -2.42; Cohen d, -0.51; P = .02; 95% CI, -5.65 to -0.59). There was no significant difference between treatments on the WHOQOL-BREF at posttreatment. Compared to PCT participants, IOK participants also reported significantly greater improvement in PTSD and MI symptoms.
Individuals in both treatments improved on measures of psychosocial functioning (WHOQOL-BREF and SDS). Those who received IOK evidenced greater improvements in work or school, social life, and home or family life (as measured by the SDS) compared to those in PCT at posttreatment. IOK participants also reported improved PTSD and MI symptoms. The findings suggest that IOK may improve several outcomes for those who experience distress due to killing in war.
ClinicalTrials.gov Identifier: NCT03764033.

PMID:
42555019
Bibliographic data and abstract were imported from PubMed on 06 Aug 2026.

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