Page 100 - JSOM Spring 2026

Case Report on the Augmentation of Cognitive Processing Therapy
with Spiritual Counseling to Address Faith-Based Concerns
for an Operator with High Religiosity

Blake Schroedter, PsyD ; Mark Schimmelpfennig, MDiv ;
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Jonathan W. Murphy, PhD *

ABSTRACT
This case report describes treatment of a Special Operations as firefights and killing combatants and noncombatants.
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Forces (SOF) Operator with high religiosity experiencing However, there is limited research on prevalence of indirect
posttraumatic stress disorder (PTSD) and moral injury after exposures in the SOF community. Increasingly more common
exposure to indirect combat-related trauma via real-time au- in SOF operational environments, indirect exposure refers to
diovisual drone feed. The patient completed virtual massed witnessing or learning about the traumatic exposure of others,
cognitive processing therapy (CPT) augmented by a single typically in close relationships, including fellow Servicemem-
spiritual counseling session to address faith-based concerns bers. These indirect exposures may give rise to secondary or
interfering with trauma processing. Initial symptom exacerba- vicarious posttraumatic stress leading to several psychiatric di-
tion occurred early during CPT, but following spiritual coun- agnoses, the most common of which likely include PTSD and
seling, the patient engaged more fully in therapy, leading to a depression. In addition, indirect exposures are also a vector
significant reduction in PTSD and depressive symptoms. This for moral injury, defined as a distinct syndrome resulting from
case highlights the importance of identifying and addressing an event that involved perpetuating, failing to prevent, bear-
faith-related moral injury early in treatment and suggests that ing witness to, or learning about acts that transgress deeply
integrating spiritual counseling with CPT may enhance out- held moral beliefs and expectations. Exposure to morally in-
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comes for Operators and other Servicemembers suffering with jurious events is common among combat veterans, estimated
vicarious posttraumatic stress stemming from indirect combat at one out of every two veterans, while clinically significant
exposure. symptoms of moral injury are rarer (6.5%). For SOF Service-
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members, estimates of moral injury are currently unavailable,
Keywords: moral injury; spiritual counseling; evidence-based but they are expected to be comparable to those observed in
psychotherapy; special operations; vicarious posttraumatic conventional forces. 7
stress
Researchers have demonstrated that evidenced-based psycho-
therapies (EBPs) for PTSD may facilitate moral injury repair,
particularly those moral injuries that focus on shame and trust
Introduction
violation phenomena. One such EBP is cognitive processing
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In recent years, several technological advances have dramat- therapy (CPT), which facilitates trauma processing by iden-
ically improved access to real-time battlefield information. tifying and challenging unhelpful, inaccurate posttraumatic
Advances in audiovisual (AV) technologies, in particular, give cognitions that may give rise to trauma-related guilt and
those off the battlefield direct access to frontline operations. shame. Though limited, CPT has been shown to reduce trau-
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This access creates a new vector for traumatic exposures for ma-related guilt and self-blame in veterans suffering with both
Servicemembers, commonly including drone operators, intel- PTSD and moral injury. 10,11 However, people with deeply held
ligence analysts, and command and control personnel. For religious beliefs may benefit when EBPs are tailored to address
those in the Special Operations Forces (SOF) community, faith-related concerns. 12
greater access to battlefield information has clear operational
benefits. However, it may also expand the vectors of trauma In this case report, we describe treatment for a SOF Operator
exposure for a population that already has high rates of ex- who experienced indirect exposure while viewing real-time
posure thereby increasing Operators’ risk of developing post- combat operations via AV drone feed. This exposure resulted
traumatic stress disorder (PTSD). in vicarious posttraumatic stress and moral injury. Based on
his high religiosity, treatment involved the combination of
Current diagnostic criteria for PTSD require direct and/or in- CPT to address PTSD and spiritual counseling focused on
direct exposure to actual or threatened death, serious injury, or moral injury. While augmenting CPT with spiritual counseling
sexual violence. Compared to conventional forces with histo- has been well-established in other populations. 12,13 this aug-
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ries of combat deployment, SOF Operators tend to have com- mentation has not been previously investigated in a religious
parable rates of PTSD from direct traumatic exposures, such Operator suffering with PTSD and moral injury.
*Correspondence to 325 S. Paulina St., 2nd Floor, Chicago, IL 60612 or jonathan_murphy@rush.edu
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1 Blake Schroedter, Mark Schimmelpfennig, and Jonathan W. Murphy are affiliated with the Department of Psychiatry and Behavioral Sciences,
Rush University Medical Center, Chicago, IL.
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