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injury. This method limited our ability to quantify the degree 7. Caterson JE. Special operations forces moral injury fact sheet. Joint
of moral injury and to monitor change during treatment. In Special Operations University Press. September 2025. Accessed Jan-
the future, researchers should include validated self-report uary 17, 2025. https://jsou.edu/Press/PublicationDashboard/273
measures of moral injury. Second, this report did not include 8. Litz BT, Walker HE. Moral injury: an overview of conceptual,
definitional, assessment, and treatment issues. Annu Rev Clin Psy-
assessment of NPCs, limiting our discernment of the impact chol. 2025; 21(1):252–277. doi:10.1146/annurev-clinpsy-081423-
that spiritual counseling had on clinical outcomes. Further- 022604
more, we could not determine whether spiritual counseling 9. Resick PA, Monson CM, Chard KM. Cognitive Processing Ther-
had an effect on moral injury or NPCs. It is possible that spiri- apy for PTSD: A Comprehensive Therapist Manual. 2nd ed. The
tual counseling had an equal or greater effect on NPCs, which Guilford Press; 2024.
are considered a leading treatment mechanism for CPT. 23,24 10. Dillon KH, Hale WJ, LoSavio ST, et al. Weekly changes in blame
Future studies should include measures of NPCs. Lastly, spiri- and PTSD among active-duty military personnel receiving cogni-
tive processing therapy. Behav Ther. 2020;51:386–400. doi:10.
tual counseling comprised only one session, making it more of 1016/j.beth.2019.06.008
a consultation rather than a specific intervention. Future re- 11. Held P, Klassen B, Zou D, et al. Negative post-trauma cognitions
searchers should consider using an empirically validated form mediate the association between morally injurious events and
of spiritual counseling that better lends itself to replication. trauma-related psychopathology in treatment-seeking veterans.
J Trauma Stress. 2017;30(6): 698–703. doi:10.1002/jts.22234
12. Harris JI, Chamberlin ES, Engdahl B, Ayre A, Usset T, Mendez D.
Conclusion Spiritually integrated interventions for PTSD and moral injury:
a review. Curr Treat Options Psychiatry. 2021;8(4):196–212.
Despite these limitations, this case report creates a template doi:10.1007/s40501-021-00248-w
for treating moral injury characterized by faith-based concerns 13. O’Garo KN, Koenig HG. Spiritually integrated cognitive process-
and PTSD. In this case, integrating spiritual counseling into ing therapy for moral injury in the setting of PTSD: initial evidence
the treatment plan helped this religious Operator engage in of therapeutic efficacy. J Nerv Ment Dis. 2023;211(9):656–663.
doi:10.1097/NMD.0000000000001686
CPT, resulting in a clinically meaningful reduction in PTSD 14. Moring JC, Dondanville KA, Fina BA, et al. Cognitive processing
and depressive symptoms. Furthermore, this case report high- therapy for posttraumatic stress disorder via telehealth: practical
lighted the effectiveness of this combined approach in address- considerations during the COVID-19 pandemic. J Trauma Stress.
ing vicarious posttraumatic stress that arose in an increasingly 2020;33(4):371–379. doi:10.1002/jts.22544
common feature of the battlefield – indirect trauma exposure 15. Held P, Kovacevic M, Petrey K, et al. Treating posttraumatic stress
through AV technologies. disorder at home in a single week using 1-week virtual massed
cognitive processing therapy. J Trauma Stress. 2022;35(4):1215–
1225. doi:10.1002/jts.22831
Author Contributions 16. Held P, Smith DL, Pridgen S, Coleman JA, Klassen BJ. More is
BS was responsible for conceptualization and writing (origi- not always better: 2 weeks of intensive cognitive processing ther-
nal draft, reviewing, and editing) of the manuscript. MS was apy-based treatment are noninferior to 3 weeks. Psychol Trauma.
responsible for conceptualization writing (reviewing) of the 2023;15(1):100–109. doi:10.1037/tra0001257
manuscript. JWM was responsible for project administration 17. Weathers FW, Bovin MJ, Lee DJ, et al. The Clinician-Adminis-
and writing (original draft, reviewing, and editing) of the man- tered PTSD Scale for DSM–5 (CAPS-5): development and initial
uscript. The authors read and approved the final manuscript. psychometric evaluation in military veterans. Psychol Assess.
2018;30(3):383–395. doi:10.1037/pas0000486
18. Blevins CA, Weathers FW, Davis MT, Witte TK, Domino JL. The
Disclosures posttraumatic stress disorder checklist for DSM-5 (PCL-5): de-
The authors have nothing to disclose. velopment and initial psychometric evaluation. J Trauma Stress.
2015;28(6):489–498. doi:10.1002/jts.22059
Funding 19. Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief
No funding was received for this work. depression severity measure. J Gen Intern Med. 2001;16(9):606–
613. doi:10.1046/j.1525-1497.2001.016009606
20. Marx BP, Lee DJ, Norman SB, et al. Symptom exacerbations in
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