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Original Article
Spiritually Integrated Cognitive
Processing Therapy: A New Treatment
for Post-traumatic Stress Disorder
That Targets Moral Injury
Michelle Pearce, PhD
1
, Kerry Haynes, DMin, BCC
2
, Natalia R Rivera,
LCSW, CADCT
3
, and Harold G. Koenig, MD
4,5
Abstract
Background: Post-traumatic stress disorder (PTSD) is a debilitating disorder, and current treatments leave the majority of
patients with unresolved symptoms. Moral injury (MI) may be one of the barriers that interfere with recovery from PTSD,
particularly among current or former military service members.
Objective: Given the psychological and spiritual aspects of MI, an intervention that addresses MI using spiritual resources in
addition to psychological resources may be particularly effective in treating PTSD. To date, there are no existing empirically
based individual treatments for PTSD and MI that make explicit use of a patient’s spiritual resources, despite the evidence
that spiritual beliefs/activities predict faster recovery from PTSD.
Method: To address this gap, we adapted Cognitive Processing Therapy (CPT), an empirically validated treatment for PTSD,
to integrate clients’ spiritual beliefs, practices, values, and motivations. We call this treatment Spiritually Integrated CPT
(SICPT).
Results: This article describes this novel manualized therapeutic approach for treating MI in the setting of PTSD for spiritual/
religious clients. We provide a description of SICPTand a brief summary of the 12 sessions. Then, we describe a case study in
which the therapist helps a client use his spiritual resources to resolve MI and assist in the recovery from PTSD.
Conclusion: SICPT may be a helpful way to reduce PTSD by targeting MI, addressing spiritual distress, and using a client’s
spiritual resources. In addition to the spiritual version (applicable for those of any religion and those who do not identify as
religious), we have also developed 5 religion-specific manuals (Christianity, Judaism, Islam, Buddhism, and Hinduism) for
clients who desire a more religion-specific approach.
Keywords
post-traumatic stress disorder, moral injury, religion, spirituality, psychotherapy
Received November 9, 2017. Received revised January 16, 2018. Accepted for publication January 23, 2018
Post-traumatic stress disorder (PTSD) is one of the most
debilitating disorders affecting military service members
and is a precipitating factor for suicide.
1
Of those that
seek treatment from PTSD, only 20% to 30% fully
recover,
2
making the development of more effective
interventions a research and public health priority. One
of the factors that seems to impede the effectiveness of
current PTSD treatments is moral injury. Moral injury
(MI) has been defined as ‘‘perpetrating, failing to pre-
vent, bearing witness to, or learning about acts that
transgress deeply held moral beliefs,’’
3
and experiencing
1
Department of Family and Community Medicine, Center for Integrative
Medicine, University of Maryland School of Medicine, Baltimore, Maryland
2
South Texas Veterans Health Care System, San Antonio, Texas
3
254th MED DET (COSC), 332d Expeditionary Medical Group Clinic,
MSAB
4
Department of Psychiatry & Behavioral Sciences, Duke University Medical
Center, Durham, North Carolina
5
Department of Psychiatry, King Abdulaziz University, Jeddah, Saudi Arabia
Corresponding Author:
Michelle Pearce, Center for Integrative Medicine, University of Maryland
School of Medicine, 520 W. Lombard Street, East Hall, Baltimore, MD
21201, USA.
Email: mpearce@som.umaryland.edu
Global Advances in Health and Medicine
Volume 7: 1–7
!The Author(s) 2018
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‘‘a deep sense of transgression including feelings of
shame, grief, meaninglessness, and remorse from
having violated core moral beliefs,’’
4
and ‘‘betrayal of
what’s right, by someone who holds legitimate authority,
in a high-stakes situation.’’
5
Notably, MI can result in
psychological symptoms (eg, shame, guilt, rage) and spir-
itual symptoms (eg, spiritual struggles, moral concerns,
loss of meaning, self-condemnation, difficulty forgiving,
loss of faith, loss of hope).
6
MI appears to be a barrier to
recovery from PTSD
5
and is positively correlated with
PTSD among Veterans.
7–10
In a recent study with 427
Veterans, 90% had at least 1 symptom of moral injury
that was rated 9 or 10 on a scale from 1 to 10, and 50%
had 5 or more symptoms at this level.
11
Spirituality is an important and complex phenomenon
that needs to be considered in the conceptualization and
treatment of PTSD. Spirituality has the potential to be a
positive and protective resource or an exacerbating
factor for PTSD or both. Active duty soldiers and
Veterans report high rates of spirituality/religiosity
(S/R),
12,13
and many reports relying on their faith to
cope.
14
Service members who reported higher S/R also
reported less substance use, risky behaviors, and better
affect.
12
On the other hand, individuals with spiritual
struggles report lower recovery rates from PTSD and a
greater need for VA (Veterans Affairs)-approved mental
health services.
15,16
Given that MI and spiritual struggles
are common among those with combat-related
PTSD,
9,17,18
a PTSD intervention that specifically
addresses a patient’s spirituality and MI may be particu-
larly effective in reducing PTSD symptoms.
6,19
Over the last decade, several interventions have been
developed to address MI in the context of PTSD, includ-
ing Adaptive Disclosure,
3
Trauma Informed Guilt
Reduction Therapy,
20
and ACT for moral injury.
21
These treatments are advances in the treatment of
PTSD and have shown promising results; however,
none of these MI interventions have specifically included
spiritual resources or targeted spiritual distress, which as
discussed are important components of MI. In contrast,
a few interventions have used spiritual resources and
these have shown promise for reducing PTSD, including
Mantra Meditation,
22
Mindfulness Meditation,
23
and
Building Spiritual Strengths.
24,25
Although these inter-
ventions included spiritual resources, they did not
target or measure MI. In addition, Building Spiritual
Strengths is a group intervention delivered by chaplains.
Notably, Resick et al. recently found that 1-on-1
Cognitive Processing Therapy (CPT) for PTSD was
more effective than group CPT.
26
In summary, although moral injury is intimately con-
nected with spiritual beliefs and values, these are typic-
ally not addressed in secular approaches, not to mention
spiritual struggles and loss of religious faith due to
trauma, which are typically not addressed at all.
Instead, secular approaches focus on thinking errors,
dysfunctional cognitions, erroneous underlying assump-
tions, and rational justifications, not on spiritual
resources, spiritual struggles, and the spiritual ramifica-
tions of trauma and their interconnection with symptoms
of PTSD. In addition, among the approaches that do
address spirituality in the treatment of PTSD, moral
injury is typically not addressed, particularly for individ-
ual treatment. Therefore, there is a need for empirically
based individual treatments for PTSD that target MI
that make explicit use of a patient’s spiritual resources,
particularly given the evidence that such resources pre-
dict faster resolution of PTSD.
9,27
Spiritually Integrated Cognitive
Processing Therapy
To address this gap, we (a clinical psychologist, an active
duty military psychologist, a psychiatrist, and a VA
chaplain, all with expertise in developing and/or
researching spiritually integrated treatments) have devel-
oped Spiritually Integrated Cognitive Processing
Therapy (SICPT). This novel treatment is an adaptation
of CPT,
28
one of the primary empirically validated treat-
ments for PTSD and one of the three treatments used by
the VA for Veterans with PTSD.
29
In addition to CPT’s
large evidence based for reducing PTSD, we chose to
adapt CPT because of the overlap between MI and
PSTD and the fact that many aspects of MI can be
addressed by the same approach used for PTSD.
CPT is designed to target inaccurate or maladaptive
beliefs—called stuck points—that result in guilt, shame,
and self-blame, rendering individuals stuck in their
trauma recovery. CPT uses cognitive restructuring and
behavioral exercises to help individuals change the way
they think about the trauma. These cognitive changes
allow individuals to better process their emotions, con-
textualize the event, and integrate the experience in a
more positive or adaptive way into their lives. Similar
to CPT, SICPT is designed for individuals experiencing
PTSD across the spectrum of severity, from mild to
severe symptom presentations.
SICPT differs from CPT in 5 major ways. First,
SCIPT specifically targets MI as a major barrier to
achieving recovery from PTSD, whereas CPT directly
targets PTSD. Second, SICPT targets MI by challenging
erroneous interpretations of trauma by focusing on cog-
nitive restructuring using clients’ spiritual/religious
resources (ie, spiritual beliefs, practices, sacred writings,
values, and motivations) to challenge maladaptive think-
ing patterns. Third, given that MI does not always reflect
erroneous interpretations—accurate and legitimate self-
blame and guilt can result from intentional perpetration
or an intentional lack of action—cognitive restructuring
may not be sufficient for the resolution of MI.
30
2Global Advances in Health and Medicine
To address the need for moral repair, SICPT employs
spiritual tools to help resolve moral injury and its dama-
ging sequelae, such as shame, guilt, rage, demoralization,
and self-handicapping behaviors. Specifically, SICPT
uses the spiritual concepts and rituals of compassion,
grace, spiritual guided imagery, repentance, confession,
forgiveness, atonement, blessing, restitution, and making
amends.
Fourth, SICPT also encourages patients to access sup-
port from or emersion in a faith community, which can
help with recovery and reintegration. Finally, in addition
to identifying spiritual resources to aid in recovery, spir-
itual struggles, which are part of MI, are specifically
normalized and addressed in treatment. Spiritual strug-
gles might include feeling angry at God for allowing this
to happen, feeling punished by God, questioning God’s
love and one’s religious faith, feeling abandoned by God
or one’s faith community, or a complete loss of faith as a
result of severely traumatic experiences. (‘‘God’’ is used
here to represent the person’s understanding of a tran-
scendent power or higher being, which may widely vary.)
Given that SICPT makes explicit use of a patient’s
spiritual/religious beliefs, this intervention is only appro-
priate for individuals who identify as spiritual or reli-
gious. In a recent multisite study, nearly three-quarters
of 427 Veterans indicated that religion was important or
very important in their lives, over 80% indicated this for
spirituality, and more than two-thirds indicated that they
would definitely engage in or be open to engaging in a
spiritually integrated treatment such as SICPT.
11
Thus,
at least among U.S. Veterans, the vast majority finds
religion/spirituality important and would be receptive
to and eligible for such a treatment.
Session Content
Similar to CPT, SICPT is delivered in 12 sessions over 6
to 12 weeks.
31
Each session is 50 to 60 min in length and
follows a similar format.
Session 1: Moral Injury and Rationale for SICPT
focuses on rapport building, education on PTSD and
MI, and the rationale for spiritually integrated cognitive
processing treatment that targets MI to reduce PTSD.
The patients’ most traumatic event to be targeted in
treatment is defined. For homework, patients write a
statement describing the impact of the trauma on their
beliefs about God, self, others, and the world; their spir-
itual belief, practices, and well-being; and how the
trauma may have violated their conscience or created
moral distress.
Session 2: Meaning of the Event and Spirituality begins
with patients reading their impact statement and discuss-
ing its meaning, particularly that of the MI and the trau-
ma’s impact on their spiritual beliefs and practices.
‘‘Stuck points’’ (ie, erroneous or unhelpful beliefs driving
the experience of negative emotions) are then added to
the stuck point log. Patients state how they define and
practice their spirituality and what spiritual resources
they have available to them. The relationship between
thoughts, feelings, and behavior are introduced using
the A–B–C (Antecedent, Belief, and Consequence) work-
sheet. For homework, patients complete A–B–C work-
sheets and the My Spiritual Resources worksheet, which
includes identifying someone in their spiritual commu-
nity that might provide support during SICPT.
Session 3: Spiritual Resources and Moral Injury begins
with a review of the worksheets completed for home-
work. Stuck points are discussed, particularly as they
relate to MI, self-blame, and spiritual struggles.
Patients are encouraged to make use of their spiritual
resources and have regular contact with their support
person. The spiritual values of cultivating kind attention
and compassion are introduced as a lens through which
to view the trauma and MI, in order to combat self-
blame and condemnation. For homework, patients com-
plete A–B–C worksheets on MI stuck points and read a
short story on compassion.
Session 4: Kind Attention and Compassion begins by
reviewing the A–B–C worksheets on MI stuck points and
by discussing story on compassion. The impact that
trauma and MI can have on one’s spiritual well-being
is explained and spiritual distress is normalized.
Lament is introduced as a formal expression of sorrow
and spiritual grief. The Spiritually Integrated
Challenging Questions worksheet is introduced to help
patients challenge stuck points using their spiritual
beliefs and values. For homework, patients complete
the Spiritually Integrated Challenging Questions work-
sheets, read the Spiritual Reactions to Trauma and MI
worksheet, and write a lament.
Session 5: Challenging Questions and Spiritual Distress
begins by reviewing the Spiritually Integrated
Challenging Questions worksheet, discussing identified
spiritual distress, and reading aloud and processing the
patient’s lament. The spiritual ritual of confession/
acknowledgement is introduced as a tool for dealing
with guilt resulting from violating one’s moral code
(eg, self-induced MI or rage/revenge for other-induced
MI); if applicable, a confession ritual is chosen by the
patient (eg, acknowledging in prayer the moral violation
to a moral authority or confession to a priest, depending
on client’s faith tradition). The Patterns of Problematic
Thinking worksheet is introduced, which is completed
for homework, along with a daily confession ritual.
Session 6: Confession Ritual and Problematic Thinking
begins by reviewing the Patterns of Problematic
Thinking worksheet and the impact of emotions and
thoughts that resulted from the spiritual ritual of confes-
sion. The spiritual tool of forgiveness is introduced as a
tool for healing MI. Discussion includes the stages of the
Pearce et al. 3
REACH model of forgiveness (Recall, Empathize,
Altruism, Committing, and Holding on)
32
and possible
targets of forgiveness (ie, self, others, God). Patients
identify someone they want to forgive for the MI. The
Spiritually Integrated Challenging Beliefs worksheet is
introduced, and the first 2 steps of forgiveness are
assigned for homework. Patients also read a short
story on forgiveness.
Session 7: Forgiveness I and Challenging Beliefs begins
with reviewing the Spiritually Integrated Challenging
Beliefs worksheet and patients’ success with and impact
of the first 2 steps of forgiveness. The last 3 steps in the
REACH forgiveness model are introduced. The theme of
trust for self, others, and God are discussed, including
how their ability to trust may have changed as a result of
the trauma and MI. For homework, patients read a
module on trust and complete the REACH forgiveness
worksheet. They also complete Spiritually Integrated
Challenging Beliefs worksheets, particularly targeting
stuck points related to forgiveness.
Session 8: Forgiveness II and Trust begins with a
review of the REACH forgiveness worksheets and the
Spiritually Integrated Challenging Beliefs worksheets,
focusing on stuck points related to trust and forgiveness.
Making amends (or restitution) is introduced as a spir-
itual tool for dealing with MI. If this is applicable,
patients choose one action to complete over the next
week to help another person, with the goal of neutraliz-
ing feelings of shame and guilt. The spiritual tool of ver-
bally blessing others is introduced, and patients are
asked to choose someone to bless. The theme of esteem
for self, others, and God/divine being is also presented.
For homework, patients read a module on esteem and
complete Spiritually Integrated Challenging Belief work-
sheets on esteem-related stuck points, engage in the
making amends action, and create and daily say a
verbal blessing for someone.
Session 9: Making Amends and Esteem begins with a
review of the completion and impact of the making
amends and verbal blessing exercises, as well as the
esteem-related Spiritually Integrated Challenging
Beliefs worksheets. The theme of power/control related
to self, others, and God/divine being is introduced next.
Spiritual discrepancies related to power and control (ie,
how one’s lived experiences may differ from one’s spir-
itual beliefs) are discussed and the emotions and stuck
points that may have risen from these discrepancies. For
homework, patients read a module on power/control and
complete Spiritually Integrated Challenging Beliefs
worksheets on this theme, particularly those related to
spiritual discrepancies.
Session 10: Power, Control, and Spiritual
Discrepancies begins with a review of the Spiritually
Integrated Challenging Beliefs worksheets related to
power/control. Spiritual discrepancies and spiritual
issues related to power, such as anger at God, the limited
nature of human perspective, free will, and active surren-
der, are discussed. The theme of intimacy related to self,
others, and God is introduced. Spiritual partnerships are
discussed, both in terms of how trauma and MI can
impact these relationships and how deepening or reenga-
ging in spiritual partnerships/community can help with
the healing process. For homework, patients choose one
way to develop greater intimacy with God or someone in
their spiritual community. They also read a module on
intimacy and complete Spiritually Integrated
Challenging Beliefs worksheets on stuck points related
to intimacy.
Session 11: Spiritual Partnerships and Intimacy begins
with a review of the Spiritually Integrated Challenging
Beliefs worksheets on intimacy and the completion and
impact of the action to deepen intimacy. The theme of
safety related to self, others, and God/divine being is
introduced. The session concludes with the concept of
post-traumatic growth (PTG; experiencing growth and
benefits as a result of going through challenges and
trauma) and how patients might be able to experience
this, if they have not already. For homework, patients
read a module on safety and complete Spiritually
Integrated Challenging Beliefs worksheets on safety-
related stuck points. They also write another trauma
impact statement, state their current level of moral dis-
tress, and describe possible PTG they may have experi-
enced or could imagine experiencing in the future.
Session 12: Post-Traumatic Growth and Safety begins
by reviewing the Spiritually Integrated Challenging
Beliefs worksheets on safety. Patients read the new
impact statement and compare it to the original impact
statement. Changes and growth are discussed, particu-
larly as they relate to MI, spiritual well-being, and PTG.
The rest of the session is spent reviewing the course of
treatment and the major concepts and skills they learned,
including their spiritual tools and resources (eg, compas-
sion, kind attention, lament, confession/acknowledg-
ment, forgiveness, making amends, verbal blessing,
spiritual partnerships). Any remaining issues that need
attention are identified, and future goals are set. Finally,
patients are asked to ‘‘pay it forward’’ to other people,
including those with similar issues, family members, their
spiritual community, and those in need.
Religion-specific SICPT Supplements
The manual-based sessions described above were
designed to be applicable for patients with spiritual
and religious beliefs, with particular care given to make
the therapy appropriate for patients who identify as spir-
itual, but not necessarily religious. We have also devel-
oped brief religion-specific SICPT supplements that
cover each of the 12 sessions. These supplements are
4Global Advances in Health and Medicine
available for 5 major world religions: Christianity,
Judaism, Islam, Hinduism, and Buddhism. For each ses-
sion, the supplements describe specific religious con-
cepts, teachings, principles, and stories about religious
figures that might inform treatment. Sacred scriptures,
prayers, and rituals that relate to the content of each
session are also provided. These religion-specific supple-
ments are designed to aid therapists in deepening the
work with their religious clients and providing back-
ground information about the various faith traditions
that might be helpful in addressing trauma and MI.
Note that given space limitations, we are limited in
how much detail we can provide on the content of the
sessions in this article. For those who would like more
detail, we would be happy to provide the full treatment
manual and religions-specific supplements that are cur-
rently being refined through field testing and a future
randomized controlled trial.
SICPT Case Study
This case is a compilation of several patients to protect
confidentiality.
James is a 39-year-old Hispanic man and Iraq War
Veteran who was diagnosed with PTSD. He presented at
the VA for treatment, and upon evaluation, he scored 57
on the PTSD Checklist—DSM-5—Military Version
(PCL-5) and described various war-related traumatic
experiences on the Life Events Checklist-DSM-5. He
reported experiencing flashbacks and nightmares,
among other symptoms, since returning to the United
States 1 year ago. The traumatic experience he named
as most troublesome for him was ‘‘doing something bad’’
on a convoy he commanded. James also shared that his
Christian faith was important to him, although he found
it hard to practice as actively as before his deployment.
Upon learning of the option of engaging in SICPT,
James chose this treatment approach.
In session 1 of SICPT, James became teary-eyed when
learning about the concept of moral injury and agreed to
write about the convoy memory that plagued him for his
impact statement that week. In session 2, James read
his impact statement. He described the power inherent
in his position as Convoy Commander and the presence,
on that day, of a visiting dignitary, an attractive female
who was assigned to travel in his vehicle. He stated that a
civilian vehicle was repeatedly attempting to pass his
convoy. At his orders, the vehicle was temporarily
deterred by other military vehicles, but the civilian
driver did not give up. Finally, as the vehicle approached
James’ vehicle, he ordered his driver to force it off the
road. Right before the vehicle crashed, he saw a man and
a woman in the front seat, with 2 small children in the
back seat. He expressed much anger at the civilian driver
for not standing down. He described the far-reaching
implications of that experience, including losing trust in
himself, others, and God, and feeling distant in his rela-
tionships. Regarding moral distress, he wrote, ‘‘Some
actions are too bad to be forgiven.’’
In session 3, during the introduction of the spiritual
values of kind attention and compassion for self, James
again became teary-eyed. He remarked that he did not
have a supportive community, and that he knew his
church would reject him if they knew what he had
done. He chose his uncle as his support person. In ses-
sion 4, he reported a great deal of spiritual distress,
which he wrote about in his lament that week.
During the review of ABC worksheets in session 5, the
therapist remarked on James’ tendency to be self-
condemning. James began to open up about why the
convoy experience bothered him so much. He said,
There is that moment of decision when you must act and
do what is right for the safety of all. But there is also that
little voice inside that knows the truth. One small part of
me forced that vehicle off the road into the overpass
embankment—not to ensure our safety—but to show
off for my VIP. What kind of person does that? I
wasn’t raised that way. I know God doesn’t approve of
that. What if those people all died in that car?
The therapist sought to convey understanding, but did
not offer any quick answers. Instead, after a few minutes,
the therapist introduced the spiritual ritual of confession/
acknowledgment, a tool for resolving justified guilt.
After discussion, James indicated he would be open to
talking with a clergy person. Instead of his pastor, he
opted for a referral to a mental health chaplain at
his VA.
In session 6, James said he had not yet met with the
chaplain, but had confessed his action to God in prayer.
He was still struggling with guilt and shame from the
event and said he wanted to work on forgiving himself.
In sessions 7 and 8, they worked through the REACH
forgiveness steps and he was able to forgive himself for
his action motivated by wanting to impress the VIP.
During this time, he also described a ‘‘great’’ visit with
the chaplain, who told him that no act is beyond the
reach of God’s grace and forgiveness.
In session 9, for his making amends activity, James
chose to volunteer with a local nonprofit that provides
clothes and furniture to impoverished families. He
wanted to dedicate his work there to the memory of
the family in Iraq that was involved in the car accident.
In session 10, he discussed his fear of returning to
church, but also his longing to have those kinds of rela-
tionships in his life again. He e-mailed the therapist on
Monday morning to say that he had gone to the Sunday
morning worship service and was pleasantly surprised
that people did not stare at him. He said that he even
Pearce et al. 5
had a nice conversation with a parishioner and that he
intended to return next Sunday. In session 11, they went
through the concept of PTG, and after the session, he
noted that maybe his deepening intimacy with his wife
was the start of this kind of growth.
In his second impact statement, which he read aloud in
session 12, James said he had learned a valuable lesson from
the convoy command on that day of the accident. He
quoted the adage of ‘‘absolute power corrupting abso-
lutely,’’ and decided that he, along with the rest of the
human community, was susceptible to temptation. He
was also able to describe the sadness he felt for the
family, but seemed to have made peace with the guilt. His
PCL score registered at 31, indicating comparably reduced
symptoms from his initial 57 score, and which fell under the
cutoff of 35 for a probable diagnosis of PTSD. He also told
the therapist that he hoped to help other Veterans like him-
self who were stuck in guilt and shame and that using the
resources of his Christian faith would help him in finding
healing from this traumatic event.
Conclusion
The recognition and treatment of PTSD has come a long
way over the last few decades. We believe one of the next
important steps for improving PTSD treatment effective-
ness is to address specific barriers to recovery. One of
these barriers is moral injury. Given that moral injury is
composed of both psychological and spiritual symptoms,
it follows that the most effective treatments for MI in the
context of PTSD will be those that address both types of
symptoms. As such, a spiritually integrated treatment
that targets moral injury may reduce one of the barriers
to full recovery from PTSD and may provide much
needed relief for those who are suffering, particularly
those who serve our country and protect our freedom.
We offer SICPT as one such intervention that has the
potential to fill this treatment gap. Research is needed to
determine the empirical effectiveness of this approach for
individuals who desire a spiritually or religiously inte-
grated treatment for trauma.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
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