Whilst behavioural activation (BA) is an empirically supported treatment for depression, some patients do not benefit. The aim of this study was to evaluate the effectiveness of two treatment augmentations to an extant manualized 8-session group version of BA. The two treatment augmentations were (a) dose–response psychoeducation to improve attendance and (b) implementation intentions to improve clinical outcomes. A cohort comparison design in routine practice comparing standard group BA (n=31, drawn from a sample of n=161, from 22 BA groups) with treatment-augmented group BA (n=31 from 3 BA+ groups). There was no effect of the two treatment augmentations on attendance or in overall mean reductions to depression (mean improvement difference=2.2), anxiety (mean improvement difference=1.9) or impaired functioning (mean improvement difference=1.5). Rates of reliable improvement in depression were significantly higher for augmented BA (odds ratio=3.21 for BA+ compared with BA). Efforts should be made to still improve outcomes for empirically supported interventions, with any treatment augmentations tested in well-controlled studies.

Moral injury is the profound psychological distress that can arise from exposure to extreme events that violate an individual’s moral or ethical code; for example, participating in, witnessing, or being subjected to behaviours that harm, betray or fail to help others. Given that the experience of moral transgression is inherent to moral injury-related post-traumatic stress disorder (PTSD), it is important to consider patients’ religious beliefs and formulate how these may interact with their distress. In this article we describe how to adapt cognitive therapy for PTSD (CT-PTSD) to treat patients presenting with moral injury-related PTSD, who identify as religious. Anonymised case examples are presented to illustrate how to adapt CT-PTSD to integrate patient’s religious beliefs and address moral conflicts and transgressions. Practical and reflective considerations are also discussed, including how a therapist’s personal beliefs may interact with how they position themselves in the work.

Key learning aims

1. (1) To understand the importance of patients’ religious beliefs in the context of moral injury-related distress.

2. (2) To understand how patients’ religious beliefs can be integrated into Ehlers and Clark’s (2000) model when working with moral injury-related PTSD.

3. (3) To offer practical adaptations for CT-PTSD to integrate patients’ religious beliefs and practices, including how to set up a consultation with a religious expert in therapy.

4. (4) To aid therapist reflection on how their personal beliefs interact with how they position themselves in therapeutic work with religious patients.