Table 1.

CT-PTSD treatment strategies with moral injury applications

CT-PTSD treatment technique	Moral injury application
Psychoeducation and normalisation	Include psychoeducation on moral injury Normalise full range of peri-traumatic experiences Read others’ accounts of similar experiences and use these as part of Socratic dialogue
Individualised case formulation	Formulate role of peri-traumatic numbing and/or dissociation in inhibiting memory processing Discuss role of mental defeat in affecting view of self if applicable Explore appraisals and role of previous beliefs and experiences
Reclaiming your life	Incorporate reclaiming of values, self-identity and connections with others, self-care Address blocking beliefs, e.g. ‘I don’t deserve to be happy’
Updating the trauma memory	Generate updating information, e.g. context of traumatic situation (e.g. circumstances, own physical and psychological state, role of others) Introduce updates to trauma memory as soon as possible Initial work on important meanings leading to shame and guilt before accessing the trauma memory in detail if indicated, e.g. the patient is reluctant to discuss it or is at risk of drop-out
Working on meanings of the trauma and its aftermath	Identify and address distorted appraisals using guided discovery, responsibility pie charts, contextualisation, surveys, addressing thinking errors, psychoeducation, and seeking opinions of others Accept responsibility for genuine fault Consider costs and benefits of ongoing self-punishment and/or angry rumination Work on moving forward through making amends via apologies and restitution, including in imagery
Trigger discrimination	Review re-experiencing to identify triggers, including ‘affect without recollection’ Learn and practise ‘then versus now’ discrimination
Site visits	Consider earlier use if patients were dissociated at time of trauma or in a professional role Encourage patients to drop occupational role focus on visit Plan the visit ahead, particularly if it includes the patient’s workplace Use virtual site visits where returning is impractical
Address maintaining behaviours/cognitive strategies	Explore costs and benefits of strategies and experiment with dropping them Reduce substance use Prioritise self-punishing behaviours and revenge rumination if presenting a risk