Individualised case formulation

An early task in CT-PTSD is developing an individualised case formulation with the patient. This is not as detailed as Ehlers and Clark’s (Reference Ehlers and Clark2000) formulation model. Instead, it provides a basic description of the main processes maintaining a patient’s PTSD and may be built on and added to as therapy progresses.

When working with PTSD in the context of moral injury, patients’ existing moral code, linked to family and cultural influences, often influence significant trauma appraisals (Murray and Ehlers, Reference Murray and Ehlers2021). Religious and spiritual beliefs can form an important part of a patients’ cultural context and influences. Therefore, time taken to explore them can help to build a culturally sensitive and meaningful formulation for the patient (Carlson and González-Prendes, Reference Carlson and González-Prendes2016).

Beck (Reference Beck2016) provides a comprehensive guide for when, and how, to explore issues of culture, spirituality and religion in CBT. Beck (Reference Beck2016) advises therapists to become comfortable opening initial discussions about these issues with all their patients in early sessions, after initial rapport has been established. However, these initial conversations may be brief at this stage. It is often the case that if religion is important to a patient, that they will refer to it early in therapy, and this can provide a natural opportunity to take their lead by asking a few additional questions about their beliefs and practices. Another way to open the discussion early in treatment might be when introducing ‘reclaiming your life’, by asking the patient if they would like to re-engage with any important spiritual or religious practices (Naz et al., Reference Naz, Gregory and Bahu2019). This can then be used as an opportunity to explore with patients the importance and meanings of these practices.

Appraisals associated with moral injury may emerge in the early parts of the therapy, for example when reviewing the results of the Post Traumatic Cognitions Inventory (Foa et al., Reference Foa, Ehlers, Clark, Tolin and Orsillo1999). However, they may emerge much later, for example after reliving a trauma memory and exploring the meanings associated with a ‘hotspot’. This affords the therapist the opportunity to explore in more detail how the patient’s appraisals of the trauma may be associated with their religious beliefs. Given the sensitive nature of this discussion, and especially when there are significant differences between the backgrounds of the therapist and patient, it can sometimes be preferable to make a mental note of the possible links, but perhaps wait to explore them in more detail once a stronger alliance has developed.

Some ideas of questions to open conversations about religion are listed below:

• • We’ve talked about how moral injury is the extreme psychological distress humans experience when we act in a way/see others acting/are subjected to acts that go against our sense of what is right and wrong, often due to being forced or having no other options. For some, our sense of right and wrong can be influenced by religious beliefs. I’m wondering if this is the case for you at all?… How true is this for you?… Do you have any religious beliefs that we should consider in our formulation we are mapping out?

• • As you’ve mentioned that you are religious, I’m wondering in what way this influenced your view of the world/other people/yourself whilst growing up?… Did these beliefs change at all after the trauma?… In what way?

• • For some people, if they grew up believing in a divine creation or believing they were a good [insert religious follower], these beliefs can often feel threatened or shattered by traumatic events they later experience. How true is this for you? Is this something you relate to at all?…

It is important to note that a formulation is a work in progress. It is common that high levels of shame and guilt can prevent a patient from initially disclosing key appraisals. Therefore, it is important for therapists to continuously model a non-judgemental attitude to build trust with a patient. As therapy progresses, it is important that the therapist keeps building the formulation in collaboration with the patient. In our experience, appraisals linked to moral injury events and religious beliefs are often only fully disclosed once a patient feels able to trust that the therapist will hold unconditional positive regard. Therefore, the therapist must have realistic expectations for initial sessions, knowing that the formulation will evolve and be added to as the therapeutic rapport builds. To model a non-judgemental attitude, a neutral, curious stance is important, along with continuous validation of a patient’s distress and the impossibility of the situations they have found themselves in.

Religious patients who have historically believed in a loving God/higher order being, or seen themselves as a well-meaning religious follower, may be more susceptible to traumas shattering trust in themselves, the world and/or divinity (Ehlers and Clark, Reference Ehlers and Clark2000; Janoff-Bulman, Reference Janoff-Bulman1992). Alternatively, perhaps if they had a prior sense of never being good enough for God’s love, patients’ may see their trauma as confirmation of previously held negative beliefs about themselves (Ehlers and Clark, Reference Ehlers and Clark2000). A therapist is encouraged to curiously explore how religious practices impact distress, using Socratic questioning (Padesky, Reference Padesky1993). If it is formulated that repetitive reassurance seeking through religious practices is maintaining a patient’s anxiety and rumination, it may be helpful for the patient to seek expert religious guidance on the moral dilemma (see later section on practical considerations for seeking advice from religious experts). However, for others, religious practices may be a positive way to cope and manage through adversity and can be mapped into the formulation as a protective factor.

Figure 1 illustrates a PTSD formulation of ‘Ali’. Ali grew up in the Middle East in a Christian culture at a time of conflict and political unrest. His upbringing gave him a strong sense of God’s transcendence, instilling in him a sense of awe and fear of God’s power. He received a lot of criticism from his caregivers growing up, giving him a sense of never being good enough. As a young man he was conscripted and enrolled to fight in the Iraq–Iran conflict under compulsory military service, against his wishes. After a period of fighting on the front lines he managed to escape and travelled to the UK to seek asylum. After settling in the UK he began ruminating on his past actions in combat, which fed a sense of shame. Over time he became very fearful of God’s judgement, believing ‘I am an evil sinner who will burn in hell’. His fear of God’s judgement amplified his sense of current threat and drove further avoidance and reassurance seeking behaviours. He stopped going to Church. This meant he became disconnected from his spiritual life and Christian community, reconfirming the belief ‘I have let God down as I am a bad man’. He avoided reading his Bible but repetitively prayed for God’s forgiveness. His constant prayer fed a sense of doubt that he had been forgiven, fuelling further prayer and further anxiety. He continuously ruminated on what he could do to make it up to God and spent his time closely monitoring news coverage of the Middle East as self-punishment to remind himself of what he had been a part of, which maintained his distress and triggered more experiencing symptoms.

Figure 1. Example formulation of a Christian veteran ‘Ali’. Italics highlights the incorporation of religious beliefs.

Identifying information (updates) that makes a hotspot less threatening

A patient’s idiosyncratic meanings, associated with the worst moments of the trauma memory (‘hotspots’), are identified through imaginal reliving or written trauma narratives. Updates, which represent new perspectives and information that were not available to the patient at the time of the trauma, are then identified using cognitive therapy techniques and Socratic questioning. Examples of helpful cognitive techniques are: exploring thinking errors, creating responsibility pie charts, discussing psychoeducation about behaviours related to moral injury and seeking advice in imagery using adaptive disclosure (Murray and Ehlers, Reference Murray and Ehlers2021). Cognitive techniques are also used to identify and challenge disordered appraisals, and where cognitions of responsibility are accurate, to support a patient to accept responsibility and find ways of moving forwards.

However, when a patient’s key trauma appraisals relate to religious beliefs that are of significance to them, it is important that the corresponding updates are also linked to the patient’s religious point of reference. Without doing so, the updating work will lack salience as it will not be anchored in the patient’s context. This can be done through using open, Socratic questions to explore if the patient knows of any religious teachings, scripture references or theology that speak to or contradict some of their negative appraisals. The therapist can use this as an opportunity to model to the patient that they are not the expert, inviting the patient to share and teach the therapist about their religion. For example, ‘I am mindful that you know a lot more about your religion than I do, so I apologise in advance if I am asking a silly question, but I am wondering if you have ever heard of any teachings from [insert relevant religion] which might take a different view to your fears of judgement or teach of forgiveness? I only ask as I understand religious theology can be quite complex and nuanced to understand’.

If a patient reports uncertainty at this point, our experience has found it can be valuable to seek advice from respected religious experts through interviews or surveys (see later section on practical considerations for seeking advice from religious experts to set this up). People with PTSD, and particularly moral injury, often withdraw from their community, meaning they miss out on opportunities to hear others’ opinions on the events they are trying to make sense of. Particularly within religious communities, some people report feeling unable to discuss their mental health difficulties within their places of worship due to fears of stigma or judgement (Ciftci et al., Reference Ciftci, Jones and Corrigan2013; Wiffen, Reference Wiffen2014). Therefore, many patients will be grappling with moral and spiritual dilemmas in isolation, and this is something spiritually competent CT-PTSD can work to address.

After agreeing that Ali wanted to seek expert advice on the topic of war and forgiveness, the therapist and Ali designed a survey for Christian experts, linking the questions to fears and beliefs from his formulation. This was because Ali felt too apprehensive to interview an expert directly, and so a survey was agreed as an alternative method which allowed him to ask questions but remain anonymous. Ali said he would define an expert as any Christian Church leader who had undergone theology training. It was agreed helpful to survey leaders across different denominations of Christianity, as Ali did not closely align to any denomination. Therefore, the survey was completed by a range of leaders including Catholic Priests, Church of England Vicars and Methodist and Baptist Ministers. An example survey response from one of the Christian leaders is shown in Fig. 2 to illustrate the questions asked and types of answers received. The service paid for the survey responses to be translated into Ali’s native language as Ali did not read English. Translation was used because responses were too detailed for an interpreter to read out in full during the session and for Ali be able to process and retain. The translated survey responses became a key relapse prevention resource at the end of therapy, that Ali could refer to if he was struggling with re-emerging PTSD symptoms. Although translation of the survey had a modest additional financial cost, it was agreed important in supporting his equity of access to all the treatment components.

Figure 2. Example survey response from a Christian leader advising Ali about God’s forgiveness and making amends.

‘Zara’ grew up with a positive sense of herself and a strong sense of right and wrong linked to her faith as a Muslim. However, her self-view was shattered by a road traffic accident where the vehicle she was driving accidentally killed a young child pedestrian who ran out into the road unexpectedly. Consequently, she believed she would be punished by Allah, leading to a high level of shame and distress. During therapy, it was highlighted that Zara was uncertain whether Allah would take into consideration the accidental nature of her actions when judging them. As she knew little about the background of the girl who died, she was very anxious about the child’s life after death and unsure how to move forwards. Therefore, the therapist and Zara collaboratively created a set of questions to ask a Muslim expert, who they invited to join a subsequent therapy session for an interview. Zara defined a Muslim expert as a scholar, someone who studies the Quran, or an Imam, a leader in a Mosque. Figure 3 provides a summary of the questions asked and answers received from an Imam from Sunni Islam, who was also a Muslim scholar.

Figure 3. Summary of Zara’s interview with an Imam regarding questions about Allah’s forgiveness, afterlife and moving forwards from the road traffic accident.

Linking updates to the relevant hotspot

Once updating information has been identified for a hotspot, the updates are integrated back into the original trauma narrative. This can be done by the patient recalling and emotionally reliving the hotspot in their mind’s eye, whilst simultaneously reminding themselves of the updating information, or reading the hotspots aloud with the updates within the narrative. Updated hotspot charts are usually generated beforehand to guide this process. Rescripting is often used in addition to convey the cognitive updates and felt sense through imagery. Incorporating specific afterlife beliefs and religious practices into rescripts, can link updating work into a patient’s wider cultural beliefs, increasing the salience of the work. Therapists may often encourage patients to draw imagery rescripts out to consolidate them and create a resource they can refer to in blueprinting.

The session after Zara interviewed the Imam, she was guided by her therapist to generate updates in her own words for her original appraisals on her hotspot chart. The updates were based on Zara’s take-home points from the Imam which she summarised to the therapist (Table 2). The newly gained knowledge that Zara was forgiven was very significant at updating her original appraisals relating to shame and guilt. In addition, discovering that all children go to heaven, no matter their background, was a new revelation for Zara. This led to her rescripting the hotspot image of the child suffering to visualising the young girl now at peace. The majority of Islam is aniconic, which means followers are often opposed to the use of icons or visual images to depict religious figures or any living creatures more generally. Therefore, Zara did not draw her rescript but saw it in her mind’s eye. Zara was encouraged to bring the new rescripted image of the child to mind when she found herself ruminating on the death.

Table 2. Example hotspot chart with updates for Zara, a Muslim woman in a road traffic accident where a young girl was killed (italics indicate updates derived from interviewing the Imam)

Therapists are encouraged to incorporate different modalities into updating work, not just rely on verbal updates, to increase updating effectiveness (see PTSD training video ‘Examples of Updating Memories in CT-PTSD Using Different Modalities’ on https://oxcadatresources.com/). Patients may find playing back a recorded clip of a religious expert teaching a new, helpful perspective linked to an update, or playing a piece of religious music which reminds them of a specific teaching, such as God’s love, useful at this point in updating. These resources can be pre-arranged and set up with the therapist in advance, so they are on hand when bringing the updates to mind.

Zara held open a copy of the Quran on a passage the Imam taught her about forgiveness (39:53) whilst closing her eyes and bringing the hotspot to mind of the child lying in the road. She was then prompted by her therapist to open her eyes and looked down at the passage when she was bringing in the update that Allah is merciful in His judgements. This brought a multi-sensory aspect to the updating work, increasing its power.

Table 3 illustrates how the key learnings from surveying Christian leaders were summarised for Ali. This material was incorporated into his trauma memory updates. In particular, the belief of ‘I am a forgiven man because I accept Jesus’ salvation’ was a powerful antidote to his original belief ‘I am an evil sinner’. As Ali did not speak English, an interpreter was used in all therapy sessions. Therefore, when creating Table 3 together in face-to-face therapy, the interpreter wrote a translation underneath in Ali’s native language. However, when therapy sessions were delivered on video call, the therapist used Google Translate live in session to provide an instant, basic translation for key phrases and pasted this below written English text.

Table 3. Example update summary for Ali after he surveyed Christian leaders

Addressing maintaining behaviours/cognitive strategies

People with PTSD cope with the sense of current threat by adopting behavioural and cognitive strategies, such as avoidance, reassurance seeking, hypervigilance and safety behaviours. These strategies block the reappraisal of distressing beliefs and prevent the processing of memories (Murray and Ehlers, Reference Murray and Ehlers2021). Therefore, the importance of exploring and formulating the function of these strategies is crucial. If these strategies are linked to religious practices and beliefs, it is important the therapist is not questioning of patient beliefs themselves, but curious to understand and support the patient to access expert religious advice where needed. Religious experts can also be useful in advising patients on how to make amends if the patient has done something repairable, or how to move forwards from irreversible events.

Ali’s formulation highlighted how he was using repetitive prayer to seek reassurance from God, which continued to feed his sense of dread. He also described ruminating for hours about how he could make it up to God, which, because it provided no new insights, maintained his sense of himself as ‘beyond redemption’. Additionally, he described watching upsetting press coverage of ongoing conflict in the Middle East to ‘punish’ himself, linked to his self-hate. Instead, Ali learnt from surveying Christian leaders that God forgives anyone who turns to Him for forgiveness. He was surprised to learn that there was nothing he could do to make himself worthy of heaven, other than accepting Jesus (Fig. 2). The Christian leaders explained that Jesus died on the cross to save humanity from their sins, and so by accepting Jesus’ salvation, Ali was worthy of eternal life in heaven on Jesus’ merit. Ali created a series of flash cards to summarise these key messages with supporting Bible quotes he found helpful. Ali was encouraged to read these when he noticed the urge to pray repetitively for forgiveness, watch the news or noticed he was trying to make the past up to God.

Following her interview with the Imam, Zara set herself the homework task of privately praying and asking Allah for forgiveness for the death of the young girl. This was something she had deliberately avoided since the accident and had fed her sense of shame. She reported this to be a very significant act, providing an immense sense of relief and ability to move forwards. The Imam was able to provide confidence that Allah would hear her prayer and forgive her. Furthermore, by asking the Imam for advice on managing nightmares, Zara learnt that she could recite scriptures to protect herself from rumination and refocus on Allah upon awakening, such 2:255 (Ayatul-Kursi) and 2:286. This supported her to manage her distress and strengthened her spiritual life (Fig. 3).

Reclaiming and making amends

Reclaiming previously valued activities after a trauma is a central element to CT-PTSD and starts early in therapy. As therapy and religion work towards the same goals of increasing a person’s sense of identity and encouraging social support networks (Weisman De Mamani et al., Reference Weisman De Mamani, Tuchman and Duarte2009), it is likely to be important to consider someone’s religious life within reclaim work.

Early on in therapy Ali had started working towards leaving the house and going on walks to connect him with his values of nature. However, learning from the Christian leaders that the Bible calls him to rejoice in Jesus’ salvation and celebrate his identify as a forgiven man gave his reclaim work cultural momentum (Isaiah 61:10, ‘I delight greatly in the Lord; my soul rejoices in my God. For He has clothed me with garments of salvation and arrayed me in a robe of His righteousness’). The therapist was then able to explore with Ali how a forgiven man would express his gratitude to God and live day to day off the back of the survey responses. With advice from the Christian leaders, Ali began re-building connections with his Christian community again by gardening for his local church.

When patients hold genuine responsibility for traumatic events, conversations in therapy can focus on how the patient can come to a place of acceptance and move forwards with their lives through focused acts of reparation (Murray and Ehlers, Reference Murray and Ehlers2021). Different religions hold different practices that may be useful to draw on to inform this work. Therefore, consulting religious experts specifically around making amends or moving forwards may be an important part of spiritually competent CT-PTSD for moral injury.

For Zara, her faith as a Muslim gave her practical avenues for expressing her grief for the child and a sense of being able to make amends. After consulting the Imam, she began donating to a road safety charity on behalf of the young girl (Sadaqah) and praying to Allah for forgiveness and mercy for the child, as she believed this would move the child into the highest heaven. These actions helped Zara rebuild a sense of being a caring person with good intentions, despite being in the wrong place at the wrong time the day of the road accident. Zara was able to use these religious practices to care for the child in afterlife.

Introducing the idea

Conversations about religion can be aided by a therapist having a basic insight into a patient’s religion to build therapist confidence asking initial open questions. There are many accessible multi-faith resources for healthcare professionals freely available online, such as NHS Scotland’s (2021) guide (https://learn.nes.nhs.scot/50422/person-centred-care-zone/spiritual-care-and-healthcare-chaplaincy/resources/). However, therapists should be mindful that there are many nuances within religion, and so a position of curiosity, not expertise, must be assumed regardless of a therapist’s knowledge. Using the example of Ali, a therapist may suggest the initial idea of consulting a religious expert by saying: ‘I’m noticing that it plays on your mind a lot that God may judge you for the events that have happened. I’m mindful that I am not an expert in Christianity, and you’ve said there are many things you also don’t know about in your faith. Therefore, I am wondering if it might be helpful for us to get some expert advice here?… In therapy we often seek specialist advise from experts on specific situations. For example, if a Christian patient has questions that relate to their faith, we can organise for a Christian expert to talk to them in therapy, who knows much more than we do about the Bible. Do you think this would be helpful for us to explore some of your fears?… If so, who do you think would be best placed to support us… And how would you refer to this person (Pastor, Priest, Minister, Leader, Vicar, Elder, Parson, Deacon, etc)?’.

Supporting patient apprehensions

If a patient is anxious about seeking expert advice, but agrees it would be important to them, it may be helpful to map out the pros and cons of consulting an expert and explore if there are any ways this could feel more accessible for them. Patients may have blocking beliefs which can be identified and addressed in session. For example, they may have concerns about anonymity or negative responses which could interact with a therapist’s own apprehensions (Murray et al., Reference Murray, Kerr, Warnock-Parkes, Wild, Grey, Clark and Ehlers2022). However, many concerns can be addressed through collaborative agreement about who is approached and how the therapist and patient set this up.

If a patient does not already know a leader or expert within their community that they would feel comfortable approaching, the therapist can offer to use their own contacts to identify someone suitable. In our experience, consulting a religious expert the patient does not know is often more acceptable to patients. This is because the expert is less likely to have mutual connections to the patient, reducing the social risks for the patient. Alternatives could also be considered if the patient is too hesitant about revealing their identity to speak to an expert directly. Instead, sending experts a written survey to complete, or the therapist interviewing the expert with pre-agreed questions and recording it for the patient to watch back, could be considered. Alternatively, the ability to videocall an expert who lives in another geographical area can increase patient confidence, as the risk of bumping into the expert is reduced, or even eliminated.

However, facilitating the patient to speak directly with an expert is often our preferred option. This is because the process allows for the therapist and patient to clarify understanding with the expert in a live discussion, reducing the potential of misunderstanding or uncertainties remaining afterwards. We have also found that hearing a compassionate expert communicate religious teachings around forgiveness or God’s love directly, can bring a warmth to the information that may not be communicated through a written survey answer, helping a patient connect with the felt sense of an update.

Planning questions

Questions are developed collaboratively with the patient in a pre-meeting planning session. It is important that the questions link to the CT-PTSD formulation, and specifically target the idiosyncratic meanings, and associated religious beliefs, driving the sense of current threat. Surveys or interviews may purely consist of questions, or present a brief vignette based on the patient’s experience along with associated questions. Questions are best kept clear, brief and succinct; see the guidance of Murray et al. (Reference Murray, Kerr, Warnock-Parkes, Wild, Grey, Clark and Ehlers2022) on designing CBT surveys. However, interviewing an expert ‘live’ also gives opportunity to clarify the information and opinions as they are discussed, and ask ad hoc follow-up questions as the discussion grows.

Searching for a religious expert

NHS Trusts usually have a chaplaincy service where trained religious leaders from a range of faiths are available to support patients with spiritual struggles. Within NHS Trusts, chaplains are usually trained in pastoral care, giving them skills in supporting people with their emotional wellbeing, as well as spiritual. Alternatively, a therapist can ask colleagues or friends from the same religious background to the patient if they are able to recommend an expert, particularly one that would be sensitive and caring to a patient in distress. Minimal information needs to be disclosed when searching for an expert to protect patient confidentiality. For example, ‘I am working with a Christian patient who has some questions related to their mental health that they would like to ask a Christian leader. As I know you belong to a Christian community, I was wondering if you would be able to recommend anyone who might be willing to speak to my patient as a one-off? We’re looking for someone who would be sensitive to mental health difficulties’.

When searching for an expert, we recommend the therapist agrees in advance with the patient any criteria. For example, would the patient be open to hearing from any expert within their religion, or does the expert need to align with the same denomination or sect as the patient? In our experience of this, the importance is therapist curiosity. For example, when working with Zara: ‘I’m mindful you know a lot more than I do about Islam, so I’m going to need your guidance. Who do you think would be best placed to answer our questions?… If we found someone willing to talk to us, would you want them to be from a certain sect, as I know there are often different groups within religions that differ from one another?’.

Once a therapist has identified a willing expert to interview, we generally recommend the therapist meets with them individually in advance to talk through the rationale, session plan and address any concerns on their part. This helps establish that the expert feels confident answering the types of questions the patient has highlighted, and the therapist feels satisfied the expert will be sensitive to the confidential nature of the conversation and the emotive impact on the patient. To do this the therapist will need to gain consent from the patient to share the patient’s background with the expert to establish their suitability. In our experience, investing time to find and prepare suitable experts increases the likelihood of a helpful and successful encounter, albeit requiring some additional therapist time in the short term. Over time therapists can build up a ‘bank’ of experts they have worked alongside, reducing the preparation time needed in the long term. With the patient’s agreement, it may be useful for the therapist to share some basic psychoeducation with the expert about what PTSD is and what CT-PTSD entails (information sheets can be found at https://oxcadatresources.com under PTSD therapy materials). This enables the expert to appreciate the context of their involvement.

In addition, it is crucial the therapist is respectful when communicating with religious experts and tries to schedule meetings around spiritual practices, such as prayer times or religious services. It may also be useful to gain the expert’s prior consent to record the interview with the patient if the patient would like to refer to the recording afterwards as a resource. In our experience, a patient may not be able to take in all the information they are given in an interview. Therefore, being able to play the recording back afterwards allows them to maximise learnings from the conversation. Furthermore, we have found that patients often find great reassurance and comfort in the words of a religious expert. Therefore, having a recording the patient can play back often becomes a useful resource they are able to refer to, for example when updating hotspots and as a blueprint resource.

Difference and the therapeutic relationship

Everyone differs in a range of ways, from visible to invisible difference, from voiced to unvoiced differences (Burnham, Reference Burnham and Krause2012). However, the multiple parts of our identity (such as gender, ethnicity, sexuality and religion) intersect to create a substantially unique viewpoint and experience of the world for each of us (Butler, Reference Butler2017; Collins, Reference Collins2000). For example, two Christian patients, one white British man and one black African woman, will have different social and political experiences of living in the UK as a Christian. Therefore, although this article has focused solely on the dimension of religion, each patient and therapist will bring to therapy a unique positioning more nuanced than ‘religious’ or ‘non-religious’ with multiple, intersecting dimensions. Acknowledging these differences between a therapist and patient’s multiple identities, and giving each other permission to correct misunderstandings, can help foster a collaborative therapeutic relationship where religious beliefs can be respectfully explored.

Approaching these discussions can be understandably anxiety-provoking for therapists, and where there are constraints on time and sessions, they may feel the urge to rush or omit this process. Despite this, investing a little extra time to explore differences of viewpoint often enhances the collaborative alliance, and can make therapy more efficient and effective (Naz et al., Reference Naz, Gregory and Bahu2019). Below are some ideas for how therapists may open these conversations with a patient and invite their feedback:

• • I have been holding in mind our work and I am mindful we are from different backgrounds and different in terms of gender/ethnicity/culture and religious experiences [insert relevant other differences]…

• • Therefore, I know I will be likely to make incorrect assumptions, mistakes or mis-interpret things you might say at times. When I do, it’s important you feel you can correct me so we can work together. Although, I have knowledge about PTSD, only you have lived your experiences and so your knowledge is really important…

• • I wonder have I got anything wrong already?… Have there been any times so far in our therapy work when I have misunderstood your cultural or religious views?…

• • Do you think there have been any times when you have misunderstood me?…

• • At times I may ask questions, not because I have a specific opinion, but because I am curious if there are any other perspectives we should consider that might be important. However, please do interrupt me if you think we aren’t going in a helpful direction…

Therapist personal beliefs

CBT therapists often report discomfort in incorporating religion into therapeutic work (Rosmarin et al., Reference Rosmarin, Green, Pirutinsky and McKay2013). This is understandable considering that they bring to their work a range of personal religious beliefs, assumptions and experiences, ranging from negative to positive, which may or may not agree with a patient’s. However, spiritually competent therapy can be increased through education and support (Rosmarin et al., Reference Rosmarin, Green, Pirutinsky and McKay2013). Therefore, the importance of supervision, where therapists can recognise and reflect on their own belief systems and intersecting identities, can enable a therapist to remain curious and patient-centred when discussing religion, regardless of therapist personal beliefs. Exercises such as cultural genograms (Shellenberger et al., Reference Shellenberger, Dent, Davis-Smith, Seale, Weintraut and Wright2007) or Salient Circles (Buchanan, Reference Buchanan2020) can be useful aids for this. Below are some suggested questions that a therapist may find useful to explore in supervision or private reflection to aid self-reflexivity, developed from Butler (Reference Butler2017):

• • What are your intersecting identities, and how does religion feature in these?

• • Which identities are often present in therapy? Which are more silent? And does this differ in supervision?

• • What is unspoken? Why might this be? What shuts down our curiosity about our patient’s religious beliefs?

• • What privileged positions do we hold that may silence our patients?

• • What viewpoints do you hold that could be seen as unfavourable or threatening by your patients?

Consistent evidence suggests that religion-adapted psychotherapy protocols can be as effective (Lim et al., Reference Lim, Sim, Renjan, Sam and Quah2014), or even more effective than standard protocols (Anderson et al., Reference Anderson, Heywood-Everett, Siddiqi, Wright, Meredith and McMillan2015). Of note, this effect appears to be independent of the therapist’s own religious or spiritual beliefs (de Abreu Costa and Moreira-Almeida, Reference de Abreu Costa and Moreira-Almeida2022). This challenges the misconception that an atheist, agnostic or therapist of a different religion to a patient is unable to deliver spiritually competent CT-PTSD.