CBT Methods for Trauma

Comparative Benefits of Cognitive and Behavioural Therapies in the Treatment of Complex Trauma

I. Conceptualizing Complex Trauma (CPTSD)

The landscape of trauma-related psychological distress has evolved significantly, with increasing recognition of presentations that extend beyond the traditional boundaries of Post-Traumatic Stress Disorder (PTSD). Complex Post-Traumatic Stress Disorder (CPTSD) has emerged as a diagnostic entity to capture the multifaceted and pervasive impact of certain types of traumatic experiences, particularly those that are prolonged, repeated, or occur within interpersonal contexts where escape is difficult or impossible. Understanding CPTSD, its distinction from PTSD, and its core features is paramount for tailoring effective therapeutic interventions.

A. Defining Complex Trauma: Distinguishing from PTSD

Complex PTSD (CPTSD) represents a more encompassing constellation of symptoms than those traditionally associated with Post-Traumatic Stress Disorder (PTSD). While PTSD, as defined by frameworks like the ICD-11, involves core symptoms such as reliving the traumatic event (e.g., flashbacks, nightmares), active avoidance of trauma-related reminders (thoughts, feelings, people, places), and a persistent sense of current threat manifesting as hyperarousal and heightened reactivity 1, CPTSD includes these PTSD symptoms but also mandates the presence of additional, severe, and persistent difficulties. These additional features primarily involve challenges in managing emotions, pervasive feelings of worthlessness, and significant disturbances in relating to others, often leading to withdrawal or a sense of profound distance.1

The genesis of the CPTSD concept is rooted in observations of individuals who endured prolonged and severe interpersonal victimisation, such as childhood physical or sexual abuse, or experiences like being a prisoner of war.4 These contexts often involve a loss of control, betrayal by trusted individuals, and a shattering of fundamental assumptions about safety and human connection. Judith Herman's seminal work in 1992 highlighted the notion of "complex trauma" to describe the array of symptoms following such chronic, repetitive, or prolonged traumatic experiences, with a central feature being a sense of captivity where escape from ongoing trauma is perceived as impossible.6 Her description encompassed PTSD symptoms alongside issues like somatisation, dissociation, affect dysregulation, and relational difficulties.6

However, a notable evolution in the diagnostic conceptualisation of CPTSD, particularly within the ICD-11, has been a shift from a strict requirement for a specific type of trauma exposure (e.g., prolonged, early-life, interpersonal) to a primary emphasis on the resultant symptom profile.4 While CPTSD is indeed more likely to develop following chronic, repetitive, or sustained trauma from which escape is difficult or impossible 5, the ICD-11 definition prioritises the presence of the core PTSD symptoms plus the specific Disturbances in Self-Organization (DSO).4 This symptom-based focus means that, theoretically, an individual could develop CPTSD following a single, extremely horrific event if it leads to the full spectrum of symptoms, or conversely, experience prolonged trauma but only meet criteria for PTSD if the DSO features are not significantly and persistently present. This approach aims to enhance diagnostic consistency for research and clinical practice but necessitates a thorough assessment of DSO symptoms that goes beyond merely documenting the trauma history. It also clarifies that "complex trauma" (the nature of the experience) and "Complex PTSD" (the clinical disorder) are related but distinct concepts.2

The understanding of what constitutes a "complex" trauma history has also broadened. The complexity of an individual's trauma exposure is considered to increase with factors such as the repetition and prolongation of traumatic events, their interpersonal and intentional nature (which often involves betrayal and violation of trust), the transgression of deeply held moral or ethical principles, and their occurrence early in life, impacting multiple developmental stages.8 Furthermore, there is growing recognition that psychological trauma, such as sustained emotional abuse or neglect, can result in levels of distress and impairment comparable to, or even exceeding, those caused by physical or sexual trauma.8 This challenges narrower definitions of trauma that historically prioritized events involving actual or threatened death or serious injury, and underscores the importance of assessing a wide spectrum of adverse experiences. The subjective experience of extreme threat, horror, and helplessness, particularly within damaging interpersonal relationships, can be profoundly traumatogenic and contribute to a CPTSD presentation.

B. Diagnostic Frameworks: ICD-11 and DSM-5 Perspectives

The two primary diagnostic manuals used globally, the World Health Organization's International Classification of Diseases, 11th Revision (ICD-11), and the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5), conceptualize and classify trauma-related disorders, particularly CPTSD, differently.

The ICD-11 formally recognizes CPTSD (diagnostic code 6B41) as a distinct clinical entity, separate from PTSD.2 To receive a CPTSD diagnosis under ICD-11, an individual must meet all the diagnostic criteria for PTSD. These PTSD criteria in ICD-11 are more narrowly defined than in DSM-5, focusing on three core clusters: 1) Re-experiencing the trauma in the here and now; 2) Deliberate avoidance of traumatic reminders; and 3) Persistent perceptions of heightened current threat (hyperarousal/reactivity).2 In addition to these PTSD symptoms, a diagnosis of CPTSD requires evidence of severe and persistent problems in three areas collectively termed Disturbances in Self-Organization (DSO): affect dysregulation, negative self-concept, and disturbances in relationships.2

In contrast, the DSM-5 does not include CPTSD as a separate diagnostic category.2 Instead, the DSM-5 working group opted to expand the criteria for PTSD to encompass some of the symptoms historically associated with complex trauma.3 These additions include symptoms such as persistent and exaggerated negative beliefs or expectations about oneself, others, or the world; persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individual to blame himself/herself or others; persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame); markedly diminished interest or participation in significant activities; feelings of detachment or estrangement from others; persistent inability to experience positive emotions; irritable behavior and angry outbursts; and reckless or self-destructive behavior.4 The rationale for this approach in DSM-5 included the high empirical bar required for introducing new diagnostic categories and the perspective that many symptoms previously described under labels like DESNOS (Disorders of Extreme Stress Not Otherwise Specified) were often part of the core PTSD symptom constellation or could be adequately captured by a diagnosis of PTSD in combination with a personality disorder, such as Borderline Personality Disorder (BPD).4

This divergence in diagnostic approaches between ICD-11 and DSM-5 has significant implications. An individual's diagnosis, and consequently the perceived focus of their treatment needs, can differ depending on which diagnostic system is employed.2 For instance, a patient might meet criteria for CPTSD under ICD-11 due to prominent DSO symptoms alongside PTSD features, but under DSM-5, they might only receive a PTSD diagnosis, perhaps with a dissociative subtype or with notations of associated features. This discrepancy poses challenges for research synthesis, as studies using DSM-5 criteria for PTSD may include a heterogeneous group of individuals, some of whom would meet ICD-11 CPTSD criteria, while ICD-11 PTSD is a more narrowly defined construct. This makes direct comparison of treatment efficacy studies and the generalization of findings across different diagnostic frameworks problematic. Clinically, an ICD-11 CPTSD diagnosis explicitly directs attention towards addressing the DSO symptoms as core components of the disorder, whereas a DSM-5 PTSD diagnosis, even with its expanded criteria, might not inherently emphasize these pervasive self-organizational difficulties to the same degree. While the DSM-5's broadening of PTSD criteria aimed to capture some CPTSD features 4, there is a concern that this approach may risk under-emphasizing the profound and distinct nature of severe DSO. If these disturbances are viewed merely as associated features of PTSD rather than integral to a distinct syndrome, therapeutic interventions might predominantly focus on the core PTSD symptoms (re-experiencing, avoidance, hyperarousal), potentially leaving significant areas of impairment related to affect regulation, self-concept, and relational capacities inadequately addressed for those who would meet criteria for the full CPTSD syndrome under ICD-11.

C. The Centrality of Disturbances in Self-Organization (DSO)

Disturbances in Self-Organization (DSO) are the cornerstone of the ICD-11 CPTSD diagnosis, representing the pervasive impact of complex trauma on an individual's fundamental sense of self, their capacity to manage emotional states, and their ability to form and maintain healthy relationships.2 These are not merely associated features but are considered core, defining characteristics that differentiate CPTSD from PTSD. The ICD-11 delineates three specific clusters of DSO, all of which must be significantly and persistently present:

1. Affect Dysregulation: This cluster encompasses a range of difficulties in managing emotional experiences. It can manifest as heightened emotional reactivity, where individuals experience intense emotional responses to even minor stressors, or conversely, as emotional numbing, particularly an inability to experience pleasure or positive emotions.2 Other manifestations include violent outbursts, reckless or self-destructive behaviors (which may serve as attempts to regulate overwhelming emotions or to feel something in the face of numbness), and dissociative symptoms that emerge under conditions of stress.4 These difficulties reflect a compromised ability to modulate emotional intensity, duration, and expression in an adaptive manner.

2. Negative Self-Concept: This involves persistent and pervasive negative beliefs about oneself. Individuals with this DSO feature often see themselves as diminished, defeated, or fundamentally worthless.2 These beliefs are typically accompanied by profound and pervasive feelings of shame, guilt, or failure, often directly related to the traumatic experience(s).4 For example, survivors may feel intensely guilty for not having escaped the traumatic situation, for not having prevented harm to themselves or others, or may internalize the perpetrator's denigration, leading to a core sense of being "bad" or "damaged".5 This negative self-view colors their interpretation of current experiences and their expectations for the future.

3. Relational Difficulties: This cluster refers to persistent problems in sustaining relationships and in feeling emotionally close to others.2 Manifestations can be varied: some individuals may consistently avoid relationships, deride them, or show little interest in social engagement. Others may enter into relationships, sometimes intensely, but struggle significantly to maintain them or to experience sustained emotional intimacy and trust.4 These difficulties often stem from betrayal, violation, or profound insecurity experienced in past interpersonal traumas, leading to problems with trust, boundary setting, and vulnerability in subsequent relationships.

The inclusion of these specific DSO symptoms in the ICD-11 CPTSD criteria was based on empirical evidence from field trials, their mapping onto earlier clinical conceptualizations such as "Enduring Personality Change After Catastrophic Experience" (EPCACE), and their strong association with higher levels of functional impairment.4 The presence of these DSO symptoms typically signifies a more severe clinical presentation and greater overall functional impairment compared to PTSD alone.6 This implies that CPTSD may necessitate more intensive, longer-duration, or multicomponent therapeutic approaches that specifically target these foundational disturbances in self-organization, beyond the processing of specific trauma memories. Therapies aiming to treat CPTSD effectively must therefore extend beyond addressing re-experiencing, avoidance, and hyperarousal to foster emotional regulation capacities, reconstruct a more positive and integrated self-concept, and build skills for healthier interpersonal functioning.

To further clarify these distinctions, Table 1 provides a comparative overview.

Table 1: Differentiating PTSD and Complex PTSD (CPTSD)

Feature

PTSD (ICD-11)

CPTSD (ICD-11)

PTSD (DSM-5)

Typical Trauma Antecedents

Any extremely threatening/horrific event(s)

Most commonly prolonged/repetitive events from which escape is difficult/impossible (e.g., chronic abuse, torture) 5

Exposure to actual/threatened death, serious injury, or sexual violence (direct, witnessed, learned about, or repeated/extreme exposure to aversive details) 3

Core PTSD Symptom Clusters

1. Re-experiencing in the here & now<br>2. Avoidance of reminders<br>3. Persistent sense of current threat

All three ICD-11 PTSD symptom clusters must be met.

1. Intrusion symptoms<br>2. Persistent avoidance<br>3. Negative alterations in cognitions and mood<br>4. Marked alterations in arousal and reactivity

Disturbances in Self-Organization (DSO)

Not required for diagnosis.

Required for diagnosis; all three clusters must be present:<br>1. Affect Dysregulation<br>2. Negative Self-Concept<br>3. Relational Difficulties

Not a formal diagnostic component, though some symptoms in "Negative alterations in cognitions and mood" and "Alterations in arousal and reactivity" overlap (e.g., negative self-blame, irritability, self-destructive behavior).4

Additional DSM-5 PTSD Symptoms

N/A

N/A

Includes: erroneous self-blame, persistent negative emotional state, detachment, inability to experience positive emotions, irritable/aggressive behavior, reckless/self-destructive behavior.4

Diagnostic Status

Separate diagnosis.

Separate diagnosis, requiring fulfillment of PTSD criteria plus DSO criteria.

Single PTSD diagnosis; CPTSD-like features may be captured within the broader PTSD criteria or as associated features/comorbidities (e.g., with BPD).2

II. Therapeutic Landscape for Complex Trauma: An Overview of Cognitive and Behavioural Approaches

The treatment of complex trauma necessitates a nuanced understanding of its pervasive effects, particularly the Disturbances in Self-Organization (DSO). Cognitive and Behavioural Therapies (CBTs) offer a range of principles and techniques that can be adapted and applied to address the multifaceted challenges faced by individuals with CPTSD.

A. Core Principles of Cognitive and Behavioural Interventions in Trauma

Cognitive Behavioural Therapy, as a broad therapeutic paradigm, operates on the fundamental principle that psychological distress is often maintained by interconnected patterns of unhelpful thoughts, distressing feelings, and maladaptive behaviours.10 The core aim of CBT is to identify these current problems and symptoms and to facilitate change by modifying these dysfunctional patterns.11 A central tenet is that alterations in one domain (e.g., thinking) can lead to positive changes in the others (e.g., emotional regulation and behaviour).11

Key therapeutic strategies employed within CBT frameworks include:

• Cognitive Restructuring: This involves teaching individuals to recognize their cognitive distortions—biased or unhelpful ways of thinking—that contribute to their distress. Once identified, these thoughts are critically re-evaluated in light of evidence and alternative, more balanced perspectives are developed.10

• Behavioural Activation and Exposure: CBT often encourages individuals to gradually face situations, memories, or emotions that they fear and have been avoiding. This exposure helps to disconfirm negative predictions and reduce avoidance behaviours.10 Behavioural activation focuses on increasing engagement in positive and rewarding activities.

• Skills Training: Clients may learn specific skills to manage their difficulties, such as problem-solving techniques for navigating challenging situations, relaxation and grounding techniques to manage physiological arousal and distress, and strategies for improving interpersonal interactions (e.g., assertiveness, communication skills).10

• Understanding Motivations: Gaining a better understanding of one's own behaviour and the behaviour and motivations of others is also a component.10

A hallmark of CBT is its collaborative nature; the therapist and client work together to develop a shared understanding of the problem and a tailored treatment strategy.10 Furthermore, CBT places a strong emphasis on empowering individuals to become their own therapists. This is fostered through in-session exercises and practical "homework" assignments designed to help clients practice and generalize learned coping skills in their daily lives, thereby enabling them to independently manage their thoughts, emotions, and behaviours more effectively over time.10 While historical information is gathered, the primary focus of CBT is typically on current life difficulties and moving forward to develop more adaptive coping mechanisms.10

When applied to trauma, these core principles are adapted to address the specific impact of traumatic experiences. For instance, cognitive restructuring might focus on trauma-related appraisals of danger, self-blame, or distorted beliefs about the world's safety. Exposure techniques are central to many trauma-focused CBTs, helping individuals process traumatic memories and reduce trauma-related fear and avoidance. While these general CBT principles are highly relevant to CPTSD, the profound and pervasive nature of the difficulties, especially the DSO symptoms like deeply ingrained negative self-concept stemming from chronic abuse, severe affect dysregulation, and entrenched relational avoidance, often necessitates more intensive, nuanced, and potentially longer-term application of these principles compared to less complex, single-event PTSD presentations. For example, challenging a core belief of inherent worthlessness developed over years of childhood maltreatment is a qualitatively different and more complex therapeutic task than challenging a specific fear-based thought related to a one-time accident.

B. Rationale for Tailored Approaches in CPTSD

The distinct clinical presentation of CPTSD, characterized by core PTSD symptoms compounded by significant and persistent Disturbances in Self-Organization (DSO) – namely affect dysregulation, negative self-concept, and relational difficulties – provides a strong rationale for therapeutic approaches that are specifically tailored or adapted to its complexities.6 Standard treatments for PTSD, while effective for many, may not sufficiently address the breadth and depth of impairment seen in CPTSD, particularly when the trauma history is chronic, repeated, or began early in life.6

One primary reason for tailoring treatment is the recognition that DSO symptoms themselves can impede engagement in, and benefit from, traditional trauma-focused interventions that heavily rely on direct processing of traumatic memories. For example, severe affect dysregulation can make it difficult for individuals to tolerate the intense emotions often evoked during exposure-based therapies.7 Similarly, profound negative self-concept can lead to feelings of hopelessness or unworthiness of healing, undermining motivation and therapeutic progress. Significant relational difficulties can also compromise the development of a secure and trusting therapeutic alliance, which is foundational to any effective therapy, especially trauma work.7 This has led to the development and advocacy of phase-based treatment models for CPTSD.12 These models typically propose an initial phase focused on establishing safety, building affect regulation and interpersonal skills (stabilization), before proceeding to a phase of direct trauma memory processing, and then a final phase of reintegration and consolidating gains.7 The underlying premise is that a certain level of stability and coping capacity is necessary to safely and effectively engage with traumatic material.

However, the necessity and optimal structure of phase-based approaches remain a subject of ongoing discussion and research. Some experts and emerging evidence suggest that a lengthy, separate stabilization phase might unnecessarily delay access to effective trauma-focused components that directly address the root of the symptoms.7 Recent studies have indicated that individuals with CPTSD can indeed benefit from standard trauma-focused treatments like Prolonged Exposure (PE) or Eye Movement Desensitization and Reprocessing (EMDR), sometimes achieving comparable gains to those with PTSD alone, and that phase-based approaches are not always demonstrably superior.7 This suggests that the severity of DSO symptoms and the individual's existing coping resources are critical factors influencing treatment choice and sequencing. A "one-size-fits-all" approach, even among those diagnosed with CPTSD, is unlikely to be optimal.

The work of Cloitre and colleagues, for instance, demonstrated that augmenting CBT with explicit skills training in emotion regulation resulted in greater treatment gains and lower dropout rates for individuals with CPTSD secondary to childhood adversity, compared to standard CBT.12 This finding supports the idea of integrating skills training with trauma-focused work, rather than strictly separating them into distinct phases, which may be a particularly beneficial model for many individuals with CPTSD. Such an approach acknowledges the need to build regulatory capacities while simultaneously (or in close succession) addressing the traumatic memories that often fuel dysregulation.

Furthermore, the complexity of CPTSD often involves a high potential for dissociation and severe emotional dysregulation during therapy, necessitating careful attention to treatment pacing, the therapeutic alliance, and the use of specific techniques to manage these challenges, prevent re-traumatization, and ensure patient safety.13 Therefore, the rationale for tailored approaches in CPTSD is not simply about whether to adapt treatment, but how to do so most effectively—be it through integrated skills components, flexibly applied phased approaches, or specifically adapted trauma-focused techniques that are sensitive to the unique challenges of this population. The central goal is to address both the core PTSD symptoms and the pervasive DSO in a way that is safe, tolerable, and leads to meaningful and lasting improvement in functioning and quality of life.

III. In-Depth Analysis of Key Cognitive and Behavioural Therapies for CPTSD

A variety of cognitive and behavioural therapies have been developed or adapted to address the challenges of trauma. For CPTSD, the key consideration is how effectively these therapies target not only the core PTSD symptoms but also the pervasive Disturbances in Self-Organization (DSO). Table 2 provides an overview of the therapies discussed in this section.

Table 2: Overview of Cognitive and Behavioural Therapies for Complex Trauma

Therapy Name

Theoretical Basis (brief)

Key Techniques/Components

Primary Therapeutic Targets in CPTSD

Noted Adaptations for CPTSD

Cognitive Processing Therapy (CPT) 20

Cognitive theory; modification of trauma-related maladaptive schemas and "stuck points"

Psychoeducation, written trauma accounts (optional), Socratic questioning, challenging stuck points (assimilation/over-accommodation) related to self/others and trauma themes (safety, trust, power, esteem, intimacy)

PTSD core symptoms, negative self-concept (self-blame, shame), maladaptive beliefs about trust and safety.

Developmentally adapted CPT (D-CPT) for youth 22; consideration of CPT-Cognitive (no written account) for high dissociation.23

Trauma-Focused CBT (TF-CBT) 24

CBT principles adapted for trauma in youth; phase-based; addresses cognitive, affective, behavioural sequelae.

Psychoeducation, Parenting skills, Relaxation, Affective modulation, Cognitive coping/processing, Trauma narrative, In-vivo exposure, Conjoint sessions, Enhancing safety (PRACTICE).

PTSD core symptoms in youth, affect dysregulation, negative self-concept (trauma-related cognitions), behavioural problems, parent-child relationship.

Longer treatment, extended stabilization phase for affect/behavioural regulation, addressing multiple trauma themes, timeline/life narrative for youth with complex trauma.24

Prolonged Exposure (PE) 26

Emotional Processing Theory; habituation to trauma-related fear structures.

Psychoeducation, imaginal exposure (revisiting trauma memory), in-vivo exposure (confronting avoided situations/cues), processing of exposures.

PTSD core symptoms (primarily fear-based re-experiencing, avoidance, arousal).

Often combined with skills-based approaches (e.g., STAIR) for complex cases, though evidence for superiority of phased approach is mixed.7 Enhanced support in some settings.15

Eye Movement Desensitization and Reprocessing (EMDR) 27

Adaptive Information Processing (AIP) model; processing of inadequately stored trauma memories.

Eight-phase protocol including history taking, preparation (resourcing), assessment of target memory, desensitization with bilateral stimulation, installation of positive cognition, body scan, closure, re-evaluation.

PTSD core symptoms, negative self-concept (via cognitive restructuring/positive cognition installation), affect dysregulation (by reducing distress linked to memories), dissociation.

Longer treatment for multiple traumas 29; careful history taking and potential initial focus on dissociation 29; resource enhancement in preparation phase.

Dialectical Behavior Therapy (DBT) / DBT-PTSD 30

Biosocial theory; dialectic of acceptance and change; targets emotion dysregulation and maladaptive coping.

Skills training (Mindfulness, Distress Tolerance, Emotion Regulation, Interpersonal Effectiveness), individual therapy, phone coaching, consultation team. DBT-PTSD integrates trauma exposure.

Affect dysregulation, interpersonal difficulties, negative self-concept (indirectly via skills, directly in DBT-PTSD), self-harm, dissociation, PTSD core symptoms (in DBT-PTSD).

DBT-PTSD is specifically designed for complex trauma, often with BPD features, integrating skills with exposure in a phase-based manner.31

Acceptance and Commitment Therapy (ACT) / TF-ACT 33

Relational Frame Theory; increasing psychological flexibility.

Acceptance, Cognitive Defusion, Present Moment Awareness, Self-as-Context, Values clarification, Committed Action. TF-ACT integrates trauma-specific psychoeducation and processing.

Experiential avoidance, cognitive fusion, lack of values clarity, inaction. Indirectly targets affect dysregulation, negative self-concept, relational issues by changing relationship to internal experiences and promoting valued living. PTSD core symptoms (in TF-ACT).

TF-ACT adapts core ACT processes to trauma survivors, often in phases (Living in Present, Healing Past, Building Future).33 Focus on values-based living despite symptoms.

Schema Therapy (ST) 36

Integrative (CBT, attachment, Gestalt); healing Early Maladaptive Schemas (EMS) and dysfunctional Schema Modes from unmet childhood needs.

Limited Reparenting, Imagery Rescripting, Chair Work (mode dialogues), cognitive/behavioural techniques, identifying EMS and modes.

Negative self-concept (core schemas like Defectiveness, Abandonment), affect dysregulation (Child/Parent modes), relational difficulties (interpersonal schemas/modes), dissociation (Detached Protector mode), PTSD core symptoms (via imagery/EMDR integration).

Well-suited for adverse childhood experiences/CPTSD.36 Early trauma processing with focus on emotional needs. Can integrate EMDR. Techniques for grounding/managing arousal.36

A. Cognitive Processing Therapy (CPT)

Cognitive Processing Therapy (CPT) is a well-established, manualized cognitive behavioural therapy specifically developed for the treatment of PTSD and its associated symptoms. Its theoretical underpinnings and therapeutic strategies are particularly relevant when considering the cognitive disturbances often central to complex trauma presentations.

1. Theoretical Foundations and Core Therapeutic Strategies

CPT is rooted in cognitive theory, which posits that individuals develop schemas—organized patterns of thought and belief about themselves, others, and the world—to make sense of their experiences and to predict and control future events.11 These schemas particularly pertain to fundamental themes such as safety, trust, power/control, esteem, and intimacy.21 Traumatic events can profoundly disrupt these pre-existing schemas or lead to the formation of maladaptive new ones. According to CPT theory, PTSD symptoms are maintained when these disruptions manifest as inaccurate or unhelpful self-statements, termed "stuck points," which interfere with the natural recovery process following trauma.21

CPT identifies two primary types of stuck points that perpetuate PTSD 21:

• Assimilation: This occurs when information about the traumatic event is distorted or altered to fit with pre-existing, often rigid, beliefs. For example, an individual with a pre-existing belief that "bad things only happen to bad people" might assimilate the experience of an assault by concluding, "I must have done something to deserve this," thereby preserving their worldview at the cost of intense self-blame.

• Over-accommodation: This involves an extreme and often generalized alteration of existing beliefs based on the new trauma information. For instance, a survivor of an assault perpetrated by one individual might over-accommodate by concluding, "All people are dangerous," or "I can never be safe anywhere."

Both assimilation and over-accommodation represent maladaptive ways of integrating the trauma. The therapeutic goal of CPT is to facilitate accommodation, which involves a more balanced and realistic modification of existing belief systems to integrate the new and often discrepant trauma information without resorting to extreme distortions.21 An example of an accommodated belief might be, "Most people are generally good, but some individuals are dangerous, and I was unfortunate to encounter one; it wasn't my fault, and I can learn to be safer while still engaging with the world."

The core therapeutic strategies of CPT are designed to help patients identify, evaluate, and modify these stuck points. This is typically achieved over 12 to 16 sessions.20 Key techniques include 11:

• Psychoeducation: Providing information about PTSD, common reactions to trauma, and the CPT model.

• Identifying Stuck Points: Helping patients recognize their specific stuck points and the emotions connected to them.

• Socratic Questioning and Cognitive Restructuring: Therapists use guided questioning to help patients examine the evidence for and against their stuck points, explore alternative perspectives, and develop more balanced and helpful thoughts.

• Trauma Narrative (optional in some CPT versions): Some versions of CPT include writing a detailed account of the traumatic event to help process emotions and identify stuck points embedded in the memory.16 CPT-Cognitive (CPT-C) omits the written trauma account.23

• Challenging Maladaptive Beliefs Across Themes: Later sessions focus on applying cognitive restructuring skills to broader themes affected by trauma, such as safety, trust, power/control, esteem, and intimacy.

CPT's focus on these core schemas makes it directly relevant to addressing the cognitive dimensions of negative self-concept (e.g., themes of esteem, self-blame) and some aspects of relational difficulties (e.g., themes of trust, intimacy) that are characteristic of CPTSD. However, its primary mechanism of change is cognitive restructuring. While this can influence emotions and behaviours, CPT may be less directly focused on building specific emotion regulation or interpersonal effectiveness skills compared to other therapies, unless these are explicitly integrated or adapted.

2. Application and Efficacy in Complex Trauma: Impact on PTSD and DSO Symptoms

CPT has a robust evidence base demonstrating its efficacy for PTSD across various populations, with meta-analyses indicating large treatment effects in terms of PTSD symptom reduction and loss of diagnosis.21 Importantly, CPT has also shown effectiveness in populations with histories of multiple traumas, including childhood sexual assault, which are often precursors to CPTSD.21

Research indicates that CPT can lead to improvements in common comorbid symptoms associated with complex trauma, such as depression, suicidal ideation, and dissociation, as well as enhancing functioning across important life domains.21 Its efficacy has also been demonstrated in individuals with comorbid personality disorders, including Borderline Personality Disorder (BPD) 21, a condition that shares features with CPTSD, particularly affect dysregulation and interpersonal difficulties.

Specific to youth, a developmentally adapted version of CPT (D-CPT) was found to be beneficial for abused young patients. A study by Sachser et al. (2017), cited in 22, showed that D-CPT reduced symptoms of disturbances in self-regulation in both youth with probable ICD-11 CPTSD and those without. Both groups exhibited similar rates of linear improvement and treatment response, although the CPTSD group presented with higher symptom severity at baseline.22 This suggests that CPT, when appropriately adapted, can target DSO-like symptoms in younger populations.

In adult populations with complex trauma, particularly those with histories of childhood abuse (CA), CPT has been compared to other active treatments. A significant randomized controlled trial by Bohus, Kleindienst, and colleagues compared DBT-PTSD to CPT for women with CA-related PTSD and co-occurring BPD features. While both therapies were found to be effective in reducing PTSD symptoms, DBT-PTSD demonstrated superiority over CPT at a 9-month follow-up on measures of PTSD severity (Clinician-Administered PTSD Scale - CAPS), borderline symptoms (Borderline Symptom List - BSL-23, which reflects aspects of negative self-concept and affect dysregulation), and psychosocial functioning (Global Assessment of Functioning - GAF).31 This suggests that while CPT is beneficial, for individuals with this specific complex presentation involving significant BPD features, an approach like DBT-PTSD that more explicitly targets emotion regulation and interpersonal skills may yield broader and more sustained functional improvements.

3. Strengths, Limitations, and Management of Clinical Challenges (e.g., dissociation, severe dysregulation)

CPT offers several strengths in the treatment of complex trauma. It has a strong and extensive evidence base for PTSD, including in populations with complex traumatic histories.21 Its structured approach provides a clear framework for therapy, and it directly addresses maladaptive cognitive distortions related to core trauma themes (safety, trust, power/control, esteem, intimacy) which are highly relevant to the DSO symptoms of negative self-concept and aspects of relational difficulties.21 Furthermore, CPT can be effectively delivered in a group format, increasing accessibility.43

However, CPT also has limitations, particularly when applied to the full spectrum of CPTSD. As suggested by the Bohus et al. trial 31, standard CPT may not be as effective as more comprehensive treatments like DBT-PTSD for individuals with severe BPD symptoms or for achieving broader functional gains in the context of CA-related CPTSD. The primary focus of CPT is on cognitive restructuring; it may not sufficiently target severe, deeply embodied affect dysregulation or entrenched maladaptive relational patterns without significant adaptation or augmentation with explicit skills-training components. Some literature suggests that for CPTSD, additional therapeutic strategies beyond standard CBT/CPT are often necessary to fully address DSO symptoms.18

Regarding the management of clinical challenges:

• Dissociation: CPT has been shown to reduce dissociative symptoms.21 However, high baseline levels of dissociation, particularly depersonalization, can negatively predict CPT efficacy.17 Interestingly, one study found that individuals with high levels of depersonalization responded better to standard CPT (which can include a written trauma account) than to CPT-Cognitive (CPT-C, which omits the written account).23 A significant drop in dissociation during the initial stages of treatment is associated with better overall outcomes.17 This suggests that monitoring and perhaps directly addressing dissociation early in CPT could be beneficial.

• Severe Dysregulation: Standard CPT does not have extensive built-in modules for directly teaching emotion regulation skills in the way that therapies like DBT do. For individuals with severe dysregulation, adaptations such as the D-CPT for youth 22, which may incorporate more scaffolding for emotional processing, or the use of adjunctive or alternative approaches like DBT-PTSD, might be necessary to ensure the patient can tolerate and engage with the cognitive work of CPT.

In essence, CPT's focus on "stuck points" related to core life schemas (safety, trust, power, esteem, intimacy) provides a direct avenue for addressing the cognitive underpinnings of negative self-concept and some of the maladaptive beliefs that fuel relational difficulties in CPTSD. By challenging assimilated or over-accommodated beliefs, CPT aims to help individuals develop more balanced and adaptive self-perceptions and worldviews. However, its primary change mechanism is cognitive. For the deeply ingrained emotional dysregulation and complex interpersonal patterns often seen in severe CPTSD, particularly those stemming from extensive childhood maltreatment, cognitive restructuring alone may be insufficient. The comparison with DBT-PTSD 31 suggests that for these highly complex presentations, therapies that explicitly teach skills for managing emotions and navigating relationships, in conjunction with trauma processing, may offer more comprehensive and lasting benefits. This points to the potential value of either augmenting CPT with skills modules or considering alternative, more broadly focused therapies for individuals with prominent DSO features that extend beyond cognitive distortions.

B. Trauma-Focused Cognitive Behavioural Therapy (TF-CBT)

Trauma-Focused Cognitive Behavioural Therapy (TF-CBT) is a highly structured, evidence-based psychotherapy model predominantly designed for children and adolescents who have experienced trauma, including complex trauma. It integrates trauma-sensitive principles with core cognitive and behavioural techniques to address a wide range of trauma-related sequelae.

1. Theoretical Foundations and Core Therapeutic Components (e.g., PRACTICE model for youth)

TF-CBT is a phase-based and components-based intervention.24 It is grounded in cognitive-behavioural principles, attachment theory, developmental neurobiology, and family systems theory, acknowledging the profound impact of trauma on a developing child and the importance of the caregiving system in their recovery.24 The model is structured to be short-term, typically ranging from 8 to 25 sessions, depending on the complexity of the trauma and the child's needs.24

The core components of TF-CBT for youth are often remembered by the acronym PRACTICE 24:

• Psychoeducation and Parenting skills: Educating the child and caregiver about trauma, common reactions, and PTSD. Simultaneously, parenting skills are taught to caregivers to help them support the child, manage their own distress, and improve parent-child interactions.

• Relaxation skills: Teaching the child techniques to manage physiological arousal and anxiety (e.g., deep breathing, progressive muscle relaxation).

• Affective modulation skills: Helping the child identify, understand, and express a range of emotions, and develop skills to manage intense or difficult feelings.

• Cognitive coping and Cognitive processing: Teaching the child to identify and challenge unhelpful or inaccurate thoughts related to the trauma, themselves, and the world (cognitive coping). This is followed by processing specific trauma-related thoughts and beliefs to develop a more adaptive understanding (cognitive processing).

• Trauma Narrative and Processing: Gradually helping the child create a narrative of their traumatic experience(s). This involves recounting the events, thoughts, and feelings associated with the trauma in a safe and supportive environment, allowing for emotional processing and integration of the experience.

• In-vivo Exposure (when needed): If the child avoids specific safe situations, places, or objects that remind them of the trauma and cause significant distress, gradual exposure to these reminders is conducted to reduce avoidance and fear.

• Conjoint child-parent sessions: Bringing the child and caregiver together to share the trauma narrative, improve communication about the trauma, and practice learned skills together.

• Enhancing future safety and Development: Developing safety plans for future potentially risky situations and focusing on consolidating treatment gains to support the child's ongoing healthy development and future well-being.

A critical element of TF-CBT is the active involvement of the non-offending parent or caregiver throughout the treatment process.24 Caregivers receive parallel sessions to learn skills to support their child, manage their own emotional reactions to the child's trauma, and improve parenting practices.

2. Adaptations and Efficacy for Complex Trauma (especially in youth, considering ICD-11 CPTSD)

TF-CBT has demonstrated robust efficacy for youth exposed to diverse, multiple, and complex trauma experiences, including those stemming from interpersonal violence within the family.24 Recognizing that complex trauma often results in more pervasive difficulties, TF-CBT can be adapted to meet these needs 24:

• Treatment Length: For youth with complex trauma, treatment is generally longer, potentially extending from 16-25 sessions or more, compared to the 8-16 sessions typical for less complex presentations.

• Emphasis on Stabilization: A greater proportion of therapy time is dedicated to the initial stabilization phase. This involves an intensified focus on building safety (both physical and emotional), trust in the therapeutic relationship, and developing affective and behavioural regulation skills. This phase might constitute up to half of the total treatment duration for complex cases.

• Sequencing of Skills: For youth with significant affective and behavioural dysregulation, relaxation and coping strategies are often introduced before extensive psychoeducation about trauma, as the latter might initially be perceived as overwhelming.

• Addressing Trauma Themes: Therapists help youth identify and understand underlying maladaptive themes (e.g., "I am damaged," "I can never trust anyone") that may have been reinforced by multiple traumatic experiences.

• Narrative Approach: For multiple or prolonged traumas, creating a timeline or life narrative may be more appropriate and manageable than a single, detailed trauma narrative for one specific event.

• Initial Focus on Safety: In complex trauma cases, establishing safety (including safety planning for ongoing threats) and building a trusting therapeutic relationship are typically the very first components implemented.

A recent naturalistic study by Jensen et al. (2022) specifically examined TF-CBT outcomes for youth meeting ICD-11 criteria for PTSD or CPTSD.45 The findings were promising: youth with CPTSD demonstrated a steeper decline in both PTSD and CPTSD symptoms (which inherently include DSO) compared to youth with PTSD only. Importantly, both groups reported similar levels of PTSD and CPTSD symptoms post-treatment, suggesting TF-CBT is effective in addressing the broader symptom profile of CPTSD in youth. Furthermore, a meta-analytic review indicated that TF-CBT is as effective for child and adolescent PTSD resulting from complex or multiple traumas as it is for PTSD following acute or single-incident trauma.48

3. Impact on PTSD and DSO Symptoms

TF-CBT effectively improves a range of trauma-related outcomes in youth, including core PTSD symptoms (re-experiencing, avoidance, hyperarousal) and achieving loss of PTSD diagnosis.24 It also addresses many other common trauma impacts, such as depressive symptoms, anxiety, and various cognitive and behavioural problems.24

The explicit components of TF-CBT directly target the Disturbances in Self-Organization (DSO) seen in CPTSD:

• Affect Dysregulation: The "Relaxation skills" and "Affective modulation skills" components are specifically designed to enhance emotional regulation capacities.

• Negative Self-Concept: "Cognitive coping" and "Cognitive processing" components help youth identify and challenge trauma-related cognitive distortions about themselves, the world, and their future, thereby addressing negative self-perceptions. The trauma narrative itself helps to re-contextualize experiences and reduce self-blame.

• Relational Difficulties: While not a primary focus in the same way as therapies like DBT, TF-CBT's emphasis on caregiver involvement, improving parent-child communication through conjoint sessions, and enhancing future safety can positively impact the child's relational environment and skills. The development of a secure therapeutic relationship also provides a corrective relational experience.

The Jensen et al. (2022) study provides direct evidence that TF-CBT leads to reductions in the three DSO clusters as part of overall CPTSD symptom improvement in youth, as measured by validated instruments for ICD-11 CPTSD.45

4. Strengths and Limitations

TF-CBT has several strengths:

• It possesses a very strong evidence base for treating PTSD in children and adolescents, including those exposed to complex trauma.24

• The model is structured yet flexible, with clearly defined components that can be tailored and adapted based on the child's developmental level and the complexity of their trauma history.24

• The integral involvement of caregivers is a significant strength, as it addresses the child's systemic environment and equips parents with skills to support their child's recovery.24

• It addresses a broad range of trauma impacts, not limited to core PTSD symptoms, but also encompassing emotional, cognitive, and behavioural difficulties.24

Potential limitations include:

• TF-CBT was primarily developed and researched for children and adolescents. While its principles are broadly applicable, its specific manualized form is less frequently applied to adults under the "TF-CBT" label (though many adult CBT approaches are inherently trauma-focused and share components).

• Some reviews have noted that its efficacy in reducing externalizing behaviour problems or depressive symptoms, while present, may sometimes be less pronounced than its impact on core PTSD symptoms.25

• Ensuring access to and engagement in TF-CBT for highly vulnerable populations, such as children in the care system, can present significant practical challenges.48

In summary, TF-CBT's explicit inclusion of components such as affective modulation, cognitive coping, and enhancing safety directly addresses DSO symptoms, particularly affect dysregulation and aspects of negative self-concept, within its structured and phased approach for youth. Its adaptability, such as the option for an extended stabilization phase for more complex cases, makes it well-suited for the developmental needs of traumatized children and adolescents who often present with the features of CPTSD. The empirical support from studies like Jensen et al. (2022) 45 specifically using ICD-11 CPTSD criteria further solidifies its role as a leading treatment for this population.

C. Prolonged Exposure (PE)

Prolonged Exposure (PE) therapy is a highly researched and manualized form of CBT designed to treat PTSD. Its core mechanism involves confronting trauma-related memories, feelings, and situations that have been avoided.

1. Theoretical Foundations (Emotional Processing Theory) and Core Therapeutic Techniques

PE is grounded in Emotional Processing Theory, developed by Foa and Kozak.26 This theory posits that PTSD develops when traumatic experiences are not adequately processed, leading to the formation of pathological fear structures. These fear structures are composed of representations of the traumatic stimuli, associated responses (physiological, emotional, behavioural), and maladaptive cognitions about the meaning of these stimuli and responses.26 Avoidance of trauma-related cues prevents the activation and modification of this fear structure, thus maintaining PTSD symptoms. PE aims to activate this fear structure and introduce corrective information that disconfirms erroneous associations and meanings, leading to habituation of fear responses and a more integrated, less threatening trauma memory.26

The core therapeutic techniques of PE, typically delivered over 8 to 15 weekly 90-minute sessions, include 11:

• Psychoeducation: Educating the patient about common reactions to trauma, the nature of PTSD, and the rationale for PE, emphasizing how avoidance maintains symptoms.

• Imaginal Exposure: Repeated, detailed recounting of the traumatic memory in the present tense during therapy sessions. This allows the patient to emotionally engage with the memory in a safe environment, promoting processing and habituation.

• In Vivo Exposure: Gradual and systematic confrontation with real-life situations, places, or objects that are feared and avoided due to their association with the trauma, but are objectively safe. Patients create a hierarchy of feared situations and progressively engage in them as homework.

• Processing: Following imaginal exposure, the therapist and patient discuss the emotions, thoughts, and insights that emerged during the exposure, helping to consolidate new learning and challenge maladaptive beliefs.

2. Application and Efficacy in Complex Trauma: Impact on PTSD and DSO Symptoms

PE is one of the most extensively studied treatments for PTSD and is strongly recommended in clinical practice guidelines due to its efficacy across diverse patient presentations.26 While initially developed with a focus on single-incident traumas, research has increasingly explored its applicability to more complex trauma presentations.

Emerging evidence suggests that PE can be effective for individuals meeting criteria for ICD-11 CPTSD. A study comparing PE, STAIR (Skills Training in Affective and Interpersonal Regulation), and SNT (STAIR + Narrative Therapy) found that PE produced greater improvements in DSM-5 PTSD symptoms compared to SNT from pre-treatment to post-treatment, and at 1-year follow-up, PE yielded greater PTSD symptom improvements than both SNT and STAIR.15 Regarding ICD-11 CPTSD symptoms (which include DSO), PE and STAIR both produced greater improvements than SNT at the 1-year follow-up, although reductions in CPTSD symptoms were not significantly different among the three conditions from pre-treatment to immediate post-treatment.15

Other research indicates that individuals with CPTSD can improve by a similar amount to those with PTSD when treated with PE.7 Improvements in CPTSD symptoms were found to be comparable whether individuals were treated with PE alone, STAIR alone, or STAIR combined with PE.7 These findings suggest that the core mechanisms of PE—direct engagement with trauma memories and feared cues—can facilitate reduction in both PTSD and associated DSO symptoms for many individuals with CPTSD. A meta-analysis of PE for PTSD demonstrated large effect sizes when compared to inactive control conditions.51

The strength of PE lies in its direct targeting and modification of the trauma memory and its associated fear structures. While this direct approach can lead to downstream improvements in DSO symptoms for some individuals with CPTSD 7, the therapy's primary mechanisms are less focused on actively building new self-regulation capacities, explicitly restructuring core non-trauma-specific self-beliefs, or teaching new interpersonal skills in the comprehensive way that some other therapies do. This makes its suitability as a standalone treatment for severe CPTSD, particularly without any augmentation or preparatory work, a key area of ongoing clinical debate and research. If DSO symptoms are primarily a consequence of unprocessed trauma memories, then PE's focus on processing these memories should theoretically lead to their resolution. However, if DSO symptoms represent more entrenched developmental deficits or patterns that have become somewhat functionally autonomous from the specific trauma memories, PE alone might be insufficient.

3. Strengths, Limitations, and Management of Clinical Challenges (e.g., dissociation, severe dysregulation)

PE offers several strengths:

• It has a very robust evidence base for reducing PTSD symptoms across a wide range of trauma types and populations.26

• Its mechanisms—direct and systematic exposure to trauma memories and cues—are well-articulated by Emotional Processing Theory and lead to efficient processing of traumatic experiences.

• Emerging evidence supports its efficacy in reducing CPTSD symptoms, including aspects of DSO, for many individuals.7

However, PE also has limitations when considering CPTSD:

• The primary therapeutic targets are fear-based PTSD symptoms. The direct targeting of DSO clusters—particularly negative self-concept beyond trauma-related appraisals, and broader relational patterns—is less explicit compared to therapies like Schema Therapy or DBT.

• Standard PE protocols may be highly challenging for clients with severe pre-existing emotion dysregulation, significant dissociative symptoms, or ongoing safety concerns, potentially leading to higher dropout rates or insufficient engagement if not carefully managed or adapted.5 Some studies evaluating PE have excluded patients with severe behavioural problems or complex dissociative disorders, limiting generalizability to the most complex cases.15

Management of Clinical Challenges:

• Dissociation and Severe Dysregulation: The standard PE protocol itself does not include extensive specific techniques for managing severe dissociation or dysregulation beyond the general distress tolerance inherent in the exposure process and the therapist's skill in pacing and processing. The focus is primarily on processing the trauma, with the expectation that this will lead to downstream improvements in regulation. For individuals with significant difficulties in these areas, a phase-based approach, such as combining STAIR with PE, is often considered to build coping capacities prior to or alongside intensive exposure work.7 However, as noted, the evidence for the superiority of such phased approaches over direct PE for all CPTSD patients is mixed.7 Some PE protocols in specific settings (e.g., residential treatment) may be enhanced with additional staff support for in-vivo work and homework completion.15 If dysregulation or dissociation becomes overwhelming during exposure, therapists typically guide patients to use grounding techniques or temporarily reduce the intensity of the exposure, but the core PE model does not emphasize extensive pre-exposure skills training for these issues.

The fact that STAIR, a skills-based approach focusing on affect and interpersonal regulation, is often studied in conjunction with or as a precursor to exposure therapy for complex trauma populations, suggests a clinical recognition that for some individuals, directly addressing DSO components is necessary to enable engagement with and benefit from the powerful mechanisms of PE.

D. Eye Movement Desensitization and Reprocessing (EMDR)

Eye Movement Desensitization and Reprocessing (EMDR) therapy is a structured psychotherapy that has gained prominence for the treatment of trauma-related disorders, including PTSD and, increasingly, CPTSD.

1. Theoretical Foundations (Adaptive Information Processing) and the Eight-Phase Model

EMDR therapy is guided by the Adaptive Information Processing (AIP) model.28 The AIP model posits that psychological distress, including PTSD symptoms, arises from traumatic experiences that are inadequately processed and stored in memory networks in a dysfunctional way. These unprocessed memories retain their original disturbing emotions, physical sensations, and beliefs, and can be easily triggered by current events, leading to symptoms.28 EMDR aims to facilitate the brain's natural information processing capacities to help integrate these distressing memories into a more adaptive and less disruptive state.27

EMDR therapy follows a standardized eight-phase protocol designed to identify and process these maladaptively stored memories 52:

1. History Taking and Treatment Planning: Gathering the client's history, identifying potential targets for EMDR processing (specific traumatic memories), and developing a treatment plan.

2. Preparation: Establishing a therapeutic alliance, explaining the EMDR process, and teaching the client self-control and stress reduction techniques (e.g., safe place imagery, grounding) to manage emotional distress during and between sessions.

3. Assessment: Activating the target memory by identifying its key components: a vivid image, a negative cognition (NC) about oneself related to the memory, a desired positive cognition (PC), the validity of the PC (VoC scale), current emotions, and the location of physical sensations. Subjective Units of Disturbance (SUD) are rated.

4. Desensitization: The client focuses on the target memory (image, NC, emotion, sensation) while simultaneously engaging in bilateral stimulation (BLS), typically therapist-guided eye movements, alternating auditory tones, or tactile taps. Sets of BLS are repeated until the client's SUD score significantly decreases. New insights, emotions, sensations, or other memories may emerge and are briefly focused on.

5. Installation: Strengthening the desired positive cognition (PC) by pairing it with the original target memory, using BLS until the PC feels fully true (high VoC).

6. Body Scan: The client scans their body for any residual tension or uncomfortable physical sensations while holding the target memory and PC in mind. If present, these sensations are targeted with BLS until resolved.

7. Closure: Ensuring the client is in a state of emotional equilibrium at the end of the session, using self-control techniques if needed. The client is briefed on what to expect between sessions (e.g., continued processing).

8. Re-evaluation: At the beginning of subsequent sessions, previously processed targets are re-evaluated to ensure that treatment effects are maintained and to identify any new targets that may have emerged.

While EMDR is an effective treatment for PTSD, there is ongoing discussion about the precise mechanisms through which BLS contributes to therapeutic change, with some research supporting its importance and other research suggesting it may not be the critical active ingredient.27

2. Application and Efficacy in Complex Trauma (addressing multiple traumatic memories)

EMDR is a strongly recommended first-line treatment for PTSD in adults.53 Numerous meta-analyses and randomized controlled trials (RCTs) have demonstrated its efficacy in reducing PTSD diagnosis, core PTSD symptoms, and associated symptoms like depression and anxiety.28

Increasingly, EMDR is being applied to individuals with CPTSD, including those with histories of early childhood interpersonal trauma.14 The AIP model provides a framework for addressing multiple traumatic memories, as EMDR protocols allow for the systematic targeting and processing of various past adverse life experiences that contribute to current distress.52 The EMDR–Teens–cPTSD study, which included adolescents with ICD-11 CPTSD secondary to childhood abuse, found that three months of EMDR therapy led to significant decreases in PTSD core symptoms, dissociation, depression, anxiety, emotional dysregulation (measured as affective lability), insomnia, and substance use, along with improvements in quality oflife.56 This provides direct evidence for EMDR's utility in a CPTSD-diagnosed youth population.

The AIP model suggests that by processing these multiple contributing memories, they can be integrated into the individual's broader autobiographical narrative in an adaptive way, reducing their ongoing pathogenic influence.53

3. Impact on PTSD and DSO Symptoms

EMDR has a well-documented impact on core PTSD symptoms, including intrusion, avoidance, and hyperarousal.28 Its effects on DSO symptoms are also becoming clearer:

• Affect Dysregulation: By desensitizing traumatic memories, EMDR reduces the emotional distress and physiological arousal associated with them, which can contribute to improved affect regulation.14 The EMDR-Teens-cPTSD study specifically showed significant improvement in emotional regulation (affective lability scores).56 The preparation phase's focus on resource installation (e.g., safe place) also provides clients with tools to manage distress.

• Negative Self-Concept: A key component of EMDR is the identification of negative self-referential beliefs (NCs) associated with traumatic memories and the subsequent installation and strengthening of more adaptive positive cognitions (PCs).52 This directly targets the cognitive aspect of negative self-concept. Processing traumatic memories that underpin feelings of worthlessness or defectiveness can lead to a more positive self-view.14 Meta-analyses have indicated moderate-large to large positive effects of trauma-focused treatments (including EMDR) on negative self-concept in CPTSD presentations.14

• Relational Difficulties: While EMDR does not typically involve explicit interpersonal skills training, the resolution of trauma-related symptoms, reduction in negative self-concept, and improved affect regulation can lead to secondary improvements in interpersonal functioning and the ability to form trusting relationships.14 Meta-analyses have also suggested moderate to moderate-large positive effects on disturbed relationships for trauma-focused treatments in CPTSD.14

• Dissociation: EMDR has been shown to reduce dissociative symptoms.14 The EMDR-Teens-cPTSD study found a reduction in peri-traumatic dissociation.56 For clients with significant dissociation, therapists may need to make modifications, such as more extensive preparation, resource development, and careful pacing of processing, potentially addressing dissociative responses directly before or during full EMDR processing.29

EMDR's AIP model conceptualizes that unprocessed memories are at the root of various psychological disturbances. In CPTSD, these memories often form the foundation of DSO symptoms. For example, repeated experiences of abuse can lead to core beliefs of worthlessness (negative self-concept) and an inability to trust others (relational difficulties), all linked to specific unprocessed memories. EMDR's structured approach to desensitizing these memories and installing adaptive positive beliefs offers a direct pathway to modifying these core aspects of DSO. The reduction of emotional distress tied to these memories inherently contributes to better affect regulation.

4. Strengths, Limitations, and Management of Clinical Challenges

Strengths of EMDR include:

• Strong empirical support for PTSD treatment across diverse populations.28

• Often reports rapid processing of traumatic memories and associated distress reduction.52

• Typically does not require detailed or prolonged verbal recounting of the trauma outside of identifying key components for targeting, which some clients prefer.27

• Growing evidence for its effectiveness in treating childhood trauma and CPTSD, including positive impacts on DSO symptoms and QoL.14

• Can be adapted for intensive treatment formats.14

Limitations include:

• The precise mechanism of action of bilateral stimulation remains a subject of debate and ongoing research.27

• Standard EMDR protocols may require extension or adaptation when addressing numerous or very early life traumas characteristic of CPTSD to ensure adequate processing.14

• The evidence base specifically for ICD-11 defined CPTSD is still developing, with many studies relying on broader definitions of complex trauma or PTSD with complex features. Some studies have small sample sizes or limited long-term follow-up data.28

Management of Clinical Challenges:

• The Preparation Phase (Phase 2) of EMDR is crucial for managing challenges in complex cases. It involves thorough psychoeducation, establishing a strong therapeutic alliance, and teaching clients self-soothing, grounding, and containment skills to manage intense emotions and dissociation that may arise during processing.14

• For clients with severe dissociation or dysregulation, the therapist may spend more time in the preparation phase, ensuring adequate resources are in place before proceeding to desensitization. Techniques for working with dissociative parts or ego states can be integrated if needed.29

• The therapist carefully monitors the client's level of distress during processing and can titrate the exposure by adjusting the length of BLS sets, returning to the safe place, or using interweaves (brief cognitive or resource-oriented interventions) to facilitate processing if it becomes blocked or overwhelming.

• The time frame for treating CPTSD with EMDR is often longer due to the multiplicity of traumatic events and associated negative cognitions that need to be targeted and processed.29

E. Dialectical Behavior Therapy (DBT) and DBT-PTSD

Dialectical Behavior Therapy (DBT) is a comprehensive, evidence-based psychotherapy initially developed by Dr. Marsha Linehan to treat chronically suicidal individuals diagnosed with Borderline Personality Disorder (BPD), a condition often characterized by severe emotion dysregulation and frequently linked to histories of complex trauma. An adaptation, DBT for PTSD (DBT-PTSD), specifically targets individuals with PTSD stemming from complex trauma, particularly childhood abuse, who also exhibit significant emotion dysregulation and other BPD-like features.

1. Theoretical Foundations and Core Skills Modules (Mindfulness, Distress Tolerance, Emotion Regulation, Interpersonal Effectiveness)

DBT is grounded in a biosocial theory, which posits that severe emotion dysregulation arises from a transaction between an individual's biological predisposition to emotional sensitivity and an invalidating developmental environment.58 The core dialectic in DBT is the balance between acceptance and change strategies.59

Standard DBT typically includes four modes of treatment:

1. Individual Therapy: Focuses on enhancing motivation, applying skills to specific life challenges, and managing therapy-interfering behaviours.

2. Skills Training Group: Teaches specific behavioural skills in four modules 30:

   • Mindfulness: Skills to increase awareness of the present moment without judgment, helping individuals observe their thoughts, emotions, and sensations, and participate more fully in life. This can be particularly helpful for reducing dissociation and rumination.

   • Distress Tolerance: Skills to cope with and survive crises and tolerate distressing emotions and situations without resorting to problematic behaviours (e.g., self-harm, substance use). Techniques include distraction, self-soothing, improving the moment, and radical acceptance.

   • Emotion Regulation: Skills to understand and identify emotions, reduce emotional vulnerability, decrease emotional suffering, and change emotions in a more adaptive way.

   • Interpersonal Effectiveness: Skills to navigate interpersonal situations effectively, such as asking for what one needs, saying no, and maintaining relationships and self-respect.

3. Phone Coaching: Allows clients to access therapist support for skills generalization in real-life situations between sessions.

4. Therapist Consultation Team: Provides support and ensures adherence to the model for therapists.

DBT-PTSD, developed by Martin Bohus and colleagues, is a phase-based treatment that integrates these core DBT principles and skills with trauma-focused exposure techniques.17 It typically involves a preparatory phase focusing on safety and skills acquisition, followed by a trauma exposure phase, and then a reintegration phase.

2. Application and Efficacy in Complex Trauma (particularly with childhood abuse history, emotional dysregulation, self-harm)

DBT and DBT-PTSD are particularly well-suited for individuals with complex trauma due to their direct focus on the core difficulties often seen in CPTSD and co-occurring BPD. The skills taught in DBT directly address the DSO clusters:

• Affect Dysregulation: Emotion Regulation and Distress Tolerance skills provide concrete strategies for managing intense and labile emotions.30

• Relational Difficulties: Interpersonal Effectiveness skills help individuals build and maintain healthier relationships.30

• Negative Self-Concept and Dissociation: Mindfulness skills can increase self-awareness, reduce self-judgment, and help individuals stay grounded in the present, counteracting dissociation and fostering a more stable sense of self.30

DBT-PTSD has demonstrated significant efficacy in treating individuals with PTSD related to childhood abuse who also present with features of BPD, such as severe emotion dysregulation and self-harm.32 A landmark RCT by Bohus, Kleindienst, et al. (2020), and its subsequent long-term follow-up by Vonderlin et al. (2024), compared DBT-PTSD to CPT in women survivors of childhood abuse with PTSD and at least three BPD criteria (including affective instability).17 This research found that while both treatments were effective, DBT-PTSD showed significant superiority over CPT at a 9-month follow-up on the primary outcome of PTSD severity (CAPS-5) and on secondary outcomes including self-reported PTSD severity (PCL-5), dissociation (Dissociation Tension Scale - DSS), severity of borderline symptoms (BSL-23), and psychosocial functioning (GAF).31 Furthermore, DBT-PTSD also demonstrated more beneficial effects than CPT on co-occurring BPD symptoms and a larger decline in self-harming behaviour.61

3. Impact on PTSD, DSO Symptoms, Self-Harm, and Functional Outcomes

Based on the evidence, particularly from the Bohus, Kleindienst et al. research program:

• PTSD Core Symptoms: DBT-PTSD leads to significant and sustained reductions in PTSD symptoms, outperforming CPT in the long term for complex presentations.31

• DSO Symptoms:

  • Affect Dysregulation: This is a primary target of DBT through its comprehensive Emotion Regulation and Distress Tolerance skills modules.30 The superior outcomes on the BSL-23 (which heavily reflects emotion dysregulation and impulsivity) in the Bohus et al. studies support its efficacy in this domain.31

  • Negative Self-Concept: While standard DBT skills training does not focus as explicitly on cognitive restructuring of core self-beliefs as CPT or Schema Therapy, DBT-PTSD integrates compassionate exposure and cognitive work that can address trauma-related negative self-appraisals. Improvements in BSL-23 scores also capture changes in identity disturbance and feelings of emptiness, which are related to negative self-concept.

  • Interpersonal Difficulties: These are directly addressed through the Interpersonal Effectiveness skills module.30 The superior improvement in GAF scores seen with DBT-PTSD reflects better overall social and occupational functioning, which is heavily influenced by interpersonal skills.31

• Self-Harm: DBT-PTSD has shown a significantly larger decline in self-harming behaviours compared to CPT in individuals with complex trauma and BPD features.61 This is a critical outcome given the high rates of self-injury in this population.

• Dissociation: DBT-PTSD leads to greater reductions in dissociative symptoms (measured by the DSS) compared to CPT in the long term.31 Mindfulness skills, a core component of DBT, are instrumental in helping individuals stay present and reduce dissociative responses.30

• Functional Improvement (GAF): DBT-PTSD resulted in significantly superior improvements in global psychosocial functioning (GAF scores) compared to CPT at the 9-month follow-up.31 This indicates a broader impact on daily life.

• Quality of Life (QoL): While a specific QoL measure was not explicitly reported as a primary or secondary outcome in the Vonderlin et al. (2024) follow-up study 31, the significant improvements in GAF scores, BSL-23, and PTSD symptoms strongly imply substantial benefits to overall quality of life.

The comprehensive nature of DBT-PTSD, which integrates robust skills training across all DSO domains with carefully paced trauma exposure, appears particularly effective for individuals with severe CPTSD stemming from childhood abuse and characterized by significant emotion dysregulation and interpersonal problems. Its demonstrated superiority over a well-established trauma-focused therapy like CPT in long-term functional outcomes for this specific, highly complex population suggests that for such presentations, addressing the "how to live differently" (skills for managing emotions, tolerating distress, and navigating relationships) alongside "processing what happened" (trauma exposure) is critical for achieving broad and lasting change.

4. Strengths, Limitations, and Comparative Efficacy

Strengths of DBT/DBT-PTSD include:

• It explicitly and comprehensively targets the core features of severe emotion dysregulation, interpersonal difficulties, and maladaptive behavioural patterns (including self-harm and dissociation) that are central to many CPTSD presentations, especially those comorbid with BPD features.30

• There is strong RCT evidence supporting the superiority of DBT-PTSD over CPT for individuals with CA-related PTSD and significant BPD features, particularly in terms of long-term functional outcomes, reduction of BPD symptoms, and self-harm.31

• Its phase-based approach allows for essential stabilization and skills acquisition before engaging in intensive trauma exposure, which can be crucial for highly dysregulated individuals.

Limitations include:

• DBT-PTSD is an intensive and often lengthy treatment program, which may pose challenges for accessibility and resource allocation.31

• The transportability of DBT-PTSD to real-world clinical settings might yield lower effect sizes compared to highly controlled RCTs, and patient adherence to the comprehensive skill-building and exposure components is key to its success.32

• While highly effective for CPTSD with BPD features, research is still expanding for its application to ICD-11 defined CPTSD in individuals who do not present with prominent BPD symptomatology.

Comparative Efficacy: As highlighted, DBT-PTSD has demonstrated superiority over CPT for women with CA-related PTSD and co-occurring BPD features across a range of outcomes at 9-month follow-up, including PTSD severity, BPD symptoms, dissociation, and psychosocial functioning.31 This positions DBT-PTSD as a particularly strong candidate for this highly complex and often difficult-to-treat population.

F. Acceptance and Commitment Therapy (ACT) and Trauma-Focused ACT (TF-ACT)

Acceptance and Commitment Therapy (ACT) is a contemporary behavioural therapy that has garnered increasing attention for its potential application to a wide range of psychological difficulties, including trauma-related conditions. Trauma-Focused ACT (TF-ACT) adapts these core principles specifically for trauma survivors.

1. Theoretical Foundations and Core Processes (Acceptance, Defusion, Values, Committed Action)

ACT is rooted in Relational Frame Theory (RFT), a behavioural account of human language and cognition. Its central therapeutic goal is to increase psychological flexibility: the ability to contact the present moment more fully as a conscious human being, and to change or persist in behaviour when doing so serves valued ends.34 Psychological flexibility involves being open to one's experiences (both pleasant and unpleasant) and engaging in actions that are aligned with deeply held personal values.

ACT targets six core interrelated processes to foster psychological flexibility 33:

1. Acceptance (or Willingness): Making room for unwanted private experiences (thoughts, feelings, memories, sensations) without trying to change, avoid, or control them.

2. Cognitive Defusion: Observing thoughts and language from a detached perspective, recognizing them as ongoing psychological events rather than literal truths or commands that must be obeyed. This reduces their impact and influence.

3. Present Moment Awareness (or Contact with the Present Moment): Paying attention to one's experiences in the here-and-now with openness, interest, and receptiveness (often cultivated through mindfulness practices).

4. Self-as-Context (or Transcendent Self): Contacting a sense of self as an observer or perspective-taker, distinct from the content of one's experiences (thoughts, feelings, roles). This provides a stable viewpoint from which to observe and accept internal events.

5. Values: Clarifying what is most important and meaningful to the individual; choosing life directions in various domains (e.g., relationships, work, personal growth).

6. Committed Action: Setting goals guided by one's values and taking effective action to pursue them, even in the presence of difficult thoughts and feelings.

Trauma-Focused ACT (TF-ACT) integrates these core ACT processes with specialized psychoeducation and techniques tailored to the needs of trauma survivors. TF-ACT often unfolds in phases, such as "Living in the Present" (focusing on safety, mindfulness, self-compassion), "Healing the Past" (acceptance of traumatic experiences, emotional regulation), and "Building the Future" (values clarification, committed action, posttraumatic growth).33

2. Application and Efficacy in Complex Trauma: Fostering Psychological Flexibility and Values-Based Living

ACT's core premise—that attempts to avoid or control unwanted internal experiences often exacerbate suffering—is highly relevant to complex trauma, where experiential avoidance is a prominent feature and can severely constrict an individual's life.34 Instead of focusing on symptom elimination per se, ACT aims to help individuals stop struggling with their internal experiences and redirect their energy towards building a rich, full, and meaningful life based on their chosen values.33 This can be particularly empowering for CPTSD survivors whose lives may feel devoid of meaning or purpose.

Evidence for ACT in complex trauma is emerging. A recent single case study utilizing a mixed-method design investigated TF-ACT for an individual with severe C-PTSD resulting from cumulative childhood abuse and war-related adversities.35 The study reported significant reductions in core C-PTSD symptoms (including hyperarousal, avoidance, intrusive memories, and emotional dysregulation) and notable improvements in psychological flexibility and overall well-being. Qualitative data further highlighted the participant's progress in reconstructing a coherent self-identity, enhancing emotional regulation skills, and developing meaningful social connections.35

Broader systematic reviews and meta-analyses of ACT for various conditions (including some PTSD studies) generally show medium effect sizes compared to control conditions and comparable efficacy to other established treatments.34 Open trials of ACT for PTSD have also shown clinically significant changes.34

The unique contribution of ACT to CPTSD treatment lies in its radical shift from symptom reduction as the primary therapeutic endpoint to the cultivation of psychological flexibility and values-based living. For individuals whose lives have been profoundly shaped and constricted by trauma and its pervasive DSO sequelae, this focus on building a meaningful life despite the potential persistence of some symptoms can be deeply transformative. It directly addresses the hopelessness, loss of identity, and disengagement from life often seen in CPTSD by empowering individuals to choose their direction and take purposeful action.

3. Impact on PTSD, DSO Symptoms, and Functional Outcomes

Based on available evidence, particularly the TF-ACT case study 35 and general ACT principles:

• PTSD Core Symptoms: The TF-ACT single case study reported reductions in hyperarousal, avoidance, and intrusive memories.35 General ACT studies also indicate benefits for PTSD symptoms, often by reducing the struggle with these internal experiences and decreasing their impact on behaviour.34

• DSO Symptoms:

  • Affect Dysregulation: The TF-ACT case study demonstrated reduced emotional dysregulation.35 ACT processes like acceptance and mindfulness help individuals relate differently to distressing emotions, allowing them to experience these emotions without being overwhelmed or resorting to maladaptive control strategies.33

  • Negative Self-Concept: Cognitive defusion techniques help individuals distance themselves from harsh self-judgments and negative self-stories, seeing them as thoughts rather than literal truths.33 Self-as-context fosters a more stable sense of self that is not defined by thoughts or experiences. Values clarification and committed action towards a valued self can help build a more positive and agentic identity. The case study noted progress in reconstructing a coherent self-identity.35

  • Relational Difficulties: Values clarification can guide individuals in identifying the qualities they wish to bring to relationships and the types of connections they want to cultivate.33 Committed action involves behaving in ways that foster these valued relationships. The case study reported the development of meaningful social connections.35

• Dissociation: While not explicitly detailed as a primary target or outcome in the provided ACT snippets for CPTSD, ACT's emphasis on present moment awareness (mindfulness) and acceptance of internal experiences could indirectly help individuals manage dissociative experiences by promoting grounding and reducing the experiential avoidance that might manifest as dissociation. The TF-ACT case study mentioned that survivors of complex trauma often exhibit dissociative symptoms as a coping mechanism, but specific outcomes on dissociation were not detailed.35

• Functional Improvement & Quality of Life (QoL): The TF-ACT single case study reported improved overall well-being, better daily functioning, and enhanced life satisfaction.35 A core aim of ACT is to improve QoL by enabling individuals to engage in values-based actions and live a more meaningful life, even if some symptoms persist.34

4. Strengths, Limitations, and Management of Clinical Challenges

Strengths of ACT/TF-ACT include:

• It is a transdiagnostic approach, applicable to a broad range of psychological distress, making it suitable for the often comorbid presentations in CPTSD.34

• The focus on values-based living offers a pathway to meaning, purpose, and post-traumatic growth beyond mere symptom reduction, which can be highly motivating for individuals who feel their lives have been derailed by trauma.33

• Mindfulness and acceptance skills are directly relevant to managing affect dysregulation and the distress associated with intrusive experiences.33

• TF-ACT provides a holistic framework by integrating mindfulness, acceptance, and value-driven behavioural changes.35

Limitations include:

• The evidence base for ACT specifically applied to ICD-11 defined CPTSD is still emerging and largely relies on case studies (e.g.35) or extrapolations from general PTSD or anxiety studies.34 More large-scale RCTs are needed.

• TF-ACT may not focus as directly or extensively on processing specific trauma narratives in the same way as CPT or PE, unless explicitly adapted to do so. The emphasis is more on changing the relationship to trauma memories rather than altering their content or structure.

• The approach requires a client's willingness to experience difficult emotions and sensations (acceptance), which can be challenging for some individuals with severe avoidance patterns.

Management of Clinical Challenges: The core processes of ACT themselves are designed to help clients manage difficult internal experiences (such as dysregulation or intrusive thoughts) without being overwhelmed. Acceptance skills help clients make room for discomfort, defusion techniques reduce the power of distressing thoughts, and mindfulness practices enhance present-moment awareness and grounding. TF-ACT, as described in 33, explicitly incorporates establishing safety, providing psychoeducation, and pacing therapy according to the client's needs. The therapeutic relationship is also crucial for creating a safe space to explore these processes.

G. Schema Therapy

Schema Therapy (ST) is an integrative psychotherapeutic approach developed by Jeffrey Young, designed primarily for chronic psychological conditions, including personality disorders and treatment-resistant mood and anxiety disorders, many of which have roots in adverse childhood experiences and complex trauma.

1. Theoretical Foundations (Early Maladaptive Schemas, Schema Modes) and Core Therapeutic Techniques (Limited Reparenting, Imagery Rescripting, Chair Work)

Schema Therapy synthesizes elements from cognitive behavioural therapy (CBT), attachment theory, Gestalt therapy, object relations, and psychodynamic psychotherapy.36 Its central premise is that many long-standing psychological problems stem from Early Maladaptive Schemas (EMS). EMS are pervasive, self-defeating patterns or themes comprising memories, emotions, cognitions, and bodily sensations, typically developed during childhood or adolescence as a result of unmet core emotional needs (e.g., needs for safety, stable attachment, autonomy, validation, realistic limits) and elaborated throughout an individual's lifetime.37 Examples of EMS include Abandonment/Instability, Mistrust/Abuse, Emotional Deprivation, Defectiveness/Shame, and Subjugation.

Individuals develop maladaptive coping styles in response to these schemas:

• Surrender: Giving in to the schema and behaving as if it is true.

• Avoidance: Trying to avoid situations or internal states that trigger the schema.

• Overcompensation: Behaving in a way that is the opposite of the schema in an attempt to fight against it. These coping styles, while understandable, often perpetuate the schemas.37

Schemas and coping styles often cluster into Schema Modes, which are temporary emotional and cognitive states or "ways of being" that an individual shifts into, particularly when their core schemas are activated.36 Common modes include:

• Child Modes: Vulnerable Child (feeling sad, anxious, defective), Angry Child (feeling enraged by unmet needs), Impulsive/Undisciplined Child (acting on immediate desires), and the Healthy Happy Child.

• Dysfunctional Coping Modes: Compliant Surrenderer, Detached Protector (emotional numbing, dissociation, avoidance), Overcompensator.

• Dysfunctional Parent Modes: Punitive Parent (self-critical, blaming), Demanding Parent (pushing for perfection).

• Healthy Adult Mode: The adaptive part of the self that is rational, nurturing, sets limits, and pursues healthy goals. The aim of therapy is to strengthen this mode.

Core therapeutic techniques in Schema Therapy include 36:

• Limited Reparenting: The therapist, within appropriate professional boundaries, provides some of the emotional experiences and validation that the client missed in childhood from their primary caregivers. This is considered a central mechanism of change, fostering a secure attachment and directly healing schemas.

• Imagery Rescripting: An experiential technique where clients re-imagine distressing childhood memories. The therapist may enter the image to protect the child self, confront abusers, or provide nurturing, thereby changing the emotional meaning and outcome of the memory and meeting unmet needs.

• Chair Work (Mode Dialogues): Clients engage in dialogues between different schema modes (e.g., Vulnerable Child and Punitive Parent, or Detached Protector and Healthy Adult) by moving between chairs representing these parts. This helps to increase awareness of modes, challenge dysfunctional modes, and strengthen the Healthy Adult.

• Cognitive Techniques: Identifying and challenging schema-driven thoughts.

• Behavioural Pattern-Breaking: Changing maladaptive behaviours linked to coping modes.

• Empathic Confrontation: The therapist empathically confronts the client's maladaptive coping styles and behaviours while validating the underlying schemas and needs.

2. Application and Efficacy in Complex Trauma and Dissociation

Schema Therapy is considered particularly well-suited for individuals with CPTSD due to its focus on the impact of adverse childhood experiences and its comprehensive approach to addressing deep-seated emotional and personality patterns.36 It offers a middle path between purely trauma-focused approaches and strictly phase-based stabilization models. ST often encourages the early commencement of processing trauma-related imagery (primarily via imagery rescripting) and other experiential exercises, with a consistent focus on meeting the client's core emotional needs throughout the process.36 The establishment of a strong therapeutic relationship characterized by limited reparenting is thought to provide the necessary safety and containment for this early experiential work.36

ST has been studied and found effective for chronic depression, particularly when associated with childhood trauma 68, and has a substantial evidence base for treating personality disorders (such as BPD), which often have significant trauma histories and overlap with CPTSD symptomatology.73

For dissociation, which is common in complex trauma, ST conceptualizes dissociative states often as manifestations of the Detached Protector mode.36 Treatment involves understanding the protective function of this mode, empathically bypassing it when appropriate, and gradually helping the client connect with and heal the underlying vulnerable child states that the Detached Protector is trying to shield. Techniques for managing acute emotional arousal or dissociation during sessions include grounding exercises, sensory engagement (e.g., using a shawl, scents, temperature variations), and playful interactions like catching a ball to orient the client to the present.36 A study protocol for testing ST specifically for Dissociative Identity Disorder (DID) has been developed, reframing "identities" as schema modes and aiming to overcome cognitive avoidance through experiential work.72

Key treatment themes in ST for complex trauma include increasing self-compassion, reattributing blame for traumatic experiences (often by challenging the Punitive Parent/Critic mode), increasing a sense of control, autonomy, and power, and strengthening the belief in one's ability to make oneself safe.36 ST can also be conceptualized as an integrative framework within which other trauma-focused interventions, such as EMDR, can be embedded.36

The unique strength of Schema Therapy for CPTSD lies in its explicit focus on identifying and healing the early maladaptive schemas and dysfunctional schema modes that directly underpin the DSO symptoms. Techniques like limited reparenting and imagery rescripting are specifically designed to provide corrective emotional experiences for developmental deficits and relational trauma. This goes beyond symptom management or the cognitive restructuring of isolated beliefs, aiming instead to foster deeper, more foundational personality change. This makes ST particularly well-suited for the pervasive disturbances in self-perception, emotional regulation, and interpersonal functioning that characterize CPTSD.

3. Impact on PTSD and DSO Symptoms

• PTSD Core Symptoms: Imagery rescripting is the primary ST technique for directly processing traumatic memories. By re-entering and altering these memories, the aim is to reduce their emotional intensity, change their associated negative meanings, and diminish intrusive re-experiencing.69 The integration of other trauma-focused methods like EMDR within an ST framework can also address these core symptoms.36

• DSO Symptoms:

  • Affect Dysregulation: This is addressed through multiple avenues: identifying and understanding the needs of emotional Child Modes (Vulnerable, Angry); challenging and reducing the influence of Dysfunctional Parent Modes (Punitive, Demanding) that exacerbate distress; strengthening the Healthy Adult Mode's capacity for self-soothing and adaptive emotional expression; and using limited reparenting to provide experiences of soothing and validation. Experiential techniques like chair work help clients process and integrate difficult emotions associated with different modes.

  • Negative Self-Concept: ST directly targets EMS like Defectiveness/Shame, Failure, Mistrust/Abuse, and Social Isolation that form the bedrock of a negative self-concept.37 Limited reparenting provides powerful corrective experiences of acceptance, validation, and worthiness. Imagery rescripting helps to change the negative meanings and self-attributions derived from past traumatic experiences. A key goal is to manage and reduce the influence of the Punitive Parent/Critic mode.36

  • Relational Difficulties: These are explored through the lens of attachment-related schemas (e.g., Abandonment, Emotional Deprivation, Subjugation) and the interpersonal patterns enacted by various coping modes (e.g., Compliant Surrenderer, Detached Protector, Overcompensator). The therapeutic relationship itself, characterized by limited reparenting, serves as a crucial arena for healing relational wounds and modeling healthier ways of relating. Mode work can help clients understand and change their maladaptive interpersonal behaviours.

• Dissociation: As mentioned, dissociation is often conceptualized as the Detached Protector mode. Therapy involves understanding its protective function, using grounding techniques during sessions, and gradually processing the underlying trauma that the mode is trying to avoid, often through carefully paced imagery rescripting.36 The aim is to help the client feel safe enough to connect with vulnerable emotions without needing to detach.

• Functional Improvement & QoL: By healing core schemas, reducing the dominance of dysfunctional modes, and strengthening the Healthy Adult mode, ST aims for broad and lasting improvements in overall functioning and quality of life. Studies on ST for personality disorders, which often involve significant functional impairment, have shown substantial symptom reduction and high rates of recovery.72

4. Strengths, Limitations, and Management of Clinical Challenges

Strengths of Schema Therapy include:

• It is a comprehensive and integrative model specifically designed to address deep-seated personality patterns and the impact of developmental trauma, making it highly relevant for CPTSD.36

• It uniquely combines cognitive, behavioural, experiential (imagery, chair work), and relational (limited reparenting) techniques, offering multiple pathways for change.

• Limited reparenting provides a powerful corrective emotional experience that can directly heal attachment wounds and unmet developmental needs.

• The schema mode concept is intuitive for clients and provides a useful framework for understanding and working with internal conflicts, dissociation, and affect dysregulation.

• It has demonstrated strong results in treating personality disorders, which share significant overlap with CPTSD.72

Limitations include:

• Schema Therapy can be a long-term and intensive treatment, which may have implications for cost and accessibility.

• It requires significant therapist training, skill, and ongoing supervision, particularly in the adept use of experiential techniques and the nuanced application of limited reparenting.

• While there is strong evidence for related conditions like BPD and chronic depression with childhood trauma 68, the body of RCT evidence specifically for ICD-11 defined CPTSD is still developing compared to therapies like CPT or PE for general PTSD.

Management of Clinical Challenges:

• Schema Therapy manages clinical challenges through its inherent flexibility and focus on safety. Exposure to traumatic material via imagery is typically gradual and always guided by the client's emotional needs and the therapist's assessment of their capacity.36

• The principle of limited reparenting is central to creating a safe therapeutic environment that allows clients to engage in challenging experiential work.36

• Specific techniques for grounding and managing emotional arousal are employed when clients become overwhelmed or dissociate during sessions.36

• A crucial aspect is the therapist's awareness of their own schemas and modes ("therapist schemas"), as these can be activated when working with complex trauma and impact the therapeutic relationship if not managed effectively.71

IV. Comparative Efficacy and Clinical Considerations for CPTSD Treatment

The treatment of Complex Post-Traumatic Stress Disorder (CPTSD) presents unique challenges due to its multifaceted nature, encompassing not only core PTSD symptoms but also significant Disturbances in Self-Organization (DSO). The choice of therapy should be guided by an understanding of the comparative strengths of different approaches in addressing this complex symptom profile.

A. Synthesizing the Evidence: Matching Therapies to Patient Profiles and Symptom Clusters

The existing evidence indicates that no single therapeutic modality holds universal superiority for all presentations of CPTSD. Instead, effective treatment planning requires careful individualization, considering the patient's predominant symptom clusters (i.e., the relative severity of core PTSD symptoms versus DSO components like affect dysregulation, negative self-concept, and relational difficulties), their capacity and readiness for direct trauma processing, the presence and nature of comorbidities, their developmental stage (particularly for children and adolescents), and the therapist's expertise in specific modalities.12

For children and adolescents, TF-CBT has a robust evidence base, including for those with complex trauma histories and presentations consistent with ICD-11 CPTSD. It has demonstrated efficacy in addressing both PTSD core symptoms and DSO-related difficulties.24 Network meta-analyses suggest that CPT, Behavioural Therapy (BT), and individual TF-CBT are among the best choices for youth with PTSD more broadly.75

For adults, particularly those with CPTSD stemming from severe childhood abuse and exhibiting significant emotion dysregulation and Borderline Personality Disorder (BPD) features, DBT-PTSD has shown superior long-term outcomes compared to CPT, especially in terms of functional improvement and reduction of BPD symptoms.31 This highlights the importance of therapies that explicitly build regulatory and interpersonal skills for this subgroup.

Well-established trauma-focused therapies such as CPT, PE, and EMDR are highly effective for core PTSD symptoms and can also lead to reductions in CPTSD/DSO symptoms, particularly when the processing of traumatic memories is central to alleviating these broader disturbances.7 Their efficacy in CPTSD appears to be enhanced when individuals have sufficient baseline regulatory capacity or when these therapies are appropriately sequenced or augmented.

Emerging approaches like ACT and Schema Therapy offer considerable promise for directly addressing the pervasive DSO, fostering values-based living, and targeting deeper personality patterns that underpin CPTSD.33 While large-scale RCT evidence specifically for ICD-11 defined CPTSD is still accumulating for these models, their theoretical frameworks and techniques align well with the multifaceted needs of this population.

A critical theme emerging from the literature is the potential value of modular or personalized approaches to CPTSD treatment. Given the inherent heterogeneity in CPTSD presentations—with varying degrees of severity across PTSD core symptoms and the three DSO clusters—a fixed, one-size-fits-all therapeutic protocol is unlikely to be universally optimal. Instead, approaches that allow for flexible emphasis on different components (e.g., intensive skills building for severe dysregulation, direct trauma processing for prominent intrusions, relational work for interpersonal difficulties, identity and schema work for negative self-concept) based on the individual's primary areas of difficulty, readiness for change, and evolving needs throughout therapy may be more effective.7 The development of modular treatments, such as some adaptations of STAIR 7, reflects this trend towards greater personalization in CPTSD care.

B. Addressing Core PTSD Symptoms versus Disturbances in Self-Organization

A fundamental consideration in treating CPTSD is the dual challenge of addressing both the core PTSD symptoms (re-experiencing, avoidance, sense of threat) and the often more pervasive Disturbances in Self-Organization (affect dysregulation, negative self-concept, relational difficulties).

Traditional trauma-focused therapies like PE, CPT, and EMDR have their primary mechanisms aimed at processing traumatic memories and altering trauma-related cognitions and fear structures, thereby directly targeting the core PTSD symptoms.7 While these interventions can have significant positive secondary effects on DSO symptoms—as improvements in trauma processing can lead to better emotional stability, self-perception, and interpersonal engagement—their direct focus is typically on the trauma-specific psychopathology.

In contrast, therapies such as DBT, ACT, and Schema Therapy place a more explicit and primary emphasis on the DSO clusters:

• DBT directly targets affect dysregulation through its emotion regulation and distress tolerance skills modules, and relational difficulties via interpersonal effectiveness skills training.30

• ACT aims to enhance psychological flexibility, enabling individuals to manage difficult internal states (including dysregulated affect and negative self-thoughts) more effectively and to engage in values-based actions that can improve relational functioning and overall well-being.33

• Schema Therapy directly addresses affect dysregulation, negative self-concept, and maladaptive relational patterns through its work on schema modes and the healing of underlying early maladaptive schemas.36

The memory and identity theory of ICD-11 CPTSD, as proposed by Brewin and colleagues, posits that intrusive, sensation-based traumatic memories and the development of negative identities (often stemming from the trauma context) together produce the full spectrum of PTSD and DSO symptoms.18 This theoretical perspective underscores the necessity of interventions that can address both dysfunctional memory processes and disturbances in self-concept and identity.

Therefore, effective treatment for CPTSD likely requires a carefully considered balance or integration of approaches. For some individuals, robust processing of traumatic memories might be sufficient to yield significant improvements across both PTSD and DSO domains. For others, particularly those with deeply entrenched negative self-schemas, severe regulatory deficits, or pervasive interpersonal mistrust stemming from early and prolonged developmental trauma, interventions that directly build self-regulatory capacities, restructure core identity beliefs, and foster new relational skills may be essential prerequisites or concurrent components to successful trauma processing. The superior outcomes of DBT-PTSD (which combines intensive skills training with trauma exposure) over CPT (primarily focused on cognitive/exposure techniques) in the Bohus et al. studies for complex childhood abuse survivors with BPD features lend strong support to the value of such integrated approaches for severe CPTSD.31

C. The Role of Phased-Based Approaches versus Direct Trauma Engagement

The question of whether to adopt a phase-based treatment approach—typically involving an initial stabilization phase before direct trauma engagement—versus proceeding more directly to trauma processing has been a long-standing debate in the treatment of complex trauma.

Historically, influential figures like Judith Herman and early ISTSS guidelines advocated for a sequential, three-phase model for CPTSD: 1) establishing safety and stabilization (including symptom management and skills building); 2) trauma memory processing (remembrance and mourning); and 3) reconnection and reintegration (re-engaging with life and relationships).6 The primary rationale for this phased approach was the concern that individuals with CPTSD, often characterized by severe affect dysregulation, dissociation, and fragile coping capacities, might be overwhelmed or even re-traumatized by direct exposure to traumatic material without adequate preparation and skill development.7 Skills Training in Affective and Interpersonal Regulation (STAIR) is a commonly implemented example of a stabilization-focused intervention often used in such models.7

However, more recent evidence and some expert opinions have challenged the universal necessity of a lengthy, distinct stabilization phase, suggesting it might, in some cases, unnecessarily delay access to the core trauma-focused interventions that target the root of the PTSD symptoms.7 Several studies have found that standard trauma-focused treatments like PE and EMDR can be successfully and effectively applied to individuals with CPTSD, sometimes without extensive prior stabilization, and that these individuals can achieve benefits comparable to those with less complex PTSD.7

This does not negate the importance of safety and adequate coping skills. Rather, the evolving perspective suggests that the critical factor may be how trauma is processed and how stabilization components are integrated. For instance, Schema Therapy often incorporates trauma processing (e.g., imagery rescripting) relatively early in treatment but within a therapeutic relationship that strongly emphasizes meeting the client's emotional needs (especially for safety and validation) through limited reparenting.36 Similarly, EMDR's standard protocol includes a preparation phase focused on psychoeducation and resource installation (e.g., safe place imagery, coping skills) before proceeding to memory desensitization.52 The work by Cloitre and colleagues on STAIR-augmented CBT/exposure also points to the benefits of integrating skills training with trauma processing, rather than viewing them as entirely separate and sequential stages for all patients.12

Ultimately, the dichotomy between "stabilization first" versus "trauma focus first" may be an oversimplification. A more nuanced approach, perhaps best described as trauma-informed stabilization and stabilization-informed trauma work, seems to be emerging. This involves a continuous assessment of the patient's regulatory capacity, dissociative tendencies, and the strength of the therapeutic alliance, guiding the therapist to flexibly titrate exposure, reinforce coping skills, and ensure safety throughout the trauma processing journey. The decision to dedicate more time to explicit skills-building before or during intensive trauma work should be guided by the severity of the individual's DSO symptoms, particularly affect dysregulation and dissociation, and their ability to engage with distressing material without becoming destabilized.

D. Managing Comorbidities, Dissociation, and Severe Dysregulation Across Modalities

CPTSD rarely occurs in isolation and is frequently accompanied by comorbidities such as depression, anxiety disorders, substance use disorders, and personality disorders (particularly BPD features).9 Furthermore, dissociation and severe affect dysregulation are intrinsic to the CPTSD construct or highly associated with it. Effective therapeutic approaches must be capable of managing these complexities.

Dissociation: High levels of dissociation can negatively impact the efficacy of many trauma-focused therapies if not specifically addressed, as it can interfere with emotional engagement and memory processing.17 However, successful reduction of dissociation, particularly in the early stages of treatment, is linked to better overall outcomes.17

• In CPT, while it can reduce dissociation 23, individuals with high levels of depersonalization may respond differently to variants of CPT (e.g., standard CPT vs. CPT-C which omits the written narrative).23

• EMDR protocols include modifications for managing dissociation, such as more extensive resourcing in the preparation phase and specific techniques to work with dissociative parts if they emerge during processing.29

• Schema Therapy conceptualizes dissociation often as the Detached Protector mode and employs grounding techniques, careful pacing of imagery work, and mode-specific interventions to address it.36

• DBT directly targets dissociative experiences through its mindfulness skills (enhancing present moment awareness and non-judgmental observation) and distress tolerance skills (providing alternatives to dissociative escape).30

Severe Affect Dysregulation: This is a core DSO symptom in CPTSD 4 and a major challenge in therapy.

• DBT/DBT-PTSD is explicitly designed to address severe emotion dysregulation through its comprehensive skills modules.30

• TF-CBT for youth often incorporates an extended stabilization phase focusing on building affective regulation skills before intensive trauma narration.24

• ACT utilizes acceptance and mindfulness strategies to help individuals manage intense emotions without attempting to suppress or eliminate them, thereby reducing their problematic impact.33

• Schema Therapy addresses affect dysregulation through mode work (e.g., soothing the Vulnerable Child, managing the Angry Child) and by strengthening the Healthy Adult mode's capacity for emotional self-regulation, often supported by the therapist's limited reparenting.36

Comorbidities: Many of the discussed therapies have demonstrated efficacy in reducing comorbid symptoms of depression and anxiety alongside PTSD/CPTSD symptoms.21 DBT-PTSD has shown particular strength in addressing comorbid BPD features.31 For substance use disorders, integrated treatment approaches are generally recommended, combining trauma-focused work with substance abuse counseling.

The management of these challenges often involves a flexible, individualized approach. Therapists must be skilled in assessing the client's current state, titrating interventions appropriately, and drawing upon techniques to enhance safety, grounding, and emotional regulation as needed throughout the therapeutic process. For individuals with very severe dysregulation or prominent dissociative features, a therapy that explicitly prioritizes skills building and stabilization (like DBT or a phased STAIR approach) before or integrated with more intensive trauma exposure may be most appropriate.

V. Clinical Guidelines and Expert Consensus

The treatment of CPTSD is an evolving field, and clinical guidelines reflect this ongoing development. Organizations like the International Society for Traumatic Stress Studies (ISTSS) and Phoenix Australia provide recommendations based on the current evidence base.

The ISTSS guidelines have acknowledged the complexities of CPTSD. While earlier recommendations leaned towards a phase-based approach (stabilization, trauma processing, reintegration) 9, more recent perspectives emphasize individualized treatment. The 2019 ISTSS guidelines do not rigidly advocate for a sequential phase-based treatment for all, but rather support a flexible, integrative approach tailored to the client's specific symptom presentation, particularly the DSO clusters.9 They highlight that CPTSD treatment is likely to involve more diverse interventions and potentially longer duration compared to PTSD.9 There is recognition that while trauma-focused interventions are key, addressing affect dysregulation, negative self-concept, and relational disturbances is crucial.9 For children and adolescents, the ISTSS notes the controversy regarding the CPTSD diagnosis due to overlap with other conditions and the effectiveness of existing interventions for emotion dysregulation, but underscores the importance of developmentally sensitive assessment and careful consideration of trauma's link to symptoms.79 Currently, there is not enough evidence for ISTSS to recommend a particular treatment specifically for CPTSD in children, suggesting existing effective treatments for related difficulties (anxiety, depression, PTSD, attachment issues) may be adapted.79 The VA's overview on CPTSD treatment also reflects this nuanced view, noting that while phase-based approaches like STAIR have been studied, standard trauma-focused treatments (PE, EMDR) have also shown efficacy for individuals with CPTSD, sometimes comparable to those with PTSD alone.7 The VA suggests that early studies have not found a definitive advantage for phase-based treatments for all with CPTSD, and future research should compare CPTSD-specific treatments against standard PTSD treatments.7

Phoenix Australia guidelines strongly recommend trauma-focused CBT (TF-CBT, including CPT, CT, PE) and EMDR as first-line psychological treatments for adults with PTSD.54 While these guidelines primarily address PTSD, they offer conditional recommendations for Narrative Exposure Therapy (NET) in cases of trauma linked to genocide, civil conflict, or torture, which are often contexts for complex trauma.54 They also acknowledge that for individuals with comorbid depression or high dissociation, or when psychological therapy is inaccessible, pharmacological options (SSRIs, venlafaxine) might be considered.54 The guidelines emphasize individualizing treatment and note the common practice of combined psychotherapy and medication for complex cases, though specific evidence for additive benefit in PTSD is still developing.54 For CPTSD specifically, Phoenix Australia notes the ICD-11 diagnostic criteria and the importance of assessing DSO symptoms, associated biopsychosocial issues (substance use, self-harm, relational challenges, dissociation, guilt, shame), and life stressors.19

A recent systematic review informing guideline development (BMJ Mental Health, 2024) reached weak clinical recommendations for trauma-focused therapies (with or without exposure) for PTSD, DBT-for-PTSD for PTSD with co-occurring BPD, and various therapies (CPT, NET, PE, Mindfulness/body-focused) for PTSD with co-occurring depression. For C-PTSD specifically, a weak recommendation was made for Skills training.61 This review highlighted the overall low certainty of evidence for many comparisons, emphasizing the need for more high-quality trials.

Overall, there is a consensus that CPTSD requires comprehensive assessment that includes DSO symptoms. While trauma-focused work remains central, the approach to this work—whether preceded by or integrated with skills-building phases—is subject to ongoing research and clinical judgment, tailored to the individual's specific presentation and needs.

VI. Conclusions and Future Directions

The treatment of Complex Post-Traumatic Stress Disorder (CPTSD) represents a significant and evolving area within psychological trauma care. The recognition of CPTSD as a distinct entity, particularly within the ICD-11 framework, underscores the need for therapeutic approaches that address not only the core symptoms of PTSD but also the pervasive Disturbances in Self-Organization (DSO)—affect dysregulation, negative self-concept, and relational difficulties—that define this condition.

Comparative Benefits and Therapeutic Mechanisms:

• Cognitive Processing Therapy (CPT) demonstrates robust efficacy for PTSD and can alleviate associated CPTSD symptoms by targeting maladaptive trauma-related cognitions and "stuck points" concerning safety, trust, esteem, power, and intimacy. Its structured approach is a strength, though for severe DSO and functional impairment, especially with BPD features, it may be less comprehensive than therapies offering explicit skills training.

• Trauma-Focused CBT (TF-CBT) is a leading evidence-based treatment for youth with complex trauma, effectively addressing both PTSD and DSO symptoms through its developmentally adapted, phase-based components that include affective modulation, cognitive processing, and crucial caregiver involvement.

• Prolonged Exposure (PE), through direct imaginal and in-vivo exposure, effectively processes trauma memories and reduces fear-based PTSD symptoms. It can also lead to improvements in CPTSD symptoms, though its direct focus on DSO is less pronounced. For individuals with severe dysregulation, PE may require augmentation or careful sequencing with skills-based interventions.

• Eye Movement Desensitization and Reprocessing (EMDR), via its Adaptive Information Processing model, facilitates the integration of traumatic memories and the installation of adaptive self-beliefs. It has shown efficacy for PTSD and promise for CPTSD, including improvements in DSO clusters like affect dysregulation and negative self-concept, and can be adapted for multiple traumas.

• Dialectical Behavior Therapy for PTSD (DBT-PTSD) stands out for its efficacy in treating severe CPTSD, particularly following childhood abuse with comorbid BPD features. Its integration of comprehensive skills training (mindfulness, distress tolerance, emotion regulation, interpersonal effectiveness) with trauma exposure provides a powerful framework for addressing both PTSD core symptoms and the full range of DSO, leading to superior long-term functional outcomes in this population compared to CPT.

• Acceptance and Commitment Therapy (ACT) / TF-ACT offers a unique approach by fostering psychological flexibility, enabling individuals to engage in values-based living despite persistent symptoms. Its focus on acceptance, defusion, and committed action can be particularly empowering for CPTSD survivors struggling with experiential avoidance and loss of meaning, showing promise in improving well-being and addressing DSO symptoms through a different lens.

• Schema Therapy (ST) provides a comprehensive model for understanding and treating the deep-seated impact of early adverse experiences that often underpin CPTSD. By targeting early maladaptive schemas and dysfunctional modes through techniques like limited reparenting and imagery rescripting, ST aims to achieve profound corrective emotional experiences and personality change, directly addressing all three DSO clusters.

Key Clinical Considerations:

1. Individualization is Paramount: No single therapy is optimal for all individuals with CPTSD. Treatment selection should be guided by a thorough assessment of the individual's primary symptom clusters (PTSD vs. DSO dominance), severity of dysregulation and dissociation, comorbid conditions, trauma history, developmental stage, and patient preference.

2. Addressing DSO is Crucial: Effective CPTSD treatment must extend beyond trauma memory processing to directly target affect dysregulation, negative self-concept, and relational difficulties. Therapies that explicitly build skills in these areas (e.g., DBT-PTSD, adapted TF-CBT) or fundamentally restructure underlying schemas and modes (e.g., Schema Therapy) or change one's relationship to internal experiences while pursuing values (e.g., ACT) are vital.

3. Phased vs. Integrated Approaches: The debate over strict phase-based treatment versus direct trauma engagement is evolving. The trend leans towards flexible, integrated approaches where stabilization and skills-building are interwoven with trauma processing, tailored to the client's capacity and needs, rather than a universally mandated lengthy stabilization phase.

4. Managing Dissociation and Dysregulation: Therapists must be adept at recognizing and managing dissociation and severe dysregulation. This may involve specific grounding techniques, pacing, and choosing modalities that inherently build regulatory capacities.

5. Therapeutic Alliance: Given the common history of interpersonal trauma and relational difficulties in CPTSD, the development of a safe, trusting, and collaborative therapeutic alliance is exceptionally critical across all modalities.

Future Directions:

• Comparative RCTs for ICD-11 CPTSD: More high-quality RCTs are needed that specifically recruit individuals meeting ICD-11 CPTSD criteria and compare different active treatments, including newer and integrative models, focusing on both PTSD and DSO outcomes, as well as functional improvement and quality of life.

• Mechanisms of Change: Research should continue to elucidate the specific mechanisms of change in different therapies for CPTSD to better understand how they impact the distinct symptom clusters.

• Modular and Personalized Treatments: Further development and testing of modular treatment approaches that allow for flexible tailoring of components to individual patient profiles are warranted.

• Long-Term Outcomes: Studies with longer follow-up periods are essential to understand the sustainability of treatment gains for CPTSD.

• Addressing Systemic Factors: For many individuals with CPTSD, trauma occurs within broader systemic contexts (e.g., poverty, discrimination, ongoing community violence). Research and clinical practice must increasingly consider how to address these factors alongside individual therapy.

In conclusion, while the treatment of complex trauma is indeed challenging, the field has made significant strides. A range of cognitive and behavioural therapies offer substantial benefits. The ongoing refinement of these therapies, coupled with a deeper understanding of CPTSD's unique psychopathology and a commitment to individualized, evidence-based care, holds the promise of improved outcomes and enhanced quality of life for those affected by the profound impact of complex traumatic experiences.

Compiled by Gemini AI 04.06.2025

CBT methods available

Stuart is accredited in psychotherapy and analysis, including in CBT and CBT based methods. As a Certified trauma specialist he is trained in the use of CBT in this specific area and modality. He is also Certified in ACT and DBT, including within the context of using them in trauma related cases. He also has a range of trainings and experience in a number of other related areas mentioned above.

Stuart practices online and from his clinic in Edinburgh.