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Theory Paper: Suggesting Compassion-Based Approaches for Treating Complex Post-traumatic Stress Disorder



Complex post-traumatic stress disorder (CPTSD) may develop following interpersonal and cumulative traumatic events, usually during early development. In addition to the core PTSD symptom profile, CPTSD presents emotional dysregulation symptoms that can be resistant to conventional treatments. Compassion-focused therapy (CFT) may be an effective intervention for addressing the more resistant symptoms in the emotional stabilisation phase of treatment rather than the trauma-processing phase. This paper explores the diagnostic validity and prevalence of CPTSD, treatment recommendations and the role of CFT in mediating shame and stabilising emotional dysregulation. We also evaluate current evidence utilising compassion-based interventions for the components of the CPTSD symptom profile and the viability of CFT as a whole. The novelty of CPTSD as a clinical condition means there is limited evidence regarding recommended treatment. Research into the efficacy of CFT and its suitability to target CPTSD’s symptom profile will contribute to the current gap in recommended treatment approaches for this condition.
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Theory Paper: Suggesting Compassion‑Based Approaches
forTreating Complex Post‑traumatic Stress Disorder
AnnabelRushforth1 · YasuhiroKotera1,2· GretaKaluzeviciute1,3
Accepted: 5 June 2022
© The Author(s) 2022
Complex post-traumatic stress disorder (CPTSD) may develop following interpersonal
and cumulative traumatic events, usually during early development. In addition to the core
PTSD symptom profile, CPTSD presents emotional dysregulation symptoms that can be
resistant to conventional treatments. Compassion-focused therapy (CFT) may be an effec-
tive intervention for addressing the more resistant symptoms in the emotional stabilisation
phase of treatment rather than the trauma-processing phase. This paper explores the diag-
nostic validity and prevalence of CPTSD, treatment recommendations and the role of CFT
in mediating shame and stabilising emotional dysregulation. We also evaluate current evi-
dence utilising compassion-based interventions for the components of the CPTSD symp-
tom profile and the viability of CFT as a whole. The novelty of CPTSD as a clinical condi-
tion means there is limited evidence regarding recommended treatment. Research into the
efficacy of CFT and its suitability to target CPTSD’s symptom profile will contribute to the
current gap in recommended treatment approaches for this condition.
Keywords Complex post-traumatic stress disorder· CPTSD· Compassion-focused
therapy· Emotional dysregulation· Emotional stabilisation phase· Trauma-processing
Complex post-traumatic stress disorder (CPTSD) was initially proposed as a disorder dis-
tinct from PTSD by Herman (1992), who argued that traumatic, usually childhood experi-
ences in CPTSD are repetitive and prolonged, with the individual feeling unable to escape
(Cloitre et al., 2009). The CPTSD symptom profile includes the underdevelopment of
emotional, social, cognitive and psychological competencies. CPTSD diagnostic criteria
include the three core PTSD symptom clusters of re-experiencing, avoidance and a sense
of threat, with three additional clusters unique to CPTSD: affect dysregulation, negative
* Annabel Rushforth
1 College ofHealth, Psychology andSocial Care, University ofDerby, Kedleston Rd,
DE221GBDerby, UK
2 Faculty ofMedicine andHealth Sciences, University ofNottingham, NG72TUNottingham, UK
3 Institute ofPsychology, Faculty ofPhilosophy, Vilnius University, Universiteto g. 9,
LT-01513Vilnius, Lithuania
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self-concept and disturbances in relationships (World Health Organization, 2018). These
three additional clusters are collectively known as ‘disturbances in self-organisation’
(DSO) symptoms (Cloitre etal., 2011; Maercker etal., 2013). The additional symptoms
reflect the unique impact complex traumatic experiences have on the development of inter-
personal skills and the emotional regulation system (Burns et al., 2010; Shipman et al.,
2005) and hippocampal function (Chetty etal., 2014) as well as the ability to form secure
attachments (Karatzias etal., 2019b). CPTSD symptoms differ from the primary risk factor
for PTSD which is one incident of intense trauma (Zuj etal., 2016). CPTSD is more likely
to arise following a combination of the above risk factors (Karatzias etal., 2019b) as they
specifically impact complexity of symptoms (Cloitre etal., 2009; Hyland etal., 2017).
Following multiple empirical investigations for the validity of construct (Cloitre
etal., 2013; Karatzias etal., 2017; Perkonigg etal., 2016; Sachser etal., 2017), CPTSD
was only recently recognised as distinct from PTSD in the International Classification
of Diseases, 11th revision (ICD-11; WHO, 2018). The ICD-11 points to DSO symp-
toms in order to differentiate CPTSD from PTSD. Meanwhile, CPTSD is not currently
recognised by the Diagnostic and Statistical Manual of Mental Disorders, 5th revision
(DSM-5; APA, 2013), although it is possible that the next revision of the DSM will con-
sider recognising the disorder (Cliotre etal., 2020).
The utility and discriminatory validity of separating the two disorders have been a
topic of debate. Prior to the publication of ICD-11, Resick etal. (2012) argued that there
is no substantial evidence to support the need for a new diagnostic category, stating that
the clinical benefit had not been established and that current research lacked rigour. In
a response, Herman (2012) argued that the authors had set an arbitrarily high standard
for inclusion of research. Additionally, Clotire etal. (2012) argued it would be clinically
beneficial to have simplicity in the overall classification structure, which would in turn
improve the conceptual organisation of symptoms and causes relevant to CPTSD.
This rebuttal has particular relevance to theDSM, given that the DSM-5 diagnostic
criteria for PTSD underwent revisions recognising additional DSO symptoms as part
of the core symptom profile. This revision, according to Cloitre etal. (2013), reduces
efficiency, as mental health providers prefer diagnoses to have a limited number of
symptoms, so as to increase diagnostic goodness of fit (accuracy of description for any
one patient), and thus to increase efficacy of treatment. Finally, the distinction between
PTSD and CPTSD, as Cloitre etal. (2009) argue further, allows for a better understand-
ing of treatment options, which is especially important given the prevalence of CPTSD:
2.6% in Israel (Ben-Ezra etal., 2018) and 3.8% in the USA (Cloitre etal., 2019), com-
pared with a 6.8% prevalence of PTSD (Gradus, 2007). However, it is possible that
CPTSD may be underdiagnosed as it is a novel and emerging disorder.
The International Society for Traumatic Stress Studies (ISTSS) recommends that
CPTSD treatment be delivered in a phase-based approach, initially addressing DSO
symptoms through an emotional stabilisation phase, prior to addressing the core PTSD
symptoms through a trauma-processing phase(Cloitre etal., 2011). One third of PTSD
patients with persistent DSO symptoms are less responsive to traditional clinical inter-
ventions (Winders etal., 2020; Van der Kolk etal., 2007) such as prolonged exposure
and cognitive-processing therapy (Jonas etal., 2013; Watkins etal., 2018). Gilbert and
Irons (2004) and Karatzias etal. (2019a) propose that these more psychologically per-
vasive DSO symptoms may be more responsive to compassion-based interventions,
and individuals with CPTSD who engage in compassion-based interventions to address
these DSO symptoms will see greater symptom reduction than those that engage in tra-
ditional clinical interventions alone.
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Compassion‑Based Interventions asaTreatment forCPTSD
Compassion-based interventions can be effective when addressing symptomology associ-
ated with shame (Karatzias etal., 2019a). Lee etal. (2001) propose that shame can medi-
ate CPTSD symptoms and Karatzias etal. (2019a) have shown an association between the
two. The Ehlers and Clark’s (2000) cognitive model of PTSD focuses on mitigating fear;
symptoms arise from event processing in a way that maintains a sense of threat. Treatment
attempts to re-process the memories of the event, reducing maladaptive coping strategies.
Lee etal.’s (2001) alternative model states that the presence of shame following a traumatic
event can maintain a self-critical dialogue and in turn a sense of threat. Shame can become
an obstacle to recovery, affecting the individual’s ability to engage in more traditional clini-
cal interventions such as cognitive behavioural therapy (CBT). Lee et al. (2001) propose
working with compassion-based interventions, such as compassion-focused therapy (CFT),
to reduce shame and self-criticism in PTSD sufferers.
CFT was initially developed as an adjunct to CBT by Gilbert (2009), aiming to balance
the affiliative system and reduce threat-based processing that can contribute to psychopa-
thology. CFT seeks to help individuals respond to their distress through a compassionate
lens, enhancing the capacity to self-soothe and reduce self-critical self-talk (Gilbert, 2009,
2010), thus allowing the individual to feel safer in their environment.
There are currently no randomised controlled trials evaluating the efficacy of CFT for
CPTSD. However, Karatzias et al. (2019a) found significant associations between low
scores on all self-compassion subscales (self-kindness, self-judgement, common humanity,
isolation, mindfulness and over-identification) and the existence of emotional hypoactiva-
tion and negative self-concept. Significant negative association between four self-compas-
sion subscales (self-kindness, self-judgement, common humanity and isolation) and dis-
turbances in relationships were also identified. High self-judgement significantly predicted
affect dysregulation and negative self-concept, which are associated with resistance to tra-
ditional clinical interventions in CPTSD (Gilbert & Irons, 2004). The most salient issue
with this study is that analyses were based on correlation, and therefore could not deduce
causality. Furthermore, self-report scales may involve biased results particularly with pop-
ulations that experience high levels of shame (Van de Mortel, 2008), as this may lead to
dishonest responses.
Despite this, these findings are an important first step in identifying psychological fac-
tors that are associated with CPTSD, which can inform future interventional research. Spe-
cifically, Karatzias et al. (2019a) found that self-compassion was not significantly associ-
ated with core PTSD symptom clusters despite several studies showing this relationship
(Winders etal., 2020). This may be partially due to previous studies using DSM-5 (APA,
2013) rather than the ICD-11 (WHO, 2018) diagnostic criteria. The ICD-11 tightened
its criteria for PTSD to avoid over-diagnosing (Hansen, 2017). In contrast, the DSM-5
expanded its criteria for PTSD from primarily a fear-based disorder to include ‘negative
alterations in cognition and mood’. These expanded symptoms include persistent negative
evaluation of self or others, elevated self-blame, negative emotional states and reckless and
self-destructive behaviour (Stein etal., 2014). These symptoms are parallel with the DSO
symptom criteria for CPTSD in the ICD-11. As a result, it is possible that studies using the
expanded criteria will find correlates between the DSM-5 PTSD symptoms of ‘negative
alterations in cognitions and mood’ and self-compassion subscales, which other studies
using the tighter ICD-11 core PTSD symptom criteria will not. This compromises clinical
utility and thus the development of treatment protocols. Uniformity regarding this would
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International Journal of Mental Health and Addiction
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contribute to cohesion in future research especially where CPTSD is concerned. As the
ICD-11 diagnostic criteria for CPTSD could be thought of as a division between different
DSM-5 symptom clusters (Stein etal., 2014), research targeting these clusters in isolation
will allow differentiation between correlates of PTSD and CPTSD, further highlighting if
these sibling disorders require qualitatively different treatment protocols. In the absence of
data regarding the efficacy of CFT for CPTSD, research regarding compassion-based inter-
ventions for CPTSD’s constituent parts, firstly the DSO symptom profile and secondly the
core PTSD symptom profile, would provide valuable insight.
Compassion‑Based Interventions asaTreatment forDisturbances
Prior to a trauma-processing phase of treatment, an emotional stabilisation phase of treat-
ment is recommended to address the DSO symptoms, ensure patient safety and avoid exac-
erbation of symptoms during the following trauma-processing phase (Cloitre etal., 2011).
To date, there have been no studies evaluating compassion-based interventions as a treat-
ment for DSO symptoms. In the absence of these studies, it is possible to assess the avail-
able research for significant effects of compassion-based interventions on the DSO symp-
tom indicators of affect dysregulation, negative self-concept and disturbed relationships as
described by the International Trauma Questionnaire (ITQ; Shevlin etal., 2018).
Research compiled from three meta-analyses (Ferrari etal., 2019; Kirby etal., 2017;
Wilson etal., 2019), one systematic review (Craig etal., 2020) and one literature review
(Kirby, 2017) regarding the efficacy of compassion-based interventions yielded five inter-
ventional studies using comparison groups exploring loving kindness meditation, mind-
fulness-based cognitive therapy with a self-compassion element, mindful self-compassion
and CFT (mindfulness-only-based interventions were excluded) as a treatment for clinical
populations displaying similar symptoms to the constituent components of DSO (emotion-
ally unstable personality disorder, depressive symptoms, mental health difficulties). The
above compassion-based interventions utilise the same theoretical framework as CFT,
aiming to reduce shame, balance the affiliative system and encourage self-soothing dur-
ing acute stress. Of the five available studies, only two used an active control group. One
of the two active control trials, Feliu-Soler etal. (2017), found significant improvements
in self-concept following a 3-week loving kindness meditation relative to a mindfulness
meditation intervention. This study may however lack population validity as it used a pre-
dominantly female sample. Although a lack of follow-up makes it difficult to ascertain if
the results were maintained, positive outcomes were achieved in a short treatment dura-
tion. In the other active control trial, Cuppage etal. (2018) found a similar result with CFT
showing significant improvements in psychopathology and a reduction in self-criticism.
The transdiagnostic nature of the group suggests that CFT is addressing the underlying
psychological processes giving rise to these psychopathologies, rather than just the symp-
toms presented. This aligns with Lee etal.’s (2001) theory of self-criticism contributing
to psychopathology. Of the remaining three studies, all found significant improvements in
depressive symptoms (Neff & Germer, 2013; Lee & Bang, 2010; Shahar etal., 2015).
Additional research shows significant improvements in outcome measures across
domains of anxiety (Gharraee etal., 2018; Navab etal., 2019; Noorbala etal., 2013; Som-
mers-Spijkerman etal., 2018), substance abuse disorder (Carlyle etal., 2019) and eating
disorders (Duarte etal., 2017). The available evidence suggests that CFT may be a suitable
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International Journal of Mental Health and Addiction
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treatment to address the range of complex symptoms in the emotional stabilisation phase.
In the absence of an agreed treatment protocol, it is worthwhile investigating this with
actively controlled, large-scale studies to establish efficacy relative to other treatments.
Compassion‑BasedInterventions asaTreatment forPTSD
Because CPTSD can be resistant to conventional PTSD treatments, alternative approaches
need to be evaluated. Much of the research regarding the efficacy of compassion-based
interventions in PTSD treatment lacks statistical significance, control groups or causal
considerations. Research compiled from a recent systematic review (Winders etal., 2020)
yielded nine interventional studies exploring compassion-based interventions for PTSD. Of
these nine, five used comparison groups, and of these five, one showed a greater signifi-
cant reduction in PTSD symptoms in the compassion-based group (using cognitive-based
compassion training) relative to the control group (Lang etal., 2017). Of the four remain-
ing studies using comparison groups, one showed an improvement in PTSD symptoms in
both the compassion-based condition (imagery re-scripting) and the traditional clinical
intervention condition (imaginal exposure) with a slightly larger improvement in the tra-
ditional intervention condition (Hoffart etal., 2015). The remaining three showed a non-
significant improvement (Beaumont etal., 2012, 2016; Held & Owens, 2015), although
these used small sample sizes and were therefore potentially underpowered, giving rise to
type II errors. Of the four studies without a control group, three found a significant reduc-
tion in PTSD symptoms following compassion-based interventions (Au etal., 2017; Kear-
aney etal. 2013; Muller-Engelmann etal., 2019). The study that did not find a reduction
in PTSD symptoms did however find an improvement in affect (Held etal., 2018). The
absence of a control group makes it difficult to ascertain if the observed effect is due to the
nature of compassion-based interventions and their effect of reducing shame and improv-
ing self-soothing capacity, or due to the effect of engaging in treatment generally. Inter-
estingly, significant correlations between PTSD symptom severity and self-compassion
have been demonstrated consistently in populations with childhood abuse or interpersonal
trauma (Barlow etal., 2017; Bistricky etal., 2017; Miron etal., 2015; Thomson & Waltz’s,
2008) implying the inconsistency of results in the above research may be mediated by this
risk factor.
Although this research is promising, it is difficult to draw conclusions about causal-
ity from cross-sectional studies. For example, it is possible that low self-compassion is a
pre-trauma risk factor for PTSD, or that self-compassion is better adopted by those with
less severe symptomatology. Greater symptom reduction was found in populations with
either higher self-judgement or elevated trauma-related shame (Au etal., 2017; Thomson
& Waltz’s, 2008). Further research is needed to clarify if this effect is only relevant to sub-
populations of PTSD, such as those with complex trauma, as the research may not general-
ise to all PTSD populations.
Given (a) the lack of statistical significance, control groups and causal considerations in the
majority of compassion-based intervention studies for PTSD and (b) the prevalence of litera-
ture reporting the efficacy of traditional clinical interventions for trauma processing such as
trauma-focused cognitive-processing therapy (Jonas etal., 2013; Watkins etal., 2018), large-
scale controlled studies are needed to propose CFT or other similar compassion-based inter-
ventions as a primary treatment during the trauma-processing phase of treatment for CPTSD.
Future interventional and controlled research is needed to support and add causality to the
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results seen in the cross-sectional data. In addition to this, future research would benefit from
improved statistical power. This could be achieved through use of a repeated measures design,
although this can be difficult in therapeutic research; another way to achieve this is to increase
sample sizes. Additionally, improvement in symptomology can be seen as a result of engag-
ing in treatment independent of the specific intervention (Safer & Hugo, 2006), and therefore
future research could benefit from including an active control group using traditional clini-
cal interventions to account for this effect. The addition of this research would justify further
investigation into CFT as a primary treatment in the trauma-processing phase of treatment of
Acceptability andViability ofCompassion‑Based Interventions
Although efficacy of interventions can be assessed with outcome measures, their acceptability
and viability are other important considerations (Moore et al., 2015). CFT has been found
to have good attrition among a variety of populations including those with dementia (94%;
Collins etal., 2018), perfectionism (96%; Rose etal., 2018) and psychosis (82%; Laithwaite
etal., 2009) and those in an inpatient setting (95%; Braehler etal., 2013). Given the challenges
faced regarding interpersonal domains as described above, this has particular relevance, as
populations with CPTSD may find it difficult to commit to a programme of treatment given
these disturbances (16–20%; Vogel et al., 2017). In addition, several studies have measured
individual satisfaction with CFT, with consistently high levels reported (Duarte et al., 2017;
Graser etal., 2016; Clapton et al., 2018), although it is worth noting that populations with
high shame may feel unable to give critical feedback, so these results should be interpreted
cautiously. Further research into satisfaction with the intervention would benefit from being
obtained blind to account for this effect. These are particularly important factors in the evalu-
ation of CFT for those who complete the therapy in groups, as it can be discouraging to peers
for the group to reduce in size or be described negatively by peers. CFT has been effectively
delivered in groups (McManus etal., 2018; FeliuSoler et al., 2017; HeriotMaitland etal.,
2014), improving cost effectiveness, waitlist time and viability for treatment centres. This is
particularly salient considering one implication for counsellors is the additional training they
may need to undertake to effectively deliver CFT.
Further studies evaluating the extent of this for 1:1 and group delivery would inform deci-
sions regarding the cost effectiveness versus potential changes in outcome measures. An
additional issue regarding the application of CFT is an absence of implementation fidelity, as
details regarding primary outcomes, who delivered the therapy, and their training were lack-
ing (Craig etal., 2020). This can cause disparity in interpretation of results, and make it dif-
ficult for group facilitators, counsellors or psychologists to deliver CFT in the way the research
has shown it to be effective. Future research would benefit from uniformity in these areas.
Although CFT could benefit from this, it is considered a highly acceptable treatment option by
patients and is well delivered in groups. In addition to outcome efficacy, these are important
considerations when assessing its strength as an intervention.
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In conclusion, the recent decision by the IDC-11 to recognise CPTSD as a disorder dis-
tinct from PTSD has raised important questions regarding risk factors, validity of con-
struct and clinical utility. However, it has been shown (Cloitre etal., 2013) that the new
diagnostic criteria promote ease of use and simplicity. It has allowed scope for stud-
ies of prevalence of CPTSD, highlighting the need to assess potential treatments. The
current recommendations of a phase-based approach of treatment (Cloitre etal., 2011)
entail addressing DSO symptoms separately to core PTSD symptoms as this promotes
ease of treatment. Evidence supports the use of CFT as a primary intervention for DSO
symptoms in the emotional stabilisation phase although there are other more suitable
and well-researched interventions for the core PTSD symptoms in the trauma-process-
ing phase. As a primary treatment for DSO symptoms, CFT could benefit from fur-
ther uniformity regarding delivery, although the treatment is considered highly accept-
able among patient populations and can be delivered successfully in groups. The above
factors imply that CFT is a highly viable option for addressing the more psychologi-
cally pervasive symptoms of CPTSD. Future research in this population would benefit
from evaluating the efficacy of a CFT intervention for emotional stabilisation prior to a
trauma-processing intervention, versus a trauma-processing intervention alone. Consen-
sus between the ICD-11 and DSM-5 regarding diagnostic criteria will be a major step
in understanding these research outcomes. More high-quality and large-scale research
investigating CFT as a primary intervention for individuals with CPTSD is a worth-
while movement towards an agreed treatment protocol for the disorder.
Conflict of Interest The authors whose names are listed declare that they have no affiliations with or involve-
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tion in speakers’ bureaus; membership, employment, consultancies, stock ownership, or other equity interest;
and expert testimony or patent-licensing arrangements), and there is no conflict of interest.
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This letter to the editor responds to a recent EJPT editorial and following commentary which express concerns about the validity of the ICD-11 complex PTSD (CPTSD) diagnosis. Achterhof and colleagues caution that latent profile analyses and latent class analyses, which have been frequently used to demonstrate the discriminative validity of the ICD-11 PTSD and CPTSD constructs, have limitations and cannot be relied on to definitively determine the validity of the diagnosis. Ford takes a broader perspective and introduces the concept of 'cPTSD' which describes a wide ranging set of symptoms identified from studies related to DSM-IV, DSM-V and ICD-11 and proposes that the validity of the ICD-11 CPTSD is in question as it does not address the multiple symptoms identified from previous trauma-related disorders. We argue that ICD-11 CPTSD is a theory-driven, empirically supported construct that has internal consistency and conceptual coherence and that it need not explain nor resolve the inconsistencies of past formulations to demonstrate its validity. We do agree with Ford and with Achterhof and colleagues that no one single statistical process can definitively answer the question of whether CPTSD is a valid construct. We reference several studies utilizing many different statistical approaches implemented across several countries, the overwhelming majority of which have supported the validity of ICD-11 as a unique construct. We conclude with our own cautions about ICD-11 CPTSD research to date and identify important next steps. © 2020 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.
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Objectives Self-compassion is a healthy way of relating to one’s self motivated by a desire to help rather than harm. Novel self-compassion-based interventions have targeted diverse populations and outcomes. This meta-analysis identified randomized controlled trials of self-compassion interventions and measured their effects on psychosocial outcomes. Methods This meta-analysis included a systematic search of six databases and hand-searches of the included study’s reference lists. Twenty-seven randomized controlled trials that examined validated psychosocial measures for self-compassion-based interventions met inclusion criteria. Baseline, post and follow-up data was extracted for the intervention and control groups, and study quality was assessed using the PRISMA checklist. Results Self-compassion interventions led to a significant improvement across 11 diverse psychosocial outcomes compared with controls. Notably, the aggregate effect size Hedge’s g was large for measures of eating behavior (g = 1.76) and rumination (g = 1.37). Effects were moderate for self-compassion (g = 0.75), stress (g = 0.67), depression (g = 0.66), mindfulness (g = 0.62), self-criticism (g = 0.56), and anxiety (g = 0.57) outcomes. Further moderation analyses found that the improvements in depression symptoms continued to increase at follow-up, and self-compassion gains were maintained. Results differed across population type and were stronger for the group over individual delivery methods. Intervention type was too diverse to analyze specific categories, and publication bias may be present. Conclusions This review supports the efficacy of self-compassion-based interventions across a range of outcomes and diverse populations. Future research should consider the mechanisms of change.
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Opioid use disorder (OUD) is reaching epidemic proportions worldwide, and is notoriously difficult to treat. Compassion focused therapy (CFT) has emerged as therapeutic tool for treating individuals exhibiting high levels of self-criticism and low self-esteem, both of which are common in OUD. Until now, however, there had been no research investigating this therapy in patients with OUD. Before running a premature clinical trial, it is important to fully assess the feasibility and acceptability of this treatment in this group of individuals. We aimed to assess the feasibility of CFT treatment in individuals with OUD in a short group intervention, which was co-created by the research team, service users and a local drugs service. The intervention involved three 2-hour sessions held over 3 weeks, where participants engaged in compassion-orientated psychoeducation and self-compassionate exercises. Individuals were randomly assigned to either the CFT group (n = 15), the active control (relaxation) group (n = 12) or the waitlist control group (n = 11). Of 103 individuals approached, 45% attended a baseline visit suggesting the treatment was acceptable to this group. A relatively low attrition rate across the 3 groups was found for CFT (21.1%), with no difference in drop-out between the groups. Qualitative analysis of interviews with participants identified a desire for more sessions. Compassion focused therapy was thus feasible and well-tolerated in those with OUD, and a further trial to evaluate any clinical differences may be warranted.
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Background: The 11th revision to the WHO International Classification of Diseases (ICD-11) identified Complex Posttraumatic Stress Disorder (CPTSD) as a new condition. There is a pressing need to identify effective CPTSD interventions. Methods: We conducted a systematic review and meta-analysis of Randomised Controlled Trials (RCTs) of psychological interventions for Posttraumatic Stress Disorder (PTSD), where participants were likely to have clinically significant baseline levels of one or more CPTSD symptom clusters (affect dysregulation, negative self-concept and/or disturbed relationships). We searched MEDLINE, PsycINFO, EMBASE and PILOTS databases (January 2018), and examined study and outcome quality. Results: Fifty-one RCTs met inclusion criteria. Cognitive Behavioural Therapy (CBT), Exposure alone (EA), and Eye Movement Desensitization and Reprocessing (EMDR) were superior to usual care for PTSD symptoms, with effects ranging from g = -0.90 (CBT; k=27, 95% CI -1.11, -0.68; moderate quality) to g = -1.26 (EMDR; k=4, 95% CI -2.01, -0.51; low quality). CBT and EA each had moderate-large or large effects on negative self-concept, but only one trial of EMDR reported data on this outcome. CBT, EA and EMDR each had moderate or moderate-large effects on disturbed relationships. Few RCTs reported affect dysregulation data. The benefits of all interventions were smaller when compared to non-specific interventions (e.g., befriending). Multivariate meta-regression suggested childhood-onset trauma was associated with a poorer outcome. Conclusions: The development of effective interventions for CPTSD can build upon the success of PTSD interventions. Further research should assess the benefits of flexibility in intervention selection, sequencing and delivery, based on clinical need and patient preferences.
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The aim of this study was to evaluate a trauma-adapted intervention for survivors of interpersonal violence that combines psychoeducation and specific mindfulness-based exercises developed for patients with posttraumatic stress disorder (PTSD) with formal practices from mindfulness-based stress reduction and loving-kindness meditation. Fourteen patients with PTSD after interpersonal violence participated in eight treatment sessions. The intervention was evaluated in a nonconcurrent multiple-baseline across-individuals design. From baseline (2, 3, and 4 weeks, randomly assigned) until 8 weeks after the intervention, self-reported PTSD symptoms and well-being were measured on a weekly basis. The intervention was further assessed through self-ratings and the Clinician-Administered PTSD Scale (CAPS-5) administered prior to treatment, immediately after treatment and at a 6-week follow-up. Tau-U analyses showed for the majority of the 12 completers a significant reduction of PTSD symptoms and a significant increase in well-being. Furthermore, we found large effects on PTSD symptoms as measured by the CAPS-5 (Hedges’ g = 1.66), as well as on depression (Hedges’ g = 1.08) and psychological distress (Hedges’ g = 0.85), complemented by relevant increases in mindfulness skills and self-compassion. This study contributes evidence that mindfulness and loving-kindness are useful for reducing PTSD in victims of interpersonal violence, especially when the intervention is tailored to the specific needs of these patients.
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Posttraumatic stress disorder (PTSD) is a chronic, often debilitating mental health disorder that may develop after a traumatic life event. Fortunately, effective psychological treatments for PTSD exist. In 2017, the Veterans Health Administration and Department of Defense (VA/DoD) and the American Psychological Association (APA) each published treatment guidelines for PTSD, which are a set of recommendations for providers who treat individuals with PTSD. The purpose of the current review article is to briefly review the methodology used in each set of 2017 guidelines and then discuss the psychological treatments of PTSD for adults that were strongly recommended by both sets of guidelines. Both guidelines strongly recommended use of Prolonged Exposure (PE), Cognitive Processing Therapy (CPT) and trauma-focused Cognitive Behavioral Therapy (CBT). Each of these treatments has a large evidence base and is trauma-focused, which means they directly address memories of the traumatic event or thoughts and feelings related to the traumatic event. Finally, we will discuss implications and future directions.
Introduction Compassion focused therapy (CFT) is an increasingly popular therapeutic modality. Its holistic and integrative approach to universal human suffering means that it is well-placed as a transdiagnostic therapy. Research into its effectiveness and acceptability has increased over the previous 10 years as the therapy has evolved, and to help consider its status as an evidence-based therapy research concerning its treatment outcomes needs evaluating. Areas covered This paper reviews research investigating the effectiveness of CFT in clinical populations. Expert opinion CFT shows promise for a range of mental health problems, especially when delivered in a group format over at least 12 hours. This is important for funding bodies and commissioning groups to consider as they allocate healthcare resources in light of current evidence-based practice. CFT is demonstrably well accepted by clients and clinicians and there is now a clear need for an updated, universally deployed, standard manual to direct future research. This will be critical in enabling widespread implementation and further adoption into mainstream clinical practice, will address the lack of standardization in current research and pave the way for further randomized control trials aimed at reducing existing methodological limitations.
Self‐compassion has emerged as an important construct in the mental health literature. Although conceptual links between self‐compassion and trauma are apparent, a review has not been completed to examine whether this association is supported by empirical research findings. To systematically summarise knowledge on the association between trauma and/or posttraumatic stress disorder (PTSD) and self‐compassion. Searches were conducted in PsycINFO, PubMed, Ovid Medline, Web of Science, Embase and PILOTS databases and papers reporting a direct analysis on the relationship between these constructs were identified. The search yielded 35 studies meeting inclusion criteria. Despite considerable heterogeneity in study design, sample, measurement and trauma type, there was consistent evidence to suggest that increased self‐compassion is associated with less PTSD symptomatology and some evidence to suggest that reduced fear of self‐compassion is associated with less PTSD symptomatology. There was tentative evidence to suggest that interventions based, in part or whole, on a self‐compassion model potentially reduce PTSD symptoms. While findings are positive for the association between increased self‐compassion and reduced PTSD symptoms, the precise mechanism of these protective effects is unknown. Prospective and longitudinal studies would be beneficial in clarifying this. The review also highlighted the variability in what is and should be referred to as trauma exposure, indicating the need for further research to clarify the concept.
The primary aim of this study was to provide an assessment of the current prevalence rates of International Classification of Diseases (11th rev.) posttraumatic stress disorder (PTSD) and complex PTSD (CPTSD) among the adult population of the United States and to identify characteristics and correlates associated with each disorder. A total of 7.2% of the sample met criteria for either PTSD or CPTSD, and the prevalence rates were 3.4% for PTSD and 3.8% for CPTSD. Women were more likely than men to meet criteria for both PTSD and CPTSD. Cumulative adulthood trauma was associated with both PTSD and CPTSD; however, cumulative childhood trauma was more strongly associated with CPTSD than PTSD. Among traumatic stressors occurring in childhood, sexual and physical abuse by caregivers were identified as events associated with risk for CPTSD, whereas sexual assault by noncaregivers and abduction were risk factors for PTSD. Adverse childhood events were associated with both PTSD and CPTSD, and equally so. Individuals with CPTSD reported substantially higher psychiatric burden and lower levels of psychological well-being compared to those with PTSD and those with neither diagnosis. © 2019 International Society for Traumatic Stress Studies.
Background Evidence suggests that attention‐deficit/hyperactivity disorder (ADHD) may accentuate varying psychological symptoms in parents. Since mothers are the most likely individuals interacting with ADHD children, it is highly probable that they will be influenced the most. Objectives This pilot study aimed to determine the effect of compassion‐focused group therapy on psychological symptoms of mothers of ADHD children. Methods A pre‐test–post‐test control‐grouped, quasi‐experimental study was carried out on a sample of 20 mothers of children with ADHD who were referred to the Health Centers of Isfahan City in Spring 2017. Prior to the intervention, the mothers’ psychological symptoms were recorded in both groups using the DASS‐21 questionnaire. Then, the mothers (n = 10) in the treatment group underwent 8 weekly sessions of 90‐min, compassion‐focused therapy. Both groups were post‐tested 1 week after the intervention. Finally, the collected data were analysed in SPSS‐23. Results The results of the study showed that, after the intervention, the mothers’ psychological symptoms in the treatment group significantly decreased (pre‐test: 36.10 ± 7.96 vs. post‐test: 33.40 ± 4.28, p value < 0.05), while no significant change was observed in the control group. Depression and anxiety levels showed a significant decrease in the treatment group as compared to the control group (p value < 0.05), while participants’ stress levels remained the same in both groups (p value > 0.05). Conclusion The findings revealed that compassion‐focused therapy resulted in an increase in self‐compassion and inner calmness levels, and a decrease in the use of avoidance coping strategy on the one hand, and the need to regulate emotions and ruminations on the other hand, among the mothers of ADHD children, which subsequently led to a decrease in psychological symptoms.