Complex post-traumatic stress disorder: a therapist's manual

1. The programme at a glance

Indication. Adults with complex post-traumatic stress disorder (complex PTSD) as defined by ICD-11, the eleventh revision of the World Health Organization's International Classification of Diseases, most often after repeated or prolonged trauma, seen as outpatients and safe today. The programme is also suitable for post-traumatic stress disorder accompanied by marked difficulties with emotion regulation, self-image or relationships, without all the requirements of complex PTSD.

Reference model. A trauma-focused cognitive behavioural therapy, multicomponent and modular. It combines emotional and interpersonal regulation skills, drawn from the published principles of the STAIR programme (Skills Training in Affective and Interpersonal Regulation, a training in the regulation of emotions and relationships designed for adults who suffered abuse in childhood; Cloitre et al., 2010, 2020), work on several chosen memories, work on shame and self-image, and work on current relationships (Karatzias and Cloitre, 2019; Maercker et al., 2022).

Format. Twenty individual weekly sessions of 60 minutes, except sessions 1, 8, 9, 10, 12 and 13, which last 90 minutes, because the full assessment and the repeated account of a memory do not fit into less. Thirty sessions at most: the added sessions are used for additional memories, one per memory, or repeat one of sessions 4 to 6, three times at most in all (section 15). Three booster sessions follow, at one, three and six months. This number takes account of the trials: sixteen sessions when eight skills sessions preceded eight exposure sessions (Cloitre et al., 2002; Oprel et al., 2021), twenty-four in another trial (van Vliet et al., 2021), and up to forty-five over a year in an integrated programme for the most severe presentations (Bohus et al., 2020).

Mechanism targeted. The disorder has two sides (section 5). The traumatic memory that triggers on its own, with avoidance and threat, is treated by going back over chosen memories until they become the past. What years of trauma have installed — emotions that overflow or shut down, a self-image made of shame, and expectations learned in danger — is treated through skills, the revision of beliefs about oneself, and new relational experiences.

Session	Focus	Session output
1	Assess the history, safety and symptoms	Safety checked, baseline measures
2	Understand what complex PTSD is	Personal model written, beliefs noted
3	Make safe, draw the lifeline, choose the pathway	Safety plan, lifeline, order decided
4	Recognise and name emotions	Three episodes broken down
5	Regulate without shutting off	Three means chosen, plan for absences
6	What you learned to expect from others	One expectation named, one test planned
7	Prepare the work on memories	Memories ordered, criteria checked
8	First memory, in full	First full account, repeated
9	The hot spots of the first memory	Hot spots worked on, update made
10	Second memory	Second account and its hot spots
11	Mid-programme review	Measures repeated, plan adjusted
12	The next memories	Remaining memories worked on or re-rated
13	The whole line	Overall account written
14	Shame and guilt	One belief about oneself re-rated
15	Treating oneself differently	Another way of talking to oneself, tried
16	Trust and boundaries	One boundary set, trust graded
17	Closeness	One step towards someone close, taken
18	Taking back one's life	Three resumptions dated
19	Preventing relapse	Risk moments, three-level plan
20	Review and next steps	Measures repeated, booster sessions scheduled

The two pathways. Sessions keep their number, which designates their content; their order is decided at session 3. With brief preparation, you follow the order of the table. With direct entry, sessions 7 to 13 follow session 3, then come sessions 4 to 6, then 14 to 20. Direct entry requires that all the criteria in section 8 are met and that the person prefers to begin with the memories; this order has not been evaluated by any trial, and section 8 says why the programme proposes it nonetheless.

What the person takes away. Nine worksheets, listed in section 47: my weekly record, my safety plan, my lifeline, my emotions, me and others, my memories one by one, what I believe about myself, the corner for those close to you, and my plan for what comes next.

What distinguishes this programme from the other manuals on this site. Three things. Unlike Post-traumatic stress disorder in adults: a therapist's manual, which treats one or a few events in twelve sessions, it deals with numerous traumas and with the disturbances of the self, which define the disorder. It gives everyone three regulation sessions, whereas that manual, in its section 34, offers regulation only when its absence prevents the work on memories: the difference lies in the diagnosis, and section 8 explains it. And it refers to the manuals on borderline personality and on dissociative identity disorder when those disorders dominate (section 9).

2. Before you begin

The five preliminary decisions

1. Is the person safe today? Violence that is still going on suspends the work on memories, not the follow-up (section 10).

2. Is there acute suicide risk, or recent self-harm? When acute, the risk is addressed first; present but contained, it requires a written safety plan, without stopping the programme (section 10).

3. Is the picture really complex PTSD? Borderline personality in the foreground, a severe dissociative disorder, severe depression or massive substance use change the order or the frame (section 9).

4. Which pathway? The decision is made at session 3, on verifiable criteria and with the person (section 8).

5. Do you have the training and supervision needed for work on memories that are numerous and long past? If not, refer to a trained colleague.

What this programme does not treat

It does not treat current violence, which falls under section 10; nor dissociative identity disorder, or a dissociation that prevents the person from staying present despite the adjustments in section 41, which fall under Dissociative identity disorder: safety, stabilisation and phase-oriented treatment — a therapist's manual; nor borderline personality with frequent suicidal or self-harming behaviour, which falls first under Borderline personality: a therapist's manual; nor children and adolescents, who have their own manual, Post-traumatic stress disorder in children and adolescents: a therapist's manual. And it does not treat on its own a severe substance use disorder, which is treated in parallel with addiction services, without waiting for abstinence (section 9).

How to use it

Read sections 3 to 15, especially section 8, then sections 37 and 38 before the first session. The work on memory rests on imaginal exposure, that is, the repeated account of the memory, in the present tense and in the first person, as described in Post-traumatic stress disorder in adults: a therapist's manual in its sections 30 (imaginal exposure), 32 (the cognitive work) and 33 (dissociation): reread them before session 8. This manual says only what changes when the memories are numerous and long past.

Each session has its aim, its steps, what you say, its common errors and its criterion for moving on; it can take up two sessions when that criterion is not met, within the limit of thirty sessions.

Two warnings specific to this reason for consultation. Supposed fragility is the first obstacle: many of these people have the work on memory postponed because they are thought too fragile, which the data do not justify (section 8) and which confirms what they think of themselves. The opposite is also a mistake: launching into an account without preparation with a person who is in danger, in a suicidal crisis, or who shuts off from everything as soon as an emotion rises exposes them to a session they will not be able to get through.

3. Presentations not to be confused

1. Post-traumatic stress disorder

What you observe. Re-experiencing, avoidance and a sense of threat, without lasting and general disturbance of emotions, self-image and relationships.

What points to it. Outside what recalls the events, emotions, self-esteem and relationships hold up.

What that implies. Post-traumatic stress disorder in adults: a therapist's manual, with several index events if necessary (its section 34).

2. Complex PTSD

What you observe. The same symptoms, and three lasting disturbances: emotions that overflow or shut down, a diminished self-image laden with shame, and difficulty feeling close to others and sustaining relationships.

What points to it. These disturbances affect most areas of life, not only the moments of reminder.

What that implies. The programme described here.

3. Borderline personality

What you observe. Instability of relationships, of self-image and of emotions, marked impulsivity, and often repeated suicidal or self-harming behaviour.

What points to it. In a study of women who had suffered abuse in childhood, four features best distinguished borderline personality from complex PTSD: frantic efforts to avoid abandonment, an unstable self-image, intense and unstable relationships, and impulsivity (Cloitre et al., 2014). In complex PTSD, the self-image tends to be lastingly negative, and relationships tend to be avoided (section 4).

What that implies. Borderline personality: a therapist's manual. The two diagnoses can coexist (section 9).

4. Dissociative identity disorder

What you observe. Lost time, unexplained discoveries, distinct identity states.

What points to it. The memory gaps concern everyday life, not only the traumas.

What that implies. Dissociative identity disorder: safety, stabilisation and phase-oriented treatment — a therapist's manual.

The three sorting questions

"Outside the moments when something reminds you of what happened, what are your emotions like?" It looks for lasting dysregulation.

"What has all this made you think about yourself?" It looks for the self-image.

"With other people, is it more that you keep your distance, or that relationships are intense and changing, with a fear of being abandoned?" It separates, as a first approach, the withdrawal of complex PTSD from the instability of borderline personality.

4. The two sets of symptoms

The core shared with post-traumatic stress

Re-experiencing lived in the present, and not simply remembered; avoidance of the thoughts, places, people and activities that act as reminders; and a sense of current threat, with hypervigilance and startle. Post-traumatic stress disorder in adults: a therapist's manual describes them in its section 4.

The disturbances in self-organisation

This is the name of the three sets that are added to the core (Cloitre et al., 2013).

Emotion regulation. It is disturbed in two directions, sometimes in the same person. Hyperactivation: intense reactions that are slow to subside, outbursts of anger, reckless or self-destructive behaviour. Hypoactivation: emotional numbing, an inability to feel pleasure, and a tendency towards prolonged dissociative states under stress.

Self-image. Lasting beliefs of being diminished, defeated or worthless, with deep shame or guilt, for example at not having overcome what happened, or at not having been able to spare other people suffering.

Relationships. Lasting difficulties in feeling close to others and in maintaining relationships. The person may avoid relationships, lose interest in them or disparage them; they may also at times experience close or intense relationships, without managing to stay engaged in them.

What misleads

The calm presentation. Very serious things recounted in a neutral tone often reflect numbing, not the absence of suffering: "what are you feeling while you tell me this?"

Anger is often taken for a character trait rather than a symptom.

Withdrawal without complaint. A very organised and very solitary life can hide an avoidance of relationships.

Brief absences. A gaze that freezes when a subject is approached signals dissociation, which changes how sessions are conducted (section 41).

5. What maintains the disorder

Three loops maintain one another, and the treatment targets all three.

The memory loop

A reminder triggers re-experiencing, lived as a present danger; that danger justifies avoidance, which prevents the memory from being processed and the prediction of danger from being disconfirmed. This is the loop of post-traumatic stress, with one particular feature: the memories and the reminders are so numerous that avoidance ends up organising an entire life.

The emotion loop

When the traumas went on for a long time, showing fear or anger was dangerous or pointless: it provoked more violence, or nobody came. The person learned to stop feeling, to shut off, or else their emotions overflow with no intermediate means. Today, an emotion rises; for lack of any other means, they shut off, drink, hurt themselves or explode; the relief is immediate, and they never learn that an emotion can be got through and come back down. The consequences — the shame of having exploded, a damaged relationship, an injury — feed the next emotion. These difficulties can also hinder the work on memories: that is the hypothesis that motivated phase-based approaches (Cloitre et al., 2010).

The loop of shame and relationships

Years of violence leave conclusions behind: "I am worthless", "I am the problem", "other people always end up doing harm". They guide behaviour — hiding, withdrawing, asking for nothing, accepting everything, or attacking before being attacked — and other people's reactions seem to confirm them. The risk of being victimised again is part of this: in a meta-analysis of eighty studies, nearly half of the people who had suffered sexual abuse in childhood had been victimised again later (Walker et al., 2019). This says nothing about any fault on the person's part, and recognising danger signals is something that can be worked on (session 16).

The complete circle

A raised voice recalls a violent parent; the memory comes back, the emotion overwhelms, shame follows, and the person withdraws or explodes. The relationship deteriorates, the belief "there is nobody you can count on" is reinforced, and the next reminder finds a person who is more alone and more vigilant. This is the circle drawn at session 2.

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