Cloitre, M., Courtois, C., Charuvastra, A., Carapezza, R., Stolbach, B., & Green, B. (2011) | References

What This Research Found

Marylene Cloitre's landmark 2011 survey established the standard of care for treating Complex PTSD—the form of trauma that develops from prolonged, repeated interpersonal abuse rather than single incidents like accidents or natural disasters. The research surveyed 50 of the world's leading trauma experts, achieving a remarkable consensus that challenged prevailing treatment approaches.

The primacy of phase-based treatment: The experts overwhelmingly recommended a sequenced, phase-based approach to Complex PTSD treatment, echoing Judith Herman's original framework but grounding it in contemporary clinical wisdom. Phase 1 focuses on safety, stabilisation, and skill-building; Phase 2 on trauma processing; Phase 3 on integration and reconnection. Crucially, the survey found that attempting trauma processing before adequate stabilisation was associated with poor outcomes, treatment dropout, and potential retraumatisation.

Affect regulation as foundation: The experts identified affect regulation—the ability to recognise, tolerate, and manage emotional states—as a core deficit in Complex PTSD that must be addressed before trauma processing can succeed. Unlike survivors of single-incident adult trauma who typically have pre-existing regulation capacities, survivors of childhood abuse or prolonged domestic violence often never developed these skills. Their childhoods were spent surviving rather than developing. Treatment must explicitly build what safe development would have provided.

Interpersonal skills as essential component: The survey revealed strong consensus that Complex PTSD treatment must address interpersonal difficulties—the pervasive problems with trust, boundaries, intimacy, and assertion that characterise this population. Survivors of prolonged relational trauma learned that relationships were dangerous, that their needs didn't matter, that speaking up brought punishment. These patterns persist even in safe relationships, including the therapeutic relationship. Skill-building in this domain was considered essential to the stabilisation phase.

The inadequacy of standard trauma protocols: Perhaps most significantly, the experts cautioned against applying treatments designed for single-incident PTSD—such as Prolonged Exposure or standard EMDR protocols—directly to Complex PTSD without substantial modification. These approaches assume a baseline of emotional regulation and relational capacity that Complex PTSD survivors often lack. Beginning trauma exposure work before building these foundations can flood the survivor's system, trigger dissociation, or replicate the overwhelming helplessness of the original trauma.

How This Research Is Used in the Book

Cloitre's research on phase-based treatment informs the recovery framework presented throughout Narcissus and the Child, particularly in Chapter 21: Breaking the Spell, which outlines the path from surviving narcissistic abuse to thriving beyond it. The book's treatment of healing directly reflects the expert consensus Cloitre documented:

"Effective trauma treatment follows a phase-based approach first articulated by Pierre Janet in the 19th century and refined by Judith Herman and others. The three phases—safety and stabilisation, trauma processing, and integration—prevent the overwhelm and retraumatisation that occurs when trauma is approached too directly too quickly."

The book emphasises that Phase 1 (Safety and Stabilisation) typically comprises 70-80% of treatment time for complex trauma—a proportion that directly reflects Cloitre's research findings. This extended stabilisation phase includes developing affect regulation skills, establishing boundaries, building support networks, and addressing co-occurring conditions—precisely the skill domains Cloitre's survey identified as essential.

The book also incorporates Cloitre's insight that survivors must develop the internal resources to tolerate trauma processing before undertaking it. In discussing why some survivors find therapy overwhelming while others thrive, the book draws on Cloitre's framework to explain that mismatched treatment—trauma processing before stabilisation—can retraumatise rather than heal.

Chapter 16: The Gaslit Self extends these principles to gaslighting recovery specifically, noting that stabilisation for these survivors includes "developing capacity to trust their own perceptions again"—addressing the cognitive dissonance and reality-testing deficits created by systematic gaslighting in narcissistic abuse.

Why This Matters for Survivors

If you've survived narcissistic abuse—whether from a parent, partner, or other significant figure—Cloitre's research speaks directly to your experience of what healing requires.

Your need for stabilisation is not weakness. You may have tried therapy where you felt pushed to "process" traumatic memories before you felt ready. Maybe you left sessions feeling worse, not better. Perhaps you dissociated, couldn't remember what was discussed, or experienced days of emotional flooding afterward. Cloitre's research validates that these experiences often signal not that you're treatment-resistant, but that the approach was wrong for your type of trauma. The world's leading experts agree: Complex PTSD requires a different sequence than other trauma types.

The skills you're missing aren't character flaws. Healthy emotional regulation, the ability to set boundaries, tolerance for intimacy, the capacity to identify and communicate needs—these develop through safe childhood experiences. If your childhood was consumed by surviving a narcissistic parent, by monitoring their moods and managing their emotions, you were too busy surviving to develop. This hypervigilant monitoring became your full-time occupation. Cloitre's research frames your struggles not as personal deficiency but as skill deficits that treatment can address. You're not broken; you just never got to build what safe development provides.

Taking time isn't taking too long. Recovery from Complex PTSD is measured in years, not months. Cloitre's survey confirms that this extended timeline reflects the nature of the trauma, not inadequacy on your part. The patterns installed during childhood development, or encoded through years of domestic abuse, are deeply wired. The experts agree that rushing this process—or comparing yourself to single-incident trauma survivors—sets unrealistic expectations. Your healing journey honours the depth of what you experienced.

The right treatment exists. Cloitre didn't just document the problem—she developed a solution. STAIR (Skills Training in Affective and Interpersonal Regulation) is an evidence-based treatment designed specifically for Complex PTSD. Unlike protocols adapted from combat trauma, STAIR was built from the ground up for survivors of childhood abuse and interpersonal violence. If you're seeking treatment, asking about phase-based approaches or STAIR training is a concrete way to find help matched to your needs.

Clinical Implications

For psychiatrists, psychologists, and trauma-informed healthcare providers, Cloitre's research has direct implications for assessment and treatment planning with narcissistic abuse survivors.

Assessment must go beyond PTSD criteria. Standard PTSD assessment (PCL-5, CAPS) may miss the affect dysregulation, negative self-concept, and interpersonal difficulties central to Complex PTSD. Clinicians should assess skill deficits in emotional regulation (Can they identify emotions? Tolerate distress? Self-soothe?), interpersonal functioning (boundary capacity, trust, intimacy tolerance), and trauma history characteristics (age of onset, duration, relationship to perpetrator). The International Trauma Questionnaire (ITQ) assesses ICD-11 Complex PTSD specifically. History of prolonged childhood abuse or extended domestic violence should trigger Complex PTSD conceptualisation.

Stabilisation is not preliminary to treatment—it is treatment. Cloitre's research reframes the stabilisation phase from "preparation for the real work" to essential, active intervention. Teaching affect regulation skills, building interpersonal capacities, and establishing safety represent therapeutic work of the highest order. Clinicians should resist pressure—from patients, insurers, or their own training—to rush toward trauma-focused interventions. For Complex PTSD, the majority of treatment time (70-80%) appropriately occurs in Phase 1.

The therapeutic relationship carries unique weight. For patients whose trauma occurred in attachment relationships, the therapeutic relationship is not merely context for intervention—it is a central mechanism of change. Cloitre's emphasis on interpersonal skill development positions the therapy relationship as a laboratory for learning: experiencing consistent, bounded, non-exploitative care may be genuinely novel for survivors whose attachment figures were sources of harm. Expect attachment themes—concerns about reliability, testing behaviors, difficulty with separations—to permeate treatment.

Consider STAIR or similar structured approaches. Cloitre's survey established principles; STAIR provides implementation. The protocol offers structured modules for affect regulation (emotion identification, distress tolerance, anger management) and interpersonal skills (assertiveness, trust, intimacy). For clinicians uncertain how to operationalise phase-based treatment, STAIR training provides concrete guidance. Group formats can enhance interpersonal skill development while providing the normalisation survivors often need.

Pharmacological support aids stabilisation. While psychotherapy forms the core of Complex PTSD treatment, medication can support the stabilisation phase by addressing symptoms that interfere with therapy engagement: severe anxiety, depression, sleep disturbance, hypervigilance. SSRIs, prazosin for nightmares, or brief use of anxiolytics during the most destabilising treatment phases may enable psychotherapeutic work to proceed. Psychiatrists should coordinate with therapists to ensure pharmacotherapy supports the phase sequence rather than rushing past stabilisation.

Treatment planning must include realistic duration. Cloitre's research supports advocating with insurers and healthcare systems for treatment duration appropriate to Complex PTSD. Brief, time-limited protocols designed for single-incident trauma are often inadequate. Clinicians may need to document the specific nature of the presentation—prolonged, developmental trauma affecting multiple domains—to justify treatment that matches the clinical picture.

Broader Implications

Cloitre's research on Complex PTSD treatment extends beyond individual therapy to illuminate patterns in how we understand and respond to prolonged interpersonal trauma at a societal level.

The Intergenerational Transmission of Skill Deficits

Cloitre's identification of affect regulation and interpersonal skills as core deficits in Complex PTSD has implications for understanding intergenerational trauma. Parents who never developed these capacities due to their own abusive childhoods cannot teach what they don't possess. A mother struggling with affect regulation cannot co-regulate her infant effectively; a father with severe interpersonal deficits cannot model healthy relating. The skills that should transmit through safe attachment relationships fail to transfer—not through malice but through absence. This framework suggests intervention points: teaching parents the skills they missed may interrupt transmission more effectively than merely identifying the problem.

Relationship Patterns in Adulthood

Adults with unaddressed Complex PTSD often find themselves in relationships that replicate familiar dynamics. Cloitre's framework helps explain why: without the interpersonal skills that secure attachment develops—boundary setting, need communication, tolerance for authentic connection—survivors navigate relationships with limited tools. The narcissistic partner who feels "comfortable" may feel that way precisely because their control pattern matches the survivor's adaptation to being controlled—a dynamic often called trauma bonding. Recovery includes developing the skills that allow different relationship choices.

Workplace and Organisational Dynamics

Cloitre's identification of interpersonal skill deficits illuminates workplace struggles common among survivors. Difficulty asserting boundaries, problems with authority relationships, sensitivity to perceived criticism, reluctance to advocate for oneself—these affect professional functioning. Patterns of people-pleasing developed for survival in abusive families carry forward into work environments. Trauma-informed workplace practices should recognise that some employees' interpersonal struggles reflect developmental trauma rather than character flaws. Employee assistance programmes could incorporate phase-based understanding when referring to treatment.

Legal and Policy Considerations

The expert consensus on treatment sequence has implications for legal and policy contexts. Family courts ordering trauma therapy for abuse survivors should understand that mandating approaches inconsistent with best practices may cause harm. Insurance coverage decisions should recognise that Complex PTSD requires different treatment duration than standard PTSD. Disability evaluations should acknowledge that skill deficits in affect regulation and interpersonal functioning—not merely PTSD symptoms—may impair functioning.

Educational Settings and Prevention

Cloitre's emphasis on skill deficits suggests prevention opportunities. Social-emotional learning curricula in schools teach the very skills—emotion identification, distress tolerance, interpersonal effectiveness—that Complex PTSD survivors lack. Developing these protective factors early can buffer against the impact of adverse home environments. Universal delivery means at-risk children receive skill-building even without identification of their home situations. School-based prevention may not eliminate trauma's occurrence but can build resilience by developing skills that traumatic home environments fail to provide.

Healthcare System Design

The phase-based model has implications for how healthcare systems should be structured to serve trauma survivors. Fragmented care—psychiatric medication from one provider, brief therapy from another, crisis intervention episodically—undermines the sustained, relational treatment Complex PTSD requires. Integrated trauma clinics offering consistent providers, phase-aware treatment planning, and multidisciplinary coordination better match the clinical needs Cloitre's research identified.

Limitations and Considerations

Cloitre's influential research has important limitations that inform how we apply its findings.

Expert consensus differs from randomised trial evidence. The 2011 survey captured what experienced clinicians believed worked, not controlled evidence of what actually works. This is a limitation—expert consensus has historically been wrong about various treatments. However, subsequent randomised controlled trials of STAIR and other phase-based approaches have largely validated the survey's recommendations, strengthening the evidence base since publication.

The treatment sequence may need individualisation. While Cloitre's research established general principles, individual patients vary. Some with strong pre-existing resources may be able to engage trauma-focused work earlier; others may require extended stabilisation. The phase model should inform clinical judgment, not replace it.

Cultural adaptation requires attention. The expert sample, while international, was predominantly Western-trained. How affect regulation and interpersonal skills manifest, what constitutes appropriate expression, and how therapeutic relationships function varies across cultures. Clinicians working cross-culturally should adapt phase-based principles to cultural context rather than applying Western norms universally.

Dissemination remains incomplete. Despite the survey's influence in specialist trauma circles, many general practitioners, psychiatrists, and even some psychotherapists remain unfamiliar with phase-based principles. Survivors may encounter clinicians who apply single-incident trauma protocols or push for premature exposure work. Patient education about Complex PTSD treatment best practices can support advocacy for appropriate care.

Research continues to evolve. Since 2011, understanding of Complex PTSD has deepened. ICD-11's formal recognition (2018) provides diagnostic framework the survey lacked. New treatment approaches continue development. Cloitre's research represents foundational principles that subsequent work refines rather than a final word.

Historical Context

The 2011 ISTSS survey emerged from decades of clinical observation that standard trauma treatments often failed survivors of prolonged interpersonal trauma. Judith Herman had proposed Complex PTSD in 1992, describing a syndrome of affect dysregulation, identity disturbance, and relational difficulties beyond standard PTSD. However, Complex PTSD remained absent from DSM, and evidence-based trauma treatments had been developed and validated primarily with single-incident trauma populations—combat veterans, sexual assault survivors, accident victims.

Clinicians treating childhood abuse survivors and domestic violence victims repeatedly observed that their patients deteriorated when exposed to standard trauma protocols. The premature focus on traumatic memories overwhelmed systems that lacked fundamental regulation capacities. Patients dropped out, symptoms worsened, and therapists wondered if their patients were simply "too difficult" or "treatment-resistant."

Cloitre's survey gave formal voice to the clinical wisdom that these patients required something fundamentally different—not adjusted dosing of the same medicine but a different treatment architecture altogether. By surveying the world's acknowledged experts and documenting their consensus, Cloitre established an evidence base that could inform guidelines and training, even in the absence of the massive research trials that had validated single-incident trauma approaches.

The paper's influence has been substantial. It has been cited over 1,000 times and directly informed treatment guidelines from the International Society for Traumatic Stress Studies. Cloitre's subsequent development and validation of STAIR provided a concrete, evidence-based implementation of the principles the survey established. When ICD-11 recognised Complex PTSD in 2018, Cloitre's research formed part of the empirical foundation justifying its inclusion.

For survivors and clinicians navigating the trauma treatment landscape, the 2011 survey represents a watershed: formal acknowledgment that Complex PTSD exists as a distinct entity requiring distinct treatment, and that the world's leading experts agree on what that treatment should look like.

Treatment of Complex PTSD: Results of the ISTSS Expert Clinician Survey on Best Practices

APA Citation