Courtois, C., & Ford, J. (2009) | References

What This Research Found

Christine Courtois and Julian Ford's Treating Complex Traumatic Stress Disorders stands as the definitive clinical guide for treating adults who survived prolonged, repeated interpersonal trauma—particularly childhood abuse, domestic violence, and other forms of captivity. Published in 2009 and now in its second edition, the book assembles contributions from the world's leading trauma experts to create a comprehensive framework that fundamentally differs from treatments designed for single-incident PTSD.

The recognition of Complex PTSD as a distinct entity: Courtois and Ford build on Judith Herman's original proposal of Complex PTSD, establishing that survivors of chronic, developmental trauma present with a constellation of symptoms beyond standard PTSD. These include severe difficulties with affect regulation—the ability to identify, tolerate, and modulate emotional states; profound disturbances in self-perception, including chronic shame, guilt, and feelings of permanent damage; and pervasive interpersonal difficulties involving trust, boundaries, and intimacy. The book argues that these symptoms are not comorbidities or complications but constitute a coherent syndrome arising specifically from prolonged relational trauma during developmentally sensitive periods.

The primacy of phased, sequenced treatment: The book's central clinical contribution is the articulation of a phased treatment model that must proceed in sequence. Phase 1 focuses on safety, stabilisation, and engagement—establishing safety in the patient's current life, developing emotional regulation skills, and building a therapeutic alliance strong enough to sustain the demanding work ahead. Phase 2 addresses trauma memory and emotion processing—working through traumatic experiences once the patient has sufficient resources to tolerate this work. Phase 3 focuses on consolidation and integration—applying gains to present and future life, rebuilding identity, and restoring connection. Crucially, the authors demonstrate that attempting Phase 2 work before adequate Phase 1 stabilisation risks retraumatisation, treatment dropout, and symptom exacerbation. The phases are not arbitrary divisions but reflect what complex trauma does to people and what healing requires.

The therapeutic relationship as treatment mechanism: For survivors whose trauma occurred in attachment relationships—with parents, partners, or other significant figures—the therapeutic relationship carries unique weight. Courtois and Ford establish that the relationship is not merely the context for delivering interventions but is itself a central mechanism of change. Through the consistent, boundaried, attuned presence of the therapist, the patient experiences what may be their first safe attachment relationship. This experience, repeated over time, gradually updates internal working models of what relationships can be. The book details how attachment dynamics manifest in treatment—testing, rupture, repair—and how therapists can navigate these phenomena therapeutically rather than reactively.

Comprehensive coverage of treatment modalities: The book includes chapters by leading experts on multiple treatment approaches adapted for complex trauma: cognitive-behavioural therapy (Christie Jackson, Kore Nissenson, Marylene Cloitre), experiential and emotion-focused therapy (Diana Fosha), sensorimotor psychotherapy (Janina Fisher, Pat Ogden), pharmacotherapy (Lewis Opler, Julian Ford), internal family systems therapy (Richard Schwartz), couple therapy (Susan Johnson, Christine Courtois), family systems therapy, and group therapy. Each chapter addresses how the modality must be modified for complex trauma—for instance, how exposure-based techniques require careful titration within the window of tolerance, or how couples work must account for trauma dynamics in relationships. This comprehensiveness allows clinicians to understand multiple approaches and select or combine them based on patient presentation.

The importance of assessment and case formulation: Courtois and Ford emphasise that treatment must be grounded in thorough assessment that captures the full Complex PTSD picture. Chapters by John Briere and Joseph Spinazzola on evidence-based assessment, and by Daniel Brown on attachment and abuse history, detail how to evaluate not just symptoms but developmental history, current functioning, dissociative processes, and attachment patterns. The resulting case formulation guides treatment planning—determining how much Phase 1 work is needed, which modalities may be indicated, what pace the patient can tolerate.

How This Research Is Used in the Book

Courtois and Ford's framework for treating complex trauma appears throughout Narcissus and the Child as the clinical foundation for understanding recovery from narcissistic abuse. The book applies their phased treatment model to illuminate what healing requires when the wound is developmental and relational.

In Chapter 12: The Unseen Child, the framework explains why survivors of narcissistic parenting require a fundamentally different treatment approach:

"Interpretation without safety replicates original neglect."

This insight, drawn from Courtois's work, captures a central dilemma in treating narcissistic abuse survivors. Therapists trained in insight-oriented approaches may interpret a patient's defences or illuminate unconscious dynamics—valuable interventions in other contexts. But for survivors whose earliest experiences taught them that their perceptions were wrong, whose emotional expressions were punished, and whose needs were systematically ignored, interpretation before establishing safety recreates the original trauma. The child learned that their inner experience didn't matter; the therapist unwittingly confirms this by moving too quickly to "the work" before establishing that the patient's experience matters and is safe to express.

In Chapter 16: The Gaslit Self, Courtois and Ford's phased model guides the discussion of gaslighting recovery:

"Recovery from gaslighting follows the phased trauma treatment model Courtois and Ford describe: safety and stabilisation first, processing second, integration third. Rushing to 'process' gaslighting experiences before developing the capacity to trust one's own perceptions again can overwhelm a system still calibrated to doubt itself."

This application recognises that gaslighting creates a specific wound—the destruction of trust in one's own perceptions—that must be addressed in the stabilisation phase. A survivor who cannot yet trust their own experience cannot safely process memories; they will doubt whether the memories are accurate, whether their responses were justified, whether they are making a big deal out of nothing. Stabilisation for gaslighting survivors specifically includes rebuilding the capacity to perceive and trust internal states.

In Chapter 21: Breaking the Spell, Courtois and Ford's framework structures the entire discussion of healing from narcissistic abuse:

"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... For survivors of narcissistic abuse, Phase 1 often comprises 70-80% of treatment time."

The book emphasises that the extended stabilisation phase is not a failure to get to "real" work but reflects the depth of what narcissistic abuse does. Survivors must learn emotional regulation skills their parents never taught, develop the capacity for safe connection their attachment relationships undermined, and establish present-day safety that chronic childhood threat never allowed. Only then can they turn toward processing traumatic memories with sufficient resources to tolerate what they encounter.

Why This Matters for Survivors

If you experienced narcissistic abuse—whether from a parent, partner, or other significant figure—Courtois and Ford's research provides both validation and roadmap for your healing journey.

Your need for extensive stabilisation is not weakness or avoidance. When others recovered from trauma seem to move more quickly, when well-meaning friends suggest you should be "over it" by now, when even therapists push toward processing before you feel ready, Courtois and Ford's research provides scientific validation for your experience. Complex PTSD from prolonged relational trauma requires a different treatment sequence than single-incident trauma. The skills that safe development naturally provides—emotional regulation, distress tolerance, capacity for trust, stable sense of self—were not installed during your childhood. They must be built now, explicitly and patiently, before you can safely approach the most painful memories. Taking the time to build these foundations is not procrastination; it is precisely what the world's leading trauma experts recommend.

The overwhelming experiences you had in therapy make sense. Many survivors have been harmed by therapy that moved too fast. Perhaps you felt flooded during sessions, dissociated and couldn't remember what was discussed, left feeling worse than when you arrived, or eventually dropped out believing you were untreatable. Courtois and Ford's research explains what went wrong: trauma processing was attempted before you had the internal resources to tolerate it. This is not your failure—it's a mismatch between treatment approach and your specific needs. Complex trauma requires phase-based treatment. If you've had bad experiences with therapy, Courtois and Ford's framework can help you understand what went wrong and seek treatment that respects where you actually are.

The therapeutic relationship may be the most important factor. For survivors whose primary relationships taught that connection means danger, that trusting leads to betrayal, that showing vulnerability invites exploitation, the idea of trusting a therapist can feel impossible or terrifying. Courtois and Ford validate these fears while demonstrating that the therapeutic relationship is central to healing. The consistent, boundaried, attuned presence of a good therapist provides experiences that begin to update your internal models of what relationships can be. You don't have to trust immediately—in fact, your caution is appropriate given your history. Trust develops through accumulated experience over time. The therapist's reliability, their ability to repair ruptures, their genuine care combined with appropriate boundaries—these experiences gradually teach your nervous system that safe connection is possible.

Your symptoms reflect adaptation, not pathology. The hypervigilance that keeps you constantly scanning for danger, the difficulty regulating emotions that sometimes overwhelm you, the dissociation that protected you from unbearable realities, the relationship patterns that recreate familiar pain—these are not signs that something is fundamentally wrong with you. They are adaptations. Your system learned to survive the environment it was in. Courtois and Ford's framework reframes Complex PTSD symptoms as survival responses that were adaptive in trauma but have become problematic in safety. Recovery involves not eliminating these responses but gradually helping your system learn that the environment has changed, that safety is possible, that the adaptations that served you then can give way to responses suited to now.

Multiple treatment modalities may serve different needs. Courtois and Ford's comprehensive approach suggests that different modalities address different aspects of complex trauma. Cognitive work can address distorted beliefs; somatic approaches can address trauma held in the body; EMDR can process traumatic memories; couples therapy can address relational patterns; group therapy can provide normalisation and interpersonal skill practice. You don't have to find the one perfect treatment—different approaches may serve you at different stages or for different symptoms. What matters is that whatever modalities are used, they are applied within the phased framework that prioritises stabilisation and proceeds at a pace your system can tolerate.

Clinical Implications

For psychiatrists, psychologists, and trauma-informed healthcare providers, Courtois and Ford's framework has direct implications for assessment, treatment planning, and therapeutic stance with narcissistic abuse survivors.

Assessment must capture the full Complex PTSD picture. Standard PTSD measures (PCL-5, CAPS) may miss the affect dysregulation, dissociative symptoms, negative self-concept, and interpersonal difficulties central to Complex PTSD. Courtois and Ford recommend comprehensive assessment including: developmental trauma history (timing, duration, perpetrator relationship); current symptom presentation across all Complex PTSD domains; dissociative processes (DES, MID); attachment patterns; current functioning and safety; strengths and protective factors. 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, not merely standard PTSD assessment.

Phase 1 is treatment, not preparation for treatment. Courtois and Ford emphasise that stabilisation work—establishing safety, building emotional regulation skills, developing the therapeutic alliance—represents active, essential intervention, not preliminary steps before the "real" work begins. For many complex trauma patients, the majority of treatment time appropriately occurs in Phase 1. Clinicians should resist pressure—from patients eager to "process," from insurers seeking brief treatment, from their own training that privileges insight—to rush through stabilisation. Skills training in affect regulation, grounding techniques, distress tolerance, and interpersonal effectiveness addresses core deficits that developmental trauma created. The therapeutic relationship provides co-regulatory experiences that may be genuinely novel for the patient. These are not secondary to trauma processing; they are its necessary foundation.

The therapeutic relationship requires particular attention. For patients whose trauma occurred in primary attachment relationships, the therapy relationship activates attachment schemas and carries unique weight. Courtois and Ford detail how to anticipate and work with attachment dynamics: the patient's testing of the therapist's reliability, hypervigilance about the therapist's emotional state, difficulty tolerating separations (between sessions, during vacations), fear that expressing needs will lead to abandonment or exploitation. These dynamics are not obstacles but opportunities—the relationship provides a laboratory for developing new relational capacities. Therapists must maintain consistent, boundaried, warm presence through the patient's testing, repair ruptures that inevitably occur, and regulate their own nervous systems well enough to provide co-regulation. This has implications for treatment frequency, session length, therapist self-care, and supervision.

Dissociation requires specialised approaches. Courtois and Ford address dissociation extensively, recognising it as a core feature of complex trauma that requires specific clinical attention. Dissociative processes range from mild disconnection to full dissociative disorders. Clinicians must assess dissociative symptoms, understand their protective function, and proceed carefully—trauma processing with a highly dissociative patient can trigger severe dissociation that retraumatises rather than heals. Phase 1 work focuses on developing grounding skills, expanding window of tolerance, and building sufficient ego strength before approaching traumatic material. The book details how to work safely with dissociative phenomena, when to slow down, and when specialised dissociation treatment may be indicated.

Treatment planning must include realistic duration. Courtois and Ford support 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. Treatment may span years, with Phase 1 potentially requiring a year or more before Phase 2 work can safely begin. Clinicians must document the specific nature of the presentation—prolonged, developmental trauma affecting multiple domains of functioning—to justify treatment matching the clinical picture. When insurance limits sessions, prioritise Phase 1 work; it is better to stabilise thoroughly than to rush into incomplete processing.

Consider adjunctive modalities based on presentation. Courtois and Ford's inclusion of multiple treatment modalities suggests that comprehensive treatment may combine approaches. Pharmacotherapy can support stabilisation by addressing symptoms like severe depression, anxiety, or sleep disturbance that impede therapy engagement. Body-based approaches (somatic experiencing, sensorimotor psychotherapy) address trauma held in the body that talk therapy alone may not reach. EMDR can process specific traumatic memories once the patient is stabilised. Group therapy can address interpersonal skill deficits and provide normalisation. Internal Family Systems can address fragmentation and self-alienation. Clinicians should consider which modalities fit the patient's presentation and coordinate care when multiple providers are involved.

Broader Implications

Courtois and Ford's framework for understanding and treating complex trauma extends beyond individual therapy to illuminate patterns across families, institutions, and society.

The Intergenerational Transmission of Dysfunction

Narcissistic parents typically have their own unprocessed trauma histories. Courtois and Ford's framework explains the mechanism of intergenerational transmission: parents who never developed affect regulation capacities cannot teach what they don't possess. Parents whose attachment relationships were characterised by fear cannot provide the secure base their children need. Parents whose sense of self was damaged by their own childhood abuse may use their children to repair that self—the core dynamic of narcissistic parenting. The skills that should transmit through safe attachment relationships fail to transfer, creating children who become parents who create children caught in the same patterns. Understanding complex trauma as a skills deficit—not merely a wound—suggests intervention points: helping parents develop the capacities they missed may protect the next generation.

Relationship Patterns in Adulthood

Adults with unaddressed Complex PTSD from childhood often find themselves in relationships that replicate familiar dynamics. Courtois and Ford'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. Trauma bonding creates neurochemical patterns that stable relationships cannot replicate. Recovery includes developing the relational skills that allow different choices—recognising red flags, maintaining boundaries, tolerating healthy intimacy that initially feels boring compared to chaos.

Workplace and Organisational Dynamics

Courtois and Ford's identification of affect dysregulation and interpersonal difficulties illuminates workplace struggles common among survivors. Difficulty asserting boundaries, problems with authority relationships, sensitivity to perceived criticism, tendency toward people-pleasing, hypervigilance about others' moods—these affect professional functioning in predictable ways. Patterns developed for survival in abusive families carry forward into work environments. Hierarchical workplaces with unpredictable leadership, public criticism, or chronic uncertainty keep trauma survivors' nervous systems activated. Organisations that understand this can design management practices—clear expectations, private feedback, predictable processes—that support rather than retraumatise. Employee assistance programmes could incorporate phase-based understanding when referring to treatment.

Legal and Policy Considerations

The expert consensus on phase-based treatment 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. Child welfare agencies making placement decisions should recognise that removing children from abusive homes during developmental windows prevents the Complex PTSD that would otherwise result—early intervention has enormous downstream benefits. 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

Courtois and Ford'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 capacities early can buffer against the impact of adverse home environments. Teachers who recognise trauma responses—not as defiance but as dysregulation—can respond with regulation support rather than punishment. School-based prevention may not eliminate trauma's occurrence but can build resilience by developing skills that traumatic home environments fail to provide. Universal delivery means at-risk children receive skill-building even without identification of their home situations.

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 Courtois and Ford identified. Primary care providers who understand the connection between childhood adversity and adult physical health can assess for trauma history when treating medically unexplained symptoms.

Limitations and Considerations

Courtois and Ford's influential work has limitations that inform its application.

Evidence base is still developing. While the phased treatment model has broad clinical consensus, the research base consists more of clinical wisdom and theoretical coherence than large randomised controlled trials. Some specific modalities described (sensorimotor psychotherapy, IFS for trauma) have smaller evidence bases than others (CPT, PE, EMDR). Clinicians should be transparent about the state of the evidence while recognising that expert consensus has value, particularly for populations underrepresented in RCTs.

The phase model may oversimplify clinical reality. While the three-phase sequence provides essential structure, clinical reality is often recursive—patients may revisit earlier phases as new material emerges, external crises disrupt stabilisation, or deeper layers of trauma surface. Strict linear adherence may miss the natural rhythm of healing. The model provides framework for clinical judgment, not a rigid protocol.

Cultural adaptation requires attention. The frameworks emerged primarily from Western clinical populations and contexts. How trauma manifests, is expressed, and is healed varies across cultures. What constitutes appropriate emotional expression, healthy boundaries, and helpful therapeutic relationships differs cross-culturally. The book includes a chapter on cultural competence by Laura Brown, but clinicians must actively adapt principles to their specific patient populations.

Accessibility remains a challenge. The comprehensive, long-term treatment Courtois and Ford describe—potentially years of intensive therapy combining multiple modalities—is beyond the reach of many survivors due to cost, insurance limitations, provider availability, and time constraints. The gap between evidence-based treatment and real-world access is substantial. Adapted, briefer, and more accessible versions of phase-based treatment need continued development.

Individual variation is substantial. Not all survivors of similar adverse experiences need identical treatment. Protective factors—including temperament, the presence of at least one safe attachment figure, and post-trauma support—moderate outcomes. Some patients with strong pre-existing resources may proceed to trauma processing more quickly; others may need extended stabilisation. The framework should inform individualised treatment planning, not replace clinical judgment.

Historical Context

Treating Complex Traumatic Stress Disorders appeared in 2009 at a critical moment in the trauma field's development. Judith Herman had proposed Complex PTSD in 1992, describing a syndrome of affect dysregulation, identity disturbance, and relational difficulties that emerged from prolonged relational trauma. However, Complex PTSD remained absent from the DSM, and the dominant evidence-based trauma treatments had been developed and validated primarily with combat veterans and sexual assault survivors experiencing single-incident trauma.

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."

Courtois brought to this challenge decades of clinical experience. Her pioneering work on incest survivors, beginning with her 1979 dissertation and continuing through Healing the Incest Wound (1988) and Recollections of Sexual Abuse (1999), had established her as a leading authority on treating sexual abuse survivors. Ford brought expertise in developmental psychopathology and the neurobiological effects of trauma. Together, they assembled the field's leading experts—Judith Herman contributing the Foreword, Bessel van der Kolk the Afterword, with chapters from John Briere, Marylene Cloitre, Diana Fosha, Janina Fisher, Pat Ogden, Richard Schwartz, Susan Johnson, and others.

The resulting volume gave formal structure to the clinical wisdom that complex trauma requires something fundamentally different—not adjusted dosing of the same medicine but a different treatment architecture altogether. The phased model, the emphasis on stabilisation, the centrality of the therapeutic relationship, the comprehensive coverage of modalities adapted for complex trauma—these provided a framework that could inform training, clinical guidelines, and research priorities.

The book's influence has been substantial. It is cited thousands of times in the clinical literature and has shaped training programs internationally. When ICD-11 recognised Complex PTSD in 2018, the phased treatment model Courtois and Ford articulated was already the standard of care among clinicians working with this population. The second edition (2020) updates the science and expands coverage, ensuring the work remains current as the field advances.

For survivors and clinicians navigating the complex trauma treatment landscape, this volume represents a watershed: the definitive clinical guide for treating the prolonged, relational trauma that narcissistic abuse creates.

Treating Complex Traumatic Stress Disorders: An Evidence-Based Guide

APA Citation