Compassion focused therapy and prolonged exposure compared in 41 adults with complex PTSD
- Researchers in Mexico City randomized 41 adults who met ICD-11 criteria for complex PTSD to individual compassion focused therapy (CFT, n = 21) or prolonged exposure (PE, n = 20): weekly 60-minute teletherapy sessions over 12 to 15 weeks, with assessment at baseline, after treatment and at six months.
- Complex PTSD symptoms fell over time in both groups, with no significant time by group interaction and no group effect. On the International Trauma Questionnaire, CFT dropped 14.95 points by the end of treatment (d = 1.95) and 16 points by follow-up (d = 2.08); PE dropped 17.15 points (d = 2.23) and 17.75 points (d = 2.31).
- Treatment was completed by 16 of 21 participants in CFT (76.19%) and 12 of 20 in PE (60%). Among completers, remission was reported in 13 (81.25%) and 10 (83.33%).
- Compassion measures moved differently: compassion from others rose only in CFT, while compassion for others fell only in PE, by 15.20 points from baseline to follow-up.
The trial set a protocol written for complex PTSD against the established exposure treatment, both delivered one to one by video. Recruitment ran through social media advertising across Mexico: 318 adults were screened, 104 met the questionnaire criteria for complex PTSD, and 41 consented and were randomized. Most were women (75.6%), aged 18 to 65.
Two arms, one hour a week
CFT began with psychoeducation and breathing regulation, moved to safe-place imagery, then spent one 90-minute session on shame memory work before turning to a compassionate biography and relapse prevention. PE followed the standard sequence of psychoeducation, in vivo exposure and imaginal exposure, shortened from 90 to 60 minutes; the first imaginal session, in session 3, ran 90 minutes. The 22 therapists were master's students or recent graduates, trained for 8 hours and supervised weekly by a trauma specialist.
Symptoms, shame and compassion
Shame fell in both arms (CFT by 20.76 points, PE by 17.85, no group difference), and so did self-criticism, depression, anxiety, stress and dissociation. The two arms separated only on the compassion scales. Compassion from others rose in CFT by 18.38 points after treatment and 20.62 at follow-up, with no significant change in PE. Compassion for others stayed stable in CFT and fell in PE by 15.20 points from baseline to follow-up. Results among completers were similar.
Choosing between them
In this trial the symptom outcome does not separate the two methods, so the choice can be made on other grounds. The question for a client with complex PTSD is what they can sustain: repeated, detailed retelling of the trauma memory, or work that starts from shame and self-criticism. Fewer people left CFT (24% against 40%), though the authors did not record why anyone left. In practice that means describing both options and their rationale at assessment, asking which the client is ready for, and reviewing the fit around sessions 3 to 4, when imaginal exposure begins. The therapist's training should not decide it.
In this trial, symptom reduction in complex PTSD did not differ between CFT and prolonged exposure, so the choice can rest on what the client can tolerate and is ready for.
Forty-one participants recruited through social media advertising in one country, treated by master's students and recent graduates. Follow-up ended at six months. The authors note that the sample size limits generalizability, that reasons for dropout were not systematically recorded, and that independent replication is needed.