Compassion-Focused Therapy Change Mechanisms in a Complex PTSD Population

Study 1: Investigating the Relationships between Shame, Compassion, and ICD-11 Complex PTSD Symptom Clusters

Complex Post-Traumatic Stress Disorder (CPTSD) is characterised by six symptom clusters with three core PTSD symptoms (re-experiencing, avoidance, and a current sense of threat) and three disturbances in self-organisation (DSO) symptoms (affective dysregulation, negative self-concept, and disturbances in relationships; World Health Organisation [WHO], 2021). Shame may play a significant role in CPTSD, and compassion may be important for reducing shame and treating CPTSD. However, the relationships between shame, compassion, and the DSO symptom clusters have not yet been investigated. This cross-sectional study investigated associations between shame (global, internal, external), self-compassion, the ability to receive compassion from others, and DSO symptom clusters in a treatment-seeking CPTSD population. Multiple regression analyses with wild bootstrapping were performed on pre-treatment data from a pre-existing database of 75 adults with probable CPTSD, controlling for multicollinearity. The three-predictor model (self-compassion, compassion from others, and global shame) accounted for significant variance in negative self-concept. Compassion from others was a unique negative predictor of disturbances in relationships. This suggests that the ability to receive compassion from others may be crucial for interpersonal difficulties in CPTSD. However, the model did not account for significant variance and had no unique predictors for affective dysregulation. Self-compassion and global shame also did not demonstrate significant unique associations with the DSO symptom clusters. The complex interplay between shame, compassion, and other factors in CPTSD symptoms warrants further investigation. The findings have implications for psychological interventions targeting interpersonal functioning in CPTSD.


Study 2: Change Mechanisms within a Compassionate Resilience Group for Complex Post-Traumatic Stress Disorder: A Single Case Experimental Design

Shame is a core feature of Complex Post-Traumatic Stress Disorder (CPTSD) that can significantly impair functioning. Compassion-Focused Therapy (CFT) aims to reduce shame and self-criticism by developing compassion. This study used a multiple-baseline single-case experimental design (SCED) to investigate the change mechanisms of a CFT-based Compassionate Resilience Group (CRG) intervention for adults with CPTSD, focusing on shame, self-compassionate action, social safeness, heart rate variability (HRV), and the three flows of compassion. Three participants with probable CPTSD were randomly allocated to different baseline lengths (one, two or three weeks) before starting the 13-session CRG intervention. Shame, self-compassionate action, social safeness, and HRV were measured daily using visual analogue scales and an HRV smartphone application. The three flows of compassion and global, internal, and external shame were assessed weekly using standardised measures. Data were analysed using visual analysis, Tau-U, Non-overlap of All Pairs, reliable change index, and clinically significant change. Participants showed mixed responses to the intervention. One participant demonstrated a significant decrease in shame and reliable improvements in compassion for and from others. Other participants showed no significant changes or increased shame, with limited data due to attrition. The study provides preliminary evidence for the CRG's potential to influence shame and particular compassion flows. However, the findings are limited by the small sample and high attrition. Further research with larger samples is needed to establish the intervention's efficacy and change mechanisms. The study highlights the importance of considering shame measurement and adopting a long-term, compassionate approach in CPTSD treatment.


The Effectiveness of Compassion-Focused Therapy for the Three Flows of Compassion, Self-Criticism, and Shame in Clinical Populations: A Systematic Review

Compassion-Focused Therapy (CFT) has shown promise for addressing mental health conditions, but reviews have lacked focus on CFT interventions and CFT’s key theoretical change mechanisms. This limits our understanding of how CFT specifically impacts the components it aims to target, such as the compassion flows, self-criticism, and shame, which might be crucial for compassionate change. This systematic review included literature from 2000 to 2024, evaluating the effectiveness of CFT on the three flows of compassion, self-criticism, and shame in 16 studies involving clinical populations. Outcomes were assessed from pre-intervention to post-intervention and pre-intervention to follow-up, with narrative synthesis. The risk of bias was appraised. The review showed preliminary findings on the effectiveness of CFT for compassion flows, self-criticism, and shame among clinical populations. Outcomes demonstrated consistent improvements in self-criticism (12 studies) and self-compassion (eight studies), with small to large effects. Reductions in external shame were also observed (six studies). There was limited and inconsistent evidence for internal shame (one study), the ability to give compassion to others (three studies), and the ability to receive compassion from others (two studies). Follow-up analysis was conducted for three studies and suggested some maintenance of outcomes, but findings were inconsistent. Certainty and clinical applicability are currently limited due to the need for more rigorous, standardised research addressing design, measurement, and sampling limitations. Further research is needed to understand the impact of CFT on interpersonal compassion and shame.