Ideal victims

Rape victims are more likely to be racialised, economically disadvantaged or disabled.7 The majority of rapes occur in private settings, often perpetrated by someone known to the victim.6 Common trauma responses include freezing, going numb or reassuring the perpetrator1—reactions that contradict societal expectations of ‘proper’ victim behaviour. Historically, a select, small group of victims fitting these ideals gained recognition, allowing a larger number to remain unseen.5

As table 1 illustrates, the ‘ideal victim’ concept can be usefully expanded to include the ‘ideal trauma’ and ‘ideal trauma responses’. While cPTSD broadens our understanding, its name—although likely to produce kinder contingencies—carries a risk: it implies it is the phenotype for reactions to complex trauma, not a phenotype. This could potentially compound exclusions and reinforce tendencies to ‘unvictim’.

Unvictiming

Unvictiming manifests through interconnected mechanisms, each demanding a deeper, hermeneutic approach to trauma recognition:

• Self-unvictiming: survivors internalise societal victimhood ideals, deeming themselves unworthy when their experiences do not fit conventional narratives. For instance, a gang member might not see being earlier given food and attention as exploitative grooming.

• Societal and institutional unvictiming: this occurs when formal systems like healthcare or legal institutions fail to recognise traumas that do not fit the ‘ideal’ victim narrative. For example, racial trauma is often under-recognised in clinical settings, limiting access to appropriate care.

• Cultural unvictiming: broader cultural norms can obscure certain traumas by dictating what is considered legitimate suffering. For example, a patient who lacks the language or resources to articulate emotional abuse as trauma may have their experiences dismissed, as acts of commission tend to be seen as more severe than acts of omission, perpetuating their invisibility.

Unvictiming—both internalised and reinforced by societal and institutional ideals—highlights a critical issue in our understanding of cPTSD: the potentially dangerous assumption that all complex trauma can be safely thought about, spoken of and heard within a relatively short timeframe after initial contact. This assumption is problematic because addressing prolonged trauma requires hermeneutic resources from both sides and significant risk for the patient in speaking and emotional capacity from the clinician in listening. Additionally, the dynamic nature of trauma often means it exists in a state that is not immediately recognisable or easily articulated.

For example, consider how our recognition of misdiagnosed attention deficit hyperactivity disorder and autism—and the iatrogenic harm caused by these misdiagnoses—has increased dramatically in the past 5 years. These issues were not non-existent before, but like sexual harassment and marital rape, they were not widely spoken of or understood within a shared framework. Even if trauma is thinkable, as ‘by and for’ groups have repeatedly told us, it is often not safe to speak openly for fear of not being heard and facing retaliation or dismissal.8 9

While we must be cautious not to overapply trauma as a lens, we cannot let psychiatry’s history of overpathologising (eg, schizophrenogenic parents, refrigerator mothers) prevent us from expanding our understanding of what it truly takes to explore traumatic experiences. Levelling the playing field here requires active and ongoing efforts at a systems level. However, small acts of micro-recognition (table 2) make a real difference too, serving as antidotes to unvictiming by registering and validating these overlooked experiences.

Unrecognised trauma

Trauma recognition can be obscured when its effects are attributed to other diagnoses, particularly in the relationship between cPTSD and its closest nosological neighbour, borderline personality disorder (BPD). Patients labelled with BPD are overwhelmingly traumatised: 71% of those diagnosed have experienced complex trauma, and they are 3.15 times more likely to have endured childhood maltreatment compared with adults with other psychiatric disorders and 13.91 times more likely than the general population.10 cPTSD was specifically designed to offer a kinder label to these individuals, as its originator, Judith Herman, noted that being diagnosed with a personality disorder was often perceived as ‘little more than a sophisticated insult’.1 Paradoxically, the introduction of cPTSD has reinforced the seeming validity of BPD, as direct comparison often does.4 This would be less concerning if three conditions were met: (1) cPTSD and BPD were shown to be discrete diagnoses; (2) they required different treatments and (3) the constructs were beneficial for both patients and clinicians. However, these conditions are unmet.

Discrete diagnoses: the distinction between trauma survivors diagnosed with cPTSD and BPD is minimal, not based on the presence of DOS but on how they manifest. Emerging literature suggests that cPTSD tends towards withdrawal and ego-dystonic traits, while BPD leans towards object-seeking and rejection tendencies.11 To illustrate, imagine two people at risk of drowning—one labelled with cPTSD might cling more persistently to a life raft, reflecting quieter withdrawal and avoidance, while the one with BPD might oscillate between louder attempts to reach the lifeguard for help and moments of despair, clinging back to the raft. Both reactions are reasonable responses to trauma; in fact, we might even admire the more vocal attempts to seek help. The underlying predicament is the same, so the high comorbidity rates are no surprise: 79% of cPTSD cases are comorbid with BPD in inpatient settings, and 40.5% of BPD cases are comorbid with cPTSD across both inpatient and outpatient samples.12 Additionally, BPD’s high heterogeneity,13 encompassing 256 possible symptom combinations, undermines its utility.4

Different treatments: therapies packaged for BPD, such as dialectical behaviour therapy and mentalisation-based therapy, are equally and adequately but not exceptionally effective11; they address transdiagnostic, non-specific issues such as emotional dysregulation14 and mentalisation.15 Medication is not recommended, and neurobiological findings have not been proven to be specific to BPD, indicating they are not specific to broad trauma sequelae.11 Emerging evidence suggests therapy is similarly effective for cPTSD.16 Most BPD and cPTSD interventions work through a phase-based approach with an initial phase dedicated to stabilising emotions and grounding before active treatment. Here lies the difference. For cPTSD, the second phase often involves trauma processing, such as Eye Movement Desensitization and Reprocessing (EMDR) or Trauma-focused cognitive behavioral therapy (TF-CBT),16 that is, trauma processing. For BPD, the second phase typically focuses on mitigating self-harm and suicidal thoughts.11 BPD therapies have high dropout rates,11 which many attribute to the focus on service goals rather than desired trauma processing.9 This is unnecessary, as trauma therapy is safe and effective for patients with BPD.17

Utility: although clinical pathways are more developed for BPD than cPTSD, BPD has the least functional utility of any diagnosis.18 This means that the diagnosis can lead to help and longer therapies, but it can also result in empathy being removed. BPD is associated with institutional bias consisting of emotional detachment, contempt and dismissal.4 9 While some patients find the diagnosis useful, others experience it as denigrating, echoing the accusations of early perpetrators—that they are too difficult, too manipulative or too seductive to deserve care, unlike the ‘real’ victims.1 4 9 BPD’s overinclusive nature means that all behaviour and reactions can be explained within its logic, leading to a specific epistemic injustice and deflating the credibility given to trauma testimony.4 Antistigma campaigns over two decades have largely failed to significantly change attitudes.4

Who counts as a victim

The advent of cPTSD in our diagnostic lexicon marks a watershed moment in trauma recognition. Yet, as we celebrate this progress, we must also critically examine its unintended consequences, particularly concerning two fundamental dynamics of victimology. First, we confront the persistent spectre of ‘deserving’ and ‘undeserving’ victims. The delineation between cPTSD and BPD, although well-intentioned, inadvertently reinforces this age-old division, perpetuating the very stigma that cPTSD’s introduction was meant to reduce. By embracing transdiagnostic19 and transmodality thinking, we can transcend these divisive categorisations, ensuring complex trauma is available as primary signifier to all trauma survivors who so wish.4 9 This paradigm shift allows us to escape the circular logic of maintaining diagnoses merely to preserve established pathways. Moreover, it acknowledges how attributing trauma to personality implies moral fault, echoing the earlier accusations survivors so often internalise.

Second, we must expand our conception of trauma to include the hidden and unacknowledged experiences that elude conventional frameworks. A vast landscape of trauma remains unseen because our current conceptual resources and societal ideals fail to capture its nuances. This unvictiming perpetuates a cycle where only those aligning with the ‘ideal victim’, ‘ideal trauma’ and ‘ideal response’ receive validation, while others are rendered invisible, reinforcing structural inequalities.

Trauma-informed care must confront and dismantle these trauma hierarchies. While addressing these, we must also focus on immediate, actionable steps in clinical encounters. Small acts of recognition serve as powerful antidotes to delegitimisation. As A.A. Milne wisely said, “Sometimes the smallest things take up the most room in your heart”.