An Ecological Model of Recognition: Diagnosis as a Relational Process Among Survivors of Childhood Sexual Abuse

While the diagnostic overlap between complex post-traumatic stress disorder (CPTSD) and borderline personality disorder (BPD) has received increasing scholarly attention, there remains a limited understanding of how adult women survivors of childhood sexual abuse (CSA) interpret psychiatric diagnoses within the relational contexts that shape their self-recognition and meaning-making processes. This study investigated the processes by which adult women survivors of CSA, diagnosed with CPTSD and/or BPD, understand their experiences of abuse, interpret their psychiatric diagnoses, and integrate these distinct yet interconnected aspects of their lived experience. Semi-structured interviews were conducted with 19 adult women survivors of CSA, and the resulting data were analyzed employing interpretive description and reflexive thematic analysis. This analysis identified a central theme: making sense of the abuse and its consequences over time. This theme encompassed four subthemes: fragmented memory, containment, and silence; internal struggles of recognition and interpretation; familial validation and invalidation; and institutional responses that either connected or failed to connect trauma to its consequences. Across these domains, psychiatric diagnoses served as relational frameworks, with their meaning being negotiated across intrapsychic, familial, and institutional contexts. These findings propose a preliminary socioecological framework that extends Kelley et al.'s model of traumatic stress to the concept of recognition itself, herein conceptualized as relational and dynamically unfolding. Clinically, these findings underscore the importance of trauma-informed diagnostic communication that collaboratively explores possible links between current difficulties and abuse history while attending to safety, pacing, and readiness. They also highlight the importance of institutional practices that integrate trauma-related information across services and into clinical formulation.