patients had histories of trauma, those with the diagnosis of borderline personality disorder had the most severe abuse histories. The younger the patients were when the abuse occurred, the more extreme was their dysfunction as adults, including suicidal and self-injurious behaviors. Other studies have validated these findings (Cozolino, 2014; van der Kolk, 2014). Although there is significant overlap in symptoms between personality disorders and trauma, it is also important to consider the unique aspects of personality disorders compared to PTSD. Ford and Courtois (2021) note distinct differences in the ways that emotion dysregulation, negative self-perceptions, and relational problems present in complex PTSD compared to borderline personality disorder. For example, complex PTSD often involves more difficulties with numbing and self-soothing compared to emotional lability/dyscontrol, and relational avoidance with complex PTSD is based on fear of closeness as opposed to avoidance of abandonment. Appropriate diagnosis in these areas is necessary to ensure proper treatment. Case Example Beth had a diagnosis of borderline personality disorder, PTSD, and depression. She had multiple somatic complaints, unstable and short-term relationships, and history of cocaine addiction. She also smoked marijuana daily. By age 42, she had attempted therapy with seven different therapists; however, she had not stayed longer Posttraumatic Stress Disorder and Culture According to Schnyder and colleagues (2016, p. 7): Given the increasing globalization of our world, we all interact on a daily basis with people from cultural backgrounds different from ours, and this is true for both our private and our professional lives. In response to this reality, practitioners working with trauma survivors need to further develop their cultural competence and sensitivity . A consensus is growing that to truly understand any psychological phenomenon or disorder, “it needs to be contextualized” and positioned “within cultural parameters” (Van Rooyen & Nqweni, 2012, p. 51). When referring to trauma, these insights mean that professionals need to contemplate “ethnocultural variations in the etiology, diagnosis, expression, and treatment of PTSD” (Marsella, 2010, p. 17). In the American Psychological Association’s (2017a) Clinical Practice Guideline for the treatment of PTSD in adults, it highlighted that cultural and diversity competence is necessary for appropriate clinical intervention. It notes that cultural competence entails not only learning about your client but also engaging in regular self-reflection on your ability to be respectful and appreciative of differences while treating the client. Culture is considered to be a commonly used, but poorly defined, word (Singer et al., 2016; Van Rooyen & Nqweni, 2012). Therefore, it is important to define the term culture before understanding its application to trauma. For use in this course, culture is defined as a set of shared beliefs, values, knowledge, customs, and behavioral practices. Although culture can persist across generations in stable form, it is also a mutable, multidimensional, and multilevel process (Singer et al., 2016). Initially, medical models ignored culture because it was believed that all humans perceived and responded to traumatic events in a uniform manner. This assumption was tied to the physiological response to traumatic stressors observed in all humans: The fight–flight–freeze system (Marsella, 2010). However, despite the evidence for a shared neurological response to trauma, research results increasingly reveal ethnocultural variations in
than two years with any of them before deciding that the work had stalled or that she had an irresolvable conflict with the therapist (common features of clients with a borderline personality disorder diagnosis). She had also spent time in a day treatment program and had tried two different courses of dialectical behavior therapy (DBT). As a professional, she had maintained a conflict-free sphere in her work life until the death of her mother from cancer when Beth was just shy of 50 years old, at which time she became unable to work. Her history included extensive medical trauma from urinary tract surgeries between the ages of 4 and 7 years, a clinically depressed mother who was often barely functional, and physical and sexual abuse by her older brother Eddie that she believes began when she was 10 years old. When she told her workaholic father about the abuse, his solution was to tell her to “just stay away from Eddie.” Her mother yelled at the brother to “leave Beth alone” but was unable to enforce any boundaries or separation. This abuse continued until Beth was 16 years old, when she called the police to come to the house after her brother choked her and left bruise marks. The situation embarrassed her professional father so much that he sent Eddie away to boarding school. This cluster of multiple forms of abuse and neglect and the experience of helplessness and nonprotection from caregivers served to crystallize Beth’s personality around these traumas. the development, presentation, and duration of trauma symptoms, as well as the effectiveness of various treatment protocols (Ennis et al., 2020; Hinton & Lewis-Fernandez, 2019). Additionally, it has been noted that an emphasis on diagnostic presentation suggests that the issue is the individual’s symptoms in response to trauma, as opposed to the causes of these traumas (e.g., systematic oppression) (Dupuis-Rossi & Reynolds, 2018). Including cultural influence in both the experience and sequelae of trauma is a progressive shift away from an overly Westernized medical model that minimizes individuality. This change in thinking fits well with an integrative, holistic approach to trauma. Van Rooyen and Nqweni (2012, p. 51) propose a “middle ground” when it comes to the intersection of a formal PTSD diagnosis and culture. They suggest that professionals should neither dismiss PTSD as a Western-created disorder nor refuse to see that culture affects the universal biological responses to stress. Instead, they should rely on useful diagnostic criteria while engaging in cultural sensitivity that accounts for cultural variations across groups. Changes made to the PTSD criteria in the DSM-5 represent a noteworthy shift toward Van Rooyen and Nqweni’s (2012, p. 51) “middle ground.” As Williams and colleagues (2014, p. 102) note, the definition of trauma now includes “repeated exposures to details about a trauma,” which accounts for the discriminatory and intergenerational trauma of some cultural groups (also known as historical trauma; e.g., African Americans and the violent history of slavery). Although culture is not always easily discernible, it influences the experience and presentation of trauma in a multitude of ways. Culture acts to filter perceptual reality and may influence interpretations and meaning-making during and after a traumatic experience (Hinton & Lewis- Fernandez, 2019; Schnyder et al., 2016). That is, even if the human biological response to trauma is relatively unchanged across cultural groups, vulnerability to trauma varies based on variables such as levels of stress and local means of the trauma (Hinton & Lewis-Fernandez, 2019). Cultural beliefs can affect individuals’ appraisal systems, including what they deem to be stressful or not stressful (Schnyder et al., 2016).
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