Systemic Betrayal
Social Determinants and Depression in Complex PTSD Survivors
Abstract
Survivors of Complex Post-Traumatic Stress Disorder (C-PTSD) often endure prolonged emotional suffering, not only as a result of early interpersonal trauma but also due to ongoing treatment deprivation and social mistreatment. Secondary harms, such as institutional betrayal, medical gaslighting, and systemic neglect, can compound psychological distress, intensifying depressive symptoms and obstructing recovery. This paper explores the relationship between C-PTSD and depression through the lens of social invalidation, integrating insights from neurobiological research, trauma literature, case studies, and critical evaluations of dominant depression paradigms. The findings underscore an urgent need for trauma-informed systems, equitable access to consistent care, and structural reforms aimed at preventing retraumatization and resisting the pathologization of contextually rooted suffering.
Introduction
Complex Post-Traumatic Stress Disorder (C-PTSD) is a trauma-related condition that arises from chronic or repeated interpersonal trauma, often beginning in early childhood. It is frequently comorbid with Major Depressive Disorder (MDD), with evidence indicating that individuals with C-PTSD are at significantly higher risk for developing depression than the general population. Although psychological and biological mechanisms contribute to this comorbidity, the role of social determinants, such as treatment deprivation and adverse experiences within care systems, remains critically important and often underexamined. Survivors may face dismissive or uninformed healthcare providers, inaccessible or inappropriate interventions, and retraumatizing institutional environments. These systemic failures can reinforce core trauma beliefs related to worthlessness, helplessness, and abandonment, thereby intensifying depressive symptoms. Such dynamics reflect Judith Herman’s (1992) notion of “a collapse of the inner world,” wherein sustained invalidation and neglect erode the survivor’s capacity for recovery.
Treatment Deprivation & Psychological Consequences
Treatment deprivation refers to the absence of timely, adequate, and trauma-informed care for individuals living with Complex Post-Traumatic Stress Disorder (C-PTSD). Many survivors report encountering long waitlists, premature therapy terminations, or exclusion from services due to misdiagnosis or financial barriers. As Judith Herman (1992) emphasizes, consistent and safe therapeutic relationships are foundational to healing from complex trauma. In their absence, trauma symptoms may stagnate or intensify, often leading to the emergence of depressive symptoms such as hopelessness, anhedonia, and despair.
A qualitative case study illustrates these dynamics through the experience of “Maria,” a 29-year-old woman with a history of childhood sexual abuse and foster care placement. Presenting with emotional dysregulation and intrusive flashbacks, Maria sought trauma therapy and disclosed active suicidal ideation. Despite this, she was placed on a six-month waitlist and offered only short-term cognitive behavioural therapy (CBT), which did not address the relational and somatic dimensions of her trauma. During the waiting period, her depressive symptoms worsened, culminating in a suicide attempt. Maria’s case exemplifies how systemic barriers to trauma-appropriate care can reinforce core trauma-related beliefs, like “I am unworthy of care,” that drive and deepen trauma-related depression (Burstow, 2003).
Medical Gaslighting and Institutional Betrayal
Survivors of Complex Post-Traumatic Stress Disorder (C-PTSD), particularly women, racialized individuals, and disabled people, face heightened risks of dismissal and misdiagnosis when seeking care. Medical gaslighting, a form of epistemic injustice in which patients’ accounts are minimized, dismissed, or reframed as irrational, can significantly exacerbate both post-traumatic and depressive symptoms (Mensah & Tomlinson, 2022). Survivors are frequently told their symptoms are “just anxiety” or “in their head,” leading to further self-doubt and the erosion of internal trust.
A second case example, “Jason,” a 42-year-old Black man and military veteran living with C-PTSD, reported chronic insomnia, emotional numbness, and suicidal ideation. Despite multiple emergency room visits, he was never screened for trauma. Instead, clinicians misdiagnosed him with antisocial personality disorder, a stigmatizing label that denied the underlying relational wounds of trauma. This repeated invalidation deepened his depressive symptoms, particularly feelings of worthlessness and social alienation. “They looked right through me,” Jason later stated. “I stopped believing help was real.”
Such encounters reflect what Smith and Freyd (2014) term institutional betrayal, a phenomenon in which systems charged with providing care instead perpetuate harm. In these cases, depression is not merely a downstream effect of trauma, but a consequence of its systemic reenactment and societal denial.
Social Mistreatment and the Erosion of Belonging
Relational trauma often leaves survivors with a deep, unmet longing for connection and safety. However, social mistreatment, rejection, stigma, and disbelief frequently lead to further disconnection, obstructing the relational repair essential for healing. In such contexts, depression is less the result of internal pathology and more a product of chronic isolation, emotional suppression, and invalidating social environments.
A community-based participatory research project with formerly incarcerated women provides a striking illustration (Scott et al., 2021). Many participants, most of whom had complex trauma histories, reported being re-traumatized by interactions with social welfare, healthcare, and criminal justice systems. One participant remarked, “It’s like the world is allergic to my pain,” capturing the pervasive sense of societal rejection. Across the study, this type of alienation was a strong predictor of depressive symptoms, especially among those with unresolved relational trauma. These findings underscore the role of social invalidation and systemic disregard in sustaining trauma-related depression.
Neurobiological Correlates of Social Retraumatization
Social mistreatment can evoke neurobiological responses that closely mirror those triggered by the original trauma. Chronic experiences of invalidation, rejection, and neglect have been shown to activate the amygdala, heightening fear and threat sensitivity, while impairing the prefrontal cortex’s ability to regulate emotional responses (Lanius et al., 2010). This neural dysregulation is strongly associated with depressive states characterized by emotional shutdown, despair, and hopelessness. Furthermore, repeated social injury may suppress the production of oxytocin and dopamine, neurochemicals essential for trust, attachment, and motivation, thereby undermining the very foundations of relational recovery and emotional engagement (Porges, 2011). These physiological changes highlight how social conditions not only reflect but also perpetuate the neurobiological imprint of trauma and depression.
The Broader Problem: Pathologizing Depression
The dominant biomedical model of Major Depressive Disorder (MDD) conceptualizes depression primarily as a disorder of brain chemistry or faulty cognition. While this framework has facilitated access to pharmacological treatment and standardized care, it has simultaneously marginalized social, political, and economic determinants of mental distress. In cases where MDD is comorbid with Complex Post-Traumatic Stress Disorder (C-PTSD), research often pathologizes depression by focusing on serotonin deficits, genetic vulnerabilities, or individual coping failures, while giving insufficient attention to social determinants like systemic trauma, structural violence, and social adversity.
As Cosgrove and Whitaker (2015) argue, psychiatric research has been significantly shaped by pharmaceutical industry interests, contributing to a reductionist and biologically deterministic understanding of depression. Social determinants, like housing instability, exposure to community violence, and economic marginalization, are frequently relegated to background variables, if acknowledged at all. Moncrieff and Cohen (2006) have further challenged the chemical imbalance theory, contending that antidepressants often induce altered mental states rather than legitimately correcting neurobiological defects.
Epidemiological studies consistently show that low-income populations, racialized groups, and trauma survivors experience disproportionately high rates of depression (Lorant et al., 2003), yet these findings remain underrepresented in dominant treatment models. Friedli and Stearn (2015) critique how contemporary mental health systems, especially within neoliberal frameworks, individualize suffering and pathologize despair while obscuring its structural origins.
This disconnect produces research and clinical models that treat the symptoms of systemic harm as individual pathology, offering medicalized solutions to what are often political, relational, and existential wounds. For survivors of C-PTSD, many of whom already contend with abandonment, betrayal, and internalized shame, this erasure of social context can retraumatize, reinforcing the very conditions that sustain their depression.
Conclusion
Depression in survivors of Complex PTSD should be understood not merely as an individual pathology, but as a consequence of systemic and social failures. Treatment deprivation, institutional betrayal, and interpersonal invalidation are not necessarily secondary to trauma, and may be extensions of it. Effective healing requires trauma-informed care that extends beyond clinical settings into all social systems, and a research agenda that centers social context, power, and justice alongside neurobiology.
References
Burstow, B. (2003). Toward a radical understanding of trauma and trauma work. Violence Against Women, 9(11), 1293–1317.
Summary: Burstow critiques traditional psychiatric models of trauma and calls for a structural understanding that includes sociopolitical oppression. Relevance: This article supports the paper's argument that depression and trauma are not merely intrapsychic but often result from systemic neglect and social mistreatment.
Herman, J. L. (1992). Trauma and recovery: The aftermath of violence, from domestic abuse to political terror. Basic Books.
Summary: Herman introduces the concept of Complex PTSD and outlines a three-stage recovery model centred on safety, remembrance, and reconnection. Relevance: The book provides foundational theory on how chronic trauma damages the psyche and why long-term, relational treatment is essential. It informs the discussion of treatment deprivation and retraumatization.
Lanius, R. A., Bluhm, R. L., & Frewen, P. A. (2010). How understanding the neurobiology of complex post-traumatic stress disorder can inform clinical practice: A social cognitive and affective neuroscience approach. Acta Psychiatrica Scandinavica, 122(2), 103–117.
Summary: This article synthesizes neuroimaging research on the brain’s response to complex trauma, highlighting changes in the amygdala, hippocampus, and prefrontal cortex. Relevance: It underpins the paper’s discussion on how social retraumatization (e.g., medical neglect or invalidation) can perpetuate biological dysregulation and depressive symptoms.
Mensah, M. O., & Tomlinson, M. (2022). The trauma of being unheard: Epistemic injustice in mental health care. Transcultural Psychiatry, 59(2), 174–190.
Summary: The authors explore how epistemic injustice, when patients’ knowledge about their own experiences is discounted, can worsen trauma and prevent healing. Relevance: This source is used to support the analysis of medical gaslighting, particularly how disbelief and dismissal of C-PTSD symptoms contribute to feelings of internalized shame, hopelessness, chronic depression and loss of trust.
Porges, S. W. (2011). The polyvagal theory: Neurophysiological foundations of emotions, attachment, communication, and self-regulation. W.W. Norton.
Summary: Porges explains how the vagus nerve regulates emotional and physiological responses to safety and threat, and how trauma disrupts this system. Relevance: This work supports the neurobiological explanation for why survivors exposed to ongoing social invalidation may remain trapped in depressive, shut-down states linked to dorsal vagal dominance.
Scott, S., Snyder, C., & Baines, D. (2021). Women, incarceration, and complex trauma: A participatory study of community-based trauma-informed practice. Affilia: Journal of Women and Social Work, 36(1), 35–53.
Summary: This study uses participatory methods to explore how women with trauma histories experience service systems post-incarceration, documenting patterns of retraumatization and social exclusion. Relevance: The paper draws on this study to demonstrate how survivors often feel re-injured by the very systems meant to support them, resulting in intensified depressive symptoms and emotional despair.
Smith, C. P., & Freyd, J. J. (2014). Institutional betrayal. American Psychologist, 69(6), 575–587.
Summary: This article defines and explores "institutional betrayal," where organizations betray the trust of individuals depending on them, exacerbating trauma. Relevance: It directly supports the essay’s argument that mistreatment by healthcare or legal systems is not a neutral error but a profound source of harm that deepens trauma-induced depression.