Wednesday, January 15, 2025

A Guide to Dialectical Behaviour Therapy for Rape & Abuse Survivors

“Asking for help isn’t a sign of weakness, it’s a sign of strength. It shows you have the courage to admit when you don’t know something, and to learn something new.”

Barack Obama

*Please note: this article is not to be used as an alternative to professional help, support, guidance, and Therapy*

In 2012, I (Campaign Founder, Aimee) made a suicide attempt which saw me end up on life support and when I woke up, I was detained under Section 3 of the 1983 Mental Health Act and admitted to a psychiatric hospital. The hospital was over 100 miles away from home and specialised in my diagnosis at the time of Borderline Personality Disorder (BPD), which meant that it facilitated the recommended therapeutic treatment for the Disorder; Dialectical Behaviour Therapy (DBT). Typically, it takes 12 months to complete a cycle or course of DBT, but my mental health had been poorly for quite a while, so I ended up actually being sectioned and undergoing DBT for two and a half years! So, after our Social Media Assistant created content on dissociation – which DBT has helped me to stop using as a coping mechanism – I was inspired to put this article together where I’ve trawled through the entirety of DBT to share with you all the most relevant and appropriate skills and techniques to support the mental health of survivors of rape and abuse…

The ‘D’ from ‘DBT’ means Dialectical and this is thought of as being where opposites meet and is taken from the idea that change, and acceptance can be combined. It is aimed at providing you with tools for dealing with hard situations and calls upon four core skills: mindfulness, distress tolerance, emotional regulation, and interpersonal effectiveness.

One of the most important aspects to learning DBT which I want everyone to know before they get into it, is that for a long time, I was left feeling completely stupid and with every single technique and skill I learnt, this just got worse. And this was mostly because I felt like a fool for not thinking to try the coping mechanisms it teaches by myself. How had I not thought to try ‘self-soothing’ or engaging in ‘distraction activities’ when I was struggling? Why hadn’t I thought of these things that could have worked instead of self-harming? What was so wrong about me that I didn’t put that little bit more effort and thought into something that could have meant keeping myself safe? How dumb could I be?

Recognising my failures to had managed my mental health in a safe and responsible way, also left me feeling incredibly responsible for all the emotional and medical/physical hardships I had gone through and all the upset I had put my loved ones through with my self-harm and suicide attempt. I guess I hadn’t really taken responsibility until then because I’d been so convinced that it was the only way I could cope with how I was feeling, what I was thinking, and all that I had – and was – experiencing. I’d thought that I didn’t have a choice, and if I didn’t; then how could it be my fault when my Mum was crying or when I was having my shin drilled into (for an IO) to administer lifesaving medical treatment? How was I guilty or to blame for anything when I didn’t have any other options? So, to discover that actually, I did have alternative ways to cope… Well, it left me feeling very guilty, but I learnt – through the Therapy – that I had been using tunnel vision because I hadn’t been able to see outside of this one-track-mind that hurting myself was the only – and the most effective – way to cope. If, at any point, I’d found insight and the ability to look outside of this mindset and thought process, then of course I’d have coped in healthier and safer ways.

Those thoughts and feelings of being responsible for not thinking of alternative coping methods, meant I got the distinct feeling that things were getting worse before they got better. And this is the final thing I wanted to say before I jump into the actual Modules; DBT isn’t an ‘instant fix’ or even an ‘easy fix.’ It can be a long process, and it can very often feel like things get worse before they get better. Unfortunately, there’s no magic wand in mental illness and even where medication is completely the answer, it doesn’t necessarily help immediately (often anti-depressants and anti-psychotics or other psychiatric medication can take weeks or even months to actually build up in your system and start helping/working, but sedatives and sleeping tablets can obviously take effect within minutes). In my opinion, this is so wrong because mental illness can be so dangerous that it should be something that’s quickly and easily mitigated in some way.

So, in undertaking DBT, be prepared for long, hard work that takes a lot of strength, effort, time, and energy. Be prepared for that notion of things worsening. Don’t lost hope that there will be improvements and positive changes and achievements along the way on your therapeutic journey though. Stay determined and dedicated to the process through the thought that there’ll come a point where all this time and effort will end up feeling completely justified and totally worthwhile. When you’ll be grateful for all your own hard work. When you’ll stop thinking ‘why did I have to work so hard when I didn’t put myself in this position?’ And instead, you’ll just think ‘look at how hard I can work and the changes I can make!’

This Module is typically the first to be taught in beginning to undergo DBT because it ‘sets the stage’ for the other Modules by teaching you several exercises that are aimed at observing your thoughts and feelings in a very non-judgmental way. I think that this Module and the exercises within it (I’ll also talk you through some of them) can be beneficial for someone with the traumatic experience of rape and/or abuse, because there is often a lot of very wrong, self-blame in survivors and that often entails judgment and giving a critique of your own thoughts and feelings. For me, my rapist/abuser wasn’t taking any responsibility or receiving any consequences, and I was so desperate for someone to, that I made it me.

Mindfulness Skills Most Helpful For Survivors

1.       Observing: The exercise for this skill is about looking at an object and noting down (you can get an online activity form to do this, here) observations of it e.g. its colour, smell, taste etc. and then you add any thoughts or feelings you experienced too. The premise of this skill which makes it really relevant for survivors is that it’s all about keeping your mind on one track. It’s about keeping just one thought in your concentration at once. Often, as a survivor of rape and/or abuse, you can find yourself struggling to concentrate on a task because your mind is too preoccupied with thoughts and memories of your experiences.

2.       Mental Body Scan: This skill is about recognising your body’s needs and requirements by taking some time out of your day to really concentrate and focus on your body by moving your awareness slowly from your feet all the way up your body to your head (there’s a PDF worksheet for this exercise, here). The reason this can be helpful for survivors is because I (and I’m sure I’m not the only person to do this) often found that I’d been so focused on just getting through the day or on keeping busy to distract myself from thoughts, feelings, and memories, that I’d forgotten to have a drink or eat something!

3.       Internal Vs External: The exercise for this skill is all about controlling whether you’re focused on internal or external events by first observing physical aspects to your environment e.g. the smells and sights etc and then concentrating on your internal thoughts and feelings and any physical sensations. Before doing this exercise, you can find out whether you naturally focus more on internal or external events by completing the checklist here. I thought it would be helpful for survivors because when you’re experiencing an overwhelming thought or feeling, this is often purely because you’re focusing too much of your energy on it and by doing so, you can become unsafe and upset.

4.       Describe Your Emotions: This is a very obvious one in terms of how to practice the skill e.g. an exercise you can do for it, as well as why it would be useful for survivors. As a survivor, you can experience some really difficult feelings that leave you struggling to cope and result in you finding yourself unable to describe or name them. A helpful resource for this includes an enormous list of emotions you can choose from to describe either how you’re feeling right now or how you felt in a particular situation and you can find it here.

5.       Wise Mind: This skill was actually first created by Marsha Linehan (a DBT Psychologist) who came up with the idea that we each have an ‘emotional mind’ and a ‘reasonable mind’ and then ‘wise mind’ is an overlapping, combined centre of both of these. It is where you’re aware of your emotions, but you can still consider facts and logic. An exercise in this skill is to think of a problem in your life and then use your wise mind by collecting evidence and information around it, identify your emotions, consider your long-term goals… (you can find the rest of the considerations and the entire exercise here). I thought this helpful for survivors because after experiencing a trauma, it can be incredibly ‘easy’ to almost instinctively focus on your overwhelming emotions and this skill can help you in a way that has the potential to stop these from being overwhelming and consuming your life.

6.       Negative Judgements: Such judgements, are defined as being both ‘unconscious’ and ‘unproductive.’ There’s an exercise here which helps you to become more aware of negative judgments becoming automatic thoughts for you. I thought this relevant for survivors for reasons which I’ve mentioned earlier around the fact that you often find yourself incorrectly blaming yourself and/or taking some sort of responsibility for your trauma.

Despite being in total control of yourself, there are things in life that you just can’t control – they’re out of your control – and whilst this is a ‘normal part of life,’ you can struggle to tolerate the distress it causes. Distress Tolerance is therefore defined as being an ability to manage actual or perceived emotional distress with your tolerance levels determining how you decide to manage the situation. This can be especially relevant for survivors of rape and/or abuse because these are traumatic experiences that can very understandably lead to a survivor struggling to tolerate any other signs of distress. This is often because other upsetting and distressing experiences can lead to reminders, memories, and actually even flashbacks of the traumas.

Distress Tolerance Skills Most Helpful for Survivors

1.       Cost Benefit Analysis: This tool can be powerful in enabling a survivor to list the costs and benefits of engaging in a particular behaviour or action and it can help you to see, more clearly, things which can often be overlooked. An exercise for this skill can be incredibly straight-forward but a little time-consuming; it involves thinking of a problematic behaviour such as self-harm, and then listing costs and then benefits of engaging in that behaviour. You then list costs and benefits of engaging in an alternative behaviour (which could actually be hard to think of – and this is a valid difficulty) and finish up the exercise by scoring these with a scale of 1 -5, with 5 being that it is really important and 1 being that it is a completely unimportant aspect. You can download a PDF worksheet for this exercise here. This skill can be helpful for survivors because often you can engage in behaviours that are aimed at coping with the aftermath of your trauma, but which actually aren’t helpful from a long-term perspective.

2.       Recognising Signs of an Emotional Crisis: This skill is aimed at improving your awareness of when you’re beginning to struggle and fall into an emotional crisis. This can be important for survivors because one of the most dangerous elements to struggling in this way is that it often feels as though it hits you by surprise and being taken off-guard can be a huge catalyst for you becoming unsafe. A huge reason for this – for me, at least – is that the abuse and rape came completely surprise, so to have an emotional crisis happen that way is a huge reminder of the trauma. An exercise in this skill is very straightforward and involves considering your thoughts, emotions, and behaviours before and during a crisis, any sensations, environment, and key triggers (there’s a PDF worksheet on this here).

3.       Distracting Activities: Finally! One of my absolute favourites! And a very obvious one! I really enjoy this skill because it’s almost a bit of healthy and safe escapism, and that’s something my mental health and risk levels massively benefit from. It also isn’t really a difficult skill to really master because often, you already know the activities you enjoy doing and spending your time engaging in (if you’re struggling to think of something though, there’s a massive list of activities here). My favourites are playing The Sims Freeplay, blogging or working on the Shake My Hand Campaign, and watching TV Shows or Movies on Netflix or Disney Plus! For survivors, doing some distracting can really help to take your mind off difficult thoughts, feelings, and memories.

4.       Grounding: This is another skill that’s almost a part of distracting activities because it’s all about shifting your focus from distressing and unsafe thoughts, feelings, and sensations. A difference, however, is that whilst distracting is about focusing on another activity, grounding techniques are centred around the thought of bringing yourself back to the ‘present moment.’ This can be a really useful skill for survivors who struggle with flashbacks and dissociation (which I did) because these are both destabilising experiences that can lead to you losing touch with reality and becoming numb to what’s actually happening. There are a variety of grounding techniques which can differ from mindful breathing (which you can find instructions on how to do, here) to doing a mental body scan (which was talked about in the Mindfulness Module here).

5.       Self-Soothing: This is another of my favourite skills in DBT and it’s basically all about doing something nice for yourself (there’s a list of self-soothing activities which are aimed at pleasing different sense e.g. taste, smell, touch etc. here). A huge difficulty that I faced with this skill – and I’m sure it isn’t unique to myself – was the notion that I didn’t deserve to feel any better. That I didn’t deserve anything nice or pleasant, and a huge reason for this was the self-blame and the responsibility I was wrongly taking for the abuse and the rape.

6.       Actions Based on Values: To support your life satisfaction, it can be really important that you set goals, develop values, and create strategies to act accordingly with those. Having some sort of sense of purpose can make emotional distress more manageable and tolerable and this can matter to survivors who often lose track of their values because they’re so focused on negative thoughts, feelings, and experiences. If you’re struggling to name or label your values and purpose, there’s a huge list of some suggestions as well as an exercise for this skill, here.

For some, Emotion Regulation sounds incredibly similar to Distress Tolerance, and so there’s a whole section dedicated to explaining the differences, here. The way I understand it though, is that one concentrates upon emotions and the other is ‘distress’ which isn’t always centred around your emotions; it can include other experiences too. Emotion Regulation is also defined (in the above link) as being ‘the process of managing and responding to your emotional storms in healthy and constructive ways. It’s about recognising and understanding your emotions and choosing how to express and act on them.’ This can be relevant to survivors of rape and/or abuse, because often, after a traumatic experience, you can get the feeling that your emotions are running away with themselves! That they’re uncontrollable and impossible to regulate.

Emotion Regulation Skills Most Helpful for Survivors

1.       Recognising Your Emotions: In DBT you’re taught that we have immediate/primary emotions which are instant responses to something and secondary emotions which are the feelings come in response to the primary emotion. Learning to recognise which you’re experiencing and how/why you’re reacting to it in a particular way, can really help in recognising early warning signs that you’re going into a mental health crisis or becoming unsafe. This can be useful for survivors who might struggle to put a label on how they feel and so they’re unable to gain insight into their motivations for negative behaviours and unhealthy coping mechanisms. You can find an exercise to help you with this skill here.

2.       Being Effective: This skill is all about learning to do what needs to be done in order to meet your needs or goals. A good exercise for this skill is to list short-term goals and then all the actions and steps you need to take to achieve them, and then doing the same for any long-term goals you may have too (there’s a PDF worksheet for doing this exercise here). This skill is helpful for survivors who might find it difficult to be effective in life and this is typically because their confidence levels have been ridden down by their rapist/abuser and the traumatic experience they’ve gone through.

3.       Cognitive Distortions: This is part of a skill labelled ‘Emotions and Cognitive Vulnerability’ but I wanted to pick out the aspect of that which I feel is most important and most helpful for survivors. There are three main cognitive distortions: All or Nothing Thinking which is where you think of an event in a biased way. Then, Catastrophising; which can sometimes mean turning a situation into having more significance that it needs to or should have. Finally, Overgeneralisation which is where you can lose a lot of hope by thinking that if a situation has upset you once, it will upset you every time it happens. These distortions are all relevant to survivors of rape and abuse because they’re thought processes you can often develop through experiencing a traumatic situation. There’s a worksheet for an exercise around this skill here.

4.       Self-Validation: Validation is a response from people which I find extremely important and beneficial to my mental health, so to develop and learn to do it for myself has been really special and useful. There’s a PDF worksheet for the two levels that are regarded as part of this skill available to download here. I think that other survivors of abuse and rape could benefit from this skill too because rapists and abusers almost always tear apart – or tear down – the survivor’s confidence levels and levels of self-assurance.

This final module of DBT utilises the useful foundational skills that the previous three modules should have helped to build within you and for your mental health. It’s said to be a means of navigating relationships, asserting your needs, managing conflict, and maintaining respect for yourself and others. I found this module useful because I have often personally struggled to be assertive in telling someone – especially professionals – what would help me and how they could better support me. For a long time, I was labelled an attention-seeker, but eventually; I learnt to be less offended and that this was because I – and my coping mechanisms – were completely misunderstood and misinterpreted. So, in a bid to change this and stop feeling incorrectly labelled and personally insulted, I was almost forced to learn how to explain my behaviours myself. And, in my opinion, that was helpful because once professionals and services understood this, there was a lot less talk of attention and being dramatic, but I also feel I shouldn’t have had to develop that skill under pressure and for the reasons I did. I think this skill can help other survivors for similar reasons; because I imagine I’m not the only one who has struggled with people holding judgements about them and their coping mechanisms.

Interpersonal Effectiveness Skills Most Helpful for Survivors

1.       Communication Style: There’s a survey/questionnaire to determine your personal communication style (such as assertiveness, aggressive, and passive etc.), here. This exercise is set to help you understand why you communicate the way that you do in order to become more mindful of how you interact with other people. This might help other survivors because going through a trauma like rape and/or abuse, can leave you reluctant to communicate with others because you likely feel betrayed by this other person (your rapist/abuser) and that can affect the trust you have in people in general.

2.       Interpersonal Boundaries: Despite being social beings who are ‘programmed’ to seek interaction, support and a sense of belonging from others, can mean that we lose sight of being individual and holding certain boundaries in certain circumstances. In this skill, it can be important to be mindful of the situation by being aware of the type of information and how much of it others are sharing to shape how you act too. It’s also important not to copy others and to act in a way that is according to your values in so far as your ultimate motivations and the relationships you want to have and develop. This might be helpful for survivors who can struggle to stay loyal to your boundaries because often, your boundaries are defied, manipulated, and betrayed for the rape and abuse to occur. There’s a worksheet available for this skill too with part one of it being here and part two here.

3.       Modulating Intensity: This skill is so important and there’s actually another worksheet with an exercise for it, here. Some steps for this skill are around level of urgency to your need the level of your vulnerability and adjusting your level of intensity. For me – and I’d imagine a lot of other survivors – it’s been massively about prioritising and figuring out exactly what I need and want in life and how much each of these things matter to my safety and my emotional wellbeing in general.

4.       Resistance and Conflict: This final skill of the final module, is all about three elements; validating another person’s point of view, repeating your own, and asking for specific information where there is a conflict in these views (you can read about each of these here). Conflict can be significant to a survivor’s mental health and levels of risk/safety because the trauma of rape and abuse is often focused and centred around the idea of conflict because you have someone forcing a behaviour or act upon you.

Resource:

The most used resource for this entire piece was: Dialectical Behavior Therapy: DBT Skills, Worksheets, Videos.

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