Neurodivergence and PTSD from Sexual Assault: A Toolkit for Moving Forward - Part 2

This toolkit was developed in response to direct requests AIDE Canada received from autistic individuals in focus groups. We recognize that this is a difficult and emotional topic and we have made every effort to avoid triggering people while still providing relevant and useful information. There are also additional resources and suggested reading at the end of the toolkit if you would like to learn more about this topic.

This toolkit is broken into two parts: 1) Understanding Post-traumatic stress disorder (PTSD) and 2) Moving Forward from PTSD.

If you are not already familiar with the symptoms of PTSD and concepts like disassociation and triggers, we recommend you read Part 1 first.

The authors recommend that you take breaks from working through this toolkit as needed. If you find this information difficult or upsetting, we also recommend seeking the support of a trained clinician for individualized therapy and/or support groups or workshops. We recognize that PTSD is not easy to deal with on your own. Professional guidance from a clinician familiar with treating PTSD in neurodivergent persons can help to lower both the frequency and intensity of flashbacks.

Remember, what happened to you was not your fault and it does not define your worth as an individual. With time and support you can find a way to move forward and live your life to its fullest. We hope this toolkit help guide you on your way.

In Part 1: Understanding PTSD, we described PTSD and some common symptoms you may experience after an attack. In Part 2: Moving Forward, we discuss how to decide who you want to talk to about your assault, describe the process for filing a police report (if you choose to do so), and provide guidance on what sort of therapies are available for PTSD and what possible modifications may need to be made to better support neurodivergent patients.

We also include the narrative from our two anonymous contributors, Jane* and Monique* (names changed for privacy), throughout this toolkit. They will share their own experiences and what worked for them. They have made every effort to share their stories without including triggering information, but their experiences may still be difficult for you to read. Their stories will be presented in bolded italics below so you can choose to skip these sections if you find them too upsetting.

Photo by Paola Chaaya on Unsplash

Personal Lived-Experience  - Initial incident:

Jane’s assault: I was sexually assaulted in 2017 after a Xmas party. I was asked to Uber to an acquaintance’s house from downtown Toronto because it was very close to mine. Nothing happened in the Uber, but when I [was] standing on the driveway he started to kiss me. I pushed him away. He then told me to come into the house as he was going to call a cab for me, and my phone had run out of battery. (I often wonder if I would have not been sexually assaulted if my phone was charged and I called a cab myself). When I got into the house, and went downstairs to his “room”, that’s when things really began.

Monique’s assault: Ten years ago, I went to see a psychiatrist to work on my insomnia and claustrophobia. It was just after my second session that I remembered being assaulted by my friend’s older brother when I was 6 years old. I had always remembered some minor details about what happened that day. I didn’t remember the worst details until after I had been describing my earliest memories of feeling trapped to my psychiatrist. The memories came in flashes over the next few days and were out of order, so they didn’t make sense. I remember wondering if I was going insane. Eventually I had enough flashes that I was able to put them together and realize what really happened that day. My doctor said that was called ‘dissociative amnesia’ and that is why I didn’t remember details until many years later.

Dealing with the aftermath of a sexual assault can feel very isolating. Some people struggle with feelings of rage, shame, embarrassment, and self-doubt. Some are worried they will be blamed for what happened or told that they are making a bigger deal about it than it is. Sometimes a person may just want to pretend it didn’t happen, so they don’t want to talk about it or be treated differently. Any of these feelings may cause a person to withdraw from others and avoid sharing their experience.

When a person buries their feelings, the emotions remain below the surface and the pain may come out in unhealthy ways. Survivors may turn to substance abuse, enter unhealthy romantic relationships or friendships, or withdraw to the point of not wanting to leave the house. Fears of their assault being repeated can lead to distrust of others and avoidance of anything that reminds them of the assault.

For some people, the feelings of isolation and depression may lead them to consider harming themselves. If you, or someone you know, is struggling with thoughts of suicide, please call or text 988 for the Suicide Crisis Helpline. They are available 24 hours per day, 7 days a week. 988 responders will listen and can help explore ways to support you. If you are looking for mental health support but do not have thoughts of harming yourself, consider reaching out to 211 to see what sorts of resources and services are available in your area.

The most important thing to remember is that you do not have to tell anyone that you don’t want to tell. This needs to happen on your own timeline, not anyone else’s. If you are thinking of telling someone, ask yourself the following questions:

1. Is there a professional who can help me? Do I feel comfortable talking about this with my family doctor, therapist, or social worker?
2. Do I have a family member or friend that I can trust enough to both support me and not talk about this to other people without my permission?
3. Will this family member/friend respect my boundaries and only talk about it if I bring it up? Will they try to push me to do something I don’t want to do (like go to the police) before I am ready?

Personal Lived-Experience  -  Additional Details:

Jane’s Experience: When he eventually called a cab, and I got home, I didn’t really understand what had happened to me. I had to recall every detail to discuss it with my best friend to put it together that I had been sexually assaulted . . . I told my close friends first. Another friend of mine kept asking me why I went into the house. The last people I told were my parents, due to how stressful and strained my relationship is with them. I thought they would blame me for it, as they do with everything else…like I had done something and deserved it.  My dad wanted to have the guy who sexually assaulted me, “strung up.”  My mum was incredibly angry and upset. She wanted me to charge the guy but trying to find a cost-effective lawyer was next to impossible.

Once you decide that you want to tell a family member or friend about what happened to you, it can be hard to figure out exactly how you want to bring it up. You may be worried about your own emotional reaction to talking about it or worried about how they may react to the news. Consider the suggestions below when deciding how and when to tell a trusted person about your assault.

Photo by Kristina Tripkovic on Unsplash

• Where do I want to tell them? You may want to talk to them in a room away from other people. Or you may prefer to be outside in a quiet park. Do you want to be seated for a face-to-face conversation, or would it be better to talk while on a walk? Working on a shared activity can give you something to do with your hands. Washing a car, gardening, painting, or working on a puzzle are all examples of activities you may want to try to keep from getting overwhelmed while you talk to them.
• What sort of support do I want from them? It is best to figure out what sort of support you are looking for before you tell a person about what happened to you. Do you want them just to listen, or do you want them to help you figure out your next steps if you choose to report it to the police? Do you want them to help you find mental health support? Do you want them with you if/when you tell others about the assault?
• How should I bring up my trauma? A person may not be in the right headspace to hear about your assault. Some people also have a history of trauma and may not have shared that with you, which could potentially be triggering for both of you. A potential way to bring it up gently is to say something like: “I have a serious and upsetting thing that happened to me. I would like to tell you about it because I trust you to support me, but don’t want to potentially trigger you. Are you in a place where you can hear about what happened to me or would you rather me talk to someone else about this?”
• What do I want to share with them? You do not need to share every detail of what happened. You may want to start with a summary of what happened and wait to see how they respond before you share more details. If you do not want to share any details, you can let them know that you are uncomfortable answering further questions at this time.

The person you tell may not know how best to react and may be experiencing their own range of emotions when learning about your sexual assault. Common emotions loved ones can experience include anger, sadness, fear, frustration, and guilt. Some sexual assault survivors describe feeling like they had to provide emotional support to the person they told, rather than receiving the support themselves.

Personal Lived-Experience with Sharing :

Monique’s Experience: The first person that I told was my (now ex) husband. Then I spoke with my best friend and reached out to two lawyers I know to see what, if any, advice they had for reporting it 25 years after the assault. I decided not to tell my parents as I knew they would blame themselves and I worried about the impact this would have on their health. I told my friends and just blurted it out in some situations when it was not appropriate. I regret how many people I told who weren’t as close of friends as I thought. I believe my ‘oversharing’ negatively impacted those relationships. I eventually told other family members as well, but my parents still do not know.

Initially, things were really bad for me. I couldn’t sleep, cried all the time, couldn’t be around unfamiliar men, and was always either scared or angry. Lots of things triggered my flashbacks and would cause me to lose minutes or even hours every day. PTSD was impacting my relationships, my work, and my ability to leave the house.

Some people may not respond in a supportive way or may ask inappropriate questions that imply that this is somehow your fault. Some people may never come around and be supportive, but sometimes people are taken off-guard and don’t think about how their questions or reactions may be perceived by others. With time, they may reflect on their response and shift their behaviour to be more in line with the sort of support you need. Remember that regardless of how the people around you respond when learning about your assault, no one asks for or deserves to be assaulted. It’s also important to remember that your assault was not caused by what you were wearing or if you were drinking. The only person to blame is the person who assaulted you.

If a person does not initially respond well, but you believe that with further conversation they can come around and be supportive, then you can try talking to them about it. Before you speak with them again, you may want to write down how their response made you feel and how you would like them to handle any discussions in the future. This way you know exactly what you want to say when they see you next. If you are uncomfortable with talking about this with them in person, you may also prefer to send it in a letter, email, or text.

If the person you told still reacts in an unsupportive way, you may choose to limit contact with them or set a boundary that this topic is off-limits for future conversations. You deserve kindness and support, and if this person is unable to provide that then you may decide to reach out to other people instead.

Photo by Alexandr Podvalny on Unsplash

Photo by Kelly Sikkema on Unsplash

There have been few studies on the best treatment options for autistic individuals with PTSD. The studies that have been done had relatively few participants or have mixed results. Also, there has been a lack of ‘well-controlled’ studies, meaning that being able to compare results and treatments between studies is a challenge¹. This makes it difficult to draw any firm conclusions about the effectiveness of different types of treatment for PTSD in neurodivergent individuals. Below we will describe the types of PTSD treatments that are available and summarize what sort of changes may need to be made to better support neurodivergent patients.

Cognitive Behavioural Therapy

Cognitive Behavioural Therapy (CBT) is often considered the gold standard in mental health treatment for neurotypical people with PTSD but may require adaptations for neurodivergent patients^2,3 (see ‘What sort of autism-specific modifications can be made to existing therapeutic approaches?’ below). CBT involves observing the relationship between one’s thoughts, feelings, and behaviours and making changes to one’s unhelpful thoughts (called ‘reframing’) to improve emotion regulation and behaviours. CBT for PTSD often includes ‘exposure therapy’, where patients are gradually exposed to certain aspects of their traumatic memories and emotions to reduce their avoidance and negative associations with the trauma. This is a controlled process that involves that patient making a collaborative decision with their mental health provider on which aspect(s) of their trauma they want to work to improve. For instance, if an assault happened at night and a patient wants to stop being afraid of leaving the house after dark, then the exposure may start with the patient and a trusted friend standing outside the front door after sunset. Over time, the patient will work up to taking a walk around the block or going to a movie with a trusted person after dark.

Trauma-Focused Cognitive Behavioural Therapy

Trauma-Focused Cognitive Behavioural Therapy (TF-CBT) was originally developed to help child and adolescent victims of sexual abuse. This treatment includes education about the impact of trauma, uses concrete language and/or pictures and social stories, and reduces distressing reminders for exposure therapy². TF-CBT uses graduated exposure to teach the child to tolerate stimuli (certain noises, smells, settings, etc.) that remind them of their trauma and eventually decrease the distress they feel when they come across those stimuli. This sort of exposure involves creating a ‘trauma hierarchy’ where environmental triggers are defined and rated from least to most distressing. Graduated exposure therapy begins by focusing on the environmental triggers that are least distressing before moving on to more upsetting triggers³.  For children, this therapeutic approach begins with a caregiver and the child having separate therapy sessions before having therapy sessions together. The goal is to help the patient feel safer and more secure and for the caregiver to be able to support their child in a more productive way. Researchers have suggested that this approach be tried with older neurodivergent people, especially those who have language challenges, but most studies so far have focused on neurodivergent children and adolescents².   

Imagery Rehearsal Therapy

Many people with PTSD have nightmares or flashbacks when sleeping. While CBT is still a standard approach, some mental health providers may suggest Imagery Rehearsal Therapy (IRT) in addition to their other treatments if a person is unable to sleep due to these chronic nightmares³. Patients will be asked to describe the original nightmare and with their mental health provider create a revised version of the dream with a better, safer ending using CBT techniques. Patients with language challenges may be asked to draw a picture of their revised dream instead of verbal descriptions.  Patients practice the new dream at home each night before going to bed. This approach has shown success in reducing trauma-related nightmares in case-studies with neurodivergent patients⁴, but more studies are needed to show its effectiveness in a larger group of neurodivergent people.

Eye Movement Desensitisation and Reprocessing Therapy

One psychological approach that has been receiving more attention in trauma research is Eye Movement Desensitisation and Reprocessing (EMDR) therapy⁵. It is used to help people process their traumatic memories and the experiences associated with them (e.g., images, emotions, physical sensations, etc.). As a person describes a memory or feelings associated with an event, they will be asked to do something called ‘bilateral stimulation’. Bilateral stimulation involves stimulating the sensory system across the midline of your body. For instance, you may be asked to follow a pen or dot that moves side to side across your line of vision or tap your fingers on a table on the right and left side of your body or using headphones as beeps alternate on the right or left speaker. It is suggested that by stimulating both sides of the body, a person can process the upsetting memory and emotions in a less overwhelming way⁶. One benefit of this approach is that memories are not required to be described in detail, which may be helpful for individuals who have challenges in verbal communication⁵. There have been a small number of studies of EMDR with Autistic individuals with PTSD, and these have found that participants experienced reduced PTSD symptoms after taking part in EMDR therapy^5,6.

Mindfulness-Based Therapy

Mindfulness is a practice where people are asked to pay attention to the present moment and observe any thoughts or feelings that come without judgement. Mindfulness is rooted in Eastern traditions as part of meditative practices but has increasingly been used in mental health treatments^7,8. The Mindfulness-Based Stress Reduction (MBSR) treatment approach has patients take part in roughly 8 weeks of 2+ hour group sessions to learn about mindfulness meditation, yoga, discussions about stress and coping, and daily mindfulness practices to do at home⁷. Mindfulness may also be combined with CBT and called Mindfulness-based cognitive therapy (MBCT), where patients learn to change their relationship with their thoughts so the take less of a hold over them (e.g., ‘thoughts are not facts’) as part of their CBT treatment^8,9.

Group Therapy and Workshops

Some regions offer group therapy and/or PTSD workshops to help patients learn more about trauma and provide guidance and tools for moving forward, although neurodivergent-specific group therapy can be a challenge to find¹⁰. Many of these programs will be offered in 6–12-week intervals and may have a waitlist. These programs will cover a variety of topics and may include information about anxiety and depression in addition to PTSD. They will also likely include CBT approaches to managing your PTSD symptoms. Your doctor or social worker can refer you to these programs, so be sure to ask about their availability if you are interested.

Personal Lived-Experience  - PTSD Recovery:

Jane’s Experience: When I was disassociating and afraid to leave my house, I was fortunate to have a CAMH community social worker assigned to me. She hooked me up with the local food bank which delivered a huge box at the start of the month and helped expedite my enrollment in a day program at William Osler hospital that was for people who had anxiety, depression, PTSD, etc. Not only did you attend “classes” during the day about such things as nutrition, sleep, and how to deal with anxiety, but you were also assigned a counselor that would also help you with your anxiety, PTSD, etc. outside of the program.

Monique’s Experience: I wanted to get better as soon as possible, so I threw myself into anything I could to improve my PTSD. I was prescribed some as-needed anxiety and sleep medications that really helped. I did CBT with my psychiatrist and later did CBT and EMDR with a psychotherapist. I appreciated how my psychiatrist was not pushy about doing exposure therapy with my CBT and let me set the pace for what we worked on. We focused on things like my hypervigilance in public and challenging my negative beliefs about the world being totally unsafe. What I liked about EMDR is that treatment feels less threatening. Something about my eyes moving or fingers tapping back and forth made my feelings and memories seem less overwhelming in the moment. I also did a PTSD group workshop at my local outpatient hospital that helped to teach coping strategies. The best things I learned in that course came from the book 8 Keys to Safe Trauma Recovery by Babette Rothschild. I especially liked her chapter ‘Remembering is Not Required’ as it put into words the feelings I had about being asked to relive details of my attack. The focus is on moving forward, not living in the past, which was exactly what I needed.

What sort of autism-specific modifications can be made to existing PTSD treatment approaches?

Many of the studies cited above have made suggestions for modifications to existing PTSD therapeutic approaches to better support Autistic patients. Some of the more common suggestions are^1,2,6:

• Providing more sessions for treatment than typical (e.g., 16 sessions instead of the standard 6-8)
• Taking more time to establish a rapport before beginning the therapeutic approach
• Adjusting the environment and/or treatment to better meet the sensory needs of the patient.
• Using children-specific protocols that do not rely as much on verbal language
• Changing the length of treatment sessions to be shorter
• Allowing another trusted person to be present for the sessions
• Offering options instead of asking open-ended questions
• Providing clear, simple instructions
• Using visuals and writing down instructions
• Having a consistent routine and session agenda
• Focus more on developing cognitive coping skills instead of focusing on the trauma

You may have limited access to support services in your area and may be placed on a waitlist for a therapist who can help you process your trauma. If that is the case, there are still things you can do in the meantime to improve your mental health.

Photo by Sixteen Miles Out on Unsplash

Sleep: Sleep challenges are extremely common in people with PTSD and can further impact your mental health. Practicing ‘good sleep hygiene’ like limiting screen time before bed, waking up at the same time each morning, and relaxation exercises can all help. For some people with PTSD, temporarily taking prescription sleep medication a couple of days a week may be useful. We recommend you speak to your doctor if you are struggling with sleep and would like to explore options. For more information on improving your sleep, check out our ‘Developing Health Sleep Habits Animated Video’ written by one of Canada’s leading sleep experts, Dr. Penny Corkum of Dalhousie University.

Exercise: Physical activity can help you sleep better, release anxiety and anger, and help to build your confidence. Some people with PTSD from sexual assault like to take part in physical activities that can help them feel safer, like self-defense or martial arts classes. Being fit enough to run quickly from dangerous situations can also improve confidence.  Some studies of women who have experienced sexual assault have shown that regular yoga practice can help with anxiety as well¹¹.

Nutrition: People who are dealing with trauma may develop unhealthy eating habits. For some, trauma can lead to a loss of appetite to the point of being underweight and/or malnourished. For others, food becomes a comfort, and they eat too many calories or binge on unhealthy food. Some people put on weight as a ‘shield’ and a subconscious way to defend themselves from future attacks under the mistaken notion that they are less likely to be attacked. If you are experiencing eating-related challenges, speaking to your doctor or a dietician can help you figure out the next steps to improving your dietary habits.

Self-Expression: Expressing your thoughts and wishes does not have to be focused on your trauma. Some people use a journal to process their feelings about their day-to-day life or concepts they are learning. Some people take up different types of art (e.g., writing, drawing, or sculpture) to focus their attention on creating something they find beautiful or interesting.

Personal Connections: One of the hardest aspects of PTSD for many people is how isolated they may feel. Fearing the world around you can make you pull back from friendships or leaving the house. It is important to reach out to trusted people and spend time with them in a relaxing area where you can feel safe. If you don’t have people, you are close to, try joining hobby groups that can give you a shared interest to focus on and build new friendships with others.

Mindfulness and Relaxation Exercises: Having regular flashbacks and/or constantly being ‘on guard’ can make it difficult to be calm and sleep. Guided meditations or practicing focusing on your breathing have been shown to help reduce anxiety. Many medical professionals recommend meditating or trying progressive relaxation exercises before bed to help improve sleep and overall mood.

Personal Lived-Experience - Enhancing Mental Health:

Monique’s Experience: I was extremely angry all the time after my flashbacks started. I had to do something with all that anger, so I started working out a lot and focusing on my diet. I was overweight when the PTSD started and lost 30 pounds in a few months. I wanted to be healthy because if I ever came across my attacker, or someone like him, I wanted to be able to feel confident enough to protect myself. I also took a self-defense class for women only as I thought if I had to practice-fight against a man I would be triggered. Sleeping has been a problem for me since childhood, but by tiring myself out from working out I could sometimes get to sleep right away instead of tossing and turning for hours. I would only let myself take sleep medication twice a week at most because I have a fear of becoming addicted. Still, being able to count on getting sleep at least twice a week really helped to improve my mental and physical health. I also journaled regularly and started painting pictures of nature to help me focus on something positive instead of all the anger. It took about a year before I started feeling human again and not just like a giant ball of rage and fear.

PTSD from a sexual assault is not easy to deal with, but with time, effort, and support, you can eventually move forward and live without it impacting your entire day. The journey to better mental health is not a straight line, there may be setbacks or times where you feel like you are not making progress fast enough. Give yourself space to feel emotions, while also giving yourself time to appreciate things you enjoy. Taking care of your need to process the past, while focusing on what you want in your future, will help you to eventually build a better life for yourself.

Photo by Lina Trochez on Unsplash

Personal Lived-Experience - Final Thoughts:

Jane: The most important thing that I found to help me was to advocate for myself. You need to keep on these people like a dog with a bone. Just keep shaking them until they give up what you need. Since I went through the day program and FINALLY found a psychotherapist that understood the autistic mind that could help me sort through this, I have been doing ok. I have other health issues that I must focus on now, that require most of my spoons (energy). I really need a spoon regenerating machine.

The other important thing is always make sure you make time for self-care, and pace yourself.  It also helps to find a psychologist/social worker that understands adult autism, to help you process what happened to you and to help you with the healing process.

Please also remember that it wasn’t your fault, nothing you said or did made the other person sexually assault you. Don’t let anyone convince you otherwise. There’s no way that you will recover overnight, but having the courage to ask for help is the first brave step. Thank you for taking it.

Monique: Slowly things began to improve from me. I think it is because I did anything that my doctor recommended as I really wanted to get better. It took a little over a year and a half for me to be able to sleep regularly without the help of prescription medication. Now, over ten years later, I only occasionally have flashbacks, and they usually last less than a minute. I still struggle with being able to trust unfamiliar men and am angry about what happened, but I am focused on moving forward. PTSD is still a part of my life, but it doesn’t rule my life anymore. I hope that the people reading this toolkit remember that they didn’t do anything wrong – their assault is not their fault. Trust yourself to pick the supports that will be most useful to you and be open to trying new ones. You may have to try a few different supports before you find the right combination that will work for you. You can get better, though, so remember that!

We thank Jane and Monique for sharing their stories with us as part of this toolkit. We also thank you, the reader, for trusting us enough to use this and other resources we recommend below as you heal. We wish you all the best on your journey to better health and happiness.

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10 - Additional Resources

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11 - References

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