Flashbask Management in Treatment of Complex PTSD
The East Bay Therapist, Sept/Oct 2005
A significant percentage of adults who suffered ongoing abuse or neglect in childhood suffer from Complex Post Traumatic Stress Disorder. One of the most difficult features of this type of PTSD is extreme susceptibility to painful emotional flashbacks. Emotional flashbacks are sudden and often prolonged regressions ('amygdala hijackings') to the frightening circumstances of childhood. They are typically experienced as intense and confusing episodes of fear and/or despair - or as sorrowful and/or enraged reactions to this fear and despair. Emotional flashbacks are especially painful because the inner critic typically overlays them with toxic shame, inhibiting the individual from seeking comfort and support, isolating him in an overwhelming and humiliating sense of defectiveness.
Because most emotional flashbacks do not have a visual or memory component to them, the triggered individual rarely realizes that she is re-experiencing a traumatic time from childhood. Psychoeducation is therefore a fundamental first step in the process of helping clients understand and manage their flashbacks. Most of my clients experience noticeable relief when I explain PTSD to them. The diagnosis seems to reverberate deeply with their intuitive understanding of their suffering. When they understand that their sense of overwhelm initially arose as an instinctual response to truly traumatic circumstances, they begin to shed the awful belief that they are crazy, hopelessly oversensitive, and/or incurably defective.
Flashbacks strand clients in the feelings of danger, helplessness and hopelessness of their original abandonment, when there was no safe parental figure to go to for comfort and support. Hence, Complex PTSD is now accurately being identified by many as an attachment disorder. Flashback management therefore needs to be taught in the context of a safe relationship. Clients need to feel safe enough with the therapist to describe their humiliating experiences of a flashback, so that the therapist can help them respond more constructively to their overwhelm in the moment.
Without help in the moment, the client typically remains lost in the flashback and has no recourse but to once again fruitlessly reenact his own particular array of primitive, self-injuring defenses to what feel like unmanageable feelings. I find that most clients can be guided to see the harmfulness of these previously necessary, but now outmoded, defenses as misfirings of their fight, flight, freeze, or fawn responses. These misfirings then, cause dysfunctional warding off of feelings in four different ways:
- fighting or over-asserting one's self with others in narcissistic and entitled ways such as misusing power or promoting excessive self-interest;
- fleeing obsessive-compulsively into activities such as workaholism, sex and love addiction, or substance abuse (uppers');
- freezing in numbing, dissociative ways such as sleeping excessively, over-fantasizing, or tuning out with TV or medications ('downers');
- fawning in self-abandoning and obsequious codependent relating. (The fawn response to trauma is delineated in my earlier article on "Codependency and Trauma" in The East Bay Therapist, Jan/Feb 03).
As clients learn that their originally helpful defenses now needlessly hinder them, they can begin to replace them with the anxiolytic and therapeutic responses to flashbacks that are outlined and listed at the end of this article. I introduce this phase of the work by giving the client a copy of this list of cognitive, affective, somatic and behavioral techniques to use as a toolbox outside of the session. These tools are also elaborated ongoingly in our sessions. I continually notice that the clients who acquire the most recovery are those who carry the list with them or post it up conspicuously at home until they are thoroughly conversant with it.
As clients begin to derive benefit from responding more functionally to being triggered, there are more opportunities to work with their active flashbacks in session. In fact, it often seems that their unconscious desire for mastery 'schedules' their flashbacks to occur just prior to or during sessions. In helping them to achieve some mastery, my most ubiquitous intervention is helping them to deconstruct the outmoded alarmist tendencies of the inner critic. This is essential, as Donald Kalshed explicates throughout The Inner World of Trauma, because the inner critic grows rampantly in traumatized children and because the inner critic is the primary initiator of most flashbacks. The psychodynamics of this is that continuous abuse and neglect force the child's inner critic [superego] to overdevelop hypervigilance and perfectionism - hypervigilance to recognize and defend against danger, and perfectionism to try to win approval and safe attachment. Unfortunately, safety and attachment are rarely or never experienced. Hypervigilance progressively devolves into intense performance anxiety and perfectionism festers into a virulent inner voice that increasingly manifests self-hate, self-disgust and self-abandonment at every imperfection. Eventually the child grows up, but she is so dominated by feelings of danger, shame and abandonment, that she is unaware that adulthood now offers many new resources for achieving internal and external safety. She is stuck seeing the present as rife with danger as the past.
I sometimes think of this phase of the work as rescuing the client from the hegemony of the critic. Despite the negative connotation rescuing has in many circles, I believe there is an unmet childhood need for rescue that I help meet when I 'save' my client from the critic. like mom didn't save her from abusive dad, or like the neighborhood didn't rescue her from her alcoholic family. This rescue process then, is a gradual emancipation from self-alienation, and a gradual deliverance from the internalized parents who trigger the client with flashback-inducing catastrophizations and perfectionistic invectives. If no one shows the trauma-locked individual that extrication from the self-torturing processes of the critic is possible, he rarely learns to rescue himself. He may live forever without discovering that he now has a variety of helpful responses [detailed in the list below] available to him to resist the triggering and exacerbating dynamics of the critic.
Over the course of therapy, I often reframe flashbacks as messages from the wounded inner child about the denied or minimized traumas of childhood. In this vein I paint flashbacks as the inner child righteously clamoring for validation of past parental abuse and neglect. Flashbacks are the child pleading for unmet developmental needs to be met, none more important than the gradual awakening of a healthy sense of self-compassion and self-protection. This is fundamental to recovery because without self-compassion, clients rarely evolve any substantive self-care habits. Similarly, without reconnecting to the instinct of self-protection, clients rarely develop effective resistance to either internal or external abuse.
When clients get that their emotional storms are messages from an inner child who is still pining for a healthy inner attachment figure, they gradually become more self-accepting and less ashamed of their flashbacks, their imperfections and their overall affective experience. They understand that the lion's share of the energy of their intense emotional reactions in the present are actually appropriate but delayed reactions to various themes of their childhood abuse and neglect. As they learn to effectively assign this emotional energy to those events and perpetrators, they metabolize and work through these feelings in a trauma-resolving way. This in turn leads to a reduction of the emotional energy that fuels their flashbacks, and flashbacks in turn, become less frequent, less intense and less enduring. Eventually flashbacks can even begin to automatically invoke a sense of self-protection as soon as the individual realizes she is triggered. Eventually this can even happen at the moment of triggering, as well as just before encountering known triggers.
Some final words. I have seen so many of my clients respond well to this model, even those who 'only' suffered neglect, I have come to conceptualize Complex PTSD as being on a continuum of severity. In this vein, it seems that with enough neglect, certain children automatically over-identify with the superego and adopt an intense form of perfectionism that, via the critic's "not good enough, not pretty enough, not smart enough, not helpful enough, etc.," triggers them over and over into painful abandonment flashbacks every time they are remotely less than perfect or perfectly pleasing.
- Say to yourself: "I am having a flashback". Flashbacks take us into a timeless part of the psyche that feels as helpless, hopeless and surrounded by danger as we were in childhood. The feelings and sensations you are experiencing are past memories that cannot hurt you now.
- Remind yourself: "I feel afraid but I am not in danger! I am safe now, here in the present." Remember you are now in the safety of the present, far from the danger of the past.
- Own your right/need to have boundaries. Remind yourself that you do not have to allow anyone to mistreat you; you are free to leave dangerous situations and protest unfair behavior.
- Speak reassuringly to the Inner Child. The child needs to know that you love her unconditionally- that she can come to you for comfort and protection when she feels lost and scared.
- Deconstruct eternity thinking: in childhood, fear and abandonment felt endless - a safer future was unimaginable. Remember the flashback will pass as it has many times before.
- Remind yourself that you are in an adult body with allies, skills and resources to protect you that you never had as a child. (Feeling small and little is a sure sign of a flashback)
- Ease back into your body. Fear launches us into 'heady' worrying, or numbing and spacing out.
[a] Gently ask your body to Relax: feel each of your major muscle groups and softly encourage
them to relax. (Tightened musculature sends unnecessary danger signals to the brain)
[b] Breathe deeply and slowly. (Holding the breath also signals danger).
[c] Slow down: rushing presses the psyche's panic button.
[d] Find a safe place to unwind and soothe yourself: wrap yourself in a blanket, hold a stuffed
animal, lie down in a closet or a bath, take a nap.
[e] Feel the fear in your body without reacting to it. Fear is just an energy in your body that
cannot hurt you if you do not run from it or react self-destructively to it.
- Resist the Inner Critic's Drasticizing and Catastrophizing:
[a] Use thought-stopping to halt its endless exaggeration of danger and constant planning to control the uncontrollable. Refuse to shame, hate or abandon yourself. Channel the anger of self-attack into saying NO to unfair self-criticism.
[b] Use thought-substitution to replace negative thinking with a memorized list of your qualities and accomplishments
- Allow yourself to grieve. Flashbacks are opportunities to release old, unexpressed feelings of fear, hurt, and abandonment, and to validate - and then soothe - the child's past experience of helplessness and hopelessness. Healthy grieving can turn our tears into self-compassion and our anger into self-protection.
- Cultivate safe relationships and seek support. Take time alone when you need it, but don't let shame isolate you. Feeling shame doesn't mean you are shameful. Educate your intimates about flashbacks and ask them to help you talk and feel your way through them.
- Learn to identify the types of triggers that lead to flashbacks. Avoid unsafe people, places, activities and triggering mental processes. Practice preventive maintenance with these steps when triggering situations are unavoidable.
- Figure out what you are flashing back to. Flashbacks are opportunities to discover, validate and heal our wounds from past abuse and abandonment. They also point to our still unmet developmental needs and can provide motivation to get them met.
- Be patient with a slow recovery process: it takes time in the present to become un-adrenalized, and considerable time in the future to gradually decrease the intensity, duration and frequency of flashbacks. Real recovery is a gradually progressive process (often two steps forward, one step back), not an attained salvation fantasy. Don't beat yourself up for having a flashback.