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by Nel Walker



Flashbacks are the intrusive ‘reliving of trauma’ - type experiences, common to people who have experienced severe trauma. In most cases, these decrease over time as a person processes the traumatic material, but for those who develop posttraumatic stress disorder or have a dissociative disorder, these symptoms do not improve. They are like pockets of past time, intruding into consciousness, causing the person to relive the original horrific experience in all its rawness and as if it were happening to them now, in the present. This is why they are so disturbing. Being with a client who is having a flashback may feel like being in the same room as a child being tortured, and knowing one cannot do anything to prevent it from having happened. But the therapist needs to keep very well grounded, so that we can turn it into a healing abreaction rather than a re-traumatising reliving of the experience.


An abreaction is the emotional release or discharge after recalling a painful experience that has been repressed. I may be using the terms, abreaction and flashback, almost interchangeably.

A flashback as such, does not have the capacity to bring about processing of the memory experience, and is traumatic in itself, thus adding to the suffering of the victim. An abreaction, which includes the emotional reaction as well, may lead to healing and integration of the memory, but not necessarily.


Clients who experience a lot of flashbacks may find it quite difficult in general to be grounded in the present, as the past experience has such a powerful pull. They may also experience other dissociative phenomena such as depersonalisation, derealisation and disorientation.


In working with clients who have been severely traumatised in childhood, dealing with flashbacks in the sessions becomes an important and usually unavoidable part of the work. There needs to be a good-enough therapeutic relationship in place, before abreactive work can be successfully undertaken. Such a relationship needs to have the strength to sustain the sense of ‘safety in the present’, while the client is going through the abreaction.


The focus in the early stages of therapy needs to be on stabilisation, containment, psycho-education (to help the client understand what is happening) and the developing of techniques for staying grounded in the present as much as possible (see ‘Stages of Therapy’ article by Mike Fisher).


In therapy, an abreactive experience may occur spontaneously, in response to an accidental trigger, in which case, it needs to be contained as carefully as possible, perhaps using some of the methods described below, or may be carefully prepared for.


More commonly, in my experience an abreaction is preceded by a period of mounting internal pressure and conflict lasting for days or even weeks before the abreactive resolution itself. It is as if a part of the self who has been holding unprocessed traumatic material from the time it happened, gets closer to the surface, with an urgent need to release the experience. The internal pressure is due to an increasingly dangerous-feeling power struggle between this part and other parts who have been maintaining the dissociation.


When a client has had some beneficial resolution in working with memories, and the denying or hostile parts have found new roles (or at least are less powerful in the system), then the client may collaborate with the therapist in working with whatever disturbing material is close to the surface, in a more planned way.



Parts that deny or ‘maintain the dissociation’


These parts are often also stuck in the past and aware only of the sense of danger, lack of power, isolation and helplessness experienced at the time of the trauma. They would feel very threatened by the emergence of the traumatised part, as if still having the same need to safeguard the rest of the self by keeping the experience both out of consciousness but also, unknown to external others. They had a very important protective role in maintaining the dissociation. Another denying part would be likely to have identified with the perpetrators’ attitudes towards the traumatised part of the self, and then used these attitudes (threats, tone of voice, perceived power, etc) as tools to keep the repression in place. Such a part often feels a sense of guilt towards the other parts, and a fear of rejection by them, when the memory of the traumatic experience does break through.


The first task may well be to communicate with these parts until they develop enough trust in the therapist, to, at least loosen their grip somewhat on the dissociated material. The denying parts need to be:


  1. valued for the vital nature of their role in helping the whole of the rest of the person to have survived by keeping this material hidden away,

  2. relieved of the intolerable burden of having been on guard duty for all those years,

  3. brought into the safety of the present,

  4. understood, validated and, when ready, to negotiate a new role.



The Abreaction


Then, as the balance of pressures gradually changes, the previously hidden traumatic experience is allowed to surface in the form of an abreaction in the therapy situation.


Because the unprocessed flashback material is frozen in time, the client will be drawn back into that time, as if she were still right there. Part of the preparation needs to be developing the experience of co-consciousness, so that while experiencing the flashback, the client is also aware of the present and its safety. The main task of the therapist during an abreaction is to maintain vital contact with the present, and to hold that for the client. When an abreaction begins to unfold, the therapist may keep speaking to the client, with such messages as, ‘It’s not happening now’, ‘You’re safely here in this room with me’, ‘It’s safe to let it come through now’, ‘You will survive because you did survive then’.


The therapist can let her know that as it’s not actually happening now, the experience can be interrupted, she can take a pause from it, if she feels that would be helpful. She can be asked to give a hand signal to show if she chooses to do that, and, if so, then the therapist helps her to ground herself in the present for a while until she is ready to go back into the experience (if she feels that is what she needs to do). The therapist is providing a strong sense of safety and containment in doing this, and it helps to give the client a sense of mastery over memory material. It may also be appropriate (if previously discussed and agreed with the client) to offer a hand to hold, so that there is a physical anchor to the present, as well as the sound of the therapist’s voice.


In adaptive information processing theory (Shapiro 2002), the linking of the neural networks holding the traumatic material, with present healthily adapted networks is the foundation of the adaptive resolution of traumatic experiences. This is partly why an often lengthy period of preparation and stabilisation is needed before working with the traumatic material. There needs to be easier accessing of, and/or building of secure enough ego-strength and grounding in the present. The development of the relationship and the client’s ability to internalise it, is vital to such a foundation, and may sometimes take months or years before the client is ready. It is often very hard for a deeply damaged person to internalise much of the secure relationship, and it requires time, patience and commitment on both sides.


I have written this article from my own experience with clients suffering from DID, but also recognising that I have learnt, consciously and unconsciously, from my clients, from others’ experiences, through reading and training. Each client is unique, and one adapts the way of working to each client. Some of what I have written above may not be relevant to the next clients I see, so I recognise, may also not be relevant to your clients, but I hope something of it may be useful.


I would be very pleased to hear of others’ thoughts and experiences on handling flashbacks or abreactions, so we can learn more together.



References


Shapiro, F (2002) EMDR as an Integrative Psychotherapy Approach: Experts of Diverse Orientations Explore the Paradigm Prism. American Psychological Association, Washington.

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