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Helping people with PTSD deal with flashbacks

VOL: 98, ISSUE: 05, PAGE NO: 40

Simon Joseph, BSc, RMN, Cert Counselling, is hepatitis specialist nurse, Bristol Specialist Drugs Service

The World Health Organization (1992) describes post-traumatic stress disorder (PTSD) as a: 'Delayed or protracted response to a stressful event (of either brief or long duration) of an exceptionally threatening or catastrophic nature... Typical features include episodes of repeated reliving of the trauma in intrusive memories ('flashbacks'), dreams or nightmares, occurring against the persisting background of a sense of 'numbness' and emotional blunting, detachment from other people, unresponsiveness to surroundings, anhedonia [an inability to appreciate humour], and avoidance of activities and situations reminiscent of the trauma... Anxiety and depression are commonly associated with the above symptoms and signs, and suicidal ideation is not infrequent. The onset of symptoms follows the trauma with a latency period that may range from a few weeks to months. The course is fluctuating but recovery can be expected in the majority of cases. In a small proportion of cases the condition may follow a chronic course over many years, with eventual transition to an enduring personality change.'

The World Health Organization (1992) describes post-traumatic stress disorder (PTSD) as a: 'Delayed or protracted response to a stressful event (of either brief or long duration) of an exceptionally threatening or catastrophic nature... Typical features include episodes of repeated reliving of the trauma in intrusive memories ('flashbacks'), dreams or nightmares, occurring against the persisting background of a sense of 'numbness' and emotional blunting, detachment from other people, unresponsiveness to surroundings, anhedonia [an inability to appreciate humour], and avoidance of activities and situations reminiscent of the trauma... Anxiety and depression are commonly associated with the above symptoms and signs, and suicidal ideation is not infrequent. The onset of symptoms follows the trauma with a latency period that may range from a few weeks to months. The course is fluctuating but recovery can be expected in the majority of cases. In a small proportion of cases the condition may follow a chronic course over many years, with eventual transition to an enduring personality change.'

When sharing this description with clients it is possible to remain positive by emphasising that most people recover and that it is a normal reaction. PTSD can manifest in grief, guilt, loss of self-esteem, loss of purpose, irritability, loss of security or loss of faith or spiritual belief (Parkinson, 1993). Substance use (alcohol, illicit drugs and prescribed drugs) or other compulsive behaviours are often adopted to reduce arousal and can interfere with attempts to provide alternative coping strategies (Joseph et al, 1997).

What are flashbacks?
Intrusive thoughts are common in PTSD. These images, sounds, emotions, sensations and smells range from mildly irritating to debilitating and unbearable. At their worst they are called flashbacks. A flashback is an intense memory of the trauma that is easily recalled because all the senses are involved and reinforced by powerful emotions (Parkinson, 1993). A flashback can be activated by 'triggers', such as a television programme, smell, sound, phrase, object, situation or person that is reminiscent of the trauma. An obvious example is the way a loud noise can remind a war veteran of an explosion. Some flashbacks occur spontaneously with no obvious trigger, particularly when the person is already stressed or anxious. Flashbacks can also occur as lucid nightmares (Joseph et al, 1997).

There are several effective techniques for coping with flashbacks, which include asking the client to discuss or visualise the content of the flashback in detail. Exposure to traumatic imagery can also be used to desensitise the person to triggers (Keane et al 1989; Marmar, 1991). It is best not to attempt these techniques without specialist training because they carry a great risk of increasing the frequency and intensity of flashbacks, especially in the initial stages. The interventions in this article do not involve discussing the content of the flashbacks and are designed to reduce the impact of flashbacks without triggering them.

The core assumptions of this approach are that flashbacks are reduced if stress is reduced and if clients can gain mastery over the 'cognitive mechanisms' involved. The aim is, therefore, to teach relaxation techniques that are carefully tailored to a person's flashback profile, while providing ongoing support and encouragement. The approach was first developed in group counselling, with clients who were experiencing flashbacks due to sexual abuse or rape. It was refined in an acute psychiatric setting with clients who were more debilitated by their flashbacks.

The client's suitability for intervention
Clients need to be motivated, open-minded and prepared for slow change to occur - over many months or even years. Clients should not be overdependent on the nurse since such clients may want to be talked through every intervention, and may be unable to continue with the work when alone. 'Homework' is an important aspect of this approach and clients are expected to practise the exercises regularly on their own. Clients also need to be able to retain the information they are given and be prepared to experiment with it creatively.

The first session
Reassure the client that you do not need to discuss the content of the flashback, or the trauma itself. Explain that a flashback is physical in nature and you will teach techniques that use the same mental apparatus to clash with it and retrain the client's memory, while helping them to become less stressed. Explain that the technique is not a miracle cure, but it will help to reduce the intensity and frequency of flashbacks slowly over a long time - but only if the client is willing to put in some hard work.

Obtaining the profile
Ask the client to describe the sensory and emotional experience. It is vital that this is done thoroughly in order to determine the right techniques. Ask variants of the following questions: Is it mainly visual? Is it in colour or black and white? Is it in focus or blurred? Do you see yourself from a distance or are you within it? Is the visual aspect the most important element? Can you still see your real surroundings or just the flashback? How long does it last? Are you aware of particular smells during the flashback? Are these important? Are there sounds? Are these noises, voices or both? Are there physical sensations? Do you feel tense and angry during the flashback, or passive? Are the emotions overpowering or do you feel blank and distant? How often do you have flashbacks? Are the flashbacks always the same? Are they more likely at certain times of the day? How long does it take you to recover from a flashback? Are there things which trigger them or do they happen spontaneously?

Once you have the profile this should be reflected back to the client and corrected if necessary. For example, 'So you have flashbacks about twice a month, usually when you are on your own. These last about 10 minutes, but it takes half-an-hour to recover. They are primarily visual and in colour. You see yourself from a distance. You feel emotionally blank and powerless. There are no sounds, smells or physical sensations. Have I missed anything out?'

Teaching simple relaxation techniques
The initial emphasis is on helping clients to isolate the flashback so that the fear of the flashback does not debilitate them. You need to teach the client a range of easy-to-remember relaxation exercises, which relate to that person's flashback profile. Exercises could include, for example, visualising a simple object, visualising a point of light tracing the outline of the body, tensing and relaxing muscles, concentrating on breathing, counting out loud, stretching, listening to a tape, self-massage, a warm bath, use of aromatherapy oils, or a combination of these. Use any relaxation techniques you know and try to learn as wide a range as possible.

Teaching orientation techniques
Clients who are aware of their surroundings during a flashback can be encouraged to try to focus on a specific, nearby object such as a picture, chair or the corner of the room. If the object is a clock they can time the flashback. Encourage them to find a suitable phrase that they can keep repeating to themselves, aloud or internally, during a flashback. This phrase could be:

- 'It's not real, it's only a dream.'

- 'I'm in my living room, it'll be over soon.'

- 'I'm at home. This is a memory.'

Clients should use whatever phrase helps them to return to reality. A partner can use similar phrases and offer reassurance.

After every flashback clients will need to recover properly to reduce stress and to isolate the flashback, making it a smaller part of their life. Encourage the client to get up after a flashback and distract themselves for about half an hour. They can get a drink (not caffeinated, as it will make them anxious), read a book, watch television, phone someone up or whatever works for them. They should also try to practise one of their relaxation exercises as soon as possible. They can time how long it takes to recover, so that the next time a flashback occurs they can keep reminding themselves that it only lasts that long at most.

Clients should be advised to use their chosen technique at every opportunity, preferably several times a day. This should reduce their general stress levels and familiarise them with the techniques.

Subsequent sessions
Subsequent sessions are based on solution-focused brief therapy (De Shazer 1988; Wilgosh et al, 1994; Saunders, 1996). Motivational interviewing (see box) is also effective because the emphasis is on encouraging behaviour change (Miller and Rollnick, 1991).

Once clients have learned the simple techniques and are comfortable with them they can try to force them to occur during a flashback to 'retrain' the mental mechanisms. Clients should be reassured that this can take a long time. Small changes should be sought and applauded. Clients should be asked what helped them to do the work and what hindered them. The work should remain the focus of the sessions. Counselling for emotional issues related to the original trauma should be restricted to separate sessions, preferably with another therapist.

Techniques can be modified by the client to reflect their ongoing experiences, or rejected and replaced with one the client is more comfortable with (even if this fits the profile less).

Advanced relaxation techniques
When clients are ready (as soon as the first session for highly motivated people) they can learn more complex techniques which fit the profile closely. The rationale given to the client is that it is important to retrain the mental apparatus used by the flashback so that the client can gain some control over it. These techniques may need to be practised for a long time before progress is noticed or there may be a lot of progress early on, with a long period of little apparent progress. The idea is to increase the emotional distance from the flashback, changing it into a memory. This principle borrows and simplifies techniques from neurolinguistic programming (McDermott and O'Connor, 1996). The following examples give an idea of the techniques involved.

For primarily visual flashbacks

Encourage the client to imagine they are seeing the flashback at the cinema. Initially the client focuses on making it appear flat, as if projected on a screen. This is followed by adding visualised props, such as a curtain, the backs of people's heads, the exit doors, the noise of people eating popcorn and so on. After this they can visualise it as a video, which they can pause, fast forward, slow down, pause, rewind or watch in black and white.

For a visual flashback with sounds and smells

Ask the client to chose an aromatherapy oil they particularly like, preferably one with a strong smell and relaxing properties. They should be taught a guided imagery for relaxation. This could be describing a peaceful scene to themselves, such as walking on a beach, flying over mountains or walking in woodland. Any visualisation that appeals to the client is acceptable. This can be put on tape or they can talk themselves through it to relaxing music. If they feel relaxed they should sniff the oil at the end of the session to associate the relaxed feeling with the smell. They should use the same oil for baths and massage.

The visualisation should become more complex with practise. Initially, it can be a vague scene or idea such as walking on a beach. With practise and encouragement the client should be able enhance the details, such as concentrating on the sound of the waves, the smell of the sea or the feel of sand underfoot (Davis et al, 1995). Eventually the client can begin to sniff the oil at the end of a flashback or during it to produce relaxing feelings and images which counteract the flashback.

Conclusion
Use whatever works. One of our clients found that singing a nursery rhyme ('Doctor Foster Went to Gloucester') out loud and visualising the good doctor falling in a puddle right up to his middle worked extremely well. Another client, who had noisy flashbacks, carried a personal stereo on which he played the Monty Python theme music when he felt a flashback starting. Creativity, a knowledge of lots of relaxation techniques and a sense of fun are essential components in making this approach a success.

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