A significant percentage of adults who experienced ongoing abuse or neglect in childhood suffer from Complex Post Traumatic Stress Disorder. As described by leading trauma theorists Judith Herman (Trauma and Recovery) and famed PTSD researcher Bessel van der Kolk, Complex PTSD is caused by "prolonged, repeated trauma" and "a history of subjection to totalitarian control" such as happens in extremely dysfunctional families. It is distinguished from the more familiar type of PTSD in which the trauma is specific and defined, but can be even more virulent and pervasively damaging in its effects. (Complex PTSD has not yet been included in the DSM.)

One of the most difficult features of Complex PTSD is extreme susceptibility to painful emotional flashbacks. Emotional flashbacks are sudden and often prolonged regressions ("amygdala hijackings") to the frightening feeling-states 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. I remember an example of this from early in my career when a handsome and intelligent client who was a professional actor came in after an audition - deep in a flashback from not getting the part - and mortifyingly burst out: "I never let on to anyone but I know that I'm really very ugly; it's so stupid that I'm trying to be an actor when I'm so painful to look at."

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 some therapists 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 humiliation and overwhelm, and the therapist needs to feel comfortable enough to provide the empathy and calm support that was missing in the client's early experience.

Responding Functionally to Flashbacks

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 reverberates deeply with their intuitive understanding of their suffering. When they understand that their sense of overwhelm initially arose as an instinctual response to traumatic circumstances, they begin to shed the awful belief that they are crazy, hopelessly oversensitive, and/or incurably defective.

Without help in the moment, the client typically remains lost in the flashback and has no recourse but to reenact his own particular array of primitive, self-injuring defenses to what feel like unmanageable feelings. These dysfunctional responses generally manifest in four different ways: [1] fighting or over-asserting one's self in narcissistic and entitled ways such as misusing power or promoting excessive self-interest; [2] fleeing obsessive-compulsively into activities such as workaholism, sex and love addiction, or substance abuse (‘uppers'); [3] freezing in numbing, dissociative ways such as sleeping excessively, over-fantasizing, or tuning out with TV or medications (‘downers'); [4] 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.)

I find that most clients can be guided to see the harmfulness of their previously necessary, but now outmoded, defenses as misfirings of their fight, flight, freeze, or fawn responses. In the context of a secure, therapeutic alliance, they can begin to replace them with the anxiolytic responses to flashbacks listed at the end of this article. I introduce this phase of the work by giving the client this list of cognitive, affective, somatic and behavioral techniques to use as a toolbox outside of the session and elaborate on them in our sessions as well.

As clients begin to respond more functionally to being triggered, there are more opportunities to work with 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. I recently experienced this with a client who rushed into my office five minutes late, visibly flushed and anxious. She opened the session by exclaiming: "I'm such a loser. I can't do anything right. You must be sick of working with me." I was pretty sure that being late had triggered her into a flashback and I wondered out loud if this were the case (tool #1: consciously identifying her experience as a flashback). Because of the safety that we had established over time, she immediately acknowledged this and let go into deep sobbing (tool # 9: grieving out the unreleased pain of the original trauma). As her tears subsided, she reported that she was remembering a time as a small child when she had literally received a single lump of coal in her stocking for Christmas as punishment for being ten minutes late to dinner (tool #12: remembering and working through the trauma she was flashing back to). As her tears morphed into healthy anger about this abuse, she felt herself coming back into an empowered sense of self. She was able to say "no" to her parents' original unfair punishment and "no" to her critic's subsequent habit of judging her harshly for every peccadillo (tool # 8: resisting the inner critic). Finally, I was able to remind her to reinvoke her sense of safety (tool # 2: establishing cognitive safety and tool #7: easing into somatic relaxation).

Rescuing the Wounded Child

In guiding clients to evolve in their ability to manage flashbacks, my most ubiquitous intervention is helping them to deconstruct the 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 not only exacerbates flashbacks, but also eventually grows into a psychic agency that initiates them. 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. Hypervigilance devolves into intense performance anxiety and perfectionism festers into a virulent inner voice that 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.

One frequent scenario occurs when a client, in the midst of reporting some minor mishap or mistake of the previous week, suddenly launches into a catastrophizing tale of her life deteriorating into a cascading set of disasters. She has flashed back to the danger-ridden times of her childhood, and her distress sounds something like this: " My boss looked at me funny when I came back from my second bathroom break this morning and I know he thinks I'm stupid and lazy and is going to fire me. I just know I won't be able to get another job. My boyfriend will think I'm a loser and leave me. I'll get sick from the stress, and with no money to pay my medical insurance and rent, I'll soon be a bag lady on the street." Teaching such clients how to recognize when they have let the inner critic's drasticizing take over, and modeling to them how to resist it with thought stopping and thought substitution (tool #8) is essential in managing flashbacks.

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 - unlike mom who didn't save him from his abusive dad, or unlike the neighborhood that didn't rescue him from his alcoholic family. Decades of trauma work have taken me to a place where my heart no longer allows me to be silent and, hence, tacitly approving, when clients verbally and emotionally abuse themselves or, put another away, identify with the aggressor via the inner 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. I describe flashbacks as the inner child righteously clamoring for validation of past parental abuse and neglect. Flashbacks are signals from the wounded child that a developmental need has not been met-none more important that the need for a parent's protection and compassion, which enable the child to develop a healthy sense of self-protection and self-compassion (hallmarks of a healthy ego). Without awakening to these instincts, clients rarely develop effective resistance to internal or external abuse, and seldom gain the motivation to use the tools below.

When clients get that their emotional storms are messages from an inner child who is still pining for a healthy inner attachment figure, and when they are able to internalize the therapist's acceptance and support, 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, and they become able to metabolize these feelings in a trauma-resolving way. This in turn leads to a reduction of the emotional energy that fuels their flashbacks, and the flashbacks, in turn, become less frequent, less intense and less enduring. Eventually flashbacks can even begin to invoke a sense of self-protection at the moment of triggering or at least as soon as the individual realizes she is triggered. Finally, as flashbacks decrease and become more manageable, the defensive structures built around them (narcissistic, obsessive-compulsive, dissociative and/or codependent) can be more readily deconstructed.

Moving through Abandonment and into Intimacy

I have seen so many of my clients respond well to this model, even those who ‘only' suffered neglect, that I have come to conceptualize Complex PTSD as being on a continuum of severity. It seems that with enough neglect, certain children automatically over-identify with the superego and adopt an intense form of perfectionism that triggers them into painful abandonment flashbacks every time they are less than perfect or perfectly pleasing.

A sweet, middle-aged male client had suffered severe emotional abandonment in childhood. He was polarized into the isolating defensiveness of the freeze and fawn responses and had never experienced an enduring relationship. As a result of our long-term work, he became more available to one and he successfully dated a healthy and available partner. For the first six months of their relationship, her kind and eliciting nature, and my coaching, enabled him to show her more and more of himself, and he was rewarded by increasingly experiencing loving feelings. However, once he accepted her request to try living together, he could no longer hide his recurring flashbacks into depression. He believed depression was his fatal flaw. His mother had turned her back on him for even the mildest dip in his mood and he was convinced any sign of depression would scare his new partner away. Whenever his mood dropped he would feel endangered and flashback into the freeze response. As his sense of isolation increased, the critic triggered him into viewing his partner as being as disgusted with his affect as his mother had been. He was on the verge of a full-fledged flight response into the old habit of precipitously ending relationships.

We spent many subsequent sessions managing this flashback into abandonment. He learned to recognize his silent withdrawals as flashbacks (tool#1). He grieved his original abandonment more deeply and more self-compassionately than ever (tool #9). Over and over, with my guidance, he confronted the critic's projection of his parent onto his partner (tool#11), practiced grounding himself in the present (tools #2 and #6), and began talking to her about his depression, and about how afraid and ashamed he was to show it. He was rewarded not only by her empathic response but also by her gratitude for his vulnerability, and she began to share an even deeper level of her own vulnerability. For the first time, he began talking to her while he was actually depressed, and soon their love began to expand into those special depths of intimacy that are only achieved when people feel safe enough to communicate about deep existential feelings.

MANAGING FLASHBACKS

(focus on bold print when flashback is active)

1. 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.

2. 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.

3. 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.

4. 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.

5. 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.

6. 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.)

7. 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 energy in your body that cannot hurt you if you do not run from it or react self-destructively to it.

8. Resist the Inner Critic's Drasticizing and Catastrophizing. (a) Use thought-stopping to halt its exaggeration of danger and need 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.

9. 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.

10. 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.

11. 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.

12. 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.

13. 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 gradual process - often two steps forward, one step back. Don't beat yourself up for having a flashback.

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Pete Walker, M.A., MFT, is a licensed Marriage and Family Psychotherapist with degrees in Social Work and Counseling Psychology. He has been working as a counselor, lecturer, writer and group leader for 30 years, and as a trainer, supervisor and consultant of other therapists for 15 years. He holds certificates in supervision from the California Association of Marriage and Family Therapists (CAMFT) and the Psychotherapy Institute in Berkeley.

Visit Pete Walker's page on East Bay Therapist