Friday, 18 September 2015
PTSD, Taking Action, and Flashback Memories
PTSD, Taking Action, and Flashback Memories
“Always get your patients to do things.”
I recently read about some research that found that saying “Ow!” or pushing a button
increased tolerance to pain, but that simple relaxation or hearing a recording of themselves
or someone else saying “Ow!” made no difference. The researchers concluded that
making some kind of vocal utterance may be an effective way of coping with pain,
and they described this as “distraction.”
However, I have a different interpretation of the results of this study.
If pushing a button works as well as saying “Ow,” that clearly indicates that a larger category
of behavior than vocalization is the key, namely taking some kind of action.
It may not matter what the action is, or whether it is effective — only that the person
is engaged in some kind of activity in an attempt to cope with the situation causing the pain.
This may result in “distraction,” but I think it is different than simply attending to something
other than the pain. Many people who have been badly injured in an accident
feel little or no pain while actively attending to other injured people or coping with the situation —
until they stop what they are doing.
Someone else responded to the article, describing the effect as “releasing the feeling,”
but I think that is also misleading, implying that a feeling is something tangible
that can be held onto or released, rather than an important signal. The purpose of having pain or discomfort in response to noxious events is to alert us to take corrective action to protect the body. Saying “Ow” is an action taken to alert others and often to solicit their help; species that don’t help each other don’t cry for help, because it would do them no good. Once the action commences,
there is no need for the pain signal, and it makes sense to focus attention on the action being taken.
I once knew someone who had been in the Peace Corps in Micronesia. Walking on the beach,
she got a nasty injury from a fishbone in her foot. The natives immediately got a mango and a knife, and told her to stab the mango with the knife to reduce the pain. I don’t think you have to use
a knife or a mango, but taking some kind of action — particularly if it mimics the mechanism of pain,
in this case stabbing in the same way that the fishbone did — can make a difference.
Action and PTSD
Now let’s explore how this may be relevant to the resolution of PTSD. In a terrifying experience,
there are 3 fundamental categories of response, fight, flight, or freeze. The first two are actions,
and whether or not they are effective, they appear to protect against PTSD.
However, freezing is the absence of action, and those who freeze are most likely to suffer PTSD later.
For over nine years I was an emergency “first responder” for our rural volunteer fire department, responding to accidents and medical emergencies as well as fighting fires.
Quite often I would arrive on the scene to find someone unmoving, staring into space,
not able to do anything in response to what had happened.
They surely had read about accidents and emergencies,
but they had never thought it could happen to them, so they were totally unprepared, frozen.
The broader message is that being prepared to do something in a terrifying situation is important. Undoubtedly there are a few situations in which doing nothing is the best — or the only — option.
But generally speaking, doing something — even if it’s not the best thing — at least
has the possibility of coping with a difficult situation. It will usually have a better chance
than doing nothing, and it will probably protect from developing PTSD later.
When someone has PTSD, a “flashback” memory is usually understood to be a terrifying one. However a flashback can also be to a memory with more positive emotions,
as described in Wikipedia:
“A flashbulb memory is a highly detailed, exceptionally vivid ‘snapshot’ of the moment
and circumstances in which a piece of surprising and consequential (or emotionally arousing)
news was heard.”
“A flashback, or involuntary recurrent memory, is a psychological phenomenon
in which an individual has a sudden, usually powerful, re-experiencing of a past experience or elements of a past experience. These experiences can be happy, sad, exciting, or any other emotion. The term is used particularly when the memory is recalled involuntarily, and/or when it is so intense that the person ‘relives’ the experience, unable to fully recognize it as memory
and not something that is happening in ‘real time.’ ”
Some time ago I started thinking about positive flashback memories, wondering what we might learn from them that we could apply to the resolution of negative flashbacks.
Let’s start with a few examples.
Positive Flashback Memories
1. When I was in my mid-20’s, living in the San Francisco Bay area, I did a lot of sailing on
the bay in a 14’ boat. One afternoon I was far out on the bay, happily “planing”
in which the boat skims across the surface of the water, going much faster than usual.
My toes were hooked under the lip of the centerboard housing, and most of the rest
of my body “hiked out” to balance the boat, as shown in the photo below.
And then my toes slipped, and I tumbled backward into the water. Now, a half-century later,
I still have a vivid snapshot of the moment when I was about 3 feet under the surface
of the water, looking up at an oval of sky framed by a transparent wall of water all around it,
just before the water closed in over my body. I am laughing uncontrollably
at the shift from supreme confidence and skill to utter chagrin.
1. One afternoon in fall, I walked out on our back deck and saw a large black bear about
20 feet up in the ash tree about 25 feet away from me. Another 25 feet away was my wife, Connirae, who was leaning down to check our tomato plants, obviously not aware
of the bear. I thought she ought to know about it, so I called out her name.
My voice frightened the bear, which slid quickly down the trunk of the tree
and rushed away from me—and directly toward Connirae. Connirae stood up
and turned toward me to see what I was calling about—and there was the bear,
charging directly toward her, only a few feet away. Before Connirae had time to recognize
it was a bear, she was looking into its eyes, which were also looking right at her. It looked terrified, and Connirae felt instant compassion for the poor creature, rather than fear.
2. Walking up a narrow rocky trail from a delightful swim in the clear creek
at the bottom of the canyon. I suddenly found myself about 3 feet to the right of the trail
where I had been walking. Only then did I become aware of the rattlesnake
coiled right in the trail, which was now to my left. I was very alert, but not afraid.
I walked around to get past the snake and continued up the trail.
In the first example, I was able to have an enjoyable response because of my knowledge
and experience. I knew how to swim, and I also knew that since I had released the rope
that held the sail, the boat would immediately head into the wind and drift slowly,
so that I could easily swim to it, get in, and continue sailing.
Someone without this knowledge probably would have been terrified of drowning,
but I had only the surprise of being unceremoniously dunked.
In the second example, Connirae saw a relevant aspect of the rushing bear that most people
might not have noticed, so she had an unusually resourceful response in what would otherwise
have been a very scary experience. By the time Connirae realized it was a bear,
it had dropped on its haunches, skidded to a stop, and turned 90 degrees to run away from her.
She was thankful that the bear saw her before she saw the bear, because
“The bear became afraid before I had a chance to.”
In the last example I must have unconsciously seen the rattlesnake and taken appropriate action, long before my conscious mind caught up with what was happening. I had a lot of experience
with rattlesnakes from my childhood on a ranch in Arizona, so I knew what to do,
and no thinking or deciding was necessary.
In the first example, my knowledge and experience protected me from terror,
in the second, Connirae’s perception protected her,
and in the third, my perception and action protected me.
It’s important to realize that in all three examples no conscious thinking or decision process
was involved. Now let’s explore how this information can be used with PTSD.
Resolving Negative Flashback Memories
When someone has a terrifying flashback experience, they are always back inside the experience, reliving it, re-experiencing the feelings that they had in the original. The first thing to do
is teach them how to re-view the same experience in a different way, namely as an outside observer watching themselves go through it. (This process is probably very familiar to most readers
After this process, the client has a neutral emotional response to the flashback memory.
Although this process resolves the memory by eliminating the terror, it doesn’t teach someone
how to respond more resourcefully to any future repetition of the terrifying event.
If something similar to the flashback event were to happen in the future,
they would be just as unprepared as they were the first time.
Creating a More Positive Alternative Scenario
If we create an alternative movie in which we respond more resourcefully, and rehearse
it in our imagination, that can prepare us for any potential repetition of a troublesome event.
The primary purpose of this is to program us with alternate ways to cope with a similar event
if it were to occur in the future. We will also feel more secure about our capability in the present,
but that is a secondary benefit. The instruction for creating a new scenario is fairly simple,
but certain criteria need to be met for it to be really effective.
Selecting, Eliciting, and Rehearsing a New Response
“I want you to recall the event that was terrifying. Without directly changing anything external
to you, how could you respond differently to lessen the negative impact of that event, neutralize it,
or possibly even make it positive? This could include any additional preparation, knowledge, understanding, perception, or action that is within your control.
The goal is to make you more resourceful and empowered in responding to that kind of event
in case something like it ever happens to you again.
“Here are some examples of what I mean. You already know that something like this
could happen to you, so that knowledge is already one kind of preparation.
You also know that you survived that event, so that is additional preparation for any repetition.
Instead of tensing up just before the crash, you could relax instead, so that your body is more supple and less likely to be injured. You could raise your arm to ward off the assailant’s blow to protect
your head. You could smile at the mugger and ask him for the time, hoping that might puzzle
and distract him. You could deliberately misunderstand what someone else said. You could perceive the signs that warn you of danger, or refuse an invitation, avoiding the event altogether.
“A thorough search of alternative actions will usually turn up many, many possibilities,
and some of the most uncommon or bizarre ones may be the most useful in changing the impact
of that situation. If your creativity runs down, ask others for help in generating
additional possibilities. After an extensive search, you may still conclude that doing nothing
was actually the best option in that situation. If so, make freezing into a choice,
rather than a default—something that you do, rather than the absence of doing.
“When you have identified something that you could do differently, create a scenario of you doing that in the context, with you inside the movie, looking out from your own eyes as the event unfolds.
As you imagine doing something different, it is fine if that changes the situation indirectly—
for instance someone else involved may respond differently to what you did differently.
“If you were to imagine a scenario in which external events are directly changed
(for instance, a rescuer enters the scene, or the assailant does something different on his own, etc.) since those changes are not under your control, they would be useless in any future repetition
of the event. Furthermore, changing external events implies that you are not able to influence
the situation yourself, the opposite of empowerment.
“If you make a change that is within your control (such as refusing an offer of a ride home)
that may change external events through changed consequences (no rape/assault).
This is a legitimate and very useful change, especially if is based on specific sensory warning cues that were available but that you ignored in the original event.
“In his really excellent book, The Gift of Fear, Gavin de Becker teaches assault victims
what cues to search for in the original event, in order to protect themselves from a future repetition. After doing this with a woman who was brutally raped, and barely escaped being murdered,
she said something like, ‘You know, it’s funny, but I feel safer now than I did before the assault.’
“When you have created a new scenario that changes the impact of an event,
test it in your imagination to be sure that it has the desired effect, and find out if you can improve it in any way. Then create at least two additional alternative scenarios — the more the better —
and test them in your experience, to be sure they are effective in reducing the negative impact
of the event.”
Carefully rehearsing a variety of more positive alternative scenarios in this way prepares you
to respond resourcefully with unconscious choices. When done thoroughly, this prepares you
to respond to any repetition with a variety of actions for coping with a difficult situation,
reduce its harmful impacts, and at the very least it should protect you from a recurrence of PTSD.
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