Substance or alcohol abuse is another comorbid con- dition that might interfere with treatment by blocking experience of anxiety or distress during self-exposure. When it is secondary to trauma, treating traumatic stress might also improve this condition. In such cases, however, CFBT needs to be combined with a substance withdrawal program. As the survivor begins to withdraw from the substance, anxiety and other traumatic stress symptoms subdued by the substance are likely to emerge, so it is important that CFBT is initiated during this period. Regular monitoring of progress is often helpful in ensuring that the timing and pace of both procedures are correctly adminis- tered. In some severe substance abuse cases an in- patient detoxification program might be necessary, followed by psychological treatment.
Flashbacks
Although flashbacks are not uncommon in mass trauma survivors, severeflashbacks with complete dis- sociation and lack of awareness of surroundings that
are likely to pose a safety risk are quite rare. To put this issue in perspective, we foundflashbacks in 15% of the earthquake survivors in a study (Başoğlu et al.,2001) conducted during the first 6 months of the disaster. None of these cases had‘extremely severe’ flashbacks according to the Clinician-Administered PTSD Scale (CAPS; Blake et al., 1990). In another study (Şalcıoğlu,
2004) of 387 earthquake survivors conducted mean 20 months post-earthquake, 14% had flashbacks, which were extremely severe in only one case (0.3%). Among 1358 war survivors (Başoğlu et al.,2005), on the other hand, 8% had flashbacks but they were extremely severe in only four cases (0.3%).
Flashbacks do not necessarily pose a problem for therapy and generally should not be considered as a counter-indication for exposure treatment. Indeed, flashbacks can be triggered by a wide range of cues in survivors’ natural environment with or without treat- ment. Furthermore,flashbacks never posed a problem for treatment in our work with earthquake survivors, other than occasionally making self-exposure a bit more difficult to conduct for the survivor. Their fre- quency substantially declined with improvement in other symptoms. Nevertheless, some potentially prob- lematic cases may need additional therapist attention. Once this problem is overcome, treatment can proceed as usual. Whenflashbacks are reported, the following questions would be useful in identifying potentially problematic cases:
* Have you ever tried to harm yourself or others
during the (flashback) event or afterwards? Have
you ever felt an inclination to do so?
* Have you ever got yourself into harmful situations
during the (flashback) event because you were not
aware of what was going on around you (for
example, having an accident or provokingfights
with other people)?
* Did you ever go missing from home for days and
were then found somewhere and had no recollection of where you were or what you did during that time?
In cases with mild to moderate brief-lastingflashbacks, a simple self-management strategy might suffice. As thefirst step in dealing with this problem, the survivor needs to be informed that flashbacks are disturbing but essentially harmless phenomena. This may come as a relief for those survivors who may interpret them as a sign of‘losing their mind.’ Helping the survivor understand that the symptom is controllable is also
useful. The following instructions might help bring the symptom under control:
⇒ Try to monitor your flashbacks and work out what triggers the symptom. It could be a sight, sound, smell, word, thought, image, emotion, or anything that reminds you of your trauma experience. Make a list of the situations that trigger them. When you encounter these situations, be aware that the symptom may
appear.
⇒ When you realise that the symptom is about to appear, sit down to one side. Breathe deeply and regularly. Focus on what is happening around you. Try to watch carefully what people are doing, what they are saying. Or try to focus your attention on something. For example, look carefully at an object near you and study its shape, colour and texture. Pick it up and feel what kind of emotion it produces. Focus all your
attention on this object.
⇒ You could carry a small bottle of cologne with you. If you do, pat some cologne on your face and hands and focus on feeling refreshed. You could also carry a string of worry beads with you. As the symptom begins, hold the beads and start
counting them in two’s or three’s. Focus on the
prayer beads and be careful not to make a
mistake when counting.
⇒ You may find other effective ways of focusing your attention elsewhere. These could be things like walking, telling yourself where you are, the
date and time, or humming a tune.
⇒ Talk to your family about your situation and tell them about this symptom. If the symptom appears while you are with them, they can
help‘bring you back to reality.’ They could do this
by touching you or telling you where
you are.
Identifying the cues that triggerflashbacks and inter- rupting the dissociation process by focusing attention on the‘here and now’ when the cues are encountered may help the person regain sense of control over the symptom. Once this is achieved the symptom is not likely to pose any problem in self-exposure exercises. As treatment progresses and other traumatic stress symptoms begin to improve,flashbacks often reduce in frequency and intensity.
In severe cases that pose a safety risk, the problem may need to be handled by the therapist in a controlled
setting. Some survivors experience flashbacks when they relate their trauma story in some detail. In such cases getting the survivor to relate the trauma story in a guided fashion might be helpful in identifying par- ticular trauma memories that trigger flashbacks. When thefirst signs of a flashback begin to emerge, the survivor is asked to stop andfight back dissociation by using the ‘grounding’ techniques described above (e.g. focusing attention on the therapist or objects in the room, patting cologne on the face, counting beads, etc.). Once dissociation recedes, the survivor is asked to focus on the particular memory (or imagery) that triggered theflashback, retain it in mind for as long as possible while also making an effort not to lose touch with reality, and interrupt the process short of a full- blown flashback. This process is repeated until the survivor is able to control the symptom or the trauma memory no longer triggers it. At some point a full- blown flashback might occur. Once it is over, treat- ment is resumed, focusing again on the particular memory that triggered the flashback. The point of this exercise is to increase the survivor’s tolerance of distress evoked by trauma memories so that it no longer triggersflashbacks. Note that this exercise can also be conducted during live exposure to trauma reminders that triggerflashbacks, if the latter can be identified. Such reminders might include, for example, the location where the trauma was experienced, sights of devastation in the environment, TV pictures of violence or disaster, etc. Therapist-guided graduated exposure to such situations in the way described above can be helpful.