Phil Manfield, Ph.D. on A New Treatment for Psychological Trauma - the Flash Technique
My friend and colleague Lewis Engel and I have had a weekly lunch for 30 years - and for the last year we've been using and talking about your Flash technique, which appears to be a potentially paradigm-busting approach to treating trauma – with rapid positive effects in which consciously accessing components of the traumatic memory is not only unnecessary, but may in fact be counterproductive to clearing such memories of their disturbing affects and negative sensory reactions.
There is currently a prevailing “exposure model” to trauma treatment, with “prolonged exposure” as a standard treatment, for example, at Veterans Administration Medical Centers. Even Eye Movement Desensitization Reprocessing (EMDR) – an established and well-researched approach given “conditional recommendation” for PTSD treatment by the American Psychological Association in their Practice Guidelines – has intermittent brief exposure to the traumatic memory. Your demonstrations show Flash to be a therapeutic process that can quickly heal and neutralize psychological trauma without any such exposure, which means there is no risk of re-traumatization.
In August 2017 and January 2018 I hosted meetings of 35 psychotherapists and researchers in San Francisco to discuss this work. You had previously completed a webinar with 70 Australian psychotherapists, which you have followed by a daylong workshop in Berkeley in October for 160 psychotherapists, and through July 2018 you’ve done five additional, all-day webinars with over trauma therapists from 20 different countries and 38 states. So nearly 2,000 trauma therapists have learned how to do this new process in the past nine months.
Awareness and acceptance of the technique’s ease and effectiveness is clearly accelerating. Something truly groundbreaking is happening here. My high tech start-up friends talk about “disintermediation” – roughly speaking, “getting rid of the middleman.” Removing conscious exposure to disturbing memories in treating PTSD and trauma will even empower people to reduce their own suffering.
Can you give us a little summary of what Flash is and how you happened upon it?
DEVELOPMENT OF THE FLASH TECHNIQUE
Gladly. Lewis Engel and I do trauma treatment using Eye Movement Desensitization Reprocessing (EMDR), and I have taught EMDR internationally to psychotherapists for twenty years. EMDR is one of six therapeutic approaches officially recommended by the American Psychological Association, and over 400,000 therapists have been trained in it around the world. A challenge using EMDR has been with people who are so highly dissociative or overwhelmed by their material that they can't focus on it; they may even be re-traumatized by bringing it up. Yet, in order to do EMDR, they need to consciously access some part of the traumatic memory.
The EMDR world in general has been focusing on that issue now for quite some time, and the usual solution to that problem has been titration: To try to take a little piece of the memory as the target, so it’s not going to be overwhelming, and process that; and then, take another little piece and another little piece. In the process of finding ways to titrate, one of the things that I was doing was trying to shorten the amount of time that the client was thinking of the disturbing memory.
So, with people who are very, very sensitive to their issues - I got it down to: “you're just going to think about it for a moment, and then stop and come back to visualizing a different, engaging or positive resource state – as quickly as possible.” And to me, a moment was like a second or two.
One day, I realized that very brief contact with the target seemed to stimulate more rapid decrease in the discomfort (or “processing”) than longer contact with the material. And then, while preparing to give a presentation on memory recall, I realized that the research literature on memory reconsolidation describes the necessity to retrieve the memory into working memory, but doesn’t really define what exactly is involved in retrieval.
So, I started to experiment with very, very brief retrieval, a fraction of a second, and that seemed to accelerate the processing, and it seemed to reduce the client's disturbance, and of course clients were much more willing to do it when they were told it would be too quick to be disturbing. Those early sessions involved exceedingly brief contact, and then, a number of quick “sets” of those exposures, and then the disturbance would come down on the Subjective Units of Discomfort Scale (SUDS). But, I started to notice that some people would say, "You know, I don't even know if I thought of the memory. It was so brief. I'm not sure I thought of it." And those people seemed to be making big leaps in processing and healing.
So I then suggested that people make such a brief contact that they don't actually think clearly about the memory, and that really was a breakthrough; that seemed to work.
Lewis and I and two other people wrote a paper about it that was published in November 2017. When I first submitted it, the editor of this major EMDR journal was intrigued and wanted me to speculate about why it worked. In doing this, I realized that we were bypassing conscious defenses by discouraging conscious accessing of the memory. It’s a lot like back in the 60’s when they were experimenting with “subliminal message research” – not flashing a coke bottle on the screen to increase sales, but careful research in which written messages were flashed on a screen so quickly that they were undetected by conscious awareness, but could be demonstrated to somehow have been registered in a subconscious realm of awareness and produced behavioral changes.
We basically changed the Flash technique protocol, and told clients, "We don't want you to even think about the memory. We want you to start with a neutral or positive engaging memory and mentally select the disturbing memory without actually accessing the image or feelings or thoughts about it;” and after doing that they might say, “I don't know if I really thought of it,” and we would say, “That's perfect."
The instruction was: “I want you to bring up a comfortable enjoyable or engaging memory or activity, then go to the disturbing memory, but so quickly that you don't see it, don't hear it, don't feel it.” So, what does that instruction mean? How do you tell people to go to the memory but don't see it and don't hear it and don't feel it? It’s something they’ve never tried before.
So, mostly, we just had to come up with metaphors to describe what we want them to do. Many of these were offered to us by people who were using the flash technique and having success. One that was suggested is “Imagine your computer’s desktop with an icon of a folder with the memory in it. Go to the folder, but don't double click on it. Select it, but don’t open it.” Or more simply, “I know that some thoughts and images from the past have been troubling to you to remember, so now let all of it be hidden in a thick forest or behind a wall such that you can’t see any of it in any way.
Other metaphors include: “It's like passing your finger through a candle flame. If you linger, you'll get burned. Just go to a blur.” This is not exposure. If it were, we would be telling them, “Imagine that each time we do this you’ll pass your finger through the flame slower and slower. This process should not be at all painful or disturbing. And so, that's the trick of Flash, to somehow get your patient to do this very strange thing, which is: “connect with the memory, but don't think about it, or feel it, or hear it, or see it.” Just merely have the intention to connect with it, and then, come back to the engaging place or pleasurable feeling state that we start people with. We ask people to start the process with some lovely or exciting scene that occurs to them: their favorite sports team or being on the beach or with their boyfriend or petting their dog; I've had several surfer clients that like to use their surfing imagery.
There are some patients that couldn’t or wouldn't do EMDR because they had such a painful childhood memory, for example, that there's just no way they're going back there, or when we got them to go back there and think about the memory, they would get overwhelmed and dissociate or shut down. There is unfortunately a significant drop out rate when treatments like prolonged exposure are used at VA Medical Centers for treatment of veterans with PTSD. The Flash technique is so fast and painless that clients don’t even consider dropping out.
An intriguing and unique possibility for the use of Flash was revealed to me recently, when I saw a new client who had been off-and-on in therapy with two different psychiatrists while getting medications over the past ten years. I had seen him in couples therapy many years before, so we had a pretty good bond already, and I mentioned that the Flash technique can be used even when the therapist is completely in the dark as to what the trauma was. He almost jumped when he asked me to clarify that he could do some work on a memory without revealing it – a memory so troubling to him that he had never mentioned it to any other person, including the two psychiatrists or his brother all of whom he really liked. I taught him the Flash in that one session, and encouraged him to use it to help him let go of the anguish evoked by that particular memory of an event that was long ago past.
That incident prompted me to think how I could successfully ask clients more directly about any such thoughts or experiences that troubled them so much that they had made the decision they could never talk about it. Usually, therapists wait for the safety and trust in the therapeutic relationship to then be the catalyst for such disclosures. With this process, clients would be more receptive.
Yes, especially since in most cases clients don't even have to talk about the issue at all to do the flash technique. Of course, when the overwhelming discomfort is reduced substantially, they might actually want to discuss it and integrate it. Although this technique could be very helpful for a variety of therapeutic approaches including Cognitive Behavioral Therapy (CBT), I have proposed that it be used in one of the beginning phases of EMDR so that, after the disturbance is no longer overwhelming, the trauma can then be fully processed in the standard way.
Just last week, after learning of Flash and the concept that disclosure wasn’t necessary, a client in his 70’s decided to talk openly about something he had never shared with anyone. I’ve known many clients who had been in previous therapy for years, even psychoanalysis, but who avoided talking about specific sexual issues, for example. This notion itself is powerful - that the flash technique can be done without embarrassment or shame.
The main difficulty with the Flash technique used to be making sure the client was actually doing what we were asking them to do. You sometimes have to be a bit of a sleuth. People may tell you that they didn't bring up the traumatic memory, and then they'll say, "But, you know, I don’t think it’s getting any better."
And you say, "Well, how do you know it’s not getting better? Did you think of it?"
"Oh, yeah, I saw it."
"Well, we don’t want you to see it. That’s the idea. We want it to be so lightning fast, that you don't see anything. Just a blur."
That is a very odd instruction! And then, you've got to make sure that when they complete the Flash, they are really in an engaging state that is “non-traumatic” and comfortable, before they make the next round-trip to, and instantly back from, this “folder”.
In the most recent protocol, we found that we don’t even need to have them consciously “go” to the target or disturbing memory at all. After identifying the disturbing memory, then they let it go – and “forget about it” and just focus on the positive engaging memory, they do a form of bilateral stimulation, such as alternately taping their right thigh with their right hand, then the left thigh
with the left, slowly, and then they blink. We have them do several sets of triple blinks, while
holding onto the positive engaging picture or imagining.
I’ve heard you mention that the initial instructions to the client are a bit like suggesting a “willing suspension of disbelief.” Can you elaborate with more cases?
Case Examples of Flash
Of course. This is such a strange process that clients often think they won’t do it right and they will fail. I say to them, “I’m the one suggesting this bizarre technique. If you do it and it doesn’t work, that’s on me, not you. You can’t fail. You have nothing to lose from following these strange instructions except maybe three or five minutes.”
We have collected quite a few examples of dramatic results over the past year, and therapists we have trained email me every day to report amazing successes. Here are a few from my own experience: One was a woman who had been sexually assaulted. And she was probably highly dissociative to begin with. And so, when she came to me, it had been a year, and she couldn't leave her house by herself. She was just terrified. The memories were so fearful that she needed her husband sitting next to her, holding her hand in my office.
After three sessions, the anxiety from the rape was basically resolved. I say, "basically," because there was so much dissociation involved, and there were whole parts of the experience that she couldn't recall, and as it got resolved, then, the memories started coming back, and were processed with Flash, until, in the end, she could remember the whole incident without anxiety, and all her symptoms had gone away.
I also worked with a mother whose adult child committed suicide after a long period of suffering. Now it was more than a year later and she was still quite traumatized. So, of course, it was important for me to first hear the story. We scheduled a two-hour session, and she didn't finish really telling me the story until 20 minutes were left in the session. I didn't want to end the session without helping somehow, so I said, "Well, I have a process I can do with you, and it may help. I don't for sure know if it can help, but I do know it won't make it any worse for you."
She agreed to try it, and after 20 minutes of doing the Flash, she started giggling when she thought of what had been the most haunting and disturbing image. It wasn't a dissociative reaction. She just got to giggling with relief and the shock of suddenly being able to think of her son’s suicide without the overwhelming pain she had lived with for so long. She was just in disbelief that it could go away in such a short time.
Some psychotherapists might ask : “Why not let her have a little bit of the fear and sadness?” Would you keep wanting to get the SUDS level down to zero, or let her be okay with a little bit of fear and pain in this situation that could be seen as completely appropriate and understandable?
The giggling was confusing to me a bit at first. And I asked her about what she was experiencing, and she replied, "Well, you know, it's been a year, and I've been crying every day. And now, it doesn't feel painful. And it is a welcome surprise that it could change so quickly."
To me, unresolved grief goes hand-in-hand with the inability to enjoy positive aspects, positive memories, because the grief is so big that the client is just staying away from it, and in the process, they stay away from all the pleasurable and positive memories. So when she was able to go home and take out the pictures and start to enjoy the memory of her son. I think, it was - It was confusing at first. And I asked her about it. I mean, clients don't let go if they don't want to. So they know what's right for them. But, it can be grief or fear or whatever - and often, it relates to something in them that is unresolved, and then, when they resolve it, they feel stronger. They feel more able to deal with the fear or the grief or whatever.
But I don't want to deprive someone of a grieving process or of being afraid, which sometimes can be an important preparation for themselves for a possible bad outcome. In this case, it sounds like it's on the way to a positive resolution in terms of her being able to go on with her life, remembering both the sadness of loss and the positive memories of a life cut short.
One other thing is that, sometimes, people's fear is superstitiously protective. They think, "If I stay afraid, then I’ll stay vigilant and nothing bad will happen." And that's a fear that you can help people dispense with. Chronic unrelenting hyper-vigilance or fear really doesn't help us.
For some clients, Lewis and I have found that it's often useful to even say, "You're going to be able to keep the wisdom from this experience, because traumatic experiences teach us. You're going to keep the wisdom without the overload of terrible grief and anxiety and all of that."
This all reminds me of my favorite story of the Dalai Lama: a journalist was interviewing him back in the 1980’s, and asked about his feelings about what had happened to his country. She reported that he looked into her eyes while explaining the incredible depth of his sadness - sorrow and grief for what had happened and was continuing to happen to his country and to the Tibetan people imprisoned, tortured, and killed. And she saw these huge depths of grief, sadness and compassion. He suddenly looked through a nearby window at a tree, and then looked back at her, and she saw his face and eyes were transformed by wonder and joy, and he said, "Life is so very colorful. Isn't it?" And he demonstrated the ability of non-attachment, and being able to go deeply into even very deep sadness, which is actually a state of being very present and alive, and then rapidly into great joy.
I know we were talking about people holding onto grief, but I’m thinking of fear also. And I guess, what you want is vigilance, enough vigilance that you can attend to what happens around you and respond appropriately, and yet, you don't want your fear to make you less effective in doing what you have to do. And I'm thinking that it is common that people come away from something that's been scary and they believe that they have to stay hyper-vigilant.
So for them, I ask them to think of their favorite sports team and their favorite player on the team, and then, I have them imagine that player getting ready to respond to a situation requiring speed and precision. I learned this while on a humanitarian trip to Turkey. I was observing a session, and the therapist asked that question. For the young client, it was the Turkish team, and it was the goalie. And the therapist said, "Well, now, think of the goalie about to respond to a shot on the goal," and then, he said, "Well, does he look really tense and scared, or does he look alert and ready to react?"
The client had been very tense, believing he had to protect his family from the next inevitable earthquake. After hearing this question, he said “he’s alert,” and he immediately visibly relaxed. He realized that his tension wasn’t accomplishing anything productive, and he didn’t need it: “Being vigilant and tense doesn’t make me any more able to protect them. I just need to be alert."
A third case example was a client who had been physically assaulted and robbed. She couldn't go to work after that, and she obsessed continuously about what had happened to her. A complication was that her aunt had died a year before, her beloved aunt who really had been a mother to her. She had always thought her aunt was staying close to her and protecting her, but now she felt she had let her down. Processing with Flash helped her regain a sense of her aunt’s spiritual presence in her life, which she found enormously comforting.
If you watch any of the many videos of demonstrations of the flash technique, there's a bizarreness to them - There's just no sense that the client is really doing any work (actually, each was a therapist in one of my workshops who volunteered to work on a real issue). There’s no indication of pain, until you get to the point that I say, "Well, has anything changed?" and they say, "Has anything changed? Of course!!" So, that's a very peculiar aspect of this process – the effectiveness and the rapidity of it without any apparent suffering.
I have done Flash on myself. I didn't know you could do this on yourself until one of my clients told me he'd been doing it every night. And I thought: Oh! That's a new dimension of this. And that night, this scene came to my mind from a movie in which a concentration camp prisoner was killed in a very brutal way, and the image was crystal clear in my mind. It would come up every month or two in my mind, and I was able to push it out of my mind, but then, it would come back a month or two later.
So I did Flash on it, moving my eyes on my own - back and forth like we do in EMDR but much slower. After the second set of eye movements, I couldn't remember the image. I could describe it to you; I could tell you exactly what it was, but I couldn't bring it to mind. I just couldn't see it. Somehow I had Kevin Costner in there and he wasn’t even in the movie. And that's been more than ten months ago, and I haven't been able to recall that image since.
Some people want to experience Flash, but can’t think of something disturbing to process. We should all be so lucky! I tell them to think of something that's disturbing from a movie, a scene that is disturbing when you think of it; then think of something positive, like a very pleasant walk in the park. Think of something that just gives you a really good feeling, grabs your attention and completely distracts you from the disturbing scene. It's best that it not be related at all to the upsetting piece. Let your eyes go slowly back and forth, and tell yourself “Flash” a few times, then say three quick “Flashes.”
At a webinar I did in Australia - I had people go to a website and put in their beginning and ending disturbance levels. 56 people responded, and on average, their disturbance went from a 7.2 disturbance level on a scale from zero to ten, to a 2.3 disturbance level. Zero would mean no disturbance at all. Since then I’ve collected reports from 593 workshop and webinar practice sessions, and the average reduction in disturbance has been consistently over 70% after about ten minutes of the Flash technique. Results have been essentially stable when I have checked back after four weeks. Interestingly, results were about as strong for self-administered Flash, which was necessary for webinars, as for therapist-administered Flash.
Another observation we made was that, people who did Flash exercises got better results the second time than the first time; it seems that once people learn how to Flash, it becomes easier and more effective for them.
We’re hoping, of course, to stimulate more controlled studies to replicate these results, but something is clearly happening in a therapeutic direction and the participants’ responses were overwhelmingly positive about their own experience with it.
It will be interesting to see the professional commentary generated from the article you wrote with four case studies that was published in the November 2017 issue of the Journal of EMDR Practice and Research, and how the greater world of trauma treatment will take note of this; it seems to be a breakthrough that clearly challenges notions of the necessity of conscious exposure to traumatic memories for healing.
Skeptics might be old enough to remember Primal (Scream) Therapy - its developer Arthur Janov, Ph.D. died last year at age 93. He wrote several books, starting with The Primal Scream (1970) describing a yearlong therapeutic process purported to make significant and lasting personality changes through catharsis and emotional release, it has been largely discredited, although John Lennon and Yoko Ono and others popularized it.
The Flash phenomenon seems to me to be just the opposite in almost every respect to Janov’s work, and hopefully controlled research will confirm the types of positive and rapid results described in numerous case studies. There already is considerable data from the psychotherapists participating in your recent workshops - that they found their own direct experience of clearing the emotion out of traumatic memories to be shockingly rapid and effective. Among these therapists and the clients you’ve treated, the Flash technique already has shown its ability to ease human suffering. I’m excited by the potential applications of Flash as a self-help exercise and as a tool for meditation. Traumatology and neuroscience will soon be digesting the implications of this breakthrough.
So, thank you, Phil, for telling us about this newly evolved and powerful technique.
Manfield, P., Lovett, J., Engel, L., & Manfield, D. (2017). Use of the flash technique in EMDR therapy: Four case examples. Journal of EMDR Practice and Research, 11(4), 195-205. doi:10.1891/1933-318.104.22.168
Philip Manfield, Ph.D.
Dr. Manfield is a psychotherapist with over forty years clinical experience, and has been licensed as a marriage and family therapist since 1975. He has authored or edited five books about psychotherapy and the use of EMDR. An international trainer, he has taught in the US, Canada, South America, Europe, Asia, Australia, and the Middle East. In January, 2001, he was honored to be featured in the book, "3 Minute consultations with America's greatest psychotherapists." (Jason Aronson, Publishers) He is currently Northern California regional coordinator for the EMDR International Association. Although a significant portion of his professional activity is devoted to EMDR training and consultation with other therapists, he reserves half my hours for direct provision of treatment to clients. Over the years I have worked with and helped hundreds of individuals and couples through a wide range of difficulties, combining EMDR with cognitive behavioral and psychodynamic strategies. His office is in Berkeley, CA near the Claremont Hotel.
David Bullard, Ph.D.
David has had a private practice of individual psychotherapy and couples therapy in San Francisco for over 40 years, and has been trained in various trauma therapies including EMDR and Somatic Experiencing (SE). He is a clinical professor in departments of medicine and psychiatry and a member of the professional advisory group of Spiritual Care Services at the University of California, San Francisco, and is a consultant for the Symptom Management Service (outpatient palliative care) at UCSF’s Helen Diller Family Cancer Center. His latest professional publication is the chapter “Sexual problems” (co-authored with the late Harvey Caplan, M.D., and with Christine Derzko, M.D.) in Behavioral medicine; A guide for clinical practice, 4th edition (2014; McGraw-Hill). He has previously conducted interviews with Robert Thurman, Ph.D., and for psychotherapy.net with William (Bill) Richards, Ph.D.; Allan Schore, Ph.D.; Bessel van der kolk, M.D.; Mark Epstein, M.D.; Ida Gorbis, Ph.D.; George Silberschatz, Ph.D.; and Lonnie Barbach, Ph.D.
Copyright © 2018 David Bullard