Text: Carien Karsten

For most trauma therapies, including EMDR, it is important that the trauma is clearly in the picture before you can treat it. That could be a disadvantage. Especially if the image is too intense for the patient to even dwell on it. In order to be able to offer help in such a situation, Philip Manfield introduced the Flash technique. With its new version of the Flash technique, if EMDR does not work enough, you can also treat a trauma.

Lees verder: Flash-Technique NL

In EMDR Magazine 16 from 2018 Priscilla Doornhein-Semmelink, Ad de Jongh and Marit Peter describe how the first version of Flash works. The bottom line is that the traumatic image is called up very briefly, after which working memory load is applied, with the aim that the patient can keep the memory in mind ever longer.  Where treatment with EMDR therapy becomes possible.

Meanwhile, Philip Manfield has developed a new version of the Flash-technique, in which the traumatic event is no longer in sharp focus at all and only needs to be named in general terms – or not. The patient then thinks exclusively of positive things and regularly blinks with the eyes. So this is not about taxing the working memory, but a distraction that makes it possible to process a nasty memory subliminally.  

Why a new Flash?

For Manfield, the reason for adapting his earlier version of the Flash technique was the rejection of his first article on Flash for the Journal of EMDR  Practice and Research. The editor-in-chief only wanted to post his article if he came up with a plausible explanation as to why Flash works. Manfield then suggested three hypotheses to explain the rapid rate.

1. These are non-reportable, subliminal processing, bypassing the conscious resistance;
2. The recollection shall be stored;
3. It works by strengthening the spectator position, rather than letting it relive the trauma.

There was no scientific evidence for any of these hypotheses. “Then I’m going to figure it out myself,” Manfield thought.  He takes the first hypothesis because he considers it most likely to.  He tests the hypothesis by letting his patients tell as little as possible about the trauma. It may remain a vague indication, or merely the indication of the age at which the trauma occurred. It’s like summarizing a newspaper article just by mentioning the headline. What he did find important was that there was no prior reminder of the aforementioned trauma. If that is the case, this will be taken as the target. This, too, is important to refer to it as briefly and generally as possible. Then he immediately asks for a positive experience and applies the bilateral stimulation to it by blinking his eyes as soon as he says ‘Flash’.  To his surprise, Manfield noticed that this will shorten the average processing over time of the trauma of 20 minutes at Flash to ten minutes.

Mechanism

In his November 2019 webinar, Manfield suggest that the technique is likely to work because the amygdala, the area involved in emotions such as anxiety, is barely activated in subliminal, hidden, exposure.  In Paul Siegel’s 2017 fMRI study, Manfield finds evidence for the treatment of spider phobia. In that study, people with spider anxiety will briefly see a picture of a spider. So short that they don’t even realize they’ve seen the picture. The fMRI-research shows that certain areas of the brain are active in unreportable exposure, thus removing the memory of the spider from its anxious charge. That something can be stored unconsciously in your implicit working memory shows the previously published article by Hassin (2009).  

The technique

For subliminal exposure, it is necessary for the patient that he is distracted considerably.  This is done with the Flash technique by allowing them to focus on positive distractions, on which they really feel involved: the Positive Engagement Focus (PEF). That positive distraction can be anything: to do something active with your (small)child, walk along the beach, enjoy sports experiences, horseback riding, a walk in the meadows. After focusing on the PEF, tapping on the thighs and repeatedly blinking his eyes quickly, you ask the patient how the traumatic memory has changed. If the patient says that it seems to be further away, less lively or he doesn’t feel so connected to it, ask about the height of the SUD. Manfield adjusts the original Flash technique.  He trains therapists in this method through a webinar  in which you learn the technique, and a webinar for advanced ones. I was happy to follow both webinars. In April 2020 Manfield will teach courses on this in England and Belgium. More than 3,000 Flash therapists are now active around the world, they their experiences through a google group.

The treatment of Gijs

I applied the Flash 2.0 more or less by chance to Gijs (38), because the next client was already waiting. If it doesn’t work, it doesn’t harm, my opportunistic premise was. Gijs is a documentary filmmaker. He’s very busy and he’s afraid he’s becoming burn out again. While he’s just recovered from burnout. He and his wife, who also works full-time, have two children:  a four-year-old daughter and a son of one and a half.  The son suffers from ear infection and often wakes up at night, so Gijs gets little sleep. Recently, his father died unexpectedly in a rather dramatic way. His father looked after the kids a lot. His mother has become very forgetful lately, suffers a lot from fears and often appeals to Gijs. ‘This is all going to pass again’ Gijs told himself. Meanwhile, his stresssyteem was in overdrive.  

With EMDR I treat Gijs for the traumatic side of his father’s death. With ten minutes left at the end of the session, I decide to treat Gijs with Flash with the target his fear of relapse. It has a SUD of 8. As a positive focus Gijs chooses a moment when he and his son are in bed on Sunday morning.  That doesn’t seem like a good idea, this focus easily mixes with the memories of his son’s insufferable crying outbursts because of the ear infection. I ask him to focus on another positive experience. He quickly got it:  at the fair with his eldestdaughter.

In less than ten minutes, the SUD drops from 8 to 2. For him it feels as if the fear is covered by the positiveexperience, which makes him unable to summon the fear experience. But why still as much as a 2?  “I think it’s so bad that my son has earache,” Gijs replies. I get that.  But does help his son dealing with his suffering? Well, no, and this time the SUD becomes 0. He does a mental video check on how he comforts his son with earache. “I’m doing well enough” is the spontaneous thought that comes to mind.  The cognitive interweavethat I applied, because the SUD was not yet 0, is called a blocking thought by Manfield. If the SUD doesn’t drop easily, he indicates, it can be because of a blocking thought.

Flash as mild form of trauma treatment

I apply the Flash-technique more often now. It is a mild form of trauma treatment that is also nice for the therapist to do, if only because you focus on pleasurable experiences. As a therapist, you have to be aware that the patient’s memory is more or less self-contained. If it turns out that the memory derives its emotional load from previous memories (feeder memory), then you have to treat the latter. You can use the body-focused flatback to find out if the patient has had the aforementioned feeling before.

So far, all therapists who participated in the webinars and trained in flash technology have not had any negative experiences with this technique.  You often hear that with a follow-up after six months patients no longer know what they had brought in. Manfield recommends that if you want to follow up, to indicate the nasty experience with a core word.

Indication for the Flash

I’m glad Gijs is so easily rid of his specter for relapse into burnout. But was it a good idea to use Flash 2.0 for this? Manfield is very firm: if you can apply the regular EMDR protocol, you have to do it. It’s more solid than the Flash–technique. You can switch to the Flash-technique when patients feel resistance to the EMDR protocol, dissociate, or be afraid of the feeling that can come up through a memory. The Flash-technique is also easy to use if the patient has a vague memory from early childhood. The details of the memory are not important for this technique. This way you can also treat traumas that the patient is so ashamed of that he or she does not want to go into detail. For the same reason, the Flash-technique works well in patients with obsessive compulsive disorder who avoid seeing their anxiety in detail.  

Extra Flash exercise

Ask the patient to bring up two nasty memories. Then use the Flash technique to treat one of those memories. Then ask if anything has changed about the other memory. That happens a lot. According to Manfield this shows again how easily you process something when you call it up, but don’t think about it. We know this from the EMDR: if you have dealt with the most similar memory, the SUD of the other memories has also often decreased.  

Flits, Flash or Blink?

Among Flash-therapists arose online a discussion about the use of the word Flash. An Australian therapist found it difficult to use that word- because it also allows for just as quick lifting your sweater to show off your breasts. They suggest saying ‘blink’, instead of flash. Manfield believes that the attention value of flash is greater than ‘blink’. Flash indicates something is about to happen. It seems to me that it doesn’t matter much whether you say flash, flash or flash. It’s also about the ritual. In that light, it might not be so crazy to say flash, if you’ve indicated that you’re using the Flash-technique.  

At the last webinar in January 2020, Manfield indicated that he would probably start the first RCT soon. Suzy Matthijssen and Ad de Jongh will also do an RCT to improve the effectiveness of the flash–technique.

Learn more

• More information can be found on the website: www.flashtechnique.com..  There you will also find the possibility to    register for the interactive webinars. 
• On www. EMDRvideo.com you will find  two  video demonstrations of the latest version of the  flashtechnique.. 

Literature

Hassin, R.H, et al., Implicit Working Memory, Consciousness and Cognition, 2009: 18-3: 665-678

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, 195-205.

Siegel P, Warren R, Wang Z, et al. Less is more: Neural activity during very brief and clearly visible exposure to phobic stimuli. Hum Brain Mapp. 2017;38(5):2466–2481. doi:10.1002/hbm.23533

Attachments

1. Framework

Basic steps Flash technique

1. Have the patient pick up a nasty memory. The eyes can stay open, but it can also be closed. Ask patient: What would the SUD be if you switched your feelings on this memory, subject or perception?? But don’t encourage the patients to do this and feel very nasty!!  Make sure you get the first feeder memory.  This is where things often go wrong.
2. Decide with the patient for a Positive Engagement Focus (PEF). It must be a memory or activity that evokes an immediate sense of pleasure. Also explicitly say that the patient should not think about the trauma.
3. Start when the patient is ready, the bilateral stimulation with tapping on the thighs or eye movements. Tap along yourself. In the meantime, ask the patient to focus on the PEF. It also works well if the patient tells you about, for example, riding and bravely telling details by asking questions.
4. Ask the patient to blink with the eyes three times quickly when you say Flash.  
5. Keep tapping, say flash every now and then. On that command, the patient flashes the eyes three times. You repeat the    Flash five or six times.
6. Ask the patient to think back to the memory and ask if he or she experiences any difference. So not like EMDR: what comes to mind?
7. Continue to call flash five times if the SUD is not 0 (step 5). If the SUD drops slowly or no longer, you can proceed to the treatment phase of the EMDR protocol and apply an intensive working memory load à la EMDR 2.0. If the SUD is 0, do the Body Scan, or the Mental Video Check (open eyes when there is turmoil and continue with Flash). Slute off asking what’s most important that someone has learned from the Flash. 

[End of frame]

• Schedule

Flash 1.0	Flash 2.0
Motivation	Motivation
Break fear of evoking a traumatic image, allowing the image to stay in the working memory ever longer.	Quick, not burdensome treatment of traumatic image. By global retrieval of memory, does not evoke fear, pain or resistance.
Treatment Target	Treatment Target
Recall a specific image.	A nasty description traumatic image meets.
Use the image provided by the patient.	Detect possible blocking thought and/or earlier memory.
	If there is a rather, similar reminder, take this as a target.
Desensitization	Desensitization
Recall the traumatic image so short calls that it is not painful. Combine with slow eye movements.	Ask to focus on a positive image. Blink your eyes three times when you say “Flash.” Combine with tapping on thighs. Repeat “Flash” five times.
Sud	Sud
Ask how high the SUD is and possibly switch to EMDR or EMDR 2.0	Ask: what has changed?At SUD > 0: why so high?
Purpose	Purpose
Keep memory in working memory for as long as EMDR is possible.	Processing trauma by not thinking about the trauma. Instead, focus on positive image.