Emotional Flashback Management in the Treatment of Complex PTSD
_http://www.psychotherapy.net/article/complex-ptsd#section-challenges-and-rewards-for-the-therapist
by Pete Walker
Early in my career I worked with David,* a handsome, intelligent client who was a professional actor. One day David came to see me after an unsuccessful audition. Beside himself, he 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."
David's childhood was characterized by emotional abuse, neglect and abandonment. The last and unwanted child of a large family, his alcoholic father repeatedly terrorized him. To make matters worse, his family frequently humiliated him by reacting to him with exaggerated looks of disgust. His older brother's favorite gibe, accompanied by a nauseated grimace, was, "I can't stand looking at you. The sight of you makes me sick!"
David was so traumatized by the contempt with which his family had treated him that he was easily triggered by anything but the most benign expression on my face. If he came into session already triggered, he would often project disgust onto me, no matter how much genuine goodwill and regard I felt for him at the time.
I have come to call these reactions, typical of David and of many other clients over the years, emotional flashbacks—sudden and often prolonged regressions ("amygdala hijackings") to the frightening and abandoned feeling-states of childhood. They are accompanied by inappropriate and intense arousal of the fight/flight instinct and the sympathetic nervous system. Typically, they manifest as intense and confusing episodes of fear, toxic shame, and/or despair, which often beget angry reactions against the self or others. When fear is the dominant emotion in an emotional flashback, the individual feels overwhelmed, panicky or even suicidal. When despair predominates, it creates a sense of profound numbness, paralysis, and an urgent need to hide. Feeling small, young, fragile, powerless and helpless is also common in emotional flashbacks. Such experiences are typically overlaid with toxic shame, which, as described in John Bradshaw's Healing The Shame That Binds, obliterates an individual's self-esteem with an overpowering sense that she is as worthless, stupid, contemptible or fatally flawed, as she was viewed by her original caregivers. Toxic shame inhibits the individual from seeking comfort and support, and in a reenactment of the childhood abandonment she is flashing back to, isolates her in an overwhelming and humiliating sense of defectiveness. Clients who view themselves as worthless, defective, ugly, or despicable are showing signs of being lost in an emotional flashback. When stuck in this state, they often polarize affectively into intense self-hate and self-disgust, and cognitively into extreme and virulent self-criticism.
Numerous clients tell me that the concept of an emotional flashback brings them a great sense of relief. They report that for the first time they are able to make some sense of their extremely troubled lives. Some get that their addictions are misguided attempts to self-medicate. Some understand the inefficacy of the myriad psychological and spiritual answers they pursued, and are in turn feel liberated from a shaming plethora of misdiagnoses. Some can now frame their extreme episodes of risk taking and self-destructiveness as desperate attempts to distract themselves from their pain. Many experience hope that they can rid themselves of the habit of amassing evidence of defectiveness or craziness. Many report a budding recognition that they can challenge the self-hate and self-disgust that typically thwarts their progress in therapy.
Emotional Neglect: A Primary Cause of Complex PTSD?
Early on in working with this model, I was surprised that a number of clients with moderate and sometimes minimal sexual or physical childhood abuse were plagued by emotional flashbacks. Over time, however, I realized that these individuals had suffered extreme emotional neglect: the kind of neglect where no caretaker was ever available for support, comfort or protection. No one liked them, welcomed them, or listened to them. No one had empathy for them, showed them warmth, or invited closeness. No one cared about what they thought, felt, did, wanted, or dreamed of. Such trauma victims learned early in life that no matter how hurt, alienated, or terrified they were, turning to a parent would actually exacerbate their experience of rejection.
The child who is abandoned in this way experiences the world as a terrifying place. I think about how humans were hunter-gatherers for most of our time on this planet—the child's survival and safety from predators during the first six years of life during these times depended on being in very close proximity to an adult. Children are wired to feel scared when left alone, and to cry and protest to alert their caretakers when they are. But when the caretakers turn their backs on such cries for help, the child is left to cope with a nightmarish inner world—the stuff of which emotional flashbacks are made.
Because of this, emotional flashbacks can best be understood as the key symptom of Complex Post-Traumatic Stress Disorder, a syndrome afflicting many adults who experienced ongoing abuse or neglect in childhood. As described by leading trauma theorist Judith Herman (Trauma and Recovery) and renowned 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; because of the prolonged nature of the trauma, Complex PTSD can be even more virulent and pervasively damaging in its effects. (Complex PTSD has not yet been included in the DSM.)
Ongoing experience convinces me that some children respond to pervasive emotional neglect and abandonment by over-identifying or even merging their identity with the inner critic and adopting an intense form of perfectionism that triggers them into painful abandonment flashbacks every time they are less than perfect or perfectly pleasing . When I encourage such clients to free-associate during their emotional flashbacks, I frequently hear a version of this toxic shame spiral: "If only I were perfect. If only I were an ‘A' student . . . a baseball hero . . . a beauty queen . . . a saint. If only I weren't so stupid and selfish, then maybe they'd love me. But who am I kidding? I'll never be anywhere near that, because I'm just a piece of shit. Who in the world could ever care about someone so pathetic?"
Responding Functionally to Emotional Flashbacks
Emotional flashbacks strand clients in the cognitions and feelings of danger, helplessness and hopelessness that characterized 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 traumatologists as an attachment disorder. Emotional 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.
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 Complex PTSD to them. The diagnosis resonates deeply with their intuitive understanding of their suffering. When they recognize that their sense of overwhelm initially arose as a normal instinctual response to their traumatic circumstances, they begin to shed the belief that they are crazy, hopelessly oversensitive, and/or incurably defective.
Without help in the midst of an emotional flashback, clients typically find no recourse but their own particular array of primitive, self-injuring defenses to their unmanageable feelings. These dysfunctional responses generally manifest in four ways: [1] fighting or over-asserting oneself in narcissistic ways such as misusing power or promoting excessive self-interest; [2] fleeing obsessive-compulsively into activities such as work addiction, 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 codependently in self-abandoning ways such as putting up with narcissistic bosses or abusive partners.
I find that most clients can be guided to see the harmfulness of their previously necessary, but now outmoded, defenses as a misfiring of their fight, flight, freeze, or fawn responses. In the context of a secure therapeutic alliance, they can begin to replace these defenses with healthy, stress-ameliorating responses. I introduce this phase of the work by giving the client the list of 13 cognitive, affective, somatic and behavioral techniques (listed at the end of this article) to utilize outside of the session. I elaborate on these techniques in our sessions as well.
As clients begin to respond more functionally to being triggered, opportunities arise more frequently for working 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." This was someone who had, on previous occasions, accepted and even been moved by my validation of her ongoing accomplishments in our work. Based on what she had uncovered about her mother's punitive perfectionism in previous sessions, I was certain that her being late had triggered an emotional flashback. In this moment, she was most likely experiencing what Susan Vaughan's MRI research (The Talking Cure) describes as a gross over-firing of right-brain emotional processing with a decrease in cognitive processing in the left brain. Vaughan interprets this as a temporary loss of access to left-brain knowledge and understanding. This appears to be a mechanism of dissociation, and in this instance, it rendered my client amnesiac of my high regard for our work together.
I believe this type of dissociation also accounts for the recurring disappearance of previously established trust that commonly occurs with emotional flashbacks. This phenomenon makes it imperative that we psychoeducate clients that flashbacks can cause them to forget that proven allies are in fact still reliable, and that they are flashing back to their childhoods when no one was trustworthy. Trust repair is an essential process in healing the attachment disorders created by pervasive childhood trauma. PTSD clients do not have a volitional "on" switch for trust, even though their "off" switch is frequently automatically triggered during flashbacks. The therapist therefore needs to be prepared to work on reassurance and trust restoration over and over again. I have heard too many client stories about past therapists who got angry at them because they would not simply choose to trust them.
Retuning to the above vignette, I wondered out loud to my client, "Do you think you might be in a flashback?" Because of the numerous times we had previously identified and named her current type of experience as an emotional flashback, she immediately recognized this and let go into deep sobbing. She dropped into profound grieving that allowed her to release the flashback—a type of grieving the restorative power of which I have witnessed innumerable times. It is a crying that combines tears of relief with tears of grief: relief at being able to take in another's empathy and make sense of confusing, overwhelming pain; and grief over the childhood abandonment that created this sense of abject alienation in the first place.
My client released some of the pain of her original trauma and of the times she had previously been stuck in the unrelenting pain of flashing back to her original abandonment. As her tears subsided, she recalled to me a time as a small child when she had literally received a single lump of coal in her Christmas stocking as punishment for being 10 minutes late to dinner. Her tears morphed into healthy anger about this abuse, and she felt herself returning to an empowered sense of self. Grieving brought her back into the present and broke the amnesia of the flashback. She could then remember to invoke the self-protective resources we had gradually been building in her therapy with role-plays, assertiveness training and psychoeducation about her parents' destruction of her healthy instinct to defend herself against abuse and unfairness. The ubiquitous childhood phrase of "That's not fair!" had been severely punished and extinguished by her parents. She reconnected with her right and need to have boundaries, to judge her parents' actions unconscionable, and to fiercely say "no" to her critics' subsequent habit of judging her harshly for every peccadillo. Finally, I reminded her to reinvoke her sense of safety by recognizing that she now inhabited an adult body, free of parental control, and that she had many resources to draw on: intelligence, strength, resilience, and a growing sense of community. She lived in a safe home; she had the support of her therapist and two friends who were her allies and who readily saw her essential worth. I also observed that she was making ongoing progress in managing her flashbacks—that they were occurring less often and less intensely.
Managing the Inner Critic
In guiding clients to develop their ability to manage emotional flashbacks, my most common intervention involves helping them to deconstruct the alarmist tendencies of the inner critic. This is essential, as Donald Kalshed explains in The Inner World of Trauma, because the inner critic grows rampantly in traumatized children, and because the inner critic not only exacerbates flashbacks, but eventually grows into a psychic agency that initiates them. Continuous abuse and neglect force the child's inner critic (superego) to overdevelop perfectionism and hypervigilance. The perfectionism of Complex PTSD puts the child's every thought, word or action on trial and judges her as fatally flawed if any of them are not 100-percent faultless. Perfectionism then devolves into the child's obsessive attempt to root out real or imagined defects and to achieve unsurpassable excellence in an effort to win a modicum of safety and comforting attachment.
The hypervigilance of Complex PTSD is an overaroused sympathetic nervous system fixation on endangerment that comes from long-term childhood exposure to real danger. In an effort to recognize, predict and avoid danger, hypervigilance develops in a traumatized child as an incessant, on-guard scanning of both the real environment and, most especially, the imagined upcoming environment. Hypervigilance typically devolves into intense performance anxiety on every level of self-expression, and perfectionism festers into a virulent inner voice that manifests as self-hate, self-disgust and self-abandonment at every turn.
When the child with Complex PTSD eventually comes of age and launches from the traumatizing family, she is so dominated by feelings of danger, shame and abandonment that she is often unaware that adulthood now offers many new resources for achieving internal and external safety and healthy connection with others. She is unaware that a huge part of her identity is subsumed in the inner critic—the proxy of her dysfunctional caregivers—and that she has had scarce room to develop a healthy self with an accompanying healthy ego.
This scenario arises frequently in my practice: A client, in the midst of reporting some inconsequential miscue of the previous week, suddenly launches into a catastrophizing tale of her life deteriorating into a cascading series of disasters. She is flashing 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 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." It's disturbing how many catastrophizing inner critic rants end with the bag lady on the street. What a symbol of abandonment!
Teaching such clients to recognize when they have polarized into inner-critic catastrophizing, and modeling to them how to resist it with thought stopping and thought substitution, are essential steps in managing flashbacks. In this case I reminded my client of the many times we had previously caught the inner critic laundry-listing every conceivable way a difficult situation could spiral into disaster, and I invited her to use thought stopping to refuse to indulge this process. I suggested that she visualize a stop sign and say "no" to the critic each time it tried to scare or demean her. I reminded her that she had learned to catastrophize from her parents, who noticed her in such a predominantly negative and intimidating way. I also reinvoked the thought substitution process we had practiced on numerous occasions, encouraging her to remember and focus on all the positive things she knew about herself. Finally, I reminded her of all the positive experiences she had actually had with her boss, and I listed the essential qualities and accomplishments we were working to integrate into her self-image: her intelligence, integrity, resilience, kindness, and many successes at work and school.
Rescuing the Wounded Child
Over the course of a therapy, I often reframe emotional flashbacks as messages from the wounded inner child designed to challenge denial or minimization about childhood trauma. It is as if the inner child is clamoring for validation of past parental abuse and neglect: "See this is how bad it was—how overwhelmed, terrified, ashamed and abandoned I felt so much of the time."
When seen in this light, emotional flashbacks are also signals from the wounded child that many of her developmental needs have not been met. Most important among these are the needs for safety and for Winnicottian good-enough attachment. There are no needs more important than those of a parent's protection and empathy, without which a child cannot own and develop her instincts for self-protection and self-compassion—the cornerstones of a healthy ego. Without awakening to the need for this kind of primal self-advocacy, clients remain stuck in learned self-abandonment and rarely develop effective resistance to internal or external abuse, and seldom gain the motivation to consistently use the 13 tools for managing emotional flashbacks at the end of this article.
When clients recognize 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 dysphoric affective experience. When the therapist repeatedly models feeling-based indignation at the fact that the client was taught to hate himself, the client eventually feels incensed enough about this experience to begin standing up to the inner critic and of investing in the extensive work of building healthy self-advocacy. When the therapist consistently responds compassionately to the client's suffering, the client's capacity for self-empathy and self-forgiveness begins to awaken. He gradually begins to desire to comfort and soothe himself in times of cognitive confusion, emotional pain, physical distress, or real-life disappointment, rather than surrender to an inner torture of self-hate, self-disappointment, and self-abandonment.
Around this time in therapy, the client also solidifies her understanding that the lion's share of the energy contained in her intense emotional flashbacks are actually appropriate but delayed reactions to various themes of her childhood abuse and neglect. Gradually—often at the rate of two steps forward and one back–-she is able to metabolize these feelings in a way that not only resolves her trauma, but builds new, healthy, self-empowering psychic structure as well. This, in turn, leads to an ongoing reduction of the unresolved psychic pain that fuels her emotional flashbacks, which subsequently become less frequent, intense and enduring. Eventually, a person experiencing an emotional flashback begins to invoke a sense of self-protection as soon as she realizes she is triggered, or even immediately upon being triggered. 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 into Intimacy: A Case Study
A sweet, middle-aged male client of mine from an upper-middle-class family had suffered severe emotional abandonment in childhood. Both parents were workaholics and therefore unavailable; as the youngest of five children, my client was hamstrung in the sibling competition for scarce parental resources. His adulthood reenacted the relational impoverishment of childhood. He was hair-triggered for retreat and isolation. He had never experienced an enduring relationship. As a result of our long-term work, however, he became more motivated to seek a relationship, and successfully dated a healthy and available partner. For the first six months of their relationship, her kind nature, along with my coaching, enabled him to show her more and more of himself, and he was rewarded by increasing feelings of comfort and love while relating with her.
When he accepted her request to move in together, however, it became harder to hide his recurring emotional flashbacks to the overwhelming anxiety and emptiness of his childhood. He was more convinced than ever that the abandonment melange of fear, shame and depression at the core of his flashbacks was the most despicable of his many fatal flaws. As we worked with this belief in therapy, he remembered many times when even the mildest dip in his mood triggered his psychotherapist mother to turn her back on him and flee to the inviolability of her locked room. He saw that the occasional utility his mother found in him depended on his keeping her buoyant and lifting her spirits. He was traumatized into a staunch conviction that social inclusion depended on his manifesting a bravura of love, listening and entertainment. A codependent defense of fawning and performing had been instilled in him. Now he could not shake off the fear that if he ever deviated from being loving, funny and bright, his new partner would be disgusted and abandon him. He reported that, in fact, his flashbacks at home had increased, provoking a desperate need to isolate and hide. His freeze response was activated and he increasingly disappeared from her into silence, the computer, excessive sleeping, and marathon TV sports viewing. During his most intense flashbacks, his fear and self-disgust became so intense that his flight response took over and he invented any excuse to get out of the house. He was besieged by thoughts and fantasies of being single again. His inner critic was winning the battle; he was sure his partner was 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, as he always had in the past when the brief infatuation stages of his few previous relationships came to an end.
We spent many subsequent sessions managing these emotional flashbacks to his original abandonment. He understood more deeply that his silent withdrawals were evidence that he was flashing back, and he committed to rereading and using the 13 steps of flashback management at such times. With my encouragement and gentle nudging, he grieved over his original abandonment more deeply and more self-compassionately than ever before in our work together. Over and over, he confronted the critic's projection of his mother onto his partner. He practiced grounding himself in the present, and at home began talking to his girlfriend about his experiences of flashing back into the abandonment melange. A crowning achievement occurred when he was finally able to disclose to her that talking vulnerably made him feel even more afraid and ashamed—and deserving of abandonment.
To his great relief, 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. Their love then began to expand into those special depths of intimacy that are only achieved when people feel safe enough to communicate about all of their cognitive, emotional and behavioral experiences—the good and the bad, the gratifying and the disappointing, the loving and the mad. (One of the great rewards of this kind of recovery work is that the individual achieves a depth and richness of communication and contact that many non-traumatized people miss out on because wider social forces have scared and shamed them out of ever sharing anything truly vulnerable.) As my client became more skilled at being vulnerable, he was rewarded with the irreplaceable intimacy that comes from commiseration—another gift that many less-traumatized members of our culture never get to discover. The degree to which two individuals mutually share all aspects of their experience is the degree to which they have real love and intimacy.
As clients learn to identify flashbacks as normal responses to abnormally stressful childhood conditions, they become free of the fear and shame that have made them isolate, overreact, or push others away at such times. Most clients experience tremendous relief when they learn to interpret their overwhelming or excessively numbing experiences as emotional flashbacks, rather then as proof that they are bad, defective, worthless or crazy. Such realizations—as rapidly evaporating as they can be in early recovery—heal the fear and shame so central to emotional flashbacks. As clients learn to stay in contact and communicate functionally from their pain, they begin to heal their core abandonment depression; they gradually discover that they are not detestable but lovable and acceptable in their deepest vulnerability. This begins to heal their attachment disorders, the most deleterious part of Complex PTSD. It allows them to evolve toward what some traumatologists call an earned secure attachment. For many people this first secure attachment is achieved with the therapist, which in turn allows the client to know that such an invaluable experience is possible. With ongoing psychoeducation and coaching from the therapist, this first safe-enough relationship can become the launching pad for seeking such a relationship outside of therapy. The ending phase of therapy is typically characterized by the client building at least one good-enough, earned secure attachment outside of therapy—one relationship where she has learned to manage her flashbacks without excessively acting out against others or herself.
Challenges and Rewards for the Therapist
What I find most difficult about this work is that it is often excruciatingly slow and gradual. Nowhere is this truer than in the work of shrinking the toxic inner critic. Progress is often beyond the perception of the client, especially during a flashback, and flashbacks are unfortunately never completely arrested.
The hardest thing of all is getting the client to see that emotional flashbacks, a bit like diabetes, are a lifetime condition that will always need a modicum of management. Good-enough management creates a good-enough life—one where flashbacks markedly and continually decrease but inevitably recur from time to time. Failure to accept this reality typically causes the client to reinvoke her old reactions to flashbacks, which in turn cause her to get lost in the self-abandonment of blaming and shaming herself.
What I love most about this kind of trauma work is seeing clients with a long history of developmental arrest, as well as feelings of helplessness and hopelessness, begin to become empowered. I am delighted every time a client responds to her own suffering with kindness or reports an action of self-protectiveness in the world at large. I love witnessing the gradual growth of self-confidence and self-expression in my clients. This inevitably seems to grow out of their recovered ability to get angry about what happened to them in childhood and to use that anger to empower and motivate themselves to face the fear of trying on new, more assertive behavior. I am also especially moved when a client learns to cry for himself in that fully functional, unabashed way where tears release fear and shame. In my experience, nothing catharsizes fear and catastrophizing obsessiveness like egosyntonic tears. I have, on thousands of occasions, witnessed clients grieving in a way that resurrects them from a flashback, back into their growing self-esteem and resourcefulness.
Another highlight of this work for me comes in the early and middle stages of therapy. I like to call it rescuing the client from the hegemony of the critic. 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 in a gross overidentification with the inner critic. I am additionally motivated to do this because of the failure of my own first long-term experience of psychoanalytic therapy, where my "blank screen" therapist let me flounder and perseverate in endless iterations of my PTSD-acquired self-hate and self-disgust. Never once was it pointed out that I could and should challenge this anti-self behavior. UCSF trauma expert Harvey Peskin would call this a failure to bear witness to the traumatization of the child. I have learned to take this a step further by not only vocally witnessing the client's flashback into the helplessness of his original abandonment, but also giving him a hand to climb out of that abyss of fear and shame.
The term rescuing and what it represents has become a taboo in the 12-Step Movement (e.g. Alcoholics Anonymous, Adult Children of Alcoholics, Incest Survivors Anonymous, etc.) and many psychotherapy circles. The word is often used in such an all-or-none way that any type of active helping is pathologized. However, I think helping clients out of the abyss of emotional flashbacks is a necessary form of active helping, or rescuing. The rescuing I refer to is different from the kind that many therapists correctly view as disempowering and unhealthy for the client. One example of this type of countertherapeutic rescuing is inappropriate or excessive advocacy. Colluding with or encouraging personal irresponsibility, such as exonerating a client's regressed or infantile acting out without steering him towards learning to interact more responsibly and salubriously with himself and the world is also a common type of problematic rescuing.
A final great reward I experience in helping clients manage their emotional flashbacks is witnessing the development of their emotional and relational intelligence. At the risk of sounding Pollyannaish, I believe Complex PTSD actually has a silver lining: the potential to reconnect with these intelligences at much deeper levels than those who are not traumatized in the family, but who suffer a truncation of their emotional self-expression and relational capacity. Wider social forces can strand individuals in the loneliness of superficial relating and can cause them to hide significant aspects of their emotional experience. A number of my clients in the later stages of recovery work have built and earned relationships that exhibit a depth of intimacy I rarely see in the general population.
*All names and identifying information have been changed to protect client confidentiality.
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