Dissociation is a common response to emotionally overwhelming experiences or recalled memories. As mental health professionals, it is crucial to understand the continuum of dissociation and its impact on our clients, especially when considering Eye Movement Desensitization and Reprocessing (EMDR) Therapy for trauma treatment. This article provides insights into assessing client readiness for EMDR reprocessing, particularly for those with significant dissociative symptoms.
Understanding Dissociation
Dissociation exists on a continuum in the population, ranging from normal to pathological levels. Normal dissociation includes everyday experiences like getting lost in a daydream, while pathological dissociation involves more severe and persistent symptoms such as depersonalization and derealization (Stein et al., 2013). The Dissociative Experiences Scale (DES) is a widely used instrument to measure dissociative experiences and can help differentiate between normal and pathological dissociation (Carlson & Putnam, 1993).
Screening for Pathological Dissociation
To assess for pathological dissociation, clinicians can use various screening tools:
Dissociative Experiences Scale (DES): This 28-item self-report measure is part of the EMDR Institute training manuals and can help determine the probability of pathological dissociation (Carlson & Putnam, 1993).
Dissociative Disorder Interview Schedule (DDIS): Developed by Colin Ross, this comprehensive diagnostic tool can help identify dissociative disorders (Ross et al., 1989).
Structured Clinical Interview for DSM-5 Dissociative Disorders (SCID-D): This semi-structured interview assesses the presence and severity of dissociative symptoms (Steinberg, 1994).
Research has shown that individuals with high levels of dissociation may require specialized treatment approaches, including a more extended stabilization phase before trauma processing (Lanius et al., 2012).
Stabilization and Preparation
For clients with pathological dissociation, stabilization and preparation are crucial before starting EMDR reprocessing. This phase may involve:
Grounding techniques: Teaching clients to stay present and connected to their surroundings (Boon et al., 2011).
Affect regulation: Helping clients manage intense emotions effectively (Van der Hart et al., 2006).
Building safety and resources: Developing internal and external resources to enhance coping skills (Gonzalez & Mosquera, 2012).
Increasing emotional tolerance: Gradually exposing clients to emotional experiences to build resilience (Cloitre et al., 2010).
The duration of this phase can vary significantly, ranging from several months to years, depending on the severity of dissociation and the client's progress (Brand et al., 2012).
EMDR Therapy techniques can be incorporated during the preparation stage:
Ego State Therapy: This approach helps integrate different parts of the self and can be combined with EMDR protocols (Forgash & Knipe, 2012).
EMDR Interweaves: These cognitive interventions can help clients maintain dual attention and process traumatic material more effectively (Shapiro, 2001).
Determining Readiness for Reprocessing
Assessing readiness for EMDR reprocessing in dissociative clients involves several factors:
Emotional stability: Clients should demonstrate the ability to regulate emotions and maintain a sense of self during sessions (Van der Hart et al., 2013).
Grounding skills: Clients should be proficient in using grounding techniques to manage dissociative symptoms (Boon et al., 2011).
Window of tolerance: Clients should have an expanded window of tolerance for processing traumatic material (Siegel, 2020).
Therapeutic alliance: A strong, trusting relationship between the therapist and client is essential for successful EMDR processing (Korn, 2009).
Containment abilities: Clients should be able to contain traumatic material between sessions without becoming overwhelmed (Gonzalez & Mosquera, 2012).
It may be beneficial to start with desensitizing more recent traumas or present triggers before addressing earlier life experiences. This approach can help contain dissociative symptoms and prevent overwhelming the client with past memories (Knipe, 2015).
Challenges and Considerations
Working with dissociative clients in EMDR therapy presents unique challenges:
Risk of destabilization: Reprocessing traumatic memories may trigger intense dissociative reactions (Lanius et al., 2012).
Fragmented memories: Dissociative clients may have difficulty accessing or integrating traumatic memories (Van der Hart et al., 2006).
Complex trauma history: Many dissociative clients have experienced multiple traumas, requiring careful treatment planning (Cloitre et al., 2011).
Therapeutic relationship: Maintaining a strong therapeutic alliance while navigating complex transference and countertransference issues is crucial (Kluft, 2013).
To address these challenges, clinicians should:
Continuously assess the client's stability and adjust the treatment plan accordingly.
Use modified EMDR protocols designed for complex trauma and dissociation (Gonzalez & Mosquera, 2012).
Collaborate with other professionals, such as psychiatrists or medical doctors, to ensure comprehensive care.
Engage in regular supervision or consultation to manage complex cases effectively (Korn, 2009).
Conclusion
Working with dissociative clients in EMDR therapy requires careful assessment, preparation, and ongoing monitoring. By understanding the continuum of dissociation, using appropriate screening tools, and focusing on stabilization before reprocessing, clinicians can help ensure that their clients are ready for EMDR therapy. This approach not only improves the effectiveness of EMDR but also reduces the risk of retraumatization or overwhelming clients during treatment.
As mental health professionals, it is our responsibility to provide trauma-informed care that respects the unique needs and experiences of each client. By taking a thoughtful and measured approach to EMDR therapy with dissociative clients, we can help them navigate their healing journey more effectively and safely.
References
Boon, S., Steele, K., & Van der Hart, O. (2011). Coping with trauma-related dissociation: Skills training for patients and therapists. W.W. Norton & Company.
Brand, B. L., Lanius, R., Vermetten, E., Loewenstein, R. J., & Spiegel, D. (2012). Where are we going? An update on assessment, treatment, and neurobiological research in dissociative disorders as we move toward the DSM-5. Journal of Trauma & Dissociation, 13(1), 9-31. https://doi.org/10.1080/15299732.2011.620687
Carlson, E. B., & Putnam, F. W. (1993). An update on the Dissociative Experiences Scale. Dissociation: Progress in the Dissociative Disorders, 6(1), 16-27.
Cloitre, M., Courtois, C. A., Charuvastra, A., Carapezza, R., Stolbach, B. C., & Green, B. L. (2011). Treatment of complex PTSD: Results of the ISTSS expert clinician survey on best practices. Journal of Traumatic Stress, 24(6), 615-627. https://doi.org/10.1002/jts.20697
Forgash, C., & Knipe, J. (2012). Healing the heart of trauma and dissociation with EMDR and ego state therapy. Springer Publishing Company.
Gonzalez, A. (2012). EMDR and Dissociation: the Progressive approach. A.I.
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Knipe, J. (2015). EMDR toolbox: Theory and treatment of complex PTSD and dissociation. Springer Publishing Company.
Korn, D. L. (2009). EMDR and the treatment of complex PTSD: A review. Journal of EMDR Practice and Research, 3(4), 264-278. https://doi.org/10.1891/1933-3196.3.4.264
Lanius, R. A., Brand, B., Vermetten, E., Frewen, P. A., & Spiegel, D. (2012). The dissociative subtype of posttraumatic stress disorder: Rationale, clinical and neurobiological evidence, and implications. Depression and Anxiety, 29(8), 701-708. https://doi.org/10.1002/da.21889
Ross, C. A., Heber, S., & Anderson, G. (1990). The Dissociative Disorders interview schedule. American Journal of Psychiatry, 147(12), 1698–1699. https://doi.org/10.1176/ajp.147.12.1698-b
Shapiro, F. (2001). Eye movement desensitization and reprocessing: Basic principles, protocols, and procedures (2nd ed.). Guilford Press.
Siegel, D. J. (2020). The developing mind: How Relationships and the Brain Interact to Shape Who We Are. Guilford Publications.
Stein, D. J., Koenen, K. C., Friedman, M. J., Hill, E., McLaughlin, K. A., Petukhova, M., ... & Kessler, R. C. (2013). Dissociation in posttraumatic stress disorder: Evidence from the World Mental Health Surveys. Biological Psychiatry, 73(4), 302-312. https://doi.org/10.1016/j.biopsych.2012.08.022
Steinberg, M. (1994). Structured Clinical Interview for DSM-IV Dissociative Disorders (SCID-D), Revised. American Psychiatric Press.
Van der Hart, O., Nijenhuis, E. R., & Steele, K. (2006). The haunted self: Structural dissociation and the treatment of chronic traumatization. W.W. Norton & Company.
Van der Hart, O., Groenendijk, M., Gonzalez, A., Mosquera, D., & Solomon, R. (2013). Dissociation of the personality and EMDR therapy in complex trauma-related disorders: Applications in phase 1 treatment. Journal of EMDR Practice and Research, 7(2), 81-94. https://doi.org/10.1891/1933-3196.7.2.81
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