Recognizing and caring for those with dissociative disorders
Recognizing and caring for those with dissociative disorders:
An essential element of basic training in EMDR
Due to the significant risks of adverse unintended effects in offering standard EMDR therapy procedures to those with unrecognized dissociative disorders, screening for the presence of a dissociative disorder is widely recognized as an essential element of EMDR therapy (Leeds 2016, p. 51, pp. 102-103; Paulsen, 1995; Shapiro, 2001, pp. 103-104, pp. 441-445).
Curiously there is no explicit mention of or standards for this training element in the EMDRIA basic training curriculum (EMDRIA, 2015). Among different providers of basic training in EMDR therapy there is wide variation in how issues are addressed regarding education, training and consultation on the nature of or screening for dissociative disorders. While total training cost, convenience of scheduling and completion rate are often top considerations when recommending or considering course selection, it is also important to find out how providers deal with helping participants with the complex cases that constitute the greater part of their caseloads.
Often some attention is given to the use of the DES-II (Carlson & Putnam, 1993) as a screening tool but without examination of its limitations – such as the lack of any validity items to catch defensive minimization of actual symptoms of a dissociative disorder. Even when participants are taught how to score the helpful DES-II taxon, they need consultation to recognize when in the face of low DES-II average and taxon scores, the clinical history and presentation strongly suggest that dissociative symptoms (and a dissociative disorder) are likely to be present, even if “hidden” sequelae. In these situations the use of a more focused mental status examination (Loewenstein, 1991) or structured clinical interview (DDIS or SCID-D-R) may be essential.
However identifying the presence of a dissociative disorder by itself does not educate nor train clinicians as to what steps they can and may need to take to work on stabilization issues with clients who are found to have a dissociative disorder. Here additional education, training and consultation in specific skills for stabilization is essential. Given the high prevalence of dissociative disorders among those with complex early trauma histories, Sonoma Psychotherapy Training Institute provides education and training in these skills during the first two days of its training program.
SonomaPTI training supervisors follow up at the second weekend of training with three hours of structured consultation based on written homework and oral case reports from participants that includes DES-II taxon probability scores, responses to the Calm/Safe Place exercise, early family experiences and clinical history. Participants are assisted to recognize clients who are likely to have dissociative disorders and to select other candidates for initial practice of the standard EMDR therapy procedural steps. With those clients identified as likely to have a dissociative disorder they are encouraged to focus on skills building to improve functions of daily living, self-regulation and work on dissociative phobias.
These participants are referred to the excellent treatment guide by Boon et al. (2011) and to other online resources such as helpful articles available from the website of Onno von der Hart (e.g. 2012) some of which were published in the Journal of EMDR Practice and Research. In this way when participants move forward after their second weekend of training to begin initial practice with the standard EMDR procedural steps they are much more likely to experience effective reprocessing and to have completed treatment sessions. These early successes and their new found strategies for stabilization in their most complex cases increases the likelihood that they will continue their professional development with EMDR therapy for years to come.
Boon, S., Steele, K., & Van der Hart, O. (2011). Coping with trauma-related dissociation: Skills training for patients and therapists. New York, NY: W. W. Norton.
Carlson, E. B., & Putnam, F. W. (1993). An update on the Dissociative Experiences Scale. Dissociation, 6, 16–27.
EMDRIA. (2015). Basic training curriculum requirements. Retrieved May 31, 2015, from http://c.ymcdn.com/sites/www.emdria.org/resource/resmgr/BasicTraining/BTCRequirements.pdf
Leeds, A. M. (2016). A guide to the standard EMDR therapy protocols for clinicians, supervisors, and consultants (2nd ed.). New York: Springer Publishing Company.
Loewenstein, R. J. (1991). An office mental status examination for complex chronic dissociative symptoms and multiple personality disorder. Psychiatric Clinics of North America, 14(3), 567–604.
Paulsen, S. (1995). Eye movement desensitization and reprocessing: Its cautious use in the dissociative disorders. Dissociation, 8(1), 32–44.
Shapiro, F. (2001). Eye movement desensitization and reprocessing, basic principles, protocols and procedures. New York: The Guilford Press.
Waller, N. G., & Ross, C. A. (1997). The prevalence and biometric structure of pathological dissociation in the general population: Taxometric and behavior genetic findings. Journal of Abnormal Psychology, 106(4), 499–510.
The DES taxon calculator, described by Waller and Ross (1997), can be obtained without charge from the International Society for the Study of Trauma and Dissociation (ISST-D), and is available at: http://www.isst-d.org/default.asp?contentID=66
The DDIS is available at www.rossinst.com/ ddis.html
The Structured Clinical Interview for DSM-IV Dissociative Disorders-Revised (SCID-D-R) is available at American Psychiatric Publishing Inc. (703) 907-7322, toll-free order telephone number (800) 368-5777, and on their website at: http://www.appi.org/home/search-results?findmethis=Marlene%20Steinberg&product=true
Onno van der Hart, O. (2012). The use of imagery in phase 1 treatment of clients with complex dissociative disorders. European Journal of Psychotraumatology 3: 8458 - http://dx.doi.org/10.3402/ejpt.v3i0.8458
See the full list of Onno van der Hart’s articles at: http://www.onnovdhart.nl/articles.html