ESSENTIAL INFORMATION FOR EMDR THERAPY WITH DISSOCIATIVE CLIENTS
The EMDR Listserve had a series of responses to a therapist's inquiry about scoring the DES Dissociative Experiences Scale). Of all the responses, none were better than Sandra Paulsen Ph.D’s response, shared with permission below. Sandra is an EMDR expert with dissociation and ego states and author of the highly recommended When There Are No Words and other publications www.bainbridgepsychology.com/ . Her in depth response to working with dissociation as an EMDR therapist was most enlightening. She summarized concerns I have had as well and mentions (highlighted below) that unexpected appearances of parts with clients who did not present as dissociative can frighten a newly trained EMDR therapist who is not prepared for managing the experience. It also can lead both therapist and client not to do EMDR.
Assessing for Dissociation
Sandra Paulsen’s post strengthened my recommendation to consultees that they routinely screen clients for dissociative disorders. In the early days of learning EMDR in the late 90’s, I had an experience with an elderly woman who turned in to a 4 year old terrified of her abusive mother in front of my eyes. There was no overt evidence of dissociation but I had not screened her for this. This challenged my confidence in my EMDR skills and lost the opportunity to assist this woman in a more effective way. I re-stabilized her and never tried EMDR with her again, referring out DID clients to others with more expertise until I gained the necessary skills and training. Current EMDR Basic Training does a much better job of orienting our new trainees about addressing dissociation with EMDR in combination with other approaches such as ego state therapy and structural dissocation theory.
I use the DES (Dissociative Experiences Scale a) for adults, for b) for adolescents and c) for children) but have the same concerns about 'false positives' on this instrument. It is just an screening and can give falsh positives or negatives, but it is a crucial step. A most dramatic example I experienced later was a client with DID who experienced stress with two of her parts of self arguing about how to fill it out. Obviously the function of those two parts of self were in contrast and showed up in their answers to this assessment. I now recommend the MID as a necessary further step when both clinical and assessment information indicates the risk for moderate to severe dissociation in a client . Below are Paulson's lengthy but valuable remarks and I thank her again for her permission to reprint.
Sandra Paulsen on EMDR and Dissociation (EMDR Institute Listserve 2011)
Assessing for dissociation with the DES-II is again on the table here, so I thought it is perhaps a good moment to continue the larger discussion about the assessment of dissociation with the SCID-D and the MID as well. I’ll begin by referring to the problem of dissociation in EMDR and its historical remedy. THE DES-II AND EMDR – A REMEDY AS FAR AS IT GOES EMDR is not just another therapy, but a divining rod for dissociation, although this fact was not initially known. Once that became clear however, the EMDR Institute’s training program was modified to say that 1) EMDR should not be used on a dissociative client without the therapist having training and experience with that population and 2) clients should be screened for dissociation before doing EMDR, likely with the DES-II.
That was necessary and good as far as it goes, but there are several problems with that recommendation. PROBLEMS WITH THE REMEDY
Here’s the logic of the problem as I see it:
1) It has been established that one shouldn’t do EMDR with any client without first ruling out the presence of a dissociative disorder, but,
2) Many EMDR clinicians continue to have the erroneous belief that they can tell who is and isn’t dissociative as if dissociative disorders are floridly manifest. [emphasis mine]. They only use the DES-II on clients whom they already suspect are dissociative, missing a great many of the non-florid dissociative diagnoses, plus,
3) The instrument most recommended in EMDR training, the DES-II, has false negatives and does not purport to be a diagnostic instrument but only a screening device. However,
4) The SCID-D, the diagnostic device put forward to be the gold standard for assessment of the dissociative disorders, is not intuitively graspable and requires that a clinician be trained in its administration and scoring, and moreover, be educated somewhat in dissociative disorders, but,
5) Most EMDR clinicians are not at all trained and experienced with dissociative disorders, and have been taught in graduate school that their occurrence is rare or non-existent. Those clinicians often only have a paradigm shift regarding the presence of dissociation the hard way, such as…
6) Since many EMDR clinicians use EMDR a great deal in their practices, they run the risk of uncovering numerous dissociative clients in the middle of an EMDR that is either eruptive or looping, which risks…
7) The client may have a suicidal crisis requiring hospitalization, stop therapy, experience a therapeutic rupture, or refuse trauma work of any kind.
8) At this juncture many EMDR clinicians turn ashen, shrivel up, and abandon EMDR altogether for the safer and tamer tools. This happens without their ever having had the needed paradigm shift about dissociation and avoidance being the bedrock of many disorders, and association being a good part of their cure, to oversimplify a complicated story. Moreover,
9) Most new EMDR clinicians are slugging their way through the Adaptive Information Processing paradigm shift already, undertaking extensive and expensive training and consultation required for safe and effective EMDR use. Training in dissociation is competing with that for hypnosis, somatic, or other therapies. In that case,
10) If dissociation seems like the caboose of the train, not its engine, training in the treatment of dissociation a low priority on a scarce training budget. THE SCID-D vs. MID Some time ago Rick Kluft opined that Marlene Steinberg's SCID-D is the gold standard for the diagnosis of dissociative disorders rather than Paul Dell's MID. I agree with Dr Kluft that the SCID-D has a relatively longer and certainly a distinguished history in the dissociation field, whereas the MID is a recent comer. However, the SCID-D is a lengthy diagnostic interview, involving exploring for some hours the particular symptoms that represent the DSM criteria for diagnosing each of the dissociative disorders. In contrast, the MID is a questionnaire.
If memory serves, the MID was initially clinically derived and then was factor analyzed to identify which items were most predictive and earned their keep. The MID is a computer administrable and scorable device and so is easy and convenient to use in a busy clinical practice. Moreover, one doesn’t have to be a wizard in dissociation to administer it, because precious few of us in the EMDR field are. It is not good news that we aren’t, because EMDR is an associative process, and what it uncovers is that which has been dissociated.
INTERVIEW VS OBJECTIVE TESTING
The tension between the SCID-D and the MID may also harken back to professional preferences. The psychiatric profession has long held the clinical interview in highest regard. The developer of the SCID-D, Marlene Steinberg, MD, is a highly skilled psychiatrist and the SCID-D is published by the American Psychiatric Press. In contrast, the psychological profession tends to hold objective testing in highest regard. The developer of the MID, Paul Dell, Ph.D. is a highly skilled psychologist. Psychologists are fond of objective testing because that method identifies with the cold eye of statistical analysis those questions that are most predictive, whether or not they have face validity. Since dissociative disorders are all about keeping secrets from self and the world, it seems smart to not rely too heavily on face validity and to have validity scales as the MID does.
I love the diagnostic interview for uncovering dissociation clinically, but in fact, most EMDR practitioners are not able to do that and yet they must assess with something. TIME AND DOLLAR COST The SCID-D is quite pricey, because a textbook and administration booklets are required, and the dollar cost adds up if it used frequently (we ’ve already established above that EMDR clinicians should using SOMETHING to check for dissociation reliably and frequently before doing EMDR in order to avoid harm). Additionally, clinician hours are involved in both administering and scoring the SCID-D for complex cases. In contrast, the MID is in the public domain, and no cost is incurred in its administration. It is self scorable when administered on the computer in an Excel spreadsheet, instantly interpretable. PRACTICALITY AND FAMILIARITY If clinical time were free, and if all EMDR therapists could be trained to reliably administer and score the SCID-D, it would be a reasonable choice for daily use. However time is at a premium, and the MID, a paper and pencil (or keyboard) test that can be administered without clinician presence, is a good and reliable step up from the DES-II, which doesn’t purport to be diagnostic. The cost comes to bear in clinical practice because many EMDR practitioners work in agency settings or with greatly reduced fees to serve the very needy traumatized population. Such clinicians can ill afford the time and dollar cost involved in acquiring, administering and scoring the SCID-D as a daily part of their practice. It’s just not practical given that we’re talking about using something with great regularity to prevent harm in EMDR use.
A BETTER APPROACH FOR THE NOVICE TO DISSOCIATION
Unless one is quite familiar with dissociative disorders, a clinician won’t typically find the SCID-D to be very approachable. EMDR practitioners are most typically not yet trained in dissociative disorders but know they need to check for dissociation with every patient before doing EMDR to avoid harm. For that novice, the computer administrable and scorable MID is a time and cost effective way to proceed. Then, if uncertainty remains after administering the MID, administering the SCID-D or referring to someone who can administer it makes the most sense for most EMDR practitioners. MORE OPTIONS I’d like to draw attention to the chapter on assessment of dissociation written by Steven Frankel, Ph.D., J.D., in the seminal tome Dissociation and the Dissociative Disorders, Dell and O’Neil (Eds) published by Routledge, 2009. That chapter includes a number of assessment methods. The book is terrific and state of the art.
As I’ve been saying for two decades: EMDR trainings should teach that dissociation is the engine of the train of traumatic sequelae, not the caboose. Association is the steam that moves the train down the track in trauma treatment whether it is EMDR or not. Bilateral stimulation in the careful procedure that is EMDR (which must be modified for safe use with dissociative disorders) is the most efficient form of association that we have. Therefore, the assessment of dissociation for EMDR practitioners must be ever so convenient, affordable, and useable even for novices in dissociation. The MID meets these criteria.
RESPECTFULLY SUBMITTED, SANDRA PAULSON PH.D.
I have found it It very rewarding to work with DID clients once I was equipped to do so. My hope is that more EMDR therapists will become competent in working with them, and certainly, not discover their need to do so by accident. I believe Sandra Paulsen’s remarks should assist significantly in this goal. Access Sandra for consultation or training at her website .
The most current MID is available online by its developer, Paul F. Dell, Ph.D. It includes the Manual, the tests, excel spread sheet for scoring and so on.
One more addition: as clinicians have been using the MID and finding it helpful, all of the reports it can generate can be difficult for those of us who are not trained in interpretation of test data. I primarily use the first report but all can be beneficial as you become familiar with the test or have a colleague who can assist you in the interpretation of the results.
Bonnie Mikelson, LISW
Director, EMDR & Beyond