ESSENTIAL INFORMATION FOR EMDR THERAPY WITH DISSOCIATIVE CLIENTS
Sandra Paulsen, Ph.D. is a well known EMDR expert with dissociation and ego states, author of the highly recommended When There Are No Words as well as other publications and workshops. www.bainbridgepsychology.com/ . Dr. Paulsen’s recent in depth response to working with dissociation as an EMDR therapist on a list serve post was most enlightening and is shared, with her permission, here.
Dr. Paulsen outlines guidelines with implementing EMDR therapy with clients who have moderate to severe dissociation. including new EMDR therapists who assume dissociation will be observable and/or they know what dissociation looks like. One of our shared concerns is unexpected appearances of parts with clients who did not present as dissociative. This can frighten a newly trained EMDR therapist who is not prepared for managing the experience and also can lead both therapist and client not to do EMDR.
Guidelines and Tools for Assessing for Dissociation
Sandra Paulsen’s most important guideline is that EMDR clinicians 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 either. I was one of those newly trained EMDR therapists who had my budding confidence challenged in my EMDR skills as well as losing the opportunity to assist this woman in a more effective way. I share this experience because mistakes do result in learning and to make others know they are not alone. I had an excellent relationship with this client and her husband, so I was able to re-stabilize her. Unfortunately, however, I 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 new trainees about addressing dissociation with EMDR in combination with other approaches such as ego state therapy and structural dissocation theory. Dr. Paulsen recommends the DES (Dissociative Experiences Scale a) for adults, for b) for adolescents and c) for children) for routine screening. The DES Scales provide just a screening, should be used in conjunction with the clinical interview, and can give falsh positives or negatives depending in part on the severity of the dissociation and the defenses of parts of self. It is, however, a crucial step. Routine screening along with clinical questions can reveal the risk for moderate to severe dissociation and allow the clinician to further explore the client’s information to assess what is needed for stabilization.
Dr. Paulsen further recommends the Multi Dimensional Inventory of Dissociation, created by Paul Dell .
The MID has been made available online to administer and scoreonline at no cost by Dell and is periodically updated as well. If the DES screening and assessment information indicates the risk for moderate to severe dissociation in a client. the MID can be used to identify symptoms, suggest a diagnosis, and indicate if personality disorders or other factors are present as well.
Below are Paulson's lengthy but valuable remarks and I thank her again for her permission to reprint. The bold type is my emphasis on key points that she shares, beyond the recommendations, above.
Sandra Paulsen on EMDR and Dissociation (post on 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. They only use the DES-II on clients whom they already suspect are dissociative, missing a great many of the non-florid dissociative diagnoses,
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 processing session 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 dissassociation 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.
Considerations
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 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 Famliarity: 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 in 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.
In Summary
As I’ve been saying…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.
Though this was posted more than 10 years ago, the message remains critical. I have found it very rewarding to work with clients with moderate to severe dissociation once I was equipped to do so. And my experience reveals that this is not the rare disorder that many professionals believe it to be. My hope is that more EMDR therapists will become competent in working with these client disorders. And further, that they would not have to, as I did, 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 .
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