Disconnect, Shut Down, Dissociate: Things we see in the office every day

  • Everyone dissociates
    • Most common presentation allows easy movement from one state to another
    • It’s important to know how much because it can interfere with processing
    • In dissociative disorders, the person does NOT easily move between states
      • Expect the unexpected
      • Often misdiagnosed when clinicians aren’t trained to recognize dissociation
      • Do NOT use EMDR processing without
        • Advanced training working with dissociation
        • Advanced training working with dissociation using EMDR
          • Specialized consultation in using EMDR when working with dissociation
          • EMDR should not be considered stand alone treatment for this population, but part of a total psychotherapeutic approach
      • Lack of appropriate safeguards may result in client over-accessing and getting stuck at high SUD when processing traumatic memories
      • Often have a variety of diagnoses due to manifestations of different “parts”
  • Important to screen each client to identify potential dissociative disorder
    • Dissociative Experiences Scale (DES) (Carlson & Putnam, 1993)
      • DES Scoring Taxon – 3, 5, 7, 8, 12, 13, 22, 27
    • Multidimensional Inventory for Dissociation (MID), v6.0 (Dell, 2012)
  • Client readiness defined in Phases 1 & 2 (History and Preparation)
    • Additional consideration of complexity of internal system
      • Client education and understanding about dissociation
      • Understanding organization of the system is imperative
      • Informed consent by all elements of the system
      • Cooperation between parts
      • State of permeability of dissociative barriers between / among memory networks
      • Motivation for change
      • Defensive shame and the urge to avoid

Useful Tools for Working with Dissociation

Jim Knipe, EMDR Toolbox: Theory and Treatment of Complex PTSD and Dissociation

Constant Installation of Present Orientation & Safety (CIPOS)

  • Uses short-term memory (STM), the first step in retaining memories in long-term memory (LTM)
    • When shifting from present safe state to thinking about trauma, the STM of present orientation is briefly available (2-20 seconds)
  • Designed to build the client’s resources by briefly going into traumatic material and then reorienting to the present multiple times
  • Resourcing the client’s ability to go into the traumatic material and consciously shift to safety of the present prepares client for processing

Back of the Head Scale (BHS)

  • Useful to determine the extent to which a client is oriented to the present
  • Can be used at any point in the session to help the client develop an awareness of the dissociative process and help the client stay grounded in the present
  • Think of a line that goes all the way from here (about 14 inches in front of the face) to the back of your head. This point (14 inches in front of the face) means you are completely aware of being present here in the room with me, that you can listen to what I’m saying and that you aren’t at all distracted by any other thoughts. Now, let the other place on the line, at the back of you head, mean that even though your eyes are open, in your mind, you are completely in a memory from the past (not present in the
    Show me where you are right now.

Loving Eyes

  • Encourages the client to form a visual image of a younger emotional part (ego state)
  • Allows the parts to become more aware of each other and become accepting and supportive of each other
    • Each part originated with an adaptive purpose
    • Maladaptive behaviors in the present were, developmentally, the best option the client had for coping at the time of the original trauma(s)
  • Useful to reduce sympathetic arousal client may be experiencing when paired with sets of BLS
  • The goal of the procedure is that the parts can look at each other through “Loving Eyes”
  • Sitting in this chair, the adult you are today. Can you just look at that child? (if yes) Just see this child and see whatever you see when you see the child. What’s good about knowing that you today are not that child? What’s good about knowing that you’re not stupid (bad, weak, helpless, etc.)?
  • With a positive response, have the client think of that and add a short set of BLS
  • When you look at the child, can you see the child’s feelings?
  • When you look at the child, how do you feel about the child? Can s/he hear you if you speak to her/him? Is there anything you know, as an adult, that would be helpful to the child, something the child doesn’t know? …Stay with that.
  • If the client reports negative material – Do you, as an adult, looking at the child, feel critical of him/her?
    • May require additional cognitive interweaves

Special Considerations

  • If skilled in working with dissociation and integrating EMDR into overall treatment
    • Entire EMDR process will need to be titrated due to fragmentation of memories
    • Invert 3-pronged approach to build the client’s resources
    • Use EMD or a recent events protocol when processing
    • Keep the client involved and grounded

Slower is faster – it will likely take years