EMDR in the treatment of dissociative disorders
WHAT IS EMDR?
EMDR stands for Eye Movement Desensitisation and Reprocessing and was developed in 1989 by Dr Francine Shapiro, an American Psychologist and Educator. It is a comprehensive, integrative psychotherapy approach which has been recognised as an effective treatment for trauma in many countries and by different organisations. In the UK, the NICE (National Institute for Clinical Excellence) guidelines for PSTD (post traumatic stress disorder) specify EMDR as a suitable treatment option. The EMDR Institute (www.emdr.com) says:
‘EMDR psychotherapy is an information processing therapy and uses an eight phase approach to address the experiential contributors of a wide range of pathologies. It attends to the past experiences that have set the groundwork for pathology, the current situations that trigger dysfunctional emotions, beliefs and sensations, and the positive experience needed to enhance future adaptive behaviours and mental health.’
HOW DOES IT WORK?
It is not entirely clear why EMDR is effective in treating trauma, although some people theorise that it may help the hippocampus (part of the brain involved in memory storage and retrieval) to process distressing memories and flashbacks. The alternating left-
CAN IT BE USED TO TREAT DISSOCIATIVE DISORDERS?
The ISSTD (International Society for the Study of Trauma and Dissociation) endorses EMDR as an adjunctive treatment in their Guidelines for Treating Dissociative Identity Disorder in Adults (2011). They recommend that EMDR is not used as a standalone treatment but as part of an overall treatment plan.
Early use of EMDR with dissociative clients, however, resulted in a number of difficulties, including ‘unintended breaches of dissociative barriers, flooding, abrupt emergence of undiagnosed alternate personalities, and rapid destabilisation’ (ISSTD, 2011). The ISSTD therefore recommend that adjustments be made to the standard EMDR protocols when working with dissociative survivors, and various safeguards put in place.
WHEN CAN EMDR BE USED WITH DISSOCIATIVE CLIENTS?
Francine Shapiro’s book, titled Eye Movement Desensitisation and Reprocessing: Basic Principles, Protocols, and Procedures (2001), contains an appendix (Appendix B) that reports on the Dissociative Disorders Task Force Recommended Guide: A General Guide to EMDR’s Use in the Dissociative Disorders. This is generally considered the gold standard for using EMDR with dissociative disorders.
These guidelines suggest the following considerations:
- the therapist needs to be experienced in working with dissociative disorders, and using EMDR with non-
- the client needs to be assessed for their readiness, for example:
- being generally stable, with good ego strength and social support
- having sufficient coping strategies
- having sufficient internal cooperation between parts
- having a history of engaging successfully in treatment
- being able to maintain a ‘dual focus of awareness’ (i.e. on the traumatic memory and on the therapist)
- having low levels of self-
harm or suicidality
- having low levels of uncontrolled flashbacks and involuntary switching
- being of sufficiently good physical health
- having no serious dual diagnoses such as non-
dissociative psychosis or serious substance abuse
- having a positive relationship with the therapist
The therapist also needs to consider their own readiness and suitability, for example:
- being sufficiently trained and experienced in working with dissociative disorders
- being able to work with a range of alternate personalities, e.g. child parts, angry and hostile parts, perpetrator-
- being able to manage crises and therapeutic ruptures
- being able to recognise hypnotic and dissociative symptoms and phenomena
- being experienced in using EMDR with non-
WHAT ARE THE MAIN RISKS OF USING EMDR WITH DISSOCIATIVE CLIENTS?
Onno van der Hart, quoted in the ISSTD Guidelines, states that:
The risk inherent with the use of EMDR with chronically traumatised individuals is that it often reactivates too much traumatic memory too quickly.
Francine Shapiro states:
The use of eye movements too early in treatment risks premature penetration of dissociative barriers. This could produce such results as flooding of the system, uncontrolled destabilisation, and increased suicidal or homicidal risk. For crisis intervention, the therapist should attempt eye movements only if the risks of failing to intervene are as high without as with the intervention.
The risks can be reduced with the following considerations:
- working only with clients who are already reasonably stable (see above)
- keeping the quantity and intensity of traumatic material at a manageable level
- isolating one target memory as much as possible
- developing a sound relationship with the client before attempting to begin work with EMDR, and knowing the client well enough to become aware of subtle signs that might indicate that the pace is too fast or there is a risk of flooding
- adjusting the pacing and type of alternating bilateral stimulation, for example using shorter sets or using audio or tactile stimulation rather than eye movements
- increasing the length of a session to allow a slower pace to process and integrate material and reground afterwards
- repeating protocols, as processing is usually incomplete after the first attempt
- using EMDR in the first instance to reduce and contain symptoms, build ego strength, develop cooperation between parts, increasing a felt sense of current day safety, and increasing distress tolerance—rather than working specifically on traumatic memories.
WHAT IS EMDR USEFUL FOR IN THE TREATMENT OF DISSOCIATIVE DISORDERS?
Shapiro states the following uses for EMDR:
- neutralising trauma through abreaction
- improving internal dialogue between parts using ego state therapy
- restructuring cognitive distortions
- developing coping skills and building alternative coping behaviours
- ego strengthening
- fusion of alternate personalities
- generalisation of resources into new situations
- facilitating meaning-
making for trauma, pain and healing
- removing obstacles to achieving life goals.
WHERE CAN I FIND OUT MORE?
International Society for the Study of Trauma and Dissociation. (2011). ‘Guidelines for treating Dissociative Identity Disorder in adults, third revision’, Journal of Trauma and & Dissociation. 12(2):115-
Shapiro, F. (2001). Eye Movement Desensitisation and Reprocessing: Basic Principles, Protocols, and Procedures (2nd Edition). New York: The Guildford Press.
EMDR Association: www.emdrassociation.org.uk
EMDR Institute: www.emdr.com