EMDR, Dissociation, and Beyond

The application of EMDR therapy in the treatment of persons with dissociative disorders relies upon many principles, concepts, theories, and scientific literature. Several problematic truisms about EMDR and dissociation have been handed down through generations of trainers and learners. Factors that have compromised mental health practitioners’ ability to recognize, diagnose, and learn to treat dissociation are explicated - both more broadly and as they relate to EMDR therapy specifically. This chapter reviews those foundational issues before embarking upon a review of the explanatory, theoretical models and neurobiological correlates of dissociation. Three domains of explanation will organize a discussion of the literature demonstrating the existence and understanding of dissociation and its clinical relevance: Neuroanatomical/neurophysiological, psychological, and subjective/phenomenological. AUTHOR(S): Madere & Coy

In practice, EMDR therapists have for years observed how bilateral dual-attention stimulation (BL-DAS) may be experienced as dysregulating, or alternatively, largely impotent as a catalyst for change in individuals with complex trauma and dissociation. The neurobiological correlates point the way to understanding why – sometimes – EMDR does not work so well in the treatment of dissociation. The adaptive information processing (AIP) model was developed through Francine Shapiro’s use of EMD and its evolutionary successor, the ‘standard protocol’ of EMDR, treating people with PTSD and complex trauma without severe dissociative symptoms (i.e., distinct self-states and/or pervasive retrograde or contemporaneous amnesia). For this reason, the model is unavoidably founded upon the assumption that all people possess both an adequately integrated sense of self before overwhelmingly painful experience intrudes and explicit recall of this experience. In this chapter, attention will first be given to the hypothesized mechanisms of action in EMDR therapy, focusing on the interaction of BL-DAS and dissociative phenomena. Then, the development and basic tenets of the AIP model will be discussed. With those concepts and challenges in mind, the AIP model will be revisited to delve more deeply into its intricacies to illuminate its dissociative gaps and propose a means for bridging these to accommodate conceptualizing treatment with dissociative clients. AUTHOR(S): Coy & Madere

This chapter explores the dimensions of ethical treatment of complex trauma and dissociation with EMDR therapy, situating it within a framework guided by the standard of care. Historical and contemporary tensions in the field related to ethical and effective treatment of this population are discussed alongside associated literatureand treatment and practice guidelines. This chapter proposes grounding EMDR therapy within a robust, multilayered theoretical framework that honors the complexity of dissociative experiences. Comprehensive treatment of persons with dissociative disorders is unavoidably integrative and requires dynamic conceptualization skills. A discussion of the scope of treatment - symptom-reduction or issue-focused, in contrast to comprehensive treatment - sets the stage for a more nuanced approach to EMDR therapy. AUTHOR(S): Madere & Coy

The relationship between the fields of EMDR therapy and dissociative disorders has been fraught since the earliest reports of undiagnosed dissociative clients decompensating after reprocessing. Subsequently, the potential risks of using EMDR therapy received significant attention in literature and conference presentations throughout the 1990s and into the early 2000s. Since then, attention has been devoted almost exclusively to modifying standard EMDR therapy to accommodate and treat dissociative symptoms and disorders. Despite the emphasis placed upon discernment and treatment of dissociation in the EMDR therapy field over the past 35 years, there has been a near-absence of attention given to ethical considerations specific to EMDR therapy and dissociation. This chapter examines the practical challenges encountered by an example EMDR therapist, including the mixed messages about treating dissociation to which EMDR practitioners are beholden, and follows their process of resolving an ethical dilemma when they encounter a client with a complex history. AUTHOR(S): Coy & Madere

Postgraduate training and consultation fill a vital role in providing knowledge and skills that are essential for conceptualizing and treating trauma and dissociation - both within the EMDR framework and more broadly. This chapter explores how practitioners, consultants, and trainers can identify and address areas of training and clinician formation that can pose obstacles to impactful treatment and influence professional burnout and longevity. Topics include common learning gaps especially relevant to practitioners who seek training in EMDR therapy, the stages of practitioner development, and how different types of consultation can meet the varying needs of the practitioner. Examples are discussed to empower practitioners, consultants, and trainers to bolster professional development and the specialized practice of EMDR therapy to treat complex trauma and dissociation. AUTHOR(S): Madere

The process of Phase I: History Taking, when complex trauma and dissociative symptoms are present, includes ensuring that stabilization and closure strategies are in place before traumatic events are actively identified. Collecting history is often a recursive process as practitioner and client navigate memory gaps, internal conflict, psychodynamics, and other unique challenges resulting from complex trauma and disruptions in functional connectivity. At the beginning of Part III of this book, this chapter offers a brief discussion of the screening and diagnostic assessment methods for dissociation. Timing, selection of tools, and the processes of identifying and evaluating dissociative symptoms will be considered to inform practitioners in discerning the scope and trajectory of treatment within the EMDR therapy frame, in particular. Case examples illustrate how screening and assessment tools may be selected and utilized at the outset of treatment and in reevaluation of the diagnosis and treatment plan. AUTHOR(S): Madere & Coy

Standard protocols and procedures of EMDR therapy can be both too much and not enough for people who experience complex trauma and dissociative disorders (DDs). Personalized adjustments to these procedures are often effective and serve to avoid risks of premature associations and harm to the client. This chapter will guide readers toward a balanced approach to finding a way forward through the phases of EMDR that match practitioner competencies and client needs. It explores the relationship between Stage 1: Stabilization and EMDR therapy and then examines Phase II: Preparation modifications and adaptations, including resource development, affect tolerance/phobias work, identifying and accessing ‘adaptive material,’ and incremental containment and consent. Nuanced Stage 2: Trauma Processing is discussed, including fractionation of targets and restricted reprocessing. For clients with DDs, more specialized tools and additional approaches described in Part IV may be necessary. Examples are offered to support measuring progress, determining the next steps, and measuring progress in the EMDR frame and beyond. AUTHOR(S): Madere

Successfully completing a three-prong treatment plan in EMDR therapy is often a struggle for EMDR practitioners, especially when working with clients who have an extensive history of traumatic events, relationships, and related experiences. Many circumstances can contribute to this. This chapter will explore how the Present and Future prongs of EMDR can be incorporated into a broader framework, including models and theories of dissociation, ego state therapy, and the three-stage model of treatment for complex trauma and dissociative disorders. By embedding EMDR therapy within this layered framework, practitioners can draw from its phases and protocols to achieve a variety of therapeutic goals, including and beyond the standard objective of sequentially processing a memory network from Past prong to Present to Future. AUTHOR(S): Madere

Ego state therapies can help us know enough about a client's self-system to determine readiness and obtain multifaceted consent for any form of resourcing and memory processing. Over the past 20 years, there has been an undeniable gravitational pull in the EMDR therapy field toward Internal Family Systems therapy (IFS) and other, IFS-inflected approaches. IFS, which is usually paired with the Theory of Structural Dissociation of the Personality, has become the ego state therapy of choice among EMDR practitioners working with dissociative clients. This chapter critically examines the basic concepts of the IFS model; discusses the sociopolitics and therapist-specific factors that may lead EMDR practitioners to gravitate toward or away from certain practice approaches; and considers the Watkinses’ Ego State Therapy. With its integration of clinical hypnosis and psychodynamic principles, Ego State Therapy offers practitioners greater flexibility in conceptualizing and treating dissociation. A case example will illustrate the expanded palette of treatment possibilities offered by integrating EMDR and Ego State Therapy. AUTHOR(S): Coy

Memory mapping is a process familiar to EMDR practitioners as a means of identifying dysfunctionally stored memories, which have formed linkages based on common elements. These elements include components of five-sense perception, emotion, inner-body sensation, and negatively valenced cognitions, and even time, if we consider that the components may link past, present, and anticipated future experiences. In the treatment of clients with severe dissociation, mapping must account for memories whose elements may be distributed in a fragmented fashion, among different self-states. This chapter will discuss the context for mapping with increasingly complex trauma in EMDR therapy practice. Definitions and history of the practice of mapping as it relates to dissociation will be touched upon. This will open the door to clarify basic procedures for mapping and discuss additional approaches to accommodate different practitioner styles and client capacities. Several considerations inform the mapping process itself, and these will be explored. The chapter will conclude with an illustrated case example, which will begin with indicators of potentially high-risk self-state activity noted in a client's diagnostic results, progress to initial mapping, and illustrate a process of deeper inquiry to identify the more deeply embedded sources of that risk. AUTHOR(S): Coy

The classic features of posttraumatic flashbacks described in DSM-5-TR imply that (a) the event(s) occurred in the past (‘memories’), (b) the experiencer is ‘flashing back’ to or experiencing dreams about a past event that they recognize as actually having occurred, and (c) the experience is fully involuntary, phenomenologically isolated (i.e., a discrete event), and ‘non-interactive’ - it does not, itself, possess motivation or intention. EMDR, in its standard protocol form, has been shown to be effective in treating the sequelae of posttraumatic stress, including flashbacks and nightmares, without the need to integrate other approaches. The adaptive information processing model and most EMDR therapy practices seem to assume these are the conditions under which EMDR therapy methods will be employed. However, when discrete self-states are present, as is the case in dissociative disorders, there are added dimensions of flashbacks that may, at the surface, resemble a ‘typical’ posttraumatic stress disorder (PTSD) presentation but confound the use of EMDR treatment-as-usual. This chapter will name and elaborate on four ways that more complex flashbacks may manifest, using Karpman's Drama Triangle to contextualize each, as well as discuss the implications for EMDR therapy conceptualization and treatment of each ‘kind’ of flashback. AUTHOR(S): Coy

The EMDR therapy and dissociative disorder (DD) literatures have established that ego state interventions can be both helpful and frequently necessary to achieve stabilization/containment, adaptive resolution of traumatic experience, and integration of treatment gains. Work with persecutory ego states, such as those patterned after outside perpetrators (i.e., introjects), tends to focus on orienting them to present realities, persuade them to stand down’ or reconsider/realign how they protect, and helping other states feel less afraid of them. However, many of these interventions also present conceptual and/or practical issues that can make it difficult to achieve or maintain treatment gains with some clients who present with more complex trauma and DDs. This chapter will begin with a discussion of the development of perpetrator introjects, as well as their function within and impacts upon a self-system. Existing approaches to working with perpetrator introjects and similar states will be examined. The focus will then pivot to elaborate the Id Protocol, a novel, yet effective, integrative EMDR therapy approach developed by the author, which permanently ‘unbinds’ perpetrator introjects from the traumatic material in which they are seemingly, inexorably bound. The protocol will be illustrated through a case example, which will provide further context for the treatment frame and necessary preparatory tasks and precautions for its safe use. AUTHOR(S): Coy