Download Resources - European Society for Trauma and Dissociation

Dissociative Disorders: Using EMDR to Facilitate the Treatment
Joanne H. Twombly, LICSW
International Society for the Treatment of Trauma and Dissociation, Executive Council
Director
EMDRIA Approved Consultant in EMDR
HAP Facilitator
American Society of Clinical Hypnosis Consultant
740 Main St. Room 105, Waltham, MA 02451
781-894-1008 [email protected]
Diagnostic Criterea and Questions [Adapted from Steinberg, 1994 - organized around the
5 Core Dissociative Symptoms]
Amnesia (includes “gaps” “lost time”)
• Have you ever felt that there were gaps, small or large, in your memory?
• Are there ever hours or days that seem to be missing or that you have difficulty accounting
for?
• Is it ever hard to remember what you did yesterday or last week?
• Have you ever found yourself going somewhere without remembering how or why you went
there?
Depersonalization (includes client feeling detached from self, ones body, ones emotions)
• Have you ever felt as if you were watching yourself from a point outside of your body? As if
from a distance?
• Have you ever felt that you were going through the motions of living but the “real you” was
far away?
• Have you ever felt like two different people? One going through the motions of living and
the other just quietly observing?
• Have you ever heard yourself speaking and thought, “Is that me?”
• Have you ever felt that your words were out of your control? Your thoughts? Your actions?
Your feelings?
Derealization (feeling detached from ones environment, that it is unreal or foreign)
• Have you ever felt as if familiar surroundings or people seemed unfamiliar or unreal?
• Have you ever felt as if your surroundings were fading away?
• Have you ever had the experience of not recognizing close friends or relatives or even your
own home?
Identity Confusion (client feeling not sure who he/she is, unsure about sexual identity)
• Have you felt as if a struggle was going on inside you?
• Have you felt confused about who you really are?
• Have you ever felt as if there was a struggle going on about who really are?
Identity Alteration (Identity alteration: client shifts from one role or identity to one or more
others)
• Have you ever felt or been told that you were acting like a different person?
• Have you ever referred to yourself or been referred to by different names?
• Have you ever found possessions inexplicitly missing? Or appearing?
• Have you ever experienced rapid changes in your ability to function? Or does your mood
ever change rapidly without clear reason?
• Do you ever have internal dialogues? Are they more like thoughts or voices? Do they
increase under stress?
Safe Space Imagery Instructions Handout
Pick a time of day that you can be alone, uninterrupted, and a time that you are feeling
relatively
calm. Get as relaxed as you can.
Go to your safe space; pick a place where nothing bad ever happened, a place you have felt
safe in, or a place that’s completely made up.
Tips: Don’t pick one from your childhood.
It can be a combination of real and made up.
It’s a place that nothing bad has ever happened in.
Some people have one Safe Space, some have more than one, and some go to
different ones every time.
Once you’re in your Safe Space, look around and notice everything about it that makes it
safe.
Tip: Some people have Safe Spaces that are totally made up of sound (e.g. being
surrounded by a song) or feelings (e.g. soft blankets).
Notice what you’re seeing, hearing, feeling, smelling, touching.
Notice if there’s anything that doesn’t feel quite right and if there is, look around and as you
look
around you’ll either see something that will help, or some thoughts will occur to you that will
help.
Tips: What you see that helps doesn’t have to make sense!
If you can’t see or figure out something that helps, you can try adding a couple
things
like putting a force field or a fence around it or adding a friendly guard dog.
Sometimes it can help to draw a picture of your Safe Space, see if it feels like a
place
you could feel safe in, and then add anything you need.
Another option is to move to a different Safe Space that’s even safer.
If nothing works, or it feels too unsafe, stop working on it. Make a note about what
made it too difficult and bring the notes to your next therapy session.
Once you are in your Safe Space you can just settle in to being there and relax. The goal is
to
create a place that you can feel totally safe, comfortable, and relaxed in.
Note: Learning to do SSI is just like learning to do anything. It often takes
a little practice, and like anything, is easiest learned when you are in a
relatively clam state. It’s like learning to drive a car. You start out in a
quiet parking lot, and leave rush hour and high speed merging for later.
Eventually, you will be able to use it to center yourself when you’re having
strong feelings, but that takes practice.

Remember: A goal is to work up to doing Safe Space Imagery everyday for 10 - 20 minutes.
For most people, doing Safe Space Imagery every day will eventually help
them feel calmer over all.
Pragmatic Principles for the Treatment of MPD (excerpted)
By Richard P. Kluft, M.D. located in “Clinical Perspectives on MPD” ed. Kluft and Fine, 3d Chapter:
Basic Principles in Conducting the Psychotherapy of MPD
1. Maintain a Secure Frame and Firm Boundaries
First, MPD is a condition that was created by broken boundaries. Therefore, a successful treatment will
have a secure treatment frame and firm, consistent boundaries. The patient needs the therapist to be a
consistent, compassionate, and considerate person who safeguards the treatment setting and
maintains him- or her-self in the role of the therapist.
2. Focus on Achieving Mastery
MPD is a condition of subjective and at times objective dyscontrol. Assaults and unwanted experiences
were passively endured by a relatively helpless youngster. Amnestic barriers and the inner battles of
alters make the patient feel helpless in the face of his or her symptoms. The MPD patient comes to feel
that his or her locus of control is external. Therefore, there must be a focus on mastery and the
patient’s active participation in the treatment process.
3. Establish and Maintain a Strong Therapeutic Alliance
MPD is a condition of both genuine and subjectively perceived involuntariness. People with MPD did
not elect to be traumatized, and they find their symptoms often are beyond their control. Therefore the
therapy must be based on a strong therapeutic alliance, and efforts to establish this must be
undertaken throughout the entire treatment process. The concept of the therapeutic alliance is
especially difficult for those MPD patients who are nurture-seeking in their orientation and who find in
the therapist’s warmth and acceptance an implicit endorsement of their with to be cared for and an
absolution of the need to face painful material and share the burden of the work of the therapy.
4. Deal with Buried Traumata and Affect
MPD is a condition of buried traumata and sequestered affect. Therefore what has been hidden away
must be uncovered and what feeling has been buried must be abreacted. It is occasionally possible to
achieve a reconfiguration of the alters without dealing with the past and to direct the therapy to the
smoother functioning of the alters, but integration cannot be achieved without dealing with the impact of
the past.
5. Reduce Separateness and Conflict Among Alters.
MPD is a condition of perceived separateness and conflict among the alters. Therefore, therapy must
emphasize their collaboration, cooperation, empathy, and identification with one another so that their
separateness becomes redundant and their conflicts muted.
6. Work to Achieve Congruence of Perception
MPD patients are highly hypnotizable and have most of the characteristics of highly hypnotizable
subjects. One aspect of this is their ability to endorse alternative realities, even rather contradictory
ones, without being overly troubled by their discrepancies.
7. Treat All Personalities Evenhandedly and with Consistency.
MPD is a condition related to the inconsistency of important others. Most MPD patients were brought
up under conditions in which the powerful figures in their environment changed drastically and
menacingly, and the patients developed different alters to relate to these different behaviors.
Therefore, the therapist must be even handed to all of the alters and must avoid “playing favorites” or
dramatically altering his or her own behavior toward the different personalities.
8. Restore Shattered Basic Assumptions
MPD patients, like other trauma victims, often emerge from their ordeals with shattered basic
assumptions (that one is relatively invulnerable, that life is meaningful, and that one can see oneself in
a positive light, Janoff-Bulman 1985). Their reading of their pasts is that they have little grounds on
which to hope for a positive outcome. They generally handle supportive or encouraging statements
quite poorly. It is my experience that MPD patients can slowly rebuild their assumptions if the positive
feedback they receive is incontrovertible and based on shared experiences within the therapeutic dyad.
9. Minimize Avoidable Overwhelming Experiences
MPD is a condition stemming from overwhelming experiences. Therefore it is essential to pace the
therapy. …manage sessions so that the patient leaves in good control.
10. Model, Teach, and Reinforce Responsibility
MPD is a condition that often results from the irresponsibility of others. Therefore the therapist must be
very responsible and must hold the patient to a high standard of responsibility once the therapist is
confident that the patient, across alters, actually understands what reasonable responsibility entails.
11. Take an Active, Warm, and Flexible Therapeutic Stance
MPD is a condition that often results from people who could have protected a child doing nothing. The
therapist can anticipate that passivity, affective blandness, and technical neutrality will be experienced
as uncaring and rejecting behavior, and that the therapy is better served by taking a more warm and
active stance that allows a latitude of affective expression.
12. Address and Correct Cognitive Errors
MPD is a condition in which the patient has developed many cognitive errors. The therapy must
address them and correct these cognitive errors on an ongoing basis.
Mothers (Parents) with DID (Joanne’s notes from Gloria Rodberg’s 2005 ISSD workshop)
Make this part of the first stage of treatment: Establishing the Psychotherapy (Kluft)
Negotiate External Children’s Safety
1. Identify parts who’re positive parents and who aren’t. (Division of labor, similar to who drives and
who doesn’t)
2. Make agreements on who should be out with the children, and who should NEVER be out.
3. Identify protector(s) to monitor.
4. Contract with all parts that external children will be protected, will not be hurt or have their needs
neglected.
5. Problem Solve, e.g. if a child part pops out with an external child, how to switch with a part who parents.
6. Negotiate directly with potential abusive and neglectful parts. It’s hard, but once you get an agreement it
works.
7. Confront about self abuse, and substance abuse behavior around external children.
8. Assess possibility of abusive and neglectful parts changing their roles to protective ones.
9. Limit the number of parent parts out with children. (Research indicates that less is better)
10. Clarify positive and negative benefits of parenting agreement. (E.g. teen parts don’t get to go out
drinking unless there’s a babysitter for the mother’s children, but if they were to go out drinking without
getting a baby sitter the mother might loose custody which makes her miserable. The teen parts don’t like
the way the body feels when the mother is crying all the time.)
A Bibliography for Child Treatment
www.energyhealing.net Click on “Trauma and Dissociation” to get child and adolescent diagnostic scales (Gary
Peterson, MD’s web site)
James, Beverley, Handbook for Treatment of Attachment-Trauma Problems in Children
James, Beverly, Treating Traumatized Children: New Insights and Creative Interventions
Silberg, J. L. (1996). The Dissociative Child: Diagnosis, Treatment, and Management. Lutherville, Maryland: The
Sidran Press.
Diagnostic Tests
The Dissociative Disorders Interview Schedule and the Dissociative Experience Scale are located at
www.rossinst.com (see below for more information about this web site).
Somatoform Dissociation Questionnaire (SDQ) 20 and 5 (Nijenhuis) are available at:
www.enijenhuis.nl
DES: Adult, Adolescent and Child DES can be downloaded from Gary Peterson, MD’s web site:
www.energyhealing.net (under Trauma and Dissociation)
Websites to Know About
www.trauma-pages.com David Baldwin's Trauma Information Pages contains many articles and
resources.
***www.isst-d.org The International Society for the Study of Trauma and Dissociation is a huge
resource. Its annual conference is excellent, and it has basic and advanced on line dissociative
disorders training program, and a child and adolescent trauma and dissociation training program.
www.leadershipcouncil.org a site “committed to providing professionals and laypersons with the
latest scientific information on issues that may affect the public health and the safety. We also seek to
correct the misuse of psychological science to serve vested interests or justify victimizing vulnerable
populations -- especially abused and neglected children.”
www.freedomofmind.com Steven Alan Hassan’s web site with information on mind control,
interventions, and differentiating cults from groups, etc.
Self Help Books
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The Giver, Lowry (easy read fiction on why tolerating negative feelings is important)
Feeling Good; Burns (chapter 3 list of cognitive distortions, chapter 4 excellent 6 step exercise
for clients - the 3 step one may be all an overwhelmed person can do)
Dance of Anger, Dance of Intimacy, Lerner (good books written for women but good for men
on assertiveness and taking care of oneself. Easy to read, easy to put into use – can often get
used!)
Out Growing the Pain, Gil. (excellent once over on symptoms adults have that connect with
abuse and neglect – easy read)
The D.I.D. Journal Kit for Therapists & People with Multiple Personality & DID.
(www.multiple-personality.com)
Haddock, D.B. (2001). The Dissociative Identity Disorder Source Book. Contemporary Books.
(for clients)
Boundaries: Where you end and I begin, Anne Katherine
Bibliography (**ed references are recommended reading)
**Blizard, Ruth A. (2001). Masochistic and Sadistic Ego States: Dissociative Solutions to the Dilemma
of Attachment to an Abusive Caretaker. Journal of Trauma and Dissociation, Vol.2(4) 2001.
Braun, B.G. (1988). The BASK model of dissociation. Dissociation, 1, 4-24.
Brown, D.P. and E. Fromm (1986). Hypnotherapy and Hypnoanalysis. New Jersey: Lawrence Erlbaum
Associates, Inc.
**Chu, J. (1008). Rebuilding Shattered Lives: The Responsible Treatment of Complex Post-Traumatic
and Dissociative Disorders. New York, New York: John Wiley & Sons, Inc.
Chu, James A. (1998). Ten traps for therapists in the treatment of trauma survivors. Dissociation
1:24-32. (Classic article on pitfalls for the wary and unwary therapist.)
Courtois, C.A. (1999). Recollections of Sexual Abuse: Treatment Principles and Guidelines. New York:
W.W. Norton & Company, Inc.
**Dalenberg, C.J. (2000). Countertransference and the Treatment of Trauma. American Psychological
Association.
**Davies, J.M., and Frawley, M.G. (1994). Eight transference-countertransference Positions. In:
Treating the Adult Survivor of Childhood Sexual Abuse. NY: Basic Books.
**Fine, C.G. (1991). Treatment stabilization and crisis prevention: Pacing the therapy of the multiple
personality disorder patient. Psychiatric Clinics of North America, 14, 661- 676.
**Frankel, Steve. The Analyst’s Role in the Disruption and Repair Sequence in
Psychoanalysis.
**Fraser, G.A. (2003). “Fraser’s ‘Dissociative Table Technique’ Revisited, Revised” Journal of Trauma
and Dissociation, Vol. 4(4) 2003.
**Gil, E. (1990). United We Stand: A Book for People with Multiple Personalities
**Kitchur, M. (2005). Strategic Developmental Model for EMDR. In EMDR Solutions, ed. Robin
Shapiro, Norton.
**Kluft, R.P. (1988). Playing for time: temporizing techniques in the treatment of multiple personality
disorder. American Journal of Clinical Hypnosis, 32, 90-98.
**Kluft, RP. (1993). Basic Principles in Conduction the Psychotherapy of Multiple Personality Disorder.
In Clinical Perspectives on Multiple Personality Disorder, ed. Kluft and Fine. Wash. DC: American Psychiatric
Press Inc.
**Kluft RP. Current issues in dissociative identity disorder. J. Prac. Psych. And Behav. Hlth. Jan.
1999:2-19. Kluft, R.P. (1999). Current Issues in Dissociative Identity Disorder. Journal of Practical Psychiatry
and Behavioral Health, 3-19. Also available at: http://www.psyter.org/allegati/180/Kluft.pdf
http://www.empty-memories.nl/www_4.html
Janet, P. (1898). Traitement psychologique de l'hystérie. In A. Robin (Ed.), Traité de thérapeutique
appliquée. Paris: Rueff.
Liotti, G. (1999). Disorganized attachment as a model for understanding dissociative
psychopathology. In J. Solomon & C. George (Eds.), Attachment disorganization (pp. 297-243). New York:
Guilford.
Lyons-Ruth, K. & Jacobvitz, D.(1999): Attachment disorganization: Unresolved loss, Relational
violence, and lapses in behavioral and attentional strategies. In: J. Cassidy and P.R. Shaver (Hg.):
Handbook of Attachment: Theory, research, and clinical applications, New York: Guilford, S. 520-554
**Nijenhuis, E.R.S.; Van der Hart, O. & Steele, K. (2004). Trauma-related structural dissociation of the personality.
Trauma Information Pages website, January 2004. Web URL: http://www.trauma-pages.com/nijenhuis-2004.htm
**Nijenhuis, E.R.S., Van der Hart, O. & Steele, K. (2006). The Haunted Self: Structural Dissociation and the
Treatment of Chronic Traumatization. Norton: 2006.
**Phillips, M. and Frederick, C. (1995). Healing the Divided Self: Clinical and Ericksonian
Hypnotherapy for Post-traumatic and Dissociative Conditions. NY: Norton.
**Ross, C.A. (1997). Dissociative Identity Disorder: Diagnosis, Clinical Features, and Treatment of
Multiple Personality. NY: Wiley.
**Steinberg M, Schnall, M. (2000). The Stranger in the Mirror. New York: HarperCollins Publishers
Inc.
Twombly, JH. (2001). Safe Place Imagery: Handling Intrusive Thoughts and Feelings. The EMDRIA
Newsletter: Special Edition, December, EMDRIA.
** Twombly, JH. (2005). EMDR for Clients with Dissociative Identity Disorder, DDNOS, and Ego
States. In EMDR Solutions, ed. Robin Shapiro, Norton.
** Twombly, JH, and Schwartz, R. (2008)The Integration of the Internal Family Systems Model and
EMDR. In Healing the Heart of Trauma and Dissociation with EMDR and Ego State Therapy. Ed. Forgash,
C. and Copeley, M. Springer Publishing: 2008.