As an EMDRIA Approved Consultant, I have faced many challenges and have had lots of questions over the years. And I have learned that other EMDR therapists have the same difficulties and the same questions. I address some of these challenges in this 4-part series: (1) My client won’t do EMDR processing, (2) Fear that the client can’t handle processing, (3) Complex Trauma. Current symptoms are high. Trauma history is long. Where do I start?, and (4) What the heck? Dissociation & parts work?
Today, we are tackling challenge #3: Complex trauma. Current symptoms are high. Trauma history is long.
Where do I Even Start?
Screen for level of dissociation
Screen for safety and other risk factors
Strengthen existing skills & resources
Find developmental deficits
Build in distress tolerance skills
Coach self-compassion skills
Work to ‘unblend’ (realize) parts of self
Build a ‘good enough therapeutic alliance’ (Secure Base)
Get approval from parts to do Desensitization Phase (BLS)
Screening for Complex Trauma & Dissociation
Clients who endured repeated traumas experience significant changes in self‐concept and in how they adapt to stressful events. Chronic trauma often leads to Complex PTSD, Borderline Personality Disorder, and/or Dissociative Disorders. Additionally, many of these clients may meet criteria for an Eating-, Mood-, or Anxiety-Disorder, ADHD and/or substance abuse. As EMDR therapists, we may be eager to move through the phases of EMDR or we may be extremely cautious. Using the previous starting points help us find a balanced middle path with our clients; of not too fast and not too slow. Respecting the clients own innate wisdom and resiliency, while building appropriate developmental building blocks.
Screening can be an important step, and there are many diagnostic and specific assessments to use; however, here we will focus on complex trauma & dissociation. Furthermore, consultation and training in this area is highly recommended, if not necessary. Many EMDR therapists are trained in using the DES-II – Dissociative Experience Scale v 2.0, in which there are versions for adults, children, & teens. Some dissociation is normal in our everyday experiences. Other more common dissociative experiences, such as depersonalization and derealization, can range from mild to severe and may accompany most mental health issues. However, some types of dissociative experiences, as listed below, will be flags for you to slow down, learn more, and screen further before proceeding.
Active suicidality, self-harm, or other dangerous behaviors
Underweight, active Anorexia or Bulimia, nutritional deficits
Active & disabling flashbacks or ‘reliving’ of traumas
Falling asleep (shutting down) in sessions
Significant alterations in self states
Lapses in time & memory – amnesia for chunks of time or events
‘Coming to’ fugues or significant trance states
High score on the Adverse Childhood Experiences Scale (ACEs) or the Family Experiences in Childhood Scale (FECS)
Comprehensive Trauma & Dissociation Assessments, include: (1) The MID – the Multidimensional Inventory of Dissociation v 6.0 (Teen & Adult version), (2) The Structured Clinical Interview for DSM-IV (SCID-D), (3) Child Dissociative Checklist (CDC), v 3.0, and (4) The Dissociative Disorders Interview Schedule.
EMDR Mechanics for Dissociation
Build greater window of tolerance
Train metaphor. Stop signal
Catching a ball to orient
‘Tapping in’ positive felt sense
Intense Sensations (DBT Skills)
Progressive Muscle Relaxation
Build a greater sense of ‘Self Energy’
Remember to connect in a nonjudgmental way that the client can be open & real with you. Don’t push the client, rather stay confident in the process and the resilience of the client. Importantly, stay self-led, tapping into your own ‘Self-Energy’ during sessions, while coaching & believing in the client.