By Shirley Young
About 80 regional members of the East Anglia EMDR Association met at Ely Beet Factory Social Club on Saturday 27th April 2018 to explore best EMDR practice in working with dissociation.
Our expert trainer for the day was Dr Mel Temple, consultant psychiatrist and psychotherapist, EMDR consultant and current clinical director and lead specialist in The Kemp Unit at The Retreat in York.
She has worked across secondary and tertiary NHS settings, with time spent also in military mental health services.The Kemp Unit at The Retreat in York is a residential setting for the stabilisation and treatment of patients with personality disorder, complex trauma and DID (Dissociative Identity Disorder).
As a general introduction Mel reflected on differences in approach to the delivery of EMDR, citing Ad De Jongh from Holland who suggests “just getting in there” in comparison with our more cautious approach in the UK.
Another difference is that there is a reluctance in the UK to accept the existence of DID (despite research evidence and diagnostic criteria existing in the DSM).
Disturbingly, Mel recently found that in an assembled group of 100 psychiatrists only three acknowledged having come across a patient with DID. Only one believed in DID, and none of them felt competent to diagnose the condition.
This may, therefore, account for patients referred to the Retreat having been diagnosed with a variety and complexity of diagnosis and frequently being on a large cocktail of medications.
Please note I have referred to “patients”, rather than “clients” here, as this is the term Mel prefers to use.
She explained that for her it holds an implicit meaning of treatment and the hope for recovery which we, as clinicians, hold for those we work with.
This hope is particularly relevant in ‘The Retreat’ setting as most individuals have been through so many treatment settings without change, that the idea of recovery with the possibility of living a functional life is a fantasy.
At ‘The Retreat’, assessment takes 12 weeks with different members of the team carrying out a thorough analysis of an individual’s presentation.
The difference between Borderline Personality Disorder (BPD) and DID in this setting can be clearly seen, as those with DID present in consistent ways either when an ANP (Apparently Normal Part) is in charge or when EPs (Emotional Parts) are triggered.
EPs tend to behave consistently, and their presentation is logical within the context of their original development.
However, individuals with the varying mood states of BPD do not show the same consistency over time.
The Retreat gradually weans patients off unnecessary medication, in line with NICE guidelines, and particularly avoids the prescription of opioids or benzodiazepines, as these facilitate dissociation.
The use of antihistamines is preferred.
Medication to target co-morbid conditions is only prescribed once the clinical picture is clear.
Mel emphasised that much of what she was sharing with us was her integration of the work of many well-known and publicised figures working with dissociation.
Patients at The Retreat benefit from a varied programme, which includes Art Therapy, Interpersonal Therapy (IPT)and Sensory Integration among others.
Meeting with a varied staff group means there are plenty of attachment opportunities.
Fundamentally there is no one way of doing things, said Mel, but integrative practice, thinking outside the box and attunement to the client is key, particularly as poor attachment appears to be the foundation for dissociation and affects neurodevelopment, functioning and sensory integration.
Mel suggested choosing the model of dissociation that you fully understand yourself as a clinician and which you can, therefore, clearly explain to your patient/client.
Dissociation is a lack of connection to what our body and brain are doing. It is a normal phenomenon which we all experience, for example when completely absorbed in a film or book.
In Mel’s experience and observation, dysfunctional dissociation, as needed to cope with the impact of experiences an individual does not have the capacity to emotionally and physically manage, usually develops in childhood.
There are different ways of dissociating, including bodily experience being translated into another disorder such as OCD or an eating disorder.
So a threat, such as the experience of a hand on the arm for example, could be misinterpreted as ‘I’m too fat’ rather than linked to its original source.
Dissociation can occur either when over aroused in the case of anger and anxiety and when under aroused when experiencing sadness.
Brain patterns of clients with DID seen by MRI and EEG studies show significantly different brain patterns with each Alter.
Dissociation is associated with poor treatment outcome, since in order to process we need all parts of the jigsaw to have an overview of our experience.
In addition, the AIP model assumes there is adaptive information available to the individual, which in the case of clients with severe trauma and dangerous attachments isn’t always true. The capacity for adaptive information may need to be developed before it is available for processing.
Mel said that in her experience, the average length of working with somebody with DID is 8-10 years.
She also suggested that these patients are difficult to work with as a lone worker in the community, as a different setting can be needed to deal with different presentations.
She suggested not to carry more than two such clients on your case load.
(Those of us in the community, I suspect, working with DID clients could see the opportunities offered by The Retreat as an unobtainable ideal, and know that lone working is par for the course! Mel suggested that it was important to document that there should be a team around the client.)
Secondary traumatisation for the therapist is also a risk, and can facilitate a loss of faith in others. The idea for instance that ritual abusers may indeed have children born for the purposes of abuse and choose children who dissociate and actively develop Alters that will behave in certain ways is a hard thing to accept.
Therefore it is essential to have balancing time after a session and ways of connecting to healthy humanity to re-ground yourself in healthy experience.
Phase orientated treatment and having more than one mind on the case is also helpful as client needs more than one healthy attachment figure.
In considering the components needed to be able to process, Mel gave us Joany Spierings’ image of a 3-legged stool. The seat is arousal management, supported by one leg for attachment, one leg for self-compassion and the other leg for tolerance of emotional experience.
So what does EMDR look like with this client group, Mel asked?
She suggested that the art of what to do is in the attunement tracking of every part of the system, and identifying what works with whom.
The approach needed is to be respectful and understanding without judgement, and to facilitate the understanding of the logic of the presentation, giving feedback and possibly using session recording as part of this process to facilitate reality orientation.
She also suggested establishing a dedicated email to manage those clients whose parts will write independently to the therapist. The boundary setting for this would be understanding that mails would only be read once a week prior to the next session.
In Stage one work (as per Janet’s Three Stages of Trauma Treatment, rather than the eight phases of EMDR), Mel named the following principals:
· In assessment always use a helicopter view, not detail;
· Notice blankness when you come to write up the session afterwards;
· Identify what are the issues as well as what the patients wants (which may develop as treatment progresses).
Key areas which might promote dissociation as a consequence of threat to the system are about:
· Invisibility – Not being seen/Not wanting to be seen/Not being who you are (having to be the carer, or be what’s wanted);
· Pathological Guilt (an easier position to hold when you really have no options as it avoids acknowledging powerlessness);
· If only I had/should have done
· I’m bad
· I’m evil
· Toxic Shame – this blocks processing.
Mel described their use of drama dolls (little wooden figures like artist’s dolls) to illustrate the effects of shaming.
For each shaming event put a blob of plasticine on the doll. If you talk to someone about the shame and you are understood, the event is given a different perspective, then the piece of shame can be removed.
However, holding shame the doll gets covered in blobs of plasticine and eventually the doll disappears under the plasticine. Hence the sense of I am bad, disgusting, evil, etc.
The drama dolls can also be used by the patient to represent different Eps, and can be dressed up in the way that represents the characteristics of each part.
Use the DES and SDQ (Somatic Disorder Questionnaire) and be aware that results can be skewed with this client group.
When clients say I don’t know – that’s really telling you that history has been blanked in some way.
When asking a patient to check in with “what are you seeing and feeling right now”, their response will provide information about how somebody is using their body connection.
Treatment is about a creating a way forward in order to develop what the client needs to function, and that cannot happen without engagement. So establishing connection with the system is important.
Where treatment is being sabotaged, ask who or what is not being heard and what is the purpose of e.g. cutting – is this replaying past events or a protective action within the understanding of the system.
It is also important to understand that presentations, including perpetrator parts, need to be understood, including why they are being activated (i.e. what purpose are they serving within the system?).
The therapist’s role is then to facilitate the patient’s understanding of the EP’s purpose (which may have been entirely appropriate at the time but not appropriate now) and then to work towards the ANP taking back appropriate control.
Developing internal meeting rooms are helpful (see Ego State Work), and using the idea of patient as conductor of an orchestra, or driver of coach and horses (all parts needing to pull in the same direction or horses get hurt or coach gets pulled over).
Despite Alters being present and operating independently, it is still possible to set boundaries, for example in ensuring that sessions start and end with the patient as ANP (Apparently Normal Person), with only the Adult ANP then driving the car when the patient leaves your office. (Noting, said Mel, that a driving licence will need to be revoked if a patient is driving from their EP.)
Practice CIPOS (Constant Installation of present orientation of safety – see Jim Knipe) and help manage arousal in the present moment.
Develop safe experiences and use BLS to reinforce.
Tap in anything that shows recovery, particularly moves towards healthy attachment and what’s gone well, and using as much BLS as possible, including through keeping BLS running through any talking.
Randomised Control Trials with IPT show good outcomes and increased functioning even without EMDR processing, highlighting the fact that attachment work is key, particular where trauma is interpersonal.
With such fragmented clients it is likely that the therapist will have to develop the following basic framework with clients both with ANP and EP’s (emotional parts):
· What are emotions;
· What is a relationship;
· What is reciprocity;
· Taking a curious position;
· Developing internal compassion, which can be abhorrent to this client group;
· Installation of attachment support figures (Laurel Parnell) can be invaluable, and magical ones can be particularly helpful;
· Focus on building resilience and present time orientation
Ninety-minute sessions are necessary, said Mel, and attunement remains key particularly as there will be surprises. Just when you think you know they system you discover you don’t!
You will need to identifying where there is resistance if processing is not going to be blocked, and phobia of body connection will need to be worked on in some clients.
BLS consolidates the positive and processes the negative in order to accelerate what’s happening.
Pay attention to when the client says a part of me wants to…
It is possible to process one memory channel where the same issue comes up over and over again, or to deal with the now (a “fingertip” issue), processing in the now and not letting it go back to the past. This can make triggers manageable.
In the end it may not be realistic to process everything, but enough so that information linked with risk and inability to manage daily life are covered.
Although we had planned to break into small groups and to have a Consultants forum, the involvement and high level of content meant that the group really wanted to continue to explore material with Mel. In the end we briefly broke into groups and formed questions for Mel.
One of the main areas of discussion in the afternoon was considering conditions where the aetiology of the condition is unclear, and where life alters around the condition.
Mel suggested that NEAD (non-epileptic attack disorder), Fibromyalgia, Chronic Fatigue, MUPS (Medically Unexplained Physical Symptoms) and Pelvic Pain could be seen as part of this group.
(Mel considered IBS to be in a slightly different category, as changes in the gut are identifiable).
In assessing these patients, she will have one session mapping the condition and then another session mapping trauma and then another session overlapping the information from both sessions as a way of considering whether the two are connected.
All in all, this was a fascinating and information-packed day, and grounding in naming the effective ways of moving forward with these clients.
My own clients (speaking as Shirley writing up the day) loved the image of the shame doll and the removal of the plasticine, and this week we went on to develop the idea of dung piles from the plasticine removal as the food for new growth and roses blooming!
Last but not least the following resources were mentioned;
· Suzette Boon & Steele – Coping with Trauma-Related Dissociation (suitable for clients)
· Treating Trauma-Related Dissociation (for therapists with their clients)