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TIRCIA · Professionals · In depth

Dissociation and EMDR: recognising, assessing and adapting treatment

What dissociation covers, how to screen for it, what the studies say and how to adjust EMDR practice

By Marie-Agnès Thulliez · Author · Publishing Director23-minute read

Illustration: in a warm consulting room, a client sits in an armchair, surrounded by fragments of images and memories drifting away from her, while a therapist guides her gaze with a small light.

A gaze that freezes in the middle of a set of bilateral stimulation, a client who no longer remembers the previous session, a voice that suddenly changes tone: every EMDR practitioner eventually encounters dissociation. It may be no more than a passing symptom of post-traumatic stress disorder (PTSD), or the sign of a dissociative disorder that profoundly changes how treatment should be conducted. Knowing how to tell the difference is part of safe EMDR practice.

This in-depth article takes stock for practitioners: what the term covers, current classifications, screening tools, what the studies say, including where they contradict one another, and the concrete adjustments that dissociation calls for in EMDR treatment.

In brief

  • Dissociation refers to an involuntary disruption of the normal integration of identity, memory, perception, emotion or control of the body. It ranges from common symptoms (depersonalisation, derealisation) to complex dissociative disorders.
  • The 11th revision of the International Classification of Diseases (ICD-11) describes seven dissociative disorders, including dissociative identity disorder (DID) and partial DID. Their validity, especially that of partial DID, is still debated.
  • When they are looked for with a structured interview, they are frequently found in psychiatric outpatient settings, in patients who had rarely been diagnosed before. Figures vary widely from one study to another.
  • In PTSD with dissociative symptoms, one meta-analysis finds no reduced effectiveness of psychotherapy, but an analysis of a recent randomised trial suggests the opposite: the question remains open.
  • For complex dissociative disorders, experts advocate a phase-oriented approach. The data supporting it remain limited: mostly uncontrolled studies, and a single small randomised trial that found no difference between groups.
  • Systematic screening from phase 1, before any bilateral stimulation, is the first safety measure.

1. What are we talking about?

ICD-11 defines dissociative disorders by an involuntary disruption or discontinuity in the normal integration of one or more functions: identity, sensations, perceptions, affects, thoughts, memories, control over bodily movements or behaviour. This disruption is most often partial and can vary from day to day (World Health Organization [WHO], 2026).

A proposed distinction: detachment and compartmentalisation

The word in fact covers different phenomena. A literature review examines a distinction proposed by several authors between two forms of dissociation (Holmes et al., 2005):

  • detachment: a sense of distance from oneself or the world, such as depersonalisation ("I see myself from the outside") or derealisation ("everything seems unreal");
  • compartmentalisation: normally accessible functions that escape voluntary control, such as dissociative amnesia, functional neurological symptoms or distinct identity states.

According to the authors, this distinction helps with case formulation and treatment choice, although it still requires controlled evaluation.

Continuum, category and structural dissociation

Not all dissociation is pathological. Becoming absorbed in a book or "driving on autopilot" are ordinary experiences. A taxometric analysis, a statistical method that tests whether a phenomenon forms a separate category or a continuum, suggested that pathological dissociation forms a category distinct from these ordinary experiences (Waller et al., 1996). This hypothesis has since been debated: among 465 students, membership of this category proved unstable from one administration to the next (Watson, 2003).

In EMDR clinical practice, a widely used model for thinking about complex dissociative disorders is the theory of structural dissociation of the personality (van der Hart et al., 2006). It describes a division of the personality between a part that manages daily life and one or more parts fixed in defensive responses to trauma. It is an influential clinical model, which guides much of the EMDR literature on dissociation, though it has not been tested as such in controlled trials.

Key points

  • ICD-11 describes dissociative disorders as an involuntary, often partial, disruption in the integration of functions such as identity, memories or perceptions.
  • According to one review (Holmes et al., 2005), distinguishing detachment from compartmentalisation helps with case formulation, but still requires controlled evaluation.
  • Not all dissociation is pathological; the hypothesis of a pathological category distinct from ordinary experiences has been debated.
  • Structural dissociation theory is an influential clinical model in EMDR, but it has not been tested as such in controlled trials.

2. Trauma and dissociation: a debate that remains open

The link between dissociation and trauma is well established at the level of associations, even though most of the data rest on traumatic experiences reported retrospectively. How to interpret it has long been debated, and two models stand in contrast.

The trauma model and the sociocognitive model

The trauma model sees dissociation as a response to traumatic experiences, especially early and repeated ones. A 2012 review concludes that the data strongly support it. According to this review, the link between trauma and dissociation is consistent and moderate in strength. It persists with objective measures of trauma and after accounting for fantasy proneness. Finally, dissociation is not reliably associated with suggestibility (Dalenberg et al., 2012).

The sociocognitive model, or fantasy model, holds that fantasy proneness, suggestibility and cultural or therapeutic influences contribute to dissociative symptoms and to memories of trauma. Its proponents criticise the Dalenberg et al. review for drawing causal conclusions from correlational data, for giving too little weight to the lack of corroboration of abuse in many studies, and for underestimating the link between dissociation and false memories. They accept that trauma may play a causal role, but a less central and less specific one (Lynn et al., 2014). A later review argues for multifactorial models (Lynn et al., 2019).

Diagnostic validity and practical consequences

The debate also concerns the diagnoses themselves. A recent German review considers DID and partial DID insufficiently validated. According to this review, the data do not support amnesia between personality states, there are no robust data on partial DID, and these presentations overlap substantially with complex PTSD and borderline personality disorder (Roepke et al., 2026). Conversely, Loewenstein, a psychiatrist in the dissociation field, stresses that these disorders are common, under-recognised and associated with a high risk of suicidal behaviour (Loewenstein, 2018).

For the practitioner, this debate has two concrete consequences. On the one hand, dissociative patients very often have a heavy trauma history, and their suffering should be taken seriously whatever label is chosen. On the other hand, caution is essential with any suggestive technique: symptoms are explored without inducing memories or "parts" that the patient has not described.

Key points

  • The association between trauma and dissociation is robust; its interpretation remains debated, because traumatic experiences are mostly reported retrospectively.
  • The trauma model and the sociocognitive model differ on the respective weight of trauma, fantasy proneness, suggestibility and cultural or therapeutic influences.
  • A recent review considers DID and partial DID insufficiently validated; Loewenstein, by contrast, describes them as common, under-recognised and carrying a high suicide risk.
  • In practice, suffering is to be taken seriously whatever the label, and exploration proceeds without inducing memories or "parts".

3. What the classifications say

ICD-11 groups seven dissociative disorders, to which are added "other specified" and "unspecified" categories.

ICD-11 titleCodeIn a few words
Dissociative neurological symptom disorder6B60Motor, sensory or cognitive symptoms (non-epileptic seizures, paralysis, gait disturbance…) not consistent with a recognised neurological disease.
Dissociative amnesia6B61Inability to recall important autobiographical memories, often traumatic, with or without fugue.
Trance disorder6B62Marked alteration in the state of consciousness or loss of the customary sense of identity, with a narrowing of awareness of the surroundings and restricted movements or speech experienced as beyond control, without a replacement identity.
Possession trance disorder6B63Trance in which the customary sense of identity is replaced by an external "possessing" identity, which appears to control behaviours or movements.
Dissociative identity disorder6B64Two or more distinct personality states that recurrently take executive control, with marked discontinuity in the sense of self and, typically, episodes of amnesia.
Partial dissociative identity disorder6B65One dominant personality state manages daily life but is intruded upon by non-dominant states (thoughts, emotions, perceptions, movements or behaviours experienced as alien, usually distressing). The non-dominant states do not recurrently take executive control; occasional, brief and circumscribed episodes remain possible.
Depersonalization-derealization disorder6B66Persistent or recurrent experiences of depersonalisation, derealisation or both.

Descriptions paraphrased from ICD-11 (WHO, 2026). Depending on the disorder, the symptoms must not be better explained by a substance, another medical condition or an accepted cultural or religious practice, and they cause significant impairment in functioning. For neurological symptoms, the diagnosis is made together with a neurologist; a neurological disease, epilepsy in particular, may coexist.

The American classification: DSM-5-TR

DSM-5-TR (Diagnostic and Statistical Manual of Mental Disorders, 5th edition, text revision), the American classification, offers similar categories: DID, dissociative amnesia, depersonalization/derealization disorder, other specified dissociative disorder and unspecified dissociative disorder. Two differences matter. It places functional neurological symptom disorder among the somatic symptom and related disorders. And it has no "partial DID" category: the corresponding presentations fall under "other specified dissociative disorder".

Since DSM-5 (2013), the American manual has also included a dissociative subtype of PTSD, defined by persistent or recurrent depersonalisation or derealisation. The authors who proposed it describe two forms of emotional dysregulation in PTSD: a common form, with re-experiencing and hyperarousal, and a dissociative form, marked by emotional overmodulation, with distinct neurobiological correlates (Lanius et al., 2010).

Dissociation and complex PTSD in ICD-11

Finally, in ICD-11 complex PTSD, the WHO clinical descriptions list dissociative symptoms under stress among the possible forms of affect dysregulation, without making them a separate symptom cluster (see our in-depth article on complex PTSD).

Key points

  • The seven dissociative disorders of ICD-11 include DID and partial DID; "other specified" and "unspecified" categories are added to them.
  • For neurological symptoms, the diagnosis is made with a neurologist; a neurological disease, epilepsy in particular, may coexist.
  • DSM-5-TR has no "partial DID" category and places functional neurological symptom disorder among the somatic symptom disorders.
  • DSM-5-TR has a dissociative subtype of PTSD; in complex PTSD (ICD-11), dissociation under stress is one possible form of affect dysregulation.

4. Frequently overlooked disorders

Prevalence figures vary widely by country, population and method. Two frequently cited studies illustrate the possible scale of the problem.

  • In the general population. In a representative sample of 628 women from a city in central Turkey, assessed with a structured interview, 18.3% had had a dissociative disorder during their lifetime. Nearly half of these cases (8.3% of the sample) fell under "dissociative disorder not otherwise specified", a category that no longer exists in that form, and 1.1% of the sample had DID. Only 28.7% of the women with a dissociative disorder had ever received psychiatric treatment (Şar et al., 2007).
  • In psychiatric outpatient settings. In a hospital outpatient clinic in New York, 24 of the 82 patients assessed with a structured interview (29%) met the criteria for a DSM-IV dissociative disorder, including 5 with DID (6%). Only 4 of these 24 patients had previously received that diagnosis (Foote et al., 2006). The authors point out that this high rate is partly due to their method and to a population heavily exposed to childhood abuse.

In both studies, most of the people affected had never been treated or never been diagnosed. They suggest that these disorders easily go unnoticed when nobody looks for them, even though their figures cannot be transposed as they stand to other countries or other clinical settings.

Key points

  • Prevalence estimates differ markedly from one country, population and method to another.
  • In two frequently cited studies, most of the people affected had never been treated or never been diagnosed.
  • They suggest that these disorders easily go unnoticed when nobody looks for them; their figures cannot be transposed as they stand to other settings.

5. Assessment

In the eight-phase EMDR approach, screening for dissociation is part of phase 1, history taking (Shapiro, 2018). Several tools are available.

  • The Dissociative Experiences Scale (DES). A 28-item self-report screening questionnaire, the most widely used (Bernstein and Putnam, 1986). A French version was validated with 140 rape victims followed at Tours University Hospital (Darves-Bornoz et al., 1999). An eight-item subscale, the DES-T (DES-Taxon), targets pathological dissociation more specifically; its ability to isolate a distinct category is debated (Merritt and You, 2008).
  • The Somatoform Dissociation Questionnaire (SDQ-20). It explores the bodily manifestations of dissociation: anaesthesia, pain, motor disturbances (Nijenhuis et al., 1996).
  • The Multidimensional Inventory of Dissociation (MID). A detailed questionnaire on pathological dissociation, intended for diagnosis, and lengthy to administer (Dell, 2006).
  • Structured interviews, such as the Dissociative Disorders Interview Schedule (DDIS), used in the two prevalence studies above, or the SCID-D (Structured Clinical Interview for DSM-IV Dissociative Disorders). These are the reference tools for supporting a diagnosis. They are built on DSM criteria, which calls for some interpretation to reach a conclusion under ICD-11.

Three rules of interpretation. A questionnaire screens; it does not diagnose. A high score is non-specific: it is also found in PTSD, borderline personality disorder and some psychotic disorders. And a low score does not rule out a dissociative disorder, since some patients minimise or are unaware of their symptoms. The French versions of the other tools have not all undergone a published validation: it is worth checking the validation of the version you use before relying on a cut-off.

Warning signs in session

  • Gaps in memory for periods of life, for sessions or for recent events; finding oneself somewhere without knowing how one got there; finding objects or writing with no memory of having bought or produced them; behaviours reported by others of which the patient has no memory.
  • Abrupt changes in tone, vocabulary, apparent age or attitude, which the patient does not seem to notice; a patient who refers to themselves as "we" or in the third person.
  • Voices that comment or converse. Their location, inside or outside the head, is not on its own enough to distinguish them from a psychotic disorder.
  • A fixed stare, lack of response, a sense of floating or of no longer feeling one's body, particularly when the trauma is mentioned; a disproportionate reaction (flight, freezing) as soon as bilateral stimulation or the safe place exercise begins.
  • A history marked by multiple diagnoses, repeated treatment failures and unexplained somatic symptoms.
  • During reprocessing: a SUD (subjective units of disturbance, from 0 to 10) that does not decrease when returning to target, or conversely drops abruptly to 0 with blunted affect; loss of dual attention; mechanical or very distant responses.

These signs call for a more thorough assessment, rather than an immediate conclusion. The differential diagnosis includes in particular psychotic disorders, epilepsy and other neurological or metabolic causes (head injury, sleep disorders, to be explored with a doctor), the effects of substances or medication, depersonalisation in panic attacks, bipolar disorder, and malingering or factitious disorder, particularly in a forensic context. Borderline personality disorder is both a differential diagnosis and a frequent comorbidity.

Key points

  • Screening for dissociation is part of history taking, in phase 1 of the EMDR approach.
  • A questionnaire screens; it does not diagnose. Structured interviews are the reference tools for supporting a diagnosis.
  • A high score is non-specific, and a low score does not rule out a dissociative disorder.
  • Warning signs call for a more thorough assessment and a differential diagnosis, rather than an immediate conclusion.

6. What the studies say

Two very different situations need to be distinguished: PTSD accompanied by dissociative symptoms, and dissociative disorders proper, such as DID. Studies also measure dissociation in different ways, which limits comparisons.

PTSD with dissociative symptoms

It is often assumed that dissociative patients respond less well to trauma-focused therapies. The data are mixed.

  • A meta-analysis of 21 trials, 9 of them randomised (1,714 patients), finds no link between the level of dissociation before treatment and the effectiveness of psychotherapy for PTSD. The studies were heterogeneous and some were of relatively low quality (Hoeboer et al., 2020).
  • A secondary analysis of a recent randomised trial, involving 193 women with PTSD related to childhood abuse and borderline features, treated with dialectical behaviour therapy adapted for PTSD or with cognitive processing therapy (CPT), finds on the contrary that baseline dissociation predicts lower effectiveness, and that an early reduction in dissociation was accompanied by better effectiveness later on (Kleindienst et al., 2025).
  • Among 284 female service members and veterans treated with prolonged exposure or present-centred therapy, the dissociative subtype was accompanied by a slightly smaller reduction in symptoms, a small effect. Dissociation decreased markedly, and the authors conclude that exposure remains indicated for these patients (Wolf et al., 2016).
  • In an intensive eight-day Dutch programme combining prolonged exposure and EMDR without a prior stabilisation phase, 168 patients, most with severe PTSD, were assessed before and after treatment. Of these, 38 (22.6%) met the criteria for the dissociative subtype, defined by two items of a clinical interview. The reduction in symptoms was large and comparable in both groups, with no significant difference, and 26 of these 38 patients no longer met the criteria for the subtype after treatment (Zoet et al., 2018). The study had neither a control group nor follow-up.
  • A secondary analysis of a randomised trial involving 104 women with PTSD related to childhood abuse adds a nuance. The level of dissociation did not modify the effect of the treatments on PTSD, and the sequence of STAIR (Skills Training in Affective and Interpersonal Regulation) followed by narrative trauma work gave the best results at all levels. In the most dissociative women, it also reduced dissociation more, and those who had received exposure preceded only by supportive counselling lost their PTSD gains during follow-up. The authors see in this a possible benefit of sequencing, still to be confirmed (Cloitre et al., 2012).

Among the individual studies presented, only Zoet et al. included EMDR, combined with exposure; the Hoeboer et al. meta-analysis also included trials with EMDR. None of these studies focused specifically on patients with DID.

Complex dissociative disorders

The guidelines of the International Society for the Study of Trauma and Dissociation (ISSTD, 2011) recommend phase-oriented treatment for DID: safety and stabilisation, work on traumatic memories, then integration and rehabilitation. The data supporting this approach remain limited.

  • The first randomised trial on complex dissociative disorders compared, in 59 patients, twenty sessions of stabilisation group treatment added to individual therapy with individual therapy alone. It showed no difference between groups at the end of treatment. Improvements appeared at six-month follow-up (Bækkelund et al., 2022).
  • A systematic review of 19 studies on DID and other specified dissociative disorder concludes that the evidence base is "emerging": all types of treatment were associated with improvements, and well-powered controlled trials are still needed (Griffiths et al., 2025).
  • The international TOP DD programme (Treatment of Patients with Dissociative Disorders) followed patients treated by community clinicians. At six years, according to questionnaires from the 61 therapists who responded, with no patient-reported data, patients had fewer stressors, fewer sexual revictimisations and better overall functioning (Myrick et al., 2017). High attrition and the absence of a control group make these results fragile.
  • An online psychoeducational programme for 111 patients with DID or other complex dissociative disorders, and for their therapists, was accompanied by reductions in dissociation, PTSD symptoms and non-suicidal self-injury, and by better emotion regulation (Brand et al., 2019). The study had no control group and analysed only the patients who remained in the programme.

EMDR with dissociative patients

On EMDR itself, the literature is mainly clinical. It describes how to integrate EMDR procedures into each stage of phase-oriented treatment: stabilisation (van der Hart et al., 2013), then work on traumatic memories and integration of the personality (van der Hart et al., 2014). It also offers tools for working with parts, such as the dissociative table technique (Fraser, 2003), and procedures for approaching a memory while staying in the present, such as CIPOS (Constant Installation of Present Orientation and Safety; Knipe, 2014). These proposals rest on clinical experience and case reports, rather than on controlled trials.

Key points

Dissociative symptoms in PTSD do not, on their own, justify setting aside trauma-focused work, but the data are mixed and an early reduction in dissociation might help. According to experts, a complex dissociative disorder calls for a phase-oriented approach and specific training, with a level of evidence that is still low.

7. In EMDR practice

The guidance that follows reflects clinical opinion, consistent with the data above, the eight-phase EMDR approach (Shapiro, 2018) and the ISSTD guidelines (2011). It is not derived from comparative trials.

  1. Screen all patients from phase 1, before any bilateral stimulation. Use a screening questionnaire and ask a few targeted questions about amnesia, lost time and voices, even before installing the safe place or resources. A high score or a warning sign leads to a structured interview, or to referral to a trained colleague.
  2. Distinguish the symptom from the disorder. Transient depersonalisation while recalling the trauma raises a different issue from DID. In the first case, trauma-focused work remains possible with adjustments. With a complex dissociative disorder, the standard protocol should not be applied as it stands. Between the two, highly dissociative complex PTSD and other specified dissociative disorder also require adjustments, case by case.
  3. Assess safety. In a psychiatric outpatient clinic, a dissociative disorder was the diagnosis most strongly associated with multiple suicide attempts, ahead of borderline personality disorder, PTSD and alcohol misuse (Foote et al., 2008). Formally assess this risk and self-harm, as well as any ongoing violence or contact with a perpetrator. Draw up a safety plan and coordinate with the patient's GP or psychiatrist, who also manages any medication. Acute suicide risk calls for urgent psychiatric assessment.
  4. Strengthen dual attention. Grounding in the present (feet on the floor, eyes on the room, objects to touch), eyes open, shorter or slower sets, tactile stimulation if needed, regular checks that the patient is still present. CIPOS, which uses bilateral stimulation to strengthen orientation to the present, then alternates very brief, counted contacts with the memory and returns to the present, measuring presence at each step, is often suggested (Knipe, 2014).
  5. Know when to stop. If the patient disconnects (fixed stare, lack of response, a change of voice or attitude), stop the stimulation, check their presence ("Where are you now? Can you feel your feet?"), reorient them with sensory cues, then resume with shorter sets, a cognitive interweave or a narrower target, or return to stabilisation. An incomplete session is closed with the usual procedures, and the patient does not leave in a dissociated state.
  6. Prepare without inducing. With a highly dissociative patient, preparation takes longer: psychoeducation, resources, work on the phobia of memories and of parts of the self, in the sense of structural dissociation theory. Exploration remains open and non-suggestive. Work begins with the part that manages daily life and with the parts the patient describes, without creating any through our questions. When memories emerge during treatment, the therapist neither confirms nor disputes their historical accuracy.
  7. Anticipate legal questions. The effect of eye movements on the reliability of memories is debated: one experimental study found more false memories after eye movements (Houben et al., 2018), and its direct replication did not find this effect (van Schie and Leer, 2019). If legal proceedings are under way or being considered, inform the patient of this uncertainty and invite them to discuss it with their lawyer before reprocessing.
  8. Get trained and supervised. EMDR work with patients who have complex dissociative disorders requires specific training and supervision by a practitioner experienced in this field. With children and adolescents, assessment and treatment are a matter for practitioners trained to work with this population.

Safety point

Where there are signs of significant dissociation (amnesia, lost time, voices or parts that take control), even before any diagnosis, do not begin bilateral stimulation before a thorough assessment, nor reprocessing with the standard protocol. First assess suicide risk, self-harm, any ongoing violence or contact with a perpetrator, and any legal proceedings.

Clarify the diagnosis with a structured interview, adopt a phase-oriented approach in line with the ISSTD guidelines (2011), and continue only with specific training and supervision. Any deterioration between sessions (more frequent switching, amnesia, self-harm) means returning to stabilisation.

Key points

  • Signs of significant dissociation: no bilateral stimulation before thorough assessment, and no reprocessing with the standard protocol; if things worsen, return to stabilisation.
  • Dissociation is screened for from phase 1, before any bilateral stimulation; with a complex dissociative disorder, the standard protocol is not used as it stands.
  • Safety is assessed: suicide risk, self-harm, ongoing violence or contact with a perpetrator; dual attention is strengthened, and stimulation can be interrupted at any time.
  • Questions should leave room for what the patient describes, without suggesting parts; complex dissociative disorders call for practitioners with specific training and supervision (guidance based on clinical opinion).

Clinical vignette

A fictional case, composed from common clinical situations.

Claire, 34, seeks help for panic attacks and nightmares related to abuse she suffered in childhood. In phase 1, she describes thoughts and impulses she does not recognise as her own, an inner voice that criticises her and urges her to harm herself, and moments when she sees herself acting "as if it weren't me", which she remembers afterwards. Her DES screening score is high. She made a suicide attempt two years ago and still occasionally cuts herself. She no longer has any contact with the perpetrator.

The therapist does not begin any bilateral stimulation. Together they draw up a safety plan; with Claire's consent, the therapist informs her GP and refers her to a colleague trained in dissociative disorders. A medical work-up rules out a neurological cause and substance use, and the clinical assessment finds nothing to suggest a psychotic disorder. A structured interview, interpreted according to ICD-11 criteria, points to partial DID, together with borderline personality traits.

The specialist colleague takes over her care. A long stabilisation phase begins: psychoeducation, grounding, work on the relationship with the critical voice, then CIPOS to learn to approach a memory briefly while staying present. After several months, self-harm has become rare and Claire knows how to prevent it; she manages to stay present when she talks about her childhood. EMDR reprocessing then begins with short sets, on a peripheral memory, under supervision. Screening made it possible to recognise the dissociative dimension and to adapt the whole treatment plan.

What is established, and what is not

  • Established: dissociative disorders are described in ICD-11 and DSM-5-TR.
  • Well supported: the association between dissociation and traumatic experiences, particularly early and repeated ones; the high frequency of dissociative disorders in psychiatric outpatient settings when they are looked for with a structured interview, with widely varying estimates.
  • Debated: the causal contribution of trauma relative to other factors; the effect of dissociation on the effectiveness of PTSD therapies; the validity of DID and partial DID.
  • Plausible but weakly supported: the effectiveness of the phase-oriented approach in complex dissociative disorders, supported mainly by uncontrolled studies.
  • Little studied: EMDR in patients with DID or partial DID; partial DID itself; the French validation of tools other than the DES.

Frequently asked questions

Is dissociation a contraindication to EMDR?

Not in itself. Dissociative symptoms in PTSD still allow trauma-focused work, with adjustments. For a complex dissociative disorder, guidelines advocate a phase-oriented approach, specific training and supervision before any reprocessing.

Can a therapist "create" DID?

This is one of the points of debate between the trauma model and the sociocognitive model. Loewenstein, a psychiatrist in the dissociation field, considers that almost no data support the idea of disorders produced by therapy or by sociocultural factors (Loewenstein, 2018). Proponents of the sociocognitive model emphasise the role of suggestibility and false memories (Lynn et al., 2014). Either way, the clinical rule is the same: explore openly and never suggest memories or parts.

What screening score should raise concern?

Cut-offs depend on the tool, its version and the population. For the DES, a cut-off of 30 is often used, including in the French validation (Darves-Bornoz et al., 1999), but the clinical interview remains essential: a high score calls for a thorough assessment, and a low score does not rule out a dissociative disorder if warning signs are present.

Is specific training needed to work with dissociative patients?

For screening and basic adjustments, standard EMDR training and good supervision are generally enough. To treat DID, partial DID or another complex dissociative disorder, specific training in dissociative disorders and supervision by an experienced practitioner are necessary.

Further reading on TIRCIA

In one sentence

Dissociation ranges from a passing symptom to a complex disorder: screening for it systematically makes it possible to continue trauma-focused work when that is feasible, and to adapt it when a dissociative disorder is present.

For EMDR practitioners, this means screening from phase 1, before any bilateral stimulation, distinguishing the symptom from the disorder, assessing safety, strengthening dual attention, preparing without inducing, and getting trained for complex dissociative disorders.

References

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This article summarises the scientific evidence available at the date of publication. It is no substitute for clinical training, supervision, or the advice of a health professional.

Declaration of interests: the author directs TIRCIA, some of whose online programmes are cited in this article.

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