EMDR is an evidence-based trauma therapy with a strong and growing research base. But its standard protocol was not designed for dissociative presentations, and applying it without modification to clients with DID or OSDD carries real risk. Without proper screening and adaptation, EMDR can bypass the window of tolerance, overwhelm stabilisation gains, trigger uncontrolled part switching, and rupture the therapeutic alliance in ways that are difficult to repair.
This is not an argument against using EMDR with dissociative clients. It is an argument for using it differently. When appropriately adapted, EMDR is one of the most effective tools available for Phase 2 trauma processing with this population. The key is sequence, timing, and technique.
Why standard EMDR is insufficient without modification
The standard EMDR protocol assumes a relatively unified client who can maintain dual awareness (simultaneously aware of the traumatic memory and the present moment) throughout processing. It assumes that distressing material will process to an adaptive resolution within the session, and that the client will be able to close down at the end. None of these assumptions hold reliably with a dissociative system.
In DID, traumatic memories are often held by specific emotional parts (EPs) who remain fixed in traumatic time. Standard EMDR can inadvertently activate a full EP rather than processing the memory from a dual-awareness position. The result is flooding rather than processing: the client is "in" the memory rather than "with" it, loses orientation to the present, and may switch without the awareness of either the client or the therapist. Sessions can end with the client destabilised, the memory inadequately processed, and the therapeutic relationship strained.
Key clinical rule: EMDR Phase 2 processing should not begin until Phase 1 stabilisation is well established across the system. This means the ANP has grounding and containment skills, key parts are aware of and tolerant of each other, there is an internal communication structure, and crisis safety planning covers the whole system. This preparation phase may take months. It is not a delay; it is the treatment.
Screening before you begin
EMDR practice guidelines recommend formal dissociation screening prior to beginning treatment. The Dissociative Experiences Scale (DES-II) is the most widely used tool and is freely available. A DES-T (taxon) score above 30 indicates the presence of pathological rather than normal dissociation and should prompt a more comprehensive assessment before any processing begins.
The MID (Multidimensional Inventory of Dissociation) provides a more granular picture, covering amnesia, identity alteration, voices, trance, and depersonalisation separately. If you have any clinical suspicion of a dissociative disorder, administer the MID and seek SCID-D assessment. Beginning Phase 2 EMDR with an undiagnosed dissociative disorder is a significant clinical risk.
Key protocol adaptations for dissociative clients
1. Work with the part, not just the ANP
Standard EMDR typically works with the presenting self. With dissociative clients, the memory being targeted is often held by an EP who is not in executive control during sessions. Effective processing requires identifying which part holds the memory and either facilitating communication between parts about the processing plan, or working directly with the relevant EP. Attempting to process a memory held by an EP through the ANP alone often produces incomplete or destabilising results.
2. Use titration throughout
Titration is not an adjunct to EMDR with this population; it is the method. Key titration techniques include:
- Distancing: The client observes the memory on an imaginary screen rather than entering it. The screen can be moved further away, made smaller, or the colour drained from it to modulate proximity.
- Fractionated processing: Process only one small piece of the memory per set. Stop, resource, and re-evaluate window of tolerance before continuing. Sessions may process only seconds of memory material.
- EMD (Eye Movement Desensitisation only): Used before full EMDR reprocessing. A more contained approach that targets single-incident distress without the associative chaining of standard EMDR.
- Containment between sets: After each set of bilateral stimulation, guide the client to contain any material that has not yet been processed before the next set begins.
3. Close every session carefully
With dissociative clients, the closing of a session requires explicit attention. Check which parts are present and in what state. Use a standard safe-place or containment exercise. Ensure the ANP is fully back in executive control and oriented to the present before the client leaves. Build adequate time into session endings — at minimum fifteen minutes for closure and grounding.
4. The Dissociative Table technique
Developed within the EMDR framework, the Dissociative Table (or Conference Table) technique invites the system to participate in processing collectively. Parts that are not ready to process can observe from a distance or wait in a safe internal space. Parts that hold relevant aspects of the memory can be invited forward in a controlled way. This approach maintains the collaborative, system-wide orientation that DID treatment requires.
What the neurobiological research shows
A 2023 study published in Frontiers in Psychology examined the neurobiological mechanisms of EMDR in dissociative disorders. The research proposed that EMDR's slow bilateral stimulation promotes non-rapid-eye-movement (NREM) sleep stage 1-like activity, which facilitates access to slow-wave sleep consolidation processes. This may explain EMDR's effectiveness in integrating traumatic memories that are otherwise stored in a non-contextualised, sensory-dominant form.
For dissociative clients specifically, this neurobiological framing supports a graduated approach: the bilateral stimulation needs to be slow enough and titrated enough to promote integration rather than reactivation. Faster bilateral stimulation or larger doses of memory material can overwhelm this integrative capacity and produce flooding rather than processing.
Research note: A 2021 pilot study on IFS therapy for complex trauma found 92% of participants no longer met PTSD criteria following treatment. While not EMDR-specific, the finding reflects the growing evidence base for parts-aware approaches to trauma processing. The most effective adaptations of EMDR for DID integrate IFS principles into case conceptualisation and session structure.
A phased approach to EMDR with dissociative clients
DES-II, MID, and where indicated, SCID-D. Establish the presence and nature of dissociative symptoms before forming a treatment plan.
Grounding, parts mapping, internal communication, crisis safety planning. EMDR resourcing techniques (safe place, calm place) are appropriate and useful in this phase.
Begin with EMDR resourcing rather than processing. Monitor how the client's system responds to bilateral stimulation before targeting traumatic material.
Identify what part holds the target memory. Map the system's relationship to that memory. Establish consent and safety protocols with the relevant parts before beginning.
Use fractionated processing, distancing, and containment as described above. Proceed more slowly than you think necessary.
Explicit closure with all parts. Grounding. Check-in with the system before the session ends. Follow up between sessions if destabilisation is possible.
When not to use EMDR yet
EMDR should not begin if: the client has no grounding or containment skills; parts are in active crisis or hostile conflict; the therapeutic relationship is not yet established; the client has no knowledge of their parts or the dissociative structure; or Phase 1 stabilisation goals have not been met. These are not permanent contraindications — they are sequencing indicators. Phase 2 work will be significantly more effective once these foundations are in place.
Seeking specialist EMDR supervision with a supervisor trained in dissociative disorders is strongly recommended before working with this population. EMDR training alone does not prepare clinicians for the clinical complexity of DID and OSDD.
Key references
- Gonzalez, A., & Mosquera, D. (2012). EMDR and Dissociation: The Progressive Approach. AI Publishing.
- Knipe, J. (2018). EMDR Toolbox: Theory and Treatment of Complex PTSD and Dissociation. Springer.
- Mosquera, D., & Ross, C.A. (2016). "EMDR in the treatment of borderline personality disorder." Revista de Psicoterapia, 27(103), 93-104.
- Schiavone, F.L., et al. (2023). "The integrative process promoted by EMDR in dissociative disorders: neurobiological mechanisms, psychometric tools, and intervention efficacy." Frontiers in Psychology, 14. PMC10505816
- Shapiro, F. (2018). Eye Movement Desensitization and Reprocessing Therapy: Basic Principles, Protocols, and Procedures (3rd ed.). Guilford Press.
- van der Hart, O., Nijenhuis, E.R.S., & Steele, K. (2006). The Haunted Self. Norton.
- Yehuda, R., & Hoge, C.W. (2016). "The meaning of evidence-based treatments for veterans with posttraumatic stress disorder." JAMA Psychiatry, 73(5), 433-434.
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