Making processing accessible when dissociation is part of the picture
EMDR work may still be possible when dissociative symptoms are present, but the clinician must identify the form and severity of those symptoms and use relevant training and consultation. The practical question is how to preserve enough present orientation and continuity for the work to be useful. A diagnosis of PTSD with dissociative symptoms is not interchangeable with a complex dissociative disorder.
Choose a bounded target collaboratively, explain what signs will prompt a pause, and agree how the therapist will help the client orient to the present. Track changes in voice, gaze, responsiveness, reported time continuity, and subjective presence without treating any one sign as diagnostic. If the client loses connection to the room or cannot report what is happening, prioritize restoring orientation rather than continuing bilateral stimulation mechanically.
Preparation Script: “When you begin to feel far away, how will I know? What helps you reconnect without feeling pushed? We can agree to pause before you lose the thread of what we are doing.”
Clinical focus: Specialist adaptation means modifying the delivery to the person's capacities, not claiming that generic scripts are sufficient for every dissociative presentation. Record the target, the signs of engagement, what interruption occurred, what restored present orientation, and the next step decided with consultation where needed. The goal is a workable route into effective treatment, not permanent exclusion from it.
Describe the experience before assigning its meaning
“Dissociation” can refer to quite different experiences. A client may feel detached from the body, perceive the room as unreal, lose track of time, report gaps in autobiographical memory, or experience discontinuities in identity and agency. Another client may use the same word for ordinary absorption, exhaustion, panic, medication effects, or a neurological episode. The word alone does not determine a diagnosis or an EMDR plan.
Ask for examples in the person's own language: “What changes first?” “How long does it last?” “What do you remember afterward?” “Does anyone notice changes you do not remember?” “What helps you know where you are?” Establish onset, context, impairment, and safety consequences. Consider medical assessment when episodes might involve seizures, fainting, sleep disorders, substance effects, or other nonpsychological causes.
Screening can identify a need for further assessment; it cannot establish a dissociative disorder or readiness for treatment by itself. Use measures within their intended populations and competence requirements. A score is one source of information alongside interview, observation, history, and, where appropriate and consented, collateral information.
Specialist input is a clinical resource, not a rejection
Seek consultation when there are substantial unexplained memory gaps, marked identity discontinuities, recurrent loss of orientation, complex self-harm patterns, or responses that exceed the clinician's training. The purpose is to refine assessment and treatment, not to tell the client they are untreatable. Consultation may support continued work, shared care, or transfer to a more appropriate setting.
Specialist input also becomes important when psychiatric or medical complexity affects safe delivery: acute mania, severe disorganization, psychosis with immediate safety implications, significant neurological concerns, or unstable physical illness. Respond to the current presentation rather than treating a lifetime diagnosis as an automatic exclusion. A person with a stable psychotic disorder and PTSD is not equivalent to a person unable to participate meaningfully during an acute crisis.
A randomized outpatient trial found that PTSD treatment with EMDR or prolonged exposure could benefit participants with psychotic disorders. Its findings argue against blanket exclusion; they do not establish that every acute presentation can be treated in an ordinary outpatient session without additional assessment or support. [33]
Distinguish PTSD with dissociation from dissociative disorders
Dissociative symptoms occurring within PTSD and a complex dissociative disorder are not interchangeable clinical categories. Evidence from general PTSD trials cannot simply be applied to every person with substantial amnesia or identity discontinuity. Equally, specialist precautions developed for dissociative identity disorder should not be converted into universal prohibitions for all clients who sometimes feel detached.
The ISSTD adult guideline is a 2011 specialist consensus document focused principally on dissociative identity disorder. It describes phase-oriented care and the need for dissociation-specific expertise when using EMDR in that population. Its age, scope, and reliance on clinical consensus must remain visible; older categorical contraindication language should not override newer evidence about PTSD with common comorbidities. [34]
This book does not provide a do-it-yourself adaptation for complex dissociative disorders. Reading a target-selection chapter is not a substitute for relevant training, consultation, and a treatment framework appropriate to the presentation.
Readiness is observable and revisable
Before proceeding with an agreed memory-focused intervention, assess whether the client understands the plan, can express consent or refusal, can communicate a pause, and can retain sufficient present orientation for the method being used. Determine what happened between earlier sessions, not only how composed the client appears in the room. An apparently calm presentation may reflect detachment, compliance, or fatigue rather than comfortable engagement.
Assessment Script: “While you notice that memory, how much do you also know you are here with me?” “If you wanted us to stop, how would you let me know?” “Are there concerns about this work that we have not made room for?” These questions do not diagnose a disorder, and they should not become tests the client must pass to please the therapist.
If orientation is lost or participation becomes unclear, stop demanding further recall. Attend to immediate safety and present contact, assess what is occurring, and decide whether the session, setting, or overall plan needs to change. Repeatedly pushing through disconnection is not a demonstration of therapeutic courage.
Preserve uncertainty about memory
Memory processing is not forensic investigation. A newly reported image, sensation, dream, or conviction does not establish historical fact. The clinician can validate the distress without confirming an unverified event: “This feels frightening and important. We do not need to decide today exactly what it means about the past.” Avoid questions that supply perpetrators, events, ages, or hidden explanations.
The ISSTD guideline itself recognizes the reconstructive character of memory and cautions against suggestive interviewing or unwarranted certainty. [34] The clinical stance here is explicit: do not use EMDR to recover missing memories, prove abuse, or fill gaps. Document whether material is remembered, inferred, imagined, dreamed, or uncertain using the person's account. If legal proceedings are involved, keep treatment and forensic roles appropriately distinct and seek relevant professional advice.
Safety planning should describe needs, not a score category
When self-harm or suicidal thoughts are present, assess their current context, intent, access to means, protective factors, and changes over time, using the appropriate clinical pathway. Obtain urgent assistance when indicated. Do not treat a low questionnaire score or a promise not to act as a substitute for assessment and a practical safety plan.
NICE advises against using risk scales to predict suicide or repeat self-harm or to decide access to treatment, and favors individualized risk formulation and collaborative safety planning. [35] This is compatible with access to trauma treatment: risk-informed care is not the same as excluding everyone who has ever self-harmed.
A useful consultation request
Provide a concise account of the presenting problems, the client's goals, observed episodes, relevant assessment, current risks, treatment history, the proposed target, and what has happened when difficult material is approached. Distinguish observation from interpretation. “The client did not recall ten minutes of the session” is more informative than “The client's system resisted.”
Ask a focused question: Is further diagnostic or medical assessment needed? What competence or service level is required? Is the proposed target appropriately bounded? What would establish feasibility, and what would prompt a pause? Do not ask a consultant simply to authorize a plan already decided.
Explain the outcome to the client in nonstigmatizing terms and maintain continuity during referral. A change of clinician should include an agreed handover and realistic arrangements for support, not abandonment after a difficult session. The ethical endpoint is an appropriate treatment pathway that the client understands—not merely completion of an EMDR target.