Structural Dissociation of the Personality and the Treatment of ...

Waarom kennis van dissociatie en de
dissociatieve stoornissen noodzakelijk is in de
EMDR-therapie
Waarom kennis van dissociatie
en de dissociatieve stoornissen
noodzakelijk is in de EMDRtherapie
Onno van der Hart
www.onnovdhart.nl
6 e EMDR Congres Nederland
Arnhem, 24 maart 2012
EMDR and complex trauma-related
disorders (including dissociative
disorders) (1)
“By far, the greatest number of reported
difficulties and stories of clinical problems
and potential harm through the improper use
of EMDR had involved clients with
dissociative disorders.”
Shapiro (2001, p. 308)
“Many EMDR-trained clinicians are untrained
in dissociative disorders and some may not
believe that dissociative conditions exist.”
Paulsen (1995, p. 34)
Increasing attention among EMDR
clinicians for these disorders, for
instance:
Dissociative Disorders Task Force (Fine et al., 1995)
Forgash & Copeley (2008)
Gelinas (1993)
Gonzalez Vazquez (2007)
Hofmann (2006)
Knipe (2007, 2009)
Lazrove & Fine (1996)
Korn & Leeds (2002)
Oppenheim, Ten Broeke, & De Jongh (2008)
Paulsen (1995, 2007, 2009)
Twombly (2005, 2007)
Warning!
24 maart 2012
6e EMDR Congres, Arnhem
This presentation contains material
that is offensive to some specialists on
dissociation
EMDR and complex trauma-related
disorders (including dissociative
disorders) (2)
“Because of the initial focus on relatively
simple PTSD, EMDR has only lately
addressed issues around pathological
dissociation. Happily, this is precisely the
area where the trauma field’s phase-oriented
approach has built considerable strength. It
would be useful and historically this seems
the right time, for EMDR clinicians to tap
into that body of knowledge.”
Denise Gelinas (2003, pp. 125-6)
Trauma-related Dissociative Disorders are not
rare at all!
EMDR therapists have a high chance to sooner
or later meet clients with complex dissociative
disorders
PREVALENCE
Onno van der Hart 1
2

Waarom kennis van dissociatie en de
dissociatieve stoornissen noodzakelijk is in de
EMDR-therapie
Prevalence of dissociative disorders (1)
“Overall, the prevalence of [DSM-IV]
dissociative disorders in inpatient and
outpatient psychiatric settings seem to be
around 10%, while approximately half of
them (5%) has DID, the most severe type
of dissociative disorders.”
V. Sar (2011)
Prevalence of dissociative disorders (2):
Somatoform dissociative disorders
“[T]he ICD-10 includes all manifestations
of the traditional hysterical neurosis under
the rubric of dissociative disorders in
accordance with the findings of modern
studies […]. Thus, epidemiological studies
covering conversion [i.e., somatoform
dissociative] symptoms may providedata
illuminating the prevalence of dissociative
disorders further.”
V. Sar (2011)
Working with patients with complex
dissociative disorders:
The necessity of training
“Many therapists begin work with [dissociative]
patients without having become conversant with
the dissociative disorders field, its literature, and
its opportunities for training.
Therapists should not proceed with exploratory
work of any sort, access [parts], or press for
historical material until they have the expertise to
undertake these endeavors in a manner that is
safe for the patient.”
Kluft (2006, pp. 296)
24 maart 2012
6e EMDR Congres, Arnhem
Prevalence of Dissociative Disorders
among psychiatric inpatients in Israel
(Ginsberg et al., 2010)
Estimates of DD range between 12 and 21%
Mainly DDNOS
No indication of DD on medical records
Diagnosis of personality disorder & psychiatric
comorbidity related to likelihood of DD diagnosis
and its severity
56.6% had diagnosis of schizophrenia; 34.5% of
affective disorder; 14% personality disorder
Psychiatric comorbidity (1)
“Patients with dissociative disorders have
relatively high number of comorbid
diagnoses which may prevent clinicians
from recognizing the dissociative disorder
in the overal picture.”
V. Sar (2011)
All this is about (complex) dissociative
disorders
BUT HOW ABOUT
DISSOCIATION?
Onno van der Hart 2

Waarom kennis van dissociatie en de
dissociatieve stoornissen noodzakelijk is in de
EMDR-therapie
EMDR and Dissociation
“[P]athological dissociation cannot be
avoided … because EMDR is designed
to treat trauma-related disorders and
pathological dissociation is a very
prominent feature of both peritraumatic
responses and
posttraumatic conditions.”
Denise Gelinas (2003, p. 123)
Dissociation: Point of departure
Dissociation is not only a sequela of
trauma, it is not an epi-phenomenon of
psychological trauma, but it rather is its
major characteristic
Dissociation: that is, dissociation of the
personality
“It is better … to speak of dissociation of
the personality.”
William McDougall, 1926, p. 234)
Also simple trauma-related
disorders are dissociative in nature
These disorders, such as PTSD, include
the existence of traumatic memories:
“The [traumatic] memory was morbific
because it was dissociated. It existed in
isolation, apart from the totality of the
sensations and ideas which comprised
the subject’s personality; it developed
in isolation, without control and without
counterpoise.”
Pierre Janet (1919/25, p. 674)
Dissociation and Trauma-
Related Disorders
“Dissociation is increasingly
recognized as a common feature
in various trauma-related
conditions.”
Vedat Sar (211, p. 6)
“Trauma implies dissociation.”
Howell (2011, p. 75)
24 maart 2012
6e EMDR Congres, Arnhem
Back to basics
Also simple trauma-related
disorders are dissociative in nature
“The morbid symptoms disappeared
when the memory again was part of
the synthesis that makes up
individuality.”
Pierre Janet (1919/25, p. 674)
Onno van der Hart 3
14

Waarom kennis van dissociatie en de
dissociatieve stoornissen noodzakelijk is in de
EMDR-therapie
The Adaptive Information
Processing Model on Traumatic
Memories
“These unprocessed memories are
stored in isolation, and contain the
affects, thoughts, sensations, and
behavioral responses that were encoded
at the time of the event.”
Francien Shapiro (2009)
Janet’s view of a century ago and
Shapiro’s more recent formulation are
highly compatible
Traumatic memories are not just
(dysfunctionally stored) information
In dissociative individuals, traumatic
memories (and emotions etc.) do not
exist in a psychological vacuum, but are
always a part of “ some [part of the]
personality”
T. W. Mitchell (1922, p. 113)
… a “self-conscious purposive thinking of
a [part of the] personality”
W. McDougall (1926, p. 543)
“All of us have
our breaking-
point. To some
it comes sooner
than to others.”
-T.A. Ross (1941,
p. 66)
24 maart 2012
6e EMDR Congres, Arnhem
Compatibility between Janet’s early
view and AIP
Janet’s “dissociated” and Shapiro’s “in
isolation” refer to the same phenomenon
(Janet also spoke about “isolated”)
There is compatibility between AIP and
Janet’s original formulation:
dysfunctionally stored memories can be
conceptualized as traumatic memories
dissociated from the remainder of the
personality
But there is more…
Traumatic Experiences as
“Breaking-Points”
Subjective experiences of
breaking-points
“I felt as though I was falling apart”
“I was shattered”
“I was beside myself”
“I felt cracked open”
“It broke me”
Onno van der Hart 4
22

Waarom kennis van dissociatie en de
dissociatieve stoornissen noodzakelijk is in de
EMDR-therapie
William McDougall on
Dissociation
“Normal personality, as we know it in
ourselves and in our neighbours, is the
product of an integrative process ...
and is susceptible to disintegration
that results in the manifestation of two
or more personalities [i.e., parts of the
personality] in and through the one
bodily organism.”
W. McDougall (1926, p. 545)
Pierre Janet on Hysteria
Hysteria “is a malady of the personal
synthesis.”
“Hysteria is a form of mental depression
characterized by (1) retraction of the field of
personal consciousness and (2) a tendency
to the dissociation and emancipation of the
systems of ideas and functions that
constitute personality.”
Pierre Janet (1907, p. 332)
These [psychobiological] systems have their
own sense of self
Trauma-related Dissociation
of the Personality
Mental Health
24 maart 2012
6e EMDR Congres, Arnhem
“Mental health is characterized by
a high capacity for integration,
which unites a broad range of
psychological phenomena within
one personality”
Pierre Janet (1889)
Integration involves binding and
differentiating
Current confusion about
dissociation
Current confusion about what dissociation
is and is not stems from the failure to
distinguish, as Janet did, between
retraction of the field (and other
alterations) of consciousness and
dissociation.
Thus, some authors define dissociation as
a narrowing of consciousness
Dissociation in Trauma Defined (1):
The essence
Dissociation in trauma entails a division
of an individual’s personality, i.e., of the
dynamic, biopsychosocial system as a
whole that determines his or her
characteristic mental and behavioral
actions
This division constitutes a core feature
of trauma
Nijenhuis & Van der Hart (2011, p. 418)
Onno van der Hart 5

Waarom kennis van dissociatie en de
dissociatieve stoornissen noodzakelijk is in de
EMDR-therapie
Dissociation in Trauma Defined (2):
Limitations of Integrative Capacity
This division evolves
when the individual lacks the capacity to
integrate adverse experiences in part or in
full,
can support adaptation in this context,
but commonly also implies adaptive
limitations
Nijenhuis & Van der Hart (2011, p. 418)
Dissociative subsystems
We call these subsystems of the divided
personality:
Dissociative parts of the personality
Sequential
Dissociation
Personality
Time
during
Trauma
24 maart 2012
6e EMDR Congres, Arnhem
Dissociation in Trauma Defined (3):
Dissociative Subsystems
The division involves two or more
insufficiently integrated dynamic but
excessively stable subsystems
These subsystems exert functions, and
can encompass any number of different
mental and behavioral actions and implied
states
Nijenhuis & Van der Hart (2011, p. 418)
Dissociation in Trauma Defined (4):
Dissociative Subsystems
These subsystems and states can be
latent, or activated in a sequence or in
parallel
Nijenhuis & Van der Hart (2011, p. 418)
Parallel
Dissociation
Time during
Trauma
Onno van der Hart 6
EP 1
EP 2
EP 3
EP 4
Latent
ANP
Personality

Waarom kennis van dissociatie en de
dissociatieve stoornissen noodzakelijk is in de
EMDR-therapie
Dissociation in Trauma Defined (4):
Conscious and Self-conscious Dissociative
Parts
Each dissociative subsystem, i.e.,
dissociative part of the personality
includes its own, at least rudimentary
first-person perspective
In other words, each part can be seen as
phenomenal subject
Nijenhuis & Van der Hart (2011, p. 418)
The criterion of “First-Person
Perspective”
Is not generally accepted in the
dissociative disorders field, which has
created confusion about the nature of
dissociative parts
A prime example is the definition of “Ego-
State” in Ego-State Therapy
Ego State: Problems with this
Definition
This concept does not differentiate
between dissociative parts of the
personality, each with its own firstperson
perspective, and other not fully
integrated subsystems of the
personality
Dissociative parts of the personality
most often consist of more than one
mental state, hence the concept “ego
state” is unduly restrictive
39
Some Terms for “Parts”
Dissociative parts of the personality
Ego States
Self-states
Part-selves
Alters, alternate personalities
Identities
Modes
“dissociation of affect”
Ego State: Definition
“An organized system of behavior
and experience whose elements are
bound together by some common
principle but that is separated from
other such states by boundaries that
are more or less permeable.”
Watkins & Watkins (1993, p. 278)
24 maart 2012
6e EMDR Congres, Arnhem
Onno van der Hart 7
Ego
States
What is the Difference Between
Ego States and Dissociative Parts?
Dissociati
ve Parts
of the
Personali
ty
Separat
e Sense
of Self,
Firstperson
Perspec
-tive
No
Yes
Elaboration Autonomy
Minimal
Minimal to
Profound
No
Yes
Intrusion Amnesia
Yes
Yes
No
Yes
Present in
Everyone
Yes
Only in
traumarelated
disorders

Waarom kennis van dissociatie en de
dissociatieve stoornissen noodzakelijk is in de
EMDR-therapie
Dissociation in Trauma Defined (4):
Possibility of Dissociative Parts
Interacting
As each dissociative part, the individual
can interact with other dissociative parts
and other individuals, at least in principle.
Nijenhuis & Van der Hart (2011, p. 418)
Certainly in the more complex cases, this
constitutes an essential therapeutic
window of opportunity
Dissociative Parts of the
Personality and Action Systems
Apparently Normal Parts (ANPs) are
mediated by action systems (AKA
motivational systems) of daily life, such as
care-giving, sociability, play, energy
regulation
Emotional parts (EPs) are mediated by
subsystems of the action system of
defensive, such as flight, fight, freezing,
(total) submission
Life of the Apparently Normal
Part of the Personality
The ANP’s normality is only apparent,
because this part of the personality
physically and mentally avoids
trauma-related cues, including his or
her intrapsychic world, resulting in
life “lived on the surface of
consciousness” (Appelfeld, 1994, p.
18).
24 maart 2012
6e EMDR Congres, Arnhem
Dissociative Parts of the
Personality Exert Functions
There are roughly two proto types of
dissociative parts:
Parts having functions in daily life:
Apparently Normal Parts (ANPs)
Parts stuck in trauma-involved defense:
Emotional Parts (EPs)
Prototypes of Dissociative
Parts
Alternations between
and co-existence of
Trauma-avoidant part(s) that experience “too little” –
numbing, detachment, amnesia, conscious and
unconscious avoidance strategies:
Apparently Normal Parts of the Personality (ANPs)
Trauma-fixated part(s) that experience “too much” –
reliving of trauma and fixation in defense:
Emotional Parts of the Personality (EPs)
Attachment to Trauma
“Such patients [i.e., their EP’s]... are
continuing the action, or rather the
attempt at action, which began when
the thing happened, and they
exhaust themselves in these
everlasting recommencements.”
Pierre Janet, (1919/25, p. 663)
Onno van der Hart 8

Waarom kennis van dissociatie en de
dissociatieve stoornissen noodzakelijk is in de
EMDR-therapie
EPs live in trauma-time
Even when EPs are not completely reenacting
their traumatic experiences, they
do not (sufficiently) differentiate between
traumatic past and (safe) present, i.e.,
they live in trauma-time
Therapists should facilitate ANPs’
realization of this fact and help EPs to
gradually become more oriented to
present reality
Development of ANP and EP in Case of
Childhood Sexual Abuse
“My loss of memory was retroactive. I
[ANP] did not remember my daddy ever
having touched me sexually. I did not
remember ever seeing my father naked.
I did not remember my daddy ever
seeing me naked.
In the future, whenever my daddy
approached me sexually I turned into my
other self [EP], and afterwards I [ANP]
did not remember anything that had
happened.”
Sylvia Fraser, My father’s house (1987, p. 15)
Primary Dissociation of the Personality:
Simple PTSD; Acute Stress Disorder
ANP
Actions Systems
Of Daily Life
Nijenhuis, Van der Hart, & Steele ( 2001)
Defense EP
PERSONALITY
24 maart 2012
6e EMDR Congres, Arnhem
ANP and EP in Victim of Chronic
Childhood Sexual Abuse:
Charcot’s Patient Augustine
Dissociation in Trauma Defined (5):
Phobic Avoidance
Dissociative parts have permeable
psychobiological boundaries that keep them
divided, but that they can in principle dissolve.
These boundaries are maintained by phobias of
traumatic memories and phobias that
dissociative parts have regarding each other.
Reminder: the mental and behavioral actions
involved in these phobias are substitute
actions.
Separation Between “Day Child”
(ANP) and “Night Child” (EP)
“Without realizing it, I fought to
keep my two worlds separated.
Without ever knowing why, I made
sure, whenever possible that
nothing passed between the
compartmentalization I had
created between the day child and
the night child.”
Marilyn Van Derbur (2004, p. 26)
Onno van der Hart 9

Waarom kennis van dissociatie en de
dissociatieve stoornissen noodzakelijk is in de
EMDR-therapie
Pierre Janet on Vehement
Emotions
“Traumas produce their disintegrating
effects in proportion to their intensity,
duration and repetition.”
P. Janet (1909, p. 1558)
Secondary Dissociation of the Personality:
Complex Trauma, BPD, DESNOS, DDNOS
ANP: Actions Systems
Of Daily Life
Nijenhuis, Van der Hart, & Steele ( 2001)
EP: Defense
Submit
EP: Defense
Freeze
EP: Defense
Fight; Attack
PERSONALITY
Levels of Dissociation of the
Personality
PRIMARY
Simple PTSD
Simple Dissociative Disorders (DSM-IV,
ICD-10; including Dissociative disorders of
movement and sensation)
SECONDARY
Chronic, complex PTSD/DESNOS
BPD, DDNOS
Complex somatoform disorders
TERTIARY
DID
Van der Hart, Nijenhuis & Steele, 2000
24 maart 2012
6e EMDR Congres, Arnhem
Somatoform Dissociation and Degree of
Reported Trauma
(psychiatric outpatients)
Onno van der Hart 10
40
38
36
34
32
30
28
26
24
22
20
SDQ-20
F = 11.11 (4, 143), p other groups; post hoc Tukey HSD
no trauma
em neglect abuse
only
one crit A DSM-IV
< 5 crit A
5 or more crit A
Nijenhuis et al., 1998
Tertiary Dissociation of the Personality:
Dissociative Identity Disorder (DID)
ANP
EP
ANP
Nijenhuis, Van der Hart, & Steele ( 2001)
ANP
EP
Fight
EP
Freeze
EP: Submit
EP
PERSONALITY
Dissociation in Trauma Defined (6):
Dissociative Symptoms
Phenomenologically, this division of the
personality manifest in dissociative
symptoms that can be categorized as
negative (functional losses such as
amnesia and paralysis) or positive
(intrusions such as flashbacks or voices),
and psychoform (symptoms such as
amnesia, hearing voices) or somatoform
(symptoms such as anesthesia or tics).
EP

Waarom kennis van dissociatie en de
dissociatieve stoornissen noodzakelijk is in de
EMDR-therapie
Dissociative Symptoms
Psychoform - Somatoform
Negative
amnesia
depersonalization
emotional
anesthesia
Positive
hearing voices
“made” emotions
re-experiencing
trauma, affective
and cognitive
components
Negative
analgesia
bodily anesthesia
motor inhibitions
Positive
localized pain
“made” bodily
feelings
re-experiencing
trauma, bodily
components
Treatment of
Primary Dissociation of the
Personality
Personal Stance:
EMDR is the recommended
treatment of choice
Processing/integrating the
traumatic memory in primary
dissociation
The ANP’s phobia of the traumatic memory is more
or less identical with its phobia of EP
Bringing the client as ANP in contact with the
traumatic memory to be processed/integrated,
involves contacting the EP that engages in its reenactment
In many cases, the succesful integration of the
traumatic memory includes the fusion of ANP and EP
Schneiderian Symptoms of
Schizophrenia (Passive
Influence)
Voices commenting, arguing, crying
(internally)
Made feelings, impulses, actions
Thought withdrawal or insertion
Hallucinations (related to trauma)
Delusions (related to trauma)
Feeling body is controlled by someone
else
24 maart 2012
6e EMDR Congres, Arnhem
Recommended Treatment of Primary
Dissociation of the Personality
“The treatment to be recommended consists
in restoring the ‘emotional’ [part of the]
personality [EP] deprived of its pathological,
distracted, uncontrolled character, and in
effecting its union with the ‘apparently
normal’ [part of the] personality [ANP]
hitherto ignorant of the emotional [i.e.,
traumatic] experiences in question.”
Charles S. Myers (1940, p. 69)
Treatment of
Secondary and Tertiary
Dissociation of the Personality
Personal stance:
EMDR can play a major role if
integrated with other approaches
specifically dealing with maintance
of dissociation of the personality
Onno van der Hart 11

Waarom kennis van dissociatie en de
dissociatieve stoornissen noodzakelijk is in de
EMDR-therapie
Therapist’s mental position
High level of integrative capacity
Grounding
Mindfulness
Genuine presence with patient
Reflective thought and behavior
Avoidance of reactive or impulsive behaviors in
the face of patient’s urgent need or dismissing
stance
Can keep the larger context in mind when
working with particular parts
Essential Treatment Principles (2)
Overcome trauma-related phobias: gradual reexposure
with relapse prevention (of avoidance,
pathological alterations in consciousness, and
dissociation)
Treat all parts of the client even-handedly and
without reification
Monitor and regulate secure attachment in
therapeutic relationship (includes management
of transference and countertransference)
Why is knowledge of dissociation
especially needed in (EMDR) treatment
of complex trauma-related disorders?
Processing/integrating one traumatic memory may
open Pandora’s box
The client’s integrative capacity is too low
The client is prone to severe affect-dysregulation
Traumatic memories and involved EPs are part of the
dissociative structure of the personality that is
maintained by a series of phobias that need to
systematically addressed
24 maart 2012
6e EMDR Congres, Arnhem
Essential Treatment Principles (1)
Join the patient where he or she is
Use a phase-oriented approach
Maintain and improve capacity to function in
normal life (work, play, self-care,
relationships)
Skills building (including RDI)
Monitor and regulate psychophysiological
arousal levels
Maintain and raise integrative capacity
(mental level)
Van der Hart, Nijenhuis & Steele, 2000
Exploring and relieving symptoms
due to [parts’] intrusions
“Often the most rapid path to symptomatic relief
is to address or access the [part] or [parts]
“behind” a problematic symptom, behavior,
affective state, or perplexity and to negotiate
with the [parts] for relief. A [part]-driven
intrusion into the dissociative surface is the most
common source of such disruptions.”
Kluft (2006, p. 292)
EPs live on the edges of
Window of Tolerance
Hyper-aroused
Onno van der Hart 12
A
R
O
U
S
A
L Hypo-aroused

Waarom kennis van dissociatie en de
dissociatieve stoornissen noodzakelijk is in de
EMDR-therapie
Phase-Oriented Treatment of
Complex Trauma Disorders
Phase-oriented treatment involves a
sequence of interventions which
systematically address inner- and outerdirected
phobias (the phobia of traumatic
memories being the most basic one)
Steele, Van der Hart, & Nijenhuis (2001)
The Central Role of Experiential
Avoidance in Trauma Reactions
All phobic responses are geared toward
avoiding or escaping the inner
experience that occurs in reaction to
the trigger or conditioned stimulus
Thus avoidance of inner experience is a
key treatment target
Phase 1: Symptom Reduction
and Stabilization
Overcoming the phobia of attachment and attachment
loss: contact with the therapist
Overcoming the phobia of mental actions (feelings,
thoughts, wishes, needs, fantasies)
Overcoming the phobia of dissociative parts of the
personality (ANP and EP)
Overcoming the stigma of getting help: issues of
“craziness,” control, and dependence.
Inner-Directed Defenses
24 maart 2012
6e EMDR Congres, Arnhem
The patient is avoidant or even phobic of
particular inner experiences (e.g.,
feelings, wishes, needs, sensations,
dissociative parts)
Shame, disgust, and fear are the most
common responses to avoided internal
contents
EMDR includes specific interventions
targeting these trauma-related phobias
(e.g., Knipe, 2007)
Dissociative phobias and treatment in
phases
Phase 1: Symptom reduction
and stabilitation
Phobia for attachment and attachment loss,
particularly with therapist
Phobia for mental actions (feelings, thoughts,
sensation, wishes, fantasies)
Phobia for dissosiative parts of personality
(ANP and EP)
Phase 3: Personality
integration and
rehabilitation
Phobia of normal life
Phobia of healthy risk taking
and change
Phobia of intimacy, including
sexuality and body image
Phase 2: Treatment of traumatic
memories
Attachment phobias related to the perpetrator(s)
Attachment phobias in EPs related
to the therapist
Phobia of traumatic memories
Overcoming the Phobia of
Dissociative Parts
Work mainly with ANP
Work with other parts (EPs) mainly
through ANP
Help ANP develop empathy and care for
other parts (EPs)
Onno van der Hart 13

Waarom kennis van dissociatie en de
dissociatieve stoornissen noodzakelijk is in de
EMDR-therapie
Specific Approaches in working
with dissociative parts
“Dissociative table,” also known as inner
meeting place
Inner safe places
Imagery for containment of traumatic
memories
Timing and joining the client where s/he is at
are essential
PHASE 3
Personality (re)integration and
(re)habilitation
Grief work
Overcoming the phobia of attachment
and detachment: intimacy (emotional
and sexual)
Overcoming the phobia of-taking and
change
Overcoming the phobia of normal life
Conclusions (2)
Treatment involves performing integrative
(mental and behavioral) actions, such as
during EMDR processing, in particular
realization of the traumatic experience and its
consequences
Realization presupposes joint activation of
ANP and EP, and requires the highest levels
of integrative capacity
81
24 maart 2012
6e EMDR Congres, Arnhem
PHASE 2
Treatment of traumatic memories
Overcoming the phobia of
attachment and detachment:
therapeutic connection with EPs
resolution of insecure attachment
(traumatic bonding) to the perpetrator
Overcoming the phobia of
traumatic memories
Conclusions (1)
Thorough knowledge and understanding of
dissociation is essential for EMDR therapists
in working of clients with complex trauma
Treatment involves working with ANP(s) and
EP(s) within their window of tolerance
Treatment focuses on the improvement of
the relationships among parts, resulting
eventually (in many cases) in the unification
of the personality
Onno van der Hart 14
80

Waarom kennis van dissociatie en de
dissociatieve stoornissen noodzakelijk is in de
EMDR-therapie
Relevant literature (1)
Boon, S., Steele, K. & Van der Hart, O. (2011). Coping with
trauma-related dissociation: Skills training for patients and
therapists. New York: Norton. (Nederlandse uitgave verschijnt
najaar 2012)
Dalenberg, C.J., Brand, B.L., Gleaves, D.H., Dorahy, M.J.,
Loewenstein, R.J. et al. (2012). Evaluation of the evidence for
the trauma and fantasy models of dissociation. Psychological
Bulletin; doi: 10.1037/a0027447.
Forgash, C. & Copeley, M. (Eds.) (2007). Healing the heart of
trauma and dissociation with EMDR and ego state therapy.
New York: Springer.
Relevant literature (2)
24 maart 2012
6e EMDR Congres, Arnhem
Van der Hart, O., Nijenhuis, E. & Steele, K. (2010). Het
belaagde zelf: Structurele dissociatie en de behandeling van
chronische traumatisering. Amsterdam: Boom.
Van der Hart, O., Nijenhuis, E. R. S. & Solomon, R. (2010).
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Zie ook: www.onnovdhart.nl voor relevante artikelen
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