Re:bls/das

In follow-up to your last comment, I'm sure you will be glad to hear that there now is some data on the effects of treatment for PTSD on dissociation. Now, it's only a beginning but there are two sources of information:

1. Richard Bryant (Bryant et al., 1998, 1999)has been studying cognitive-behavior therapy (CBT)for the treatment of Acute Stress Disorder (ASD). In contrast to PTSD, the diagnosis of ASD *requires* the person experience dissociative symptoms. Bryant has published two studies on this. He finds that after 5 sessions of CBT (exposure plus anxiety management), fewer patients go on to meet criteria for PTSD (between 8-20% at posttreatment,15-23% at 6 month follow-up) than patients treated with supportive counseling (56-83% at posttreatment, 67% at posttreatment). This is important because meeting criteria for ASD is predictive of PTSD. Specifically, Harvey & Bryant (1998) previously found that 78% of motor vehicle accident victims diagnosed with ASD developed met criteria for PTSD 6 months after the treatment compared to only 4% of those who did not meet criteria for ASD.

Now, they unfortunately do not provide specific measures of dissociation. However, the mere presence of dissociation (as required by the ASD diagnosis) does not preclude a good outcome nor does it necessitate additional interventions to achieve the outcome. In fact, in their second study, they dismantled the CBT program and found that the exposure component alone was not worse than the full exposure plus anxiety managaement program.

2. Cloitre et al. (2002) utilized a combined treatment that provided adult female CSA victims with 8 weekly one-hour sessions in which patients learned affect regularion skills based on the DBT model. Then patients received 8 twice-weekly sessions of imaginal exposure therapy. This sequential treatment was compared with a 12-week WL control (subjects were randomly assigned). They measured dissociation with Briere and Runtz's (1990) Dissociation Scale before prior to treatment, after 8 weeks of skill training, and then at the end of treatment. There was no change in dissociation from the beginning of the study to the end of the skills training in either group. Thereafter, dissociation decreased significantly with the application of exposure therapy but not in the control condition.

Unfortunately, this study did not have an exposure only condition, so we cannot determine whether or not there was a sleeper effect of pretreatment with skills training. However, these data do nothing to preclude the possibility that exposure therapy alone can reduce dissociation. By the same token, maybe standard EMDR works for dissociation as well. If you want to assert that your dissociation protocol is superior to standard EMDR, then the burden of proof rests with you.

Perhaps the situation with dissociation is not so dire as you suspect.

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