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Introduction to the Multidimensional Inventory of Dissociation Catholic Psychotherapy AssociationWebinar, August 16, 2019

Jennifer Madere, MA, LPC-S / www.mid-assessment.com 1

Integrating the Multidimensional Inventory of Dissociation into Clinical Practice

Presented via Webinar for Catholic Psychotherapy AssociationAugust 16, 2019

Co-author (not presenting):D. Michael Coy, MA, LICSWEMDRIA Approved ConsultantSeattle, [email protected]

All current MID documents can be found at: www.mid-assessment.com

Jennifer Madere, MA, LCP-SEMDRIA Approved ConsultantCedar Park, [email protected]

Welcome to the MID…

• This presentation is an introductory and review-focused discussion of the MID

• The MID Report is a rich document, which means there is a lot to cover in our time today

• You’ll have a chance to get to know the main features of the MID and The MID Report

• You’ll also learn about formulating questions for, and conducting, the follow-up interview

Learning Objectives1. Participants will be able to describe and identify key

indicators to assess further for pathological dissociationearly in treatment (before certain kinds of resourcing andall trauma accessing), and when concerns arisethroughout treatment

2. Participants will be able to complete administration,scoring, and navigation of the MID Analysis to inputclient responses; view and interpret results of The MIDReport; and, perform a clinical interview to clarify resultsof the assessment and direction of treatment includingreadiness for trauma resolution work.

3. Participants will be able to describe several uniqueapplications of the MID Report, based on case examples,and how the MID can be used to clarify diagnosis andguide treatment planning in both clinical andconsultation roles.

What that means is…Part 1 (90 minutes)

▫ Myths and Facts about Dissociation ▫ MID: At-a-Glance▫ Key MID Concepts: Mindset and 23 Symptoms ▫ Administering the MID: Why, When, and What▫ The MID Documents▫ Walk through of the process of administering and

scoring MID ▫ Detailed discussion of The MID Report▫ Q & A – as time permits



What that means is…Part 2 (90 minutes)

▫ Understanding The Extended MID Report▫ Reading and Understanding the Charts and Graphs ▫ Making sense of the initial MID Results –

developing hypotheses and questions▫ Preparing for, conducting, and concluding the

follow-up interview▫ Capacity to report▫ Additional uses and settings▫ Q&A

• Dissociation is always serious

• DID is a fad• Origins are iatrogenic or

due to fantasy/imagination of the patient

• Dissociative disorders are rare

• DID is the same entity as borderline personality disorder

• Dissociation/DID cannot be reliably diagnosed

• DID is primarily diagnosed in North America by DID ‘experts’ who over-diagnose the disorder

• Diagnosis leads to deterioration, and treatment is harmful to the patient

• There is no specified treatment standard of care

Common Myths About Dissociation(Brand, et al., 2016; Ross, 2015; Steinberg, 2001)

Facts About Dissociation(Brand, et al., 2016; Ross, 2015; Steinberg, 2001)

• Dissociation can be a normal and common response to stress

• DID affects 2-6% of psychiatric inpatients, and is generally as common as Borderline PD and Schizophrenia

• Most individuals who meet criteria for DID have been treated in the mental health system for 6-12 years before they are correctly diagnosed

• DID is consistently diagnosed in treatment settings worldwide

• No clear relation between dissociation and BPD (Laddis, et al., 2017)

• Can be diagnosed based on pre-existing symptoms, and differentiated from simulators in neuropsychological research

• Reliability is good, especially when using assessments

• Good prognosis in many cases when clinicians are well trained and follow treatment guidelines. See Treatment Guidelines at isst-d.org

• Inappropriate therapeutic interventions can exacerbate symptoms

MID Mindset (Dell, 2009)

There are at least 3 levels/domains of explanation for dissociation:

1) Neuroanatomical-neurophysiological2) Psychological3) Phenomenological (subjectively experienced) and

observable symptoms of dissociation

Phenomenological definition of dissociation: “The phenomena of pathological dissociation are recurrent, jarring, involuntary intrusions into executive functioning and sense of self (p.226).”

The structure of the MID and its results are based largely on the viewpoint that the phenomenology of dissociation, and particularly DID, is defined by “overwhelmingly internal and subjective, not external and observable” signs and symptoms (Dell, 2009, p. 226).



MID: At-a-Glance

• MID first published: 2006, Paul Dell. Current version 6.0

• MID Analysis, created by Jürgen Schmidt with Paul Dell.

▫ Currently in version 4.0, version 5.0 will arrive in late-2019/early-2020

• Format: 218 items – 0-10 scale (similar to Dissociative Experiences Scale)

▫ 168 dissociation items, 50 validity items. Measures 23 dissociative

symptoms. Modeled after MMPI. 74 Scales.

• Time to administer: 30-60 minutes for client to complete

• Time to score: 10 minutes to enter scores, plus time to review results

• Training required: familiarity with DES, basic Excel skills

• All documents are available for download (or request) from www.mid-

assessment.com

MID: At-a-Glance• Relative to other measures, the MID assesses more broadly and

deeply, and uses measurement of subjective experience instead

of clinician judgment. The MID differentiates and offers a

diagnostic impression regarding:

▫ Post-Traumatic Stress Disorder

▫ OSDD-1 (DDNOS-1b in DSM-IV-TR)

▫ Dissociative Identity Disorder

▫ Somatic Symptom Disorder (Somatization Disorder in DSM-IV-TR)

▫ Problematic Borderline Personality Disorder traits

• How reliable is it? The MID is shown to correctly diagnose 87-

93% of DID cases (Dell, 2006).

Key MID Concepts: 23 SymptomsCriterion A: General Symptoms of Pathological Dissociation

• General memory problems• Depersonalization• Derealization• Post-traumatic flashbacks• Somatoform symptoms• Trance

Key MID Concepts: 23 SymptomsCriterion B:Partially-Dissociated Intrusions into Consciousness from Another Self-State

• Child voices• Two or more parts that converse, argue, or struggle• Persecutory voices that comment harshly, make threats, or command

self- destructive acts• Thought insertion or withdrawal• “Made” or intrusive feelings and emotions• “Made” or intrusive actions• “Made” or intrusive impulses• Speech insertion (unintentional or disowned utterances)• Temporary loss of well-rehearsed knowledge or skills• Disconcerting experiences of self-alteration• Profound and chronic self-puzzlement



Key MID Concepts: 23 SymptomsCriterion C: Fully-Dissociated Intrusions Into Executive Functioning and Self (Amnesia)

• Time loss• “Coming to” • Fugues• Being told of disremembered actions• Finding objects among one’s possessions• Finding evidence of one’s recent actions

Refer to your handout for definitions of the 23 symptoms

Why Use the MID?• To ensure proper care for clients seeking healing by gathering

information broadly and deeply to support interventions used in stabilization/containment and trauma resolution work.

•

Nonmaleficience, aka ‘Do No (More) Harm’

"Accurate diagnoses are critical for appropriate treatment planning. If DID is not targeted in treatment, it does not appear to resolve"

(Brand et al., 2016, p. 258).

“There is a high cost to patient, therapist, and the therapeutic alliance in failing to adequately consider the possibility of dissociative disorders

before first using EMDR in a patient’s treatment”(Shapiro, 2018, p. 499).

When DID is actively treated by knowledgeable and experienced clinicians, recovery success rate is 91-94%. When treated actively by

“neophytes,” success rate is 25%. When dissociation is acknowledged but not addressed directly, success rates are 2-3%

(Kluft, 1985).

Why Use the MID?Words of wisdom (Dalenberg, 2000):

▫ Clinicians tend to disbelieve or even not hear what clients tell them about their traumatic experience

▫ Clinicians inevitably give a mix of subjective and objective responses to clients, which can affect client presentation and disclosure

▫ Clinician “interpretations” tend to be received as blaming or shaming

Check your own emotional regulation and countertransference!

When to Use the MID• Ideally during Stage 1 (stabilization, containment) of

psychotherapy —it is a critical aspect of history taking and formulating a diagnosis and treatment plan.

• Prior to resourcing that could link to major memory networks, employing hypnotic interventions, and/orintentional accessing or resolution of traumatic memory material.

• Francine Shapiro (2018, p. 499) states:▫ Every patient should be screened for the presence of an

underlying dissociative disorder▫ Monitoring for evidence of “switching” in session is not

sufficient▫ If a dissociative disorder is suspected, conduct further

diagnostic evaluation (the MID is one of three options mentioned)



• If these major factors of concern are apparent prior to screening:▫ Extensive trauma and/or substance use history

▫ Extensive treatment history

▫ Numerous prior diagnoses such as:

Bipolar I or II

Major Depression

Borderline Personality Disorder (traits, prior diagnosis)

ADD/ADHD (with comorbid trauma history)

Eating disorders

▫ Voices or “loud thoughts”

▫ Blank spells (or other possible indicators of amnesia)

When to Assess Rather than Screen When to Assess• So, if you didn’t assess upfront, and you notice...

▫ Standard grounding or containment methods are unsuccessful▫ Your client abreacts spontaneously (‘goes back there’) during

history taking or trauma accessing▫ Phobia for pleasant or unpleasant emotion and/or sensation▫ A persistent inability to access different aspects of memory,

whether pleasant or unpleasant (e.g., felt sense)▫ The level of emotional activation does not decrease, drops

rapidly, or drops in-session but has increased upon re-evaluation

▫ Chronic treatment obstacles such as: recurring defensive responses, ‘self-sabotage’, or secondary gain issues

…among many other possibilities, then PAUSE and ASSESS.

When to Assess - Slow Down

• If the above or other clear signs and symptoms of dissociation are present, the therapeutic next step is to slow down and shift the focus to stabilization, containment, and further assessment.

• Step back, calmly and thoughtfully, from working with the trauma material. Do not ‘push through’ the client’s symptoms by diving deeper into the traumatic material.

Avoid activating explicit traumatic material

until you know more.

MID DocumentsTo administer, score, and interpret the MID, clinicians will need:

• MID – Containing 218 questions for the client to complete

▫ Other versions available: Adolescent, Spanish, German, Italian, Hebrew, French, Chinese, Finnish, Norwegian

• MID Analysis v4.0 – A calculation/interpretive spreadsheet used to score the MID▫ MID Analysis is an Excel spreadsheet, and can be used in Microsoft

Excel for Windows, Mac, or iOS via desktop computer or tablet

• An Interpretive Manual for the Multidimensional Inventory of Dissociation (MID), 2nd Edition – Includes detailed instructions for scoring and interpreting The MID Report

Clinicians may download current versions of all documents from www.mid-assessment.com



Administering the MID: What• The test-taker completes the 7-page MID

Administering the MID: When• Before a session: instruct the client to arrive about 60

minutes early to complete the MID in lobby/waiting areaPros: Seeing the client immediately after completion can allow the clinician to support and observe client if needed

• During a session: clinician can read items and notate scores, or client can complete as usual while clinician observes and supports as needed. May take longer than 60 minutes.

Pros: Observing client's process of answering items can offer valuable clinical information- Clinician must be careful to avoid explaining items or influencing answers

• After a session: client may complete the MID in lobby/waiting area after session, checking in with clinician at next transition break

Pros: Offers some support for clients who have difficulty arrivingearly to session

Administering the MID: How Long?• How Long: Usually between 30-60 minutes. Scenarios

you might see with a client include:

▫ Client finishes quickly (too cold)• This approach will likely yield a skewed score, and is unlikely to

represent the client's actual phenomenological experience• Client finishes very slowly (too hot)

• This approach indicates high internal conflict and/or over-analyzing. The client is likely to feel exhausted afterward and score either very high or very low.

• Client finishes in the typical timeframe (just right)• This approach is most likely to yield scores and diagnostic

impressions that match the client's presentation

The client’s Window of Tolerance (Siegel, 1999) and capacity for self-observation are key factors here – so of course it is understandable that some clients taking the MID will err on the side of too cold or too hot...

Administering the MID: Instructions• What: The test-taker is asked to complete the 7-page MID• Instructions:

▫ How often do you have the following experiences when you are not under the influence of alcohol or drugs? Please circle the number that best describes you. Circle a “0” if the experience never happens to you; circle a “10” if it is always happening to you. If it happens sometimes, but not all the time, circle a number between 1 and 9 that best describes how often it happens to you.

NOTE: No timeframe of experience is specified (e.g., “the last six months”) because episodes of amnesia are very diagnostically important and often infrequent or undetected

If a client endorses ever having the described experience, even so far back as childhood, the score for that item is 1 or higher

• MID item language is to be interpreted literally.



• Upon opening the MID Analysis v4.0, immediately select “Save As…” and rename for the client being assessed

• Data entry takes about 5-10 minutes• Enter client information and responses (0-10) in the light

cyan/blue fields in Questions tab

• Save again to preserve the client’s initial responses• The MID Report, Extended MID Report, and Line and Bar

Graphs are now ready to review

Scoring the MID Overview of the MID Report

1. Validity Scales

2. Pathological Dissociation

3. Cognitive and Behavioral Psychopathology

4. Criterion A: General Dissociative Symptoms

5. Criterion B: Partially-Dissociated Intrusions

6. Criterion C: Fully-Dissociated Actions (Amnesia)

7. Self-State or Alter Presence/Activity

8. Schneiderian First-Rank Symptoms

9. Clinician’s Pre-MID Assessment Summary

10. MID Initial Impressions and Observations

The MID Report: 1. Validity Scales

• Offer insight into a client’s awareness of themselves• Indicate any ’response biases’ in overall results

▫ Phobias or concern about a diagnosis (or no diagnosis)▫ Tendency to offer extreme responses to items▫ Emotional functioning (or dysfunction) of self-system▫ Willingness and capacity to accurately report their

experience




• Capacity to accurately report?▫ Yes—because pathological dissociation is meant to keep

overwhelming pain held outside conscious awareness, hidden from oneself and the world, to ensure survival

▫ As such, highly elevated/very low scores do notautomatically invalidate MID results—they provide context for greater understanding of a complex self

The MID Report: 1. Validity Scales The MID Report: 1. Validity Scales

• Defensiveness measures the client’s willingness (or capacity) to report normal cognitive lapses and distraction• ‘Passing’ here means the client responded with a ‘o’

• The name of this scale does not necessarily suggest that a client is outwardly ‘defensive’; rather, it reflects how defended they are as a self

We’ll spend a bit more time examining this scale shortly…


• Rare Symptoms are truly unusual and bizarre experiences• A high mean score here is the best indicator that the client

may be attempting to intentionally skew the MID results• In more extreme instances, may indicate that the client’s

perception is highly distorted or that a perpetrator-identified part is trying to discount the self-report of other parts

• “Ten” Count is the tally of the MID’s 218 items answered as ‘10,’ suggesting high distress or potentially invalid reporting


• The BPD Index offers indicators of a client’s acutely dysfunctional (i.e., Borderline) personality traits• The BPD Index sometimes indicates covert aspects of self-

system functioning rather than overt behavioral traits• Emotional Suffering adds further context for a client’s

perception and potential response bias on the entire MID• Attention-Seeking, Factitious Behavior, and

Manipulativeness may reflect present or past coping



The Defensiveness/Minimization Scale

• Most scales on the MID evaluate symptoms based on the statistical premise that higher responses equals greater frequency (thus, severity) of a symptom overall

• Recall that Defensiveness assesses a person’s lack of willingness (or capacity) to endorse normal cognitive lapses or distraction

• Because this scale is looking for denial—and lack of awareness—of normal cognitive lapses, Defensivenessis evident when a client gives an answer of ’0’ (i.e., ‘this never happens for me’) on a Defensiveness item

The Defensiveness/Minimization Scale

• Consistently low ratings (0, 1, or 2 out of 10) on Defensiveness items means that the client is claiming to have remarkably few normal cognitive lapses

• Remember: Defensiveness equals defendedness:

‘How defended is my client: How aware, able, or willing are they, at this time, to accurately report on their experience of these phenomena?’

’And, if they are unable (or unwilling, or afraid) to accurately report on experiences that happen for everyone(Defensiveness Scale items) what else on the MID might they have under-reported?’

The MID Report: 2. Pathological Dissociation Scales

• Offer indicators of severe dissociation• Remember, some dissociative clients may

defensively refuse to acknowledge, or may be consciously unaware of, their symptoms—meaning that some interesting numbers may appear here




The Mean MID Score is equivalent to a DES score▫ A score of >20 suggests the presence of a dissociative

disorder, though a lower score does not rule one out▫ A score of less than 4.0 + high Defensiveness means

Further Investigation Is Definitely Needed


• The Mini-MID Score narrows the context down further▫ Based on 19 dissociative items that strongly discriminate between

persons with DID and those who are non-dissociative• Severe Dissociation tallies how many of the 168 MID

dissociation items the client ‘passed’• Dissociative Symptoms tells us how many of the 23 Criterion

A, B, and C symptoms the client ‘passed’


• The I Have DID Scale reflects the client’s awareness of dissociative alters

• The I Have Parts Scale reflects the client’s awareness of particular kinds of parts activity

• Some clients with undiagnosed DID may feel more comfortable reporting parts activity rather than any awareness of discrete alters


• Previously diagnosed clients may score 60.0+ on either or both of these scales

• Clients without prior awareness or diagnosis may score at 40.0 or lower on either or both of these scales

• If the I Have DID Scale score is notably higher than the I Have Parts Scale score, it suggests that the client is emotionally attached to a DID diagnosis




• The Amnesia Symptoms scale tallies how many of the 31 amnesia-related items the client ‘passed’▫ These 31 items are distributed across the Temporary Loss of

Knowledge scale and the six Criterion C symptoms

• The Mean Amnesia Score tells us what percentage of the time the client reported experiencing amnesia

The MID Report: 2. Pathological Dissociation ScalesThe MID Report: 3. Cognitive and Behavioral Psychopathology Scales

The Cognitive and Behavioral Psychopathology Scales evaluate cognitive and behavioral functioning

▫ Cognitive Distraction▫ First-Rank Symptoms▫ Psychosis Screen▫ Critical Item Score

The MID Report: 3. Cognitive and Behavioral Psychopathology Scales


▫ Cognitive Distraction includes experiences of forgetfulness, distractibility, absent-mindedness, mistake-proneness, and having difficulty sustaining concentration and focus

▫ This scale is comprised of the same exact 12 items as the Defensiveness scale• Very low scores on these 12 items indicate defensiveness• Very high scores on these exact same items indicate

cognitive distraction, high levels of which are common amongst persons with complex trauma histories




• First-Rank Symptoms offers a snapshot of the number of items ‘passed’ and the overall Mean score for eight ‘classic’ symptoms of DID

• These eight symptoms are delineated under Schneiderian First-Rank Symptoms

• Psychosis Screen looks at explicitly psychotic features• ‘Passed’ items should equal ‘0’• A score of 2+ suggests psychotic/delusional symptoms• Clients experiencing psychosis may score 3–4• This scale and Rare Symptoms have some overlap


• The Critical Item Score measures the 10 dissociative and post-traumatic symptoms that are harmful or potentially dangerous, in specific categories

Dangerous Persecutory Voices Dangerously Toxic PTSD Fugues Dissociated Self-Injurious Behavior Manipulative Self-Injury

The MID Report: 4, 5, and 6. Criterion A, Criterion B, and Criterion C

The MID’s 23 dissociative symptoms are divided into 3 relatively discrete categories:• Criterion A: General

Dissociative Symptoms• Criterion B: Partially-

Dissociated Intrusions• Criterion C: Fully-

Dissociated Actions (Amnesia)

Refer to your handout for definitions of the

23 dissociative symptoms




Diagnostic Impressions are determined by

Clinical Significance Scores:

Dissociative Identity Disorder (DID)

‘Pass’ 4 from Criterion A + 6 from Criterion B + 2 from Criterion C

(or 1 + ‘pass’ Criterion B9)

Temporary Loss of Knowledgeis a ‘hybrid’ symptom— it is both intrusive and amnestic


Diagnostic Impressions are determined by

Clinical Significance Scores:

Other Specified Dissociative Disorder, Type 1 (OSDD-1) ‘Pass’ 4 from Criterion A + 6 from Criterion B + Less than 2

between Criterion C/B9)


Diagnostic Impressions are determined by Clinical

Significance Scores:Post-traumatic Stress Disorder (PTSD)

▫ ‘Pass’ Criterion APTSD, Dissociative Subtype

(according to DSM-5 criteria) ‘Pass’ Criterion A4 + Criterion A2 (Depersonalization) and/or Criterion A3 (Derealization)

Somatic Symptom Disorder ‘Pass’ Criterion A5 with

a Clinical Significance Score of 151+


The MID Report:7. Self-State or Alter Presence/Activity Scales



• The Self-State or Alter Presence/Activity Scales break down parts activity by the most prevalent types/roles within the self-system

• This scale essentially describes ‘who the parts are’ based on emblematic influences and behavior


• Child self-states indicate overtly younger parts, which may tug for the therapist to ‘rescue’ or protect them

• The Helper, Angry, and Persecutor scales indicate self-states whose role it is to protect the self from further harm—sometimes in paradoxical or even dangerous ways

• Opposite Gender parts activity is binary-gendered• Can be framed in terms of a client’s dominant, subjective

experience of gender identity


‘Opposite Gender’ and Trans/Genderqueer Clients

Only one item on the MID addresses gender explicitly:▫ Item 201: ‘Switching back and forth between feeling like

a man and feeling like a woman.’

• The Dissociative Initiative* offers this frame: ▫ Some people have a sense of a male and female versions of

themselves

▫ Some people have different personalities who identify differently with regards to gender

▫ Some people find that their sense of gender identity is fluid, changing from day to day, in some cases because of co-conscious switching between parts

▫ It can be helpful to be aware that trans experiences are common for people with multiplicity, and multiplicity experiences are common for people who are trans

*The Dissociative Initiative (http://di.org.au)

The MID Report:8. Schneiderian First-Rank Symptoms



Kurt Schneider (1959) identified 11 ‘first-rank’ symptoms that he claimed were characteristic of schizophrenia. Kluft(1987) noted that the first eight of these were common in clients with DID, but that the last three were not. Dell (2001) observed that these eight first-rank symptoms have something in common: Each is a peculiar intrusion into the person’s executive functioning and/or sense of self.

The MID Report:8. Schneiderian First-Rank Symptoms

The MID Report: 9. Clinician’s Pre-MID Assessment Summary

The information in these fields is transferred directly from Pre-MID Diagnosis and Comments fields on the Questions tab, where client data is entered to generate MID results.

The MID Report: 9. Clinician’s Pre-MID Assessment Summary

The fields will display as ‘0’ on The MID Report if no demographic/diagnostic data is entered on the Questionstab.

The MID Report:10. MID Initial Impressions and Observations



Provides• Diagnostic impressions based on clinical significance scores

• The symptoms and impressions noted must be validated via a clinical follow-up interview—they enhance clinical judgment, but are no replacement for it

• Context for the Mean MID Score, based on MID research, to aid the follow-up interview

• Information on how validity scale scores may influence other scales

The MID Report:10. MID Initial Impressions and Observations

Questions?

Despite its assessment and diagnostic power…

Ensuring valid MID results absolutely requires interpretation and a clinician-directed,

follow-up interview

Keys to Understanding The MID Report

Four Key Concepts in Making Sense of the Results

▫ ‘Passing’▫ Clinical Significance Scores▫ Mean Scores▫ Items / Symptoms ‘Passed’

Let’s turn the keys, one at a time…

Keys to Understanding The MID Report: ‘Passing’ an Item

On the MID, each item/question has its own ‘passing’ value, called the cut-off value for clinical significance, which tells us where along the ‘0 to 10’ scale that item takes on importance as a dimension of the symptom being assessed.

Example: For the Criterion A symptom Memory Problems, the test-taker must respond with a 4 or greater on the ‘0 to 10’ scale for ‘Forgetting what you did earlier in the day’ to be relevant to the overall symptom.



Keys to Understanding The MID Report: ‘Passing’ (aka Having) a Symptom

And, each symptom has a ‘passing’ value called the Cut-off Score, which tells us how many items/questions the client must ‘pass’ in order for the MID to conclude that a symptom is actually a symptom (what is called Clinical Significance).

Example: For Memory Problems, the test-taker must pass 5 or more of the 12 Memory Problems items for that to be recognized as clinically significant – meaning the client hasthat symptom, according to the MID.

Keys to Understanding The MID Report: Clinical Significance

So, when we see‘Clinical Significance’

on The MID Report and Dissociation Scales Graph,

those numbers(ranging from 0 to 300)

tell us what percentage of the required number of items

the client ‘passed’ for each symptom.

225 for Derealization?This person passed 225% of

the number of items required for Derealization to be

recognized as a symptom.

In the Validity Scales, we can see that the Example Client scored a Mean of 3.3 (on a ’0 to 100’ scale) across the 12 Rare Symptoms items...

Keys to Understanding The MID Report: Mean Scores

We can also see that theExample Client ‘passed’ 3 out of the

total 12 Rare Symptoms items…

Keys to Understanding The MID Report: Number of Items/Symptoms ‘Passed’



…and in the Pathological Dissociation Scales, we can see that the Example Client ‘passed’ 119

out of the 168 Severe Dissociation items,and ’passed’ 20 out of the 23

Dissociative (Criterion A, B, and C) Symptoms

Keys to Understanding The MID Report: Number of Items/Symptoms ‘Passed’

Understanding the MID: The Extended MID Report

• Offers a fine-grained view of most MID Scales and provides the context for the follow-up interview

• Let’s take a look at the Memory Problems scale…

Client’s responses carried over from the Questions tab



Item (question) number from MID, with corresponding item language to the right



Cutoff value (for clinical significance) for each item


Remember, if the client’s response on the specified item is equal to/greater than this number, then they have ‘passed’ the item, and it now counts toward the overall clinical significance for this symptom.

We call it ‘raw’ because it hasn’t yet been converted from the original ‘o to 10’ MID scale to the ‘0 to 100’ ‘how much of the time’ percentage we see on The MID Report and the Dissociation Scales Graph.

Almost all scales reflected in The MID Extended Report display a Mean Score.


‘Raw’ mean score (0–10 scale)

The boldface number in parentheses is the number of items the client needs to ‘pass’ on this scale in order for Memory Problems to be recognized as a symptom. The number furthest to the right is the ‘raw’ Clinical Significance score—it shows up as a proper ‘percentage of items passed’ score on the MID Report and the MID Diagnostic Graph.


Cutoff Score for Clinical Significance for the symptom overall

Keep in mind that you’ll only see the Cutoff Score (x): field for the 23 Criterion A, B, and C symptoms, since these are the only scales reflected in The MID Report that are relevant to diagnosis. Other scales on TheExtended MID Report will display the Mean Score and/or number or percentage of Items Passed.


Cutoff Score for Clinical Significance for the symptom overall



Understanding the MID: The MID Report Line and Bar Graphs

Line Graphs Bar Graphs

Understanding the MID: The MID Report Line and Bar Graphs

The MID Report Graphs offer▫ A comparison between your client’s scores and

other, diagnostically relevant populations’ MID scores

▫ A context to help you understand what your client’s scores actually mean in a ‘big picture,’ visual sense

▫ Information not available elsewhere in The MID Report, particularly in the Clinical Summary Graph and Factor Scales Graph

▫ Identical information in both line and bar graph formats, catering to different visual preferences

The MID Dissociation Scales Graphillustrates the client’s Mean Scoresfor the 23 dissociative symptoms, as compared to norms for particular diagnostic categories:

• Nondissociative

• PTSD

• DDNOS-1b/OSDD-1

• DID

The PTSD profile on this and all other graphs indicates persons diagnosed with PTSD who are notdissociative.

The MID Report: The MID Dissociation Scales Graph

The MID Diagnostic Graph forms the core of The MID Report, and

compares the client’s Clinical Significance Scores with the previously noted diagnostic

populations for the Validity Scales

and the 23 dissociative

symptoms reflected in

Criterion A, B, and C.

You may have noticed that it’s a lot easier to read these graphs if you

turn them sideways…

The MID Report: The MID Diagnostic Graph



Clinical Significance=

100+

200=2x Clinical

Significance

300=3x Clinical

Significance



If you see your client’s Defensiveness Scale score near the ‘Nondissociative’ point (magenta), and either notably high or abnormally low scores in the other Validity Scales, and some or all of the 23 dissociative symptoms, it's worth considering whether your client’s MID results align with:

• What you notice, sitting in the room with your client

• Their known history

• The subtleties in their presentation

Sometimes, though not always, the MID is revealing only the tip of a yet-to-be-discovered iceberg.

The MID Clinical Summary Graphprimarily reflects what percentage of items the client ‘passed’ for each of the following:

• Dissociation Scales

• Parts and Alters Scales

• Validity Scales

• Characterological Scales

• Functionality/Impairment Scales

As with the other graphs, the client’s scores are compared to those of other diagnostically relevant populations.

The MID Report: MID Clinical Summary Graph

The MID Factor Scales are based on a large (N=1,359) factor analysis of the MID's 168 dissociation items. That factor analysis identified 12 ‘first-order’ factors (symptoms). Hierarchical factor analysis of the 12 first-order factors extracted a single

‘second-order’ factor (i.e., dissociation).

The MID Factor Scales Graph reports Mean Scores for each of these 12 ‘first-order’ factors.

It’s wise to examine these factors for your client, as they sort out the MID’s items in a way that differs from the rest of the MID scales.

The MID Report: MID Factor Scales Graph



1) If I get "#REF" as a result what does that mean?▫ It means that something other than the numerals 0-10

were entered in the item answer column in the Questions tab – check for entry mistakes spaces and two scores entered together (e.g., a response of '14’)

2) What if the scores don't yield any definitive diagnostic impression?

▫ Examine what the client does endorse, taking the Validity Scales into consideration

3) What if the scores are so high that all of the diagnostic thresholds are passed?

▫ Examine Mean Scores and Line Charts, in light of Validity Scales

Preparing for the Follow-Up InterviewFrequently Asked Questions

• Based on the items/scales requiring clarification, elicit supporting evidence by asking questions such as:▫ What did you have in mind when you said that?”▫ “Could you give me an example of this, in your experience?”

• Clinicians may clarify that items were to be interpreted literally, and according to instructions▫ If your client does not identify with, or is unfamiliar with, the

experience described, the answer must be ‘O’▫ Substance-induced experiences should be excluded from

reporting▫ Clinician knowledge of symptom features (refer to handout)

can inform whether qualitative data fits with the MID definition of the symptom

• You may revise the original scoring when items are endorsed at significantly higher/lower frequency in follow-up than originally reported (on either side of the cutoff value for clinical significance for an item)

Conducting the Follow-Up Interview

• Symptoms are a sign of the client’s resilience in the face of harm▫ The client may respond to results with feelings of shame and fear

• Where is the client in their healing journey?▫ What is your client’s past experience of treatment providers?▫ Where are you in your knowledge and skill set?

• How much knowing can the client, their family, and others handle?▫ Are they going to respond to the results with acceptance or denial?▫ Might you encounter disbelief or anger from their family?▫ Will collaborating professionals accept, or challenge, the results?

• Informed consent▫ How committed is the self-system to maintaining the status quo?▫ This is an ongoing process with complex trauma and dissociation

• Treatment planning▫ Collaborative, properly paced, and attentive to the client’s needs

Concluding the Follow-Up InterviewWhat’s the Frame for Sharing Results?

The Contextual FrameCapacity to Report: When to Assess

• “Immediately” may not be the ideal time for assessment

• Assessment earlier in treatment tends to be better, for the sake of moving efficiently forward, but…▫ Sometimes, the client has a very narrow Window of Tolerance

(Siegel, 1999) at the start of therapy▫ It may be therapeutically necessary to administer the MID in

‘installments’ to aid the client’s self-evaluation capacity• Use client feedback and sound clinical judgment to pace



The Contextual FrameCapacity to Report

• Accurate endorsement of MID items relies upon many factors, including:▫ The client's level of awareness of symptoms▫ The degree of denial or phobia related to

symptoms▫ Which parts are answering items, allowing

access/awareness, or not...▫ Whether other language has been given and/or

adopted to explain symptoms

Broader Applications of the MID• Aid in consultation/supervision

▫ Clarify or re-evaluate diagnoses in context of trauma▫ Clarify readiness for trauma accessing/processing▫ MID Report provides data to review together

• Standard assessment tool in treatment programs▫ MID may be administered when clients present indications of

dissociation, to determine clinician / program goodness-of-fit

• Discernment tool in clinical research▫ For example: Andreas Laddis, Paul F. Dell, & Marilyn Korzekwa

(2017). Comparing the Symptoms and Mechanisms of “Dissociation” in Dissociative Identity Disorder and Borderline Personality Disorder, Journal of Trauma & Dissociation, 18(2).

• Forensic use, etc.▫ Need to support or confirm diagnosis for court or 3rd party▫ To gauge progress in therapy (intervals of 1 year or more)

Broader Applications of the MID• A differential diagnosis tool for evaluations related

to a referral for the Rite of Exorcism.▫ DSM-5 addresses possession as a feature of DID and

within Culture Related Diagnostic Issues (APA, 2013). Criterion A for DID reads as follows: “Disruption of identity characterized by two or more

distinct personality states, which may be described in some cultures as an experience of possession. The disruption in identity involves marked discontinuity in sense of self and sense of agency, accompanied by related alterations in affect, behavior, consciousness, memory, perception, cognition, and/or sensory-motor functioning. These signs and symptoms may be observed by others or reported by the individual (APA, 2013, p 293).”

▫ While it is not the role of a mental health professional to diagnose possession, ruling out presence of a dissociative disorder may be appropriate.

Please refer to your handout

Case ExampleMID Diagnostic Impression of OSDD-1



Case Example: OSDD-1Upon first review, note:

▫ Validity scale elevation?▫ Any scales that are oddly elevated or depressed, based on client

presentation and history (see Comments/Observations)▫ Areas of concern: Critical Items, Psychosis Screen, Amnesia

Scales (Criterion C), and Self-State / Alter Activity▫ Identify items/scales near cutoff scores or clinically significant

levels, especially within areas of concern

Review Line Charts

Possible questions:• Based on this data, how might you guess this client would present?• What scales would you want to focus on in the follow-up interview?• Based on this data, what stabilization methods might you suggest or

employ?• What indications do you see that this client may be ready/not ready

for trauma processing?

Questions?

Please refer to the current edition of the MID Manual for more in-depth exploration of the information presented here.

All current MID documents can be found at: www.mid-assessment.com

D. Michael Coy, MA, LICSWEMDRIA Approved [email protected]

Jennifer Madere, MA, LPC-S

EMDRIA Approved Consultant

[email protected]

ReferencesDell, P. F. (2006). The Multidimensional Inventory of Dissociation (MID): A Comprehensive measure of pathological dissociation. Journal of Trauma & Dissociation, 7(2):77-106.

Dell, P.F., Coy, D.M., & Madere, J.A. (2017). An Interpretive Manual for the Multidimensional Inventory of Dissociation (MID). Second Edition. Self-Published.

International Society for the Study of Trauma and Dissociation (2011). Guidelines for Treating Dissociative Identity Disorder in Adults, Third Revision. Journal of Trauma & Dissociation, 12(2):115-187.

Kluft, R.P. (1994). Treatment trajectories in Multiple Personality Disorder. Dissociation. 7(1): 63-76.

Laddis, A., Dell, P.F., & Korzekwa, M. (2017). Comparing the symptoms and mechanisms of "dissociation" in dissociative identity disorder and borderline personality disorder. Journal of Trauma and Dissociation, 18(2):139-173.

Ross, C. (2015). When to Suspect and How to Diagnose Dissociative Identity Disorder.Journal of EMDR Practice and Research, Volume 9(2):114-120.

Shapiro, F., (2018). Eye Movement Desensitization and Reprocessing (EMDR) Therapy: Basic Principles, Protocols and Procedures. Third Edition. The Guilford Press. New York.

ReferencesSomer, E., & Dell, P.F. (2005). Development of the Hebrew Multidimensional Inventory of Dissociation (H-MID): A valid and reliable measure of pathological dissociation. Journal of Trauma & Dissociation, 6(1):31-53.

Steinberg, M., Schnall, M. (2001). The Stranger in the Mirror: Dissociation, the HiddenEpidemic. New York, NY: Harper Collins.

Szada, J. A. (2017). A grounded theory study of the experiences of mental health professionals which may lead them to make referrals for exorcism. (Doctoral dissertation) Retrieved from ProQuest, UMI Publishing (Accession No. 10286036)