Beyond Trauma-Informed Care: MET(T)A Protocol: The ...

BEYOND TRAUMA-

INFORMED CARE:

MET(T)A

PROTOCOL: THE

MINDFULNESS

AND EMDR

TREATMENT

TEMPLATE FOR

AGENCIES

STEPHEN DANSIGER, PSYD, LMFT

C4 WEBINAR

© 2019 STARTAGAINDen of the Lioness, 2012

Dr. Stephen Dansiger• PsyD

• Licensed MFT in California

• Buddhist Practitioner over 30 years

• Including One Year at a Zen Buddhist monastery

• Teaches Dharma classes locally and internationally

• Presenter 2016/18/19 EMDRIA Conferences

• Creator/Founder of MET(T)A Protocol

• EMDRIA Approved Consultant/Certified Therapist

• Senior Faculty, Institute for Creative Mindfulness

• Author, Clinical Dharma; Coauthor, EMDR Therapy and Mindfulness for Trauma-Focused Care; Author, Mindfulness for Anger Management

• Master of Health Care Innovation (MCHI), University of Pennsylvania, 3rd Cohort

James, n.d.

OBJECTIVES• Demonstrate how to provide trauma treatment in

a way that promotes healing from substance use disorders, eating disorders, and other mental health disorders through the application of the MET(T)A Protocol.

• Apply EMDR therapy as a complete system of healing and primary psychotherapy as opposed to implementing it as a treatment approach or technique.

• Describe how an integration of Buddhist mindfulness, Pierre Janet (Three Stages of Trauma Treatment) and Dr. Francine Shapiro (Eight Phase Protocol) provides the theoretical orientation for the delivery of trauma-focused care.

• Discover how to implement trauma-focused programming within a treatment system guided by mindfulness and EMDR therapy.

Toastmaster, 2016

SAFETY

TRUSTWORTHINESS AND

TRANSPARENCY

PEER SUPPORT

COLLABORATION AND MUTUALITY

EMPOWERMENT, VOICE, AND CHOICE

CULTURAL, HISTORICAL, AND GENDER ISSUES

SAMHSA’S KEY PRINCIPLES OF A TRAUMA-INFORMED APPROACH

© 2019 StartAgain

SAMHSA, 2014

© 2019 StartAgain

TRAUMA-INFORMED CARE

• Emphasis on education and information surrounding trauma

• Recognizes the role that unhealed trauma plays in human behavior.

• Provides a template for minimizing harm in the delivery of human services.

• Offers an educational framework for human services systems.

TRAUMA-INFORMED CARE TRAUMA-FOCUSED CARE

TRAUMA-FOCUSED CARE

• Trauma education in addition to addressing and targeting the trauma

• Assumes that unhealed trauma plays a major role in presenting issues.

• Denotes greater action in the delivery of treatment services.

• Promotes proactive treatment planning to heal the legacy of trauma.

Marich & Dansiger, 2018

Teitell. 2017

Trauma-Focused Care…

• Emphasizes and targets trauma as it is the underlying cause of pathology, providing education and utilizing this education to promote healing and target trauma.

• Fosters education in addition to targeting traumatic material.

• Targets and addresses trauma through the lens of the Eight Phase Protocol.

• Directly treats trauma experiences, related symptoms and syndromes.

Katzin, n.d.

Trauma-Focused Care Philosophies: Safety

© 2019 StartAgain

• A first order of treatment is to establish conditions of safety to the fullest extent possible. The survivor cannot progress if a relative degree of safety is not available or attainable (Ford & Courtois, 2009).

• Recognize the centrality of affect-regulation (emotional management; ability to self-soothe) as foundational to all treatment objectives and consistently foster this ability in the survivor (Kezelman & Stavropoulos, 2012).

• Clear boundaries and well-defined roles are essential to providing a safe environment for survivors (Elliot et al., 2005).

Meyers, 2014

Trauma-Focused Care Philosophies: Building Trauma Resiliency

• Recognize the impact that trauma has on coping strategies and development.

• Highlight adaptation over symptoms and resilience over pathology (Elliot et al., 2005).

• Too often, programs focus so intently on problems that they miss the many strengths a person brings to the human service setting (Elliot et al., 2005).

• Reframing behaviors and symptoms as understandable survival mechanism strategies and highlighting survival over everything that is not working reduces shame and guilt and increases self-esteem.

• Treatment should be tailored and individualized; one size does not fit all. Adapt the therapy to the survivor rather than expecting the survivor to adapt to the therapy (Kezelman & Stavropoulos, 2012).

© 2019 StartAgainCordova, 2018

Trauma-Focused Care Philosophies: Building Trauma Resiliency

• View each survivor as the expert on his/her own life, and give him/her maximum choice and control over his/her recovery (Elliot et al., 2005).

• Provide psychoeducation: Allow the understanding of the impact of trauma to guide treatment. • Understand the prevalence of trauma, the impact of

trauma on the brain and body, the impact of trauma on an individual’s life and development, and the complex pathways to healing and recovery.

• Key aspects of psychoeducation should be sensitively communicated to the survivor, with a view to normalizing distressing/problematic internal experiences and responses for which they may otherwise hold themselves solely responsible (Kezelman & Stavropoulos, 2012).

© 2019 StartAgain

Trauma-Focused Care Philosophies: Validate

© 2019 StartAgain

• View many behaviors that are now the focus of treatment as developed originally as ways of coping with and adapting to traumatic events (Elliot et al., 2005).

• Validate symptoms of trauma as expectable and adaptive reactions to traumatic childhood experiences (i.e. as the outgrowth of normal responses to abnormal conditions) (Kezelman & Stavropoulos 2012).

• The survivor must be involved in a substantive way in the design, evaluation, and delivery of the services they use (Elliot et al., 2005).

Trauma-Focused Care Philosophies: Reduce Possibility

of Retraumatization© 2019 StartAgain

• Do not re-traumatize—clinicians most often do this by prodding for too many details too soon or coming across as interrogatory.

• Do consider that getting an exact, chronological history may be unsafe or impractical because of how the memories are stored.

Marich, 2019

Eight Phases of EMDR Therapy

1. Client History (includes treatment planning)

2. Client Preparation

3. Assessment (of the target memories)

4. Desensitization

5. Installation

6. Body Scan

7. Closure

8. Re-Evaluation

Southwest Family Guidance Center and Institute, 2017

The Four Faces of EMDR Therapy: Marich, 2011

1. Protocol-Oriented EMDR Therapy

• Strict adherence and fidelity to the protocols and procedures as developed by founder Dr. Francine Shapiro

• EMDR viewed as an approach to psychotherapy

• EMDR is used alongside other interventions

2. Flexible EMDR Therapy

• Modifications are made to original protocols and procedures to better fit client’s needs

• Other models of treatment conceptualization are incorporated aside from the AIP model

• Used alongside another approach to psychotherapy

3. EMDR Therapy as a Technique

• EMDR is simply used as an adjunctive technique or procedure to another psychotherapeutic orientation (e.g., Gestalt, 12 Step, client-centered therapy, choice theory, psychoanalysis)

• EMDR does not dominate or guide the treatment

4. EMDR-Informed Interventions

• Use of EMDR-informed interventions or evolutions of original EMDR elements into a new technique or approach to therapy

Holmer, 2010

EMDR Therapy Integrated into Practice as a Technique

© 2019 StartAgain

• “EMDR is simply used as an adjunctive technique or procedure to another psychotherapeutic orientation (e.g., Gestalt, 12 Step, client-centered therapy, choice theory, psychoanalysis).”

• “EMDR does not dominate or guide the treatment.”

• “Use of Shapiro’s original protocols and procedures with modifications made by the clinician to better suit the clinician’s personal style or to better accommodate the client’s learning/processing styles and other unique needs.”

Marich, 2011, p. 38

Driscoll, 2016

How to Implement EMDR Therapy as a Primary

Psychotherapy• Apply the systems of healing inherent within EMDR

therapy:

• Model (Adaptive Information Processing; AIP),

• Methodology (Eight phases),

• Mechanism (Mindfulness, right and left-brain integration, REM sleep, orienting response and working memory)

• Protocol (Three phases: treating the past, present and future)

• Structured with a beginning, middle, and an end.

Rolando, 2017

How to Implement EMDR Therapy as a Primary

Psychotherapy• Treat every client as an EMDR therapy client in

Phases 1 and/or 2 upon admission to a treatment center or private practice.

• Apply EMDR therapy as delivering the three stages of trauma treatment originally proposed by Janet in 1889 and as described by van der Hart, Brown, & van der Kolk in 1989.

Caram, 2017

The Eight Phases as a Complete

System of Healing

• Phases 1 and 2 of EMDR therapy, client history and then stabilization and preparation, support the intake and rapport building stage and building of resourcing and resiliency with our clients.

• The 3rd through 6th phases of EMDR therapy are concerned with reprocessing and adaptively transforming traumatic material.

• Phases 7 and 8 of EMDR therapy provide the third stage of trauma treatment, that of ongoing treatment plan reevaluation, personality reintegration, relapse prevention and application of new insights in day to day living.

© 2019 StartAgain

Dansiger, 2019

Wesenaar, n.d.

The MET(T)A Protocol

• MET(T)A is a new and innovative way to envision and implement agency mental health treatment that is grounded in the 30 years of research, theory and practice of EMDR therapy, as well as the 2600 years of research theory and practice of the Buddhist psychology of Mindfulness.

• Implements EMDR therapy as the primary psychotherapy of a treatment center, agency, or private practice.

• Is a trauma-focused solution in which trauma resolution and adaptive reprocessing are the focal points of treatment and the implementation of mindful lifestyle development serves to anchor stabilization and boost retention of treatment gains.

• Honors the current belief that there is a deep need for trauma resolution to be a key focus of treatment in order to strengthen relapse prevention and create sustainable long-term recovery.

CDE, n.d.

The MET(T)A Protocol

• Every client seeking treatment for SUD’s is considered to be in Phase 1 and/or 2 of EMDR therapy upon admission.

• Explicitly utilizes the first two phases of EMDR therapy, client history and treatment planning (Phase 1), in addition to stabilization, resourcing, and preparation (Phase 2) for every client.

• A MET(T)A addictions or mental health treatment center/agency will provide phases 3 through 6 for those that are sufficiently stabilized and resourced.

© 2019 StartAgainMcClellan, 2018

Premise of a MET(T)A Protocol Center

• The MET(T)A Protocol guides the whole treatment center, not just the individual therapy conducted in a clinician’s office.

• All clinicians are trained in EMDR therapy and all clinical and line staff receive training in Buddhist mindfulness and trauma-focused care.

• All group therapy and activities support Janet’s three stages of trauma treatment and EMDR therapy as the primary psychotherapy.

• All operations and therapeutic endeavors run through the eight-phase protocol, the AIP model, the three stages of trauma treatment model, and Buddhist mindfulness.

Treatment Components of the MET(T)A Protocol

© 2019 StartAgain

• Employs trauma-focused mindfulness practices to enhance self-regulation skills and to foster individuals to adopt adaptive and mindful living patterns.

• Teaches ethical livelihood practices based on the Buddhist psychology of the Eightfold Path.

• Implements long-term aftercare support in the form of providing every client that discharges from treatment a therapeutically aligned mindfulness coach in one of the following specializations: Life coaching, recovery coaching, or trauma resilience coaching.

• Founded upon the clinical experience which suggests that integrating mindfulness and EMDR therapy represents best practice for providing trauma resolution, and trauma resolution represents the best outcome for people suffering from SUD’s and other mental and emotional health issues.

Tull, 2019

Treatment Components of the MET(T)A Protocol

• Based on the premise that mindfulness practice is the foundation for successful trauma resolution as it appears to desensitize trauma and PTSD symptoms.

• The MET(T)A Protocol takes Shapiro’s admonition from her AIP model as the core principle that informs treatment: Maladaptively stored memories become a primary focus of treatment and adaptive resolution of those memories is a primary goal.

• Clients are resourced and prepared to tolerate the trauma resolution work, and then when ready, begin reprocessing the maladaptively stored events.

• All clinicians at a MET(T)A SUD’s or eating disorders center are trained in EMDR therapy with a trauma-focused mindfulness approach and clinical meetings are conducted in the fashion of EMDR therapy consultations.

© 2019 StartAgainWeidner, 2005

Mindfulness Defined• English term mindfulness first coined in 1881

• Comes from the Sanskrit word smriti meaning “awareness,” specifically, “coming back to awareness”

• Paying attention in a particular way: on purpose, in the presence of the moment, and non-judgmentally; as if your life depended on it (Kabat-Zinn, 2003/2005/2011).

• The self-regulation of attention to the conscious awareness of one’s immediate experiences while adopting an attitude of curiosity, openness, and acceptance (Bishop, Lau, Shapiro et al., 2004).

© 2019 StartAgain

New Orleans Museum of Art, n.d

Mindfulness Within a MET(T)A Protocol System

• Integrating mindfulness practices into Phase 1 and Phase 2 of EMDR therapy as a way of building internal and external resources and helps to support phases 3 through 8 of EMDR therapy.

• Mindfulness practices used in the MET(T)A Protocol:

• Four Foundations of Mindfulness

• The Dharma

• Classical Mindfulness Practices

• Loving Kindness

• Self-Compassion Practices

• Healthy staff: Teaching clinicians/staff mindfulness practices to buffer against burnout and addressing countertransference issues. © 2019 StartAgain

Montserrat, 2016

Mindfulness in Trauma-Focused Care: An Antidote

• A tenet of trauma-focused care is assisting the survivor to maintain awareness of the present without being triggered into past.

• Mindfulness assists clients in changing their relationship with triggering material and intrusive symptoms.

• The root of the symptoms associated with surviving a trauma are mindless.

• Mindfulness is the opposite of what results from trauma.

• Therefore, an antidote to trauma symptoms is mindfulness.

© 2019 StartAgain

Kaufman et al., 2017

Mindfulness

• Mindfulness has been shown to mitigate the psychological, behavioral, and physiological changes associated with adverse childhood experiences, trauma and increased allostatic load.

• Mindfulness indirectly negates the acute response to trauma and stress.

• Mindfulness benefits survivors of trauma through inhibiting underlying consequences of chronic exposure to stress and trauma such as psychiatric, metabolic and cardiovascular disease through the influence on lifestyle choices, underlying biochemistry and neurobiology.

Rik Center, 2016

Ortiz & Sibinga, 2017

The Buddha

• The Buddha, born as Siddhartha Gautama, grew up as a royal in Northern India/Nepal.

• In his late 20s, he left the palace that until that time he had been sequestered in to shield him from the suffering of the world.

• He then saw suffering in all its forms — old age, sickness and death.

• He was moved to great compassion, and upon seeing a mendicant, he went on a spiritual search and practiced for seven years, primarily as an ascetic.

• His ultimate discovery was a need to find a Middle Path between extreme worldliness and extreme mortification of the body.

O’Brien, 2018

© 2019 StartAgain

The Buddha

• He sat for seven days under the Bodhi tree, and then described his experience during a teaching career spanning over 45 years.

• His first and primary teaching was that of the Four Noble Truths and the Eightfold Path.

• From a psychological perspective, he did a single case study on himself consisting of direct experience and direct observation that lasted six years.

• From this case study, he devised a comprehensive system of psychology and spiritual practice and discovered that the cause of suffering was not the pain of life, but rather the maladaptive clinging, craving and aversion in response to pleasure and pain.

Dvorksy, 2013

© 2019 StartAgain

The Four Noble Truths and The Eightfold Path

• The first truth says there is dukkha (suffering or unsatisfactoriness) in this life.

• The second truth declares that clinging (and aversion) are the cause.

• The third truth states that it is possible to end suffering, by turning toward the causes and conditions of clinging and aversion and healing them.

• The fourth truth describes the Eightfold Path, which suggests building wisdom in order to set skillful intentions, living ethically in speech, action and livelihood, and making the effort to develop mindfulness and concentration through meditation practice.

© 2019 StartAgain

Buddhism for Kids, n.d.

Prescription: The Eightfold Path

Cure:

Get into and through these causes and conditions to end the suffering.

Symptoms and causing of suffering:

Craving, clinging, aversion, unhealthy attachment.

Diagnosis:

Suffering as the core problem of life.

© 2019 StartAgain

Principles Underlying Buddhist Mindfulness: The Medical Model Based on the Four Noble Truths

Three Stages of Trauma TreatmentPierre Janet, 1889

(as described by van der Hart, Brown, & van der Kolk, 1989)

• Stage I: Stabilization - symptom-oriented treatment, and preparation for liquidation of traumatic memories.

• Stage 2: Identification - exploration, and modification of traumatic memories.

• Stage 3: Relapse prevention - relief of residual symptomatology, personality reintegration, and rehabilitation.

• Janet’s model calls for a beginning, middle and end to treatment, thus providing clients with a vision for the future and the possibility of beginning, participating in, and terminating treatment.

Miranda, n.d.

Dr. Francine Shapiro• Founder of EMDR therapy in 1987

• One of the core developments that came out of Shapiro’s work is the rethinking of what constitutes trauma, and where our focus should be as it pertains to what constitutes traumatic experiences.

• Initial descriptions of trauma all focused on the nature of the event.

• Rather than exclusively concentrating on the nature of the traumatic event, insight on how to treat survivors of trauma must be seen through the trauma survivor him/herself. “Just as ‘Beauty is in the eye of the beholder,’ so is clinical dysfunction” (Shapiro, 2007, p. 68).

• “Big T” and “Small t” traumas.

• We need to look at what happened to the person internally as the result of events rather than the nature of the event.

• Shapiro and her contemporaries spent the last 30 years helping all stakeholders to begin to flip the script.

Mental Research Institute, n.d

© 2019 StartAgain

Dr. Francine Shapiro

• Developed the Adaptive Information Processing (AIP) Model to explain what she saw as a result of EMDR therapy, which she believed to be the adaptive reprocessing of previously maladaptively processed memories.

• The AIP views the cause of pathology as the unprocessed traumatic memory while the dysfunctional beliefs, emotions, sensations, and behaviors are regarded as the symptoms (Luber & Shapiro, 2009), suggests that trauma resolution become the focus of treatment.

• This is in keeping with Buddha’s Third Truth which describes the “cessation of suffering” and Janet’s call for “personality reintegration and rehabilitation.”

Orchid, 2017© 2019 StartAgain

The MET(T)A Protocol: An Integration of Three

Systems• The MET(T)A Protocol represents a true

integration of the three systems set forth by Buddha, Janet, and Shapiro, in that each can be found embedded within each other, while each maintains its own primary integrity.

• Janet’s Stages are infused by the Eightfold Path of the Buddha and are drawn out into the Eight Phases of the EMDR therapy protocol.

• Janet’s theory that dissociation and neurosis represented a reversion to more primitive or less skillful responses to life’s challenges matches Buddha’s conceptualization of a regression to clinging and aversion — the responses of the survival instincts of the brain and nervous system.

Eurodiaconia, 2016

© 2019 StartAgain

The MET(T)A Protocol: An Integration of Three Systems

• The Eightfold Path gives both therapist and client a design for living that extends out beyond the office, where mindfulness can become the rule rather than the exception.

• This can bring a greater attunement between client and therapist, a deeper preparation phase, more effective reprocessing, and most of all, more robust relapse prevention and personality reintegration.

Lawrence, 2012

© 2019 StartAgain

The MET(T)A Protocol: An Integration of Three Systems

• Finally, the Eight Phase Protocol, when seen through the AIP model and used as the primary therapeutic modality, provides a trauma-focused solution that brings relief to sufferers of a variety of maladies already reflected in the EMDR research on PTSD.

• The relief from lesser adverse life events that have been maladaptively processed signals that EMDR therapy delivered in this way, infused by Buddhist mindfulness and psychology and structured through Janet’s stages and the AIP model, can address any non-organic complaints.

© 2019 StartAgain

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