Transcript
Hey everyone, welcome to Scaling Up Your Impact. I’m Kelly Smyth-Dent, and today I want to talk about something that’s really transformed my clinical practice – the Stepped Care Approach to mental health.
You know, I’ve been thinking a lot about how we approach trauma treatment compared to emergency medicine. It’s actually kind of fascinating when you think about it. When someone comes into the ER with a serious injury, what’s the very first thing the medical team does? They stabilize the patient, right? They stop the bleeding, monitor vital signs, make sure the person isn’t in immediate danger – and only then do they move on to deeper treatments or surgery.
But in mental health? We often do things completely backwards. A client comes in clearly dysregulated, maybe experiencing flashbacks or panic attacks from trauma, and what do many of us do? We dive straight into exploring childhood wounds or processing traumatic memories before ensuring their nervous system can actually handle that kind of work.
I’ve seen this play out so many times, both in my own early practice and with supervisees. Clients get overwhelmed, sometimes drop out of therapy, or even leave sessions more dysregulated than when they came in. And we wonder why trauma therapy can be so challenging.
That’s exactly why I’m so passionate about the Stepped Care Approach that’s been developed and refined by organizations like mine, Scaling Up. It gives us a structured, thoughtful pathway for trauma treatment that prioritizes stabilization before deeper work begins. Think of it as bringing the wisdom of emergency medicine into our mental health practice.
So today, I’m going to walk you through each step of this model – from stabilization techniques to assessment and planning, all the way to advanced interventions for complex cases. Whether you’re a fellow clinician or just someone interested in understanding mental health treatment better, I think you’ll find this really illuminating.
STEP 1: STABILIZATION
Let’s start with Step 1: Stabilization. This is absolutely crucial, and honestly, it’s the step we’re most likely to rush through or skip entirely in traditional therapy approaches.
What exactly do I mean by stabilization? Well, it’s about helping clients regulate their nervous systems and return to their window of tolerance before attempting any deeper therapeutic work.
The window of tolerance is such a useful concept. It describes that zone where we can function effectively – where we’re present, engaged, and able to process information and emotions. When we’re within this window, we can think clearly and respond thoughtfully rather than just react.
But trauma and chronic stress can dramatically narrow this window, making it harder for clients to stay regulated. Outside this window, clients either experience hyperarousal – feeling anxious, panicky, or overwhelmed – or hypoarousal – feeling numb, disconnected, or shut down. And here’s the thing: when clients are outside their window of tolerance, therapy that involves processing difficult material simply isn’t effective and can even be harmful.
I remember working with a client – let’s call her Maya – who had experienced a car accident and was having intrusive memories and panic attacks. In my earlier days as a therapist, I might have jumped straight into processing the accident. Instead, using the Stepped Care Approach, we spent several sessions just focused on stabilization by conducting the ASSYST intervention to re-regulate her nervous system first and expand her window of tolerance.
ASSYST stands for Acute Stress Syndrome Stabilization, and it fills the gap between basic Psychological First Aid and more intensive trauma treatments like EMDR therapy.
What I love about ASSYST is its flexibility. It can be used within hours, days, or months after a traumatic event, or during ongoing stressful situations. It can be delivered individually or in groups, in-person or online. And it doesn’t require clients to verbally recount their traumatic experiences in detail, which can sometimes be retraumatizing.
Instead, ASSYST focuses on regulating the nervous system by addressing the sensory and somatic components of the traumatic experience. It helps reduce immediate intrusive symptoms and expands the client’s capacity to handle distress.
Now, here’s an important point: for many clients, stabilization techniques alone might be sufficient to facilitate healing. Some research has shown that about 90% of people who receive ASSYST in a group format don’t require further individual treatment.
For others, stabilization creates the essential foundation for deeper work. Once clients can regulate their emotions, stay present during sessions, and have expanded their window of tolerance, they’re ready for Step 2 of the Stepped Care Approach.
STEP 2: ASSESSMENT AND TREATMENT PLANNING
Once a client has achieved basic stabilization, we move to Step 2: Assessment and Treatment Planning. Again, this parallels what happens in emergency medicine after initial stabilization – the medical team conducts a thorough assessment, runs tests, and develops a comprehensive treatment plan.
In mental health terms, this means conducting a full evaluation of the client’s history, symptoms, strengths, supports, and challenges. We’re looking to understand not just the presenting problems but also the underlying patterns and potential sources of distress.
This is where we determine whether the client would benefit from additional interventions beyond the stabilization techniques already provided. Some clients might be ready to complete therapy after stabilization, while others need more intensive treatment.
The treatment planning component involves mapping out a structured approach to therapy, establishing clear goals, and identifying the most appropriate interventions. I always make this a collaborative process with my clients, ensuring that the plan aligns with their priorities and readiness for change.
For many clients who have experienced trauma, EMDR Therapy emerges as a recommended next-level treatment during this phase. EMDR – Eye Movement Desensitization and Reprocessing – is an evidence-based approach specifically designed to process traumatic memories and reduce their emotional impact.
What makes EMDR particularly valuable in the Stepped Care model is its structured protocol. It includes its own built-in stabilization phase before processing begins, reinforcing the importance of preparation and resource-building before addressing traumatic material.
Through EMDR’s eight-phase approach, clients can process traumatic memories that were previously overwhelming to their nervous system. The bilateral stimulation used in EMDR helps the brain process information differently, allowing traumatic memories to be stored in a way that reduces their emotional charge.
I’ve seen amazing transformations with clients using this approach. One client, who had experienced childhood abuse and had tried numerous therapies over the years, told me that EMDR helped her feel like the memories were finally “just memories” rather than experiences that still felt happening in the present moment. But it was the thorough stabilization work we did first that made the EMDR processing so effective.
For some clients, standard EMDR sessions will be sufficient to address their needs. Others with more complex presentations may require additional support, which brings us to Step 3 of the Stepped Care Approach: Advanced Care.
STEP 3: ADVANCED CARE
Step 3 focuses on Advanced Care for complex cases. To continue our medical analogy, this is comparable to ICU-level care or specialized surgery – intensive interventions designed for situations where standard treatments aren’t sufficient.
In mental health, complex cases might include clients with developmental trauma, multiple traumatic experiences, dissociative disorders, or comorbid conditions that complicate treatment. These clients often benefit from specialized approaches that go beyond standard therapy protocols.
Scaling Up offers two primary advanced care options within our framework: EMDR-GAP Training and EMDR Intensives.
The EMDR GAP Training stands for Group, ASSYST, and PRECI – three powerful protocols designed to address various trauma presentations. The Group component refers to the EMDR Integrative Group Treatment Protocol, which allows therapists to provide EMDR therapy in a group setting, reaching more people simultaneously.
This is particularly valuable in community settings or after large-scale traumatic events where individual therapy for everyone might not be feasible. I’ve seen this used effectively after natural disasters and in community mental health settings where resources are limited.
The ASSYST component, which we discussed earlier, provides stabilization techniques, while the PRECI protocol (Protocol for Recent Critical Incidents) addresses both recent traumatic events and ongoing traumatic stress.
This specialized training equips therapists to work with complex trauma presentations using a stepped-care approach. It’s particularly valuable for addressing situations where clients are experiencing ongoing traumatic stress rather than single-incident trauma.
Another advanced care option is EMDR Intensives – concentrated treatment periods where clients receive multiple hours of EMDR therapy over consecutive days rather than weekly sessions. This approach can accelerate healing for clients who aren’t progressing with standard weekly sessions or who need more focused, in-depth processing.
EMDR Intensives might involve several hours of therapy per day for anywhere from one to five days. This immersive approach allows for deeper processing of traumatic material without the week-long gaps that can sometimes interrupt momentum in traditional therapy schedules.
I remember working with a client who had experienced complex trauma and was struggling with severe PTSD symptoms. We decided to try an EMDR Intensive approach, and over three consecutive days of longer sessions, he made more progress than in the previous six months of weekly therapy. The continuity and depth of the work made a tremendous difference in his healing process.
These advanced interventions require additional training and expertise from therapists. They represent the highest level of care within the Stepped Care model and are reserved for cases where standard approaches haven’t been sufficient or where the complexity of the presentation requires more specialized treatment.
CONCLUSION
So, what makes the Stepped Care Approach so valuable for mental health practice? I think it comes down to a few key points.
First, it provides a structured pathway from stabilization to advanced interventions, ensuring clients receive the appropriate level of care based on their needs and readiness. By prioritizing stabilization before deeper trauma work, we create safer therapeutic experiences and potentially prevent retraumatization.
Second, it optimizes resources – not every client needs the most intensive treatments. Some might achieve significant healing just through stabilization techniques, while others benefit from the full spectrum of care. This helps us allocate our clinical resources more effectively and ensures clients don’t receive more intervention than necessary.
Third, it gives clinicians a clear framework for decision-making. Rather than guessing whether a client is ready for trauma processing or trying to figure out why therapy isn’t progressing, the Stepped Care Approach provides clear guidelines for assessment and intervention planning.
I encourage all mental health clinicians to reflect on their current practice. Are you prioritizing stabilization before deeper therapeutic work? Do you have a structured approach for determining the appropriate level of care for each client? How might incorporating elements of the Stepped Care Approach enhance your effectiveness?
For those interested in deepening their skills in this area, Scaling Up offers comprehensive trainings in each component of the Stepped Care model – from ASSYST for stabilization to EMDR Basic Training and specialized advanced EMDR protocols for complex cases. These trainings can equip you with valuable tools to enhance your practice and better serve your clients.
Remember, just as emergency medicine prioritizes stabilization before deeper intervention, we can create more effective mental health treatments by ensuring clients have the regulation skills and nervous system stability they need before processing traumatic material.
It’s about meeting clients where they are and providing the right intervention at the right time – not rushing into deeper work simply because that’s what we think therapy should look like.
Thank you for joining me today on Scaling Up Your Impact. I hope this exploration of the Stepped Care Approach has provided valuable insights for your practice or your understanding of mental health treatment. See you next!