PTSD: National Center for PTSD
Potential of Mindfulness in Treating Trauma Reactions
Potential of Mindfulness in Treating Trauma Reactions
Mindfulness is most commonly conceptualized as involving attention to and awareness of the present moment, and nonjudgmental acceptance (1-3). Awareness of the present involves observing thoughts, feelings, and sensations by focusing one's attention on the current moment (2). While attending to the present, mindfulness also entails a stance of acceptance, or willingness to experience an array of thoughts and emotions without judgment (4).
Clinical utility of mindfulness for treatment following trauma
The potential clinical utility of integrating mindfulness-based exercises in extant PTSD treatments has yet to be examined empirically (5). However, given the beneficial effects of mindfulness practice on enhancing emotion regulation as well as decreasing anxiety and depressive symptoms (6-9), mindfulness has been increasingly discussed in the context of PTSD and its treatment (10-12). The relevant theoretical and empirical literature suggests that mindfulness may serve clinically meaningful functions in alleviating PTSD symptoms.
Regular mindfulness practice can lead to a greater present-centered awareness and nonjudgmental acceptance of potentially distressing cognitive and emotional states as well as trauma-related internal and external triggers (5, 13). Awareness and acceptance of trauma-related thoughts and feelings may serve as an indirect mechanism of cognitive-affective exposure. This may be especially useful for individuals with PTSD, as it may help decrease experiential avoidance, reduce arousal, and foster emotion regulation. For instance, among trauma-exposed individuals evaluated at a single time point, greater levels of acting with awareness and accepting without judgment were associated with lower levels of posttraumatic stress symptoms (11). Regular mindfulness practice has also been shown to decrease physiological arousal (14- 15).
Adjunct to empirically-supported treatments for PTSD
Empirically-supported treatments for PTSD, such as Cognitive Processing Therapy (CPT, 16) and Prolonged Exposure (PE, 17), are effective in decreasing symptoms for many individuals who suffer from PTSD. Both of these treatments direct the client to recall traumatic events in a controlled fashion. For the last decade, exposure to and processing of trauma-related thoughts, feelings, and memories have been considered important components of effective treatment for PTSD. However, a significant proportion of sufferers either do not seek help, drop out of treatment, refuse these treatments, or are not substantially helped by them (5, 18-19).
Combining mindfulness or other skills to strengthen emotion regulation with existing empirically-supported PTSD treatments may improve outcomes in the following ways:
Engagement. Mindfulness may appeal to clients who do not pursue evidence-based treatments or cannot tolerate them (5, 20-21). Mindfulness practice may improve symptoms and it may also help such clients become engaged with a therapist or treatment process.
Preparation. Mindfulness practice could be introduced prior to treatment. Learning to observe internal reactions without judgment and to accept feelings, sensations, and thoughts as they arise might usefully prepare patients to tolerate the unpleasant emotions that trauma processing elicits.
Less rumination. If implemented as an adjunct to CPT or PE, mindfulness could be encouraged throughout the treatment course. Increased awareness of trauma-related re-experiencing symptoms may allow patients to break a ruminative cycle by gaining some distance from trauma-related intrusive thoughts and feelings. It may foster acceptance rather than avoidance.
Compliance. Patients using mindfulness skills during treatment may be better able to persevere through trauma processing and benefit more fully from trauma-focused treatments.
Specific mindfulness-based interventions
Several psychotherapeutic interventions incorporating training in mindfulness are clinically relevant to traumatic stress. Although data are currently lacking on the efficacy of these interventions in PTSD populations specifically, research has supported the utility of these treatment approaches for various mental health concerns. Moreover, these interventions may be clinically useful for patients with PTSD as they target symptoms such as anxiety, depression, or emotion dysregulation that commonly co-occur with posttraumatic stress. At this time, the interventions listed below might best be considered meaningful tertiary care for patients with PTSD.
Acceptance and Commitment Therapy (ACT). The goal of ACT is to increase psychological flexibility and facilitate behavior change, such that patients become more committed to moving toward identified goals and values (12, 22). Randomized controlled trials are currently underway to evaluate the efficacy of ACT as a stand-alone treatment for PTSD. ACT targets avoidance of thoughts, memories, emotions, and other private experiences. Mindfulness exercises are one of a variety of techniques used to increase willingness to experience thoughts and feelings and thus facilitate psychological flexibility. In PTSD, these experiences may include intrusive recollections of the traumatic event and emotional states of guilt or anger. Patients are taught to be aware of private events without judging or attempting to control them (5, 8).
Dialectical Behavior Therapy (DBT). DBT is a multifaceted treatment for borderline personality disorder and related problems (23). In addition, DBT often has been used prior to the implementation of PTSD-specific treatments such as exposure-based interventions to address difficulties with emotion regulation and distress tolerance (24). DBT incorporates training in mindfulness as one of four areas of skill-building. In DBT, mindfulness involves three "what" skills (observing, describing, and participating) and three "how" skills (taking a nonjudgmental stance, focusing on one thing in the moment, and being effective).
Mindfulness-Based Stress Reduction. This treatment has primarily been employed to help patients manage stress associated with a variety of physical health conditions, such as chronic pain (25-28). It has also been shown to be a useful treatment approach for anxiety disorders and depression (7, 29), conditions that commonly co-occur with PTSD (30). Mindfulness meditation, a part of this therapy, is intended to cultivate a de-centered and nonjudgmental perspective in relation to physical sensations as well as cognitions and emotions (27).
Mindfulness-Based Cognitive Therapy. This consists of an eight-week group intervention that draws upon both mindfulness and cognitive therapy techniques, with the aim of reducing the risk of depressive relapse (8, 31). Patients are taught to focus more carefully on everyday events and allow thoughts to occur without trying to avoid or suppress them. Mindfulness Based-Cognitive Therapy thus might be a useful tertiary care program for patient struggling with PTSD and depression.
Mindfulness-Based Relapse Prevention. Mindfulness skills are employed in this prevention therapy as a technique for coping with urges to use substances following treatment for drug abuse and addiction (32). These skills help patients engage in "urge surfing" by observing their urges as they appear, accepting them nonjudgmentally, and 'riding the waves' without giving in to the urges. The prevalence of substance abuse problems among individuals with PTSD has been explained in terms of the emotional avoidance function of drug and alcohol use. As such, mindfulness interventions can be used to address substance use and other behaviors used to avoid trauma-related experiences (33).
Assessment of mindfulness
Adequately measuring mindfulness is important in assessing if the essential components of mindfulness are what is responsible for change when it is used. Self-report instruments differ slightly in their conceptualizations of mindfulness. Two of the most widely used instruments to date are the Mindful Attention Awareness Scale (MAAS, 34) and the Five Facet Mindfulness Questionnaire (FFMQ, 1). The MAAS assesses awareness of present experience throughout daily life. The FFMQ (23) measures a range of facets and covers observing, describing, acting with awareness, acceptance without judgment, and non-reactivity to inner experience.
Other mindfulness measures include the Cognitive Affective Mindfulness Scale - Revised (35), the Philadelphia Mindfulness Scale (36), and the Freiburg Mindfulness Inventory (37). Each of these measures is designed to assess an individual's tendency to be aware of their present experience over time, or trait mindfulness. In contrast, the Toronto Mindfulness Scale (38) was developed to assess state mindfulness, or the degree to which one is able to reach a mindful state during mindfulness practice, such as meditation. Although each of the available measures has demonstrated solid psychometric properties in initial research (e.g., 39), further work is needed to address the discrepancies in definitions and assessments of mindfulness and its various facets (2, 40) and to determine whether these measures are sensitive to changes in mindfulness levels over time.
Mindfulness-based approaches have been shown to be useful for problems commonly seen in trauma survivors such as anxiety and hyperarousal. Mindfulness practice has potential to be of benefit to individuals with PTSD, either as a tertiary or a stand-alone treatment. However, before definitive conclusions can be drawn about the efficacy of mindfulness in treatment of PTSD, further basic and applied research is needed.
- Baer, R. A., Smith, G. T., Hopkins, J., Krietemeyer, J., & Toney, L. (2006). Using self-report assessment methods to explore facets of mindfulness. Assessment, 13, 27-45.
- Bishop, S. R., Lau, M. A., Shapiro, S., Carlson, L., Anderson, N. D., Carmody, J., et al. (2004). Mindfulness: A proposed operational definition. Clinical Psychology: Science and Practice, 11, 230-241.
- Block-Lerner, J., Salters-Pedneault, K., Tull, M. T., Orsillo, S. M., & Roemer, L. (2005). Assessing mindfulness and experiential acceptance: Attempts to capture inherently elusive phenomena. Acceptance and mindfulness-based approaches to anxiety: Conceptualization and treatment (pp. 71-99). New York: Springer Science + Business Media.
- Roemer, L., & Orsillo, S. M. (2002). Expanding our conceptualization of and treatment for generalized anxiety disorder: Integrating mindfulness/acceptance-based approaches with existing cognitive-behavioral models. Clinical Psychology: Science and Practice, 9, 54-68.
- Follette, V. M., & Vijay, A. (2009). Mindfulness for trauma and posttraumatic stress disorder. In F. Didonna (Ed.), Clinical handbook of mindfulness (pp. 299-317). New York: Springer Science + Business Media.
- Bernstein, A., Tanay, G., & Vujanovic, A. A. (in press). Concurrent relations between mindful attention and awareness and psychopathology among trauma-exposed adults: Preliminary evidence of transdiagnostic resilience. Journal of Cognitive Psychotherapy.
- Kabat-Zinn, J., Massion, A. O., Kristeller, J., & Peterson, L. G. (1992). Effectiveness of a meditation-based stress reduction program in the treatment of anxiety disorders. American Journal of Psychiatry, 149, 936-943.
- Segal, Z. V., Williams, J. M. G., & Teasdale, J. D. (2002). Mindfulness-based cognitive therapy for depression: A new approach to preventing relapse. New York: Guilford Press.
- Vujanovic, A. A., Bonn-Miller, M. O., Bernstein, A., McKee, L. G., & Zvolensky, M. J. (in press). Incremental validity of mindfulness skills in relation to emotional dysregulation among a young adult community sample. Cognitive Behaviour Therapy.
- Orsillo, S. M., & Batten, S. V. (2005). Acceptance and commitment therapy in the treatment of posttraumatic stress disorder. Behavior Modification, 29, 95-129.
- Vujanovic, A. A., Youngwirth, N. E., Johnson, K. A., & Zvolensky, M. J. (2009). Mindfulness-based acceptance and posttraumatic stress symptoms among trauma-exposed adults without axis I psychopathology. Journal of Anxiety Disorders, 23, 297-303.
- Walser, R. D., & Westrup, D. (2007). Acceptance & commitment therapy for the treatment of post-traumatic stress disorder and trauma-related problems: A practitioner's guide to using mindfulness and acceptance strategies. Oakland, CA: New Harbinger Publications.
- Walser, R. D., & Hayes, S. C. (1998). Acceptance and trauma survivors: Applied issues and problems. In V. M. Follette, J. I. Ruzek & F. R. Abueg (Eds.), Cognitive-behavioral therapies for trauma (pp. 256-277). New York: Guilford Press.
- Baer, R. A. (2003). Mindfulness training as a clinical intervention: A conceptual and empirical review. Clinical Psychology: Science and Practice, 10, 125-143.
- Shapiro, D. H. (1982). Overview: Clinical and physiological comparison of meditation with other self-control strategies. American Journal of Psychiatry, 139, 267-274.
- Resick, P. A., Monson, C. M., & Chard, K. M. (2007). Cognitive processing therapy: Veteran/military version. Washington, DC: Department of Veterans' Affairs.
- Foa, E. B., Hembree, E. A., & Rothbaum, B. O. (2007). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences. Therapist guide. New York: Oxford University Press, Inc.
- Hembree, E. A., Cahill, S. P., & Foa, E. B. (2004). Impact of personality disorders on treatment outcome for female assault survivors with chronic posttraumatic stress disorder. Journal of Personality Disorders, 18, 117-127.
- Schottenbauer, M. A., Glass, C. R., Arnkoff, D. B., Tendick, V., & Gray, S. H. (2008). Nonresponse and dropout rates in outcome studies on PTSD: Review and methodological considerations. Psychiatry: Interpersonal and Biological Processes, 71, 134-168.
- Becker, C. B., & Zayfert, C. (2001). Integrating DBT-based techniques and concepts to facilitate exposure treatment for PTSD. Cognitive and Behavioral Practice, 8, 107-122.
- Cloitre, M., Koenen, K. C., Cohen, L. R., & Han, H. (2002). Skills training in affective and interpersonal regulation followed by exposure: A phase-based treatment for PTSD related to childhood abuse. Journal of Consulting and Clinical Psychology, 70, 1067-1074.
- Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (1999). Acceptance and commitment therapy: An experiential approach to behavior change. New York: Guilford Press.
- Linehan, M. M. (1993). Cognitive-behavioral treatment of borderline personality disorder. New York: Guilford Press.
- Wagner, A. W., & Linehan, M. M. (2006). Applications of dialectical behavior therapy to posttraumatic stress disorder and related problems. In V. M. Follette & J. I. Ruzek (Eds.), Cognitive-behavioral therapies for trauma (2nd ed., pp. 117-145). New York: Guilford Press.
- Kabat-Zinn, J. (1982). An outpatient program in behavioral medicine for chronic pain patients based on the practice of mindfulness meditation: Theoretical considerations and preliminary results. General Hospital Psychiatry, 4, 33-47.
- Kabat-Zinn, J. (1990). Full catastrophe living: Using the wisdom of your mind to face stress, pain and illness. New York: Dell.
- Kabat-Zinn, J. (1994). Wherever you go, there you are: Mindfulness meditation in everyday life. New York: Hyperion.
- Kabat-Zinn, J., Lipworth, L, & Burney, R. (1985). The clinical use of mindfulness meditation for the self-regulation of chronic pain. Journal of Behavioral Medicine, 8, 163-190.
- Ramel, W., Goldin, P.R., Carmona, P.E., & McQuaid, J.R. (2004). The effects of mindfulness meditation on cognitive processes and affect in patients with past depression. Cognitive Therapy and Research, 28, 433-455.
- Kessler, R. C., Sonnega, A., Bromet, E., Hughes, M., & Nelson, C. B. (1995). Posttraumatic stress disorder in the national comorbidity survey. Archives of General Psychiatry, 52, 1048-1060.
- Teasdale, J. D., Segal, Z., & Williams, J. M. G. (1995). How does cognitive therapy prevent depressive relapse and why should attentional control (mindfulness) training help? Behaviour Research and Therapy, 33, 25-39.
- Marlatt, G. A., & Gordon, J. R. (1985). Relapse prevention: Maintenance strategies in the treatment of addictive behaviors. New York: Guilford Press.
- Batten, S. V., & Hayes, S. C. (2005). Acceptance and commitment therapy in the treatment of comorbid substance abuse and post-traumatic stress disorder: A case study. Clinical Case Studies, 4, 246-262.
- Brown, K. W., & Ryan, R. M. (2003). The benefits of being present: Mindfulness and its role in psychological well-being. Journal of Personality and Social Psychology, 84, 822-848.
- Feldman, G., Hayes, A., Kumar, S., Greeson, J., & Laurenceau, J.-P. (2007). Mindfulness and emotion regulation: The development and initial validation of the cognitive and affective mindfulness scale-revised (CAMS-R). Journal of Psychopathology and Behavioral Assessment, 29, 177-190.
- Cardaciotto, L., Herbert, J. D., Forman, E. M., Moitra, E., & Farrow, V. (2008). The assessment of present-moment awareness and acceptance: The Philadelphia mindfulness scale. Assessment, 15, 204-223.
- Walach, H., Buchheld, N., Buttenmuller, V., Kleinknecht, N., & Schmidt, S. (2006). Measuring mindfulness--the Freiburg mindfulness inventory (FMI). Personality and Individual Differences, 40, 1543-1555.
- Lau, M. A., Bishop, S. R., Segal, Z. V., Buis, T., Anderson, N. D., Carlson, L., et al. (2006). The Toronto mindfulness scale: Development and validation. Journal of Clinical Psychology, 62, 1445-1467.
- Baer, R. A., Smith, G. T., Lykins, E., Button, D., Krietemeyer, J., Sauer, S., et al. (2008). Construct validity of the five facet mindfulness questionnaire in meditating and nonmeditating samples. Assessment, 15, 329-342.
- Grossman, P. (2008). On measuring mindfulness in psychosomatic and psychological research. Journal of psychosomatic research, 64, 405-408.