Living with What Is: Mindfulness-Based
Treatments for Trauma Survivors
A paper by Harrison Blum
for “Trauma and Loss Counseling” with Professor Pat Rathbone
Harvard Divinity School, Spring 2011
This paper assesses current literature on mindfulness as used in the
treatment of trauma survivors.
A brief introduction to trauma and
mindfulness will lay the groundwork for speaking of the promise of
mindfulness for ameliorating trauma symptoms and reviewing several
therapeutic
approaches
that
integrate
mindfulness
cultivation.
Difficulties and potential dangers of wedding mindfulness and trauma
treatment will also be considered. The paper will close with mention of
the responsibility both therapists and meditation teachers have to be
clear in their roles, and of the feminist opportunity meditation teachers
have in working more directly with trauma survivors.
Laying the Ground: Trauma and Mindfulness
A broad and workable definition of trauma is “anything that overwhelms a
person’s ability to cope and subsequently impedes their ability to function
effectively.”1 The experience of trauma is dictated by a person’s response to an
event rather than being intrinsic to the event itself.2 The term Posttraumatic Stress
Disorder (PTSD) is commonly evoked by the word trauma. PTSD is a condition of
distress persisting more than one month after the initial traumatic incident.3 It is
characterized by episodes of re-experiencing qualities of the traumatic event after
the fact. Those suffering from PTSD may respond to their proclivity for such
Victoria M. Follette & Aditi Vijay, Clinical Handbook of Mindfulness, ed. Fabrizio Didonna (New York:
Springer, 2010), 300.
2 Follette & Vijay, 301.
3 Follette & Vijay, 302.
1
1
episodes by shutting down or becoming hyper-aroused toward people, places, or
activities suggestive of the original trauma incident. Shy of developing PTSD, there
are a host of other trauma symptoms, from short-term increased anxiety to longterm relational repercussions.4 While certain demographics are more likely to
undergo trauma, it is not just something that happens “out there;” rather, some
studies suggest the average person will experience at least one traumatic event in
her or his lifetime.5
Certainly not all trauma survivors are able or choose to undergo treatment.
In some cases, a survivor’s resiliency and strong social support systems can be
enough to bring healing. In others, recovery is not realized. Survivors who do
engage in trauma therapy can expect to work toward the goals of being “in the
present with no intrusion from past distressing events, no fear of that intrusion or
their own affect, and the ability to function and to relate well to themselves and
others.”6
One good definition of mindfulness is “awareness of present experience with
acceptance.”7 It differs from other types of self-awareness in that “its mode of
functioning is perceptual or ‘prereflexive,’ operating on, rather than within, thought,
feeling, and other contents of consciousness.”8 Rather than being concerned with
Follette & Vijay, 301-2.
Follette & Vijay, 299.
6 Robin Shapiro, The Trauma Treatment Handbook: Protocols Across the Spectrum (New York: W. W.
Norton & Company, 2010), 57.
7 Christopher K. Germer, Mindfulness and Psychotherapy, ed. Christopher K. Germer, Ronald D. Siegel,
& Paul R. Fulton (New York: The Guilford Press, 2005), 7.
8 Kirk Warren Brown & Richard M. Ryan, “The Benefits of Being Present: Mindfulness and its Role in
Psychological Well-Being, Journal of Personality and Social Psychology 84 (April 2003): 822-848.
4
5
2
ushering in any certain state, mindfulness brings an accepting curiosity to what is
already here and now.
Buddhist practices of meditation are one long-standing source for cultivating
mindfulness, and are a significant influence on the present intersection of
mindfulness and Western psychology. Buddhist mindfulness meditation, also often
called insight or vipassana meditation, is a practice of fostering awareness and
acceptance of present experience. An object of meditation, or anchor, is often
chosen, such as the breath or bodily sensations. Other aspects of experience, such as
thought and emotion, are observed and labeled but not given attention and energy
to further develop.
While cultivated by Buddhism, it would be misguided to say mindfulness is
Buddhist. Mindfulness-Based Stress Reduction founder Jon Kabat-Zinn states “there
is nothing particularly Buddhist about it…It is an inherent human capacity.”9 It is
the deliberate fostering and sustaining of this capacity that Buddhist meditation and
several current trauma treatments attempt. Also shaping this work are elements
from “cognitive, behavioral, experiential, and psychodynamic theories.”10
Just as some survivors work through and heal their trauma symptoms
without treatment, so too do some people have propensities for mindfulness
without formal training. Mindfulness training, though, has been shown to correlate
Jon Kabat-Zinn, “Mindfulness-Based Interventions in Context: Past, Present, and Future,” Clinical
Psychology: Science and Practice 10 (June 2003): 144-156.
10 Adele M. Hayes & Greg Feldman, “Clarifying the Construction of Mindfulness in the Context of
Emotion Regulation and the Process of Change in Therapy,” Clinical Psychology: Science and Practice
11 (Fall 2004): 255-262.
9
3
with increased continuity of mindfulness.11 “Mindfulness per se is not unusual;
continuity of mindfulness is rare indeed.”12
Mindfulness in the Amelioration of Trauma Symptoms
Increased self-awareness and self-acceptance, two common results of
mindfulness practice, have been shown to reduce symptoms of trauma. The United
States Department of Veteran Affairs holds that “regular mindfulness practice can
lead to a greater present-centered awareness and nonjudgmental acceptance of
potentially distressing cognitive and emotional states…[which are] associated with
lower levels of posttraumatic stress symptoms.”13 Indeed, “noticing and contacting
private experiences without judgment is a part of the path to self-acceptance, which
is a fundamental issue for many trauma survivors.”14
One specific benefit of mindfulness for trauma survivors can be an increased
safety in the body, as “traumatized people often are terrified of the sensations in
their own bodies.”15 Encouraging awareness of the felt body with acceptance might
not change how the body feels, but it can change how one relates to those feelings.
Such acceptance avoids the trap of increasing overall stress caused by trying to
change or control discomfort.16 Rather than control, psychological awareness and
Brown & Ryan (exact page number not available).
Germer, 9.
13 U.S. Department of Veteran Affairs, Potential of Mindfulness in Treating Trauma Reactions,
http://www.ptsd.va.gov/professional/pages/mindful-PTSD.asp (March 2011).
14 Victoria Follette, Kathleen M. Palm, & Adria N. Pearson, “Mindfulness and Trauma: Implications for
Treatment,” Journal of Rational-Emotive & Cognitive-Behavior Therapy 24 (Spring 2006): 45-61.
15 Bessel van der Kolk, “Yoga and Post-Traumatic Stress Disorder: An Interview with Bessel van der
Kolk, MD,” Integral Yoga Magazine 7 (Summer 2009): 12-13.
16 Follette, Palm, & Pearson, 195.
11
12
4
flexibility are encouraged.17 Other positive results of mindfulness, as measured in
one study by the Mindful Attention Awareness Scale (MAAS), can include “lower
neuroticism, anxiety, depression, unpleasant affect, and negative affectivity.”18
These beneficial effects of mindfulness can in turn help trauma survivors
invest in the therapeutic process and strengthen the therapeutic relationship—a
central aspect of most trauma treatments. Paul Fulton, clinical psychologist and
President of the Institute for Meditation and Psychotherapy, states, “It might almost
be said that the relationship is the treatment.”19
Mindfulness-Based Trauma Interventions
As trauma symptoms manifest in different ways, so too does trauma therapy.
“The multidimensional nature of PTSD means that in clinical reality, a combination
of several different approaches is often needed.”20 Many psychologists champion
mindfulness training as an ideal complement to the psychotherapeutic process
across these different approaches.21 Even if not directly included the therapeutic
model, mindfulness exercises can be practiced at the beginning of sessions to help
orient toward the work.22 In addition to the benefits already outlined for survivors,
increased mindfulness of therapists can enable them to better fulfill their side of the
therapeutic relationship. “The therapist offers the patient the possibility of staying
Follette & Vijay, 310.
Brown & Ryan.
19 Paul R. Fulton, Mindfulness and Psychotherapy, 57.
20 Bessel van der Kolk, Psychological Trauma (Washington, DC: American Psychiatric Press, Inc.,
1987), xvii.
21 Shapiro, 64; Follette, Palm, & Pearson 53-6.
22 Follette, Palm, & Pearson, 204.
17
18
5
emotionally present with the therapist.”23 To offer this possibility, the therapist
must herself be present.
Several types of therapy do directly involve mindfulness training.
Mindfulness-Based Stress Reduction incorporates mindfulness meditation and yoga,
largely in the treatment of chronic pain but also for anxiety and depression—two
symptoms of trauma. Mindfulness-Based Relapse Prevention teaches the practice of
“urge surfing,” wherein clients practice being present with instead of acting on their
urges for substance use, a common coping mechanism for trauma survivors.24
Mindfulness-Based Cognitive Therapy aims to increase awareness of and openness
to thoughts and feelings with the end goal of changing them for the better.25
Dialectical Behavior Therapy (DBT) “integrates mindfulness into the treatment
package as part of the skills training” toward developing “specific skill sets such as
emotion regulation and distress tolerance.”26 Mindful Awareness in Body-oriented
Therapy (MABT) “incorporates massage, mindfulness, and the emotional processing
of psychotherapy” toward “accessing and accepting sensory and emotional
awareness in the body, an important foundation for self-awareness and selfregulation in the treatment of PTSD.”27 Paired with exposure therapy, mindfulness
“offers clinicians a way in which to target the avoidance that is a barrier to effective
trauma therapy.”28
Janet L. Surrey, Mindfulness and Psychotherapy, 94.
U.S. DVA website.
25 Follette, Palm, & Pearson, 49-50.
26 Follette, Palm, & Pearson, 55.
27 Cynthia Price et al., “Mindful Awareness in Body-Oriented Therapy for Female Veterans with PostTraumatic Stress Disorder Taking Prescription Analgesics for Chronic Pain: A Feasibility Study,”
Journal of Traumatic Stress 20 (June 2007): 239-249.
28 Follette & Vijay, 309.
23
24
6
Recent case studies demonstrating the efficacy of these therapies are
instructive in their suggestions, though often limited by small sample sizes. One
study demonstrates mindfulness training to have reduced trauma symptoms for 15
Sri Lankan children exposed to war and the 2004 tsunami.29 Alessandra Pigni, a
clinical psychologist working in the Palestinian Territories, found mindfulnessbased therapies help two women traumatized by the death of their sons to “be with
their bodily experience, to infuse their practice with a sense of acceptance and
gentleness, to settle and calm the mind, and develop a new relationship with their
experience.”30 In the U.S. Northwest, 14 female veterans experiencing trauma
symptoms were shown through MABT to gain “learning tools for relief/relaxation,
increased body-mind connection, and increased trust/safety” as well as “a sense of
control over their pain.”31 Also in the U.S. Northwest, 29 incarcerated trauma
survivors were shown to have reduced substance use upon release within three
months of taking a Vipassana meditation course in the prison (declines in other
trauma-related symptoms were not observed, however).32
Difficulties and Dangers
Care needs to be taken when seeking to manifest the therapeutic potential of
mindfulness in the process of trauma treatment. Though “increased awareness is
Claudia Catani et al., “Treating Children Traumatized by War and Tsunami: A Comparison Between
Exposure Therapy and Meditation-Relaxation in North-East Sri Lanka.” BioMed Central- Psychiatry,
published online: May 2009.
30 Alessandra Pigni, “A First-Person Account of Using Mindfulness as a Therapeutic Tool in the
Palestinian Territories.” Springer—Science and Business Media, LLC. published online: November,
2009, 156.
31 Price (exact page number not available).
32 T. L. Simpson et al., “PTSD Symptoms, Substance Use, and Vipassana Meditation among
Incarcerated Individuals.” Journal of Traumatic Stress 20 (June, 2007): 239-249.
29
7
presumed to lead to greater psychological and emotional freedom in both the
psychodynamic and mindfulness traditions,” these traditions have some important
differences.33 Clinical psychologist Carolyn Clement presents that “Buddhist
psychology…presumes a cohesive self.”34 As opposed to Western psychology,
“traditional Buddhist psychology does not include a theory of early individual
development and does not encompass the vulnerabilities that result from profound
disturbance in the mother-infant relationship or in formative relationships more
generally.”35 While Buddhist psychology can offer useful tools for self-awareness
and acceptance, it could be shortsighted to navigate through traumatic territory
without pairing these tools with the developmental maps presented by Western
psychology.
It is also well to understand that while mindfulness can increase well being,
this does not translate into a “the more the better” equation for all people.
Mindfulness for trauma survivors should be taught progressively, with clientcentered assessment. “What to one person may be experienced as an opportunity
for growth or transcendence, to another may be felt as a horrifying leap into the
void.”36 One way to begin slowly is to start by cultivating awareness of external
events, such as sound and sight.37 Walking meditation, with its focus on the
sensation of the foot touching the ground, can be another appropriate technique for
Paul R. Fulton & Ronald D. Siegel, Mindfulness and Psychotherapy, 35.
Carolyn Clement, “The Evocation of Death Anxiety on a Meditation Retreat,” Psychoanalytic
Dialogues 15, (No. 2 2005): 139-152.
35 Clement, 140.
36 Clement, 140.
37 Follette and Vijay, 313.
33
34
8
beginners.38 Some mindfulness-based therapies structure in such progression.
MABT interventions have three progressive phases—body literacy, awareness, and
acceptance, which are introduced over 8 one-hour sessions.39
When implementing such incremental teaching, those introducing
mindfulness practices to trauma survivors still need to be prepared to trouble-shoot
difficulties. Dr. Bessel van der Kolk, founding director of the Trauma Center in
Boston, speaks to this in an interview about yoga for trauma survivors. “Yoga
teachers need to be aware that material will come up during class and they need to
be prepared at all times to help people to calm down their bodies, by working with
the breath and quieting poses.”40 Robin Shapiro, author of the Trauma Treatment
Handbook (2010), offers a supportive disclaimer when offering meditation
instruction to a client for the first time. “This exercise works well for a lot of people.
Once in a while it brings up big distressing feelings. If that happens, let me know,
and we’ll do something with them.”41
Mindfulness meditation teacher Amy Schmidt and psychologist John Miller,
in their article “Healing Trauma With Meditation,” offer guidance for what a
therapist or mindfulness instructor might do if he or she does perceives the practice
bringing up too much too soon for the client. Attention can be placed on the breath
or the body, as is safest for the client. Mindfulness of the body need not include the
whole body, and can be focused on one small, specific place. Such a place may be
found by scanning for a place in the body that feels comfortable and safe. Practice
Siegel, 190.
Price.
40 van der Kolk, 2009, 13.
41 Shapiro, 59.
38
39
9
sessions can be kept short, with a “focus on balance and equanimity rather than
effort and progress.”42 Painful thoughts, emotions, and feelings in the body can be
touched upon in small doses, retreating back to a more comfortable object of
attention when needed. With a curiosity toward such challenging moments, they
can be labeled to help illumine what is actually present in the moment. Affirmations
of self-love can be reflected upon as a form of self-care. Finally, at times when
trauma symptoms are too overwhelming to be navigated, distraction can be used as
a fallback to shift the survivor’s focus.43
The context of a meditation retreat warrants special consideration for
trauma survivors. “On the one hand, it can reenact the feeling of being isolated and
silenced by the perpetrator, the family, or society. But a retreat can also provide a
stable and safe space in which they can begin to relax—often for the first time.”44
While meditation retreat intake forms do usually include questions about past or
ongoing psychiatric treatment, there is no formula to predict who might experience
an exacerbated condition during retreat. Trauma symptoms may arise gradually
and their outward indicators cryptically. A survivor might first experience a general
sense of panic. This could be followed by kinesthetic flashbacks related to the
traumatic event. Visual flashbacks might then follow, with varying degrees of
understanding on the part of the survivor. Miller and Schmidt state that “when a
meditator experiences a flashback, often the intrusion of these painful memories
into conscious awareness can be an indication that the meditator needs to stop
John J. Miller & Amy Schmidt, “Healing Trauma With Meditation,” Tricycle 13 (Fall 2004): (exact
page number not available).
43 Miller & Schmidt.
44 Miller & Schmidt.
42
10
practice and address the trauma through psychotherapy; a [meditation] teacher is
usually the best person to make this determination.”45
Not all signs of struggle should be taken as harmful, however. “In a
meditation retreat, much as in psychoanalysis, crises present unique opportunities
for growth.”46 Indeed, an apparent worsening of symptoms can actually be part of a
larger cycle from avoidance to acceptance, and then destabilization to healing.47
Again, the key is not to overwhelm the survivor with the pace of this process.
As a survivor develops mindfulness skills and moves through the healing
process, an important, and perhaps counter-intuitive, objective could be not to do
away with all forms of judgment. While the non-judgmental awareness of
mindfulness has been shown to be therapeutic in many capacities, a 2009 study of
183 traumatized police officers from a Midwestern state found that a certain degree
and kind of judgment is necessary for posttraumatic growth (PTG). “PTG is defined
as positive changes within a person resulting from an event that disrupts one’s view
of the world…[often] manifested as a greater appreciation for life, more meaningful
interpersonal relationships, and an increased sense of personal strength.”48 The
study suggests that “possessing a sense of, and exerting psychological control over,
the traumatic experience may facilitate meaning-making, coping, and ultimately the
development of PTG,” while “acceptance without evaluation may not elicit enough
Miller & Schmidt.
Clement, 143
47 Steven Hayes et al. ed., Mindfulness and Acceptance: Expanding the Cognitive-Behavioral Tradition
(New York: Guilford Press, 2004),159.
48 Brian A. Chopko & Robert C. Schwartz, “The Relation Between Mindfulness and Posttraumatic
Growth: A Study of First Responders to Trauma-Inducing Incidents,” Journal of Mental Health
Counseling 31 (October, 2009): 363-377.
45
46
11
cognitive processing of the event” to support PTG.49 Care should therefore be taken
when presenting the practice of non-judgmental awareness to leave space for
honoring a survivor’s belief system and ways of making meaning.
As with all interventions, cultural sensitivity should be applied. Mindfulness,
both its specific techniques and general inward focus, will connote different things
for different people. In the case from Sri Lanka mentioned above, “meditation and
relaxation” were already found to be part of the Tamil culture there.50 In the
Palestinian Territories, Pigni found the women she was working with responded to
mindfulness training as an enticing novelty. While the practice itself was unfamiliar
to them, it did map on well to the Palestinian Arab tendency “to describe their
suffering in somatic terms using metaphoric expressions.”51
In addition to Western psychologists and meditation teachers looking at how
they bring mindfulness practices to other cultures, they would do well to examine
how they are bringing mindfulness into their own. Andrew Olendzki, Executive
Director and teacher at the Barre Center for Buddhist Studies, speaks well to this
concern.
The appearance and practice of mindfulness theory in Western psychotherapy is
a modern instance of cultural adaptation of Buddhist psychology. The question
remains whether psychotherapy, in its effort to make mindfulness useful in
clinical practice, will neglect its potential for radical liberation, or whether
Buddhist psychology and practice will invigorate psychotherapy with its broad
conception of human potential.52
Chopko & Schwartz, (exact page number not available).
Catani, (exact page number not available).
51 Pigni, 153.
52 Andrew Olendzki, Mindfulness and Psychotherapy, 261.
49
50
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Responsibilities and Promise
As overlap increases between the roles of therapist and meditation teacher,
these professionals should be forthright about their intentions, techniques, and
training background. This ground can be ambiguous for clinical psychologists
drawing from Buddhist practices, and should be clarified as much as possible both
for themselves and their clients. Christopher Germer, clinical instructor in
psychology at the Harvard Medical School and Director of the Institute for
Meditation and Psychotherapy, states “it cannot be overemphasized that Buddhist
psychology is not a religion in the familiar, theistic sense.”53 He also suggests that
psychologists using mindfulness-based interventions, specifically the editors and
contributors of his work Mindfulness and Psychotherapy (2005), are more “students
of Buddhist psychology and meditation rather than Buddhists.”54 While this may be
the case, the distinction between studying Buddhism and being Buddhist can be
subtle. A psychologist telling her patient that she is not Buddhist might be speaking
her truth, but might also meditate regularly at a Buddhist center and study Buddhist
texts—behaviors to an outsider that could understandably be read as being
Buddhist. To the extent that faith and religious affiliation is of consequence to a
survivor, articulating one’s professional role and religious identity must be done
with consideration of the client’s sense of what being Buddhist means.
Consideration should also be given to ensuring the path between
mindfulness and trauma therapy is a two way street. Clinical psychologists are
clearly being influenced by the promise of mindfulness, but are mindfulness
53
54
Germer, 12.
Germer, xv.
13
meditation teachers being affected by the need for trauma therapy? Are meditation
teachers branching out to teach mindfulness skills to those in the most need, and not
just to those who find their way to retreat and meditation centers? Such outreach
could appeal to survivors more than clinical applications, as “meditation, yoga, and
martial arts instruction are not as culturally stigmatized as psychotherapy.”55 Those
with the most experience offering mindfulness meditation instruction could also be
the most qualified to serve as the “tip of the iceberg” teachers needed for disasterrelief work, wherein the ideal are quick trainings for disaster interventions that are
“pragmatic and short to allow for a high number of affected individuals to be treated
within a short time.”56
Across the circumstances calling for trauma intervention, “critical issues [are
raised] about responsibility, and about the mutual obligations between victims and
society.”57 Van der Kolk expounds, “This opens up the issue of human rights: Do
people have the right to expect support when their own resources are inadequate,
or do they have to live with their suffering and not expect any particular
compensation for their pain?”58 Within human rights, the issue of women’s rights is
specifically at play, as women are two times more likely than men to develop
PTSD,59 “likely due to the greater exposure to violent crimes associated with severe
distress.”60 As individuals known to the survivors perpetrate a high number of
Shapiro, 64.
Catani.
57 van der Kolk, 1987, x.
58 van der Kolk, 1987, xi.
59 Follette & Vijay, 301.
60 Price.
55
56
14
these sexual and/or violent crimes, the additional suffering and trauma of betrayal
can compound this distress.61
In light of the gendered nature of trauma, stepping out of meditation and
retreat centers to meet the front lines of trauma survival can be one way to answer
Rita Gross’ call to manifest Buddhism After Patriarchy (1993). With a worldview
that makes laudable space for gender equality but a history that betrays repeated
patriarchical manifestation, Buddhism and its technologies of mindfulness would be
well utilized in the healing of women suffering trauma, trauma presumably more
often induced by the actions of men.
Conclusion
This paper discussed the practices, risk, and promise located at the
intersection of mindfulness and trauma therapy. It will hopefully be of some use to
both clinical psychologists and mindfulness meditation teachers seeking to learn
more about the other’s work in healing trauma survivors, though the author is not
the former and is only newly stepping into the role of the latter.
61
Follette & Vijay, 304.
15
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17