PTSD: National Center for PTSD
Potential of Mindfulness in Treating Trauma Reactions
Vujanovic, Niles, Pietrefesa, Potter, & Schmertz
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 traumarelated 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.
Conclusion
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.
See: http://www.ptsd.va.gov/professional/treatment/overview/mindful-PTSD.asp