Clinical Handbook of Mindfulness (84 page)

peutic alliance
, doctoral thesis, Massachusetts School of Professional Psychology.

16

Mindfulness for Trauma and

Posttraumatic Stress Disorder

Victoria M. Follette and Aditi Vijay

The only way out is through.

– Robert Frost

As a result of events such as the terrorist attacks of September 11th, the

bombings in Madrid in 2004, and multiple armed conflicts throughout the

world, the word
trauma
and the term
posttraumatic stress disorder
(PTSD)

have become a part of the popular lexicon. The word trauma comes from

the Greek word for
wound
and in psychological terms it has come to refer

to distressing experiences that overwhelm an individual’s ability to func-

tion. Psychological trauma is associated with exposure to external events,

which is considered painful and can impact internal psychological processes

(Wilson, Friedman & Lindy
,
2001).
However, it is important to note that trauma does not occur in a vacuum or in an isolated context; other environmental factors impact the exposure to trauma and the subsequent responses

or reactions. The effects of trauma are not limited to PTSD. Rather they can

be multidimensional and impact numerous domains of life. These complex

responses to trauma can affect an individual’s relationships, level of function-

ing, and ability to engage and participate in one’s own life. The exposure

to a potentially traumatic event is a statistically normative experience with

some estimates suggesting that the average person will be exposed to at least

one potentially traumatic event over the course of a lifetime
(Bonanno, 2005;

Breslau, 2002).
Trauma is defined as an event where someone “experiences, witnesses or confronts an event or events that involved actual or threatened

death or serious injury, or a threat to the physical integrity of self or others”

(APA, 1994,
pp. 427–428). It is important to note that while some individuals exhibit signs of psychological distress following exposure to a traumatic

event, others recover their prior level of functioning without external inter-

vention. While labeled as “disorders,” PTSD and acute stress are considered

by many to be normal response patterns to extremely stressful life events

(Wilson et al., 2001).

In response to the need for treatment for survivors of trauma, cogni-

tive behaviorists have developed exposure based treatments that are effec-

tive in treating reactions to trauma
(Foa & Meadows, 1997).
Exposure based therapy targets the cognitions and emotional reactions associated with

memories of the traumatic event. Cognitive processing therapy (CPT) is a

related evidence-based treatment that incorporates elements of cognitive and

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Victoria M. Follette and Aditi Vijay

exposure therapy. Although CPT was originally developed to intervene with

victims of sexual assault, recent research indicates that CPT is effective in

veterans with chronic PTSD
(Monson et al., 2006).

While exposure based treatments have documented utility, the literature

also indicates that a proportion of trauma survivors have difficulty engag-

ing in exposure based treatments and therefore do not always fully experi-

ence the benefits
(Becker & Zayfert, 2001).
We propose that mindfulness enhanced behavioral treatments will prove to be a useful treatment that

provides an alternative for approach for clients who are either unwilling

or unable to engage in traditional therapies. Moreover, in that our treat-

ment addresses a variety of domains that are beyond trauma-related symp-

toms, it can provide an approach that is more suitable for clients presenting

with a wide range of problems associated with trauma exposure (Follette,

Palm & Rasmussen-Hall,
2004; Follette, Palm & Pearson, 2006).
This chapter will briefly present the literature on trauma and mindfulness and the utility

of the construct of mindfulness within an integrative behavioral approach

to treatment. The integrative behavioral approach draws from the theoret-

ical foundations and practices associated with what has been called third

wave behavior therapy. This “third wave” builds upon the earlier traditions

of behavior therapy and provides a contextual approach for dealing with

complex psychological problems. Traditional behavior therapy focused on

problematic behavior and emotion and attempted to changes these behav-

iors through conditioning and behavioral principles
(Hayes, 2004).
The second wave of behavior therapy moved toward targeting faulty cognitions

and pathological schemas and became known as cognitive-behavior ther-

apy. Ineffective behavior was modified through the application of a cogni-

tive model that targeted dysfunctional beliefs and/or information processing.

Third wave behavior therapy integrates components of the first and second

waves while also emphasizing constructs of mindfulness, acceptance, val-

ues, and dialectics. Third wave behavior therapy is based on an empirical,

principle-focused approach that emphasizes function over form, where the

underlying cause of behavior is targeted rather than the topography. These

approaches tend to utilize experiential and contextual change strategies in

conjunction with more traditional behavioral approaches. The treatment

approaches that have emerged in association with this movement (accep-

tance and commitment therapy [ACT], functional analytic psychotherapy

[FAP], and dialectical behavior therapy [DBT]) seek to enhance a client’s

existing repertoire by enhancing psychological flexibility, leading to more

effective behavior
(Hayes, 2004).
Our integrative behavioral approach to the treatment of trauma draws on the third wave behavior therapy practices and

to enable therapists to tailor treatment idiographically, while remaining the-

oretically and philosophically consistent. In order to demonstrate the appli-

cation of this approach, a clinical illustration will be utilized to demonstrate

how mindfulness exercises can be implemented with a trauma survivor and

enhance overall treatment.

Trauma

A traumatic event is considered to be anything that overwhelms a person’s

ability to cope and subsequently impedes their ability to function effec-

tively.
Cloitre, Cohen & Koenen (2006)
assert that trauma is defined as “any
Chapter 16 Mindfulness for Trauma and Posttraumatic Stress Disorder

301

circumstance in which an event overwhelms a person’s capacity to protect

his or her psychic well-being or integrity, where the power of the event

is greater than the resources available for effective response and recovery”

(p. 3). Inherent within this conceptualization is the notion that a distressing

event on its own is not considered traumatic; a critical part of determin-

ing the impact of an event is the individual reaction. Thus, trauma exposure

represents a complex relationship between the traumatic event, the indi-

vidual and their response. The impact of such an event can be shattering

for some people, while others are able to resume life with seemingly few

interruptions. Trauma-related distress can be compounded by the individ-

ual’s desire to spend a great deal of time processing the event while at the

same time avoiding reminders of the experience. The movement between

seeming opposite poles in reacting to the experience is referred to as the

central dialectic of trauma
(Herman, 1992;
Follette & Pistorello, 2007).

Initial definitions and conceptualizations of trauma assumed that any indi-

vidual who was exposed to an event outside the range of normal human

events would develop some form of psychological distress. Research now

indicates that exposure to potentially traumatic events is far more “normal”

than was originally assumed and that the development of psychological dis-

tress is not the necessary response to the event
(Breslau, 2002; Bonanno,

2005).
While there is some controversy about the precise figures, there is evidence that the rates of PTSD vary in relation a variety of factors including the population and the type of trauma exposure. Traumatic stress has

been studied most often within the context of exposure to combat, inter-

personal violence, and natural disasters. However, new data is also emerg-

ing in the domain of exposure to terrorist events. Epidemiological studies

indicate that in veterans from the Vietnam War, 30.9 percent of male vet-

erans and 21.2 percent of female veterans developed PTSD
(Breslau et al.,

1998).
The experience of rape is highly associated with PTSD, with 65 percent of males and 45.9 percent of women who experience a rape developing

PTSD. The literature indicates that 13–30 percent of the general population

is exposed to a natural disaster during the course of their lifetime (Briere

& Elliott,
2000).
Overall, men are more likely to report witnessing injury or death while women are more likely to experience some sort of interpersonal

violence (Fairbank, Ebert & Caddell, 2001). Gender is a moderating variable

in developing PTSD with women being two times more likely than men to

develop the disorder (Breslau et al., 1998). Finally, changes in technology and

the geopolitical context have significantly increased the risk of exposure to

terrorist events.

The Psychological Sequelae of Trauma

There is a range of adverse outcomes that are associated with psychologi-

cal trauma that is not limited to the development of PTSD. Acute stress dis-

order (ASD) is a psychological disorder that is characterized by cluster of

anxiety and dissociative symptoms that include derealization, depersonaliza-

tion, dissociative amnesia, and a subjective sense of numbing (APA, 1994).

In ASD, these symptoms manifest within the month following the traumatic

event. This diagnostic category was introduced into the DSM in order to

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Victoria M. Follette and Aditi Vijay

distinguish between time-limited reactions to trauma and longer term post-

traumatic stress disorder. Specifically, distress that persists for longer than

one month is labeled as posttraumatic stress disorder. The psychological dis-

tress that ensues following a traumatic event can also include depression,

anxiety, eating disorders, substance abuse or self-harm behaviors in addition

to PTSD (Polusny & Follette, 1995). Moreover, the resulting distress of trauma

exposure can be associated with later difficulties in engaging in and maintain-

ing personal relationships. This distress may manifest immediately following

the traumatic incident or much later in life
(Cloitre et al., 2006).

PTSD is the psychological disorder most commonly associated with trauma

exposure and it is different from all other psychological disorders in that the

etiology is specified within the diagnostic criteria. Specifically, in order to

be eligible for this diagnosis, clients need to have been exposed to a trau-

matic event. However, as noted earlier, exposure to a distressing event is not

sufficient to determine the psychological outcome. Rather it is the response

of the individual and associated symptomatology that determines the classi-

fication of the event. PTSD is characterized by a constellation of symptoms

that are clustered into the following categories: reexperiencing, avoidance

of stimuli and hyperarousal. Individuals reexperience the trauma in various

ways including recurrent or intrusive recollections, distressing dreams or

extreme distress at exposure to cues that remind them of the trauma. The

second cluster of symptoms includes persistent avoidance of anything that

is a reminder of the trauma. This includes a general sense of numbness that

may manifest as avoiding thoughts, feelings or conversations associated with

the trauma. Hyperarousal symptoms include insomnia, irritability or angry

outbursts, difficulty concentrating, hypervigilance and an exaggerated startle

response
(Fairbank et al., 2001).
The clusters of PTSD symptoms are reciprocal in nature with symptoms from one cluster influencing the behavioral

manifestations of the other symptom clusters
(Wilson, 2004).
When an individual reports symptoms from one of these clusters, it is probable that func-

tioning in other areas is impacted and that they are experiencing symptoms

from more than one cluster. For example, if an individual is reexperiencing

the event, it likely that they are also having difficult concentrating at work or

that they are not able to sleep properly. This underscores the importance of

a comprehensive assessment in order to determine the range of disturbance

and to get an accurate glimpse of what is going on with the client.

Complex PTSD is a category that is conceptualized as including symptoms

in addition to those specified in the diagnostic criteria for PTSD. As research

into trauma and PTSD evolved, researchers and clinicians noticed that the

original DSM diagnosis of PTSD did not fully capture the symptoms that sur-