Clinical Handbook of Mindfulness (86 page)

evant controlling variables and allows for an individualized understanding

of the client
(Follette & Naugle, 2006).
A functional analysis examines the relevant behavior, its antecedents and the consequences. When conducting

such an analysis, the clinician is working to determine what the relevant con-

trolling factors are for an individual client, as well as what might influence

the probability of behavior change. The purpose of this analysis is to select

and investigate the relationships between variables that are observable and

changeable, in that we cannot change historical factors such as the exposure

to the trauma itself. Focusing only on the traumatic event, ignoring other sig-

nificant proximal and distal variables could lead to inappropriate case con-

ceptualization with a resulting misapplication of treatment components. A

functional analytic assessment allows the clinician to get an idiographic pic-

ture of the client so that treatment can be tailored in a manner that is most

likely to lead to a positive outcome.

Learning Theory and the Development and Maintenance

of PTSD

Mowrer’s Two-Factor theory offers a widely accepted model to explain the

way PTSD is developed and maintained. The Two-Factor theory asserts that

psychopathology is a function of classical conditioning and instrumental

learning
(Mowrer, 1960).
A behavioral formulation of two-factor theory provides a framework through which to conceptualize the development and

maintenance of PTSD
(Keane, Zimering & Caddell, 1985).
The first factor proposes that fear is learned through classical conditioning. The traumatic

event serves as an unconditioned stimulus that is conditioned and subse-

quently associated with intense feelings of fear. Through the process of clas-

sical conditioning, the feeling of fear is sustained through emotional learning

despite naturally occurring consequences that would typically extinguish it.

The second factor of the model details the avoidance behaviors that ensue

to prevent coming into contact with the conditioned cues, therefore reduc-

ing the possibility of extinguishing the behavior. Through the process of

instrumental learning, individuals avoid conditioned cues that evoke anxi-

ety. The individual feels that their anxiety has been lessened by the avoid-

ance of the aversive stimulus thus reinforcing their avoidant behaviors. In

Chapter 16 Mindfulness for Trauma and Posttraumatic Stress Disorder

307

individuals with PTSD, symptoms from any of the clusters (avoidance, reex-

periencing or hyperarousal) can serve to help the individual avoid cues that

evoke anxiety or distress. The two-factor theory explains the development

and maintenance of PTSD, and the behavioral principle of stimulus general-

ization explicates the phenomenon of the complex reactions to a variety of

stimuli. It is a common observation that for some individuals PTSD is exac-

erbated over time. Stimulus generalization is the process that occurs when a

novel stimulus evokes stronger reactions in an individual because it is similar

to an already conditioned stimulus. This process of stimulus generalization

can occur in trauma survivors whereby they react to a range of stimuli by

attempting to avoid an increasing number of potentially anxiety evoking sit-

uations. Classical conditioning is critical in the development of PTSD while

instrumental learning and the reinforcement of avoidance, reexperiencing

and hyperarousal behaviors are critical in maintaining PTSD
(Keane et al.,

1985;
Fairbank et al., 2001).

Third Wave Behavior Therapy

A contextual behavioral approach underlies third wave treatments, which

contends that the only way to truly understand behavior is to examine it

within the context in which it occurs. A notable feature of third wave

approaches is the emphasis on the distinction between the function and form

of behavior. The ability to identify and then target the underlying causes of

behavior has powerful implications for treatment. Experiential avoidance is

one construct that has been proposed as a framework for which concep-

tualizing the functionally similar behaviors that are associated with trauma

(Hayes, Wilson, Gifford, Follette, & Strosahl, 1996).

Experiential Avoidance

Experiential avoidance is a process that occurs when an individual is reluc-

tant or unwilling to experience unpleasant thoughts, feelings or emotions

(Hayes et al., 1996).
This avoidance is conceptualized as a functional diagnostic dimension that organizes behavior by function rather than topogra-

phy and encompasses a large and varied class of behaviors associated with

a range of psychopathologies. Trauma-related symptoms represent a class of

cases in which the initial presentation of behaviors is varied, but the function

that they serve is similar. Therefore in order to affect the most significant

gains, the primary goal is to target the function of the behavior in the client’s

life. For example, a client may present with severe substance use issues and

reports of frequent self-harm. While these behaviors appear to be different

on the surface, it is frequently observed that the underlying cause and the

function are similar. We see both these strategies as ones that are utilized to

avoid unpleasant thoughts and feelings associated with prior trauma. Thus,

it is the avoidance itself that becomes the target of treatment. Of course, it is

important to note that experiential avoidance is not always harmful. Avoid-

ance can be utilized strategically, thus enabling an individual to function in

an adaptive manner when coping with competing environmental require-

ments. Experiential avoidance becomes clinically relevant when it interferes

with the client’s ability to live life fully and in a valued manner.

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Victoria M. Follette and Aditi Vijay

Avoidance is increasingly recognized as a central component in the main-

tenance of trauma symptoms by a range of trauma researchers (Briere &

Runtz,
1991;
Foa, Riggs, Massie & Yarczower, 1995;
Plumb & Follette, 2006).

The experiential avoidance paradigm represents one conceptualization that

is useful when working with survivors of trauma, however others have devel-

oped clinical approaches that also include a focus on avoidance. While EA

may not
always
be maladaptive, continuous attempts to avoid a range of

thoughts and feelings can lead to disruptions across a range of domains that

can include but is not limited to psychological distress
(Follette et al., 2004).

In a review of problems associated with a history of sexual abuse, Polusny &

Follette
(1995)
posit that trauma survivors attempt to avoid their distress in a variety of ways, including substance abuse, self-harm, and intimacy avoidance. While these behaviors provide some short-term relief, in the long term

they are related to other difficulties and increased general distress. Higher

levels of experiential avoidance have been shown to be associated with

increased trauma symptomatology as well as other forms of psychopathol-

ogy
(Plumb, Orsillo & Luterek, 2004).

The behavioral conceptualization of PTSD contends that avoidance of

feared stimuli serves to maintain trauma symptoms or PTSD. The process

of experiential avoidance provides a deeper look into the ways that a variety

of behaviors (e.g., substance use, self-harm, reexperiencing, etc.) can func-

tion as avoidant behaviors because they do not allow the individual to remain

in contact with the present moment, thus avoiding contact with important

areas of their lives. These avoidant behaviors serve to maintain trauma symp-

tomatology over an extended period of time. This chapter proposes an inte-

grative behavioral approach to treatment that incorporates techniques, mind-

fulness, from third wave therapies to target experiential avoidance.

Psychological flexibility, which is increasingly considered to be related to

EA, is a construct that is operationalized as “contacting the present moment

as a conscious human being, and, based on what that situation affords, acting

in accordance with one’s chosen values” (Hayes, Strosahl, Bunting, Twohig

& Wilson,
2004;
Bond & Bunce, 2003).
Psychological flexibility enables an individual to persist in changing his/her actions in accordance with important life values. Elements of contemporary behavior therapy seek to increase

psychological flexibility by broadening the individual’s repertoire through

the incorporation of mindfulness and acceptance techniques which allow

individual’s to live a values consistent life. Our approach targets experiential

avoidance, in a variety of ways, in order to increase psychological flexibility.

Treatment of Trauma

The majority of current treatments for trauma focus on reducing trauma

symptoms, which is appropriate for a large number of clients (Becker &

Zayfert,
2001;
Follette, Palm & Rasmussen-Hall, 2004).
There is compelling evidence to indicate that exposure therapy, based on Mowrer’s two-factor

theory, is effective in the treatment of trauma (Rothbaum, Meadows, Resick

& Foy,
2000).
Specific techniques for exposure (in vivo vs. imaginal) can vary depending on a variety of theoretical and practical considerations. Exposure

therapy is thought to function in a number of ways, including activation of

Chapter 16 Mindfulness for Trauma and Posttraumatic Stress Disorder

309

the fear structure, change in the relationship to the thoughts and feelings

associated with the trauma memories, and establishing more accurate cog-

nitions about the trauma. Exposure also helps to demonstrate that anxiety

does not remain constant when either imagining or being in a feared situa-

tion and that simply experiencing anxiety, distress or PTSD symptoms does

not automatically lead to loss of control
(Foa & Meadows, 1997).

Although there is evidence in support of the efficacy of exposure, many

clinicians are apparently reluctant to utilize it because of lack of training

or concerns about the client’s ability to tolerate the work. Moreover, some

clients actually do refuse this treatment, either at intake or early in the

therapy process. Clinical concerns include increases in suicidal thoughts, dis-

sociation, self-harm, and premature termination in clients who begin expo-

sure based therapies for trauma
(Becker & Zayfert, 2001).
There is evidence to suggest that many trauma survivors adopt an avoidant coping strategy

to manage the distress evoked by the trauma and memories of the trauma

(Rosenthal, Rasmussen-Hall, Palm, Batten & Follette, 2005).
While exposure targets the distressing and unpleasant feelings associated with the traumatic

event, a limited repertoire of coping skills, including an unwillingness to

engage in the exposure work, may limit the utility of this approach for some

individuals. Additionally, in cases of complex PTSD, individuals may not have

developed normative regulation skills that are necessary to engage in this

type of treatment. We believe that mindfulness enhanced exposure offers

clinicians a way in which to target the avoidance that is a barrier to effective

trauma therapy. Additionally, an alternative therapy approach can be useful

in treating the myriad of trauma symptoms that are not directly related to

the PTSD.

Mindfulness

As it has been already well explained in the first part of the book, the ori-

gins of mindfulness practice are in Eastern philosophies and principles (Fol-

lette, Palm & Pearson,
2006;
Baer, 2003).
Marlatt and Kristeller (1999)
define mindfulness as “bringing one’s complete attention to the present experience on a moment to moment basis” (p. 68). Kabat-Zinn defines mindful-

ness as “paying attention in a particular way: on purpose, in the present

moment and nonjudgmentally”
(Kabat-Zinn, 1994,
p. 4). Despite the slight variability in definitions, the core components of mindfulness involve coming into contact with the present moment and observing that moment in a

nonjudgmental way. While there are many ways to develop one’s mindful-

ness practice, one widely recognized way to do this is through meditation.

Several of the mindfulness-based interventions teach individuals a range of

skills that help them to attend to internal experiences that are occurring in

the moment. While the skills that are taught and the methods used to teach

them vary, the majority of these interventions promote a nonjudgmental atti-

tude to one’s internal experiences.
(Baer, 2003)
Extant literature indicates that mindfulness-based interventions are effective in the treatment of a variety of psychological and physical disorders
(Baer, 2003;
Shapiro, Carlson, Astin & Freedman,
2006).
Mindfulness has been shown to be effective with
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Victoria M. Follette and Aditi Vijay

reducing pain and in treating depression
(Kabat-Zinn, Lipworth, & Burney,