Clinical Handbook of Mindfulness (87 page)

1985;
Segal, Williams & Teasdale, 2002).

Data suggests that the capacity to self-regulate emotions is related to mind-

fulness and overall psychological well-being
(Brown & Ryan, 2003).
Many clients report deficits in the ability to notice, label, and regulate internal

experiences associated with emotions. Mindfulness is one potential strategy

to help individuals learn skills that will enhance their ability to self-regulate

thereby allowing them to manage distress. The preliminary data establishing

the utility of mindfulness with psychological difficulties has important and

positive implications for treatment of trauma and PTSD.

Mindfulness and Trauma

Research on the incorporation of mindfulness into existing treatments for

trauma is promising
(Becker & Zayfert
,
2001;
Cloitre, Cohen & Koenen,

2006).
Mindfulness encourages acceptance rather than avoidance and can

provide a tool in facilitating exposure to feared stimuli. We do not consider

mindfulness to function as a form of control but rather to increase psycho-

logical awareness and flexibility when responding to emotional experiences

(Follette et al., 2006).
In part, mindfulness is a way to provide a client with skills to help them manage the distress that occurs when engaging in exposure work.

For some individuals who have experienced trauma, there might have

been behaviors or strategies such as dissociation that were utilized as a sort

of survival mechanism. While these behaviors may have been adaptive in

that context, they are no longer useful in the current context and may even

be dangerous, by putting the client at risk for revictimization. In some cases

these behaviors are characterized as obvious avoidance strategies while in

other situations they manifest as hypervigilance symptoms, which we would

conceptualize as another form of avoidance. Both of these classes of behav-

iors share an “unawareness” of the environment in common, whether it

is misreading potentially threatening situations or an inability to accurately

label their own feelings. The goal of mindfulness is to facilitate individuals

ability to become aware of their experiences in the present moment in order

to build the foundation to fully engage in not only therapy but also their lives

(Follette & Pistorello, 2007).

Integrative Behavioral Approach

Our approach to treatment is guided by a contextual behavioral approach;

with the fundamental assumption that it is most effective to understand the

function of behavior rather then merely its topography. This approach is

not aimed solely at targeting symptoms and reducing distress, but is also

aimed at addressing the mechanism that mediates the distress. The addi-

tional goal of this work is in helping the client move forward and to iden-

tify values and goals associated with a meaningful life. A contextual behav-

ioral approach examines relevant historical and environmental variables, as

described in a functional analytic clinical assessment, in relation to the devel-

opment and maintenance of psychological distress
(Follette et al., 2004).
The integrative behavioral approach utilizes an experiential avoidance paradigm

Chapter 16 Mindfulness for Trauma and Posttraumatic Stress Disorder

311

to conceptualize distal and proximal factors that are also related to current

stressors and long-term consequences of trauma
(Hayes et al., 1996;
Follette et al.,
2004).
This approach has ACT at its core, however it also incorporates techniques from DBT and FAP. We believe the similar theoretical foundations of these approaches, makes this integration coherent in fundamental

principles
(Follette et al., 2004).
As noted above, this integrative behavioral approach utilizes different aspects of treatment from contemporary behavior

therapies in order to be able to tailor the treatment to the particular needs of

the client. The integrative behavioral model seeks to avoid theoretical eclec-

ticism by combining the approaches of DBT
(Linehan, 1993),
ACT (Hayes,

Strosahl & Wilson,
1999),
and FAP
(Kohlenberg & Tsai, 1991).
However, we should also note that both ACT and DBT have described coherent treatment

approaches that do not involve any integration (cf.
Walser and Hayes, 2006

and
Wagner and Linehan, 2006).

In the initial stages of therapy, the primary goal is to assist the client in

building and enhancing a skill set that will be useful in engaging the difficult

work to follow. Various acceptance strategies, mindfulness practice, distress

tolerance, and interpersonal skills are at the core this early work (Hayes,

Strosahl & Wilson,
1999;
Linehan, 1993).
The overarching goal of mindfulness practices in this context is to begin to get the client to let go of the

agenda of controlling internal experiences. Skills such as emotion regulation

and accurate expression of emotions serve to enrich the individual’s behav-

ioral repertoire to cope with negative emotions. Once it has been established

that a client is willing to experience increased levels of distress, treatment

will move toward mindfulness-enhanced exposure.

DBT was originally developed to treat individuals with BPD who exhib-

ited suicidal and parasuicidal behaviors
(Linehan, 1993).
It is based on the concept that self-injurious behavior is associated with the emotion dysregulation that is related to avoiding or escaping difficult thoughts and feelings. As

with ACT, this treatment embraces the dialectic of acceptance and change in

order to live the life that is desired. DBT uses concepts such as self-validation

to help clients accept themselves as they are while working toward changes

they want in their lives. For many trauma survivors, self-acceptance can be a

difficult step and mindfulness is one way to work toward it.

FAP is a key behavioral treatment that provides important strategies for

dealing with the relationship factors associated with a history of trauma. FAP

asserts that the therapeutic relationship can be utilized as an agent of change

(Kohlenberg & Tsai, 1991)
and provides necessary foundational work for clients with what has been described as complex PTSD. At its core, FAP

targets clinically relevant behaviors that occur in session such as difficulty

in developing a sense of trust and safety in relationship to another person.

Therapists are able to respond contingently to behaviors in order to rein-

force adaptive and appropriate behaviors. One reason we consider FAP to be

so essential in trauma therapy is that it helps the client to build a repertoire

for developing an alliance with the therapist that can lead to doing the diffi-

cult work of letting go of previous strategies of control and avoidance. The

integrative behavioral approach integrates constructs of mindfulness and skill

development to help the client learn to accept distressing thoughts and feel-

ings as they build a more fulfilling life. As treatment progresses, the concept

of acceptance is also incorporated to help the client begin to engage in new

312

Victoria M. Follette and Aditi Vijay

behaviors that may be anxiety provoking but are associated with the client’s

valued life directions. The integration of these treatment approached allows

us to tailor treatment to the individual clients needs without sacrificing the

theoretical integrity.

Clinical Vignette

In order to demonstrate the incorporation of mindfulness practices within

an integrative behavioral paradigm, we will use a clinical vignette. Consider

for a moment the following description of a trauma survivor:

Helen is a 32-year-old woman who presents for treatment to work on the

guilt she experiences as a result of sexual abuse that occurred over a period

of six years, beginning at the age of eleven. While she had a close relationship

with her biological father, he passed away suddenly after being involved in

a motor vehicle accident when she was seven. Her mother remarried three

years later. Her stepfather began to abuse her approximately one year after

his marriage to Helen’s mother
.

When describing her reasons for seeking treatment at this time, Helen

describes feeling as though she “did something” to precipitate the abuse and

that she has difficulty concentrating at work or sleeping through the night.

She reports that these difficulties have made it difficult to remain in a rela-

tionship, which is something that she wants. Helen indicated that over the

past fifteen years she has used alcohol and self-harm to try to cope with dif-

ficulties in her life. Additionally, she reports that it is extremely difficult to

remain in treatment because therapists ask her to do things that are very

difficult for her, so she has terminated therapy twice before
.

At this initial stage of treatment, the goal is to help the client develop

a skill set to deal with distressing thoughts and feelings without engaging

in self injury. It is also clear that building a strong therapeutic relationship

will be necessary in order for her to tolerate the work. In keeping with the

integrative behavioral approach, we would suggest beginning with a com-

bination of mindfulness and distress tolerance skills. In a sense, we use the

distress tolerance skills as a bridge to safety for the client, with the longer

term goal being “radical acceptance” in a way that moves beyond emotion

management. As stated earlier, the mindfulness exercises will serve to allow

the client to experience the present moment as it is not what it seems to be.

That is, in this moment the trauma is over, has been survived, and the client

is in a safe place. Thoughts and feelings are accepted, not as a reality, but as

learned reactions to prior experiences. The client does not have to run, hide,

self injure, or do any other behavior to get rid of her internal experiences.

Rather, she can just sit with this moment and notice the range of her thoughts

and feelings, noticing that they cannot kill or harm her-learning to just be in

this present moment. In order to provide a context for this work, we are also

discussing values with the client with respect to the life they would like to

live. This work is helpful in investing the client in the therapeutic process

and in providing a rationale for the importance of the work they are doing.

This orientation to living a valued life is a critical step in that treatment for

Chapter 16 Mindfulness for Trauma and Posttraumatic Stress Disorder

313

trauma is difficult work and it is important that the client have a sense of the

direction of the work.

During the preliminary stages of mindfulness practice it is important to

begin with more basic exercises as a foundation. A mindful breathing exer-

cise can be a good place to start.

Let’s start by closing your eyes and simply noticing your breath. It has been

noted that sometimes trauma survivors are reluctant to close their eyes and

that is fine, they can do these exercises with their eyes open, direct them to

look at a neutral point somewhere in the room.) Notice the air as it comes

into their body and through their lungs. Notice the inhalation and exhala-

tion of your breath. Notice how you feel when you are taking in air and how

you feel as you expel your breath. You are not changing how you breathe,

you are simply noticing your breath and how your body feels. It is ok to

notice when you are distracted or your attention is elsewhere. Simply notice

this and return your attention to your breathing
.

(Follette and Pistorello, 2007)

This is an example of a basic mindfulness exercise for clinicians to use with

clients, especially in the early stages of treatment. Returning to the breath is

at the core of most mindfulness practices and provides a fundamental skill

that can always be used. As with all behaviors, mindfulness is a skill that can

be developed and like any other skill it needs to be practiced.

The therapist can introduce different forms of mindfulness exercises,

always with the goal of bringing clients attention to the present moment.

It is often easiest to start with mindfulness exercises that target bodily or

physical sensations. In addition to the breathing mindfulness, mindfulness

exercises involving external stimuli such as colors in the room, the taste of

food, and sounds in the environment can be useful. These exercises address

the physical aspects of the environment and provide a tangible starting place

for the client. As the client demonstrates mastery of these concepts, the ther-

apist can introduce the concept of mindfulness in relation to noticing inter-

nal thoughts and feelings. As therapy progresses to exposure based work,

it is important to integrate mindfulness and other self-regulation strategies

as appropriate. We assert that the incorporation of these skills will facilitate