Entropy Rules

Mindfulness Based Interventions:

Mindfulness PTSD Trauma Recovery

    Just as all survivors of trauma do not develop PTSD, likewise not all survivors of child maltreatment go on to develop the clinical syndrome of PTSD. Instead, they may be diagnosed with a variety of mental disorders including depression, substance use disorders, personality disorders, dissociative disorders, and others (Herman, 1997), while still others may be affected in ways not labeled as psychopathology. Many of the developmental effects of maltreatment result in ways of thinking, feeling, and behaving that are similar in some ways to individuals with PTSD, as has been discussed previously. Additionally, survivors of child maltreatment do develop PTSD. For example, estimates of the proportion of child sexual abuse survivors who develop PTSD range from 37% to 53% (Kendall-Tackett, Williams, & Finkelhor, 1993; McLeer, Deblinger, Atkins, Foa, & Ralphe, 1988; McLeer et al., 1998). Mindfulness and meditation have been used in treatment with individuals with PTSD symptomology with some benefit; some of these studies are discussed next.
    A recent meta-analysis of 10 studies (N=643) examining meditation- and mindfulness-based interventions for PTSD found that mindfulness practices significantly improved PTSD and depression symptoms compared to controls (Hilton et al., 2016). Overall mindfulness appears to be a beneficial component of treatment for people diagnosed with PTSD, although the authors mention that higher quality studies are needed to make stronger conclusions (Hilton et al., 2016). The majority of research on the impact of MBIs on trauma-related outcomes has been conducted in samples of veterans exposed to military-related trauma. This literature has been generally promising, indicating decreases in depression and PTSD symptoms; effect sizes for symptom reduction have been in the small to medium range (e.g., Kearney, McDermott, Malte, Martinez, & Simpson, 2012; King et al., 2013; Owens, Walter, Chard, & Davis, 2012).
    A pilot study of Mindfulness-Based Stress Reduction (MBSR) for trauma-exposed women showed that participation in MBSR was linked to reduced perceived stress, depressive and anxious symptoms, and PTSD symptoms, increases in mindfulness, and improvements in emotion regulation. This study also examined inflammatory biomarkers in blood samples at 3 time points, showing that participating in MBSR led to improvements in inflammatory biomarkers. This is key since exposure to interpersonal trauma is associated with chronic physiological inflammation that can lead to numerous health problems and premature death. Most but not all of the participants in the study were exposed to some form of child maltreatment (Gallegos, Lytle, Moynihan, & Talbot, 2015).
    Kelly (2015) has written about Trauma Informed Mindfulness Based Stress Reduction (TI-MBSR). TI-MBSR has been hypothesized to be effective at promoting a sense of internal safety by gaining the ability to understand and regulate trauma-based emotional responses (Allen, 2001, 2005). To this end, TI-MBSR includes a psychoeducational component about posttraumatic reactions in addition to mindfulness meditation. The rationale is that with accurate information about the impact of trauma on functioning, and the attainment of self-regulatory capacity through regular mindfulness practice, a person can develop a new, nonreactive relationship to trauma symptoms. Compared to other MBIs, MBSR is particularly well-suited to enhancing interpersonal functioning among adult survivors of child maltreatment because it includes information on habitual communication styles (e.g., assertive, aggressive, and passive-aggressive). Additionally, TIMBSR has included information regarding the effects of trauma on parenting, including how to use mindfulness to work with trauma-related parenting difficulties. Kelly and Garland (2016) conducted a Stage 1 RCT of TI-MBSR and found that relative to the control group participants in TI-MBSR enjoyed statistically and clinically significant decreases in symptoms of PTSD and depression, as well as reduced anxious attachment. Amount of home practice significantly predicted improvements in PTSD symptomology (Kelly & Garland, 2016).
    Boden and colleagues (2012) explored associations between facets of mindfulness and PTSD residential treatment outcomes in a group of veterans undergoing residential PTSD treatment for combat-related trauma. They found changes in mindfulness explained 19% of the variance in PTSD symptoms and 24% of the variance in depressive symptoms post-treatment. Specifically, acting with awareness was associated with reductions in PTSD severity, and a nonjudgmental attitude was associated with reduced depressive symptoms (Boden et al., 2012).
    Cross-sectional findings provide insight into how the experience of trauma impacts mindfulness and the role that mindfulness could play in trauma recovery. For example, Boughner, Thornley, Kharlas, and Frewen (2016) investigated how experiences of trauma, including adverse experiences in childhood, influenced mindfulness and the development of PTSD. Lifetime exposure to trauma was associated with less acting with awareness (perhaps associated with a tendency towards dissociation), and less nonjudging (potentially related to negative self-, other-, and world-schemata, combined with negative bias in attention and memory), but higher observing (possibly associated with sympathetic nervous system overactivation; i.e., posttraumatic hypervigilance). More adverse childhood experiences were associated with lower describing, acting with awareness and nonjudging. They found that describing, acting with awareness, and nonjudgment partially mediated the associations between exposure to traumatic events and PTSD symptoms. Nonreactivity partially mediated the association between adverse childhood experiences and PTSD symptoms. Interestingly, greater levels of mindful observing partially mediated the positive association between lifetime trauma exposure and PTSD and dissociative symptoms. While the authors suggest mindful observing may be a risk factor for greater psychological distress, especially in individuals facing more trauma and adversity, this unexpected association could also be based on conflation between mindful observing and PTSD related hypervigilance. The distinctions between trait mindfulness and mindfulness practice, or state mindfulness, are important for trauma-related research due to considerable construct overlap between trait mindfulness and aspects of PTSD symptomology (Boughner et al., 2016).
    Another study found that it is actually the nonjudgment component of mindfulness, rather than simple present moment awareness, that appears to help soothe negative affect. In a sample of female physical and sexual assault survivors, Valdez et al. (2016) discovered that present moment focus in the absence of a nonjudgmental attitude led to significantly less positive affect and significantly more negative affect in response to telling personal trauma narratives. Thus it appears that at least for trauma survivors, the nonjudgmental component of present moment awareness is crucial for reducing negative affectivity (Valdez, Sherrill, & Lilly, 2016).
    Mindful nonjudgment also appears to soothe negative affect in response to posttraumatic reactions. Lang et al. (2012) presented evidence that mindfulness meditation helps survivors of trauma by enabling the ability to intentionally shift attention, reconsider maladaptive cognitive schemata, and develop a nonjudgmental stance towards experience. The ability to shift attention targets the attentional bias towards trauma-related stimuli associated with PTSD, improving cognitive control (e.g.. Buckley, 2000). Mindfulness can interrupt the processes of worry and rumination, and associated negative affect that characterize posttraumatic stress (e.g., Ehring, Szeimies, & Schaffrick, 2009). Nonjudgmentalness may help to temper the negative interpretational bias and anxiety sensitivity (i.e., fear of sensations associated with anxiety), and also may support approach goals, facilitating exposure and habituation to stimuli that previously elicited extreme distress (Lang et al., 2012).
    In addition to the importance of nonjudgment, present moment awareness itself plays a major role in healing posttraumatic reactions. Reducing emotional avoidance is a key aim of many exposure-based trauma therapies (e.g. Prolonged Exposure [Rothbaum, Foa, & Hembree, 2007]; Cognitive Processing Therapy [Resick, Monson, & Chard, 2017]). The development of mindfulness capacities may help implicitly reduce avoidance of trauma-related material as it arises in the individual's present moment experience (Thompson, Arnkoff, & Glass, 2011). Mindfulness has been conceptualized as a potentially potent resilience factor in the face of traumatic experience as it counteracts some of the major risk factors associated with the development of posttraumatic stress symptomology, namely experiential avoidance, chronic dissociation, and emotionally disengaged coping (Thompson et al., 2011).
    Mindfulness has also been associated with enhanced trust and utilization of social support. Kuhl and Boyraz (2016) found that mindfulness predicted enhanced general ability to trust others and utilize social support in trauma-exposed college students but only for individuals reporting low or moderate PTSD symptoms. Approximately 75% of the sample has some exposure to trauma in their lifetime (as measured by the Brief Betrayal Trauma Survey, an instrument which includes items related to child maltreatment; Goldberg & Freyd, 2006). Although information on type of trauma was collected it was not reported in the paper due to nonsignificant correlations between type of trauma and the variables of interest (i.e., mindfulness, trust, and social support; Kuhl & Boyraz, 2016). However, it is interesting to note the association between mindfulness and enhanced relational capacities.
    Mindfulness techniques may also help reduce posttraumatic hyperarousal. In an online self-report study Kalill, Treanor, and Roemer (2014) found the facet of mindfulness related to the ability to verbally describe present moment experience was associated with lower PTSD related hyperarousal, while mindfulness-related nonreactivity was associated with less severe PTSD symptomology overall, and lower re-experiencing and hyperarousal in particular. A portion of the sample (18%, N=28) reported childhood physical or emotional abuse and 7% (N=11) reported childhood sexual abuse. These associations held while controlling for negative affect, age, number of traumas, and number of years since trauma exposure (Kalill et al., 2014).
    In summary, many survivors of child maltreatment go on to receive a variety of diagnoses, including PTSD. Hilton and colleagues (2016) meta-analysis suggests mindfulness-based interventions for PTSD consistently lead to improvement in PTSD and depression symptoms, improved emotion regulation and reduced inflammatory biomarkers. Cross-sectional research on mindfulness and trauma suggests mindfulness may help trauma survivors by reducing implicit emotional avoidance (e.g., Thompson et al., 2011). Nonjudgment and cognitive control of attention are other key mechanisms (e.g., Lang et al., 2012), which may help facilitate utilization of social support (Kuhl & Boyraz, 2016) and lead to reduced trauma-related hyper arousal (Kalill, Treanor, & Roemer, 2014).

⇲ About The Author

Robin Hertz, MA is currently in the process of completing a PhD in Clinical Psychology at the University of Oregon.