Mindfulness Interventions for Both the Therapist and the Client to Increase Therapeutic Effectiveness When Treating Trauma

Mindfulness Interventions for Both the Therapist and the Client to Increase Therapeutic Effectiveness When Treating Trauma
This is a reserach paper that I wrote… it is very involved… it covers many of the bases surrounding mindfulness and recovery.
Abstract: Research has suggested that Mindfulness interventions can be extremely beneficial in the treatment and prevention of symptoms associated with trauma and vicarious trauma. The intention of this paper is to look into the possible positive effects of incorporating Mindfulness practices into therapist self care routines, and therapeutic interventions.  To arrive at such an end this paper will briefly discuss the basic tenants of mindfulness and will then move on in examining studies which have noted the positive effects of mindfulness integration. In closing this paper will outline why a Mindfulness state is so critical in relation to recovery from trauma.
Research has shown that mindfulness based interventions are helpful in promoting overall health (Krasner 2004). Mindfulness is described as a non-judgmental meta-cognitive state in which a person becomes very aware of their thoughts, surrounding, and feelings and attempts to experience all stimuli without judgment and without relating the stimuli to the past or the future. “In contrast, Mindlessness is a state of rigidity in which one adheres to a single perspective and acts automatically” (Carson and Langer 2006). Research has shown that clients who have experienced trauma often engage in avoidance behaviors and therefore make both concerted and unconscious efforts to be mindless (Follette et al. 2006). The research  has shown that participating in mindfulness instruction or therapy has a positive impact in relation to stress reduction, maintenance of and avoiding relapse of depression, stress reduction for therapist and health care workers, longevity for the elderly, proper self care for person’s with diabetes, emotional health for cancer patients, and is found to be positive for self development in general (Waller & Carlson, 2006; Walach et al., 2007; Shapiro et al., 2007; Gregg et al., 2007; Shapiro et al.,2005; Krasner 2004; Helen & Teasdale, 2004; Martin, 2002; Teasdale et al., 2000) (Williams, 2000; Alexander, 1989). New findings specifically related to trauma demonstrate that existing CBT, DBT and ACT methods are more effective when used in conjunction with Mindfulness practices (Follette et al. 2006). Specifically, clients with PTSD seem to be more likely to fully engage in exposure treatment without resorting to avoidance behaviors if they have training in mindfulness (Follette et al. 2006). Avoidance is not only a process of the client; it is also a process of the therapist. Studies have shown that health care workers are particularly vulnerable to vicarious trauma and burnout (Shapiro et al. 2007; Shapiro et al. 2005; Walach et al. 2007). Carson and Langer has suggested that when therapists use mindfulness for self development, they allow themselves to be more authentic and free of judgment in the therapeutic setting; by freeing themselves from the confines of objectivity therapists allow themselves to experience clients and their narratives without psychological avoidance thereby reducing the likelihood of vicarious trauma (2006).
According to Segal, Williams and Teasdale (2000) the following steps are necessary to reach a state of mindfulness.  In a mindful state a person attempts to reach a point of non- judgment in which they remain impartial to their experience and try not to evaluate whether his/her surrounding are positive or negative. The person will be patient in that they can enjoy the now and accept that things will come with time. They will experience the world with a beginner’s mind, meaning that they will view the world with openness similar to if they were to be viewing something for the first time. The person will have a trust in him or herself. The person will have a non-striving disposition in that he/she will not be trying to do anything; instead she/he will simply accept what is. She or he will have an acceptance for all thoughts feeling, sensations and beliefs; in acceptance the person might take a meta-cognitive standpoint and accept that all the perceived stimuli simply are and don’t need to be interpreted. Finally the person will have a position of non-attachment in that they will not attempt to create an identity or a meaning out of their experience. This last point is particularly important for trauma survivors. It is often an inability to assimilate the trauma into a person’s stagnant narrative that results in higher level of symptoms (Crofford 2007; Wilson et al. 2006; Carson and Langer 2006). By helping the client towards a more mindful perspective, the client will be able to attain a wiser more dialectic view of experiences and will therefore be able to accommodate more seemingly contradictory plot lines into their narrative (Carson and Langer 2006). Or the client will reach a higher level of mindfulness in which they attain a comfort in accepting that the self is not defined by subjective of collective narratives and that we simply are.
Mindfulness based interventions usually follow a seven or eight week format in which each session discusses a certain theme (Krasner 2004). The clients learn to identify the automatic pilot (doing something without any awareness of what you are doing),to deal with barriers (firmly held beliefs that limit a person’s ability to perceive things differently), to learn mindful breathing (used to help people experience life without cognitive defensiveness, problem solving or judgment),  to stay present (to experience thoughts feelings and body sensations without judgment), to allow one’s self to attend to stimuli without judgment (this is when clients learn to accept their freedom to choose the way they react to stimuli, they begin by accepting that the stimuli simply is without trying to make sense of it),  to accept that thoughts are not facts (clients focus of feelings that surface with certain thoughts and realize that there are no truths and the way we interact with a thought is a matter of choice), to take care of one’s self (which is to be aware of the thoughts that lead us towards depression and choose to view them in a new way; it also involves joining the community and letting yourself experience positive things), and finally the clients review everything they have learned and use the group to explore the experience (Waller, Carlson, Englar-Carlson, 2006). The goal of a mindfulness intervention is for acceptance to take the place of resistance. After a traumatic incident individuals might find themselves hyper-vigilant and anxious, both of which reduce the individuals present focus in attempt to avoid what has been or what could be. In truth, life is unpredictable and striving to make universal meanings in order to make a predictable future is the very foundation of anxiety (Tolle 1999).
Research has shown that offering mindfulness services to beginning therapists and health care workers has a positive impact on their ability to successfully implement self-care skills and to lead less stressful lives (Shapiro et al.,2005; Shapiro et al.,2007). Shapiro and colleagues found that, “using a prospective, cohort-controlled design, participants in the MBSR (mindfulness based stress reduction) program reported significant declines in stress, negative affect, rumination, state and trait anxiety, and significant increases in positive affect and self-compassion”(2007). The same was found in the earlier study with health care workers (Shapiro et al., 2005). People in the health care field experience a high potential for stress. The previously mentioned study offers a very practical solution to a rather large issue concerning staff burnout and their resulting ability to aid clients. The positive effects of this study are immense and pave the way for future studies which might find even more useful results. For example, rumination is related to depression, so mindfulness might be a preemptive strike against the possibility of depression (Shapiro et al., 2007). The field of counseling is riddled with jargon, but the author would suggest that rumination is a different way of explaining a mindless state in which an individual strives to assimilate a traumatic plot line into their existing narrative. This is where vicarious trauma comes forth. Therapists are burdened with an existential chaos that erupts as a client’s traumatic experience cannot be integrated into our own subjective narratives. When this happens therapists too can experience PTSP like symptoms, which might put the therapeutic relationship in jeopardy as the therapist engages in avoidance behaviors and is therefore not fully present for the client (Carson and Langer 2006).  
The benefits of mindfulness training are extremely relevant to the therapeutic process. Essentially, mindfulness trainings offer a proactive way of building those core skills which are most important to therapeutic relationship.  Shapiro et al. found that MBSR interventions on beginning therapists raised self compassion and that self compassion is positively related to successful therapy as noted in out come studies (2007).  Carson and Langer have written extensively about how the non-judging process of mindfulness allows individuals to accept themselves as they are and therefore promotes authenticity (2006). They also describe the pitfalls of self evaluation; as the process requires much of the therapist’s mental effort be directed towards assimilating behaviors towards external ambiguous expectations thereby removing energy that could be directed towards the therapeutic process (Carson and Langer 2006).  As mentioned earlier the non-judgmental aspects of mindfulness aid the therapist in curtailing avoidance behaviors; the same process also facilitates unconditional positive regard (Carson and Langer 2006).  If therapists are not evaluating clients based on their constructed belief system they are more able to view the clients, particularly those who might have been perpetrators, with unconditional positive regard. This creates a positive feedback loop as the response to unconditional positive regard is for the client to be authentic in the therapeutic process. The founding principles of mindfulness are related to being in the present or the now, so mindfulness allows for the therapist to be fully present with the client and to not be distracted by the past or the future (Tolle 1999). So then, Mindfulness might directly affect the therapeutic outcomes of client who are experiencing therapy with a therapist who is involved in mindfulness trainings.
Mindfulness appears to be playing a significant role in the resurgence of the philosophy that the mind and the body are connected and should be treated as such. Exciting research has been conducted in which Mindfulness trainings have had a positive impact on patients with cancer, patients with diabetes, and the elderly population (Alexander, 1989; Walach et al., 2007; Gregg et al., 2007). The studies should not be all too surprising as the medical field has long been aware that stress has a negative affect on physical health. Crofford found that, “somatic syndromes characterized by pain, fatigue, sleep disturbance, anxiety, depression, and cognitive dysfunction are associated with stress exposure” (2007). As mentioned earlier Mindfulness studies have been shown to both reduce stress and to prevent a relapse in depression; one might extrapolate that future studies will then find a link between mindfulness and the reduction of somatic syndromes (Shapiro et al. 2007; Teasdale et al 2000).  The body scan is a process by which the participant focuses on his/her breath and is encouraged to pay special attention to specific parts of the body; the goal is for the client to gain a greater awareness of the body. Preliminary research conducted by Berceli and Napoli have found that mindfulness training in conjunction with somatic stress release stretches have the potential to reduce somatic symptoms in trauma survivors (2006). Through mindfulness, patients are learning acceptance of what is without judgment, and with such an acceptance perhaps these individuals are able to look at their situations with a greater honesty. This paper contends that with this greater honesty, people might be encouraged to drop defenses so that they are more willing and able to take that action which is necessary in the present.   Additionally, Hassain et al. found that authenticity is positively related to self esteem; this means that the more authentic a person is in a therapeutic process the more likely they are to feel an increase in self esteem as they make progress; the inverse was found to be true as well in that a lack of authenticity related o poor self-esteem (2003).
Studies on the personal factors that are consistently correlated amongst perpetrator and the factors which seem to inhibit the rehabilitation process amongst perpetrators have a huge overlap with what some authors have termed ‘mindlessness’(Craig et al. 2003; Blake and Gannon 2008; Carson and Langer 2006; Van Wijk et al. 2006; Langer and Louis 1980). The recurring theme amongst perpetrators is their lack of empathetic development and their automatic behavioral patterns based on socially undesirable schemas (Blake and Gannon 2008). The reason that mindfulness is so often used with traditional CBT or the newer DBT is that it allows thought processes, behaviors and feelings to come to awareness without being hindered by those avoidance strategies which arise from a negative evaluation of the relevant action (Follette et al. 2006). In order to help a perpetrator to arrive at more socially conducive thoughts and behaviors it is first necessary that the individual be aware of their existing schema and resulting responses (Follette et al. 2006). Research on rapists has suggested that the perpetrator seems to misinterpret the social cues of the victim and they lack the ability to empathize or to understand the emotions of the victim (Blake and Gannon 2008). Though Blake and Gannon were not suggesting Mindfulness interventions, their description of the perpetrators was clearly overlapping with Carson and Langer’s description of a Mindless state (2008; 2006). If a perpetrator is reacting to stimuli according to rigid schema then the same misinterpretation and resulting response is destined to repeat itself; if, with mindfulness training, the perpetrator looked at stimuli as novel they could be less likely to react according to pre-set principles (Follette et al. 2006).
Mindfulness has long been a positive moment for the human culture and we are currently seeing a resurgence of such practices as the West moves towards an acceptance of greater ambiguity. Mindfulness practice works very well in conjunction with many current therapeutic interventions (Follette et al. 2006). This paper wishes to conclude with an integration of Mindfulness with existentialism. Yalom and other existentialists have contended that much of human suffering is the result of an existential anxiety which arises from trying to arrive at a meaning in life (2002). PTSD symptoms after trauma seem to have relation to this existential drive towards making meaning out of the traumatic experience and in fact some have benefited from the creation of a subjective meaning such as becoming an advocate (Herman 1992). At times it is impossible to incorporate a traumatic instance into what we believe to be an objective and linear existence. In an effort to avoid such an existential anxiety people may become hyper vigilant to use the present to avoid what could happen in the future, or use avoidance to avoid what was in the past. Mindfulness is a method of focusing on the present so as to not concern your self with meaning, thereby reducing the possibility of existential anxiety (Tolle, 1999). If a question were to be used to some up the intention of mindfulness perhaps it would be, “If you have no control over the past or the future why not use your freedom to be as you desire right now?” It is not the intention of the author to minimize traumatic experiences, and it is understood that the Mindfulness worldview can be interpreted as minimizing the impact of trauma. Unfortunately, the impact of trauma can be minimized as Mindfulness all together is not concerned with the past or the future (Tolle 1999).  However, it is necessary for clients to adapt to a post modern/constructionist/present focused/timeless view of reality (or lack of reality) to benefit from Mindfulness practices. By focusing awareness in the present we can all benefit from an increased understanding of ourselves and an increased comfort in our unique authenticity.
Alexander, Charles N.; Langer, Ellen J.; Newman, Ronnie I.; Transcendental Meditation, mindfulness, and longevity: An experimental study with the elderly. Journal of Personality and Social Psychology, Vol 57(6), Dec 1989. pp. 950-964.

Barker-Collo, Suzanne; and Read, John. Models of Response to Childhood Sexual Abuse: Their Implications for Treatment. Trauma, Violence, & Abuse, Apr 2003; vol. 4: pp. 95 – 111.

Blake, Emily and Gannon, Theresa. Social Perception Deficits, Cognitive Distortions, and Empathy Deficits in Sex Offenders: A Brief Review Trauma Violence Abuse 2008 9: 34-55
Berceli, David and Napoli, Maria; A Proposal for a Mindfulness-Based Trauma Prevention Program for Social Work Professionals. Complementary Health Practice Review, Vol. 11, No. 3, 153-165 (2006)
Brown, Kirk Warren; Ryan, Richard M.; The benefits of being present: Mindfulness and its role in psychological well-being. Journal of Personality and Social Psychology, Vol 84(4), Apr 2003. pp. 822-848.
Carson, Shelly and Langer, Ellen. Mindfulness and self-acceptance. Journal of Rational-Emotive & Cognitive-Behavior Therapy, Vol. 24, No. 1, Spring 2006

Craig L. A.; Browne, Kevin D; and Stringer, Ian; Treatment and Sexual Offence Recidivism. Trauma, Violence, & Abuse, Jan 2003; vol. 4: pp. 70 – 89.

Crofford, Leslie J. Violence, Stress, and Somatic Syndromes Trauma Violence Abuse 2007 8: 299-313.
Follette, Victoria; Palm, Kathlene and Pearson, Adria. Mindfulness and trauma: Implications for treatment. Journal of Rational-Emotive & Cognitive-Behavior Therapy, Vol. 24, No. 1, Spring 2006 
Gregg, Jennifer A.; Callaghan, Glenn M.; Hayes, Steven C.; Improving Diabetes Self-Management Through Acceptance, Mindfulness, and Values: A Randomized Controlled Trial. Journal of Consulting and Clinical Psychology, Vol 75(2), Apr 2007. pp. 336-343. [Journal Article]
Herman, Judith; Trauma and Recovery. New York, 1992: Basic Books.
 , M. S., & Langer, E.; A cost of pretending. Journal of Adult
Development, 2003. 10(3), 261–270.
Horowitz, Mardi J. Self- and relational observation..; Journal of Psychotherapy Integration, Vol 12(2), Jun 2002. pp. 115-127.

Katreena, Scott; Predictors of Change among Male Batterers: Application of Theories and Review of Empirical Findings. Trauma, Violence, & Abuse, Jul 2004; vol. 5: pp. 260 – 284.

Krasner, Michael; Mindfulness-Based Interventions : A Coming of Age? Families, Systems, & Health, Vol. 22 (2), Summer 2004. pp. 207-212
Langer, Ellen J.; Imber, Lois; Role of mindlessness in the perception of deviance. Journal of Personality and Social Psychology, Vol 39(3), Sep 1980. pp. 360-367.
Looman, Jan; Dickie, Ida; and Abracen, Jeffrey. Responsivity Issues in the Treatment of Sexual Offenders. Trauma Violence Abuse 2005 6: 330-353. 
Ma, S. Helen; Teasdale, John D.; Mindfulness-Based Cognitive Therapy for Depression: Replication and Exploration of Differential Relapse Prevention Effects. Journal of Consulting and Clinical Psychology, Vol 72(1), Feb 2004. pp. 31-40. [Original Journal Article]
Martin, Jeffery R. The common factor of mindfulness–An expanding discourse: Comment on Horowitz (2002).; Journal of Psychotherapy Integration, Vol 12(2), Jun 2002. pp. 139-142. [Comment/Reply] 
Paul, Lisa A.; Gray, Matt J.; Elhai, Jon D.; Massad, Phillip M.; and Stamm, Beth Hudnall. Promotion of Evidence-Based Practices for Child Traumatic Stress in Rural Populations: Identification of Barriers and Promising Solutions. Trauma Violence Abuse 2006

Runyon, Melissa K.; Deblinger, Esther; Ryan, Erika E.; and Thakkar-Kolar, Reena. An Overview of Child Physical Abuse: Developing an Integrated Parent-Child Cognitive-Behavioral Treatment Approach. Trauma, Violence, & Abuse, Jan 2004; vol. 5: pp. 65 – 85.

Ryan, R. M., & Deci, E. L. Self-determination theory and the
facilitation of intrinsic motivation, social development, and well-being.
American Psychologist, 2000. 55, 68–78. 
Shapiro, Shauna L.; Astin, John A.; Bishop, Scott R.; Mindfulness-Based Stress Reduction for Health Care Professionals: Results From a Randomized Trial. International Journal of Stress Management, Vol 12(2), May 2005. pp. 164-176. [Original Journal Article]
Shapiro, Shauna L.; Brown, Kirk Warren; Biegel, Gina M.; Teaching self-care to caregivers: Effects of mindfulness-based stress reduction on the mental health of therapists in training. Training and Education in Professional Psychology, Vol 1(2), May 2007. pp. 105-115. [Journal Article]
Stelmach, Lew B.; Review of Attentional processing: The brain’s art of mindfulness. Canadian Journal of Experimental Psychology, Vol 50(3), Sep 1996. pp. 328-329. [Review-Book]
Teasdale, John D.; Segal, Zindel V.; Williams, J. Mark G.; Prevention of relapse/recurrence in major depression by mindfulness-based cognitive therapy. Journal of Consulting and Clinical Psychology, Vol 68(4), Aug 2000. pp. 615-623.
Tolle, Eckhart. (1999) The Power of Now. Canada: Namaste Publishing Inc.
Van Wijk, Anton; Vermeiren, Robert; Loeber, Rolf; Hart-Kerkhoffs, Lisette’t; Doreleijers, Theo; and Bullens, Ruud. Juvenile Sex Offenders Compared to Non-Sex Offenders: A Review of the Literature 1995-2005 Trauma Violence Abuse 2006 7: 227-243 
Vien A. and Beech, A. R.. Psychopathy: Theory, Measurement, and Treatment Trauma Violence Abuse 2006 7: 155-174.
 Walach, Harald; Nord, Eva; Zier, Claudia; Mindfulness-based stress reduction as a method for personnel development: A pilot evaluation. International Journal of Stress Management, Vol 14(2), May 2007. pp. 188-198. [Journal Article]
Waller, B. Carlson, J. Englar-Carlson, M. (2006) Treatment and relapse prevention of depression using mindfulness-based cognitive therapy and Adlerian concepts. The journal of individual psychology, Vol. 62
Williams, J. Mark G.; Teasdale, John D.; Segal, Zindel V.; Mindfulness-based cognitive therapy reduces overgeneral autobiographical memory in formerly depressed patients. Journal of Abnormal Psychology, Vol 109(1), Feb 2000. pp. 150-155.
Wilson, John P. ; Drozdek, Boris; and Turkovic, Silvana. Posttraumatic Shame and Guilt
Trauma Violence Abuse 2006 7: 122-141.
Yalom, I. D. (2002). The Gift of therapy. New York: HaperCollins Publisher Inc.