Mindfulness is most commonly conceptualized as involving attention to and awareness of the present moment, and nonjudgmental acceptance (1-3). Awareness of the present involves observing thoughts, feelings, and sensations by focusing one's attention on the current moment (2). While attending to the present, mindfulness also entails a stance of acceptance, or willingness to experience an array of thoughts and emotions without judgment (4).
The potential clinical utility of integrating mindfulness-based exercises in extant PTSD treatments has yet to be examined empirically (5). However, given the beneficial effects of mindfulness practice on enhancing emotion regulation as well as decreasing anxiety and depressive symptoms (6-9), mindfulness has been increasingly discussed in the context of PTSD and its treatment (10-12). The relevant theoretical and empirical literature suggests that mindfulness may serve clinically meaningful functions in alleviating PTSD symptoms.
Regular mindfulness practice can lead to a greater present-centered awareness and nonjudgmental acceptance of potentially distressing cognitive and emotional states as well as trauma-related internal and external triggers (5, 13). Awareness and acceptance of trauma-related thoughts and feelings may serve as an indirect mechanism of cognitive-affective exposure. This may be especially useful for individuals with PTSD, as it may help decrease experiential avoidance, reduce arousal, and foster emotion regulation. For instance, among trauma-exposed individuals evaluated at a single time point, greater levels of acting with awareness and accepting without judgment were associated with lower levels of posttraumatic stress symptoms (11). Regular mindfulness practice has also been shown to decrease physiological arousal (14- 15).
Empirically-supported treatments for PTSD, such as Cognitive Processing Therapy (CPT, 16) and Prolonged Exposure (PE, 17), are effective in decreasing symptoms for many individuals who suffer from PTSD. Both of these treatments direct the client to recall traumatic events in a controlled fashion. For the last decade, exposure to and processing of trauma-related thoughts, feelings, and memories have been considered important components of effective treatment for PTSD. However, a significant proportion of sufferers either do not seek help, drop out of treatment, refuse these treatments, or are not substantially helped by them (5, 18-19).
Combining mindfulness or other skills to strengthen emotion regulation with existing empirically-supported PTSD treatments may improve outcomes in the following ways:
Engagement. Mindfulness may appeal to clients who do not pursue evidence-based treatments or cannot tolerate them (5, 20-21). Mindfulness practice may improve symptoms and it may also help such clients become engaged with a therapist or treatment process.
Preparation. Mindfulness practice could be introduced prior to treatment. Learning to observe internal reactions without judgment and to accept feelings, sensations, and thoughts as they arise might usefully prepare patients to tolerate the unpleasant emotions that trauma processing elicits.
Less rumination. If implemented as an adjunct to CPT or PE, mindfulness could be encouraged throughout the treatment course. Increased awareness of trauma-related re-experiencing symptoms may allow patients to break a ruminative cycle by gaining some distance from trauma-related intrusive thoughts and feelings. It may foster acceptance rather than avoidance.
Compliance. Patients using mindfulness skills during treatment may be better able to persevere through trauma processing and benefit more fully from trauma-focused treatments.
Several psychotherapeutic interventions incorporating training in mindfulness are clinically relevant to traumatic stress. Although data are currently lacking on the efficacy of these interventions in PTSD populations specifically, research has supported the utility of these treatment approaches for various mental health concerns. Moreover, these interventions may be clinically useful for patients with PTSD as they target symptoms such as anxiety, depression, or emotion dysregulation that commonly co-occur with posttraumatic stress. At this time, the interventions listed below might best be considered meaningful tertiary care for patients with PTSD.
Acceptance and Commitment Therapy (ACT). The goal of ACT is to increase psychological flexibility and facilitate behavior change, such that patients become more committed to moving toward identified goals and values (12, 22). Randomized controlled trials are currently underway to evaluate the efficacy of ACT as a stand-alone treatment for PTSD. ACT targets avoidance of thoughts, memories, emotions, and other private experiences. Mindfulness exercises are one of a variety of techniques used to increase willingness to experience thoughts and feelings and thus facilitate psychological flexibility. In PTSD, these experiences may include intrusive recollections of the traumatic event and emotional states of guilt or anger. Patients are taught to be aware of private events without judging or attempting to control them (5, 8).
Dialectical Behavior Therapy (DBT). DBT is a multifaceted treatment for borderline personality disorder and related problems (23). In addition, DBT often has been used prior to the implementation of PTSD-specific treatments such as exposure-based interventions to address difficulties with emotion regulation and distress tolerance (24). DBT incorporates training in mindfulness as one of four areas of skill-building. In DBT, mindfulness involves three "what" skills (observing, describing, and participating) and three "how" skills (taking a nonjudgmental stance, focusing on one thing in the moment, and being effective).
Mindfulness-Based Stress Reduction. This treatment has primarily been employed to help patients manage stress associated with a variety of physical health conditions, such as chronic pain (25-28). It has also been shown to be a useful treatment approach for anxiety disorders and depression (7, 29), conditions that commonly co-occur with PTSD (30). Mindfulness meditation, a part of this therapy, is intended to cultivate a de-centered and nonjudgmental perspective in relation to physical sensations as well as cognitions and emotions (27).
Mindfulness-Based Cognitive Therapy. This consists of an eight-week group intervention that draws upon both mindfulness and cognitive therapy techniques, with the aim of reducing the risk of depressive relapse (8, 31). Patients are taught to focus more carefully on everyday events and allow thoughts to occur without trying to avoid or suppress them. Mindfulness Based-Cognitive Therapy thus might be a useful tertiary care program for patient struggling with PTSD and depression.
Mindfulness-Based Relapse Prevention. Mindfulness skills are employed in this prevention therapy as a technique for coping with urges to use substances following treatment for drug abuse and addiction (32). These skills help patients engage in "urge surfing" by observing their urges as they appear, accepting them nonjudgmentally, and 'riding the waves' without giving in to the urges. The prevalence of substance abuse problems among individuals with PTSD has been explained in terms of the emotional avoidance function of drug and alcohol use. As such, mindfulness interventions can be used to address substance use and other behaviors used to avoid trauma-related experiences (33).
Adequately measuring mindfulness is important in assessing if the essential components of mindfulness are what is responsible for change when it is used. Self-report instruments differ slightly in their conceptualizations of mindfulness. Two of the most widely used instruments to date are the Mindful Attention Awareness Scale (MAAS, 34) and the Five Facet Mindfulness Questionnaire (FFMQ, 1). The MAAS assesses awareness of present experience throughout daily life. The FFMQ (23) measures a range of facets and covers observing, describing, acting with awareness, acceptance without judgment, and non-reactivity to inner experience.
Other mindfulness measures include the Cognitive Affective Mindfulness Scale - Revised (35), the Philadelphia Mindfulness Scale (36), and the Freiburg Mindfulness Inventory (37). Each of these measures is designed to assess an individual's tendency to be aware of their present experience over time, or trait mindfulness. In contrast, the Toronto Mindfulness Scale (38) was developed to assess state mindfulness, or the degree to which one is able to reach a mindful state during mindfulness practice, such as meditation. Although each of the available measures has demonstrated solid psychometric properties in initial research (e.g., 39), further work is needed to address the discrepancies in definitions and assessments of mindfulness and its various facets (2, 40) and to determine whether these measures are sensitive to changes in mindfulness levels over time.
Mindfulness-based approaches have been shown to be useful for problems commonly seen in trauma survivors such as anxiety and hyperarousal. Mindfulness practice has potential to be of benefit to individuals with PTSD, either as a tertiary or a stand-alone treatment. However, before definitive conclusions can be drawn about the efficacy of mindfulness in treatment of PTSD, further basic and applied research is needed.