Professional Psychology: Research and Practice 2011, Vol. 42, No. 1, 24 –31

In the public domain DOI: 10.1037/a0022272

Mindfulness in the Treatment of Posttraumatic Stress Disorder Among Military Veterans Anka A. Vujanovic and Barbara Niles

Ashley Pietrefesa and Stefan K. Schmertz

National Center for PTSD, Veterans Affairs Boston Healthcare System, Boston, Massachusetts and Boston University School of Medicine

Veterans Affairs Boston Healthcare System, Boston, Massachusetts

Carrie M. Potter National Center for PTSD, Veterans Affairs Boston Healthcare System, Boston, Massachusetts How might a practice that has its roots in contemplative traditions, seeking heightened awareness through meditation, apply to trauma-related mental health struggles among military veterans? In recent years, clinicians and researchers have observed the increasing presence of mindfulness in Western mental health treatment programs. Mindfulness is about bringing an attitude of curiosity and compassion to present experience. This review addresses the above question in a detailed manner with an emphasis on the treatment of military veterans suffering from posttraumatic stress disorder (PTSD) and related psychopathology. In addition, the integration of mindfulness with current empirically supported treatments for PTSD is discussed with specific attention to directions for future research in this area. Keywords: mindfulness, posttraumatic stress disorder, treatment, military veterans

PTSD (VHA Office of Public Health and Environmental Hazards, 2010). Both trauma exposure and PTSD are associated with high rates of co-occurring psychiatric disorders (Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995) and significant impairments in interpersonal relationships, occupational functioning, physical health, and overall quality of life (Institute of Medicine [IOM], 2010). Therefore, the evaluation of existing treatment services is essential to the provision of cutting-edge, evidence-based treatment modalities to veterans, a core mission of the VHA (Veterans’ Affairs [VA] Office of Inspector General, 2009). Currently, vari-

“You can’t stop the waves, but you can learn to surf.” —Jon Kabat-Zinn

Increasing numbers of returning veterans are presenting to the Veterans Health Administration (VHA) for mental health services related to trauma exposure or posttraumatic stress disorder (PTSD). Indeed, preliminary epidemiological findings indicate a high rate of trauma exposure among service-seeking Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) veterans (Hoge et al., 2004), with approximately 25.5% of returning Veterans presenting to VHA meeting diagnostic criteria for

Editor’s Note. This article was submitted in response to an open call for submissions concerning the provision of Psychological Services by practitioner psychologists to veterans, military service members, and their families. This collection of 12 articles represents psychologists’ perspectives on the mental health treatment needs of these individuals along with innovative treatment approaches for meeting these needs.—JEB

such as exercise and mindfulness meditation, in traumatized individuals. ASHLEY PEITREFASA received her PhD in clinical psychology from Binghamton University, State University of New York. She is currently completing a clinical postdoctoral fellowship in the National Center for PTSD at VA Boston Healthcare System. Her research interests include examining factors that contribute to the etiology and maintenance of anxiety disorders, particularly cognitive processes and avoidance behaviors. STEFAN K. SCHMERTZ received his PhD in clinical psychology from Georgia State University. He is currently completing a clinical postdoctoral fellowship within the VA Boston Healthcare System. His research and clinical interests are in mindfulness, acceptance based interventions, as well as trans-diagnostic processes that contribute to psychopathology. CARRIE M. POTTER received her BA in psychology from Colby College. She is currently a Psychology Research Technician in the Behavioral Science Division of the National Center for PTSD at VA Boston Healthcare System. Her research interests include examining the mechanisms underlying the etiology and maintenance of PTSD and substance use disorders. CORRESPONDENCE CONCERNING THIS ARTICLE should be addressed to Dr. Anka A. Vujanovic, Ph.D., National Center for PTSD–Behavioral Science Division, VA Boston Healthcare System, 150 South Huntington Avenue (116B-2), Boston, MA 02130. E-mail: [email protected]

ANKA A. VUJANOVIC received her PhD in clinical psychology from The University of Vermont. She is currently a Staff Research Psychologist in the Behavioral Science Division of the National Center for PTSD at VA Boston Healthcare System, and Assistant Professor of Psychiatry at Boston University School of Medicine. Her research interests are focused upon the examination of biopsychosocial risk and maintenance factors relevant to PTSD and co-occurring substance use disorders. BARBARA NILES received her PhD in clinical psychology from Rutgers, The State University of New Jersey. She is currently a Staff Psychologist in the Behavioral Science Division of the National Center for PTSD at VA Boston Healthcare System, and Assistant Professor of Psychiatry at Boston University School of Medicine. Her research and clinical interests focus on the promotion of health-enhancing behaviors, 24

SPECIAL ISSUE: MINDFULNESS AND PTSD

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ous mindfulness-based interventions are being utilized across the VHA, particularly in PTSD Clinics. These interventions have great—yet empirically underexplored—potential to facilitate treatment of PTSD and co-occurring conditions.

mindfulness, and by extension, a well-accepted definition (Bishop et al., 2004). For purposes of this review, we refer to mindfulness according to this most common operational definition, which emphasizes the two factors of awareness and acceptance.

What Are the Current Empirically Supported Treatments for PTSD?

What Are the Relations Between Mindfulness and Psychopathology?

Empirically supported treatments for PTSD, such as Cognitive Processing Therapy (CPT; Resick, Monson, & Chard, 2007) and Prolonged Exposure (PE; Foa, Hembree, & Rothbaum, 2007), are effective in decreasing symptoms for many individuals who suffer from PTSD. Indeed, the VHA has instated requirements that these treatments be “rolled out” nationally, such that CPT and PE are increasingly available to veterans with PTSD. Both CPT and PE direct the client to recall traumatic events in a controlled fashion. Both treatment modalities (to varying degrees) also are focused upon exposure to and cognitive processing of trauma-related thoughts, feelings, and memories, the central ingredients for effective PTSD treatment. However, a large proportion of trauma-exposed veterans (with and without PTSD) do not seek help, drop out of treatment, refuse these treatments, or are not substantially helped by them (e.g., Schottenbauer, Glass, Arnkoff, Tendick, & Gray, 2008). Many veterans may have a limited skill set of adaptive coping skills and particular difficulty engaging in cognitive-affective processing of trauma (e.g., Becker & Zayfert, 2001). Furthermore, veterans may not believe they are “ready” to engage in trauma-focused treatment. Thus, in many instances, veterans are referred to skills-based group treatment programs, which often consist of mindfulness-based components (e.g., dialectical behavior therapy; Linehan, 1993), as a precursor or adjunct to individual CPT or PE. Mindfulness, often considered within the “third wave of behavior therapy,” has both theoretical and empirical promise for better understanding the etiology and maintenance of PTSD and improving treatment outcomes (e.g., Vujanovic, Youngwirth, Johnson, & Zvolensky, 2009; Walser & Westrup, 2007). Many PTSD clinics within the VHA offer some form of mindfulness-based treatment as adjunctive therapy (see Table 1) in individual and/or group formats. Yet, relatively little is known about the effectiveness of mindfulness as an exclusive or supplementary treatment approach for PTSD populations generally, and military veterans with PTSD, specifically.

In both cross-sectional and treatment studies, mindfulness (or mindfulness skills) has been negatively (inversely) associated with anxiety, depressive symptoms, substance abuse, chronic pain, and borderline personality disorder symptoms (e.g., Baer, 2006; Hofmann, Sawyer, Witt, & Oh, 2010; Kabat-Zinn, Lipworth, & Burney, 1985; Lynch, Trost, Salsman, & Linehan, 2007; Parks, Anderson, & Marlatt, 2001). Mindfulness also has been positively related to greater emotion regulation and various indices of wellbeing (e.g., Brown & Ryan, 2003; Vujanovic, Bonn-Miller, Bernstein, McKee, & Zvolensky, in press).

What Is Mindfulness? Mindfulness is most commonly conceptualized as involving two key components: (1) intentional regulation of attention to and awareness of the present moment, and (2) nonjudgmental acceptance of the ongoing flow of sensations, thoughts, and/or emotional states (Baer, Smith, Hopkins, Krietemeyer, & Toney, 2006; Bishop et al., 2004). Awareness is cultivated through intentional regulation of attention to present experience. While attending to the present, mindfulness also entails a stance of acceptance, or willingness to experience the array of one’s thoughts and emotions without judgment. Awareness of one’s present-centered experience might be considered a necessary first step toward nonjudgmental acceptance of that experience. Notably, the literature is lacking consensus on an overarching theoretical framework for

In What Ways Might Mindfulness Be Helpful for People With PTSD? Given the beneficial effects of mindfulness practice on enhancing emotion regulation as well as decreasing anxiety and depressive symptoms, mindfulness has been increasingly discussed in the context of PTSD and its treatment (see Orsillo & Batten, 2005). The potential clinical utility of integrating mindfulness-based exercises with PTSD treatments has not yet been subjected to empirical scrutiny (Follette & Vijay, 2009). Nonetheless, the theoretical and empirical literature suggests that mindfulness may serve at least four clinically meaningful functions in alleviating PTSD symptoms. First, regular mindfulness practice can enhance or create a greater present-centered awareness and nonjudgmental acceptance of distressing internal states as well as trauma-related triggers (e.g., Walser & Westrup, 2007). Indeed, mindfulness may serve as an indirect mechanism of cognitive-affective exposure, as it involves an intrinsic willingness to approach, rather than to avoid, distressing thoughts and feelings. Mindfulness practice may increase an individual’s ability to attend to thoughts and emotions as they arise and to tolerate distressing internal experiences by observing their transient nature. This may be an especially useful skill for individuals with PTSD, as it may help facilitate approach-oriented coping with trauma-related internal or external cues and decrease experiential avoidance. Through mindfulness practice, an individual with PTSD may become more willing to confront trauma-related triggers, including cognitions and emotions, but also people, places, and activities. Consistent engagement in these exercises may decrease PTSD avoidance symptoms over time, thus targeting the core maintenance factor of the disorder (Foa, Riggs, Massie, & Yarczower, 1995). Furthermore, “mindfulness enhanced exposure” (Follette & Vijay, 2009, p. 309) may target trauma-related symptoms related to PTSD (e.g., depressive symptoms). Second, individuals who are more aware of present experience may be better able to effectively engage in various forms of treatment. For example, greater levels of present-centered awareness might facilitate client-therapist communication via enhanced openness. Clients who are more keenly aware of their thoughts and

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Table 1 Treatments Involving Mindfulness Practice Mindfulness exercise duration Interventions Incorporating Mindfulness Acceptance and Commitment Therapy (ACT)

Dialectical Behavior Therapy (DBT)

Interventions Based on Mindfulness Mindfulness-Based Stress Reduction (MBSR)

Brief

Brief

Extended

Relevant clinical resources and manuals

Empirical support for specific conditions and relevant populations

•Get out of your mind and into your life: The new Acceptance and Commitment Therapy (Hayes, 2005) •A practical guide to acceptance and commitment therapy (Hayes & Strosahl, 2005) •Acceptance and commitment therapy: An experiential approach to behavior change (Hayes, Strosahl, & Wilson, 1999) •Learning ACT: An Acceptance and Commitment Therapy skills-training manual for therapists (Luoma, Hayes, & Walser, 2007) •Acceptance & commitment therapy for the treatment of posttraumatic stress disorder: A practitioner’s guide to using mindfulness and acceptance strategies (Walser & Westrup, 2007) •Cognitive-behavioral treatment of borderline personality disorder (Linehan, 1993) •Integrating DBT-based techniques and concepts to facilitate exposure treatment for PTSD (Becker & Zayfert, 2001)

•Psychotic symptoms (Bach & Hayes, 2002)

•Full catastrophe living: Using the wisdom of your body and mind to face stress, pain, and illness (KabatZinn, 1990) •Wherever you go there you are: Mindfulness meditation in everyday life (Kabat-Zinn, 1994)

•Anxiety disorders (Kabat-Zinn, Massion, Kristeller, & Peterson, 1992)

Mindfulness-Based Cognitive Therapy (MBCT)

Extended

•Mindfulness-Based Cognitive Therapy for depression: A new approach to preventing relapse (Segal, Williams, & Teasdale, 2002)

Mindfulness-Based Relapse Prevention (MBRP)

Extended

•Mindfulness-Based Relapse Prevention for substance use disorders (Bowen, Chawla, & Marlatt, in press)

•Anxiety and depression (Forman, Herbert, Moitra, Yeomans, & Geller, 2007) •Prevention of disability from stress and pain (Dahl, Wilson, & Nilsson, 2004) •Social phobia (Dalrymple & Herbert, 2007) •Polysubstance abuse (Hayes et al., 2004)

•Borderline personality disorder (Linehan et al., 2006) •Binge eating disorder (Safer, Robinson, & Jo, 2010)

•Depressive rumination (Ramel, Goldin, Carmona, & McQuaid, 2004) •Substance use disorders (Marcus et al., 2009) •Recurrent depression (Ma & Teasdale, 2004; Teasdale et al., 2000) •Anxiety, depression, and distress in cancers (Foley, Baillie, Huxter, & Price, 2010) •Substance abuse relapse (Bowen et al., 2009)

Note. Interventions incorporating mindfulness utilize mindfulness exercises and techniques as components of a multifaceted treatment, while interventions based on mindfulness utilize mindfulness practice as the sole or primary intervention.

emotions may be better able to talk about them in treatment. Furthermore, greater levels of nonjudgmental acceptance of internal experience might decrease shame, guilt, and difficulties in self-acceptance, core issues for many individuals with PTSD (e.g., Henning & Frueh, 1997). Third, regular mindfulness practice has been shown to decrease physiological arousal and stress reactivity (e.g., Delizonna, Williams, & Langer, 2009), perhaps via greater awareness and acceptance of such symptoms. In this manner, mindfulness might have

a beneficial effect on symptoms of PTSD-related hyperarousal over time. As one example, mindfulness, indexed by the Mindful Attention Awareness Scale (MAAS; Brown & Ryan, 2003), has been associated with more adaptive sleep functioning (Howell, Digdon, & Buro, 2010). It is thought that mindfulness may foster a greater sensitization to bodily cues (e.g., breathing rate, heart rate), thereby providing individuals with the necessary awareness to self-regulate in a more adaptive manner (e.g., Brown & Ryan, 2003). The cultivation of greater interoceptive awareness and

SPECIAL ISSUE: MINDFULNESS AND PTSD

acceptance may also serve indirectly as exposure to uncomfortable physical sensations (e.g., chest tightness), thus increasing tolerance to such sensations over time. Furthermore, with ongoing attention to bodily processes, individuals are thought to become more attuned to their intrinsic needs and thus better able to tend to those needs. Finally, “mindful distraction” exercises (e.g., grounding; Batten, Orsillo, & Walser, 2005) can be used to foster psychological flexibility, such that individuals might learn (a) when it is appropriate and beneficial to sit with distressing internal experience, and (b) when it might be more constructive to shift attention away from ruminative thoughts and prevent dissociation. Psychological flexibility has been defined as the ability to adopt a present-centered stance and to act in accordance with one’s values in a given situation (Hayes, Strosahl, Bunting, Twohig, & Wilson, 2005). Indeed, mindfulness training has been associated with the cultivation of sustained attention and attention switching (e.g.,Jha, Krompinter, & Baime, 2007), or the increased ability to selectively direct attention from one stimulus (e.g., internal experience) to another. Relatedly, mindfulness training has also been associated with an increased ability to inhibit secondary elaborative processing of thoughts, feelings, and sensations (e.g., Jha et al., 2007). Thus, with increased mindfulness training, veterans might be better able to notice repetitive negative thinking and to prevent extensive engagement with maladaptive ruminative processes by attending to the present moment.

How Is Mindfulness Being Used in Psychological Treatments With Relevance to PTSD? Several psychotherapeutic interventions incorporating training in mindfulness are clinically relevant to PTSD. Although research has supported the utility of these treatment approaches for various mental health concerns (see Table 1; for a review, see Baer, 2006), data on the effectiveness of these interventions for PTSD populations, specifically, are lacking. Nevertheless, these interventions may be clinically useful for clients with PTSD, as they target a variety of conditions and symptoms that frequently co-occur and overlap with PTSD. Presently, the mindfulness-based interventions described below might best be considered meaningful adjunctive care for clients with PTSD. For example, in the VHA, these treatment programs have been adapted for use with PTSD clients, using clinical judgment and best care practices; while specific data on their level of effectiveness with veteran or PTSD populations are pending.

Acceptance and Commitment Therapy (ACT) The goal of ACT (Hayes et al., 1999) is to increase psychological flexibility and facilitate behavior change, such that clients become more committed to moving toward identified goals and values. 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. Clients are taught to be aware of private events without judging or attempting to control them (e.g., Walser & Westrup, 2007). In

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addition, mindfulness exercises are used to demonstrate how difficult private events, such as thoughts and memories associated with traumatic experiences, can be experienced safely (Walser & Westrup, 2007).

Dialectical Behavior Therapy (DBT) DBT (Linehan, 1993) is an empirically supported, multifaceted treatment for borderline personality disorder and related problems that are commonly comorbid with PTSD (e.g., Shea, Zlotnick, & Weisberg, 1999). DBT involves individual and/or group-based training in mindfulness as one of four areas of skill-building, which include distress tolerance, interpersonal effectiveness, and emotion regulation. DBT often has been used prior to the implementation of PTSD-specific treatments, such as exposure-based interventions, to provide skills training in emotion regulation and distress tolerance that may be necessary prior to more intensive PTSD-specific treatment (Wagner & Linehan, 2006). For example, veterans identified as having a need for increased skills related to regulating emotion and/or tolerating distress might participate in DBT skills groups before or during individualized PTSD treatment, or as a stand-alone intervention.

Mindfulness-Based Stress Reduction (MBSR) A major component of MBSR (Kabat-Zinn, 1990, 1994) is focused mindful meditation with the intention of cultivating a decentered and nonjudgmental perspective in relation to cognitions, emotions, and physical sensations. MBSR encourages methodical scanning of the body and incorporates Hatha yoga as a means of fostering awareness and acceptance of cognitive, emotional, and physical processes. Primarily, MBSR has been employed to help clients manage stress associated with a variety of physical health conditions, such as chronic pain (Kabat-Zinn et al., 1985). It has also been shown to be a useful treatment approach for anxiety disorders, depression, and substance abuse (see Table 1), conditions that commonly co-occur with PTSD.

Mindfulness-Based Cognitive Therapy (MBCT) MBCT (Segal et al., 2002) is a group intervention that is largely based on MBSR. It draws upon both mindfulness and cognitive therapy techniques and aims to prevent the recurrence of major depressive episodes. In MBCT, clients are taught to focus more carefully on everyday events and to allow thoughts to occur without trying to avoid or suppress them. MBCT thus might be a useful adjunctive care program for individuals struggling with both PTSD and depression, a common diagnostic comorbidity (Kessler et al., 1995).

Mindfulness-Based Relapse Prevention (MBRP) Mindfulness skills are employed in MBRP (Bowen, Chawla, & Marlatt, in press) as a technique for coping with urges to use substances following treatment for substance use disorders. These skills help clients engage in “urge surfing” by observing their urges to use substances as they occur, accepting them nonjudgmentally, and “riding the waves” without giving in to the urges. The prevalence of substance use disorders among individuals with PTSD has been explained in terms of the emotional avoidance

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function of drug and alcohol use. As such, mindfulness interventions can be used to simultaneously address substance use and other behaviors aimed at avoiding trauma-related experiences (Batten & Hayes, 2005).

Clinical Caveats Extended (e.g., 30 – 40 minutes) mindfulness exercises may be inadvisable for some veterans with PTSD who exhibit significant difficulties regulating emotion. Clients experiencing high levels of re-experiencing symptoms may not be willing or able to focus their attention on present experience. For example, MBSR training materials recommend that clients with PTSD who are not in concurrent treatment for PTSD be screened out of the program (Santorelli & Kabat-Zinn, 2009). Prolonged mindfulness exercises that include long silences may be contraindicated for clients who lack skills for tolerating and regulating the intensity of painful feelings that may arise. Stabilization of symptoms may be necessary before such clients can engage in extended mindfulness programs. Instructor-guided exercises of shorter duration (e.g., 5-10 minutes) may be more appropriate in these circumstances.

Does Research Support the Use of Mindfulness in the Treatment of PTSD? Three published cross-sectional studies to date have examined associations between mindfulness and posttraumatic stress symptoms in trauma-exposed nonclinical samples, though none has focused on veterans or clinical PTSD populations. First, Vujanovic and colleagues (2009) found a significant, negative relationship between posttraumatic stress symptoms and both the “acting with awareness” and “nonjudgmental acceptance” scales of the Kentucky Inventory for Mindfulness Skills (Baer, Smith, & Allen, 2004). This relationship remained statistically significant even after controlling for the variance accounted for by negative affectivity and number of trauma exposure types. “Nonjudgmental acceptance” emerged as the most robust mindfulness factor, demonstrating incremental negative associations with each of the posttraumatic stress symptom clusters, while acting with awareness was incrementally negatively associated with only the reexperiencing symptom cluster (Vujanovic et al., 2009). Second, in a sample of undergraduate students, Thompson and Waltz (2010) found incremental negative relations between “nonjudgmental acceptance”—as indexed with the Five Facet Mindfulness Questionnaire (Baer et al., 2008) —and posttraumatic stress avoidance symptoms, even after controlling for various indices of experiential avoidance. Third, in an adult community sample, Bernstein, Tanay and Vujanovic (in press) found that levels of mindful attention and awareness—as measured with the MAAS—were significantly and negatively associated with posttraumatic stress symptom severity, psychiatric multi-morbidity, anxious arousal, and anhedonic depression symptoms, above and beyond number of traumatic event types. Taken together, these studies support the clinical utility of mindfulness, as higher levels of mindfulness were related to lower posttraumatic stress and related symptoms and vice versa. To our knowledge, only one treatment study has been published regarding the efficacy of mindfulness-based interventions for traumaexposed or PTSD populations, specifically. An 8-week MBSR pilot

program, comprised of 2.5- to 3-hour classes and a 5-hour silent retreat, was conducted with 27 adult survivors of childhood sexual abuse (Kimbrough, Magyari, Langenberg, Chesney, & Berman, 2010). The authors concluded that this trial of MBSR was efficacious in significantly decreasing posttraumatic stress symptoms, with symptoms of avoidance/numbing most significantly reduced. This MBSR trial, though lacking a randomized controlled condition, demonstrated promising results with regard to the efficacy of a mindfulness-based intervention for reducing symptoms of posttraumatic stress among adult survivors of childhood trauma. Several clinical trials are underway, examining the efficacy of mindfulness-based interventions as stand-alone interventions for PTSD populations. For example, preliminary unpublished data, based on a sample of veterans with PTSD, compared two 8-week telehealth treatments for PTSD—mindfulness and PTSD psychoeducation—in the context of a randomized trial. Findings suggest that a brief introduction to mindfulness can significantly reduce PTSD symptoms among veterans (Niles, Klunk-Gillis, Silberbogen, & Paysnick, 2009).

Can Mindfulness Be Integrated With Empirically Supported Treatments for PTSD? Currently, there is a significant dearth of empirical work supporting the implementation of mindfulness training as an adjunct to the empirically supported treatments for PTSD. Theoretically, mindfulness training may improve outcomes if implemented as an adjunct to CPT and PE through a variety of aforementioned avenues, or in the context of stand-alone interventions such as ACT (Walser & Westrup, 2007). However, it is important to note that such postulations are purely speculative at present. It seems imperative for future clinical research efforts to focus upon elucidating if, how, and which mindfulness-based approaches might be clinically meaningful in the treatment of PTSD. A number of important questions remain: Is it beneficial for mindfulness practice to be introduced prior to CPT or PE and/or encouraged throughout the course of these interventions? Can the ability to observe and accept present-centered experiences nonjudgmentally usefully prepare clients to tolerate the unpleasant emotions that trauma-related emotional and cognitive processing often entails? Would increased awareness of PTSD re-experiencing symptoms allow clients to gain some distance from PTSD-related intrusive thoughts and emotions? Does the cognitive-behavioral approach of noticing and changing problematic thought patterns, advocated by CPT and PE, conflict or coincide with the nonjudgmental, acceptance-based stance of mindfulness training? Do mindfulness levels change over time by virtue of participation in CPT or PE as a result of the increased meta-awareness and acceptance of thoughts and emotions encouraged by these interventions? Are clients who use mindfulness skills during treatment less likely to drop out of treatment and able to engage more fully in treatment? Does the efficacy of mindfulness-based interventions differ based on trauma exposure type (e.g., combat, sexual abuse) or clinical population (e.g., military veterans)? Indeed, comparative clinical trials examining the efficacy of CPT and/or PE and complementary treatment groups incorporating adjunctive mindfulness-based components (e.g., mindfulness skills during the course of treatment; DBT skills pretreatment) seem especially important to ad-

SPECIAL ISSUE: MINDFULNESS AND PTSD

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vancing our understanding of these psychological processes and improving treatment outcomes.

tions to veterans and other populations to improve psychological treatment outcomes among trauma survivors.

How Might Clinicians Learn More About Mindfulness-Based Interventions?

References

In its traditional form, mindfulness is learned through practice as an experiential exercise that transcends intellectualized rote learning of skills (Gunaratana, 2001). The training of clinicians in the application of mindfulness interventions is often discussed as an important issue in ensuring treatment fidelity, and clinicians are encouraged to maintain their own mindfulness practice in order to better instruct others (e.g., Santorelli & Kabat-Zinn, 2009). Thus, it is recommended that clinicians with interest in mindfulnessbased interventions begin learning by reviewing the relevant literature, with particular attention to treatment manuals of interest to the specific needs of their clinical cases (see Table 1). Furthermore, the utility of engaging in experiential trainings, often provided at clinical workshops, cannot be overemphasized. Experiential learning and practice of the diverse approaches to mindfulness skills practice offers not only an invaluable introduction to relevant concepts but also to the most effective ways that such concepts can be introduced to clients and integrated into case conceptualization and treatment planning. Given the relative paucity of data on how to best integrate mindfulness with empirically supported PTSD treatments, clinicians may be guided by current treatment programs for conditions commonly co-occurring with PTSD, as well as by specifically consulting the mindfulness exercises recommended for populations manifesting especially heightened difficulties with emotion regulation (see Table 1). Currently, the development of the most effective methods of training and preparation of clinicians interested in incorporating mindfulness-based practices remains an issue in need of greater empirical scrutiny.

Summary and Future Directions As the utilization of mindfulness-based interventions increases across the VHA and mental health clinics and practices, more generally, research is necessary to determine the mechanisms by which mindfulness skills and practices might alleviate psychological problems, including PTSD, among veterans. Likely the most salient issue facing mindfulness research and practice is the aforementioned lack of consensus about its definition. Indeed, mindfulness has been presented as a “state of mind, a trait of mind, a particular type of mental process, or the method for cultivating any or all of the preceding categories” (Grossman, 2008; p. 405). Inconsistencies also exist at the practice level with regard to how mindfulness is described and what components are emphasized (Bishop et al., 2004). Interwoven with efforts to define mindfulness are attempts to develop reliable and valid assessments (e.g., Baer et al., 2006). The continual refinement of mindfulness assessment instruments is a crucial step, as it would allow researchers and clinicians to reliably investigate the effectiveness of current mindfulness interventions (e.g., charting mindfulness skills over time), ways in which mindfulness practices may facilitate clinical change, and the role that mindfulness may play within various treatment programs. It is imperative that future work continues to examine the applicability of mindfulness interven-

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Received June 14, 2010 Revision received August 6, 2010 Accepted August 16, 2010 䡲

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