(p. 161) Mindfulness-based therapies
Life can be found only in the present moment. The past is gone, the future is not yet here, and if we do not go back to ourselves in the present moment, we cannot be in touch with life.
(Thich Nhat Hanh, Taming the Tiger Within)1
In the spring of 2013 I did a search of the psychology and psychotherapy books in Blackwell’s bookshop in Oxford, looking for new developments in the trauma therapies. There was little of note but one word kept recurring time and again as I glanced at the titles on the spines. Mindfulness. There were more than a dozen books on mindfulness with subjects that ranged from urban living to bee-keeping. Doing something, anything, mindfully obviously had selling power. There is even, I discovered later, a Rough Guide to Mindfulness.2 Thirty years ago my friend, John Teasdale, introduced me to the work of Jon Kabat-Zinn, now the guru of all things mindful. I read Full Catastrophe Living and was impressed by the work that he had done on physically ill patients at Boston’s Massachusetts General Hospital, USA.3 I was given copies of his body scan and yoga tapes (as they then were), and I have used these forms of relaxation ever since, on my patients and on myself. Kabat-Zinn has a wonderfully calm voice and the exercises were no more difficult to do than conventional relaxation methods; in fact, to my mind they are the best relaxation exercises I have used. I will discuss Kabat-Zinn’s work later in this chapter. However, I almost did not include a chapter on mindfulness-based therapies for the simple reason that there was very little work geared specifically to major traumas. A great deal on stress and anxiety, and, more recently, on the prevention of relapse after treatment for depression. But on PTSD virtually nothing. I suspect this will have changed by the time you read this book as the mindfulness bandwagon rolls on.
(p. 162) Given that mindfulness therapies have a particular focus on what is going on in the mind in the present moment, it is not difficult to see their potential in the trauma field. Learning to step back from the vivid power of a trauma flashback and respond with calm acceptance seems on the face of it a good strategy. Learning a simple but effective strategy for managing stress is likely to be helpful. Therefore, in this chapter I review the various mindfulness-based interventions. Included under this heading are two therapies that draw upon mindfulness, acceptance and commitment therapy (ACT) and compassion focused therapy (CFT). Steve Hayes and Paul Gilbert, the founders of these two therapies, might bridle at this categorization since their therapies are much more than versions of mindfulness. Each has a rich and diverse psychological heritage that merits consideration in its own right. Yet it is mindfulness that I want to highlight in relation to the trauma therapies. In both ACT and CFT mindfulness is a key concept that flows through everything that is done in both therapies.
But before I launch into an account of mindfulness-based interventions (MBIs), I want to highlight an important distinction. On the one hand, mindfulness can be equated with a therapeutic technique, or, more accurately, a set of techniques, that may be useful additions to existing therapies. For example, you might want to add a mindfulness meditation exercise like the body scan or the sitting meditation to your current approach to trauma. Perhaps incorporating a mindfulness technique would enable exposure or imaginal reliving therapy to work more effectively, or, as has been suggested, make these therapies more palatable and so reduce the drop-out rate. On the other hand, in mindfulness, we have a radically different philosophy of mental health, and indeed of life generally, the origins of which go back to Buddhism. All the major promoters of the various MBIs stress its philosophical basis though they vary in the extent to which they explicitly draw on Buddhist ideas and practices. To be properly mindful entails making a lifelong commitment to regular practices of meditation or similar exercises. To therapists who already have an established way of working—all of you, in other words—is it practicable to propose such a radical change? Is it not more realistic to ask if mindfulness has something to add to established ways of working? But would we then fail to do justice to the true meaning of the term? A major thread that runs (p. 163) through this chapter therefore is whether mindfulness can be shorn of its philosophical roots, or whether to be truly mindful requires a fundamental rethink of how we as therapists engage in helping traumatized people.
The introduction of mindfulness into Western psychotherapy owes much to the pioneering work of Jon Kabat-Zinn in the field of chronic pain and stress. Over three decades he developed and evaluated a group therapy called mindfulness-based stress reduction (MBSR), introducing methods of meditation and hatha yoga that have since become widely used.4 Kabat-Zinn’s definition of mindfulness is one that is most commonly referred to in the literature, namely “paying attention in a particular way: on purpose, in the present moment, and nonjudgmentally.”5 This definition contains two features, present awareness and the suspension of judgment, or acceptance. Present awareness means more than simply being in the present; it also embraces the notion of “sustained attention,” or sati in Buddhism, whereby a mindful individual concentrates his or her attention intensely on an object, feeling, or thought. Anyone who has tried to do this soon learns that the mind wanders and so the mind needs to be trained to achieve a sustained, concentrated focus, which is where meditation comes in.
Being nonjudgmental is also something that most of us tend to find difficult; suspending our tendency to evaluate ourselves and others is not something that comes naturally. It also raises fundamental questions about the way we live. Thus, the Buddhist notion of dukkha (suffering) entails standing back from and tolerating painful experiences rather seeking to change them, a view that seems at first sight contrary to the aims of most Western therapies. Mindfulness is based upon an ethical system that few Western therapists are familiar with. In 2004, however, a group of Western scientists arrived at a consensus on how mindfulness might be operationally defined:
1 The self-regulation of attention to focus on current experiences (thoughts, feelings, sensations).
2 An attitude of curiosity, experiential openness, and acceptance of these experiences.6
(p. 164) This definition makes no reference to a system of values presumably because it is placing mindfulness within the values that inform the Western scientific tradition. In this account, mindfulness refers simply to a way of thinking (concentrated and in the present) and an attitude of mind (curious and open to experience). I could in theory train myself to be mindful in this way without adopting any of the Buddhist philosophical baggage. Despite this attempt to establish an agreed definition, mindfulness is still being used in a variety of ways. For example, one of the major exponents, Bruno Cayoun, uses the term “equanimity” to describe an attitude toward present experience that results in a state of tranquility. He sees his form of mindfulness therapy as one in which progress toward equanimity gradually replaced a stressful way of life.7 Definitions will only take us so far. It is more useful to examine how the mindfulness therapies actually work. In practice, what do the various MBIs offer and how might this be applied in the trauma field?
In a review of the research on mindfulness interventions, Keng et al. (2011) concluded that there was good empirical support for mindfulness in general both in terms of studies showing a positive correlation with psychological health, and also in terms of interventions leading to an increased sense of well-being, a reduction in psychological symptoms and emotional reactivity, and improved behavioral regulation.8 A similar conclusion was arrived at in an earlier review by Baer (2003) although at that time there were relatively few controlled trials.9 Fjorback et al. (2011)10 reviewed the research on randomized controlled trials (RCTs) of two MBIs, mindfulness-based stress reduction (MBSR) and mindfulness-based cognitive therapy (MBCT). They concluded that MBSR improved mental health in both clinical and nonclinical subjects, and that MBCT was effective in preventing relapse in depression. However, more specific questions remain unanswered mainly because the research has not been done or the studies are inconclusive. Thus, it is not possible to conclude anything from research studies about the value of different MBIs, nor about the components of the therapy packages, nor whether or not the regular practice of meditation is a necessary component, nor about the (p. 165) mechanisms of change. Nor can we conclude anything about mindfulness interventions for PTSD or other trauma reactions because too few studies have been published. None of this is surprising or unexpected. Published research often lags behind clinical practice and even where more research has been done, definitive conclusions are rarely to be drawn. From the perspective of an interested and open-minded therapist working in trauma, the more important question might be: what features of the various MBIs might be particularly useful for my work? And, further, what benefits might come, both to me and to my clients, from being more mindful in my work?
Mindfulness-based stress reduction
Kabat-Zinn’s MBSR program was the first systematic application of mindfulness in a clinical context. In the early 1980s it was set up in a general hospital in the form of weekly group sessions of up to 30 people, meeting for between 2 and 2.5 hours for an 8- to 10-week course. The focus was on stress reduction using mindfulness meditation techniques such as the sitting meditation, the body scan, and hatha yoga exercises. There were homework assignments and discussions of what stress was and how to cope with pain and discomfort. Three things distinguished the approach from the various anxiety and stress management therapies that were around at the time. Firstly, there was the presence and authority of Kabat-Zinn. “Here was a man with clarity and purpose,” wrote Dr. Joan Borysenko, who in 1981 attended a class as an observer, “who exuded a kind of confident strength that invited people to make an all-out effort on their own behalf. I thought to myself, ‘This guy don’t pussyfoot around.’”11 Those who have met Kabat-Zinn, seen his videos, or listened to his CDs can testify to an extraordinary personal authority; it is no surprise that he has now become something of a guru in the mindfulness field.12 While we tend to be focused on methods, we should not overlook the person, particularly when it comes to mindfulness, which is in essence an experiential approach. The therapist’s significance as a role model, someone who shows in his very being the benefits of what he is teaching is hugely important. One of the debates within mindfulness is whether or not teachers/therapists should be practicing mindfulness themselves before training others in it. I think there is only one answer to that.
(p. 166) The second distinguishing feature lies in the explicit reference to Buddhist ideas and practices. When I read Full Catastrophe Living for the first time I was excited by the idea of a very different approach to the mind and one that was based on insights and methods that had been honed over thousands of years in Eastern philosophies. To get people to commit to making effortful changes in their everyday lives, which is a crucial part of all mindfulness approaches, it is necessary to instill a strong motivation to change and what could be more powerful than the idea of releasing oneself from all suffering? It is not enough in itself of course and “suffering” is understood in a different way from everyday usage. MBSR also brought simple methods of meditation and yoga into the lives of people who had never thought of doing anything of that sort, with beneficial effects. Throughout, MBSR emphasized the importance of personal experience and of regular practice in learning to be mindful, and of applying mindfulness to one’s life on a daily basis. This is a thread that runs through all the MBIs.
The third distinguishing feature of MBSR is that of the nature of the clients. Kabat-Zinn worked in a general hospital and the people he first invited to his group suffered from a variety of physical symptoms and problems. In Full Catastrophe Living the roll call of people included a man with AIDS, another who had had a heart attack, a woman who had had a cerebral aneurysm, another woman who could not walk because of chronic pain, a man with severe migraine headaches, and a woman with insomnia, just to mention a few.13 The application of psychology to medical problems (behavioral medicine) was in its infancy. Most stress management therapies were being applied to people with mental health problems such as the various anxiety disorders, treatments that were being carried out either in primary care settings or the mental health services. Why do I mention this? For the simple reason that mindfulness began as a holistic approach, one in which body and mind are one. The meditation methods begin with the body and it is through the body’s actions (and inaction) that the mind is trained. Although the behavioral methods for treating anxiety sometimes used forms of physical relaxation, relatively little attention was paid to the body. Indeed, the exponents of the exposure methods that came to dominate behavioral (p. 167) treatments for anxiety in the 1970s and 1980s regarded physical relaxation as superfluous since, it was believed, anxiety habituated purely as a result of exposure (see Chapter 7). By focusing on the body, MBSR homed in directly on physical experience, encouraging people to make changes there and then in the group, and then later in their daily lives. The therapy was not about talking about the meaning of stress or even about one’s personal problems. Nor was it about keeping diaries or records of stressful events. Nor about identifying and changing negative thoughts. The focus in MBSR was firmly on the meditation exercises and attaining the attitude of mindfulness through regular practice. Without the meditation exercises, people cannot still their minds however much they might like to. Once they have learned the requisite strategies, and implemented them through regular experiential practice, the benefits come, provided of course that people continue to practice mindfulness on a daily basis.
Mindfulness-based cognitive therapy
Mindfulness and cognitive therapy (CT) might seem unlikely bedfellows. In CT a key feature is the identification of negative thoughts and beliefs that underpin emotional problems with a view to challenging and changing them. Described in this way CT is clearly a problem-solving therapy and as such it appears to contradict the basic tenet of mindfulness, that acceptance rather than change is the goal. This apparent contradiction disappears when we take into account that MBCT was developed not as a specific therapy but as a way to prevent relapse in depression.14 The essence of relapse prevention is enabling people to recognize early warning signs and to engage in actions that prevent the return of the full-blown condition. By learning to attend mindfully on a regular basis and to accept thoughts as merely “mental events” (clouds passing in the sky) rather than “real” (i.e. telling the truth about themselves), clients have a strategy that can prevent them being sucked backed into the negative spiral of powerful beliefs and emotions. The combination of mindfulness and CT works because they complement each other. The benefit of MBCT is that it takes clients a step beyond the immediate gains of a successful treatment; it provides a different (p. 168) way of seeing the world that, in depression at least, seems to help to prevent relapse.15
MBCT is a highly structured, 8-week, group intervention combining many of the features of MBSR (meditations, regular mindfulness practice) as part of a strategy for counteracting possible relapse from depression. Mark Williams, who with John Teasdale and Zindel Segal developed the approach, has synthesized the methods into a self-help book taking it beyond depression to life in general.16 Each session introduces mindfulness in the form of one of a number of practical, short (20–30-minute) meditation exercises (on CDs) that are learned and then are to be practiced regularly (6 days out of 7). In addition to familiar meditations they introduce other simple exercises such as “habit releasers” (breaking ingrained habits by doing something new and unexpected) and “befriending meditation” (celebrating loving kindness and compassion). Throughout, the emphasis is on working to achieve a detached or “decentered” state of mind, breaking the identification of oneself with one’s thoughts, accepting the flow of thinking as merely mental events. In other words, embracing a new way of engagement in the world based broadly on Buddhist principles and practices.
It is difficult to know how useful MBCT as a self-help strategy may be. In the original work with depressed people in remission, the treatment groups were run by therapists with considerable expertise and understanding of depression. In fact, Teasdale et al. (2003) argued that careful problem analysis and formulation should go hand in hand with mindfulness in MBCT, something that a purely self-help approach lacks.17 That is true of all self-help strategies however; it is the unavoidable downside of the self-help approach.18
Two significant features of MBCT distinguish it from MBSR. First, it uses established CT methods as well as mindfulness. Second, the clients focused on are those with mental health problems rather than physical problems. Other than that there is much similarity between them. Both follow a time-limited (8-week) group course. Both use the same meditation exercises (with a few additional ones in MBCT). Both approaches seek to establish regular meditation practice that will last beyond the therapy.
(p. 169) Mindfulness-integrated CBT
In Cahoun’s mindfulness-integrated CBT (MiCBT), mindfulness is integrated into both therapy and relapse prevention as part of a four-stage intervention.19 Like the other mindfulness therapies it follows an 8-week program though the length may vary according to the problems being treated. Also included are CDs of mindfulness exercises.20 As I mentioned earlier, Cayoun uses the term “equanimity” in which he incorporates the Buddhist notion of the awareness of the impermanence of all things with the idea that the goal of therapy is to attain a sense of tranquility, calmness, and composure. The basic strategy is the now familiar mindfulness one of learning the art of attending to things in the present moment and thereby gaining detachment from worldly matters. MiCBT pays particular attention to emotions, seeking to detach the hold powerful feelings may have by “decomposing” them into four constituent parts, mass, temperature, motion, and cohesiveness. While many of the customary CBT methods are used, exposure, for example, the difference is that an experiential element is added. Between core beliefs and the emotions that give rise to them are bodily sensations and these are the key to the way the therapy works. In other words, like the original MBSR, people are trained to focus on their body and, through practicing mindfulness, learn to observe sensations with acceptance and detachment. The goal is to decouple personal experience from the sense of self and to be aware of the physical and mental reactions without reacting to them as they have done in the past.
In the second half of the program, the focus switches to other people, particularly those close to the client. The main aim is to learn to relate to others through the filter of acceptance and what is called “experiential ownership,” using mindfulness methods. This means learning to take responsibility for one’s own reactions and “disown” taking responsibility for the reactions of others. Empathy and compassion come into the final stage. This is the most explicit statement of the values that underpin MiCBT notably being compassionate, learning to forgive others and oneself, and a sense of having an attachment to all living beings. In the exercise, “grounded empathy,” mindfulness meditation is extended to allowing pleasant sensations to radiate through the whole body and then (p. 170) directing these sensations together with empathic and well-wishing thoughts to others. Finally, there is discussion of relapse, how it is possible to see the return of problems in a nonjudgmental way, reflecting the impermanence of experience, and to continue applying the mindful strategies of observation and acceptance to those problems.
The significance of MiCBT is that it fully integrates mindfulness and CBT throughout the whole therapy. The apparent contradiction in aims that I highlighted earlier is resolved by substituting acceptance and detachment of negative emotions for Socratic challenges. This means that while the overarching goal of therapy may be to “get better,” the way of achieving this is through detachment rather than change.
Acceptance and commitment therapy
ACT is a therapeutic approach that has many of the features of other MBIs, notably developing an attitude of mindful engagement with the world in which openness, flexibility, and acceptance are key features.21 What distinguishes ACT from other MBIs is its philosophical underpinnings in behavioral science. A key feature is functional contextualism, which, as the name implies, states that all actions are situated in a context and are defined by the impact on that context: any particular human activity is understood in terms of whether or not it achieves a stated goal. ACT directs attention away from realist terms like “anxiety” or “depression” to a functional analysis of behavior in context. Someone may say that they suffer from panic attacks, for example. In ACT “panic attack” is properly understood in terms of what takes place during an attack (behavior, feelings, and thoughts) and how this impacts on the context (the antecedents and the consequences). ACT has close links to a scientific account of language and cognition, known as relational frame theory (RFT). It is beyond the scope of this chapter to discuss RFT and those interested will find an account in Hayes et al. (2001).22
To properly grasp how ACT works as a therapy, however, means gaining an understanding of its philosophical assumptions since everything flows from them. The idea of contextualism, for example, means that beliefs, including core beliefs about oneself and the world, are true only in terms of their usefulness, not true in themselves. In ACT there is (p. 171) an important shift from taking the content of one’s thoughts literally, known as cognitive fusion, to standing back from those thoughts and seeing them as the “self-in-context,” a process known as defusion. This is essentially what happens in the present-moment focus of mindfulness we have already discussed. Examples of defusion techniques in ACT include thanking one’s mind for a thought, watching thoughts go by as if they were written on leaves floating down a stream, repeating words out loud until only the sound remains, or giving thoughts a shape, size, and texture. Therapeutically, the goal of ACT is not so much to alter a person’s self-story but to weaken their attachment to it. It is the difference between wanting not to be depressed and taking a detached perspective on yourself when depressed, between wishing depression away (in order to get better) and learning not to get caught up in a self-story of being a depressed (or indeed a nondepressed) person.
ACT identifies six ways in which people may be stuck in their self-story and six ways of gaining that detachment. I have already mentioned cognitive fusion and the notion of letting your thoughts pass you by (defusion). Experiential avoidance describes the way people avoid sensations, feelings, thoughts, and memories even though this may not be in their long-term interest. The alternative is acceptance, which is not a passive tolerance or resignation but an active process of regarding inner experiences, however unpleasant, as a focus of interest, curiosity, and observation. Inflexible attention describes the way certain rules are taken as given and this is countered by a shift to present moment attention, leading to greater flexibility as other possibilities are opened up. The conceptualized self describes the way people’s identity is taken up with a particular view of themselves that is often resistant to change (“I am a depressive,” for example). This view may be rigid and negatively valued although a positively valued view of oneself would also fit the bill if it were rigidly held. The shift is to the self-in-context (also known as the observing self) which is achieved by engaging in various mindfulness exercises such as imagining that one is older and writing a letter of advice back to the person struggling now, or engaging in eyes-closed mindfulness activities where one is asked to look at difficult experiences and then to notice who is noticing. These four processes are inter-related (p. 172) and come together to form the “acceptance” part of ACT. This is defined as “the voluntary adoption of an intentionally open, receptive, flexible, and nonjudgmental posture with respect to moment-to-moment experience.”23
The other two key processes are values and commitment. Values are freely chosen, personal choices that become evident through experience. They are what most matters to people and a crucial part of ACT is helping people determine what their values are and how they relate to their actions. Commitment entails deliberately taking action that serves the value. Values are not arrived at through problem-solving or logical reasoning; instead, they represent what is ultimately of intrinsic worth to an individual. Very often people’s actions are not in pursuit of what they most value but arise out feelings of guilt or because of social rules or because they have lost touch with what matters most to them. ACT seeks to help the person to generate their own psychological purpose and meaning and thereby choose actions that are consistent with those values. An exercise can be done in which a person is encouraged to imagine what they would like their family and friends to say about them at their funeral, thereby bringing out what really matters to them. Many therapists shy away from working on values, believing that personal values should be left to the person. But that is to ignore the crucial role values play in all therapies. The quasi-medical model of therapy instills particular values, namely that PTSD, depression, anxiety, or whatever it may be, is an illness from which one can get better through expert help. Similarly, CBT is based on valuing certain types of thinking over others. In ACT the therapist believes that people’s problems can be understood and changed only by addressing what the individual truly values and enabling them to discover ways they can live in accord with those values.
In a book aimed at practitioners Walser and Westrup (2007) applied ACT to the treatment of PTSD and other psychological problems following major trauma.24 A course of therapy lasts between 8 and 16 sessions of 1 hour in individual therapy or 90-minute sessions in group therapy. Each session begins with a mindfulness exercise and takes clients through the various features of ACT as outlined earlier. There is a particular emphasis on experiential exercises and the therapist’s use of (p. 173) metaphor. An example of both is the chessboard exercise in which, using an actual chessboard and pieces, the client is invited to place “good” and “bad” thoughts and feelings on to the chessboard as black and white pieces, and then shown how a “war” between the pieces is futile and endless. If knocked off the board, pieces just return; there is no prospect of winning. What is constant and unchanged is the board and this becomes a metaphor for the observing self.25 Each session ends with specific homework exercises that are reviewed in the subsequent session. The first half of the therapy is about learning to detach from the contents of the mind and to recognize the continuity of a self that transcends particular thoughts and feelings, to put aside problem-solving and control strategies and adopt a stance of willingness to hold whatever feelings there may without reacting to them. In trauma, this can mean realizing that struggling to get rid of PTSD symptoms (a control strategy) has not worked. Instead, one can learn that it is possible to tolerate the emotional pain (acceptance) and yet continue to live one’s life according to personal values (valued living). In doing so the pain may lessen. The second half of therapy is given over to elucidating the values that matter most for each person (personal meaning) and arriving at a commitment to live one’s life accordingly. Values are like a compass point: they point to a direction but they are not in themselves goals. To be a loving parent to one’s children is a value that may be achieved in different ways that can be formulated into specific goals.
The combination of mindfulness, experiential and practical exercises, and a coherent philosophy based on behavioral science makes ACT stand out from other MBIs except compassion focused therapy (CFT) (see following section). It can be used on its own or in conjunction with CBT therapies although, as I discuss in the final section, there are significant differences between ACT and CBT that make them uneasy bedfellows.
Compassion focused therapy
CFT is the brainchild of the clinical psychologist and academic, Paul Gilbert.26 As the name implies, compassion is at the center of the therapy. The definition of compassion that informs CFT is one derived from (p. 174) Buddhist thought namely, “sensitivity to suffering in ourselves and others with a deep motivation to alleviate it and prevent it.”27 This definition combines the idea of an emotional sensitivity to pain and suffering with the commitment to do something about it. This is similar to the combining of “acceptance” and “commitment” in ACT. In addition, compassion is felt not only for the suffering of others but, crucially, also for oneself. Compassion is not just being nice to others. It entails developing the capacity to be kind and loving with the courage to act compassionately. For a good discussion of the virtues of compassion, love, and kindness, see Feldman and Kuyken (2011)28 and Gilbert and Choden (2013).29
CFT arose out of Gilbert’s work with those with severe mental health problems, people who had a difficult, often abusive upbringing, who were deeply troubled by shame and self-criticism and found it difficult to open up to others emotionally or be kind to others or, crucially, to themselves. He noticed how the Socratic arguments that underpin CBT often had little or no emotional impact: people could see the logic but not feel the effect. A different approach was needed, one that took into account the nature of the deep-seated emotions and provided a therapy that was both individually tailored and also firmly based on scientific knowledge. There are many facets to CFT. It is based on a sophisticated understanding of the relationship between brain, behavior, and emotions, centered on the interaction of different regulatory systems and their effect on behavior.30 While the threat and protective system is well known, and clearly relevant to the trauma therapies, less attention has been paid to the soothing, calming system that underpins attachment and is often lacking in the people Gilbert tried to help. The basic science is something that is brought into CFT and explained in a simplified, diagrammatic way to sufferers, partly in order to counteract the pervasive idea that they are at fault. Brain systems work for very good reasons (e.g., as a protection against threat) that sometimes cease to be adaptive but nevertheless persist. CFT also makes clear that the mind/brain is not a unified, rigid entity and how other possibilities are opened up when the differing regulatory systems are understood (what Gilbert calls “multi-minds”).
CFT makes use of a range of therapeutic strategies that include mindfulness exercises, behavior therapy techniques, various forms of imagery, (p. 175) metaphor, Gestalt methods such as the empty chair exercise, as well as recognizing the vital importance of the therapeutic relationship. Training in and the practice of mindful compassion is a key defining feature of CFT. Here Gilbert draws upon the many different Buddhist ideas and methods not just the meditation exercises that have become familiar in other therapies.31 In clinical practice a contrast is made between being in “threat mind” when the mind is geared toward self-protection, and being in “compassionate mind” where the mind is open to feeling compassionate to others and oneself. The work of therapy is based on developing and practicing the “compassionate mind.” CFT has been adapted for trauma sufferers in the form of a self-help book.32
What impresses me most about CFT is the comprehensive and clinically sensitive way the therapy is carried out. There is recognition and understanding of the role of unconscious processes, of the way past history shapes the present problems, of the value of initial and later formulations, of the importance of taking action and incorporating that into the therapy, and of the therapeutic relationship. Given the prominence Gilbert gives to the soothing and affiliative system, it is not surprising that particular attention is paid to the therapeutic relationship since that is a key attachment that can aid or hinder therapy. One possible drawback about CFT is that it is impossible to pin it down to particular methods or even to a therapy school. It developed out of CBT but draws on psychoanalytic, Gestalt, and spiritual practices. Although it uses many techniques, it has a strong personal element. It has little truck with psychiatric diagnoses. While an interested therapist could take up a particular method or loosely follow the idea of being compassionate, this would not do justice to CFT. Like ACT, a commitment is needed to be immersed in both the theory and practice in order to do the therapeutic work properly. Moreover, like ACT, it has at its heart a set of values that CFT therapists model and teach.
How might the MBIs be of benefit to trauma treatments?
All the MBIs I have reviewed have in common the idea of training the mind in present awareness using meditation methods. We could see this feature as the crucial one and, having learned to use the methods (p. 176) ourselves, add them into our existing trauma therapy. Exposure therapies like prolonged exposure (PE) and cognitive processing therapy (CPT) might be easier to tolerate if mindfulness meditation is introduced. This has already happened in some therapies in the Veterans Administration Program in America and seems to have enabled veterans to tolerate the exposure better.33 But this would be at best a limited use of what mindfulness can offer and in one way misleading as I will show. In the final part of the chapter I want to focus on four distinctive features of mindfulness.
1. Scientific explanation and Buddhist philosophy
The coming together of science and Buddhist philosophy seems an odd alliance. Yet all the MBIs do this to some degree, most comprehensively in ACT and CFT. From the point of view of helping trauma sufferers, the meta-message of therapy is: “It is not your fault that you are the way you are. But you are still responsible for your actions and, with help, can escape the trap you find yourself in.” In CFT this is taught directly to clients in terms of the persistence of archaic survival responses in the brain. In ACT the emphasis is more on early experience that leads to the programming of certain reactions to trauma (vulnerability). These are not contradictory but complementary ideas of course. The Buddhist idea of releasing oneself from suffering (dukka) is consistent with the scientific idea that our sense of self is the problem and we can work to release ourselves from striving through mindfulness meditation and other exercises. While Buddhist ideas underpin all the MBIs, there is no requirement to study Buddhism or to agree with all the fundamentals of this spiritual and philosophical way of thinking. On the other hand, the values of acceptance and compassion are avowedly Buddhist and some understanding of what they mean philosophically is sensible. Paul Gilbert provides the best account of these in his general book, Mindful Compassion.34
2. The central importance of experiential change
What the mindfulness exercises provide is a physical way of learning to detach oneself from the grip of powerful thoughts and feelings. In CT this was done, originally at least, through teaching clients to recognize (p. 177) and challenge negative thinking using the Socratic method, an essentially verbal and rational process that is of limited use when it comes to deeply entrenched beliefs where rationality/irrationality is not their most important characteristic. Mindfulness offers an alternative strategy of learning to still the body and mind together in order to achieve detachment and acceptance thereby opening up new possibilities. This is seen most comprehensively in Cayoun’s MiCBT. It has implications for both exposure methods and traditional CBT ones that need to be addressed if mindfulness in adopted into or used alongside of a CBT approach. The most fundamental is to shift the aim of therapy away from a quasi-illness, problem-solving model to one where the goal is not to get rid of symptoms, or even to get better, but to acquire an attitude of mind of calmness, equanimity, and acceptance. Unless this distinctive difference is addressed there is a risk that mindfulness methods will simply be seen as an adjunct to a problem-solving approach, a way of relaxing clients or allowing them tolerate exposure better. That would undersell what the MBIs have to offer.
3. The crucial importance of values
In CFT, the central value is compassion for oneself and others. Compassion entails not just the capacity for responding with feeling to the sufferings of others and oneself, but also in making a commitment to act compassionately. In ACT, compassion is not given separate prominence but comes into the process of enabling people to rediscover key personal values and, as in CFT, to make a commitment to action consistent with valued living. Therapists treating people with PTSD and other trauma reactions need to be able to work with personal values rather than remain within the quasi-medical model of “getting better.” This presents something of a dilemma. Most clients want to get better and so there is a potential disjunction between what the client wants and what mindfulness offers. This disjunction may be resolved by pointing out that, even though the mindfulness approach does not directly seek to get rid of symptoms, it results in something similar, a state of equanimity and calmness in which symptoms cease to be emotionally disturbing and may well disappear. The mindfulness therapist explores with the (p. 178) client what has and has not worked before to show how problem-solving methods have not worked, resulting in a state of creative hopelessness as it is known in ACT. From this state, new ways of engaging in the world can be learned.35 For trauma therapists interested in incorporating mindfulness methods into their work focusing on personal values may not be familiar. This underlines the importance of therapists taking on board the mindfulness approach as a whole rather than cherry-picking methods that appeal to them. To be truly effective therefore requires a thorough training in one or more of the MBIs.
4. The therapeutic relationship
I believe the therapeutic relationship is important in all therapies but in mindfulness it is arguably particularly important. Firstly, the experiential exercises that are the foundation of the approach require considerable interpersonal skills to present and carry out. They are largely unfamiliar to clients and a therapist needs sensitivity to make them credible. He or she also needs to have experienced the value of them himself/herself. The therapist is both an expert and model for mindfulness. While in theory it is possible to teach mindfulness methods as purely technique, in practice that would be a hollow form of the therapy. Secondly, the values that underpin mindfulness, notably compassion for others, come directly into the therapy. The therapist shows compassion for the client, drawing on key personal attributes such as empathy and acceptance. These virtues are not particular to mindfulness and are found in other therapies. But, with the exception of the Rogerian therapies, only mindfulness therapies put them at the heart of the therapeutic process. Thirdly, in mindfulness the quasi-medical model that has dominated many forms of psychological therapy is explicitly rejected. In its place is a relational model, including the person’s relations with him- or herself. The therapeutic relationship is the crucible in which change will take place. Again, other therapies, psychodynamic therapy, for example, are also relational therapies but they work in a different way from mindfulness. I discuss the relational model in more detail in Chapter 15. Finally, clinical descriptions of mindfulness therapies show how personal the therapy is both to the clients and the therapist.
(p. 179) Summary
◆ Mindfulness has become increasingly popular both as a way of life and a therapy.
◆ In Western mindfulness therapies (MBIs) there has been a bridge made between scientific advances in understanding the brain and the ideas and methods that come from Buddhist thought. This is an exciting and thought-provoking development.
◆ Most published research on MBIs has been directed at problems other than trauma with a few exceptions. Yet it is clear that mindfulness could play a significant part in helping trauma sufferers. The strategy of detached acceptance, for example, would seem particularly useful to help with flashbacks, hyperarousal, and ruminations.
◆ It has been suggested that one benefit of mindfulness is that it makes established therapies like prolonged exposure more acceptable to trauma sufferers. However, that separates the meditative and other exercises from the therapy as a whole. Given that mindfulness offers a radical alternative to problem-solving, it is odd to incorporate some methods within a problem-solving form of therapy. Where mindfulness has been integrated into cognitive therapy, it is has been either in terms of relapse prevention as in MBCT or in terms of adopting the mindfulness philosophy while drawing on the pragmatic CBT techniques as MiCBT.
◆ ACT and CFT are two MBIs that fully integrate Western science and mindfulness. Both have developed clinical programs for use with trauma sufferers.
◆ To make best use of mindfulness, trauma therapists need to have engaged in it themselves. In doing so they will need to confront the shift away from problem-solving, the value of experiential methods, the fact that mindfulness requires a lifelong commitment to meditation and other exercises, and an understanding and sharing of certain values.
1 Thich Nhat Hanh (2004). Taming the Tiger Within: Meditations on Transforming Difficult Emotions. New York: Riverhead Books.
2 Tobler, A. and Herrmann, S. (2013). The Rough Guide to Mindfulness: The Essential Companion to Personal Growth. London: Penguin.
3 Kabat-Zinn, J. (1990). Full Catastrophe Living: How to Cope with Stress, Pain and Illness Using Mindfulness Meditation. London: Piatkus.
4 Kabat-Zinn, J. (2013). Full Catastrophe Living: How to Cope with Stress, Pain and Illness Using Mindfulness Meditation. Revised and updated edition. London: Piatkus.
5 Kabat-Zinn, J. (1994). Wherever you Go, There You Are: Mindfulness Meditation for Everyday Life. London: Piatkus, p. 4.
6 Bishop, S., Lau, M., Shapiro, S., et al. (2004). Mindfulness: a proposed operational definition. Clinical Psychology: Science and Practice, 11, 230–241.
7 Cayoun, B.A. (2011). Mindfulness-Integrated CBT: Principles and Practice. Oxford: Wiley-Blackwell.
8 Keng, S.-L., Smoski, M.J., and Robins, C.J. (2011). Effects of mindfulness on psychological health: a review of empirical studies. Clinical Psychology Review, 31, 1041–1056.
9 Baer, R. (2003). Mindfulness training as a clinical intervention: a conceptual and empirical review. Clinical Psychology: Science and Practice, 10, 125–143.
10 Fjorback, L.O., Arendt, M., Ornbol, E., Fink, P., and Walach, H. (2011). Mindfulness-based stress reduction and mindfulness-based cognitive therapy–a systematic review of randomized controlled trials. Acta Psychiatrica Scandinavia, 124, 102–119.
12 There is a downside to the therapist’s personal authority, which is that of idealizing the individual as happens in cults. In 2011, I took a friend to hear Jon Kabat-Zinn talking to a group of committed mindfulness therapists. My friend was so uncomfortable at the idealization of Kabat-Zinn and the grandiose claims he made about the scope of mindfulness that he left. Of course many others have gone on to use mindfulness and Kabat-Zinn has been exemplary in subjecting MBSR to evaluation. I am not suggesting that mindfulness is Kabat-Zinn or vice versa. But I am pointing to the importance of the person and acknowledging that in Jon Kabat-Zinn, mindfulness has had the benefit of an exceptional man without whom I suspect it would not have flourished as it has done.
14 Teasdale, J.D., Segal, Z.V., Williams, J.M.G., Ridgeway, V.A., Soulsby, J.M., and Lau, M.A. (2000). Prevention of relapse/recurrence in major depression by mindfulness-based cognitive therapy. Journal of Consulting and Clinical Psychology, 68, 615–623.
(p. 181) 15 For a more detailed theoretical account of the relationship between mindfulness and cognitive therapy, based on the Teasdale and Barnard (1993) interactive cognitive subsystems (ICS) model, see Teasdale, J.D., Segal, Z., and Williams, J.M.G. (1995). How does cognitive therapy prevent relapse and why should attentional control (mindfulness) help? Behaviour Research and Therapy, 33, 25–39.
16 Williams, M. and Penman, D. (2011). Mindfulness: A Practical Guide to Finding Peace in a Frantic World. London: Piatkus.
17 Teasdale, J.D., Williams, J.M.G., and Segal, Z.V. (2003). Mindfulness training and problem formulation. Clinical Psychology: Science and Practice, 10, 157–160.
18 The book is extremely clear and provides the best exposition I have read of how MBCT works in practice. Through the attached CDs the various meditation exercises can be done immediately. I can see why it has rapidly become a bestseller. The problem with self-help books, however, is that they demand commitment, which is particularly true of MBCT where the regular exercises are the key to approach. Without an external authority I suspect that this will be much harder to achieve.
21 Hayes, S.C., Strohsahl, K.D., and Wilson, K.G. (2012). Acceptance and Commitment Therapy: The Process and Practice of Mindful Change, 2nd ed. New York: The Guilford Press.
22 Hayes, S.C., Barnes-Holmes, D., and Roche, B. (eds.) (2001). Relational Frame Theory: A Post-Skinnerian Account of Human Language and Cognition. New York: Plenum Press. See also the website of the Association of Contextual Behavioral Science, <http://contextualscience.org/rft>.
23 Hayes, S.C., Strohsahl, K.D., and Wilson, K.G. (2012), p. 272. (Italics in the original.)
24 Walser, R. and Westrup, D. (2007). Acceptance and Commitment Therapy for the Treatment of Post-traumatic Stress Disorder: A Practitioner’s Guide to Using Mindfulness and Acceptance Strategies. Oakland, CA: New Harbinger Publications.
26 Gilbert, P. (2010). Compassion Focused Therapy: Distinctive Features. London: Routledge.
27 Dalai Lama (1995). The Power of Compassion, cited in Gilbert, P. (2010) p. 3.
28 Feldman, C. and Kuyken, W. (2011). Compassion in the landscape of suffering. Contemporary Buddhism, 12, 143–155.
29 Gilbert, P. and Choden (2013). Mindful Compassion: Using the Power of Mindfulness and Compassion to Transform our Lives. London: Robinson.
30 Paul Gilbert outlines three, interacting regulatory systems that are important to an understanding of how CFT works, namely, the drive and excitatory system, the (p. 182) threat focused and protection system, and the soothing and affiliative system, see Gilbert (2010), Chapter 6, pp. 43–51.
32 Lee, D. with James, S. (2012). The Compassionate Mind Approach to Recovering from Trauma using Compassion Focused Therapy. London: Robinson.
33 Vujanovic, A.A., Niles, B., Pietrefesa, A., Schmertz, S.K., and Potter, C.M. (2011). Mindfulness in the treatment of posttraumatic stress disorder among military veterans. Professional Psychology: Research and Practice, 42, 24–31.