An Overview of the Research on Mindfulness Based Interventions for Treating Symptoms of Post-traumatic Stress Disorder

Objective: This systematic review aimed to collate and evaluate the existing research for the use of mindfulness based approaches to treat post-traumatic stress disorder. Primary objectives were to explore the effects of mindfulness based approaches on post-traumatic stress symptoms and associated psychological distress; with secondary objectives to explore the attrition rate, adverse effects, resource implications and long term effects of such interventions. Method: Research databases, EMBASE, OVID MedLine, Psycinfo, CINAHL and PILOTS were systematically searched, relevant authors in the field were contacted and a hand search of relevant papers was conducted. Results: The search resulted in 12 studies that met eligibility criteria. Many of these studies lacked methodological rigour. The majority of studies indicated positive outcomes with improvements in post-traumatic stress symptoms, particularly in reducing avoidance. Conclusions: The preliminary evidence for the use of mindfulness based approaches to treat post-traumatic stress symptoms is encouraging, although further studies with more robust research design are required. MINDFULNESS AND PTSD 2 An Overview of the Research on Mindfulness Based Interventions for Treating Symptoms of Post-traumatic Stress Disorder: A Systematic Review. Post-traumatic stress disorder (PTSD) is defined as a presentation of characteristic symptoms following direct exposure, witnessing or learning of an event that involves actual or threatened death or serious injury or harm to self or others (American Psychiatric Association, 2013). PTSD is characterised by four clusters of symptoms which can be summarised asre-experiencing traumatic events which may occur through flashbacks or nightmares, negative cognitions and mood, avoidance of trauma related cognitions and triggers which may present as dissociation or emotional numbing; and hyper arousal such as, hyper-vigilance to threat, irritability and sleep problems (APA, 2013). PTSD symptoms can be variable in terms of impact, severity, and duration; many researchers have suggested that a chronic form of complex PTSD may occur following prolonged or repeated traumatic events (Cloitre et al., 2009). PTSD is a significant health issue: it has been estimated that 25-30% of people who experience a traumatic life event go on to develop PTSD (National Institute Clinical Excellence, 2005). A recent study highlighted the high prevalence rate of trauma symptoms amongst mental health service users: 89% of a representative sample of individuals referred to primary care psychology reported exposure to traumatic life events and 51% met the screening criteria for PTSD despite trauma not always being the primary reason for referral (Noel, Gillanders & Power, 2012). PTSD Interventions The cognitive model of PTSD largely dominates the literature and is one of the most pervasive models for conceptualizing the development and maintenance of this disorder (Ehlers & Clark, 2000). The model proposes two main perpetuating factors which lead to a perceived sense of current threat: negative appraisals of the traumatic events and disrupted processing of trauma MINDFULNESS AND PTSD 3 memories through avoidance. The cognitive model has informed the main approaches for intervention such as Prolonged Exposure (PE), Cognitive Behavioural Therapy (CBT), and neurobiological approaches such as Eye Movement Desensitisation and Reprocessing (EMDR). There is a significant evidence base for these approaches and the effectiveness of these interventions has been well documented (Powers, Halpern, Ferenschak, Gillihan & Foa, 2010; Mendes, Mello, Venture, Passarela & Mari, 2008; Seidler & Wagner, 2006). However attrition rates for these treatments are often high; a review of 55 empirical studies of CBT and EMDR found that it was not uncommon for drop-out rates to be as high as 50% (Schottenbaurer, Glass, Arnkoff, Tendick & Gray, 2008). Clinical trials have also shown that a subgroup of PTSD patients may not benefit from CBT or PE approaches, and a substantial amount of participants have residual PTSD symptoms post treatment (Bradley, Greene, Russ, Dutra & Westen, 2005). Becker, Zayfert and Anderson (2004) surveyed 852 psychologists working with trauma, and found that exposure techniques were highly under-utilized and widely unaccepted in clinical practice; this was due to a reported lack of training or experience and perceptions about contraindications of using exposure, including increased symptoms of dissociation, reexperiencing, anger and suicidality. Therefore it is important that interventions are further developed to ensure they are acceptable and feasible for implementation in clinical practice and effective for the majority of individuals. Previous diagnostic criteria for PTSD characterized it as an anxiety disorder and therefore interventions have traditionally focused on exposure techniques (APA, 2000). However the diagnostic criteria for PTSD have been updated to include the presence of negative cognitions and mood which reflects the wide range of different emotions, besides anxiety, that may be experienced as part of PTSD (APA, 2013). It is recognised that the emotions experienced by MINDFULNESS AND PTSD 4 individuals with PTSD may be variable, depending on the type of traumatic event experienced (Amstadter & Vernon, 2008). A recent study found that in a representative sample of people with PTSD referred to a trauma clinic, less than 50% experienced anxiety as their primary emotion and the rest experienced sadness, disgust or anger as their primary emotion; the use of exposure techniques were significantly less effective for the nonanxiety based PTSD group (Power & Fyvie, 2013). This is an important finding for individuals who experience emotions other than anxiety following traumatic events as exposure therapy may not be effective, and may even attenuate negative emotions. Consequently, it is important for interventions to be further developed and researched to address symptoms of negative cognitions and mood. Therapies such as Cognitive Processing Therapy (CPT) have been shown to be more effective than exposure techniques for treating PTSD particularly for reducing guilt cognitions (Resick, Nishith, Weaver, Astin & Feuer, 2002). CPT has also indicated effectiveness in working with symptoms of anger, guilt, shame and cognitive distortion including self-blame in trauma survivors (Resick, Galovski, Uhlmansiek, Scher, Clum, & Young-Xu, 2008). Emotions such as shame are an important contributing factor for the development and maintenance of PTSD (Leskela, Dieperink & Thuras, 2002). Lee, Scragg and Turner (2001) have proposed a clinical model for shame based, and guilt based, PTSD. The authors propose that emotions such as guilt, shame and humiliation perpetuate PTSD symptoms and give a sense of current threat through attacking personal integrity. They suggest that high levels of guilt and shame prevent individuals from presenting to services for treatment and may contribute to early drop-out from therapy (Lee et al., 2001). Shame is an emotion that is characterized by harsh judgment of oneself and the use of avoidance and self-criticism as safety behaviors (Gilbert, 2009). One technique which has been applied to reduce avoidance whilst acknowledging MINDFULNESS AND PTSD 5 difficult emotions and thoughts in a non-judging manner is mindfulness. Mindfulness is an approach which aims to increase acceptance therefore may be useful for working with negative cognitions such as self-blame and negative mood, including shame or guilt. Mindfulness Mindfulness is described as ‘the awareness that emerges through paying attention on purpose, in the present moment, and non-judgmentally to the unfolding of experience moment by moment’ (Kabat-Zinn, 2003, p.145). Mindfulness therefore promotes mental wellbeing by changing the relationship individuals have with their thoughts, increasing the ability to observe thoughts and emotions in an accepting way. Mindfulness has been widely researched in psychiatric, physical health, and healthy populations (Baer, 2003). Meta-analytic studies have shown mindfulness based approaches to be effective for stress reduction (Chiesa & Serretti, 2009) and for anxiety and depression (Hofmann, Sawyer, Witt & Oh, 2010). Mindfulness practice originates from Buddhism, although mindfulness techniques have been integrated with western approaches. Mindfulness has been incorporated into a number of so called ‘third wave’ therapeutic approaches including Mindfulness Based Stress Reduction (MBSR), Mindfulness Based Cognitive Therapy (MBCT), Acceptance and Commitment Therapy, and Dialectical Behaviour Therapy (Baer, 2003). The most commonly cited mindfulness approach is Mindfulness Based Stress Reduction (MBSR). MBSR is delivered in a group setting over 8 weekly sessions lasting 2-2.5 hours each, with a full day session around week 6. The intervention is multifaceted and consists of mindfulness meditation, experiential exercises, Hatha yoga, discussion about stress and coping, and regular homework tasks including daily practice of mindfulness (Kabat-Zinn, 1990). Mindfulness Based Cognitive Therapy (MBCT) is based on MBSR, although incorporates a MINDFULNESS AND PTSD 6 cognitive component; focus is placed on being more aware of thoughts and feelings with an emphasis on changing the relationship an individual has with their thoughts rather than changing or challenging the content of the thoughts (Segal, Williams & Teasdale, 2012). MBCT was developed originally as an intervention for recurring depression, and is a manualised program of 8 weekly classes plus 1 all day session. Mindfulness and PTSD Mindfulness has recently received increased attention within the research on PTSD. Theoretical reviews have outlined the argument for use of mindfulness techniques as a means of reducing avoidance, aiding emotion regulation and increasing distress tolerance in traumatized in