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10 Tips for Offering Trauma-Sensitive Mindfulness in Psychotherapy

A trauma-informed approach to mindfulness adapts mindfulness techniques to better meet the needs of individuals experiencing posttraumatic stress symptoms. A prescribed approach to mindfulness risks further harm by reinforcing traumatic circumstances such as coercion, unpredictability, and dysregulation. In contrast, the proposed flexibility of trauma-sensitive mindfulness empowers individuals to safely engage in the present moment at a pace that is feasible for them. This article will start with a brief overview of mindfulness practice and how mindfulness can be incorporated in psychotherapy. Then, the term trauma-sensitive mindfulness will be defined, and the rationale for adopting a trauma-informed approach to mindfulness in psychotherapy will be provided. Next, 10 suggestions will be offered for ways that mental health providers can make mindfulness offerings trauma-sensitive during psychotherapy. Lastly, this article concludes with resources for further exploration about trauma-sensitive mindfulness.

Defining Mindfulness

The concept of mindfulness originates from ~2,500-year-old Buddhist teachings aimed to liberate suffering, develop a heightened awareness of the mind, and acknowledge impermanence of the self (Lee, 2018). Traditional mindfulness is practiced within a comprehensive system of Buddhist ethics and doctrines (Tsering, 2006). Over the last 40 years, the Eastern concept of mindfulness has been adapted to a secular approach within Western popular culture and health research contexts where it is most defined as “moment-to-moment, nonjudgmental awareness, cultivated by paying attention in a specific way, that is, in the present moment, and as non-reactively, as non-judgmentally, and as openheartedly as possible” (Kabat-Zinn, 2015, p. 1481).

As a result of the recent popularization of secular mindfulness, there is risk of the appropriation of this practice. Surmitis et al. (2017) offer suggestions for the culturally responsible integration of mindfulness within psychotherapeutic spaces. When referring to mindfulness in this article, the definition provided by Kabat-Zinn (2015) will be utilized through a secular lens; however, it is important to acknowledge the historical roots of mindfulness and strive for continuous learning to honor such history as well as the evolution of mindfulness in healthcare and research settings.

Mindfulness in Psychotherapy

Mental health is one of the main fields integrating mindfulness into care practices. Mindfulness in the context of psychotherapy may include specific mindfulness-based therapies such as Mindfulness Based Stress Reduction (Kabat-Zinn, 1982), Dialectical Behavior Therapy (Linehan, 1993), Mindfulness-Based Cognitive Therapy (Segal et al., 2012), Acceptance and Commitment Therapy (Hayes, 2003), Sensorimotor Psychotherapy (Ogden et al., 2006), and Compassion Focused Therapy (Gilbert, 2010). Additionally, mental health providers may utilize individual mindfulness activities when working with clients as techniques with various goals such as emotional regulation, grounding, or relaxation (MacDonald, 2016). In general, evidence supports the benefits of mindfulness for improving a variety of psychological outcomes such as anxiety (Call et al., 2014), depression (Kirk et al., 2021), posttraumatic stress (Kearney et al., 2013), and emotion regulation (Davis et al., 2011) in clinical and nonclinical samples.

Trauma-Sensitive Mindfulness

While there are documented benefits of mindfulness practice on mental health, there is also an emerging area of literature about mindfulness-related difficulties and the limitations of mindfulness meditation practices. A critique of research about mindfulness-based interventions is the lack of studies reporting on adverse events (Binder & Hjeltnes, 2021). In the few studies that have reported adverse events, the prevalence rates are small with minimal adverse effects (Baer et al., 2019). However, mental health providers who offer mindfulness activities in session should be aware that potential adverse effects of mindfulness do exist (Baer et al., 2020; Britton et al., 2021). This possibility is especially important to know if providers are referring clients to mindfulness opportunities outside the psychotherapy context (e.g., meditation groups run by non-mental health professionals or meditation apps that do not specify inclusion of trauma-sensitive practices).

Mindfulness-based interventions that have been adapted specifically for clinical samples experiencing psychosis (Chadwick et al., 2005), posttraumatic stress (Banks et al., 2015), and risk of suicide (Williams et al., 2014) have shown symptom reduction. Notably, these interventions included specific modifications based on the mental health symptoms of the sample; therefore, it is imperative to approach the concept of mindfulness, whether in the context of a psychological intervention or as a single technique employed during psychotherapy, with a flexible approach to enhance the effectiveness of mindfulness experiences for the client.

Consequently, trauma-sensitive mindfulness acknowledges that mindfulness opportunities may need to be adjusted for clients coping with traumatic stress and other mental health symptoms by offering choices, providing guided anchors, and honoring that mindfulness may trigger a spectrum of trauma reactions (Treleaven, 2018). Thus, mental health providers that offer mindfulness activities in psychotherapy are encouraged to do so with a trauma-sensitive lens to foster a space where clients may engage in these techniques safely.

10 Tips for Offering Trauma-Sensitive Mindfulness in Psychotherapy

  1. Ask for consent before introducing a mindfulness activity.

Trauma often occurs without the consent of an individual. When the mindfulness activity is shared as an invitation, the client can choose whether this activity is something they would like to engage in and can practice agency. Asking for consent invites the client to practice an activity rather than needing to comply with “expected participation.” Compliance and seeking to meet others’ expectations may have been elements of the clients’ trauma, so these dynamics should be avoided in the healing space.

  1. Share the activity with the client prior to engaging in it.

By providing the client with an outline of the mindfulness activity, the mental health provider creates a predictable environment for the client. This is in opposition to the nature of trauma: overwhelming circumstances that occur unexpectedly to the individual. Possible ways to share the mindfulness activity with the client could be by letting the client read through the script of a guided meditation before using it in practice or establishing a time frame for the activity (e.g., “I will keep time for 30 seconds as you practice deep breathing”).

  1. Allow the client to choose what mindfulness activities are of interest to them and when to practice.

This is another way to foster an environment where the client can practice agency and utilize skills that they find important and useful to their personal journey. There are a wide variety of mindfulness activities such as guided imagery, movement-based (e.g., walking or stretching), and sensory-based (e.g., feeling, smelling, seeing). Every client will have different levels of interest, comfort, and willingness to engage in mindfulness activities. Remember to honor these choices rather than prescribing a mindfulness activity because it is assumed to be “calming” or “helpful” for a particular client. Likewise, providing the client choice around when to try mindfulness activities (e.g., start or end of session, as a resource for moments of dysregulation, or to pause during sessions) allows the client to experiment with how to use mindfulness techniques to best support them, if at all.

  1. Offer the opportunity for the client to ask questions before engaging in the activity.

Holding space for questions and fully answering any questions denotes that the mental health provider is not withholding any information from the client so that an informed decision about participation can be made. There is a lot of uncertainty associated with trauma while it is occurring and regarding the onset of symptoms and triggers afterwards. Thus, sharing knowledge about the mindfulness activity creates a shared power dynamic between the client and the mental health provider where curiosity can take place. If the client has hesitancy about any element of the mindfulness activity, this could be an opportunity to explore those concerns. It might also mean the client is not ready to engage in this activity yet, and that is okay.

  1. Co-create the space.

Mindfulness does not have to be practiced in a room with dimmed lighting, essential oils, or images of nature. While these elements can be useful for some individuals, they can also serve as triggers for other individuals. Thus, if the client prefers that the lights stay on, then keep the lights on. It is important to collaborate to establish an environment in which the client feels safe enough to engage in mindfulness activities that day.

  1. Understand the “window of tolerance” (Siegel, 1999).

This model is used to understand trauma reactions (Corrigan et al., 2011) and can also be applied to the context of mindfulness to suggest why different mindfulness activities may sometimes move individuals into (e.g., regulation) or out of (e.g., dysregulation caused by hypoarousal or hyperarousal) their window (Treleaven, 2018). This information may be an educational tool to validate the client’s experience(s) with mindfulness activities rather than reinforce a sense of shame or notion of “I’m doing this wrong” if an activity is dysregulating.

  1. Safety plan and establish an anchor that the client can use if the mindfulness activity becomes too dysregulating (Treleaven, 2018).

Mindfulness activities that involve sustained internal awareness may be dysregulating for clients and could increase awareness of posttraumatic stress symptoms that can be healing at some time and too overwhelming at others. Therefore, working with the client to create a safety plan will be beneficial so both parties understand how to end a mindfulness activity in a way that will be supportive and accessible for the client. Likewise, the use of a predetermined anchor, such as a tangible object to hold or a picture to view in the practice space, may help the client if dissociation begins because of the mindfulness activity.

  1. Provide options throughout the experience.

Traumatic situations and symptoms of posttraumatic stress can leave an individual feeling powerless and with a distorted sense of time. By giving options in the mindfulness activity, the mental health provider constructs a space where choices can be made based on the experience of the client. Similarly, the client is never stuck in the mindfulness experience. Some ways to offer options to the client include deciding when to open or close the eyes or where to physically be in space (e.g., sitting, standing, moving, or adjusting throughout the activity).

  1. Be willing to adapt scripted mindfulness activities to make the experience trauma-informed.

Mental health providers should always be aware of the power of words. Reading mindfulness scripts found online or from a book may include language that is constrictive or inappropriate for the client who is experiencing posttraumatic stress. Adaptations to written mindfulness exercises might be adding words or phrases such as “when you’re ready” or “if you’d like” to a guided imagery script so the client feels like they have some control over the experience rather than being forced into the mindfulness activity.

Furthermore, the content of the mindfulness activity may need to be adapted to enhance the client’s sense of safety. For example, the loving-kindness or metta meditation (Salzberg, 1995) is practiced by sending positive phrases to different people in one’s life. The recipients of the loving-kindness thoughts follow this order: yourself (i.e., self-compassion), an individual that you feel strong positive feelings towards, an individual that you feel neutral about, and an individual that you have difficulty or strong negative feelings towards. Depending on where the client is at in their healing journey, sending intentional loving-kindness thoughts to an individual that the client has difficulty or strong negative feelings towards may not be useful or appropriate because it could be triggering to send forced positivity to perpetrators. Clients should never be encouraged to send intentional loving-kindness thoughts to somebody who has caused them harm for the purpose of a mindfulness activity unless they are at a place in their healing journey where they have decided that this would be a useful practice to adopt. This can only be determined by the client. Therefore, the metta meditation could be adapted so the client only practices send loving-kindness thoughts to the first three recipients -self, close positive individual, and neutral individual- to decrease the possibility of dysregulation.

  1. Prepare a referral list of local mindfulness facilitators, remote programs, apps, websites, or other resources that utilize a trauma-sensitive approach to mindfulness.

It will be beneficial to be prepared with additional resources so that if the client would like to further explore mindfulness, then they can be directed to appropriate resources that will employ trauma-sensitive practices rather than leaving the client to find these opportunities on their own. Mindfulness is a broad and popular practice that must be facilitated by trained practitioners in ethical ways to prevent client harm especially when offered in a mental health context. Thus, maintaining an updated list of trauma-informed mindfulness facilitators will allow mental health providers to confidently refer clients to safe resources if the client would like to further develop their practice.

Summary

The incorporation of mindfulness within the psychotherapy session can be a useful tool to enhance client mental health outcomes and the quality of the session overall. This article shared 10 suggestions for offering trauma-sensitive mindfulness activities in psychotherapy, yet this list is only a start. Mental health providers that are offering mindfulness during psychotherapy are encouraged to seek formal training opportunities and refer to professional resources in trauma-sensitive mindfulness practices to ensure that they are offering safe and effective techniques for healing rather than solidifying the trauma paradigm. Mindfulness is a deeply personal practice, and the outcomes will vary for each client based on their unique lived experiences. In alignment with one of the ethical guidelines of both traditional mindfulness and professional psychotherapeutic practices, to truly do no harm, then mindfulness in psychotherapy must be offered in a trauma-sensitive way.

Resources for Further Exploration:

  • Cheetah House: organization that supports meditators in distress and offers educational trainings for clinicians providing mindfulness
  • David Treleaven, PhD: author of the book, Trauma-Sensitive Mindfulness Practices for safe and transformative healing and offers online training programs, free virtual community calls, and a podcast about trauma-sensitive mindfulness
  • Trauma-Informed Mindfulness with Teens by Sam Himelstein
  • Mindfulness Skills for Trauma and PTSD: Practices for Recovery and Resilience by Rachel Goldsmith Turow
Cite This Article

Dietrich, K. M. (2022, January). 10 tips for offering trauma-sensitive mindfulness in psychotherapy. [Web article]. Retrieved from http://www.societyforpsychotherapy.org/10-tips-for-offering-trauma-sensitive-mindfulness-in-psychotherapy

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