The use of mindfulness in trauma counseling.
Article Type: Report
Subject: Psychic trauma (Care and treatment)
Meditation (Methods)
Meditation (Health aspects)
Counseling (Methods)
Counseling (Health aspects)
Authors: Goodman, Rachael D.
Calderon, Angela M.
Pub Date: 07/01/2012
Publication: Name: Journal of Mental Health Counseling Publisher: American Mental Health Counselors Association Audience: Professional Format: Magazine/Journal Subject: Health; Psychology and mental health Copyright: COPYRIGHT 2012 American Mental Health Counselors Association ISSN: 1040-2861
Issue: Date: July, 2012 Source Volume: 34 Source Issue: 3
Topic: Canadian Subject Form: Counselling; Counselling
Geographic: Geographic Scope: United States Geographic Code: 1USA United States
Accession Number: 297915510
Full Text: Although there is increasing support for the use of mindfulness-based interventions in counseling, there has been little discussion of its use in trauma counseling. We explore the use of mindfulness interventions within trauma counseling, with particular attention to how mindfulness can address the neuropsychological aspects of trauma. A case example explicates the application of mindfulness in trauma counseling. Implications for counseling practice and counselor training and recommendations for future research are discussed.

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Although mindfulness has been used for centuries in healing and spiritual development, the use and study of mindfulness in mental health counseling is recent. Among the impressive outcomes of mindfulness practice are decreased anxiety, depression, and stress, and increased compassion (Shapiro & Carlson, 2009). Mindfulness has broad potential because it can easily be combined with other counseling protocols and applied in both preventive and remedial counseling.

The mindfulness focus on body sensation and awareness may particularly benefit clients seeking counseling after a traumatic event (Brach, 2003). Emergent research on the physiological and neurobiological aspects of trauma demonstrates the usefulness of body awareness in trauma counseling (Rothschild, 2000; Scaer, 2001). Controlled body awareness and sensation exercises can help trauma survivors to decrease hyperarousal syinptoms, reconnect when dissociated from their body, and differentiate past trauma memories from here-and-now sensations. Through mindfulness, trauma survivors may build strength and resilience by acquiring a sense of control, developing internal resources for symptom reduction and healing, and facilitating the meaning-making process.

This article explicates the use of mindfulness in trauma counseling, with particular attention to the neuropsychological aspects of trauma. After reviewing the literature on both mindfulness and trauma, we present a case example demonstrating the use of mindfulness with a counseling client who had experienced trauma. We also discuss the implications for mental health counseling and future research possibilities.

LITERATURE REVIEW

Foundations of Mindfulness

Although definitions vary, mindfulness generally refers to nonjudgmental, present-moment awareness (Brantley, 2003). The underpinnings of mindfulness are found in most spiritual and religious traditions but are often associated with Buddhism (Shapiro & Carlson, 2009). Practices like meditation are used to develop mindful awareness. While meditation is a formal mindfulness practice, mindfulness can also be cultivated informally by being purposefully present throughout the day, for instance, by paying attention to bodily sensations during conversations (Shapiro & Carlson, 2009).

Because there are many sources for detailed descriptions of mindfulness practices (e.g., Brantley, 2003; Kabat-Zinn, 1990; Shapiro & Carlson, 2009), for our purposes we will simply review the elements of mindfulness that are especially relevant to its use in trauma counseling. Mindfulness is thought of as involving the cultivation of concentration, attention, and nonjudging acceptance of whatever is being experienced in the present moment (Bishop et al., 2004). It consists in allowing present-moment experiences rather than fighting against or clinging to emotions or thoughts that are assessed as either negative or positive. Mindfulness is also relating to experiences with curiosity and loving-kindness (or friendliness), which allows for deeper understanding (KabatZinn, 1990).

Mindfulness and Mental Health Counseling

In the past 30 years there has been increased popular demand for and academic interest in the mental health benefits of mindfulness (Coffey, Hartman, & Fredrickson, 2010). Extensive scholarship has examined how mindfulness-based interventions affect psychological distress. In particular, research has studied the use of mindfulness techniques and mindfulness-informed counseling to reduce anxiety and stress (Shapiro & Carlson, 2009). Mindfulness-based stress reduction (MBSR), the technique developed by Jon Kabat-Zinn (1990), and related techniques, such as mindfulness-based cognitive therapy (MBCT), have been found to reduce anxiety and depressive mood symptoms in individuals with anxiety disorders, including generalized anxiety disorder (Evans et al., 2008; Kabat-Zinn et al., 1992).

Mindfulness has also proved effective in reducing anxiety and psychological distress among health care students and practitioners and in increasing empathy (Shapiro, Astin, Bishop, & Cordova, 2005; Shapiro, Schwartz, & Bonner, 1998). Mindfulness was also effective in reducing symptoms of attention deficit hyperactivity disorder (ADHD), anxiety', and depression in adolescents and in adults diagnosed with ADHD (Zylowska et al., 2008). Even short-term mindfulness interventions, such as 15 minutes of focused breathing, lowered both emotional volatility and negative affect (Arch & Craske, 2006). The positive psychological effects of mindfulness include promoting a sense of wellbeing and a positive emotional state (Brown & Ryan, 2003).

Some mental health professionals have also begun to explore the relationship of mindfulness to trauma counseling (Follette, Palm, & Pearson, 2006), where mindfulness practices seem promising because they help clients to reconnect with their bodies and increase present-moment awareness (Brach, 2003). For example, the mindfulness-based Dialectical Behavior Therapy (DBT) was found to be effective in treating women with both posttraumatic stress and borderline personality disorders (Harned & Linehan, 2008). Acceptance and Commitment Therapy (ACT), which is also mindfulness-based, was found to be effective in reducing PTSD symptoms (Twohig, 2009). Chopko and Schwartz (2009) examined the relationship between mindfulness and posttraumatic growth (PTG), finding that some, though not all, aspects of mindfulness were correlated with PTG.

Foundations of Trauma

Understanding of trauma has expanded in recent decades, spurred by the 1980 inclusion of posttraumatic stress disorder (PTSD) in the American Psychiatric Association (APA) Diagnostic and Statistical Manual of Mental Disorders Third Edition (DSM-III). Previously the study of trauma was sporadic and inconsistent. At times traumatic stress was attributed to a weakness in character or thought to be a disorder, hysteria, that occurred only in women (Herman, 1997). Then both the Vietnam veterans' movement and the women's movement in the 1970s (Herman, 1997) began to legitimize consideration of trauma as the result of psychological stress that could affect individuals regardless of gender or "strength" of character.

Much of the study and treatment of traumatic stress has been influenced by the DSM, which defined both trauma and its symptoms. The definition of a traumatic event has changed over time; the DSM-IV-TR currently defines it as an event in which "The person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others" (APA, 2000, p. 467). Critics noted that this definition minimizes individual perception and also excludes trauma that might be transmitted from parents to children (transgenerational trauma) or that results from experiences of systemic oppression, such as racism (Bryant-Davis & Ocampo, 2005; Goodman & West-Olatunji, 2008; Rothschild, 2000). Other definitions broaden the definition of a traumatic event by emphasizing individual perception and characterizing such an event as something that an individual perceives as sudden, uncontrollable, and negative (Carlson, 1997).

DSM-delineated symptoms--reexperiencing, hyperarousal, and avoidance (APA, 2000)--are generally reflected in the literature. Reexperiencing is evidenced when the individual experiences intrusive recollections of the trauma, has recurrent and distressing dreams, and is distressed by internal or external reminders of the trauma. Hyperarousal is represented by disturbed sleep, difficulty concentrating, an exaggerated startle response, and irritability or angry outbursts. Individuals experiencing avoidance have difficulty recalling the trauma, a restricted affect, a tendency to avoid thoughts or feelings related to the trauma, and a tendency to detach from others.

Neuropsychological Aspects of Trauma

Recently counseling has focused on the neuropsychological aspects of trauma. The response to stress and trauma is regulated by the brain's limbic system, including the autonomic nervous system (ANS) and the hypothalamicpituitary-adrenal (HPA) axis (Rothschild, 2000; Scaer, 2001). As Rothschild described it, under normal conditions two components of the ANS, the sympathetic branch (SNS) and the parasympathetic branch (PNS), balance the body to meet experiences of stress or relaxation. Stress on an individual, including rage, terror, anxiety, or trauma, activates the SNS; corresponding somatic experiences include a decrease in digestion, pallid skin, dilated pupils, and increases in heart rate, respiration, blood pressure, and perspiration (Scaer, 2001; van der Kolk, 1994).

When an individual experiences a threat, signals from the amygdala to the hypothalamus activate the SNS, causing the adrenal glands to release epinephrine and norepinephrine in preparation for fight or flight (Rothschild, 2000). Once the threat has passed, the hypothalamus signals the pituitary gland to release cortisol, halting the alarm reaction and returning the body to homeostasis (Rothschild, 2000). In some cases, instead of light or flight a threatened individual will freeze, although this response is less well understood (Scaer, 2001); it appears that when neither fight nor flight seems possible, the PNS will activate and mask the SNS response, causing the body to become immobile (Rothschild, 2000). Levine (1997) posited that failure to discharge this frozen energy after a traumatic event leads to the formation of somatic symptoms and continuing post-trauma symptoms, including hyperarousal.

The limbic system of an individual who experiences a traumatic event may become dysfunctional, causing arousal without the presence of a threat (Rothschild, 2000). For such a person, heightened arousal may result from cortisol levels that are too low to stop the process (van der Kolk & Saporta, 1993). Individuals who have experienced trauma may be more likely to experience arousal without a threat when they are reminded of the threat through an external stimulus, such as a smell and sound, or an internal stimulus, such as a somatic symptom (Rothschild, 2000; van der Kolk, 1994). Thus a cycle of somatic symptoms (pain, nausea, fatigue) and post-trauma symptoms can be triggered both internally and externally.

Traumatic experiences can deeply affect the formation of memory. Memory formation occurs through two disparate systems that are both part of the limbic system: explicit memory and implicit memory (Scaer, 2001; van der Kolk, 1994). Rothschild (2000) described the process of memory formation as follows: The hippocampns mediates the explicit or declarative memory system, which stores facts, language, descriptions, and narratives. It provides conscious understanding of meaning and the sequence of events. However, the hippocampus is not mature until a person is about 3 years old. The implicit or nondeclarative memory is mediated by the amygdala, which is mature and functional from birth. The implicit system allows individuals to unconsciously recall previously learned procedures or behaviors, such as riding a bicycle. It also contains emotional and sensory information. The two systems work together to process experiences, with the implicit memory facilitating storage of emotional reactions and the explicit memory making sense of the experiences.

Traumatic experiences disrupt the normal process of memory formation. When a person experiences traumatic stress, hormones are released that suppress the activity of the hippocampus (van der Kolk, 1994). With the mediating hippocampus suppressed, the explicit memory system cannot effectively create a narrative memory of the event (Rothschild, 2000). However, because the amygdala is not suppressed, the traumatic event is stored in implicit memory. This is consistent with the reports of some trauma survivors, who describe intense emotional recollections of their experiences that lacked context (Scaer 2001). Other studies have found decreased hippocampal volume in individuals diagnosed with PTSD (Kitayama, Vaccarino, Kutner, Weiss, & Bremner, 2005; Lindauer et al., 2004).

Mindfulness and Trauma Counseling

Given the unique aspects of trauma and its psychological and neuropsychological symptoms, mindfulness has great therapeutic potential. Avoidance of feelings and emotional numbing are common in trauma survivors, creating disconnection from both self and others and possibly increasing intrusive thoughts (Follette et al., 2006). Techniques that address somatic symptoms and allow a closer connection with the body and present-moment experiencing are recommended (Levine, 1997; Rothschild, 2000). Focusing on bringing quality attention and being willing to feel what is present and be with the breath, the body, or a particular soothing image can be useful exercises to increase mindful attention and the mind-body connection (see the body scan exercise described below). Counseling can enable clients to reduce arousal when there is no threat while also learning to trust arousal sensations that occur when there is a threat. Initial stages of trauma counseling, which typically focus on safety and restoring control (Herman, 1997), can use mindfulness techniques to moderate arousal and maintain contact with present sensations, thereby decreasing re-experiencing (Rothschild, 2000). For example, a client can practice bringing to mind a comforting image and returning attention to this image throughout the day to increase the sense of safely and decrease arousal.

Mindfulness may also be useful in addressing a lack of declarative traumatic memories. To do so, the counselor might focus on helping a client make sense of memories and put them in context--an important part of trauma recovery (Rothschild, 2000). The ability to pay close, friendly attention to memories and sensation is a skill that can be built through mindfulness practice and used to focus on remembering aspects of the traumatic experience (and thus create declarative memory) without becoming overly aroused.

Herman (1997) described how trauma survivors first reconstruct and then transform traumatic memories to make new meaning for their lives. Mindfulness and body awareness can be used to help a client separate past from present when recalling a traumatic event and adding the narrative memory component (Rothschild, 2000). Furthermore, the mindful approach to investigating whatever arises gently and with kindness engenders an attitude of openness and curiosity that can allow a trauma survivor to see aspects of the traumatic event in new ways (Brach, 2003). Habitual thoughts, such as self-blame, might be explored, allowing for the possibility of transformation instead of the stagnation that often follows avoidance and fear of such thoughts.

The following case example, which demonstrates the use of mindfulness techniques in trauma counseling, represents a distillation of our experiences. Integrated into the description are considerations related to the neuropsychological aspects of trauma.

THE CASE OF VICTORIA

Victoria, a 34-year old woman from a Central American country and mother of a 4-year-old girl, sought services at a community counseling agency. She reported that she had been rescued from human trafficking three years before and at that time had started counseling at the same agency. She had engaged in counseling for about a month, then terminated because she did not feel that it was helpful.

Victoria reported that she did not want to talk about her painful past experiences, she wanted help with "concrete" symptoms. She reported having problems falling asleep; normally she slept for three hours at the most and sometimes not at all. This had been happening for several years. She also reported difficulty concentrating on tasks like reading or studying.

Among other symptoms, Victoria said, she constantly felt anxious and at times over-ate. She often experienced pressure on her chest and uncontrollable crying. She said she felt a lot of anger at times that she was concerned about. Victoria did not like music, could not stand loud noises, and had a great dislike for wearing makeup. Both music and makeup reminded her of her years as a sex slave. With just one relative as her only social support, Victoria felt isolated. She reported feeling close ties to her family but had limited contact with them because they lived in other states or out of the country.

Initial Phase of Counseling

Based on Victoria's intake session, the counselor developed a case conceptualization to begin work with her. Many of Victoria's symptoms seemed to be related to her traumatic experiences; the counselor noted that Victoria was having typical post-traumatic reactions, including an exaggerated startle response, avoidance of traumatic reminders, emotional reactivity, sleep disturbance, and difficulty concentrating. She also noted that Victoria lacked social support and seemed to be using overeating and perhaps other strategies to cope with her symptoms.

The counselor also integrated both cultural and social justice considerations into her plan for working with Victoria. First, she noted that the client's trauma was likely to have been exacerbated by systemic stressors, such as being forced to move to a new country with a new language and culture, lack of a support system, sexism and gender-based oppression, and racism and anti-immigrant sentiments. The counselor ascertained salient aspects of the client's culture, including the importance of family, community, and faith. In particular, she thought that these currently diminished sources of support for Victoria could be renewed.

The immediate goal was to build a relationship of trust and support between the counselor and Victoria (Herman, 1997). The counselor first checked whether any immediate issues related to safety and security needed to be addressed. After Victoria reported that there were none, the counselor elicited Victoria's own goals for counseling. Victoria said that she felt she needed to talk to someone about her current problems, but she did not want to talk about her experience as a survivor of human trafficking because she felt the previous counseling experience had just opened up deep wounds that left her emotionally drained; it had no positive results or resolution. Now, she wanted relief from her current symptoms.

After assessing the situation, the counselor introduced psychoeducational tools to help Victoria normalize some of her symptoms and the mental, emotional, and physical repercussions of trauma. Understanding common reactions to trauma is a first step in decreasing arousal and the reactivity that can escalate when a client experiences certain symptoms (Rothschild, 2000). Victoria responded positively, reporting that the information helped her feel less "crazy" about what she was experiencing.

As trust began to build, the counselor next introduced mindfulness. She explained how the concept of mindful awareness was sometimes helpful for people who had experienced stress and trauma. Victoria was responsive to the description of mindfulness, saying that she thought the counselor was describing something she knew already but had never known what it meant. She reported feeling an intense and peaceful sense of alertness at times when she was sitting quietly in church. The counselor proposed that they use mindfulness exercises to address the symptoms Victoria had reported, and she agreed.

Second Phase: Addressing Symptoms

After explaining the concepts of mindfulness, the counselor began to introduce techniques directed to Victoria's presenting problems. The first symptom related to the cognitive rumination that triggered Victoria's worry and emotional distress. Victoria was also experiencing emotional numbness. Other prominent symptoms were sleep disturbances and excessive eating.

To provide Victoria with essential mindfulness tools, the counselor led her through a body scan exercise designed to promote the ability to pay close attention to whatever felt true and authentic at that present moment (Shapiro & Carlson, 2009). The exercise consists of bringing the client's attention to her own present physical experience. Victoria was asked to sit comfortably with legs and arms uncrossed (the exercise can be also done lying down). The counselor then asked Victoria to pay close attention to her breathing for about a minute. During this minute, the counselor asked Victoria to notice the movement of her belly and to feel the sensation of her stomach rising and falling as air went in and out of her body. The counselor then guided her to observe the sensation in her nostrils as she felt air passing in and out.

Next, the counselor informed Victoria that the body scan would move from her head to her toes (it can also be done from toes to head). Slowly, intentionally, and systematically, Victoria was asked to bring her awareness to each body area and observe any comfortable or uncomfortable sensations or a lack of sensation and any arising emotion, thought, or image attached to the area being observed. She was then asked to breathe in to and out from this region a few times and then let go of it in her mind as her attention shifted to the next region, her face. Victoria was asked to scan her face, starting from her chin, then moving to mouth, teeth, tongue and then to cheek bones, eyes, and forehead. Once again, the counselor asked Victoria to breathe in to and out from each area. The counselor then asked her to move her attention to her neck, shoulder, shoulder blades, her right arm, and her left arm. The counselor continued slowly moving downward to the toes.

Once Victoria had reached her toes, she was asked to recall any area where she had felt discomfort or any sensation that called for her attention and bring her awareness back to that place, without judging the sensation as good or bad. Once Victoria was focused on the chosen region, she was again asked to breathe in to and out from it as she let go mentally of the sensations and thoughts and inner images associated with it and the muscles in that region physically let go, too, releasing much of the accumulated tension. Throughout the scan, the counselor reminded Victoria that each time her mind wandered, she could bring it back to the part of the body where she had been focused when her mind drifted off. Likewise, the counselor clarified throughout that it was simply Victoria's experience; it was neither good nor bad, simply her experience at that precise moment. Along with awareness of the breath, the body scan provides the essential skills for all types of meditation techniques (e.g., sitting and walking meditation).

Consistent with current knowledge about traumatic memory (Rothschild, 2000; Scaer, 2001), individuals who have experienced trauma may lose touch with the present moment and feel fearful or distracted, just as Victoria had reported. Body scan and body awareness exercises are recommended for post-trauma counseling so that the client can differentiate what is happening now from what happened in the past (Rothschild, 2000). Because the body scan helps clients keep attention focused for an extended period, it also helps them develop concentration, calmness, and mindfulness (Kabat-Zinn, 1990). There are a number of ways in which the exercise can be conducted (see, for example, Kabat-Zinn, 1990 or Shapiro & Carlson, 2009). Victoria practiced this exercise at home and reported that it was helpful when she became deeply lost in fearful thoughts or ruminations about her problems.

Next the counselor introduced short mindful breathing exercises in which Victoria was instructed to pay close attention to the act of breathing while at the same time allowing thoughts and emotions to come through without holding on to them-the counselor used the idea of being a witness to their presence. The same practice applied to paying attention to emerging emotions. During this process, the counselor introduced short sentences reminiscent of kindness, nonjudgment, acceptance, trust, and love. Sentences ranged from saying "Yes" to whatever emerged for the client to "May I bring peace and kindness to my heart/mind," "May I bring love and tranquility to this moment," or "May I be with my body in a loving way." After hearing these options, Victoria was asked to choose a sentence or word based on her present experience and set the intention for the exercise as she repeated it silently.

The goal of this intervention was both to create a calming quality during the session and to create space for Victoria to be able to connect to her here-and-now mind, heart, and body through breathing and intention. This intervention was also directed at exploring and decreasing the numbness Victoria was experiencing, but in a slow and controlled way that did not create reactivity (Rothschild, 2000). The counselor would begin sessions with a mindfulness breathing exercise, asking Victoria to sit comfortably, with her eyes closed or half open, and breathe in and out while repeating to herself, "I breathe in, I breathe out," or "in, out." She was asked to pay close attention to the air coming in and going out and observe her belly rising and falling. Intermittently, the counselor would ask Victoria to return to sensing her breath. She was advised to practice mindful breathing for 10 minutes every day.

After a few weeks of performing the body scan at least twice and practicing short mindful breathing exercises during each session, in addition to her own daily practice, Victoria began to report changes in her emotional and mental state. She was becoming less reactive to her thoughts and reported aspects of self-regulation and improved sleeping patterns that may have been associated with these changes. Victoria and the counselor discussed how she could also use mindfulness in eating by taking time to observe, sense, and experience any cognitive, sensory, and emotional reactions to each bite of food during regular meals and snacks. Recognizing her tendency to overeat, Victoria reported that she felt empowered by her ability to bring friendly, nonjudgmental attention to her eating, she ate more slowly, and she was able to taste food more fully. Victoria reported that this exercise helped her notice the similarities in the mindfulness exercises and that she was becoming more aware of her own mind, heart, and body.

Soon after, the counselor asked Victoria to again notice her own mind and heart, as she had described it, and see if she noticed the initial sadness that prompted her crying episodes. Victoria observed the sadness and said that she felt she was struggling very hard to figure out what was behind the sadness. Using a sitting meditation practice, the counselor asked Victoria to repeat the word "struggle" and allow anything to emerge as a result. The counselor also encouraged her to use a body scan or open her eyes if she began to feel overwhelmed by emotions, and noted that she, the counselor, would also watch for this and intervene.

As she meditated, Victoria became tearful and reported a sense of deep pain and loss. She said it was intense at times, but that she was able to step back and become a witness to herself and her pain. The counselor reminded Victoria that there was no expectation of a certain outcome or of fixing or eliminating the pain. Instead, it was an opportunity for Victoria to open to the possibility of redefining her relationship with her own suffering as it might surface in the future. She encouraged Victoria to try similar practices at home so that she could explore new emotions as they arose. As Victoria continued coming to sessions and practicing in her daily life, she indicated that her family had been noticing changes in her, such as a more calming presence, better moods, and more motivation.

Third Phase: Addressing Trauma

After six weeks of counseling, Victoria reported that her sleep disturbances, lack of concentration, and anxiety problems were much less disruptive and more manageable. As the counselor and Victoria discussed her progress and any additional goals she had for counseling, she said that she now felt ready to talk about her traumatic experiences. She reported that she had talked about them in the previous counseling sessions, but that the discussion had always left her feeling exhausted and re-traumatized. She now wanted to "resolve" her experiences as much as possible.

Before discussing the traumatic experiences, the counselor and Victoria talked about which mindfulness techniques could help keep her grounded. Victoria identified the body scan technique, which allowed her to become present in the moment should her fear or anxiety arise. The counselor also suggested that Victoria use a broad-to-narrow approach in which she first gave labels to sections or "chapters" of her traumatic experiences, then filled in more detail as she felt comfortable (Rothschild, 2000).

Victoria first identified four chapters of her traumatic experience: before becoming a sexual slave, being a sexual slave, being rescued, and after being rescued. For each chapter, the counselor asked Victoria to notice what emotions and thoughts arose and watch them with curiosity. The chapter approach also promoted the development of narrative memory, reminding Victoria that these events had occurred in the past. After the general discussion of her chapters, Victoria and the counselor explored each more fully, identifying salient aspects of each chapter, including her strengths and forms of resilience both before and after the traumatic experiences. The counselor and Victoria proceeded cautiously, so that retelling the traumatic experiences did not become re-traumatizing. Being able to return to the present moment and use body scans and breathing exercises helped Victoria to retain a sense of control and grounding.

Victoria reported that while talking about the traumatic events, the mindfulness perspectives helped her to be more accepting and even appreciative of her feelings. For example, she noted that her anger toward and fear of the people who had kept her as a sexual slave were appropriate feelings. They were painful, but she did not feel an urgent desire to make the anger or fear go away because she no longer felt overwhelmed and controlled by them. She was able to acknowledge that her mind and body were giving her information and she could honor and be thankful for the information. She still felt the sensations were difficult to experience at times, but she also felt that she could ground herself in the present moment using her body scan technique so that she was aware that she was not currently in danger.

Her trust of her present-moment experiences also increased her trust in herself. She reported that she had blamed herself and felt guilty about how the symptoms were affecting her. She had expected that she would be able to "just get over it" and was frustrated that she could not. By allowing feelings to arise without judgment, she felt a new mastery over her reactions to the feelings and an understanding that they were normal. She reported feeling a sense of strength that she attributed to the strengths and resilience she had felt before the trauma and that were more fully developed after enduring the trauma.

Termination of Counseling

After several sessions Victoria had talked through each of the chapters in her traumatic experiences. She noted that she was beginning to see these as part of her past but also accept that elements of the trauma would probably always impact her in some way. She reported that she felt she had new skills for coping and that she was continuing to use the mindfulness exercises in her daily life. She also reported that she had begun regularly attending church with a number of other individuals from Central America. She had not as yet ventured to talk with anyone but felt more connected to the community and hopeful about finding support there.

Victoria felt she could end counseling, and she and the counselor discussed the improvement in her symptoms and how she had integrated her traumatic experiences. An outstanding concern was that Victoria still had limited social support, but she did report that she felt more able to seek social support because her anxiety and sleep disturbances were reduced. The counselor told Victoria about a local resource that provided support to survivors of violence and noted that the group also offered opportunities for social action and awareness should Victoria be interested. The connections to a spiritual community and to individuals taking action to prevent injustice could be particularly helpful for Victoria, given the nature of her traumatic experience and continued stressors related to the sociopolitical context.

The counselor encouraged Victoria to continue with the mindfulness exercises and to remember the principles of mindfulness: acceptance, nonjudging, curiosity, and patience. While the techniques used during counseling might continue to work, Victoria could use her own strengths and insights to identify new and perhaps even more effective ways of approaching mindfulness. The counselor emphasized that life would almost certainly pose new challenges and that Victoria could use mindfulness to be flexible and responsive in meeting them. She could also use the resources that she had begun to rediscover through mindfulness, such as her faith and sense of strength.

DISCUSSION

Implications

Mindfulness can be effective in counseling individuals who have experienced trauma. As understanding of trauma has expanded, it is now evident that many people experience traumatic events or highly stressful events in everyday life (Bryant-Davis & Ocampo, 2005; Lewis, Lewis, Daniels, & D'Andrea, 2011). Mindfulness can help many clients to either reduce current symptoms or moderate future symptoms when stressful events occur. Mindfulness can thus be used explicitly for symptom reduction, an important first step in working with trauma survivors, who may benefit from the increased sense of control (Herman, 1997). As understanding of trauma and its neuropsychological outcomes increases, counselors can customize mindfulness practices to address this new knowledge and increase their effectiveness. Mindfulness might also be used within less clinical settings to reduce stress and develop coping skills, such as during counseling outreach, psychoeducational workshops, or prevention initiatives.

One important recommendation is to customize mindfulness interventions to each individual client. In trauma counseling, helping the client to regain a sense of control is critical, so any interventions should have this goal in mind. Mindful interventions should also be culturally congruent, making sense in terms of the client's worldview and drawing on existing strengths and cultural ways of healing. While emerging research in counseling and neuropsychology offers indications about how post-traumatic symptoms may manifest and how the memory may be affected, trauma reactions are also culture-bound. As the neuropsychological aspects of trauma become better understood, applications across cultures need to be evaluated.

Counselor educators can use the information provided to train counselors in how to use mindfulness techniques with clients. Because mindfulness has shown benefits for health care providers (Shapiro et al., 1998, 2005), it should be recommended and integrated into counselor training. Mindfulness exercises can play the dual role of self-care technique for the counseling student and intervention technique for the future counselor. Because burnout prevention and counselor self-care continue to be critical to effective practice, mindfulness training in counselor education programs should be explored. Counselor-trainees who themselves learn to integrate mindfulness into their self-care and clinical repertoire will be better prepared to prevent burnout and work with clients who can benefit from these techniques.

Future Research

Research is needed to understand how mindfulness might best be applied in trauma counseling. It should examine how mindfulness might be used to reduce symptoms, identifying which specific strategies or techniques are effective for which symptoms. Developmental level and other individual and group characteristics should also be examined, because they may affect the effectiveness of mindfulness techniques. For example, specific techniques should be validated for working with children or with clients who have experienced chronic trauma. Continued focus on the neuropsychological aspects of trauma and mindfulness counseling can be of great help in treating trauma.

Increasingly there is a recognition that trauma is common (Bryant-Davis & Ocampo, 2005; Lewis et al., 2011). There is therefore a need for mental health counselors to be engaged in prevention as well as remediation. Research might examine how mindfulness may be used as a preventive technique to promote resilience and strategies for coping with stress and trauma. Longitudinal studies could examine the long-term effects of either preventive or remedial mindfulness interventions. Such studies would identify which interventions have lasting impact and which stimulate short-term improvement. Ideally, counselors could promote a holistic, lifespan approach to both trauma prevention and recovery.

Research could also identify specific resilience factors that are outcomes of such programs or are strengthened by them. It is very important to not assume that all interventions are effective for all people. Certainly, a variety of individual, family, community, and cultural factors would impact the effectiveness of techniques. Furthermore, mindfulness techniques for service providers, such as counselors, and for other individuals working in stressful or emotionally impactful workplaces should also be studied. Cultivating and evaluating techniques that uniquely meet the needs of and promote resilience among individuals and communities can benefit clients, counselors, educators, and researchers.

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Rachael D. Goodman is affiliated with George Mason University and Angela M. Calderon with the University of Florida. Correspondence about this article should be directed to Dr. Rachael D. Goodman, Krug Hall 201C, Mail Stop IF5, 4400 University Drive, Fairfax, VA 22030.
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