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The Use of Mindfulness in Trauma Counseling

Article in Journal of Mental Health Counseling · July 2012

DOI: 10.17744/mehc.34.3.930020422n168322

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The Use of Mindfulness in

Trauma Counseling
Rachael D. Goodman
Angela M. Calderón

Although there is increasing support for the use of mindfulness-based interventions in counsel-
ing, there has been little discussion of its use in trauma counseling. We explore the use of mind-
fulness interventions within trauma counseling, with particular attention to how mindfulness
can address the neuropsychological aspects of trauma. A case example explicates the applica-
tion of mindfulness in trauma counseling. Implications for counseling practice and counselor
training and recommendations for future research are discussed.

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 & Garlson,
2009). Mindfulness has broad potenfial beeause it ean easily be combined with
other counseling protocols and applied in both preventive and remedial coun-
seling.
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 neurobiologieal aspects of trauma
demonstrates the usefulness of body awareness in trauma counseling
(Rothschild, 2000; Seaer, 2001). Gontrolled body awareness and sensation
exercises can help trauma survivors to decrease hyperarousal symptoms, recon-
nect when dissociated from their body, and differenfiate past trauma memories
from here-and-now sensations. Through mindfulness, trauma survivors may
build strength and resilience by acquiring a sense of control, developing inter-
nal resources for symptom reduction and healing, and facilitating the mean-
ing-making process.
This article explicates the use of mindfulness in trauma counseling, with
particular attention to the neuropsychological aspects of trauma. After review-
ing the literature on both mindfulness and trauma, we present a case example
demonstrating the use of mindfulness with a counseling elient who had

Rachael D. Goodman is affiliated with George Mason University and Angela M. Calderón 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.

254 0 Journal of Mental Health Counseling

 Mindfulness and Trauma

experienced trauma. We also discuss the implications for mental health coun-
seling and future research possibilities.

LITERATURE REVIEW
Foundations of Mindfulness
Although definifions vary, mindfulness generally refers to nonjudgmen-
tal, present-moment awareness (Brantley, 2003). The underpinnings of mind-
fulness are found in most spiritual and religious traditions but are offen
associated with Buddhism (Shapiro & Carlson, 2009). Pracfices like medita-
tion are used to develop mindful awareness. While meditation is a formal
mindfulness practice, mindfulness can also be eultivated informally by being
purposefully present throughout the day, for instanee, by paying attenfion to
bodily sensations during conversations (Shapiro & Carlson, 2009).
Because there are many sourees for detailed descripfions of mindfulness
pracfices (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 accep-
tanee of whatever is being experieneed in the present moment (Bishop et al,
2004). It consists in allowing present-moment experienees rather than fighting
against or clinging to emotions or thoughts that are assessed as either negative
or positive. Mindfulness is also relafing to experienees with curiosity and lov-
ing-kindness (or friendliness), which allows for deeper understanding (Kabat-
Zinn, 1990).

Mindfulness and Mental Health Counseling

In the past 30 years there has been inereased popular demand for and aca-
demic 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 eounsel-
ing to reduce anxiety and stress (Shapiro & Carlson, 2009). Mindfulness-based
stress reduefion (MBSR), the technique developed by Jon Kabat-Zinn (1990),
and related techniques, sueh as mindfulness-based cognifive therapy (MBCT),
have been found to reduce anxiety and depressive mood symptoms in individ-
uals 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 psycholog-
ical distress among health care students and practitioners and in inereasing
empathy (Shapiro, Asfin, Bishop, & Cordova, 2005; Shapiro, Sehwartz, &
Bonner, 1998). Mindfulness was also effeefive in reducing symptoms of attention

255
deficit hyperactivity disorder (ADHD), anxiety, and depression in adolescents
and in adults diagnosed with ADHD (Zylowska et al., 2008). Even short-term
mindfulness intervenfions, such as 15 minutes of focused breathing, lowered
both emotional volatility and negafive affect (Arch & Graske, 2006). The posi-
five psychological effects of mindfulness include promoting a sense of well-
being and a positive emotional state (Brown & Ryan, 2003).
Some mental health professionals have also begun to explore the relation-
ship 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 Dialecfical Behavior Therapy
(DBT) was found to be effective in treafing women with both posttraumatic
stress and borderline personality disorders (Harned & Linehan, 2008).
Acceptance and Gommitment Therapy (AGT), which is also mindfulness-
based, was found to be effective in reducing PTSD symptoms (Twohig, 2009).
Ghopko 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.

Eoundations of Trauma
Understanding of trauma has expanded in recent decades, spurred by the
1980 inclusion of posttraumatic stress disorder (PTSD) in the American
Psychiatric Associafion (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 char-
acter 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 legifimize consid-
erafion of trauma as the result of psychological stress that could affect individ-
uals 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).
Gritics noted that this definifion minimizes individual perception and also
exeludes trauma that might be transmitted from parents to children (transgen-
erational trauma) or that results from experiences of systemic oppression, such
as racism (Bryant-Davis & Ocampo, 2005; Goodman & West-Olatunji, 2008;
Rothschild, 2000). Other definifions broaden the definifion of a traumafic
event by emphasizing individual perception and characterizing such an event

256
 Mindfulness and Trauma

as something that an individual perceives as sudden, uncontrollable, and neg-

afive (Carlson, 1997).
DSM-delineated symptoms —reexperiencing, hyperarousal, and avoid-
ance (APA, 2000)—are generally refiected in the literature. Reexperiencing is
evideneed when the individual experiences intrusive recollecfions 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 concentrafing, 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

Recenfiy counseling has focused on the neuropsychological aspects of
trauma. The response to stress and trauma is regulated by the brain's limbic sys-
tem, including the autonomie nervous system (ANS) and the hypothalamic-
pituitary-adrenal (HPA) axis (Rothschild, 2000; Scaer, 2001). As Rothschild
described it, under normal conditions two components of the ANS, the sympa-
thetic 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 somafic expe-
riences include a decrease in digesfion, pallid skin, dilated pupils, and
increases in heart rate, respirafion, blood pressure, and perspirafion (Scaer,
2001; van der Kolk, 1994).
When an individual experiences a threat, signals from the amygdala to
the hypothalamus acfivate the SNS, causing the adrenal glands to release epi-
nephrine and norepinephrine in preparation for fight or fiight (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 home-
ostasis (Rothschild, 2000). In some cases, instead of fight or flight a threatened
individual will freeze, although this response is less well understood (Scaer,
2001); it appears that when neither fight nor fiight seems possible, the PNS will
acfivate and mask the SNS response, causing the hody 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
confinuing post-trauma symptoms, including hyperarousal.
The limbic system of an individual who experiences a traumafic event
may become dysfuncfional, 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 fiauma may be more likely to expe-
rience arousal without a threat when they are reminded of the threat through

257
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 hippocampus 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 hip-
pocampus is not mature until a person is about 3 years old. The implicit or non-
declarative 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 sup-
press the activity of the hippocampus (van der Kolk, 1994). With the mediat-
ing 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 mem-
ory. 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 individu-
als diagnosed with PTSD (Kitayama, Vaccarino, Kutner, Weiss, & Bremner,
2005; Lindauer et al, 2004).

Mindfulness and Trauma Counseling

Civen the unique aspects of trauma and its psychological and neuropsy-
chological 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
 Mindfulness and Trauma

is no threat while also learning to trust arousal sensafions that oecur when there
is a threat. Inifial 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 prac-
tice bringing to mind a comforting image and returning attention to this image
throughout the day to increase the sense of safety and decrease arousal.
Mindfulness may also be useful in addressing a laek of declarafive trau-
matic memories. To do so, the counselor might focus on helping a elient make
sense of memories and put them in context—an important part of trauma
recovery (Rothschild, 2000). The abilify to pay close, friendly attenfion to
memories and sensation is a skill that can be built through mindfulness prac-
tice and used to focus on remembering aspects of the traumatic experience
(and thus create declarafive 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 ean be used to help a elient separate past
from present when recalling a traumatic event and adding the narrafive mem-
ory component (Rothschild, 2000). Furthermore, the mindful approach to
invesfigafing 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 transformafion 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 neuropsycho-
logical aspects of trauma.

THE GASE OF VIGTORIA

Victoria, a 34-year old woman from a Gentral 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 fime 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 expe-
riences, she wanted help with "concrete" symptoms. She reported having prob-
lems 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 concentrafing on tasks like reading or studying.

259
 Among other symptoms, Victoria said, she constanfly felt anxious and at
times over-ate. She offen experienced pressure on her ehest and uncontrollable
erying. 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 soeial support, Victoria felt isolated.
She reported feeling close fies to her family but had limited contact with them
because they lived in other states or out of the eountry.

Initial Phase of Counseling

Based on Victoria's intake session, the counselor developed a case con-
ceptualization to begin work with her. Many of Vietoria's symptoms seemed to
be related to her traumafie experiences; the counselor noted that Victoria was
having typical post-traumatic reactions, including an exaggerated startle
response, avoidance of traumafie reminders, emotional reaetivity, sleep distur-
bance, and difficulty concentrating. She also noted that Victoria lacked soeial
support and seemed to be using overeating and perhaps other strategies to cope
with her symptoms.
The counselor also integrated both cultural and social jusfice considera-
tions 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 particu-
lar, she thought that these currently diminished sourees of support for Vietoria
could be renewed.
The immediate goal was to build a relafionship of trust and support
between the eounselor and Victoria (Herman, 1997). The counselor first
checked whether any immediate issues related to safety and seeurity needed to
be addressed. Affer Victoria reported that there were none, the eounselor
elicited Vietoria'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 leff
her emofionally drained; it had no posifive results or resolution. Now, she
wanted relief from her current symptoms.
Affer assessing the situation, the counselor introduced psychoeducational
tools to help Victoria normalize some of her symptoms and the mental, emo-
fional, and physical repercussions of trauma. Understanding common reae-
fions to trauma is a first step in deereasing arousal and the reacfivity that can
escalate when a client experiences certain symptoms (Rothschild, 2000).

260
 Mindfutness and Trauma

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 describ-
ing 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 quiefly in church. The counselor proposed that they use mindful-
ness exercises to address the symptoms Victoria had reported, and she agreed.

Second Phase: Addressing Symptoms

After explaining the concepts of mindfulness, the eounselor 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
& Garlson, 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 coun-
selor then asked Victoria to pay close attention to her breathing for about a
minute. During this minute, the counselor asked Victoria to notice the move-
ment of her belly and to feel the sensafion of her stomach rising and falling as
air went in and out of her body. The counselor then guided her to observe the
sensafion 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, inten-
tionally, and systemafically, 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 fore-
head. 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 con-
tinued slowly moving downward to the toes.
Once Victoria had reached her toes, she was asked to recall any area

261
where she had felt discomfort or any sensafion that called for her attenfion and
bring her awareness back to that place, without judging the sensafion 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 aecumulated tension. Throughout
the scan, the counselor reminded Victoria that each fime 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 expe-
rience 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., sit-
ting and walking meditafion).
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 disfiacted, 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 exam-
ple, Kabat-Zinn, 1990 or Shapiro & Carlson, 2009). Victoria pracficed this
exercise at home and reported that it was helpful when she became deeply lost
in fearful thoughts or ruminafions about her problems.
Next the counselor introduced short mindful breathing exercises in
which Victoria was instructed to pay close attenfion to the act of breathing
while at the same fime allowing thoughts and emofions to come through with-
out holding on to them—the counselor used the idea of heing a witness to their
presence. The same pracfice 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 kind-
ness 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 silenfiy.
The goal of this intervenfion 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 hreathing and intention. This inter-
venfion was also directed at exploring and decreasing the numbness Victoria
was experiencing, but in a slow and controlled way that did not create reactiv-

262
 Mindfulness and Trauma

ity (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 com-
ing 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 practic-
ing 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 expe-
rience any cognitive, sensory, and emotional reactions to each bite of food dur-
ing regular meals and snacks. Recognizing her tendency to overeat, Victoria
reported that she felt empowered by her ability to bring friendly, nonjudgmen-
tal 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 similari-
ties 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 over-
whelmed 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 sur-
face 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 com-
ing 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 eounseling, Victoria reported that her sleep distur-
bances, lack of eoneentration, and anxiety problems were much less disruptive
and more manageable. As the counselor and Victoria discussed her progress
and any addifional goals she had for eounseling, she said that she now felt ready
to talk about her traumafic experiences. She reported that she had talked about
them in the previous eounseling sessions, but that the discussion had always
left her feeling exhausted and re-traumafized. She now wanted to "resolve" her
experiences as much as possible.
Before discussing the traumafic experiences, the counselor and Victoria
talked about which mindfulness techniques could help keep her grounded.
Victoria idenfified the body sean technique, which allowed her to become pre-
sent in the moment should her fear or anxiety arise. The counselor also sug-
gested that Victoria use a broad-to-narrow approach in which she first gave
labels to secfions or "chapters" of her traumafic experiences, then filled in
more detail as she felt comfortable (Rothschild, 2000).
Victoria first idenfified four chapters of her traumafic experience: before
becoming a sexual slave, being a sexual slave, being rescued, and after being res-
cued. For each chapter, the counselor asked Victoria to nofice what emofions
and thoughts arose and watch them with euriosify. The chapter approach also
promoted the development of narrafive 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, idenfifying salient aspects
of eaeh chapter, including her strengths and forms of resilience both before and
after the traumafic experiences. The counselor and Victoria proceeded eau-
fiously, so that retelling the traumafic experiences did not become re-traumafiz-
ing. Being able to return to the present moment and use body seans and
breathing exercises helped Victoria to retain a sense of control and grounding.
Victoria reported that while talking about the traumafic events, the mind-
fulness perspectives helped her to be more accepting and even appreciafive of
her feelings. For example, she noted that her anger toward and fear ofthe peo-
ple 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 informafion and she
could honor and be thankful for the informafion. She sfill felt the sensations
were difficult to experience at fimes, 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 guilfy about how the
symptoms were affecfing her. She had expected that she would be able to "just

264
 Mindfulness and Trauma

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
Affer several sessions Vietoria had talked through each of the chapters in
her traumatie 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 ven-
tured to talk with anyone but felt more connected to the community and hope-
ful about finding support there.
Victoria felt she could end counseling, and she and the counselor dis-
cussed the improvement in her symptoms and how she had integrated her trau-
mafie experiences. An outstanding concern was that Victoria sfill had limited
soeial support, but she did report that she felt more able to seek social support
because her anxiety and sleep disturbanees were reduced. The counselor told
Victoria about a local resouree that provided support to survivors of violence
and noted that the group also offered opportunifies for social acfion and aware-
ness should Victoria be interested. The connections to a spiritual community
and to individuals taking action to prevent injustice could be particularly help-
ful for Victoria, given the nature of her traumafie experience and confinued
Stressors related to the sociopolitical context.
The counselor encouraged Victoria to confinue with the mindfulness
exercises and to remember the prineiples of mindfulness: acceptanee, non-
judging, curiosity, and pafience. While the techniques used during counseling
might confinue to work, Vietoria could use her own strengths and insights to
identify new and perhaps even more effective ways of approaching mindful-
ness. The counselor emphasized that life would almost certainly pose new
challenges and that Victoria could use mindfulness to be flexible and respon-
sive in meeting them. She could also use the resources that she had begun to
rediseover through mindfulness, such as her faith and sense of strength.

DISCUSSION
IînplicaHons
Mindfulness can be effective in counseling individuals who have experi-
enced trauma. As understanding of trauma has expanded, it is now evident that

265
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 reducfion, an important first step in work-
ing with trauma survivors, who may benefit from the increased sense of control
(Herman, 1997). As understanding of trauma and its neuropsychological out-
comes 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, psychoeducafional workshops, or prevention
initiatives.
One important recommendation is to customize mindfulness interven-
tions 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 neu-
ropsychology offers indications about how post-traumafic symptoms may man-
ifest 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.
Gounselor 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 exer-
cises can play the dual role of self-care technique for the counseling student
and intervention technique for the future counselor. Because burnout preven-
tion and counselor self-care continue to be critical to effective practice, mind-
fulness training in counselor education programs should be explored.
Gounselor-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 effec-
tive for which symptoms. Developmental level and other individual and group
characterisfics should also be examined, because they may affect the effective-
ness of mindfulness techniques. For example, specific techniques should be
validated for working with children or with clients who have experienced

266
 Mindfulness and Trauma

chronic trauma. Continued focus on the neuropsychological aspects of trauma

and mindfulness counseling can be of great help in treafing 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 prevenfion as well as remediafion. Research
might examine how mindfulness may be used as a prevenfive technique to pro-
mote resilience and strategies for coping with stress and trauma. Longitudinal
studies could examine the long-term effects of either prevenfive or remedial
mindfulness intervenfions. Such studies would idenfify which intervenfions
have lasting impact and which sfimulate short-term improvement. Ideally,
counselors could promote a holisfic, lifespan approach to both trauma preven-
fion and recovery.
Research could also idenfify specific resilience factors that are outcomes
of such programs or are strengthened by them. It is very important to not
assume that all intervenfions are effecfive for all people. Certainly, a variety of
individual, family, community, and cultural factors would impact the effective-
ness of techniques. Furthermore, mindfulness techniques for service providers,
such as counselors, and for other individuals working in stressful or emofion-
ally impactful workplaces should also be studied. Culfivafing and evaluafing
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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