Mindfulness-Based Cognitive Therapy for Posttraumatic Stress Disorder

Table of Contents

Cover

Title Page

Notes on Authors

Foreword

Acknowledgments

Photo Credits

Notes on Audio Resources

1 Introduction

2 Trauma, PTSD, and Current Treatments

Diagnostic Criteria for PTSD

Biology of PTSD

Who Develops PTSD?

Current Evidence-Based Treatments for PTSD

3 Mindfulness

Mindfulness Defined

Mechanisms of Action

How Mindfulness is Different

Treatments Utilizing Mindfulness

4 Overview of MBCT for PTSD

Outline of MBCT Sessions

Basic CBT Principles Used in MBCT

MBCT Mindfulness Exercises

Mindful Inquiry

5 Delivery of MBCT for PTSD

Which Delivery Format is Best to Use and When?

MBCT for PTSD Delivered in an Individual Format

MBCT for PTSD Delivered in a Group Format

Practicalities for Conducting MBCT Sessions for PTSD

Future Directions

6 Developing Personal and Professional Competence

The Importance of the Therapist’s Own Practice

Mindfulness and Therapist Self-Care

Developing Competence in MBCT for PTSD

Resources

MBCT curriculum books

MBCT-related books and articles

Other relevant mindfulness books and articles

PTSD and trauma-related books and articles

Other relevant clinical books

Video and audio training resources

Mindfulness exercise audio recordings

Selected websites

Selected applications for iPhone and Android

References

Index

End User License Agreement

Additional praise for Mindfulness-Based Cognitive Therapy for Posttraumatic Stress Disorder

An empirically strong program like MBCT simply begs the question: how can we use it to help other groups than those for whom it was originally developed? In other words, how can we bring this powerful means of dealing with suffering to other groups who also suffer? No diagnostic group is more deserving than those who suffer from the effects of trauma and the authors have done a wonderful job of laying out the territory of MBCT for PTSD. Using clear and concise examples and rationale, snippets of dialogue from sessions, and sound logic for the adaptations they have made, Sears and Chard have made a major step forward toward bringing the healing power of MBCT to the huge and deserving group of individuals struggling with PTSD.

Steven D. Hickman, Psy.D.,

Associate Clinical Professor, UC San Diego Departments of Psychiatry and Family Medicine & Public Health, Executive Director, UC San Diego Center for Mindfulness

This is a timely, well-thought-through adaptation of the original MBCT protocol. Sears and Chard present a mindfulness-based treatment protocol for PTSD that supports the development of mindful awareness. Mindful awareness offers the promise of mediating the often strong reflexive conditioned patterns of reactivity that are the hallmark of this condition. By directing the mind to mindfully attend in a particular way to body sensations, automatic patterns of negative thinking, and strong and difficult emotions, our PTSD clients now have an additional way of relating to these states. This is one that offers them the capacity to respond rather than react, supporting different behavioral choices over time. I have no hesitation in recommending this book.

Susan Woods, MSW, LICSW,

Senior Guiding Teacher, Mindfulness-Based Professional Training Institute, UC San Diego

Sears and Chard have masterfully built a comprehensive guide to identifying, selecting and implementing appropriate treatments for trauma. Their book is jam packed with treatment options that address how to manage the roller coaster of the process while keeping your eye on the goal of overcoming the impact of trauma. One of this book’s strengths is a clear description of trauma’s impact and the merging of research-based approaches to address that impact. They pull it all together for you. With practical tools and examples, this book will be your go-to manual for mapping out an appropriate and successful treatment plan for the victim of trauma.

Rebecca Born, MSW, LISW,

author of Beyond Recovery to Restoration: Working with the Trauma of Sex Abuse.

This timely book is for the many clinicians who ask whether, and how, individuals who suffer from PTSD might benefit from MBCT. Dr. Sears’ and Chard’s book provides a great support to clinicians with a succinct, clearly written, state-of-the-art answer to how MBCT may add to current PTSD interventions.

Mark A. Lau, Ph.D.,Vancouver CBT Centre and Clinical Associate Professor of Psychiatry, University of British Columbia

Richard Sears and Kate Chard combine their expertise in PTSD treatment and research in this comprehensive and thought-provoking resource for clinicians. They provide practical guidance on adapting Mindfulness-Based Cognitive Therapy for those who have PTSD while addressing considerations unique to such issues as combat or sexual trauma. Both mental health professionals and mindfulness teachers will find this book helpful and accessible whether they currently offer or are preparing to offer MBCT for PTSD programs or wish to make informed referrals.

Louanne W. Davis, PsyD,

Indiana University School of Medicine

Among the many striking lessons from two well-respected clinicians in the field is Drs. Sears’ and Chard’s emphasis on the healing power of human compassion and presence. This incredible book masterfully applies their knowledge and understanding of the impacts of trauma and mindfulness into this innovative approach to treating symptoms associated with posttraumatic stress disorder. Their rich integration of science and clinical case examples, along with their ability to capture unique principles and synthesize them into practical tools experienced practitioners can use to aid in the healing of trauma survivors, is truly a remarkable contribution to the treatment of PTSD. This is a must read for all therapists, students, and researchers alike.

Brandi L. Luedtke, Psy.D,

HSPP, developer of Mindfulness-Based Cognitive-Behavioral Conjoint Therapy for PTSD.

"Mindfulness-Based Cognitive Therapy for Posttraumatic Stress Disorder is a well needed and timely contribution to the field of trauma treatment and PTSD. This book provides both the professional and personal reader an in-depth understanding of what trauma and PTSD are, and how both cognitive therapy and mindfulness, when merged together, co-create an effective series of methods for trauma and its aftermath.

As mindfulness becomes an increasing growing edge of western psychotherapeutic knowledge the wisdom teachings of the East become a most urgent and helpful way of assisting both clinicians and clients with new tools for transforming suffering and healing trauma."

Ronald A. Alexander, Ph.D.,

author of Wise Mind, Open Mind, Executive Director of the OpenMind Training Institute in Santa Monica, CA.

Mindfulness-Based Cognitive Therapy for Posttraumatic Stress Disorder

Richard W. Sears and

Kathleen M. Chard

This edition first published 2016

© 2016 John Wiley & Sons, Ltd.

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Library of Congress Cataloging-in-Publication Data

Names: Sears, Richard W., 1969– author. | Chard, Kathleen M., author.

Title: Mindfulness-based cognitive therapy for posttraumatic stress disorder / Richard W. Sears and Kathleen M. Chard.

Description: Hoboken : Wiley-Blackwell, 2016. | Includes bibliographical references and index. | Description based on print version record and CIP data provided by publisher; resource not viewed.

Identifiers: LCCN 2015043945 (print) | LCCN2016001119 (ebook) | ISBN 9781118691427 (pdf) | ISBN 9781118691434 (epub) | ISBN 9781118691458 (hardback) | ISBN 9781118691441 (paper)

Subjects: LCSH: Post-traumatic stress disorder–Treatment. | Mindfulness-based cognitive therapy. | BISAC: PSYCHOLOGY / Clinical Psychology.

Classification: LCC RC552.P67 S38 2016 (ebook) / LCC RC552.P67 (ebook) | | DDC 616.85/21–dc23

LC record available at http://lccn.loc.gov/2016001119

A catalogue record for this book is available from the British Library.

Cover image: Photo © Olivia Ossege

To our families, for their unwavering support

Notes on Authors

Richard W. Sears, PsyD, PhD, MBA, ABPP, is a licensed psychologist in the state of Ohio, USA, board certified in clinical psychology by the American Board of Professional Psychology (ABPP), and is the Director of the Center for Clinical Mindfulness & Meditation. Dr. Sears is clinical/research faculty at the University of Cincinnati Center for Integrative Health and Wellness, and Clinical Assistant Professor at Wright State University School of Professional Psychology. He runs a private psychology and consultation practice out of his office in Cincinnati, and regularly conducts MBCT groups in the community. He is a psychologist contractor with the Cincinnati VA Medical Center, where he was lead clinician for a randomized controlled trial of MBCT for veterans with PTSD. He is also Associate Professor of Clinical Psychiatry and Behavioral Neuroscience with UC College of Medicine, working with Dr. Sian Cotton and Dr. Melissa DelBello at Cincinnati Children's Hospital on projects involving mindfulness with brain scans. He regularly gives professional trainings online and across the United States.

Dr. Sears is author of Mindfulness: Living Through Challenges and Enriching Your Life, Building Competence in Mindfulness-Based Cognitive Therapy, Mindfulness in Clinical Practice (with Dennis Tirch and Robert Denton), Consultation Skills for Mental Health Professionals (with John Rudisill and Carrie Mason-Sears), and The Sense of Self: Perspectives from Science and Zen Buddhism. He is co-editor of the books Perspectives on Spirituality and Religion in Psychotherapy (with Alison Niblick) and The Resilient Mental Health Practice: Nourishing Your Business, Your Clients, and Yourself (with Jennifer Ossege).

He is also a fifth degree black belt in Ninjutsu/To Shin Do, and once served as a personal protection agent for the Dalai Lama of Tibet with his teacher, Stephen Kinryu-Jien Hayes. He has a PhD in Buddhist Studies from Buddha Dharma University, receiving ordination in three traditions, and authority to teach koans (inka) under Wonji Dharma in the Zen lineage of Seung Sahn. His website is www.psych-insights.com.

Kathleen M. Chard, Ph.D. is the Associate Chief of Staff for Research and Director of the Trauma Recovery Center at the Cincinnati VA Medical Center, and Professor of Psychiatry and Behavioral Neuroscience and Director of the UC Health Stress Center at the University of Cincinnati. As the Veterans Administration CPT Implementation Director, Dr. Chard oversees the dissemination of Cognitive Processing Therapy to VA clinicians across the United States. She is the author of the CPT for Sexual Abuse treatment manual and is co-author of the Cognitive Processing Therapy: Military Version manual. Dr. Chard is an Associate Editor of the Journal for Traumatic Stress and she is an active researcher. She has conducted several funded studies on the treatment and etiology of PTSD and she currently is exploring the efficacy of CPT with veterans with PTSD and comorbid traumatic brain injury. She was the Principal Investigator of a randomized controlled trial of MBCT for veterans with PTSD.

Foreword

Mindfulness-Based Cognitive Therapy, at its inception, was designed to address the vulnerabilities of patients who were partially or largely in recovery from their illness. Its adaptation for people who have experienced trauma holds the potential for extending the reach of mindfulness-based clinical care, beyond the scope of the foundational model. But caution is also warranted, as it is likely that this promise will only be realized if the treatment being delivered actively addresses the needs of patients whose symptoms are more acute and severe – something the original model did not focus on as strongly.

Richard Sears and Kathleen Chard provide a compelling, pragmatic, and ultimately convincing template for how to do this in the context of treating PTSD. Their approach is grounded in (1) the clinical reality that trauma is among the most common conditions that present for treatment – meaning that most clinicians will encounter trauma in their practice, (2) incrementalism – at present no single treatment is entirely sufficient for the treatment of PTSD, and mindfulness meditation offers the means for augmenting or consolidating previous trauma therapies, and (3) customization – MBCT has been revised and translated to speak to the experience of trauma and its sequelae. This includes shortening some of the practices, increasing the focus on the body, and routines of self-care. Clinicians are also cared for throughout the protocol. For example, take the common scenario in which a patient complains that I don’t want to learn how to become more aware, I am already too aware!. The sensitive discussion of how to balance practices that may well increase client stress with the possibility of gaining skills in affect tolerance and meta-awareness of emotions encapsulates an important moment of engagement in this type of work. This book succeeds because it takes these multiple standpoints on symptoms and the therapy frame into account, and is very generous with transcripts that illustrate how these elements can be worked with through a mindfulness lens. I am grateful to Richard and Kate for facilitating MBCT being provided to patients suffering from PTSD, and its exposition has been so well crafted.

Zindel V. Segal, Ph.D.

Distinguished Professor of Psychology in Mood Disorders

University of Toronto Scarborough

Toronto, June 2015

Acknowledgments

We deeply appreciate and salute Zindel Segal, Mark Williams, and John Teasdale for their tireless efforts to develop, test, and so freely share MBCT, as well as Jon Kabat-Zinn, Saki Santorelli, Elana Rosenbaum, and the pioneers of MBSR. We are especially honored that Dr. Segal took the time to write the foreword to this book.

We would also like to thank all of the staff of the Trauma Recovery Center, who make a profound difference every day in the lives of so many. We are particularly grateful for our MBCT for PTSD research team: Kristen Walter, Lindsey Davidson, and Jeremiah Schumm.

We also acknowledge and salute the pioneering work of Anthony King, Thane Erickson, Nicholas Giardino, Todd Favorite, Sheila Rauch, Elizabeth Robinson, Madhur Kulkarni, and Israel Liberzon, who conducted trials of group MBCT for PTSD at the Ann Arbor VA in Michigan, USA. We have also been inspired by the MB-CBCT for PTSD work of Louanne Davis, Brandi Luedtke, and their colleagues at the Indianapolis VA.

We also feel very fortunate to have connected with and been inspired by so many mentors, colleagues, and friends in the fields of mindfulness and trauma: Dennis Tirch, Robert Denton, Susan Woods, Randye Semple, Jean Kristeller, Ryan Niemiec, Patricia Resick, Candice Monson, Matt Friedman, Paula Schnurr, Ariel Lang, Susan Albers, Sarah Bowen, Ruth Baer, Mark Lau, Rebecca Crane, Dan Siegel, and Jamie Marich. We especially appreciate Philippe Goldin for taking the time to share his experiences in using MBSR for veterans with PTSD as we began our MBCT for PTSD research.

A special thank you goes out to Olivia Ossege, for her lovely and peaceful photographs, including the one on the cover. We would also like to thank Diane Baumer for her diligent editing skills.

We are also very appreciative of the support and encouragement of Darren Reed, Roshna Mohan, Andy Peart, Amy Minshull, Vimali Joseph, Lynette Woodward, and everyone at Wiley-Blackwell for making this writing project a reality.

Last but not least, we wish to thank all the courageous trauma survivors who shared their journeys with us, and helped to shape our understanding of PTSD. Though we have changed their names and some of the details, we will share some of their struggles and successes with you.

Photo Credits

The photographs on page 74 (Creating a path through the chaos) and page 122 (Duck swimming in pond) are both used with kind permission from Olivia Ossege on behalf of Jennifer M. Ossege. All other photographs are by Richard W. Sears.

Notes on Audio Resources

Readers will find digital MBCT audio files free to download and give to clients at www.psych-insights.com

Body Scan

Sitting Meditation (Breath, Body, Sounds, Thoughts)

Three Minute Breathing Space

Loving-kindness

Many thanks to Jon Kabat-Zinn, Zindel Segal, Stephen K. Hayes, and Susan Woods for their inspiration and influence toward the creation of these recordings.

1

Introduction

Our world today is filled with violence. Even those who specialize in working with trauma victims can be stunned by the stories they hear of childhood abuse, family violence, sexual assaults, and the atrocities of war. Such events can leave lasting scars for those who experience them, whether or not the residual effects lead to full-blown clinical disorders like posttraumatic stress disorder (PTSD).

Inevitably, no matter what kind of clinical work one does, all therapists will encounter clients with some history of trauma. Therefore, we believe that all competent clinicians should have an understanding of PTSD, and at least some level of working knowledge of the principles involved in the treatment of individuals with trauma histories.

Clients are often reticent to seek out treatment, and even our best evidence-based practices for PTSD, such as Cognitive Processing Therapy (CPT; Chard, 2005; Resick et al., 2008) and Prolonged Exposure (PE; Foa et al., 1999), may not be effective at reducing symptoms to a sub-clinical level more than 70% of the time (Resick, Nishith, Weaver, Astin, & Feuer, 2002). Hence, tools to enhance current treatments, and to decrease residual symptoms, are continually being sought. This need resulted in the authors collaborating on a feasibility study to adapt mindfulness-based cognitive therapy (MBCT) for the treatment of individuals with PTSD.

MBCT is an eight-session program, meeting once per week with regular home practice assignments, which teaches the skills of mindful awareness and the principles of cognitive-behavioral therapy. It was first developed in the 1990s by Zindel Segal, Mark Williams, and John Teasdale (Segal, Williams, & Teasdale, 2013), adapted from mindfulness-based stress reduction (MBSR), developed in the 1970s by Jon Kabat-Zinn, Saki Santorelli, Elana Rosenbaum, and their colleagues (Kabat-Zinn, 2013).

MBCT was originally designed to help individuals with a history of major depressive disorder prevent future recurrences. The more episodes a person experiences, the higher the risk for depression coming back again. After two major depressive episodes, the chance of having yet another recurrence rises to 70–80% (Keller, Lavori, Lewis, & Klerman, 1983; Kupfer, 1991).

A major focus of MBCT is teaching mindfulness skills, which fosters our capacity to pay attention to present moment experiences. Becoming aware of automatic reaction patterns opens up the possibility of making more adaptive choices. By noticing, rather than avoiding, unpleasant thoughts, emotions, and body sensations, clients can learn to relate to them differently. One of the techniques clients practice is known as decentering (Piaget, 1950; Piaget & Morf, 1958; Segal, Williams, & Teasdale, 2013), which involves recognizing thoughts as mental events, rather than getting overly caught up in them as if they were always perfect representations of reality. Learning to stay present with strong emotions and body sensations counteracts maladaptive avoidance patterns. By noticing the warning signals of rising levels of stress, depression, anxiety, or pain, clients can be proactive to take care of themselves, instead of ignoring those signals until they become overwhelming and more difficult to handle.

The evidence base for MBCT is strong, demonstrating significant reductions in depressive relapse rates, especially for those who have suffered three or more previous episodes (Chiesa & Serretti, 2011; Hofmann, Sawyer, Witt, & Oh, 2010; Kuyken, Crane, & Dalgleish, 2012; Ma & Teasdale, 2004; Piet & Hougaard, 2011; Segal, Teasdale, & Williams, 2004; Teasdale, Segal, & Williams, 1995; Teasdale, Segal, Williams, Ridgeway, Soulsby, & Lau, 2000; Williams & Kuyken, 2012). MBCT has also been shown to be as effective as maintenance antidepressant pharmacotherapy in preventing depression from returning (Kuyken, Byford, Byng, Dalgleish, Lewis, et al., 2010; Segal, Bieling, Young, McQueen, Cooke, et al., 2010).

Inspired by its success in preventing depressive relapse, clinicians and researchers have continued to study and adapt MBCT for a variety of populations and presenting issues, such as addictions (Bowen, Chalwa, & Marlatt, 2010), bipolar disorder (Deckersbach, Hölzel, Eisner, Lazar, & Nierenberg, 2014), cancer (Bartley, 2011), children and adolescents (Semple & Lee, 2011), eating disorders (Kristeller & Wolever, 2011), generalized anxiety disorder (Evans, Ferrando, Findler, Stowell, Smart, & Haglin, 2008; Roemer & Orsillo, 2002; Roemer, Orsillo, & Salters-Pedneault, 2008), health anxiety (Surawy, McManus, Muse, & Williams, 2014; Williams, McManus, Muse, & Williams, 2011), stress (Rimes & Wingrove, 2011; Sears, 2015), and tinnitus (Sadlier, Stephens, & Kennedy, 2008).

Given the frequent comorbidity of depression and PTSD, the usefulness of decentering from intense thoughts and emotions, and the importance of working with avoidance, investigating the potential benefits of using MBCT for PTSD holds much promise. Later in this book, we will discuss the preliminary results of studies like those done by the authors at the Cincinnati VA PTSD clinic, by Anthony King and colleagues at the Ann Arbor VA (King, Erickson, Giardino, Favorite, Rauch, Robinson, Kulkarni, & Liberzon, 2013), and Louanne Davis and Brandi Luedtke at the Indianapolis VA (Davis & Luedtke, 2013). We will also share clinical experiences from work we have done in private practice, medical agencies, and other settings.

Interest in mindfulness among clinicians has quickly grown in popularity in the last decade, inspired by the personal benefits, the brain