MiT-T - Mindfulness Informed Therapy for Trauma disorders

Copyright (c) 2013 Mindfulness Training Australia, All Rights Reserved | info@bemindful.com.au
MiT FOR TRAUMA DISORDERS
Cameron Aggs Clinical Psychologist & Director
Mindfulness Training Australia
cam@bemindful.com.au
Sponsored by The Belfast Trust

Overview
• Session 1:
– Overview of mindfulness and key concepts
– Experiential exercises: 3MBS, 2H and 4B techs
• Session 2:
– Mindfulness in the context of trauma
– Mindfulness and case formulation
• Session 3:
– Mindfulness and the psychotherapy relationship
– Facilitating the 3MBS, 2h and 4B techs

Materials and Process
• Slides
• Experiential activities
– Participate as much as you feel comfortable
– Respect one another’s confidentiality
– Volunteering for demonstrations
• Choose a client to keep in mind
• Password resources

Begin with the end in mind
• Safety, Safety, Safety
• Mindfulness should be embodied (RB2RB)
• Mindfulness and process: Deepening the clinical narrative
• No 1 Mindfulness Target: Enhancing a willingness to feel into
and to safely experience SIFT experiences
– Importance of the breath
– Relevance of Self-As-Context
• Know your mechanisms!
• Find your entry point. Scaffold.
• Make sure you have enough resources to build the
capacities you are seeking to foster
• Make sure you can do what you are asking of your clients.

4Breaths Technique
Coming into a state of presence:
• Lightly, mindfully watching the breath
• Coordinating with the fingers: Motor-
movement
• Rounds of 4
“These 4-Breaths are Mine”

What does mindfulness mean to you ?
Copyright (c) 2013 Mindfulness Training
Australia, All Rights Reserved | MiT -
Mindfulness Informed Therapy

“Bringing one’s complete attention to the
experiences occurring in the present
moment, in a nonjudgmental or accepting
way”
(Brown & Ryan, 2003; Kabat-Zinn, 1990).
What is Mindfulness?

Our “map”:
IAA model of mindfulness
(Shapiro et al., 2006)
Intention
Attention Attitude
Paying attention in a particular way…
Kabat-Zinn, 1994, p4
and non-judgmentally.
on purpose, in the present moment,

Holding in Mind: Intentions
• What do you want from mindfulness?
• This moment…?
• This meditation / workshop / this session…?
• More generally inc this treatment episode?
Tip #1: Mindfulness is an intentional activity

Attending Skills
Placing your attention where you want it…
• Attentional placement:
– Shifting and sustaining attention
• Non-judgmental Awareness
– Inhibiting secondary appraisals
• Noticing and Naming
– Ability to put inner experience into words

The process of mindfulness
(the WHAT and HOW)
Noticing and naming
with mindful attitudes
(internal & external
experiences)
Letting go (creating
space)
Focus/Re-focus
attention
Choose an aspect of
internal or external
experience to focus
attention on

Attending:
• Using your faculty of attention as a tool:
Disengaging from worry and rumination
• Fostering Internal Attunement / Meta-CognItive
Awareness: What’s happening for me now..?
• The ability to come into a state of “Presence”

3 Qualities of Presence
• Light: As in buoyant in the Mind
– Unencumbered by past and future and fixation
• Relaxed: As in soft in the body
– Particularly the belly, chest, shoulders, jaw
• Grounded: The bum in the chair and the feet on the
floor
– Mind ‘riding’ the breath
Light. Relaxed. Grounded.

Presence…
“The mind if not stirred, will become clear”
Sogyal Rinpoche

4Breaths Technique
Coming into a state of presence:
• Lightly, mindfully watching the breath
• Coordinating with the fingers: Motor-
movement
• Rounds of 4
• Combine with FBB technique
“These 4-Breaths are Mine”

Mindful Attitudes: More than just
Attention
The anaesthetic of internal attunement….

Attitudes
GOAL
• Curiosity :
• Openness
• Acceptance
• Love
Metaphor / key principles
• Curious Explorer
• “It is already here: Let me
feel it
• As an active state
• Friendliness
Saying ‘Yes’ to Experience

3 Minute Breathing Space = Making a Space for
What is Happening now
Step 1: Taking stock / Gathering the mind
Step 2: Focusing and redirecting the attention
Step 3: Expanding awareness and returning
Hot tip: Bookmark: youtube “3 minute breathing space” (it’s the
first one that comes up)
Experiential Exercise: 3MBS:

I-SIFT
• I (me)
• Sensations
• Images
• Feelings
• Thoughts

MINDFULNESS: COMPONENTS AND
CENTRAL CONCEPTS

Central Concepts
• The ubiquity of human suffering
• Internal experiences are transient and change
with time
• Thoughts and emotions are not facts
• Though some are very ‘sticky’
• They happen within a larger context: The Space
of the Mind

A Central task
• To disengage from fixation on verbally-based
mental content and fusion with emotional
material

And again…
“The mind if not stirred will become clear”
-Sogyal Rinpoche

But!
• Before ‘Letting-Go’, of thoughts we must learn
to ‘Be-With’ our primary emotional
experiences
Saying ‘Yes’ to experience
- Tara Brach
“It’s already here…. Let me feel it”
-John Kabat-Zinn

‘Being – With’
• Special relevance to anxiety disorders…
• Feeling into
• Going deeper….
• Making a space

BREAK! 

Review…
Mindfulness is the capacity to come into a
state of presence, to not be overly judgmental
/ non-catastrophic about our encounters with
suffering, and to make space for whole range
of affective life, with the confidence that it is a
SIFT experiences are passing on through….

Correlational Research
Greater mindfulness
associated with higher:
• Healthy self-regulation
• Emotion regulation
• Positive affect
• Quality of life & life
satisfaction
• Social skills
• Relationship Satisfaction
• Academic competence
Mindfulness interventions
resulting in greater:
• Feelings of calm/relaxation
• Social skills
• Personal and social well-
being
• Self-esteem and self-
acceptance
• Awareness and recognition
of types of emotions
• Self-efficacy for reducing
substance use
• Sleep quality

Mindfulness: Does it Matter?
Greater mindfulness
associated with lower:
• Depressive symptoms
• Anxiety
• Stress
• Internalizing symptoms
• Externalizing behaviour
problems
• Worry and rumination
• Negative affect
• Substance use coping
• Somatic complaints
• Psychological inflexibility and
thought suppression and
control
Mindfulness interventions
resulting in lower:
• Depressive symptoms and low
mood
• Anxiety
• Stress
• Internalizing symptoms
• Externalizing behaviour
problems
• Difficulties with emotion
regulation
• Problem behaviours in the
classroom
• Keng, S.L. (2011). Effects of mindfulness on
psychological health: A review of empirical studies.
Clinical Psychology Review. 31, 1041-1056

What: spectrum of mindfulness-informed interventions
Mindfulness-informed interventions
• Acceptance and Commitment
Therapy (ACT)
• Dialectical Behaviour Therapy –
adolescents (DBT-A)
• Individualised intervention plan: (e.g.
MiT)
Mindfulness-based interventions
• Mindfulness-based stress
reduction (MBSR)
• Mindfulness-based cognitive
therapy (MBCT)
• Independently developed
mindfulness programs (MiCBT)
Embodying and modelling of mindfulness with clients

Modelling Mindfulness,
Psychotherapy Process
Mindfulness Informed Therapy
Mindfulness as
metaphor, psychoeducation and
technique
 Adults and children
 Increasing capacity with age (and development) for children to engage in
independent mindfulness practice

Mindfulness and Psychotherapy
Process: Clinical Algorithm
Client Characteristics:
• What is the client’s presenting problem?
• Severity and Level of impairment?
• Stage of Change?
• Client’s theory of Change
• Character organisation?
- Courtesy, Joe Coyne

Mindfulness and Therapist Factors
• Theoretical orientation
• Level of training and supervision
• Clinical assumptions
• Presence of a personal practice
• How we deal with our own suffering
• Access to Resources

Mindfulness and Systemic Factors
• Nature of the Services
• Type and scope of intervention
• Frequency of Contact
• Broader social, economic ecology

My Clinical Assumptions
• The Importance of Following the clients lead:
What moment is this?
• Live Company: A mind-minded other..
• Psychotherapy as Co-regulation
• Behavioural Activation
• Scaffolding:
• Importance of Understanding Mechanisms
• Entry Point >>>> Consolidating Gains

Mindfulness and Trauma….

What is Trauma
“Any circumstance in which an event, or series of
events, overwhelms a person’s capacity to protect his
or her psychic well-being or integrity, where the
power of the event is greater than the resources
available for effective response and recovery.”
Cloitre, Cohen & Koenen (2006)

Single Incident trauma
Large-T (Single Incident)
• Car accidents
• Sexual Assault
• Natural Disaster
• Exposure to combat

Complex Trauma
Small-”t” (chronic)
- Trauma that occurs repeatedly and
cumulatively, usually over a period of time and
within specific relationships and contexts
(Courtois, 2004)
- Chronic missatunement by attachment
figures, neglect, child abuse
- ‘The Troubles’
- Response of Self (ROS) matters

Three Clusters of PTSD
• Re-experiencing: Recurrent or intrusive
recollections, distressing dreams
• Avoidance of stimuli: Numbness, thought
suppression, experiential avoidance
• Hyperarousal:
insomnia, irritability/anger, difficulty
concentrating, hypervigliance, (Fairbank et
al., 2001)

Experiential Avoidance: The Primary
Target of MiT
• Posttraumatic symptoms are developed and
maintained by experiential avoidance (EA)
• EA: Defined as an unwillingness to experience
unwanted internal events.
• Habitual attempts to avoid trauma-related
thoughts, emotions and memories lead to the
core symptoms of PTSD.

Experiential Avoidance**
In both undergraduate and combat-exposed
samples, experiential avoidance was found to be a
stronger predictor of current psychological distress
than was the severity of the index trauma and previous
psychological distress!
Plumb, Orsillo, & Luterek, 2004

Mechanisms of Change: You Are Safe Now
A Biopsychosocial Approach
Biologically:
• Relaxation Response:
Parasympathetic Nervous System Activation
• Diaphramatic breathing:
Optimal Oxygen / Carbon Dioxide ratio

You are safe now…
Psychologically
– Present moment awareness: The trauma is past
– Non-judgmental assimilation of trauma into
coherent narrative (importance of psychotherapy
relationship
– Thoughts / feelings / memories can be felt and
observed
– Observing Self / Sense of Agency

You Are Safe Now
Socially
– Enhancing capacity for social meditation
– Effective engagement in relationships
– Values based living

Mechanisms of Change: Exposure
Safety Exposure Emotional Processing
Repeated Exposure Mastery
• Biologically
• The Breath: Entering the relaxation response
• Decreasing stress and tension in the body

Exposure
Psychologically
• Feelings can be felt, memories can be integrated into
coherent narrative
– Ie inner experiences can be felt, named, and shared
• One-moment at a time
• Curious Explorer: SIFT

Exposure
Relationally
• The Therapy Relationship is safe:
– Mind Minded,
– Accurate Attunement: Following Lead
– Containing
– At the client’s pace

Clinical Markers **
• Viewing, trauma-related thoughts and feelings from a
nonjudgmental perspective,
• Increase their contact with the present moment: The
trauma is not now.
• A felt awareness that thought suppression, avoidance
etc is unnecessary and counter productive
• Behavioural Activation / Acting with Awareness:
Moving on into a values congruent future

Mindfulness and Treatment Planning
• Safety
• Embodied Mindfulness
• Mindfulness and the Working Alliance
• Assessment
• PsychoEducation
• Mindfulness as Metaphore / Deepening the
Narrative
• Experiential

Mindfulness and Treatment Planning
• Find your entry point
• Start somewhere – review and revisit
• Scaffolding new parts of mindfulness in line with
unfolding treatment trajectory and
understanding of mechanisms of mindfulness.
• Link in session activities to homework exercises.
• Practice. Practice. Practice.
• Be curious every session - track the client

Safety
The theory:
• Appreciation for the impact of (particularly complex)
trauma on the ability to use relationships productively
and ‘feel into’ experience
• The ambiguous nature of mindfulness
• Radical departure from usual way of being / defensive
structures
The Practice:
• POC Exercise: Agency
• Eyes Open Modification

Mindfulness Practice: 2 Hands
• Place one hand is on the chest and the other
hand on the abdomen.
• Breathe and notice:
– Where is the breath moving?
– Is the breath deep or shallow? Fast or slow?
– Which hand is moving more?
• Rate our of 100%

POC: Points of Contact – Inward focus
Noticing the feeling of your feet on the floor, bottom
in the chair and your breathing…
For clients:
• Engenders safety (groundedness and an ‘inward
focus’
• De-stabilising aspect of mindfulness practice
• Deepens the impact of the therapy
relationship, potentiates the therapy hour
For the therapist:
• The how of ‘Therapeutic Presence’
• Enables frustration tolerance

Practice!
• Coach each other through the P.O.C > 2Hands
• Provide a rationale: Link to assessment and
ongoing socialisation process
• Encourage partner (You are fostering a
trajectory to end in a sense of Mastery)
• Provide feedback
• Swap

Mindfulness as Assessment
• Assess trauma type and severity
• What is the clients theory of change, level of
impairment etc?
• Mindfulness and a sense of agency and safety
– Modifying Points of Contact exercise

Psychoeducation: IAA terms
Intention
Attention Attitude
Focusing/refocusing on the here
and now
Noticing and naming
Letting go and creating space
Checking in
Curiosity
Kindness
Willingness
Choosing
Slowing down
Remembering
Knowing why

Psycho-Education: Know your
Mechanisms!
Self-Compassion
DefusionPositive Affect
Acceptance
Interoceptive
Exposure
Agency
RelaxationAttention Switching

Psycho-Education: Acceptance
Acceptance is an intentional activity…
Saying “Yes” to experience
- Tara Brach
“It’s already here…. Let me feel it”
-John Kabat-Zinn

Mindfulness & Metaphor
• Using metaphors to illustrate and explore mindfulness concepts
– Keep it simple and Don’t overload with too many or varied metaphors
Metaphor Target area
Clouds in the sky Self as Context: Interoceptive Experiences are safe
Leaves on a stream /
River Bank
Internal experiences are constantly changing + Observer Self
Training the Puppy Gentle and Firm orientation to attentional control. Forming a
relationship with the self
Narrowing focus –
widening lense
Attention is a tool
‘Turning Towards’,
Saying ‘Yes’
Mobilising acceptance in behavioral terms
Train of thought Internal experiences are constantly changing
Making space /
feeling into…
Mobilising acceptance in behavioral terms

Potential Experiential Mindfulness
Trajectory
• 2 Hands >>> P.O.C >>>> 4 Breaths >>>
• 3Rs >>> 3MBS >>>
• Breathing Meditation >>>> Body Scan
>>>>Sitting with discomfort

Mindfulness Practices:
4 Breaths or Breath Counting
4 Breaths
• With each breath touch the thumb to
finger-tip and note an experience. As
you begin a new breath move your
thumb to the next finger.
• Notice (with curiousity):
– 4 breaths
– 4 external experiences
• sensory information like
sights, sounds, smells, what they are
touching
– 4 internal experiences
• thoughts feelings, body
sensations, urges
– A combination of internal and external
experiences
• The process of ‘letting go’ by moving
your fingers physically ‘creates space’.
Breath Counting

Clinical Uses for Meditation
• Selling meditation: Finding a way of talking about meditation
that makes sense.
• Constraining gains: starting with FBB +4B
• To focus a session: Do at Beginning
– Establish a narrative for this early on and stick with it.
• As treatment: Emotional processing, attention
training, synergies with schema-focused and cognitive work

• As homework: Start with diaphragmatic
breathing (Crawl and/or two breaths) prior to
doing guided meditations
• Using meditation like a Personal Trainer.
Discourse: Building neural circuits
• Trajectory:
– Start with Body scan (relaxation
– > breathing meditation (attention regulation),
– > noticing thoughts and feelings (meta-cognitive
awareness
– > guided imagery (creating a safe place)
– > sitting with discomfort (interoceptive exposure /
emotional processing

Meditation-Check list: Learning
Opportunities
Attention
• Thoughts will continue to be there and that is okay
• You can learn to let go of thoughts
Attitude
• Things are okay as they are
Experiential
• The present moment is a nice place to hang out
• Your ally is close at hand: Diaphragmatic breathing:
Long, deep and slow
• Feeling it at a physical level

In-session meditation: Emotional Processing
• Discuss a worry - Find the bottom line /what is the
essential message?
– Eg. “I am not good enough”
• Guide a meditation starting with relaxing into FBB
• Evoke the message: “Imagine it like a radio
station….”
• Notice feelings and body sensation. Special
attention to belly and chest.

Using Metaphors
Clouds in the Sky
Mentally “placing” internal experiences (usually thoughts) on the object and
allow it to move (or not move) as it naturally wants to.
– Does … (object) stick around?
– Does it feel ok if … (object) is not moving on?
– Background (sky) is ‘observing self’/‘self-as-context’
– Noticing that the background can observe the objects that move through
it
– Are you the … (object) or the … (background)? *‘self-as-context’ rather
than ‘self-as-content’+
If the child has the capacity, you can link other internal experiences (e.g.,
feelings) to other objects/events that occur in the background
– Are you still able to be … (the background) even when … (feeling) is also
happening?

No Pest Control
(reactions happen)
• Imagine your distressing or unwanted
thoughts, feelings, body sensations are like …
cockroaches…
• Being able to let the experience be…
– Not feeling bad that it is here
– Not trying to get rid of it
– Not running away from it
– Not letting the cockroaches control how you act
– Not trying to make the experience positive (e.g., a butterfly)
• Being ok with the experience coming and going… like
cockroaches running around you...
• Being able to notice the experience and still being able to
chose what to do

Nature of Attention
Spotlight
• Shining light on where you
want to focus your attention
Puppy on a leash
• Like a puppy attention
naturally wanders (jumps
around)
• It takes time to train a puppy
(attention) to be able stay in
the one place for any length of
time
• Getting angry at the puppy
doesn’t help
• Be kind to your wandering
mind

Train of thought
• Thoughts don’t stop and they often jump from
one topic to another.
• The train of thought can be fast or slow
• Creating Space: “Are you standing on the
platform or are you riding on the train?”

Thought Parade

Take Home Summary
• Safety, Safety, Safety
• Mindfulness should be embodied (RB2RB)
• Deepening the clinical narrative
• Enhancing a willingness to feel into and to safely
experience SIFT experiences
– Importance of the breath
– Relevance of Self-As-Context
• Know your mechanisms: Password Resources
• Find your entry point. Build from there.
• Make sure you have enough resources to build
the capacities you are seeking to foster

Thank You!
More information at www.bemindful.com.au
Email me: cam@bemindful.com.au

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