Mindfulness (2014) 5:742–755

DOI 10.1007/s12671-013-0231-9

ORIGINAL PAPER

A Proposed Protocol Integrating Classical Mindfulness

with Prolonged Exposure Therapy to Treat Posttraumatic
Stress Disorder
Lobsang Rapgay & Jae L. Ross & Owen Petersen &
Christine Izquierdo & Monique Harms & Sandra Hawa &
Sarah Riehl & Amanda Gurganus & Greta Couper

Published online: 2 July 2013

# Springer Science+Business Media New York 2013

Abstract Mindfulness is a strategy that has become increasing- though, classical mindfulness has yet to be empirically investi-
ly considered as a potential treatment for posttraumatic stress gated or supported.
disorder (PTSD). The aim of this study was to review and
synthesize extant research on mindfulness, current mindfulness- Keywords Classical mindfulness . Exposure therapy .
based interventions, and evidence-based treatments for PTSD. A Posttraumatic stress disorder
theoretical foundation for classical mindfulness and a preliminary
protocol integrating classical mindfulness and prolonged expo-
sure for the treatment of PTSD was introduced. We conducted a Introduction
systematic search of relevant databases according to predefined
criteria. Studies were eligible for inclusion if they sought to Posttraumatic stress disorder (PTSD) is an anxiety disorder
define mindfulness, employed mindfulness-based interventions characterized by the development of an array of symptoms
for PTSD, or included evidence-based treatments for PTSD. following exposure and sometimes continued re-exposure to a
Original Buddhist texts and resources were used to develop, significantly traumatic event (American Psychological Asso-
support, and differentiate classical mindfulness from existing ciation 2000). Up to 60 % of Americans will experience at least
mindfulness-based interventions for PTSD. We identified a one traumatic event in their lifetime (Foa et al. 2007). Studies
non-sufficient and inconclusive operationalization of the concept demonstrate a lifetime prevalence rate of 8 % in the adult US
of mindfulness. Furthermore, there is limited research on the population and highest rates (ranging from one third to more
application of mindfulness for PTSD, and the few existing than half of those exposed) are found among survivors of rape,
studies have demonstrated mixed results. The proposed integra- military combat and captivity, and ethnically or politically
tion of classical mindfulness with prolonged exposure appears to motivated internment and genocide (American Psychological
address specific limitations to current interventions for PTSD. A Association 2000).
definition for classical mindfulness was drawn from the classic Because mindfulness has been shown to be a promising
Buddhist teachings. The mastery and application of the compo- adjunct and treatment for a number of psychiatric and psychoso-
nents of classical mindfulness provide a potentially more effec- matic disorders, there are attempts made to study whether it is
tive way to use mindfulness for the treatment of PTSD. Al- effective for PTSD. According to current definitions, mindful-
ness is the process of being fully present with each moment of
one’s experiences in an accepting and non-judgmental manner
L. Rapgay (*)
Department of Psychiatry and Biobehavioral Sciences,
(Kabat-Zinn et al. 1992). However, currently employed versions
University of California Los Angeles, 300 Medical Plaza, of mindfulness have been modified significantly from classical
Suite 2331, Los Angeles, CA 90095-6968, USA mindfulness (CM), which is the ancient form of the practice as
e-mail: [email protected] articulated in original Buddhist teachings, most notably the Four
J. L. Ross : O. Petersen : C. Izquierdo : M. Harms : S. Hawa :
Foundations of Mindfulness (Satipatthana-sutta). This CM prac-
S. Riehl : A. Gurganus : G. Couper tice entails the sequential acquisition of mindfulness of bodily
Alliant International University, Alhambra, Los Angeles, CA, USA sensations, feelings, thoughts, and mental objects (Analayo
Mindfulness (2014) 5:742–755 743

2006). CM involves the acquisition of refined perceptual and 2011). One meta-analytic review of outcome PTSD literature
cognitive skills, such as concurrent focal and broadening the found that treatment dropout rates for PE and CPT range from
breadth of attention to know internal and external experiences 0 to 50 % among various population samples (Schottenbauer
objectively so that maladaptive thoughts, feelings, and behaviors et al. 2008).
can give way to more adaptive ones (Rapgay and Bystrisky Although extant literature has predominantly explored sta-
2009). tistically significant findings that indicate a response to treat-
Researchers generally agree that current treatments for PTSD, ment (e.g., reduction in symptom criterion), it becomes relevant
though effective, face limitations, such as high dropout rates, to differentiate between statistical (i.e., numeric improvements
treatment resistance, and symptom persistence long after com- on a measure) and clinical significance (i.e., meaningful change
pletion of treatment. Mindfulness is a strategy that has become in an individual’s life), in that the latter has yet to be included as
increasingly considered as a potential alternative treatment for a dominant outcome measure in the traditional evidence-based
PTSD. This paper introduces the theory and practice of the treatments for PTSD (Hayes et al.1999). Thus, considering the
original Buddhist form of mindfulness, what this paper refers discrepancies and limitations in efficacy and research findings
to as CM, and proposes how clinically integrating this form into examining standard treatments for PTSD, there has more re-
prolonged exposure therapy, a well supported clinical interven- cently been considerable emphasis placed on incorporating
tion for PTSD, may increase the effectiveness of treating anxiety integrative and alternative health care interventions to existing
disorders. In an effort to further define and refine mindfulness evidence-based treatment protocols.
skills and specific clinical utility, this paper will focus solely on
PTSD treatment intervention in an attempt to introduce a tailored
protocol for a specific clinical presentation. Definition of Mindfulness

The concept of mindfulness has its roots in Eastern introspec-

Current PTSD Treatments tive psychological practices, specifically Buddhist psychology,
over 2,500 years ago (Black 2011). Mindfulness is first found in
Current evidenced-based treatments for PTSD include cogni- the Buddhist writing Satipatthana-sutta in a summary about
tive processing therapy (CPT), prolonged exposure (PE), stress meditation (Analayo 2006). The term “mindfulness” stems
inoculation therapy, rapid eye movement desensitization and from the Pali word sati, which translated means possessing
reprocessing, virtual reality, and cognitive therapy and selective awareness, attention, and remembering (Bodhi 2000). Western
serotonin reuptake inhibitors, sertraline (Zoloft), and paroxetine science has empirically studied mindfulness for approximately
(Paxil) (Karlin et al. 2010; VA/DoD 2010). 40 years and the definition has been continually revised (Black
Studies examining the effectiveness of trauma-focused and 2011). The most recognized Western definition of mindfulness
psychotropic interventions used with mixed PTSD samples have comes from Dr. Jon Kabat-Zinn, a central founder of mindful-
demonstrated a variety of significant posttreatment outcomes ness research. He defined mindfulness as purposely paying
(Chard 2005; Ehlers et al. 2003; Foa et al. 1999; IOM 2008; attention in the present moment and without judgment
McLay et al. 2011; Ponniah and Hollon 2009; Tarrier et al. 1999; (Kabat-Zinn 1994). Kabat-Zinn went on to note, “This kind
Van Der Kolk et al. 2007; Weiderhold and Weiderhold 2010). of attention nurtures greater awareness, clarity, and acceptance
Research studies and meta-analysis have provided inadequate of present-moment reality” (p. 4). Although mindfulness has
efficacy data in the treatment of PTSD primarily because of been defined and measured in many ways by different re-
methodological limitations, such as limited focus on reduction searchers, there is general agreement regarding the involvement
in symptom criteria, and inconsistency in outcome findings of sustained attention to the present moment; yet, differences
(Friedman et al. 2007; IOM 2008; Stein et al. 2003). exist between the proposed definitions, and an unequivocal
PE studies have demonstrated between 47 % (Schnurr et al. operational definition of the construct of mindfulness has not
2007) and 60 % efficacy (Rauch et al. 2009; Tuerk et al. 2011). been reached (Chiesa and Malinowski 2011).
In a meta-analytic review by Bradley et al. (2005), non-
response rates to PTSD treatments were shown to be as high
as 67 % for PE intervention. Also, several study reviews Classical Mindfulness
highlighted that many trauma-exposed victims could not en-
gage in exposure-based therapies that involve repeated con- To address the various definitions and current inconsistencies in
frontations of the traumatic situation causing high levels of understanding mindfulness, this paper explores the original
anxiety, due to a lack of adequate required coping skills needed constructs of mindfulness as a foundation for developing an
to benefit from these treatment modalities (Foa et al. 2007; operational definition. The Four Foundations of Mindfulness
Follette and Vijay 2009; Owens et al. 2012; Resick et al.2002; entails the sequential acquisition of mindfulness of bodily
Sharpless and Barber 2011; Tuerk et al. 2011; Vujanovic et al. sensations, feelings, thoughts, and mental objects (Thera
744 Mindfulness (2014) 5:742–755

1998). The original Buddhist teaching of The Four Foun- which can be applied therapeutically to change maladaptive
dations of Mindfulness has been adapted for clinical appli- thoughts, feelings, and behaviors into adaptive ones (see Fig. 1
cation (Satipathana-Sutra) and integrated the practice of for a brief overview of the processes and their therapeutic
samatha (concentration), with vipassana (insight) (Thanissaro effects).
1995). This paper references Bikkhu Analayo, a prominent The first process is awareness training: the ability to maintain
scholar/practitioner in the ancient texts of Buddhism because a sense of the self-observing the focal object/task. With practice,
his version is most consistent with scientific findings about this process becomes a metacognitive skill to observe one’s
sustained attention and distributed attention in Western cog- own experience (thoughts, feelings, and sensations). The
nitive sciences as compared to existing alternate versions metacognitive skill is applied therapeutically to facilitate sub-
(Analayo 2006). ject–object differentiation, a perceptual and cognitive function
This paper defines CM as the practice and process of gaining critical to processing external and internal threatening informa-
selectively sustained and distributed attention skills. Sustained tion effectively (Fox and Riconscente 2008). People with se-
attention is the cognitive capacity to maintain focus on an object vere anxiety disorders, such as PTSD, tend to identify the
or everyday task (Seli et al. 2012). Distributed attention is the experiences of anxiety with the self in an undifferentiated state
cognitive capacity to expand the breadth of attention to access and therefore cannot effectively observe and process their
and process peripheral information (Rowe et al. 2007). The thoughts and feelings (Hart et al. 2008).
process of CM involves training in sustained attention skills to Re-experiencing, a primarily sensory reliving of the trauma
know maladaptive sensations, thoughts, feelings, and behaviors in the present moment, is a symptom in which the individual
to such degree that attentional resources currently invested in cannot differentiate between the self and his or her sensory
them may become available for processing peripheral informa- experiences (Ehlers et al. 2004). Awareness training is a po-
tion, also defined as distributing attention. These two main tential strategy to help anxious individuals to differentiate
constructs of CM can facilitate experiential insights into triggers between the self as observer and the sensations as the observed
and links among the focal and peripheral information as a (Garland and Gaylord 2009).
means of developing adaptive thoughts in lieu of maladaptive Mastery of awareness leads to the next process: selective
sensations, thoughts, and feelings (Thera 1998). sustained attention. This is the process of selecting one stimulus
Central to the practice of CM is utilizing sustained and from many and focusing on it for prolonged periods of time.
distributed attention to increasingly know a focal task/object Sustained attention in CM is an engaged, perceptual and cog-
and allocating freed attentional resources for accessing and nitive activity with the objective to observe many details of the
processing peripheral information. These mechanisms of CM object and memorize them for future recall (Lamrimpa 2011).
are consistent with attentional load theory in cognitive psy- Knowing an object through such focused observation facilitates
chology and neuroscience. Attentional load theory is a robust habituation to threatening objects and consequently serves as a
finding in the study of attention (Lavie et al. 2004). The theory form of exposure strategy. Repeated exposure via selective
shows that when a complex central/focal task or object is sustained attention may help to discredit and disconfirm the
mastered, meaning it is known so well that it becomes second projected threatening meaning ascribed to the trigger of anxiety
nature to the individual, the attentional resources once highly (Vujanovic et al. 2009).
invested in it are then released and made available for periph-
eral contextual information (Lavie et al. 2004). Analayo (2011)
described the process of body mindfulness as the incremental
decrease in effortful attention on the abdominal breathing, thus The six processes, mental skills, and therapeutic effects
freeing attentional resources that can be distributed toward 1. Sensory Awareness Metacognitive skills Subject Object differentiation
processing peripheral bodily sensations (Analayo 2011). More
2. Sustained Attention knowing details through exposure habituation and
importantly, this practice of concentration (samatha) verifies
that once one achieves sustained attention on the object, the tolerance inhibition of non-relevant information attentional control

object no longer requires the same amount of mental effort and 3. Non-controlling, non-judgmental approach unbiased state non-resistance to
attention to engage with it (Lutz et al. 2008). all types of pleasant and unpleasant experiences
To acquire sustained and distributed attention, one must first
4. Processing Hindrances = overcoming resistances = overcoming avoidance behavior
master six major perceptual and cognitive processes associated
with sustained attention (sensory awareness, sustained atten- 5. Processing conflicts in learning = overcoming processing conflicts = increase

tion, non-controlling/non-judgmental approach, processing proficiency

hindrances, processing conflicts in learning, monitoring), and 6. Monitoring = increase prioritizing, controlling and executing = increase executive
two associated with distributed attention (mental flexibility and
functioning
peripheral processing) (Rapgay and Bystrisky 2009). Training
in these processes over time leads to acquiring mental skills, Fig. 1 The six processes, mental skills, and therapeutic effects
Mindfulness (2014) 5:742–755 745

One way in which sustained attention facilitates prolonged a major problem that requires addressing them systematically
exposure is by helping individuals develop and enhance their when detected (Rueda et al. 2005). Without resolution, these
attentional control or the ability to inhibit interference from conflicts can remain as major obstacles to progress in training
distracters and habitual response patterns. The more effective (Rapgay and Bystrisky 2009).
an anxious individual is in utilizing attentional control, the Equally important is the process of periodic monitoring dur-
more likely he or she will be able to sustain attention on the ing mindfulness training. Periodically monitoring an individual’s
object of mindfulness (Thera 1998). Research has shown that level of performance, which subtasks are performed easily and
subjects with high anxiety who have good attentional control which present a challenge, is critical to enhance an efficient
are better able to manage their responses to threatening stimuli learning of sustained attention. Monitoring facilitates executive
as compared to those with poor attentional control (Eysenck functions of prioritizing, controlling, and executing perceptual
et al. 2007). and cognitive tasks (Korenblum et al.2007). Due to limited
Engaging in a non-judgmental and non-controlling way attentional resources, one key to successful training is wise and
enhances the therapeutic effects of training in awareness and efficient management of resources. Periodically monitoring is
sustained attention. Maintaining awareness in this manner in- critical to employing one of mindfulness’ central functions of
volves not evaluating and judging past-, present-, and future- developing experiential insights into maladaptive thoughts, feel-
related thoughts and feelings and at the same time avoiding ings, and behavior (Bodhi 2011).
active suppression of unwanted thoughts and feelings that arise
to consciousness (Thera 1998). The process also includes
avoidance of making conscious efforts to invite or actively Broadening and Distributing Attention
show curiosity about thoughts and feelings. For instance, if a
judgmental thought arises, one does not evaluate it or try to Mastering mindfulness of the focal object frees attentional re-
inhibit it from the experience. By allowing thoughts to arise sources that can be distributed to access and process the pe-
without judgment and control, particularly those normally ripheral environment (Analayo 2011). When one anchors part
inhibited, one is effectively learning to deter habitual reactive of their attention on a task such as even abdominal breathing
processes. This is critically important to the effective manage- cycles and distributes the remaining attention to the rest of the
ment of anxiety induced by habitual reactions (Behar et al. body, a sense of expansion and movement is created (Analayo
2009). 2011). This process of creating a sense of internal expansion
Managing distractions and hindrances that arise during at- and movement is critical for facilitating mental flexibility: the
tempts to master the other processes is vital to mindfulness ability to respond mentally to challenges in adaptive ways. A
practice. Distractions are casual external or internal stimuli that sense of expansion and movement is vital to combat the narrow
suddenly arise outside one’s control. Identifying, labeling, and and rigid state of mind activated by anxiety, which inhibits the
relinquishing them process such stimuli. On the other hand, individual’s ability to access and process peripheral contextual
hindrances are resistances consciously or unconsciously acti- information (Gable and Harmon-Jones 2012).
vated to avoid the practice of mindfulness (Bodhi 2000). For Familiarity with anchoring and distributing of attention tech-
instance, a common response of many individuals initially niques allows an individual to become more sensitive to
training in mindfulness is, “it is too difficult.” This response distressing bodily sensations. This facilitates an individual’s se-
can be an example of the resistance to engaging in the practice lection of the more distressing sensations and allocation of some
of mindfulness. Anxious individuals commonly engage in such attention towards them in a non-judgmental and non-controlling
resistance strategies (conscious and unconscious) when en- way. When he or she can do so effectively, the joint effect of the
countering a challenging task in their lives and most often tend innate relaxation generated by the even abdominal breathing
to use the same pretext as a way to avoid the stress of learning cycles and peripheral processing of the primary distressing bodily
something demanding, difficult, or triggering (Rapgay and sensation reinforce each other to reduce the intensity of the
Bystrisky 2009). Hindrances that arise while engaging in mind- sensations naturally (Analayo 2011). When achieved, the same
fulness practice must be identified and addressed using standard process is applied to anxiety-related thoughts and feelings that
psychotherapeutic processing approaches, like psychodynamic maintain the primary bodily sensations.
or cognitive behavioral therapy, in order to successfully proceed
in mindfulness training.
The success of acquiring proficiency in sustained and dis- Classical Mindfulness Training to Acquire Sustained
tributed attention depends on mastery of a number of secondary Attention
processes. Sustained and distributed attention training involves
multiple perceptual and cognitive subtasks. Many of these sub- Acquiring skills in sustained and distributed attention is
tasks are conducted simultaneously or back-to-back, innately achieved through formal training sessions in an 8-week pro-
causing conflicts in balancing them. Processing such conflicts is tocol of six daily sessions of approximately 25 min. Because
746 Mindfulness (2014) 5:742–755

acquisition of the skills is dependent on regular and formal While these exercises seek to create the basis for sustained
training, individuals need to be ready and willing to undergo attention, they also serve the function of training the anxious
this kind of training for optimal benefit. Acquiring mastery individual in bodily sensory awareness. This serves as a
and efficiency in each of the four modules is necessary before means to acquire metacognitive skills and subject–object
proceeding to the next because the modules build upon one differentiation or the ability to be aware of one’s own sensa-
another (Rapgay and Bystrisky 2009). tions, thoughts, and feelings objectively. This is a necessary
Training in sustained and distributed attention is challenging. clinical function to manage severe anxiety (Vakili and Fada
Research in sustained attention shows that mental fatigue sets in 2006).
rapidly after the initial activation (Mackworth 1968). In tradi- When one can successfully accomplish the above task, the
tional Buddhist meditative traditions, mental fatigue is a major next training is in broadening and distributing the remaining
concern, and emphasis is placed on regulating the employment attentional resources to the rest of the body. Repeatedly
of mental and physical effort as one way to manage mental sustaining attention on the details of the abdominal breathing
fatigue (Wallace 1999). cycle for 3 min or more results in knowing the cycles so well
Module I of the current classical mindfulness training is that one can divest some of the attentional resources from the
designed to help regulate the application of physical and mental activity to the rest of the body without compromising the
effort by mastering the relaxation of the body as a complement integrity of the activity.
to generating a settled, alert state of mind. These are acquired Sustained attention training, or samatha, involves system-
through the practice of five exercises that progressively build atic performance-based tasks. The process facilitates learning
upon one another in the first 2 weeks. The objective is to create and motivation by rewarding one’s self when the specific
a mental and physical state capable of managing the challenges goals of the practice are achieved. Rewards and reinforce-
and demands of sustained attentional training (Mackworth ments of gains achieved create a sense of self-efficacy critical
1968). to the success of sustained attention training (Tomporowski
The first exercise is to master abdominal breathing to the and Tinsely 1996).
point in which one can do it without focused attention. To start,
one directs attention to each rising and falling of the abdomen
continuously from beginning to end of each cycle without any Review of Current Mindfulness-Based Interventions
interruptions from distractions. The objective is to sustain
attention continuously and progressively for increasing num- Currently, there exist several interventions that integrate
bers of abdominal breathing cycles. The goal is to finally mindfulness-based exercises that have been considered for
sustain attention for 3 min or more without any mental in- use with PTSD. Mindfulness-based stress reduction (MBSR)
terruptions (Rapgay et al. 2011). Once this skill is mastered, is a structured group program of mindfulness training devel-
one learns to consciously activate long and short abdominal oped by Kabat-Zinn (1990). MBSR consists of multiple
movements. Then, one learns to induce even, smooth rising forms of mindfulness practice, including formal and infor-
and falling abdominal movements to the point that they can be mal meditation practice as well as hatha yoga (Kabat-Zinn
generated without conscious effort. When generating even 1990). MBSR has been shown to produce moderate to
smooth risings and fallings of the abdomen without conscious marked reductions in anxiety and depression (Kabat-Zinn
effort is mastered, the fourth exercise teaches individuals to et al. 1992; Ramelet al. 2004), two common conditions
employ that ability to expand the abdominal relaxation gradu- comorbid with PTSD (Kessler et al. 1995). Kearney et al.
ally to the rest of the body. (2012) recently conducted an open trial study to assess the
Once able to generate natural relaxation of the tense body acceptability and safety of MBSR techniques for veterans
by employing the even smooth abdominal movements, one with PTSD. The study included 92 combat veterans in treat-
is ready to engage in the final exercise. In this exercise, the ment for PTSD. Participants were grouped together in
individual places and holds attention to the specific area groups consisting of 20–30 participants each and taught
underneath two fingertips placed on the upper abdomen MBSR skills adjunctive to their usual care. Self-report mea-
and attends to each even rising and falling of the abdomen. sures revealed that participants experienced significant im-
Repeated practice of the dual tasks is designed to facilitate provement in mental health, “including measures of PTSD,
the ability to place and hold attention and carry out the task depression, experiential avoidance, and behavioral activa-
with increasing comfort and ease. This skill of placing and tion as well as mental and physical health-related quality of
holding attention is critical for training sustained attention. life,” including an increase in mindfulness skills at a 6-month
Without the ability to hold the object steady, it is difficult to follow-up (Kearney et al. 2012, p. 111). However, the lack of
sustain attention on the object for any period. This is akin to inclusion of a control arm and non-randomized inclusion of
trying to sustain focus on a constantly moving external study participants greatly diminish the validity and subse-
object, compared to one that is static (Wallace 1999). quent conclusions of the study. Symptom improvement
Mindfulness (2014) 5:742–755 747

could be attributed to a variety of confounding factors in unpleasant emotions elicited from processing trauma (Follette
addition to MBSR training such as non-specific effects re- et al. 2006; Vujanovic et al. 2010).
lated to participation in a group or provider interaction.
Despite the limitations, the study suggests that veterans with
PTSD may benefit safely from including mindfulness skill Challenges with the Current Understanding
training as adjunct to their usual clinical care. This study’s of Mindfulness
findings support that future research on MBSR for PTSD is
warranted. Mindfulness is a key component of a number of current
Acceptance and commitment therapy (ACT) seeks to help mindfulness-based interventions for PTSD and other anxiety
clients become more mindful of thoughts, accept private expe- disorders. Unfortunately, in the variety of interventions, a uni-
riences without judgment, develop greater clarity about person- formly accepted and clearly defined operationalization of mind-
al values, and commit to needed behavioral change (Walser and fulness does not exist, making it difficult to determine its active
Westrup 2007). Walser and Westrup (2007) developed an ACT- agent of change (Bishop et al. 2004). Without operationalizing
based intervention for treating PTSD, which includes daily mindfulness, further research is limited to effectiveness studies.
mindfulness exercises to enhance the ACT principles of “ac- Attention has been described as a main function of mind-
ceptance of experience, de-fusion from the literal meaning of fulness, yet it is not clear what type of attention is associated
thought, continuous contact with the present moment, and with the various mindfulness interventions. Because it is well
transcend sense of self” (p. 17). However, clinical outcome data established that attention is a complex, multifaceted system, it
utilizing the ACT protocol are significantly lacking, thus any is important to know what type of attention is being trained
conclusions regarding efficacy and effectiveness are greatly (selective, sustained, divided, distributed, etc.). When such
limited. distinctions are not made, varying measures of attention may
Dialectical behavioral therapy (DBT) is a multifaceted ther- be employed to determine the effect of mindfulness leading to
apy shown to be effective in treating borderline personality varying outcomes.
disorder and related problems successfully (Linehan 1993). While some interventions assign acceptance as a central
DBT is sometimes used to address difficulties with emotion function, original forms of mindfulness do not associate accep-
regulation and distress tolerance prior to the implementation of tance as a feature of mindfulness for a number of reasons. The
PTSD-specific treatments such as exposure therapy (Wagner original forms associate mindfulness with the integrated prac-
and Linehan 2006). DBT incorporates mindfulness training as tice of samatha (concentrative) and vipassana (insight) skills, to
one of four skill-building areas. As reported in Vujanovic et al. know things as they are rather than the habitual way of knowing
(2010), “In DBT, mindfulness involves three ‘what’ skills (ob- them on the basis of how one wishes them to be, or how one
serving, describing, and participating) and three ‘how’ skills thinks they are. Consequently, mindfulness seeks to develop an
(taking a non-judgmental stance, focusing on one thing in the objective, engaged state of mind capable of carrying out this
moment, and being effective)” (para. 12). Although a review of type of learning.
the literature reveals that a randomly controlled trial using DBT As a result of these issues and other factors, there has been a
for PTSD treatment has yet to be conducted. slow but growing interest to revisit the original mindfulness
In mindfulness-based cognitive therapy (MBCT), Segal teachings from the Buddhist texts to increase the understanding
et al. (2004) created an intervention to prevent relapse of of the perceptual and cognitive theory underlying mindfulness.
depressive symptoms. In the intervention, patients are taught The trend can already be observed in the shift from MBSR to a
to mindfully focus on everyday events without avoiding or more traditional vipassana form in mindfulness-based cognitive
suppressing them. Although MBCT has been well studied in therapy, a validated treatment protocol for reducing the recur-
the recurrence of depression, a randomized control trial (RCT) rence of depressive episodes (Teasdale et al. 2000).
involving MBCT and PTSD has yet to be conducted.
A review of the literature reveals there has yet to be an RCT
examination of the clinical use of integrating mindfulness-based Differences Between CM and Alternative Mindfulness-
interventions in existing empirically supported treatments for Based Interventions
PTSD. However, “relevant theoretical and empirical literature
suggests that mindfulness may serve clinically meaningful func- Although there are similarities among existing mindfulness-
tions in alleviating PTSD symptoms” (Vujanovic et al. 2010, based interventions such as ACT, DBT, MBSR, etc., there are
para. 2). Combining mindfulness with existing empirically sup- significant differences between these alternative approaches
ported PTSD treatments may strengthen emotion regulation and and CM. Broadly speaking, alternative approaches to mind-
improve treatment dropout rates by helping clients become more fulness train individuals to watch, observe, and maintain a
engaged with a therapist or treatment process. Additionally, somewhat detached state from negative catastrophic thoughts,
mindfulness interventions can prepare clients to better tolerate feelings, and bodily sensations (Teasdale et al. 2000). In CM,
748 Mindfulness (2014) 5:742–755

individuals are initially taught to develop a mental distance functions of object (e.g., thoughts) or strategies to overcome
between themselves as an observer and their experiences. The maladaptive judgments and control (Teasdale et al. 2000).
objective is to help the individual develop subject–object The underlying assumption according to the proponents of
differentiation between themselves and their cognitive and this approach is that by instructing an anxious individual to
emotional experiences. Once the individual acquires the abil- proactively inhibit negative, thoughts, and feelings, he or she
ity to differentiate, he or she is trained to directly experience will be able to distance him or herself from becoming
anxiety-related bodily sensations, thoughts, and feelings by ensnarled negativity (Teasdale et al. 2000). Such an approach
inhibiting habitual tendencies to elaborate, describe, and give is not new in psychotherapy. Anxious individuals, to avoid
meaning (Sayadaw 2010). According to CM, detaching from experiencing the anxiety and distress caused by their fears,
direct experience in order to watch anxiety-related sensations, have long used reassurance and safety thoughts. Further-
thoughts, and feelings is a form of avoidance since detach- more, it is well known that such approaches provide transient
ment gets in the way of direct experience. Furthermore, pro- relief and continue to do so as long as the individual buys
cessing thoughts, feelings, and sensations, as is encouraged in into the process (Leahy 2003). However, clinical literature
alternative approaches, has been shown to interfere with the shows that in reality, anxious individuals believe that nega-
exposure process during exposure therapies and actually tive thoughts are real and factual and need to be avoided in
serves as avoidance (Barlow 1993). In contrast, CM strives the first place. The belief is rooted in schemas that are deep
to inhibit processing of such thoughts and feelings in order to seated, and therefore, it is unlikely safety thoughts such as
directly engage the object of experience (Sayadaw 2010). “negative thoughts are just thoughts and not real” may
More specifically, the two vary in a number of other important change the underlying triggering schema. Consequently,
ways. The first is in terms of the type of training in attentional such thoughts act as negative reinforcers that in the long
control. Alternative interventions focus on repeated attentional run increase the fear (Leahy 2003).
switching (i.e., attend to the breath until a thought, feeling, or In contrast, CM regards any preconception or value such as
sensations enters awareness, at which time the individual is acts of acceptance as barriers to experiencing sensations,
encouraged to become curious about these experiences). On the thoughts, or feelings as they exist—such preconditions shape
other hand, CM focuses on maintaining singular sustained atten- and color the real experience (Rapgay and Bystrisky 2009). In
tion on an individual, selected object. Because the goal of CM, the individual is trained to know through direct experi-
sustained attention in CM is to know the object completely, ence how negative and positive thoughts and feelings produce
attention is manipulated to retain the integrated object in memory negativistic or positive behavior that leads to more pain and
for later retrieval. Consequently, any other object or experience suffering or more internal calm and adaptive behavior, respec-
that is non-relevant and distracts from the process of knowing is tively. Maladaptive judgmental thoughts and control are re-
immediately inhibited (Lamrimpa 1992). placed with more adaptive judgments and control abilities in
Alternative approaches encourage exploring and discovering order to manage one’s anxiety (Rapgay and Bystrisky 2009).
thoughts and feelings that arise during focusing on the breathing Training in broadening of attention to increase mental flex-
(Kabat-Zinn 1990). Encouraging switching of attention in this ibility is another factor in which CM and alternative approaches
manner disrupts continuous sustained attention on the selected differ. In CM, one of the main objectives of training sustained
object by focusing on processing rather than experiencing the attention is the development of broadening of attention
object. In CM, sustained attention shifts from detection and (Analayo 2006). Sustained attention is employed to know the
categorical discrimination to knowing the specific details of the object so well that it can be accurately reproduced in memory
selected sensation, feeling, or thought. Such detailed knowledge even when the object is not within perceptual access. The
of an anxiety-related sensation, feeling, or thought allows for invested attention and mental effort can now be divested and
more immediate recognition of such a feeling as it arises as well distributed toward concurrent processing of peripheral informa-
as the personal consequences of the thought, feeling, or sensa- tion. Broadening of attention facilitates decreasing mental ri-
tion. Consequently, motivation to direct oneself to process the gidity associated with anxiety. Mental flexibility facilitates
triggers and maintaining factors of the experience in order to find alternative ways of processing anxiety-related thoughts and
a more adaptive approach is enhanced. feelings and derives broader and more global insights (Gable
Another important difference between the two approaches and Harmon-Jones 2012).
is the explicit emphasis alternative approaches place on We have presented a broad overview of a few of the impor-
acceptance of experience (accepting whatever enters aware- tant differences between CM and alternative approaches in an
ness without control or judgment) (Baer 2006). This ap- effort to differentiate consequent clinical implications of inte-
proach encourages individuals to view thoughts as simply grating CM with an empirically supported exposure interven-
thoughts and not facts and trains in the ability to dismiss tion such as prolonged exposure therapy. Additional subtle
experiences once they enter one’s awareness without any differences exist, but further detailed discussion and exploration
subsequent training in understanding the features or of such differences are beyond the scope of this paper.
Mindfulness (2014) 5:742–755 749

Prolonged Exposure Therapy session is dedicated to discussing continued application of

techniques learned in treatment, relapse prevention, and treat-
Of the current empirically supported treatments for PTSD, Foa’s ment termination (Foa et al. 2007).
(2007) prolonged exposure therapy appears most appropriate to
benefit from integrating CM. Prolonged exposure therapy is a
cognitive–behavioral program used to treat adults with previous Integrating Classical Mindfulness with Prolonged
experiences of trauma that have as a result suffered PTSD. Exposure Therapy
Through cognitive restructuring, and in vivo and imaginal expo-
sures, PE helps an individual to confront anxiety-evoking situa- Currently, the consensus is that mindfulness is a complementary
tions to minimize or eliminate excessive anxiety (Foa et al. adjunct to various standard treatments of psychiatric disorders
2007). (Segal et al. 2004). Consistent with this viewpoint, we present an
The treatment program consists of 10–15 weekly or twice- integrated protocol combining CM with PE therapy, with the
weekly treatment sessions typically lasting 90 min each. During effort to ensure that inclusion of CM is not used to duplicate,
session 1, the therapist presents an overview of the program (25– replace, or contradict any clinical functions addressed effectively
30 min), discusses the treatment procedures that will be used in by PE (see Fig. 2 for a brief summary of the protocol).
the program, explains that the focus of PE is on PTSD symp- As noted, PE (Foa et al. 2007) involves imaginal and in vivo
toms, collects information relevant to the trauma using the Trau- exposure to the trauma via multiple narratives of the primary
ma Interview (45 min), introduces breathing retraining (10– trauma event in an effort to identify the most distressing reactions
15 min), and assigns homework (5 min). Session 2 gives clients and resistances and process and restructure those reactions and
the opportunity to provide a detailed narrative about their re-
actions to the trauma and how it influences them. The structure of Phase I: 1. Psycho-education
the session is as follows: review homework (5–10 min), present Sessions 1-2
2. Training in the 5 preliminary exercises of CM
agenda for session (3 min), educate client about PTSD symptoms
3. Multiple Narratives of the Primary Trauma
by discussing common reactions to trauma (25–30 min), discuss Episode to reduce anxiety and identify the hot
the rationale for exposure with emphasis on in vivo (real-time spots
direct experience) (10 min), and introduce the Subjective Unit of Phase II-Part A: 1. Treating cluster symptoms of re-experiencing,
Distress Scale, a hierarchical rating scale of subjective experience Sessions 3-4 hyper-sensitivity, numbness, and
of distress (5 min). Next, the therapist and client construct an anger/aggression with CM strategies of (a)
subject object differentiation (b) inhibition of
in vivo hierarchy, a prioritizing of anxiety-provoking situations
habitual negativistic responses, and tolerance
unique to each client (20 min), and then select in vivo assign- of threat via exposure
ments for homework (15 min). Session 3 begins with homework 2. In vivo Exposure
review (10–15 min) followed by presentation of the rationale for
Phase II-Part B: 1. Treating Hotspots/Resistances such as
imaginal exposure or assisting the client in visualizing and Sessions 5-8 catastrophic, negativistic thoughts, severe
recounting the traumatic events (10–15 min). Following this anxiety, and avoidance behavior with (a)
explanation, the therapist conducts imaginal exposure (45– Socratic Questioning (b) Evidence for and
against, and (c) Behavioral Experimentation
60 min), processes with the client (15–20 min), and assigns
new homework (5 min) (Foa et al. 2007). 2. Treating Hotspots/Resistance with (a) Placing
and Holding attention on the image associated
Intermediate sessions (4–9 or more) consist of homework
with the trigger of trauma (b) Processing
review, followed by up to 45 min of imaginal exposure, 15– resistances to holding attention on the
20 min of post-exposure processing of thoughts and feelings, triggering image (c) Integrating the adaptive
thoughts and feelings into the text of the
and approximately 15 min of in-depth discussion of in vivo
narrative (d) Repeated reading the modified
homework assignments. As treatment progresses, the client is narrative (e) Process hotspots and resistances
encouraged to describe the trauma in great detail during the as described above (f) Develop habituation to
the triggering image (g) Conscious relaxation
imaginal revisiting and focus on the most distressing aspects of
of mental effort and attention from the
the trauma experience or memory “hot spots.” In later sessions, triggering image and distributing much of it
imaginal exposure becomes shorter (about 30 min) as the client towards the rest of the body to process bottom
improves (Foa et al. 2007). up distressing bodily sensations, anxiety
producing thoughts and feelings.
The final session includes homework review, 20–30 min of
imaginal exposure, discussion of the exposure, with emphasis Phase III: 1. Integrating adaptive thoughts, and feelings
Sessions 9-12 into the entire text of the narrative reading it
on how the experience has changed over the course of treat- several times
ment, and a detailed review of the client’s progress. It is
2. Relapse Prevention
imperative in this final session to integrate the processed infor-
mation back into their personal narrative. The final part of the Fig. 2 Summary of the protocol
750 Mindfulness (2014) 5:742–755

resistances into adaptive thoughts, feelings, and behaviors into works, and what is required of them. Individuals will also train in
the relevant part of the narrative. Multiple narrations of the the five exercises of the preliminary practices of CM (see details
trauma help to reduce anxiety, reduce avoidance behavior, and of the exercises above) and narrate the primary trauma episode
recall and link fragmented memories about the trauma (Foa et al. several times in the sessions. During the multiple narratives of the
2007). primary trauma episode, the therapist focuses on identifying hot
CM on the other hand has two major therapeutic functions spots or resistances that the individual exhibits during the narra-
that are not directly provided by PE: first to directly treat tive in order to form a hierarchical list of these resistances (Foa
attention, memory, and other cognitive impairments associated et al. 2007).
with trauma and second to develop tolerance toward the nega- Before addressing hot spots, the therapist needs to focus on
tivistic and threatening experiences via prolonged and repeated treating the severe cluster of symptoms associated with trauma:
exposure (Treanor 2011). Generally, when PE is applied as a (a) re-experiencing, (b) hypersensitivity, vigilance, and arousal,
stand-alone treatment, a variety of CBT strategies are used to (c) withdrawal and numbing, and (d) affective problems such
process resistances (Foa et al. 2007). However, we recommend as anger and aggression (Ehlers et al. 2004; Hart et al. 2008).
complementing CBT strategies with CM so that attentional and Without regulation, the severity and debilitating effects of
memory impairments can be directly targeted for better treat- these symptoms can prevent the individual from processing
ment outcome. cognitive impairments, maladaptive thoughts, feelings, and
Numerous studies show major attentional, memory, and other behaviors that maintain the trauma-related symptoms.
cognitive impairments associated with PTSD (Hart et al. 2008). CM strategies can be learned and employed directly to
Research supports the neuropsychological evidence about mem- address these symptoms. First, the skills of sensory awareness
ory deficits in this disorder with the finding that many PTSD of bodily sensations acquired during the first 2 weeks are
individuals have a smaller sized hippocampus, the part of the employed to deal with the most prominent cluster of symptoms:
brain associated with memory (Jatzko et al. 2006). Research also re-experiencing. The patient learns to use sensory awareness to
shows that PTSD individuals demonstrate an attentional bias develop subject–object differentiation, i.e., that he or she senses
toward trauma-related stimuli compared to control groups the sensory experiences as separate from himself or herself
(Pineles et al. 2009). Studies reveal individuals with PTSD (Wells and Sembi 2004). The individual can then reduce
exhibit significant difficulty with executive functioning in prior- over-identification with the bodily sensations during the re-
itizing, controlling, and executing cognitive and perceptual tasks experiencing of trauma.
(Aupperle et al. 2011). After the individual de-identifies with the sensations, the
While PE may indirectly reduce the related cognitive impair- individual is then encouraged to sustain attention in a non-
ments in attention and memory, it has been shown that strategies judgmental, non-controlling way on a specific distressing
that directly target attentional and memory problems associated sensation from among the hierarchy. The individual main-
with anxiety and attentional disorders reduce correlated symp- tains the bodily relaxation triggered automatically by the
toms (Amir et al. 2010). CM could enhance the treatment of even, smooth, and comfortable risings/fallings of the abdo-
PTSD because it directly trains sustained attention and facilitates men without conscious effort (see details above). Sustained
memory function. attention is designed to inhibit distracters and habitual re-
Rationale for employing CM as a secondary exposure inter- sponse patterns in order to facilitate prolonged exposure to
vention is twofold. The first is to reduce resistance to PE-based the hierarchy of distressing sensations (Treanor 2011).
exposure that many individuals experience, and often results in a Prolonged exposure is employed to know the details of the
high dropout rate, by developing a foundation of metacognitive sensations as a means to acquire tolerance of the distracters
skills that will assist in coping with distressing experiences that produce anxiety.
triggered by subsequent exposure techniques (e.g., bodily sensa- Both sensory awareness and sustained attention are carried
tions). Second, CM exposure seeks to develop tolerance for the out in a non-judgmental and non-controlling way to prevent
perceived threat in trauma rather than aiming to extinguish fear, reactive habitual responses. However, to engage in awareness
as in the case of PE. Developing tolerance is more manageable and attention in a non-judgmental and non-controlling way, it is
for individuals because it produces less anxiety and distress important to resolve any processing conflicts that arise. Aware-
(Zvolensky et al. 2011). ness and sustained attention are higher cognitive processes that
involve a number of perceptual and cognitive subtasks that need
to be coordinated (Rueda et al. 2005). Clinical populations
Phase I of the 12-Week Integrated CM-PE Treatment generally encounter difficulty coordinating these subtasks and it
Protocol: Sessions 1 to 2 is critical that when coordinating problems arise they are
addressed immediately. For instance, many individuals with
In the first two sessions, individuals are provided psycho- PTSD may have difficulty in coordinating the tasks of sustaining
education about the main symptoms of PTSD, how the treatment attention while generating automatic even abdominal breathing
Mindfulness (2014) 5:742–755 751

cycles, and without resolution, further training will be severely be thoughts and feelings triggered by the image. The objective of
compromised. sustaining attention on a new realization, such as an adaptive
Periodical monitoring of one’s performance is an integral thought, is to integrate it into the mental continuum through
part of CM training. This monitoring ensures rapid and knowing the details of the image and its associated meanings
accurate responses to the chosen tasks, that tasks are (Lamrimpa 2011).
performed as instructed, and effective choices are made Next, the individual incorporates the restructured adaptive
between alternative tasks. Finally, these tasks are employed image and associated thoughts and feelings into the relevant
to achieve the goals of the practice (Korenblum et al. 2007). place in the narrative. The daily reading of the increasingly
modified narrative not only reduces anxiety, but also avoidance
behavior as the individual becomes increasingly habituated to
Phase II: Sessions 3 to 8 recalling greater details of the trauma (Robjant and Fazel
2010). When maladaptive thoughts, feelings, and behaviors
During the second phase, after cluster symptoms have been recur in real time outside the sessions, the individual is
contained to a manageable level, the therapist and individual reminded that these are expected and they, per se, are not the
can proceed to work collaboratively with the primary hot spots. problem; the important thing is how the individual appraises
Generally, resistances will include negativistic, catastrophic and reacts to them.
thoughts, and extreme feelings of anxiety, guilt, and/or shame, After the integration of the adaptive thoughts and feelings into
etc. Avoidance behaviors to monitor include cognitive, affec- the narrative, the individual returns to the original image of the
tive, and behavioral resistances as well as recurrence of any of trigger (e.g., the headlights of the oncoming car) and verbalizes
the cluster symptoms associated with PTSD (Foa et al. 2007). the most feared thoughts, feelings, and impulses associated with
When any of the cluster symptoms recur, the intervention the image. At this point, the individual is assessed for signs of
described in phase I is applied until the symptoms are managed. increased ability to sustain attention on the triggering image by
The first step in treating the primary resistance is to identify identifying evidence of recall of greater details of the image and
the key event or situation that triggers the trauma. The therapist memories compared to the baseline responses. When negativistic
assists the individual in discovering the underlying main image thoughts, affective distress, or avoidant behaviors occur and
associated with the trauma that triggers excessive anxiety and interfere with the sustained attention, the two-step method of
distress. Anxious individuals may report more than one image; processing with CBT, and integrating the restructured, adaptive
therefore, it is critical to spend enough time methodically identi- thought, feeling, or behavior into the narrative, is conducted as
fying the key image. Once the image is identified, such as the many times as needed.
headlights of an oncoming car before impact, the individual is When the individual is able to sustain attention for longer
asked to recall and describe as much detail as he or she can periods on the triggering image and there are signs of habitua-
remember of the image as well as the events before and after the tion, the individual is asked to relax the amount of mental and
event. A copy of the individual’s initial narrative should be attentional resources allocated to the image and learn to con-
documented to serve as a recall baseline of the trauma. sciously expand the breadth of awareness to the rest of the body.
Next, the individual is assisted with holding the image of the
trigger (e.g., headlights) in his or her mind’s eye as long as
possible while periodically verbalizing the main negative and Phase III: Sessions 9–12
catastrophic thoughts, including varying distressful bodily sen-
sations (Treanor 2011). At this point, individuals might react By this phase, the individual has developed tolerance of the
instantly with cluster symptoms. The identified symptoms are threatening image. During sessions 9–12, the therapist helps the
processed with CM strategies as instructed earlier. After success- individual to consciously relax and relinquish the mental effort
ful regulation of cluster symptoms, catastrophic thoughts, ex- and attention applied to the image. The individual learns to
treme anxiety, and/or avoidant behavior may arise in response to distribute attentional resources to awareness of the rest of the
continued exposure (Foa et al. 2007). When the individual re- body while anchoring a part of the attention on the threatening
sponds with catastrophic thoughts such as, “I don’t know how I image.
will survive,” the therapist helps the individual process the An individual’s increased bodily awareness results in greater
maladaptive thought. A set of three CBT interventions, Socratic spatial flexibility. The therapist can then help the individual
questioning, evidence for and against, and behavioral experi- gradually become aware of specific distressing bodily sensations,
ments, are recommended to replace the catastrophic thought with anxiety-producing thoughts, feelings, and impulses. The individ-
a more rational thought. ual can then detect and shift from one stimulus to the next and
Once the catastrophic thought is restructured, sustained label and relinquish them. The objective is to increase orienting
attention is applied to the underlying image representative of attention, discrimination, and labeling while remaining anchored
the adaptive thought, while the individual verbalizes associated on the primary threatening image.
752 Mindfulness (2014) 5:742–755

The individual then identifies the most distressing bodily reduces symptoms and, more specifically, how and what facets
sensation or thought and engages in divided attention between of attention it affects.
the triggering image and the peripheral sensation in a non- In noting this, a need for an accurate operationalization,
judgmental and non-controlling way for extended periods. The including what specific attentional processes are targeted, was
process of maintaining non-judgmental and non-controlling observed. In an attempt to respond, we offer CM, a definition
awareness of the peripheral sensations or images, coupled with drawn from the Buddhist text Satipatthana-sutta, and contend
relaxation of the body by even abdominal breathing cycles, and that it may be complimentary and easily integrated into PE, a
the effects of successfully processing distressing bodily sensa- widely known and effective treatment for PTSD. The
tions and negativistic or catastrophic thoughts will help to reduce Satipatthana-sutta text details a practice that involves the sequen-
the intensity of the peripheral distressing sensations and cata- tial acquisition of mindfulness of bodily sensations, feelings,
strophic thoughts. thoughts, and mental objects (Analayo 2006). CM also aids in
As the distressing symptoms decrease, the individual will the development of refined perceptual and cognitive skills such
become increasingly aware of the changing interaction between as concurrent focal and broadening the breadth of attention in
the triggering image and the sensations, thoughts, and feelings order to know internal and external experiences objectively so
produced by peripheral anxiety (Analayo 2006). When addition- that maladaptive thoughts, feelings, and behaviors can give way
al memories associated with the trigger are recalled, the individ- to more adaptive ones (Rapgay and Bystrisky 2009). These skills
ual will notice increased anxiety-producing sensations, thoughts, can be a complimentary adjunct to PE and remain cost-free,
and feelings. Conversely, if the anxiety-producing sensations, accessible, and easily taught.
thoughts, or feelings increase, the image of the trigger is also More directly, the term mindfulness, derived from the Pali
affected. Changes will be acquired as the individual observes word sati, means “to possess awareness, attention, and remem-
these interactions, experiential insight into moment-to-moment bering” (Bodhi 2000). In CM training, sati is cultivated and
triggers, habitual reactions, and perceptual responses (cognitive, refined in a step-by-step manner, to build and strengthen spe-
affective, and behavioral). The clinically relevant insights are cific attentional faculties. This begins with focus on the breath
then added to the relevant parts of the narrative. followed by integration of other bodily sensations: an intention-
In the final two sessions, the individual reviews and de- al exercise in selective and sustained attention. This practice is
scribes the entire narrative, including the recalled memories, expanded sequentially to include thoughts, emotions, and be-
and adaptive thoughts, feelings, and behaviors at least twice. In havior resulting in increased attentional control and this skill
the very last session, progress in treatment is reviewed, and allows clients to adjust and improve their subjective experience
relapse prevention is practiced. The individual is recommended and better manage their re-experiencing of trauma (e.g., flash-
to return for maintenance sessions every 2 weeks for 3 months backs). Although PTSD was the central focus of the current
and once every month for 3 months thereafter. paper due to the increased limitations among existing PTSD
interventions and the lack of supported mindfulness-based in-
terventions for PTSD, it is important to note the versatility of
Conclusions and Future Directions CM training which is also applicable to other types of anxiety
disorders albeit with appropriate modifications. For instance,
In this paper, we aimed to critically analyze the current state of the central exposure component required in PTSD intervention
research on applying mindfulness to the treatment of PTSD, to would be less prominent for generalized anxiety disorder, but
identify the lack of a sufficient operationalization of the concept, would place greater focus on various levels of distorted cogni-
and, in an attempt to remedy such, offer a definition drawn from tions. Discussion of the various applications and modifications
the classic Buddhist teachings: classical mindfulness. Mindful- of CM for other anxiety disorders is beyond the scope of this
ness is currently employed in a variety of contexts to treat PTSD, current paper, but is encouraged.
but the current research is diluted by a lack of specifics. In Future research directions should also include an empirical
treating PTSD, mindfulness research correlates improvements investigation of the effectiveness of the proposed CM integrated
in attention to improvements in symptoms, but the various and with PE therapy 12-week protocol using a PTSD population
specific types of attention current versions of mindfulness aim to sample initially, as well as PTSD treatment-resistant populations
develop or improve remains muddled. For example, studies of (e.g., dropouts, ineffective results, etc.). The literature may also
the most popular form of mindfulness in psychological practice benefit from comparing the efficacy and effectiveness of the
today, MBSR, are inconclusive in determining what specific type integrated CM-PE protocol for PTSD treatment with studies
of attention is being trained. This also impacts the currently utilizing traditional PE intervention in order to confirm specific
offered operationalized definitions of mindfulness, leaving them areas in which CM may or may not supplement the current PE
unclear as well. The current research remains unresolved as it protocol. Also, future research would benefit from studying the
varies greatly in the types of attention studied and presents with effects of increased, sustained, and distributed attention training
conflicting results. It remains ambiguous how mindfulness (according to CM) to general attention and acceptance training
Mindfulness (2014) 5:742–755 753

(as found in alternative mindfulness interventions such as Chard, K. M. (2005). An evaluation of cognitive processing therapy for
the treatment of posttraumatic stress disorder related to childhood
MBSR) in order to facilitate a more in-depth understanding of
sexual abuse. Journal of Consulting and Clinical Psychology,
the functions and benefits of cultivating specific attentional skills, 73(5), 965–971. doi:10.1037/0022-006X.73.5.965.
as well as determining which attentional processes would be Chiesa, A., & Malinowski, P. (2011). Mindfulness-based approaches: are
most beneficial in the treatment of PTSD symptoms. they all the same? Journal of Clinical Psychology, 67(4), 404–424.
Committee on Treatment of Post-traumatic Stress Disorder Institute of
We admit that this paper serves only as the tip of the
Medicine [IOM]. (2008). Treatment of post-traumatic stress disorder:
iceberg. Although it is helpful to have identified a need and an assessment of the evidence. Washington: National Academies Press.
responded with an appropriate effort, our claims could be Ehlers, A., Clark, D., Hackmann, A., McManus, F., Fennell, M.,
greatly substantiated by empirical data. Now that specific Herbert, C., & Mayou, R. (2003). A randomized controlled trial
of cognitive therapy, a self-help booklet, and repeated assessments
attentional facets have been targeted, research could attempt
as early interventions for posttraumatic stress disorder. Archives of
to solidify the correlates noted before that had previously run General Psychiatry, 60(10), 1024–1032.
the risk of inappropriate generalization. Multiple measures of Ehlers, A., Hackmann, A., & Michael, T. (2004). Intrusive re-experiencing
selective and sustained attention exist and could be utilized to in post-traumatic stress disorder: phenomenology, theory, and thera-
py. Memory, 12, 403–415. doi:10.1080/09658210444000025.
strengthen the argument that gains in these pieces of atten-
Eysenck, M. N., Derakshan, N., Santos, R., & Calvo, M. G. (2007).
tional control can result in an improved subjective experience Anxiety and cognitive performance: attentional control theory.
or decrease in PTSD symptoms. These results would be more Emotion, 7(2), 336–353.
appropriate for generalization as they would rest on a refined Foa, E., Dancu, C., Hembree, E., Jaycox, L., Meadows, E., & Street, G.
(1999). A comparison of exposure therapy, stress inoculation
operationalization of mindfulness that includes a direct indi-
training, and their combination for reducing posttraumatic stress
cation of the attentional processes involved. disorder in female assault victims. Journal of Consulting and
Clinical Psychology, 67(2), 194–200.
Foa, E. B., Hembree, E. A., & Rothbaum, B. O. (2007). Prolonged
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