Mindfulness Skills for Trauma and PTSD: Practices for Recovery and Resilience
Turow, R. G. (2017). Mindfulness skills for trauma and PTSD: Practices for recovery and resilience. WW Norton & Company.
Book Review By:
Vivian Khedari, MA
The New School
Simon A. Rego, PsyD, ABPP, A-CBT
Montefiore Medical Center/Albert Einstein College of Medicine
Rachel Goldsmith Turow’s (2017) Mindfulness Skills for Trauma and PTSD is an excellent guide for mental health providers working with trauma survivors. The author presents her own eloquent and well-paced explanations for Posttraumatic Stress Disorder (PTSD) symptomatology and rationale for incorporating mindfulness practice while dexterously integrating sections on scientific research (via “Research Highlight” boxes), patient narratives of their experiences (via “In Their Own Words” sections), and concise instructions of various mindfulness exercises. The result is a pleasantly written and easy to follow resource that goes a long way toward making mindfulness for trauma and PTSD (as well as depression) accessible to any audience.
Goldsmith Turow facilitates the use of mindfulness skills to improve PTSD symptomatology, first by providing an overview of the core concepts of mindfulness (e.g., attention, beginner’s mind, nonjudgment, etc.), the nature and effects of trauma (e.g., types of traumatic events, common challenges after trauma, etc.), and definitions of PTSD and complex PTSD, and then by smartly presenting the reader with stand-alone chapters that provide specific exercises meant to address each of the DSM-5 (APA, 2013) PTSD symptom clusters (i.e., intrusion symptoms, avoidance, negative alterations in cognitions and mood, marked alterations in arousal and reactivity), as well as dissociation and numbing.
Goldsmith Turow typically presents psychoeducational material at the start of each chapter (related to each chapter’s theme), often with both “upsides” and “downsides” to the symptom/approach, and followed by a number of mindfulness practices that can be applied specifically to each post-traumatic symptom. She further divides the exercises between those with the potential to cause immediate relief during a moment of crisis and those that require long-term, sustained practice before resulting in noticeable symptom improvement. This novel approach to organizing the presentation of mindfulness exercises has many advantages. For starters, in line with the clinical understanding that one size does not fit all when it comes to treating PTSD, the way the exercises are organized enables clinicians and clients to pick and choose exercises that are best tailored to their specific and immediate needs. Finally, she emphasizes universal themes, provides a rationale for starting with the “small stuff” and then titrating to painful experiences, and emphasizes practice.
A second advantage of the way the exercises are presented is that in alerting the reader to the exercises’ short term vs. long term effect and their symptom specificity, the author avoids frustrating and discouraging them with the unmet expectation that all mindfulness practices should result in an immediate improvement in any and all symptoms. In fact, the author is refreshingly honest in that she does not present mindfulness as a panacea. To the contrary, from the very beginning she is careful to note the limitations of mindfulness. She even goes as far as pointing out that some experiences are not within the individual’s own capacity to overcome through individual mindfulness, such as experiences of discrimination or a violent environment.
A third advantage of the symptom-specific exercise presentation lies in its ability to address a common critique and resistance to the use of mindfulness for PTSD symptom improvement. While there is a large body of evidence supporting the beneficial effects of mindfulness on PTSD symptom severity (Boyd, Lanius, McKinnon, 2018) there are practitioners who caution against its use in general, and instead encourage practitioners to consider each patient’s specific symptom presentation and characteristics in order to determine if a mindfulness-based approach would be appropriate (Frewen & Lanius, 2015; Follette, Briere, Rozelle et al., 2015). Specifically, they warn that mindfulness-based approaches may increase distress or destabilize clients who are particularly prone to flashbacks, rumination, or easily triggered trauma memories, given that they reduce avoidance of trauma-related thoughts and emotions and may increase exposure to traumatic memories and emotional states, and may also be difficult for patients who have not developed appropriate emotion regulation or distress tolerance skills (Follette, Briere, Rozelle et al, 2015).With her insightful presentation of exercises specific to symptom clusters, the author is able to advance the discussion past these critiques. She offers, for example, the distraction technique of “changing the channel” and the exercise of “remembering with self-compassion” as short-term and long-term strategies to cope with intrusion, respectively. Neither one of these calls for the typical and quintessential mindful practices that encourage meditation and awareness of the body and emotions, instead these exercises address what the individual needs: a way to work through a moment of heightened intrusions.
Goldsmith Turow (2017) both starts and ends her book with a compassionate invitation towards balancing change and acceptance by finding the beauty of a new baseline or new “normal” that comes after trauma recovery. In the opening section she does so by speaking of the “kintsukuroi”, the broken pottery that has been beautifully repaired by filling its cracks with gold or silver. In the ending chapter, she returns to this notion by speaking of posttraumatic growth and resilience through the lenses of both Buddhist mindfulness tradition and Western psychology. Of note, she expertly summarizes the concept of the “four abodes” (loving-kindness, compassion, sympathetic joy, and equanimity), each with “near and far enemies” and explanations of how to cultivate them using mindfulness and compassion practices.
Despite its many virtues, while Mindfulness Skills for Trauma and PTSD is presented as a potential self-help resource, the contents of the text may be used most effectively in conjunction with ongoing counseling. Some of the exercises offered may require more scaffolding and facilitation in order for a reader to engage with them in an effective manner. An example of this would be the author offering the practice of mindfulness during graded exposure in chapter seven (“Forge Ahead Gently: Mindfulness Practices for Avoidance”), wherein she briefly explains to the reader how to complete an exposure hierarchy and tracking of subjective units of distress. This exercise, presented as part of a collection of other mindfulness practices that are much more accessible, may oversimplify the theory, challenges and difficulty of completing exposure-based exercises and create an overly ambitious expectation in the reader that, without support, could result in distress and frustration, and, ultimately, potential disengagement from treatment. This limitation may be particularly applicable to patients with high levels of symptoms, which may impact their concentration and verbal learning. Indeed, there is an overall sense that this book, like most self-help tools, would likely be of most benefit to clients with either sub-threshold or mild-to-moderate PTSD.
Notwithstanding the limitations, this book impresses as accessible and validating, seamlessly integrating scientific literature, first-person accounts of experiences, and special considerations, while also addressing misconceptions and stumbling blocks, and providing step-by-step instructions on dozens of different mindfulness practices. Undoubtedly, this text will be useful to clients. In addition, however, it has the potential of becoming a go-to desk reference for clinicians interested in working with trauma, dissociation, and PTSD and, would be equally useful for clinicians interested in expanding their repertoire of mindfulness skills. Taken together, it has the potential to have a positive impact on the lives of many individuals (if it has not done so already). Goldsmith Turow models a compassionate and practical tone with which to speak to clients about trauma and mindfulness that will be incredibly valuable for practitioners working with trauma survivors.
References:
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5). American Psychiatric Pub.
Boyd, J. E., Lanius, R. A., & McKinnon, M. C. (2018). Mindfulness-based treatments for posttraumatic stress disorder: a review of the treatment literature and neurobiological evidence. Journal of Psychiatry & Neuroscience, 43(1), 7–25. doi: 10.1503/jpn.170021
Follette, V. M., Briere, J., Rozelle, D., Hopper, J. W., & Rome, D. I. (Eds.). (2015). Mindfulness-oriented interventions for trauma: Integrating contemplative practices. Guilford Publications.
Frewen, P., & Lanius, R. (2015). Healing the traumatized self: consciousness, neuroscience, treatment (Norton series on interpersonal neurobiology). WW Norton & Company.
Turow, R. G. (2017). Mindfulness skills for trauma and PTSD: Practices for recovery and resilience. WW Norton & Company.
Vivian Khedari DePierro is a clinical psychology doctoral candidate at The New School for Social Research, currently completing her psychology internship at Montefiore Medical Center. She first trained as a psychologist at Universidad Católica Andres Bello in Caracas, Venezuela. She has extensive clinical experience working in English and Spanish with children and adults and is particularly interested in the treatment of psychological trauma and working with at-risk youth, forcibly displaced people and immigrants. Her research experience includes the study of physiological markers of complex and acute trauma the U.S, South Sudan and South Africa;x and she recently completed the first RCT of The Field Guide for Barefoot Psychologists – a culturally-informed educational guide that balances psychosocial and biological explanations for the mental-health consequences of forced migration and provides a menu of self-care exercises for refugees – in the Zaatari refugee camp, Jordan, as part of her doctoral dissertation. Vivian integrates her research work into her clinical practice, working through a lens that considers clinical theory, psychobiology and the cultural and sociopolitical context.
Simon A. Rego, PsyD, ABPP, A-CBT is Chief Psychologist, Director of Psychology Training, and Director of the CBT Training Program at Montefiore Medical Center and Associate Professor of Psychiatry and Behavioral Sciences at Albert Einstein College
of Medicine. He is a former member of the Board of Directors of both the Association for Behavioral and Cognitive Therapies (ABCT) and the Anxiety and Depression Association of America (ADAA). He has over 35 publications (including 2 books), has given more than 165 professional presentations, and constantly works with the media in order to educate the public about the latest mental health news using a simple, non- sensationalized approach.
