Chapter Eight – Mindfulness TrainingTreatment-Guide-Chapter-8

This chapter briefly described the mindfulness component of ITCT-A.


As noted earlier, it is an optional module because it requires some specific training and experience on the part of the therapist, and it may not be appropriate for all adolescents, especially those who are chronically overwhelmed or psychologically unstable. On the other hand, mindfulness-based interventions are increasingly applied in clinical settings, and a growing body of research supports the effectiveness of this approach in treating a variety of symptoms and disorders (Chiesa & Serretti, 2011; Hofmann, Sawyer, Witt, & Oh, 2010; Piet & Hougaard, 2011) in children (e.g., Semple & Lee, 2011) and adults (e.g., Kabat-Zinn, 1994). When included in ITCT-A, mindfulness meditation can address a number of the issues commonly seen in traumatized adolescents, including coping with stress, acute or generalized anxiety symptoms, depressive symptoms, and management of strong emotions. Mindfulness training often includes formal meditation practices, but also incorporates an attitude of acceptance toward everyday experiences that can be helpful in coping with the aftermath of trauma.

Mindfulness has been described as “paying attention, in a particular way, on purpose, in the present moment, and intentionally (Kabat-Zinn, 1994, p. 4). Attention is a defining characteristic of mindfulness, generally focused on ongoing awareness of thoughts, emotions, and sensory perceptions. While specific interventions must be adapted to the developmental needs of adolescents in general and the specific needs of traumatized youth, some core tenets that have been established in adult work still apply.

Simple mindful awareness activities – for example, the one described below – can be taught by a therapist with only minimal training, for example, having attended a meditation class and having his or her own meditation practice. When it is possible for the client to undergo more extensive or formal mindfulness training, we (like others) generally recommend that the teacher be fully qualified to teach meditation, usually by virtue of formal teacher training and a daily meditation practice (Crane, Kuyken, Hastings, Rothwell, & Williams, 2010; Segal, Williams, & Teasdale, 2013). As noted elsewhere (Briere & Scott, 2012), we also suggest that the client’s more intensive meditation training be conducted by someone other than the treating clinician, typically in a group format. In this way, the treating clinician does not have to be as highly trained in meditation and can tend to the more pressing clinical issues often presented by traumatized clients (Briere, in press). The two most common group mindfulness training models are Mindfulness-Based Cognitive Therapy (MBCT; Segal, Williams, & Teasdale, 2013) and Mindfulness-Based Stress Reduction (MBSR; Kabat-Zinn, 1994), both of which are frequently offered by established meditation or mindfulness training centers.

As noted earlier, meditation is not appropriate for all clients at all times (Briere, 2012). It may be contraindicated, for example, for adolescents who are currently in unstable environments or experiencing extreme emotional distress. Severe depression or anxiety disrupts concentration and can make it very difficult to maintain attention on breath or body meditations. A minority of adolescents who have been physically or sexually abused may find that focusing on the body can intensify flashbacks or physiological hyperreactivity. Those who are currently abusing alcohol or substances may find it difficult to maintain a consistent practice or experience little benefit from it. For these reasons, the clinician should always conduct a careful evaluation before beginning mindfulness training.

Assuming that there no contraindications, and that the youth has a safe, stable environment within which to practice, the most basic steps of a breath mediation, which can be presented to the adolescent, are as follows (paraphrase as needed):

1. Find a quiet place where you can be alone without interruption for at least 10 minutes or longer. Try to use this same place every time you meditate. If you can, try to do this exercise at the same time every day.

2. Sit in a chair, or on the floor, with your back straight and your hands in your lap. Sit comfortably, with your body balanced on its own weight, not leaning against the chair or the wall. You can lie down, if you wish, but this may make you sleepier, which can make it harder to concentrate.

3. See if you can close your eyes, or at least lower your eyelids. If this makes you anxious, it is fine to leave them open. If you want to keep your eyes open, use a “soft” (unfocused) gaze, with eyes directed downward about 3 feet ahead of you.

4. Focus your attention on your breathing and only on your breathing: feel the air going into your lungs, note the pause between breaths, and then feel the air going out.

5. When your mind wants to think about other things, just remind yourself to go back to your breathing – watching and feeling the breath go in and out. People usually have a hard time just paying attention to their breath. Their mind wanders. That’s okay. It’s just what minds do. Don’t criticize yourself when this happens, just briefly notice that you were thinking, and then go back to watching and feeling yourself breathe in and out. Let your thoughts and feelings come and go. You don’t need to believe they are important, or even true. They are neither good nor bad, right nor wrong – they are just thoughts and feelings that come and go. Notice them, and then return to watching your breath.

6. Try to do this for at least 10 minutes a day, every day, if you can. You can keep a clock or watch next to you to keep track of the time, but try not to look at the time too often. If it has been less than 10 minutes, just go back to paying attention to your breath. Eventually, you may want to spend more than 10 minutes mediating, or to meditate more often. It is up to you.

Although the instruction usually is for the adolescent to practice this exercise at home, it is also helpful for the client to meditate with the clinician in the first 10 minutes of each session, at least for the first few weeks, so that the therapist can monitor the client’s progress and answer relevant questions. Once the youth has learned basic mindfulness skills, he or she can be encouraged to incorporate mindfulness into his or her everyday life in less structured ways as well, for example, by practicing mindful (here-and-now) awareness while brushing his or her teeth, eating meals, listening to music, or walking to school. Learning to refocus attention in this way can function as a basic relaxation technique and may help the youth moderate emotional distress or physiological hyperarousal.


Mindfulness of Thoughts and Emotions

Beyond focusing on the breath, mindfulness also can be of thoughts and feelings. Catastrophic thoughts easily escalate the intensity of emotional reexperiencing. The practice of mindful awareness allows the client to see clearly, without judgment, what is happening in his or her mind in the present moment. Some trauma-related thoughts and emotions are past focused-that is, the adolescent’s attention is focused on the previously experienced traumatic events. Others are future focused, such as anticipatory anxiety and behavioral avoidance of places or people associated with the traumatic experiences. In contrast, mindfulness is the cultivation of present-focused attention. For this reason, the present-centered focus of mindful awareness allows the adolescent to be less caught up in thoughts about the past and worries about the future.

Exercises like the one above therefore involve not only attention to the breath, but also to the mind, teaching the youth to “watch thoughts and feelings go by,” noticing what arises in the mind, but then letting the thoughts or feelings go as he or she returns his or her attention to the breath. As the client gains skill in this domain, the therapist can change the exercise slightly, giving more attention to the idea that as thoughts and feelings come and go, they are “just” events in the mind, not necessarily reflecting truth or reality. It may be helpful to note to the youth that

Thoughts are just what the mind does. It thinks, all the time. Sometimes the thoughts make sense, sometimes they don’t, but all they are, are thoughts. The same goes for feelings, they are just feelings. Thoughts and feelings feel “real,” and they are. They are real thoughts and real feelings. But, sometimes they don’t tell the truth.

Taking a step back from one’s own thoughts in this way can be a liberating experience. Thoughts become merely events in the mind, and not necessarily evidence of any current reality. This reduced identification with internal processes (sometimes referred to as metacognitive awareness) can help the adolescent manage the intensity of strong emotions by identifying thoughts and emotions for what they are – transient, intrapsychic experiences, not necessarily evidence of what is true or real. By practicing looking at thoughts as “just thoughts” – ever changing and often unrelated to what is happening in the present – the adolescent learns that he or she doesn’t need to believe (or react to) everything he or she thinks.

Metacognitive awareness can be reinforced after meditation periods, by having occasional discussions with the client about the idea that cognitions are just thoughts, not facts. We (Briere & Lanktree, 2011) suggest paraphrasing some version of the following:

When you are meditating, it is good to notice when you are thinking. When you meditate, your thoughts kind of come and go, in your mind, right? That’s normal, that’s what your mind does – it makes thoughts. Lots of them. But these thoughts are just thoughts, they come out of nowhere, we think them, and then they go away. Then new thoughts come.

[engage the youth in discussion of his or her own experience]

When you meditate, let those thoughts come and go, and remember that they are just thoughts, not always facts about anything that is real. Sometimes we get into trouble by thinking that our thoughts are true. Sometimes they are, but sometimes they aren’t. Sometimes, these thoughts are things you learned a long time ago that aren’t true. Just let them be thoughts, coming and going. They are just thoughts, memories, things you say to yourself that, lots of times, don’t have much to do with your life right now. Just notice them, and then go back to paying attention to your breath.

In this way, mindfulness becomes, among other things, an aspect of affect regulation: if the client’s emergent or triggered thoughts or feelings are not necessarily accurate perceptions, but rather “just” productions of the mind and history, then they can be less frightening, anger-inducing, or depressing. Similar to trigger work (described in Chapter 11), mindfulness allows the youth to be less reactive in response to internally-experienced, trauma-related material or processes, as he or she comes to see that they are only what they are.