Although several studies have demonstrated the efficacy of prolonged exposure (PE) for the treatment of posttraumatic stress disorder (PTSD), there are concerns regarding its clinical applications. The exacerbation of symptoms during exposure, poor adherence to treatment, and early treatment dropout are suggested to occur because of an unwillingness for some PTSD clients to confront feared trauma-relevant stimuli and experience anxious arousal during exposure. The application of mindfulness and emotion regulation skills during PE may be a useful substitute for clients’ attempts to escape, avoid, or control anxious arousal during treatment. Presented is the clinical case of a 19-year-old college student with severe PTSD resulting from a childhood sexual assault. The article discusses the client’s success with the mindfulness, emotion regulation, and PE approach, in addition to reductions in anxiety sensitivity over the course of treatment, as well as implications for practice and further research.
BaerR. A. (2003). Mindfulness training as a clinical intervention: A conceptual and empirical review. Clinical Psychology: Science and Practice, 10, 125-143. doi:10.1093/clipsy.bpg01510.1093/clipsy.bpg015
2.
BaerR. A.SmithG. T.AllenK. B. (2004). Assessment of mindfulness by self-report: The Kentucky Inventory of Mindfulness Skills. Assessment, 11, 191-206. doi:10.1177/107319110528350410.1177/1073191105283504
3.
BagbyR. M.ParkerJ. D.TaylorG. J. (1994). The twenty-item Toronto Alexithymia Scale–I. Item selection and cross-validation of the factor structure. Journal of Psychosomatic Research, 38, 33-40. doi:10.1016/0022-3999(94)90005-110.1016/0022-3999(94)90005-1
4.
BarleyW. D.BuieS. E.PetersonE. W.HollingsworthA. S.GrivaM.HickersonS. C.. . . BaileyB. J. (1993). The development of an inpatient cognitive-behavioral treatment program for borderline personality disorder. Journal of Personality Disorders, 7, 232-240.
BeckerC. B.ZayfertC. (2001). Integrating DBT-based techniques and concepts to facilitate exposure treatment for PTSD. Cognitive and Behavioral Practice, 8, 107-122. doi:10.1016/S1077-7229(01)80017-110.1016/S1077-7229(01)80017-1
7.
BlakeD.WeathersF. W.NagyL. M.KaloupekD. G.CharneyD. S.KeaneT. M. (1997). Clinician Administered PTSD Scale (Rev.). Boston, MA: Behavioral Science Division, Boston National Center for Post-Traumatic Stress Disorder.
8.
BohusM.HaafB.StiglmayrC.PohlU.BoehmeR.LinehanM. (2000). Evaluation of inpatient dialectical-behavioral therapy for borderline personality disorder—A prospective study. Behaviour Research and Therapy, 38, 875-887. doi:10.1016/S0005-7967(99)00103-510.1016/S0005-7967(99)00103-5
9.
BursteinA. (1986). Treatment noncompliance in patients with post-traumatic stress disorder. Psychosomatics, 27, 37-40.
10.
ButlerK. (2002). On the borderline. Tricyle: The Buddhist Review, 11, 47-49, 98-106.
11.
ChamblessD. L.OllendickT. H. (2001). Empirically supported psychological interventions: Controversies and evidence. Annual Review Psychology, 52, 685-716. doi:10.1146/annurev.psych.52.1.68510.1146/annurev.psych.52.1.685
12.
CloitreM.KoenenK. C.CohenL. R.HanH. (2002). Skills training in affective and interpersonal regulation followed by exposure: A phase-based treatment for PTSD related to childhood abuse. Journal of Consulting and Clinical Psychology, 70, 1067-1074. doi:10.1037/0022-006X.70.5.106710.1037/0022-006X.70.5.1067
13.
DevillyG. J. (2004). An approach to psychotherapy toleration: The Distress/Endorsement Validation Scale (DEVS) for clinical outcome studies. Journal of Behavior Therapy and Experimental Psychiatry, 35, 319-336. doi:10.1016/j.jbtep.2004.08.00110.1016/j.jbtep.2004.08.001
14.
FirstM. B.SpitzerR. L.GibbonM.WilliamsJ. B. W. (1997). Structured Clinical Interview for Axis I DSM-IV disorders. New York: Biometrics Research Department, New York State Psychiatric Institute.
15.
FoaE. BDancuC.HembreeE.JaycoxL.MeadowsE.StreetG. (1999). A comparison of exposure therapy, stress inoculation training, and their combination for reducing posttraumatic stress disorder in female assault victims. Journal of Consulting and Clinical Psychology, 67, 194-200. doi:10.1037/0022-006X.67.2.19410.1037/0022-006X.67.2.194
16.
FoaE. B.HembreeE. A.CahillS. P.RauchS. A. M.RiggsD. S.FeenyN. C.YadinE. (2005). Randomized trial of prolonged exposure for posttraumatic stress disorder with and without cognitive restructuring: Outcome at academic and community clinics. Journal of Consulting and Clinical Psychology, 73, 953-964. doi:10.1037/0022-006X.73.5.95310.1037/0022-006X.73.5.953
17.
FoaE. B.KozakM. J. (1986). Emotional processing of fear: Exposure to corrective information. Psychological Bulletin, 99, 20-35. doi:10.1037/0033-2909.99.1.2010.1037/0033-2909.99.1.20
18.
FoaE. B.RothbaumB. O. (1998). Treating the trauma of rape: Cognitive behavioral therapy for PTSD. New York, NY: Guilford.
19.
FoaE. B.RothbaumB. O.RiggsD. S.MurdockT. B. (1991). Treatment of posttraumatic stress disorder in rape victims: A comparison between cognitive-behavioral procedures and counseling. Journal of Consulting and Clinical Psychology, 59, 715-723. doi:10.1037/0022-006X.59.5.71510.1037/0022-006X.59.5.715
20.
FolletteV. M.PalmK. M.HallM. L. R. (2004). Acceptance, mindfulness, and trauma. In HayesS. C.FolletteV.LinehanM. M. (Eds.), Mindfulness and acceptance: Expanding the cognitive-behavioral tradition (pp. 192-208). New York, NY: Guilford.
21.
FolletteV.PalmK. M.PearsonA. N. (2006). Mindfulness and trauma: Implications for treatment. Journal of Rational-Emotive & Cognitive-Behavior Therapy, 24, 45-61. doi:10.1007/s10942-006-0025-210.1007/s10942-006-0025-2
22.
GrossJ. J.JohnO. P. (2003). Individual differences in two emotion regulation processes: Implications for affect, relationships, and well-being. Journal of Personality and Social Psychology, 85, 348-362. doi:10.1037/0022-3514.85.2.34810.1037/0022-3514.85.2.348
23.
HallC. A.HendersonC. M. (1996). Cognitive processing therapy for chronic PTSD from childhood sexual abuse: A case study. Counselling Psychology Quarterly, 9, 359-371. doi:10.1080/0951507960825871410.1080/09515079608258714
24.
HassijaC. M.GrayM. J. (2007). Behavioral interventions for trauma and posttraumatic stress disorder. International Journal of Behavioral Consultation and Therapy, 3, 166-175.
25.
HölzelB. K.LazarS. W.GardT.Schuman-OlivierZ.VagoD. R.OttU. (2011). How does mindfulness meditation work? Proposing mechanisms of action from a conceptual and neural perspective. Perspectives on Psychological Science, 6, 537-559. doi:10.1177/174569161141967110.1177/1745691611419671
26.
JaycoxL. H.FoaE. B. (1996). Obstacles in implementing exposure therapy for PTSD: Case discussions and practical solutions. Clinical Psychology & Psychotherapy, 3, 176-184. doi:10.1002/(SICI)1099-0879(199609)3:3<176::AID-CPP100>3.0.CO;2-110.1002/(SICI)1099-0879(199609)3:3<176::AID-CPP100>3.0.CO;2-1
27.
Kabat-ZinnJ. (1982). An out-patient program in behavioral medicine for chronic pain patients based on the practice of mindfulness meditation: Theoretical considerations and preliminary results. General Hospital Psychiatry, 4, 33-47.
28.
Kabat-ZinnJ. (1994). Wherever you go, there you are: mindfulness meditation in everyday life. New York, NY: Hyperion.
29.
Kabat-ZinnJ. (2003). Mindfulness-based interventions in context: Past, present, and future. Clinical Psychology Science Practice, 10, 144-156. doi:10.1093/clipsy.bpg01610.1093/clipsy.bpg016
30.
KeaneT. M.BriefD. J.PrattE. M.MillerM. W. (2007). Assessment of PTSD and its comorbidities in adults. In FriedmanM. J.KeaneT. M.ResickP. A. (Eds.), Handbook of PTSD science and practice (pp. 37-77). New York, NY: Guilford.
31.
KeaneT. M.FairbankJ. A.CaddellJ. M.ZimeringR. T. (1989). Implosive (flooding) therapy reduces symptoms of PTSD in Vietnam combat veterans. Behavior Therapy, 20, 245-260. doi:10.1016/S0005-7894(89)80072-310.1016/S0005-7894(89)80072-3
32.
KilpatrickD. G.BestC. L. (1984). Some cautionary remarks on treating sexual assault victims with implosion. Behavior Therapy, 15, 421-423. doi:10.1016/S0005-7894(84)80011-810.1016/S0005-7894(84)80011-8
33.
KilpatrickD. G.VeronenL. J.ResickP. A. (1979). The aftermath of rape: Recent empirical findings. American Journal of Orthopsychiatry, 49, 658-669.
34.
KoonsC. R.RobinsC. J.BishopG. K.MorseJ. Q.TweedJ. L.LynchT. R.. . . BastianL. A. (1998, November). Efficacy of dialectical behavior therapy with borderline women veterans: A randomized controlled trial. Paper presented at the meeting of the Association for the Advancement of Behavior Therapy, Washington, DC.
35.
LarsenD. L.AttkissonC. C.HargreavesW. A.NguyenT. D. (1979). Assessment of client/patient satisfaction: Development of a general scale. Evaluation and Program Planning, 2, 197-207. doi:10.1016/0149-7189(79)90094-610.1016/0149-7189(79)90094-6
36.
LevittJ. T.CloitreM. (2005). A clinician’s guide to STAIR/MPE: Treatment for PTSD related to childhood abuse. Cognitive and Behavioral Practice, 12, 40-52. doi:10.1016/S1077-7229(05)80038-010.1016/S1077-7229(05)80038-0
37.
LinehanM. M. (1993). Cognitive-behavioral treatment of borderline personality disorder. New York, NY: Guildford.
38.
LinehanM. M.ArmstrongH. E.SuarezA.AllmonD.HeardH. L. (1991). Cognitive-behavioral treatment of chronically parasuicidal borderline patients. Archives of General Psychiatry, 48, 1060-1064.
39.
LinehanM. M.SchmidtH.DimeffL. A.CraftJ. C.KanterJ.ComtoisK. A. (1999). Dialectical behavioral therapy for patients with borderline personality disorder and drug-dependence. American Journal of Addiction, 8, 279-292. doi:10.1080/10550499930568610.1080/105504999305686
40.
MarksI.LovellK.NoshirvaniH.LivanouM.ThrasherS. (1998). Treatment of post-traumatic stress disorder by exposure and/or cognitive restructuring. A controlled study. Archives of General Psychiatry, 55, 317-325. doi:10.1001/archpsyc.55.4.31710.1001/archpsyc.55.4.317
41.
MonsonC. M.FriedmanM. J.La BashH. J. A. (2007). A psychological history of PTSD. In FriedmanM. J.KeaneT. M.ResickP. A. (Eds.), Handbook of PTSD science and practice (pp. 37-77). New York, NY: Guilford.
42.
MowrerO. H. (1960). Learning theory and behavior. Hoboken, NJ: John Wiley & Sons. doi:10.1037/10802-00010.1037/10802-000
43.
OwensG. P.WalterK. H.ChardK. M.DavisP. A. (2011). Changes in mindfulness skills and treatment response among veterans in residential PTSD treatment. Psychological Trauma: Theory, Research, Practice, and Policy, 4, 221-228. doi:10.1037/a002425110.1037/a0024251
44.
PetersonR. A.ReissS. (1992). Anxiety Sensitivity Index manual (2nd ed.). Worthington, OH: International Diagnostic Systems.
45.
PitmanR. K.AltmanB.GreenwaldE.LongpreR. E. (1991). Psychiatric complications during flooding therapy for posttraumatic stress disorder. Journal of Clinical Psychiatry, 52, 17-20.
46.
ReissS.PetersonR. A.GurskyD. M.McNallyR. J. (1986). Anxiety sensitivity, anxiety frequency, and the prediction of fearfulness. Behaviour Research and Therapy, 24, 1-8. doi:10.1016/0005-7967(86)90143-910.1016/0005-7967(86)90143-9
47.
ResickP. A.NishithP.WeaverT. L.AstinM. C.FeuerC. A. (2002). A comparison of cognitive-processing therapy with prolonged exposure and a waiting condition for the treatment of chronic posttraumatic stress disorder in female rape victims. Journal of Consulting and Clinical Psychology, 70, 867-879. doi:10.1037/0022-006X.70.4.86710.1037/0022-006X.70.4.867
48.
RiggsD. S.CahillS. P.FoaE. B. (2006). Prolonged exposure treatment of posttraumatic stress disorder. In FolletteV. M.RuzekJ. I. (Eds.), Cognitive-behavioral therapies for trauma (pp. 65-95). New York, NY: Guilford.
49.
RothbaumB. O.AstinM. C.MarstellerF. (2005), Prolonged exposure versus eye movement desensitization and reprocessing (EMDR) for PTSD rape victims. Journal of Traumatic Stress, 18, 607-616. doi:10.1002/jts.2006910.1002/jts.20069
50.
ScottM. J.StradlingS. G. (1997). Client compliance with exposure treatments for posttraumatic stress disorder. Journal of Traumatic Stress, 10, 523-526. doi:10.1002/jts.249010031510.1002/jts.2490100315
51.
SmithB. W.OrtizJ. A.SteffenL. E.TooleyE. M.WigginsK. T.YeaterE. A.. . . BernardM. L. (2011). Mindfulness is associated with fewer PTSD symptoms, depressive symptoms, physical symptoms, and alcohol problems in urban firefighters. Journal of Consulting and Clinical Psychology, 79, 613-617. doi:10.1037/a002518910.1037/a0025189
52.
TarrierN.PilgrimH.SommerfieldC.FaragherB.ReynoldsM.GrahamE.BarrowcloughC. (1999). A randomized trial of cognitive therapy and imaginal exposure in the treatment of chronic posttraumatic stress disorder. Journal of Consulting and Clinical Psychology, 67, 13-18. doi:10.1037/0022-006X.67.1.1310.1037/0022-006X.67.1.13
53.
TeasdaleJ. D.SegalZ.WilliamsJ. M. G. (1995). How does cognitive therapy prevent depressive relapse and why should attentional control (mindfulness) training help?Behavior Research Therapy, 33, 25-39. doi:10.1016/0005-7967(94)E0011-710.1016/0005-7967(94)E0011-7.
54.
TelchC. F.AgrasW. S.LinehanM. M. (2001). Dialectical behavioral therapy for binge eating disorder. Journal of Consulting and Clinical Psychology, 69, 1061-1065. doi:10.1037/0022-006X.69.6.106110.1037/0022-006X.69.6.1061
55.
Van MinnenA.ArntzA.KeijsersG. P. J. (2002). Prolonged exposure in patients with chronic PTSD: Predictors of treatment outcome and dropout. Behavior Research and Therapy, 40, 439-457. doi:10.1016/S0005-7967(01)00024-910.1016/S0005-7967(01)00024-9
56.
VujanovicA. A.NilesB.PietrefesaA.SchmertzS. K.PotterC. M. (2011). Mindfulness in the treatment of posttraumatic stress disorder among military veterans. Professional Psychology: Research and Practice, 42, 24-31. doi:10.1037/a002227210.1037/a0022272
57.
WaldJ.TaylorS. (2007). Efficacy of interoceptive exposure therapy combined with trauma-related exposure therapy for posttraumatic stress disorder: A pilot study. Journal of Anxiety Disorders, 21, 1050-1060. doi:10.1016/j.janxdis.2006.10.01010.1016/j.janxdis.2006.10.010
