Book Review: Trauma-Sensitive Mindfulness: Practices for Safe and Transformative Healing by David Treleaven

David Treleaven is an American writer, educator, and trauma professional who's spent the past decade researching one question: is meditation practice safe for people who have suffered trauma?  Earlier this week, his first book, Trauma-Sensitive Mindfulness: Practices for Safe and Transformative Healing (published by W.W. Norton and Company, click on link for Amazon UK purchase) finally became available in the UK on Kindle.

It is no understatement to say many of us have been eagerly awaiting this work. I’ve been checking its publication status every few weeks, having written previously about some of my own more challenging experiences with meditation and trauma here: experiences which Brown University researcher Willoughby Britton estimates may be shared by as many as 5% of meditation practitioners and potentially more.

At a workshop Willoughby Britton led on meditation-related difficulty hosted by the University of Bangor Centre for Mindfulness Research and Practice in July, the message to mindfulness teachers and practitioners was that we simply don’t have enough information presently about who might experience clinically significant adverse responses to meditation or how long these might impact upon a person’s life. Some who experienced severely adverse effects were seasoned meditators and spiritual practitioners engaged in lengthy retreats: some had enrolled on local community programmes to support their health and wellbeing and experienced challenges in their first body scans.

The tension around such uncertainty was palpable in the room.  While for those of us for whom meditation had resulted in significant challenges, it brought a measure of shared relief, inevitably for many mindfulness teachers and providers, it also invoked a sense of unease around the questions of responsibility this posed.  In some cases, severely adverse experiences had resulted in ongoing disability and even, tragically, death: pretty scary!

 One thing seemed obvious, current attempts to “screen out” risk were unlikely in and of themselves to prevent all potential harm (with anecdotal evidence suggesting NICE compliance on exclusion criteria might be remarkably low). Building competency in skilful responding was important. This is where David Treleaven’s book comes in, surveying the foundations of trauma-sensitive mindfulness before proposing practices and principles for trauma-sensitive practice. 

Why Trauma-Sensitive Mindfulness?

Leading trauma specialist Pat Ogden famously defined trauma as “any experience that is stressful enough to leave us feeling helpless,frightened, overwhelmed, or profoundly unsafe” (2015, p. 66). As such, trauma is ubiquitous:  part of what it is to be human, with the potential to arise everywhere and anywhere. None of us is or will be immune to experiences of trauma, with the majority of likely to be exposed to events that can engender post-traumatic stress at least once in our lifetimes. 

As mindfulness spreads like wildfire from the boardroom to the preschool, it is clear that the probability of individuals with histories of trauma engaging in mindfulness increases all the time.  Given this, it is imperative, he argues, that all meditation and mindfulness teachers are aware of trauma, how it presents and how to respond to it in ways that alleviate suffering. 

Treleaven is clear that, for many, mindfulness practices can be a substantial resource in meeting the challenges arising from this very human experience of meeting with a sometimes violently frightening and unpredictable world: a world in which all certainty and coherence can fall way in a single moment.

Mindfulness can enhance present-moment awareness, increase self-compassion and support self-regulation. It can also facilitate detection and staying present with the intensity of feeling and bodily sensation that arise in undertaking trauma therapies, and is a core feature of some, such as EMDR, a recognised evidence-based treatment for post traumatic stress disorder.

However, Treleaven also reminds us that, particularly when it comes to traumatic experience, the provision of mindfulness meditation in particular may need to be modified or differentiated in ways that don’t aggravate the experience of traumatic stress in practitioners, features of which can include flashbacks (re-experiencing trauma), heightened emotional arousal and dissociation (a disconnect between thoughts, feelings and physical sensations) and, in some cases, retraumatisation, or relapsing into a severely traumatised state. 

Mindfulness itself, he states, does not cause trauma – but the practice of mindfulness meditation, especially where this is offered without an understanding of how to recognise and respond to it, can become problematic for some in ways we can’t currently predict easily.   

Trauma Informed Practice: The Four-R’s

Given the lack of clear research-based recommendations, Treleaven presents the case that adopting trauma-informed practice for the delivery of all mindfulness courses may reduce risks.

Treleaven bases his trauma-sensitive mindfulness practices on recommendations from the US National Centre for Trauma-Informed Care and suggests mindfulness providers can support trauma-informed practices by:

-          Realising the impact of trauma, and paths people may take to recovery

-          Recognising the signs and symptoms of trauma in those whom they serve

-          Responding by integrating trauma knowledge into all policies, procedures and practices and

-          Seeking to actively Resist Restraumatisation

To this end, Treleaven surveys what is currently known about trauma: what it is, how common it is, how invisible it can be, what forms it takes and who may be more likely to experience more of it. This involves differentiating traumatic stress from definitions more commonly utilised in stress reduction literature, introducing post-traumatic stress, PTSD and its prevalence across demographics.

It also involves discussing the concept of integration as core to trauma understanding for mindfulness practitioners.  In traumatic stress, it is known that our relationship to experience sometimes disintegrates:  what we feel and experience in the body doesn’t make sense in the mind in some important way, and thoughts, memories and sensations are either cut off or flood our systems, reducing our sense of balance and self-trust (for an excellent resource on how trauma impacts on memory integration, check out this recent comic). Strong experiences of fear and shame present particular barriers to integration and can lead to overwhelm, which may be particularly relevant in some meditation contexts given the absence of ongoing relationship and opportunities for social feedback, intensifying distress.

 Of critical importance for the mindfulness trainer is understanding the sometimes involuntary and incapacitating nature of traumatic stress, understanding it as more than simply an intensely negative emotion. Treleaven argues it is crucial we recognise the trauma response as survival-based and arising deeply from within our psychobiology.  Treleaven recounts experiences with countless survivors of trauma who have revealed traumatic symptoms to teachers either to be told to persist, keep practising, return to the cushion and stay in ways that, while compassionately intended, have inadvertently caused harm to distressed practitioners.

In the face of this, the task for mindfulness teachers, Treleaven suggests, is to respect “the potency and complexity of trauma”, to learn what it is and also to learn what to do to serve students and clients facing it. 

Treleaven carefully and systematically walks through the principles and practices of secular mindfulness provision, illuminating aspects particularly relevant to trauma in relation to the four primary means of mindfulness in the Buddhist text the Sattipattana Sutta, and also with reference to common concepts referenced in secular mindfulness, such as present moment awareness, non-judgemental attention, self- and emotional-regulation and body awareness. In each case, these are helpfully and personably illustrated with reference to case examples and the broader trauma literature.

With great care and sensitivity, Treleaven illuminates how all aspects of mindfulness can be called upon to support and resource a trauma survivor as they engage in trauma therapy, while also highlighting pitfalls which may be of relevance to the mindfulness teacher: in particular, over-attending to traumatic stimuli in ways that can prove too much. 

Referencing Peter Levine's use of the myth of Medusa  (who must not be looked at directly or the observer will turn to stone) to explain the links between attention and trauma, Treleaven points out how in following basic meditation instructions, survivors will eventually encounter traumatic stimuli, and must learn to titrate how much attention to bring to bear on this or risk physiological dysregulation. This can be very hard to manage alone.

From: Willoughby Britton CMRP Workshop: July 2017

Of special relevance in the trauma context, each of us has hardwired, automatic orienting responses below the level of conscious attentional control.  These can be very "trigger-sensitive" in trauma survivors who may have compulsive safety seeking strategies below conscious awareness.  Over attending to what's happening in the body can lock survivors into a potentially debilitating loop.

From:Willoughby Britton CMRP Workshop: July 2017

We need to learn how to manage these reflexive orientations, recognising them as an intelligent survival strategy that has been learned, and cannot be "unlearned", simply brought into awareness carefully and supported with the addition of carefully introduced attentional shifting/stabilising strategies. This is best achieved in the context of a skilful supportive relationship with someone adequately trained to observe and respond to such strategies, particularly given the tendency for survivors to swing from fear (fight/flight) responses to immobility (freeze) responses that are emanating from the primitive brain (not easy to control through the areas of the brain that mindfulness is most helpful with developing).  Survivors can learn to negotiate a "window of mindfulness" or "window of tolerance" (Pat Ogden) through learning to attend to signs of dysregulation and come back to anchor in the present moment using individually relevant strategies. 

From: Willoughby Britton CMRP Workshop: July 2017

 Five Principles of Trauma-Sensitive Mindfulness

From a practitioner perspective, it is in the second part of the book that the theoretical rubber meets the road with complete and practical chapters on five principles for supporting mindfulness practitioners with a trauma history in cultivating safe presence in mindfulness meditation, and knowing when meditation might not be advisable.

These principles include:

1.       Learning to stay mindfully within a “window of tolerance” to regulate arousal

2.       Shifting attention flexibly:  supporting stability and preventing fear/immobility cycles

3.       Keeping the body in mind: working skilfully and respectfully with dissociation as a survival strategy

4.       Practising in relationship to support safety and stability in survivors: in relationship with a therapist or teacher and in community

5.       Understanding social context: working effectively across difference and power hierarchies

Here, Treleaven provides a wealth of carefully synthesised, personably presented information about a range of modifications and strategies, continuing to seamlessly integrate these with trauma literature and case vignettes -  an absolute must-read for mindfulness practitioners.

The  Bigger Picture

Throughout, Treleaven persuasively argues that adopting trauma-sensitive practice can support practitioners not only in minimising distress for those with whom we work but in meeting the broader promise of mindfulness as a vehicle for social transformation.

In particular, Treleaven advocates for recognition that trauma is often a political issue, with certain groups of individuals more likely to experience traumatic events, or to have these ignored, discounted or brushed off when they are raised within oppressive systems.  While many of the exemplars provided are tailored to the North American social context, it is clear that they have potential relevance to any community, any complex social system.

Treleaven is passionate about the adoption of a non-neutral ethical stance that recognises that our liberation is bound up in one another’s, and the recognition that as long as we situate trauma and responding to it within the realm of personal responsibility, we run the risk of unintentionally reinforcing dynamics that are connected to the proliferation of trauma. 

At the heart and soul of this? Our human interconnectedness is core to our ethical practice of mindfulness. This means reaching beyond our assumptions and adopting an honest, self-reflective stance when we encounter that which scares or challenges us, triggers our own wounds or is beyond the limits of our current understanding. Through adopting trauma-informed mindfulness as a practice, we can turn towards the ubiquity and tragedy of human suffering and embody a collectively compassionate response: 

"At an even broader scale, I believe we’re at a crucial crossroad with trauma-informed practice. Going down one fork of that road, it shrinks into a checklist. This is akin to diversity training in institutions where the focus is largely on interpersonal actions and an insistence on ignoring our collective conditions. At its most reductionist, the focus here becomes “tell me what not to say” or being “politically correct”. Along the other road, these work towards.. justice, which involves looking at how larger structures pertain to one another and locating ourselves in that bigger picture. Walking this path offers greater recognition of our own and other people’s dignity and worth. It also calls all of us into claiming our own agency for what actions we want to contribute towards transforming the society in which we live… Each of us, in our own way, will need to find this stake for ourselves and take accountable action toward a more just, compassionate future” (David Treleaven)