Not everyone who experiences profound distress will develop post-traumatic stress disorder (PTSD)–and most responses to trauma resolve naturally over time with conservative management. However, as reported by the National Center for PTSD, 8 percent of women and 4 percent of men develop PTSD after trauma—about 12 million people per year in the US That’s only a fraction of the 50 to 60 percent of people who experience trauma at some point in their life, yet the numbers add up to a high burden of PTSD in the population.
It’s important to understand who is more or less likely to develop PTSD in order to develop sensitive screening and management protocols. Screening low-risk people is not desirable because it could provoke unnecessary distress through inquiry, while identifying who is prone to PTSD enables healthcare systems, clinicians, and individuals to pursue resource-efficient tracking post-trauma.
Resilience, for example, has been shown to mitigate the risk of PTSD (Horn and Feder, 2018) Resilience is related to the concept of “trait mindfulness,” an individual’s baseline disposition to be mindful psychologically and behaviorally, in the absence of deliberate practice or training.
In order to understand the relationship between facets of trait mindfulness and PTSD risk, researchers Harper, Jones, Goodwin and Steven (2022) conducted a meta-analysis of the scientific literature. The results of their study were recently published in the Journal of Psychiatric Research.
Following a careful protocol for selecting only high-quality studies to analyze, researchers culled an original set of 2,153 studies down to a final 42 papers with relevant, non-overlapping findings. Studies included had a low risk of publication bias and consistent quality of methodology. Included studies used a variety of instruments to estimate mindfulness, PTSD, and related measures of interest. For instance, the Five Facet Mindfulness Measure, the Mindful Attention Awareness Scale, the Kentucky Inventory of Mindfulness Skills, the Clinician Administered PTSD Scale, and self-reported PTSD symptoms were commonly used.
There are five basic facets of mindfulness that add up to total trait mindfulness:
• observe, the tendency to witness without excessive engagement;
• describes, a related tendency to name events as they take place;
• act with awareness, the inclination to make decisions and execute on them while reflecting on the implications, rather than acting more impulsively or thoughtlessly;
• nonjudgment, in responding to events without excessive criticism of oneself or others; and
• nonreactivity, the quality of maintaining equanimity in the face of emotional challenges.
Data analysis pooled relevant findings from over 15,000 participants to identify consistent correlations among different aspects of mindfulness and PTSD.
Which Facets of Mindfulness Are Associated with Lower PTSD?
Overall, greater trait mindfulness was significantly associated with decreased PTSD symptoms, and lower rates of PTSD were associated likewise with greater mindfulness (a “bivariate” association). The statistical relationship between mindfulness and PTSD was robust, accounting for a considerable 15.2 percent. The effect varied with profession, stronger for military personnel, firefighters, aid workers, and long-haul truck drivers, and lower for students. The most significant relationship was found for professionals likely to experience trauma in the course of their work.
Of the five facets of mindfulness, four were associated with decreased PTSD symptoms: Nonjudging and acting with awareness had the strongest associations, followed by describing and nonreactivity. Of note, observing had a small but nonsignificant association with increased PTSD symptoms, possibly due to relationships with excessive detachment leading to dissociation, numbing, and avoidance, which may worsen PTSD for some—for example among civilian survivors of war in whom avoidant coping leads to failure to address problems, ultimately worsening the course of illness.
Using Mindfulness to Respond Adaptively to Trauma
This study is important because it synthesizes data from many studies to reveal how trait mindfulness and PTSD are related. While it is unsurprising that naturally higher levels of mindfulness correlate with lower PTSD risk and symptom burden, several findings stand out.
First, although further research is needed, the effect was stronger for people in professions with higher levels of baseline trauma. This finding needs to be interpreted with caution, as different studies defined groups differently. It may mean that training for such work does increase resilience, partially via increased in mindfulness; that more temperamentally mindful individuals are more likely to enter high-stress professions and make it through training; and that high-stress experiences offer opportunities for personal growth and development (post-traumatic growth).
Specific facets of nonjudging and acting with awareness had the strongest correlations with lower PTSD. Nonjudging is associated with making fewer negative attributions and decreased distraction from criticism, leaving more room for reappraisal and problem-solving–both adaptive coping styles associated with resilience. Acting with awareness is also related to better appraisal and decision-making, as reflection-in-action allows for ongoing evaluation and course correction.
Describing and nonreactivity support accuracy of appraisal, decision-making, and problem-solving, as well as good emotion regulation–all trauma-protective responses supporting self-care and adaptive response to traumatic experiences. In the aggregate, these traits allow one to think through crisis situations while they are happening, exercise executive function in holding off on less effective behaviors until alighting on optimal choices–and knowing when perfect is the enemy of good to make tough calls when there is not ideal choice.
Observing may be a double-edged sword, and it requires more investigation. On one hand, it may help people maintain some distance, when trying to engage or fix things may exacerbate suffering. Observing may help one “bear witness,” a concept borrowed from pastoral counseling, helpful when working in highly distressing situations where no immediate solution is available; simply put, it means remaining compassionately engaged, listening actively, and being present through suffering. From this point of view, observing oneself mindfully can be a way to stay with one’s own emotional pain without abandoning oneself, and the mindful practice of observing can therefore be useful with traumatic experience. On the other hand, observing may lead to disconnection, undermining engagement and getting in the way of active approaches when they are again available.
While this study focused on whether trait mindfulness1 and PTSD are related, research (Boyd, Lanius & McKinnon, 2018) and clinical experience suggest that practicing mindfulness, for some individuals, may be useful in mitigating PTSD following trauma. In addition to the coping approaches described, mindfulness practice has also been shown to have positive effects on restoring brain network activity, altered in PTSD.
Understanding when mindfulness helps and when it can interfere with recovery is important for addressing the ubiquitous trauma in our lives. How can we more broadly yet selectively incorporate mindfulness and related approaches, such as compassion-based practice, into professional training, day-to-day life, and clinical settings including primary care and therapy?
Trauma is not the cause of all mental illness. But it is significantly associated not just with PTSD but also depression, anxiety, substance- and alcohol-related disorders, eating disorders, personality problems, and other sources of suffering. Addressing trauma is a part of overall health and well-being.