The Present-Moment-Awareness Intervention for Post-Traumatic Stress: Strosahl & Robinson’s Five Phase Model

The core dilemma of post-traumatic stress is how to carry painful personal history forward in life. If clients use fragmented attention and avoidance to cope with what has happened, living a vital life is all but impossible. The alternative is to carry the objective reality of the trauma without the all-encompassing negative self-stories that result from the mind’s misguided sense-making operations. Most life traumas simply cannot be understood rationally, so the only option is to drop the quest for sense-making and just carry the history itself. Present-moment-awareness interventions with traumatized clients proceed through all five phases: dis­rupting strategies that involve fragmented attention and avoidance (noticing); helping them to create an objective story of the trauma (naming); teaching detachment from evaluations that are nestled within the story —whether those evaluations are derived from the self, others, or the world (letting go); holding the sense of being flawed, to blame, and undeserving softly (softening); and using the experience of being a trauma survivor as a powerful motivational force (expanding).

Notice

The best way to persistently avoid making contact with painful history is to learn to be inattentive in general. When post-traumatic stress symptoms are triggered by some internal or external cue, these clients’ attention may be so fragmented that they only make contact with vague, overly general memories and a jumbled mess of associated private experiences. Part of this problem is due to the excessive dominance of bottom-up attention in clients with trauma. However, selective, scattered attention also serves an important psychological function: if they can’t recall traumatic events with any pre­cision, they may still be distressed when their history shows up, but not as distressed as they’d be if these events were crystal clear in the mind’s eye. Thus, the immediate goal with traumatized clients is to make specific demands of their attention that will result in more clinically useful behaviors. To that end, it’s important not to bounce from one time period to another, and from one painful experience to another; this won’t help them integrate and assimilate their trauma history into a coherent self-story. The clinician endeavors to help a client survivor of trauma to show up and focus on core aspects of traumatic experiences.

Name

At this point, the objective details of the trauma are seen in a safe, permis­sive, nonjudgmental atmosphere. The associated emotional pain is “in the room,” so to speak, but most often, due to fragmented attention, the client has not been able to bring this private experi­ence under verbal regulation. Clients may feel overwhelmed by the emotional experience, and, without intention, change the subject or even leave the session abruptly. Thus, it’s crucial for the clinician to quickly transition from the telling of the story to the eliciting and supplying of verbal labels for the wide variety of distressing private experiences contained in the story.

Let Go

When traumatized clients do make contact with their painful history, one unfortunate result is that it often triggers a very unproductive form of rumination in which they go over the traumatic events again and again trying to make sense of the incomprehensible. The problem being, it’s impossible to make sense of the incomprehensi­ble by doing anything other than naming it as an incomprehensible event. It happened, and that’s all that can really be said about it. This stance is unacceptable to the busy mind, which is absorbed in trying to figure out who’s right and who’s wrong, who’s good and who’s bad, who got treated fairly by life and who got screwed, and, lastly, who’s to blame. The busy mind tells the human that any narrative lacking these important elements is incomplete and must be gone over, again and again. This particular form of sense-making is responsible for maintaining post-traumatic stress symptoms over time. Thus, it’s essential for clinicians to help these clients learn to recognize this process for what it is, not what it appears to be.

Soften

One of the great ironies of being the victim of a traumatizing event is that the person eventually gets to be the one to blame for the event. Because the mind is simply unable to generate a full and coherent story to explain an incomprehensible trauma, it adopts a default rule to plug the many holes in the story. The default rule is that the victim’s real or perceived flaws, as well as the victim’s actions or lack thereof, are ultimately the cause of the traumatic event. Further, the victim’s contemporary emotional or func­tional problems are explained as a direct result of those same real or perceived flaws. So, with traumatized clients, the goal of the softening phase of the present-moment-awareness intervention is to call out the mind and demonstrate the existence of this rule that leaves the client holding the bag.

Expand

The expansion phase of present-moment processing involves helping clients understand that survivors of trauma possess a deep appreciation for what’s important in life. In part, this is due to the fact that they’ve been exposed to the dark side of humanity, yet they still keep coming back to make their lives meaningful and special. This requires a special kind of resilience that, if put into the service of seeking valued life outcomes, provides tremendous motivational force. The goal is to convert the dark energy of trauma into the bright energy of using personal values to create a life that matters.

For a guide to the intervention model, refer to Inside This Moment by Kirk Strosahl, PhD, Patricia Robinson, PhD, and Thomas Gustavsson, MSc, and Real Behavior Change in Primary Care by Patricia Robinson, PhD, Debra Gould, MD, MPH, and Kirk Strosahl, PhD.