Mindfulness-based interventions for veterans with

posttraumatic stress disorder.

The wars in Afghanistan and Iraq heighten the need for effectivepsychological treatment for
veterans returning from combat who aresuffering from Posttraumatic Stress Disorder (PTSD; see
AmericanPsychiatric Association, DSM-5, 2014). Approximately 25.5% of returningveterans from
Operation Enduring Freedom (OEF) and Operation IraqiFreedom (OIF) present to the Veterans
Health Administration (VHA) formental health services related to trauma exposure and PTSD
(Vujanovic etal., 2013). Also, according to Price et al. (2013), OEF/ OIF veteransare at greater risk
for PTSD because of increased combat exposure whencompared with veterans of past military
operations. Veterans with traumaexposure and PTSD often experience co-occurring affective
disordersincluding anxiety and depression (Owens et al., 2012).
This paper examines the efficacy of mindfulness meditation in the treatment of veterans who are
suffering from PTSD. The benefits of meditation as a modality and future directions are explored
* What is mindfulness meditation?
Meditation may be broadly classified as concentrative or non-concentrative (e.g., mindfulness
meditation), depending on the manner in which mental attention is trained. Concentrative
techniques include intense focus on a particular object (e.g., a candle flame or the sensation of
breathing); focus is repeatedly brought back to the object if attention falters. In contrast, in nonconcentrative techniques like mindfulness meditation, individuals cultivate awareness and
acceptance of all mental events. The goal is to observe moment-to-moment shifts in internal
experiences without judging their content (Strauss et al., 2011).
The roots of mindfulness meditation can be traced to TibetanBuddhism practices, which were
designed to evoke a new way ofperceiving. Mindfulness is a 2,500-year-old tradition devoted to
mentaltraining. Mindfulness is grounded in human attention and awarenessmindfulness involves
intentionally placing attention on the presentmoment with an awareness that is non-evaluative
(Bishop et al., 2004;Shapiro et al., 2006); this makes it possible to systematically exploreand refine
one's awareness.
Understanding one's mind through awareness cultivates kindness and compassion toward oneself,
which then extends to others (Bruce et al., 2010; Siegel, 2007b). Greeson's (2009) review of
mindfulness research and theory supports the claim that mindfulness meditation increases
compassion. Further, Siegel (2007a) suggested that mindfulness practice helps individuals accept
and embrace their minds with kindness and compassion.
An appropriate operational definition of mindfulness focuses on the elements of cognitive processes
(Bishop et al., 2004). These elements involve "self-regulation of attention," "the recognition of
mental events occurring in the moment," and "adopting a particular orientation toward one's
experiences in the present moment that is characterized by curiosity, openness, and acceptance"
(Bishop et al., 2004, p. 232). Mindfulness practice can be used with other therapeutic skills such as
with mindfulness communicating and listening. Furthermore, learning mindfulness provides the
ability to attune with others during healing and facilitates the development of empathy.
* History of mindfulness meditation

MBIS spawned from mindfulness-based stress reduction MBSR, which began in 1979 at the
University of Massachusetts Medical Center. Brown et al. (2007) stated, "MBSR is most clearly
rooted in eastern philosophy and psychology, which emphasizes the importance of experiential,
meditative practice as a primary vehicle for personal development and transformation" (p. 219). As
a student of Yoga, Vipassana (seeing clearly) meditation, and Zen, Jon Kabat-Zinn (founder of
MBSR) included a range of informal and formal practices to cultivate mindfulness. Vipassana is a
Buddhist tradition that works well in mainstream settings because it provides specific and direct
instructions for sustaining attention and awareness. MBSR was developed to help people cope with
chronic pain issues or stress-related disorders. This approach explored human distress rather than
the triggers.
Further, MBSR taught individuals to recognize and accept their thoughts and feelings with a
nonjudgmental attitude; other psychotherapies focused on solutions to help people
restructure cognition and coping strategies (Silverton & Kabat-Zinn, 2012). MBSR included formal
and informal practices for the cultivation of mindfulness. Meditation is a primary means through
which mindfulness is cultivated. MBSR can be described as a psycho-educational
program facilitated on a daily basis over an 8-week period that includes 2.5 to 3 hour long classes
with one day of silence in the 6th or 7th week. MBSR can assist veterans with a variety of physical
health conditions as well as anxiety disorders, depression, and substance abuse issues
that commonly co-occur with PTSD. Mindfulness-based treatment for veterans with PTSD combines
scientific analysis and narrative of mental states with calming MBSR and Buddhist strategies.
Mindfulness focuses on simple mental awareness and acceptance of openhearted attention from one
moment to the next. It is a "way of being" (Kabat-Zinn, 1994, p. 4) in choosing to think nonjudgmentally. MBIS can reduce posttraumatic stress in combat veterans (Rosenthal et al., 2011).
* Rationale for mindfulness meditation as treatment for PTSD
Mindfulness meditation does not require pharmaceutical interventions nor does it interfere with
medications. In fact, studies indicate that meditation is an efficient adjunct to medication and
case management in veterans with symptomatology related to exposure to trauma.

Results in currently used first line interventions for veterans with PTSD including cognitive
processing therapy (CPT; Resick et al., 2007), prolonged exposure (PE) therapy (Foa et al.,2007),
stress inoculation training (sit; Foa et al., 1999; Foa et al., 1991), and eye movement desensitization
and reprocessing (EMDR; Shapiro 2001; Shapiro, 1989) indicate that some individuals do not make
clinical gains and there is a significant drop-out rate (Schottenbauer et al., 2008).
In addition to psychotherapeutic treatments for PTSD practice guidelines recommend
pharmacologic agents including serotonin-reuptake inhibitors (SSRIS) and serotonin norepinephrine
reuptake inhibitors (SNRIS) (Kearney et al., 2012). However, according to Kearny et al. (2012),
behavioral interventions and pharmacological treatments reduce the hallmark features of chronic
PTSD, but often fail to address the full psychopathology. Augmenting treatments with mindfulness
meditation has the potential for improving care for veterans with PTSD (Hoge, 2011). As such,
integrating mindfulness meditation with psychotropic and psychotherapeutic interventions is best
suited for working with veterans with PTSD. Veterans may choose this type of intervention because
it is nonpharmacological and does not focus on trauma (Bormann et al., 2013b).
Another significant reason for utilizing MBIS in working with veterans with PTSD is the neurological
changes resulting from mindfulness meditation. For example, Singleton et al. (2014) found

that participation in MBSR therapy increases gray matter concentration in the brainstem. Holzel et
al. (2011) also confirmed increases in gray matter concentration, signifying that participation in
MBSR is related with changes in parts of the brain associated with learning and memory processes,
emotion regulation, and self-referential processing.
Also, MBIS enhance middle prefrontal lobe function, such as self-insight, morality, intuition, and
fear modulation (Siegel, 2007a). Davidson (2000) indicated that activation of the middle prefrontal
lobe corresponds with faster recovery to baseline after being negatively provoked. Mindfulness
practice activates the brain region associated with adaptive responses to stressful or negative
situations (Cahn & Polich, 2006). Based on the reviews, mindfulness meditation creates lasting
neurological benefits for veterans with PTSD for emotion regulation, fear modulation, memory
processing, and recovery from trauma exposure.
* Review of mindfulness meditation for veterans with PTSD mindfulness-based stress reduction
(MBSR)
A study at the VA Puget Sound Health Care System, Seattle, WA described the utility of MBSR with
veterans experiencing PTSD. Kearny et al. (2013a) conducted a randomized controlled pilot study
on the effects of participation in a mindfulness program for veterans with PTSD. Forty-seven
participants were randomized to MBSR or treatment-as-usual (tau). Data were collected from 25
intervention group patients and 22 patients in the control group at baseline. Assessments occurred
at baseline, 2 months, and 4 months follow-up. The MBSR followed the format originally developed
by Jon Kabat-Zinn (1982). The veterans practiced meditation and had homework assignments.
Participants developed attentional skills by placing sustained attention on a specific experience
such as the breath and flexibility of attention by letting go of rumination. Body scan, gentle Yoga,
meditation, and informal mindfulness were used with elements of loving-kindness, nonjudgment,
and awareness. Participants in the tau group received usual care for PTSD. Findings indicated that
veterans with PTSD who took part in the MBSR reported improvement in mindfulness skills as
compared with those assigned to tau. The MBSR group also showed increased mental healthrelated quality-of-life (QOL). Limitations of the study included the small sample and an active
control group. Another weakness was the lack of a formal assessment of PTSD at baseline. Also,
treatment fidelity to the MBSR program was not assessed. Lastly, many of the veterans in the tau
group were prescribed benzodiazepines, which could have influenced the results (Kearney et al.,
2013a).
In a different study, Kearny et al. (2012) assessed mental health outcomes of veterans with PTSD
who participated in a MBSR program and reviewed the associated factors including depression,
behavioral activation, experiential avoidance, QOL, and mindfulness. MBSR was provided as an
adjunct to the usual care of veterans at VA medical center. The veterans' issues included PTSD,
chronic pain, depression, and physical disability. The intervention was delivered by group to 74
male and female veteran participants in an 8-week MBSR course. All participants continued their
usual psychiatric and psychological care during the study. Participants met once per week
(2.5 hours per session) and practiced mindfulness meditation and Yoga. The mindfulness
instructions in the class focused on attention and attitude, exercises, discussions, and homework
assignments. Veterans were asked to bring sustained attention to an aspect of their experience
(thought, emotion, or bodily sensation) and flexibility in the ability to disengage from ruminative
cycles of thought (Kearny et al., 2012). Openness, loving-kindness, curiosity, and non-judging of
present-moment experience including unpleasant experiences were encouraged. Informal MBSR
homework practices such as mindful eating were encouraged. Clinically significant change from
baseline in PTSD symptoms and functional status was calculated at the 2-month and 6-month time
points.

Results indicated that veterans who participated in MBSR experienced significant improvements in
physical QOL and mental health, including measures of PTSD, depression, experiential avoidance,
and behavioral activation. A strength of this study was that mindfulness skills increased over the
course of the study and increased mindfulness played a role in the positive changes. One weakness
of the study was the lack of a randomized control group. Another limitation was the use of selfreport measures without a clinician interview to substantiate self-reports. Additionally, the study
was conducted with Caucasians only. However, the findings from this study provide support for
the potential for teaching MBSR to veterans with PTSD (Kearney et al., 2012).
MBSR significantly reduces self-reported distress, emotional and physical symptoms, and mood and
disturbance in veterans with PTSD. Thus, based on empirical research one can conclude that MBSR
has a significant role in the regulation of physical health as well as psychological states in the QOL
for combat-related symptoms and PTSD in veterans.
* Three meditative techniques
Lang et al. (2012) reviewed the theoretical and empirical basis for meditation as an intervention for
PTSD. Different mechanisms underlie different meditative approaches. Three meditation techniques
examined in this review include mindfulness meditation, mantra meditation, and compassion
meditation. Firstly, Lang et al. described how mindfulness meditation can create cognitive change
that can be applied to PTSD veterans who demonstrate attentional bias toward trauma-related
stimuli. Mindfulness can also be applied to deficits in cognition and the ability to inhibit irrelevant
information, both of which explain re-experiencing symptoms. Additionally, mindfulness changes
cognitive styles of worry and rumination with greater attention to the present; this is
associated with lower PTSD symptom severity in trauma-exposed adults. Assuming
a nonjudgmental stance counteracts the tendency of people with PTSD to negatively interpret
experiences and assists them to face fear-provoking stimuli. This key element of mindfulness
counteracts avoidance, which is a common characteristic of veterans with PTSD.
Secondly, Lang et al. (2012) indicated that mantra meditation is linked to decreasing physiological
arousal and heightening awareness of one's thoughts facilitating emotional self-regulation. Thus, it
can serve as an intentional distraction to disturbing thoughts and behaviors and allows "mindful
distraction" (p. 768). Additionally, mantra meditation reduces the autonomic fight or flight response
and counteracts this aspect of PTSD. These factors can be taught to veterans with PTSD as a
coping mechanism when memories are triggered intentionally during PE therapy.
Thirdly, Lang et al. (2012) also described compassion meditation. Theoretically, this potentially
leads to a heightened sense of warmth and closeness to others (Lang et al., 2012). This type of
meditative approach has been linked to social connectedness and increases in positive emotion
leading to increases in personal resources, resilience, a sense of mastery, and social support, all of
which contribute to life satisfaction. Social connectedness can assist veterans with PTSD who feel
detached and have difficulty with interpersonal relationships. Veterans with PTSD may also have a
diminished ability to empathically connect with others and deficits in empathy are reflected in
verbal aggression in veterans with PTSD (Lang et al., 2012). As a result, veterans with PTSD can
benefit from an induction of positive emotions. Also, because PTSD is associated with autonomic
hyperarousal, positive emotions can reduce anxiety-related reactivity and assist veterans
in developing resilience and the ability to recover from negative experiences.
The three different types of meditative techniques reviewed were considered to reduce
symptomatology and improve quality of life (QOL) for people with PTSD. Findings indicate that
mindfulness meditation has the best empirical support for treatment of PTSD and may enhance

other first-line interventions in treating veterans (Lang et al., 2012).

* Mindfulness-based practice and training
Vujanovic et al. (2013) reviewed how mindfulness meditation is adapted in the treatment of PTSD
among military veterans. Vujanovic et al. described difficulties integrating mindfulness-based
practices and training clinicians to develop knowledge and the ability to alleviate psychological
problems including PTSD among veterans. The researchers suggested part of the problem was due
to the lack of consensus regarding the definition of mindfulness (e.g. "as a state of mind," or "a trait
of mind," and a "type of mental process") (Vujanovic et al., 2013, p. 22). Further, the researchers
suggested that mindfulness assessments to evaluate effectiveness are always changing; refinement
of these instruments would create a reliable method of measurement for efficacy.
One weakness of Vujanovic et al's (2013) review was the lack of adequate research studies of
mindfulness treatment for veterans with PTSD and nonclinical populations. Another weakness was
the reference to inconsistencies in the practice level. Practice levels improved and spread rapidly
over the past 10 years. Also, the authors' suggestion that the definition of mindfulness is confusing
is dated.
* Mindfulness via telehealth
Niles et al. (2012) conducted a study of two telehealth interventions for veterans with combatrelated PTSD. The study compared mindfulness meditation and psycho-educational treatments
for combat-related PTSD using a telehealth approach. There were two in-person sessions and six
telephone sessions used in both modalities. There were 33 male veteran participants with combatrelated PTSD, between the ages of 23 and 66. Substance abuse was not an exclusion criterion and
participants were not required to discontinue ongoing treatment with other mental health providers
during the 8-week study period. Most participants were taking psychiatric medications, which were
assessed throughout the study. Results indicated that telehealth treatments for PTSD using
mindfulness was feasible and associated with high satisfaction rates in the treatment of PTSD for
veterans. Compliance was very high for homework completion, and veterans engaged in sessions
substantially more than the protocol requested. The study provides evidence that participation in
mindfulness intervention via telephone can reduce symptoms of PTSD more than the
psychoeducation intervention. Weaknesses of this study were the small sample size and the fact
that the participants in the psychoeducation group had greater PTSD symptoms. Additionally, the
brief treatment would need to be extended in length or paired with other interventions to create
lasting effects (Niles et al., 2012).
* Facets of mindfulness
Boden et al. (2012) investigated changes in facets of mindfulness meditation and PTSD treatment
outcome with military veterans. They tested the prospective associations between pre-to posttreatment changes in facets of mindfulness and PTSD and depression severity at treatment
discharge among 48 military veterans in residential PTSD treatment adhering to a cognitivebehavioral framework. All participants experienced combat-related trauma. Facets of mindfulness
meditation were measured using the Kentucky Inventory of Mindfulness Skills (KIMS; Baer et al.,
2004). The findings indicated that elements of mindfulness increased during the course of
treatment. Changes in the facets of mindfulness were associated with reductions in post-treatment
PTSD and depression severity. Awareness and nonjudgmental acceptance were recognized as core
components of mindfulness facets and strong predictors of positive PTSD treatment outcome.
Further, CBT for PTSD can facilitate the development of acting with awareness and

nonjudgmental acceptance. Limitations of this study were the lack of a control group and the small
sample. Also, self-reported mindfulness may or may not represent actual change (Boden et al.,
2012).
* Mindful attention and awareness
Bernstein et al. (2011) evaluated the concurrent relations between mindful attention and awareness
and psychopathology among trauma-exposed adults. Participants included 76 adults including 35
women with average age of 30. The investigators also Corepower Yoga Workout evaluated the
phenomenological nature of these associations to identify patterns of association with vulnerability
and resilience. Approximately 93.4% of the sample was Caucasian, 2.6% was African American,
1.3% was Hispanic, and 2.6% identified as Other. All participants smoked cigarettes.
Findings indicated that mindful attention and awareness were significantly and strongly
concurrently predictive of level of PTSD symptom severity, psychiatric morbidity, anxious arousal,
and anhedonic depression. Statistical evaluation of the phenomenological pattern of
these associations indicated high levels of mindfulness exclusively co-occurred with low levels of
psychopathology symptoms or high rates of mental health. Low levels of mindfulness co-occurred
with a wide range of symptom levels. Limitations of this study include the methodology, which
precluded inferring causality. Further, it is not clear whether the results can be generalized to
exposure in war experiences. However, the study did include evidence of concurrent associations
between mindful attention and awareness and trauma-related psychopathology (Bernstein et al.,
2011).
* Sleep-focused mind-body bridging (MBB)
Nakamura et al. (2011) conducted a pilot randomized controlled trial of sleep-focused mind-body
bridging (MBB) to help veterans with PTSD and sleep disturbances. MBB incorporates mindfulnessbased cognitive behavior therapy (MBCT) and MBSR to comprise the mindfulness awareness
training program which focuses on mind training in regulating mental and physical states of the
person. There were 63 participants (male and female veterans 18-70 years old) with self-reported
sleep disturbances who received either MBB or an active sleep education control. Both
interventions were conducted in two sessions, once per week. A sleep hygiene program taught
participants to limit exercise, eating, alcohol and caffeine intake before bed, to use a bed
for sleeping, and to establish a regular bedtime. Each MBB session had objectives of identifying
causes of sleep difficulties and reducing daytime stress.
The study was conducted over 3 weeks and participants had two sessions of standard-of-care sleep
hygiene (SH) or MBB, which ran concurrently over two consecutive weeks, one per week for 1 hour
for SH and 1.5 hours for MBB. Awareness skills to help individuals calm the mind and relax the
body were taught. Participants used mind-body mapping exercises to write in a free association of
thought patterns, which helps identify unrealistic expectations.
This short study evaluated whether MBB could improve symptoms and other co-occurring symptoms
in veterans such as PTSD, depression, and health-related QOL. Additionally, the study assessed
whether MBB could increase mindfulness as an underlying mechanism. Results indicated
that sleep-focused MBB in two sessions greatly reduced patient-reported sleep disturbances and
PTSD symptoms and increased overall levels of mindfulness in comparison to those observed in the
standard-of care SH intervention. Mindfulness mechanisms did increase. However there was
no improvement in depression symptoms or QOL indices. Results suggested that the effectiveness
of mindfulness practice facilitated health and well-being including sleep and reductions in PTSD
symptoms. Using a mindfulness-based approach as an adjunct sleep intervention can be considered

for future interventions. Limitations of this study include the shortness of the treatment, the lack of
clinical evaluation for veterans who participated, and self-report data. Another weakness was the
lack of assessment of daily changes in sleep patterns based on sleep diary data and no follow-up
assessments.
* Yoga meditative therapy
Yoga is a meditative approach which incorporates mindfulness elements. According to a survey by
Libby et al. (2012), Yoga therapy for veterans with PTSD is effective when tailored to emphasize
autonomic regulation, mindfulness, and acceptance. The VA's Northeast Program Evaluation
Center (NEPEC) responsible for conducting evaluations of the VA Specialized PTSD treatment
programs required PTSD program coordinators to complete the survey. Libby et al. suggested that
Yoga therapy for veterans with PTSD can be customized to reinforce therapeutic concepts used in
other evidence-based practices for PTSD.
In another study, Emerson et al. (2009) reviewed the application of Yoga practices in treating war
veterans suffering from PTSD. They described how Yoga helps veterans recover from trauma by
learning to calm down or self-regulate. Emerson et al. indicated that Yoga practices including
mindfulness meditation can reduce autonomic sympathetic activation, muscle tension, and blood
pressure, and improve neuroendocrine and hormonal activity, and decrease physical symptoms
and emotional distress, thus increasing QOL. For these reasons, Yoga is a promising addition to
other interventions for addressing emotional, cognitive, and physiological symptoms associated with
PTSD.
In an article entitled Warriors at Peace by Neal Pollack (2010), combat veterans from the Vietnam
War, the Persian Gulf War, OEF, and OIF provided convincing testimonials for the efficacy of Yoga.
The article described symptoms associated with PTSD which included insomnia, nightmares,
migraines, anxiety, depression, disturbing memories, disconnectedness, inability to
focus/concentrate, anger, pain, confusion, and irritability. Pollack provided information about
the success of programs for veterans with PTSD including: There and Back Again (Charlestown,
Massachusetts); Yoga Warriors (Massachusetts); Yoga Center Yoga program at the Justice Resource
Institute (Brookline, Massachusetts); Integral Yoga Institute (New York, NY); the iRest
Yoga Programs offered at Integrative Restoration Institute (San Rafael, California); the Walter Reed
Army Medical Center, (Washington D. C.); the Miami and Chicago Army VA Hospitals; and Camp
Lejeune (North Carolina) (Pollack, 2010).
Further, in a recent study published in the Journal of Traumatic Stress, researchers identified Yoga
as beneficial for veterans with PTSD. The study focused on the effects of breathing-based
meditation, which balances the autonomic nervous system (Seppala et al., 2014)
The literature reviewed strongly indicates the efficacy of Yoga as a beneficial addition to other
psychotherapeutic interventions for veterans with PTSD.
* Loving-kindness meditation
The role of mindfulness meditation and conventional interventions for PTSD strive to alleviate
emotional suffering. Loving-kindness is a crucial ingredient in mindfulness meditation and "is
a complementary and alternative approach that facilitates increased positive emotions through
meditation exercises designed to develop feelings of kindness and compassion for self and others"
(Kearney et al., 2013b, p. 427).

Kearny et al. (2013b) conducted a pilot study with veterans with PTSD to assess feasibility of lovingkindness meditation as an intervention and to gather preliminary evidence on clinical
outcomes. Forty-two veterans with PTSD (58.1% male; 40% female, and 81.4% Caucasian)
participated in a 12week loving-kindness meditation course as an adjunct to their usual care at a VA
Hospital. The procedures included mindful breathing, loving-kindness meditation, repetition of
phrases, daily life integration of loving-kindness, and group discussion. Homework assignments
involved lessons learned in sessions and incorporation of loving-kindness meditation at home.
Results indicated increased self-compassion and mindfulness skills as well as reductions in
symptoms of PTSD and depression. The high rate of compliance with loving-kindness meditation
provided preliminary support for this kind of intervention with veterans with PTSD. Limitations
included the lack of a control group. Improvement might be due to nonspecific effects
of participation in group rather than specific effects of loving-kindness meditation. Additionally, the
sample was composed mainly of self-referred Caucasians who previously participated with a
MBSR program; thus, the findings could not be generalized. The follow-up was at 3-months and
longer follow-up would be needed to assess durability of improvements.
In summary, loving-kindness a crucial element of mindfulness can serve clinically meaningful
functions in alleviating PTSD symptoms in veterans (Vujanovic et al., 2013).
* Mantra meditation
Mantra meditation involves focusing on a word, phrase, or object to encourage relaxation.
Transcendental Meditation (TM) directs attention to a mantra that is repeated until the repetition
no longer requires conscious direction (Lang et al., 2012). A related practice is referred to as the
Mantram Repetition Program (MRP) which uses a sacred word or phrase that is repeated
intermittently.
In recent years, there has been a major effort to make mantra meditation available to veterans with
PTSD. For example, "Warrior Mind Training" is a course offered in some branches of the U.
S. military to decrease combatants' operational stress and PTSD (Lang et al., 2012). Another
example is evident in the film "Operation Warrior Wellness" created by David Lynch to provide tm to
veterans with PTSD (Lang et al., 2012). In fact, research indicates that the first studies of
meditative modalities for veterans with PTSD involved mantra meditation. These studies included
tm and mantra repetition, which reduced PTSD symptomatology for veterans with combatrelated trauma.
In a randomized clinical trial (RCT) with veterans diagnosed with PTSD, Bormann et al. (2013a)
explored the efficacy of the MRP that teaches three tools for training attention and regulating
emotion. The first tool is considered spiritual concentrative meditation in which a mantram (a
sacred word or phrase) is repeated silently throughout the day. The second tool taught is a slowing
down by thinking or acting intentionally and carefully for self-reflection, training awareness,
and setting priorities. The third tool is a one-pointed attention or mindfulness and involves
awareness of choice to purposely focus on one thing. These tools reflect elements of the mindfulness
meditative approach including; attention, awareness, and mindful of the moment-to-moment
without judgment. The trial was conducted with 146 outpatient veterans diagnosed with PTSD and
who were sober for at least 2 months prior to joining the study. Participants were confirmed
as having been on "stable types of medication and doses of psychotropic medications for at least
two months" (p. 261). Participants were randomly assigned to both medication and
case management alone (i.e., treatment-as-usual (TAU), or (b) TAU coupled with a 6-week psychoeducational group mantram repetition program (MRP + TAU). Participants in this group were asked
to record the number of days per week they practiced repeating mantrams and number of times per

day that mantram was initiated using portable wrist

http://www.holisticonline.com/Yoga/hol_yoga_benefits.htm counters and daily tracking forms. There
were 136 veterans (66 in MRP + TAU; 70 in tau) who completed posttreatment assessments.
Results indicated significantly greater symptom reductions in self-reported and clinician-rated
PTSD symptoms in the MRP + TAU compared with tau alone.
Results indicated that twice as many participants, 24% of MRP + TAU subjects, compared with 12%
tau subjects, had clinically meaningful improvements in PTSD symptom severity. MRP + TAU
subjects also reported significant improvements in depression, mental health status, and existential
spiritual well-being compared with tau subjects. A strength of this study is that veterans may seek
this type of treatment because it does not rely on psycho-pharmaceuticals. Another strength is that
MRP does not focus on trauma but tends to enhance spiritual well-being. One weakness of this
study was due to the tau group not meeting weekly during the 6-week intervention period and so
the results may be attributed to group social support rather than the MRP intervention. A second
weakness was that participants were self-selected and open to novel treatment modalities. Thirdly,
the participants were males and the findings cannot be generalized to women veterans.
Additionally, the researchers did not assess the presence of personality disorders (Bormann et al.,
2013a).
In a previous study Bormann et al. (2008) assessed the feasibility, effect sizes, and satisfaction of
mantram repetition, which requires the spiritual practice of repeating a sacred word or phrase
throughout the day in the management of symptoms of PTSD. There were 29 participants ranging
in age from 40 to 76 years. In terms of ethnicity, 66% were Caucasian, 14% were African American,
10% were Hispanic, and 10% were other. All had approximately 13 years of education and served in
the Vietnam, Korean, or the first Gulf Wars. A two group (intervention vs. control) by two time (preand post-intervention) experimental design was used. PTSD symptoms, psychological distress, QOL,
and patient satisfaction were measured. A 6-week (90 min/week) mantram intervention consisted of
a psycho-educational approach on the symptoms of PTSD and skills on how to choose and silently
repeat a mantram. Veterans were also taught the concepts of slowing down the thinking process,
setting priorities, and mindfulness as a focusing tool. Mantram participants also continued with
usual medical care.
The participants in the usual care delayed-treatment control group continued with their usual
medical care and medication. They did not have group meetings during the 6-week intervention
period. Findings indicated that compared to controls, the intervention group demonstrated reduced
PTSD symptom severity, psychological distress, and increased QOL and mindfulness. The clinicianassessed scores improved less dramatically. Results indicated that a spiritual program was
feasible for veterans with PTSD. They reported moderate to high satisfaction. Effect sizes showed
promise for symptom improvement but more research is needed. Results indicated potential for this
type of innovative, inexpensive alternative approach to treating PTSD. Limitations were the small
size sample and the lack of recruitment of veterans returning from Iraq or Afghanistan. As a result,
the findings cannot be generalized to veterans with PTSD with experiences in recent war-related
trauma (Bormann et al., 2008).
Bormann et al. (2013b) conducted a qualitative analysis of an MRP used for managing PTSD
symptoms in veterans with 65 outpatient veterans. The study was a companion to the Bormann et
al. (2008) study and used the data collected at that time. Ninety-eight percent of the sample
was male ranging in age between 39 and 75 and 37% were non-Caucasian. Eighty percent of the
participants experienced war zone combat trauma and 42% were wounded in combat. The MRP
consisted of six weekly group sessions (90min/wk) on how to choose and use a mantram, slow down
thoughts and behaviors, and develop mindfulness for emotional regulation. Critical incident

research technique interviews were conducted at 3 month postintervention. Interview categories

included triggering events and symptomatic responses, coping mechanisms, and associated
outcomes. A total of 268 triggering events were collected for analysis from the 65 participants who
completed the MRP. Findings indicated that in a wide range and variety of situations where
consistent use of mantram repetition was applied, the outcome was positive and prevented
violence and harm to others. Additionally, mantram improved interpersonal relationships with
family, friends, and strangers. Limitations of the study included the sample which was primarily
male, middle-aged, and with chronic PTSD. The MRP with the meditative technique including
the one-point mindfulness factor delivered in a psychoeducational format, could provide a holistic
approach for emotional regulation, reduce stigma of mental health treatment, and help veterans
who refuse or drop out of other trauma-focused therapies (Bormann et al., 2013b).
* Transcendental meditation (TM)
A pilot study on the effects of transcendental meditation (tm) in veterans of OEF and OIF with PTSD
was conducted by Rosenthal et al. (2011). Participants of OEF and OIF between 25 and 40 years of
age with a history of combat-related PTSD were recruited. Participants practiced tm for 20 minutes
twice a day. They were allowed to continue with their regimen of psychotropic medication. The
study was divided into a screening/baseline visit, tm instruction, an 8-week assessment,
data collection, and a 12 week final checkup. tm was taught over 3 consecutive days and
participants were asked to meditate 20 minutes twice a day for 12 weeks. Eleven veterans were
originally screened and seven were enrolled. Three subjects withdrew for various reasons including
redeployment. The results were based on the five remaining participants.
Findings indicated that subjects reported feeling calmer, less stressed, less anxious, and
improvement in their sleep. Veterans reported feeling "more alive," "happier," "more focused,"
deeply rested," "having a big weight lifted from my shoulders," "having clarity," and "having more
peace in life." Participants also reported improved communication with family, friends, and
coworkers and being more engaged in their daily lives. Limitations of this study were the small
sample size and the lack of a control group. A placebo effect could not be ruled out.
Brooks and Scarano (1985) conducted an earlier randomized controlled trial of the tm technique as
a treatment for combat-related PTSD among Vietnam War Veterans, which was important in
identifying the potential role of tm as an adjunct intervention. This study included a comparison
between tm and psychotherapy in the treatment of post-Vietnam adjustment. Eighteen male
Vietnam veterans were randomly selected to participate in one of two treatment groups. One group
was taught tm over a 4-day period and weekly follow-up meetings over a 3-month period. They were
instructed to meditate twice daily for 20 minutes. The participants assigned to the psychotherapy
group were provided weekly individual therapy and could have family counseling if wanted. The
psychotherapy was integrative, using various theoretical approaches including cognitive,
existential, and psychodynamic. Nine dependent variables were measured before and after the 3month period.
Results indicated that the tm group experienced significant improvement in symptomatology
including anxiety, depression, insomnia, and quality of life and stress reactivity. The therapy group
showed no significant improvement on any measure. One weakness of this study was the lack of a
control group. Also, it was not clear if all participants met full diagnostic criteria for PTSD. The
authors did not indicate if participants were allowed to continue with psychotropic
medications. Additionally, due to the small sample size the results could not be generalized to
others with PTSD (Brooks & Scarano, 1985).

The review of the studies of mantram repetition and tm techniques for PTSD has shown some
positive effects and potential. More research including studies with larger sample sizes, control
groups, heterogeneous participants, and follow-up would be beneficial.
* Integrating mindfulness with other interventions
Several attempts have been made to integrate cognitive behavior therapy (CBT) with meditation in
the treatment of veterans with PTSD using MBIS that spawned from MBSR. Some of these include;
(a) mindfulness-based cognitive therapy (MBCT; Segal et al., 2002); (b) dialectical behavior therapy
(DBT; Linehan, 1993); (c) acceptance and commitment therapy (ACT; Hayes et al., 1999); and (d)
mode deactivation therapy (MDT; Apsche et al., 2002).
* Mindfulness-based cognitive therapy (MBCT)
MBCT has mindfulness enhancement as a central element (Brown et al., 2007) and includes
monitoring of pleasant and unpleasant events and a variety of exercises for building awareness and
compassion which can be applied in treating veterans with PTSD. For example, Owens et al. (2012)
explored the relationship between mindfulness skills and PTSD for veterans through MBCT as an
adjunct to CPT. Findings suggested that mindfulness skills may help decrease symptoms in veterans
with PTSD. In another study of MBCT for combat veterans with PTSD, King et al. (2013) included
mindfulness-based facets including; mindful eating, body-scan, mindful stretching, mindfulness
meditation, and mindfulness breathing techniques. The outcomes seen in MBCT adapted for PTSD
were similar to effects of MBSR. Results indicated reduction in avoidant symptoms a common issue
among combat veterans. Also, mindfulness attention in a nonjudgmental approach through
acceptance led to decrease in self-blame and an increase in a positive worldview.
* Dialectical behavior therapy (DBT)
Central to DBT is the acceptance of change, emotion regulation, and distress tolerance. The
dialectics involve the desire for change and fear of failure. Veterans with PTSD who require emotion
regulation or a need to develop more appropriate distress tolerance can benefit from DBT. For
example, Becker and Zayfert (2001) described a program that integrates DBT strategies to facilitate
PE therapy. The program utilized all the DBT techniques and mindfulness skills. The authors
reported that mindfulness facilitated the PE process by teaching patients to selectively activate,
accept, and tolerate the experience of anxiety. The research reviewed supports the idea that DBT is
a comprehensive treatment to assist veterans with distress tolerance. DBT can be adapted to treat
psychosocial issues by addressing emotion regulation for veterans with PTSD resulting in QOL
improvement.
* Acceptance and commitment therapy (ACT)
ACT produces psychological flexibility through acceptance, commitment, and awareness in the
capacity for change. act can benefit veterans with PTSD in providing mindfulness exercises to
demonstrate how thoughts and memories of traumatic experiences can be safely
experienced (Vujanovic et al., 2013). Orsillo and Batten (2005) reviewed act in the treatment of
veterans with PTSD as a behavior therapy based on functional contextualism. Avoidance of external
or internal cues that can trigger re-experiencing of traumatic events is depicted as
emotional avoidance in veterans with PTSD. ACT specifically is directed at decreasing the veteran's
use of avoidance in coping with unwanted thoughts, feelings or memories, and "at increasing their
acceptance or willingness to experience private events while engaging in previously avoided
behavioral action" (p. 97). Through mindfulness exercises individuals can be taught to be aware of

private events without judging them or becoming caught in the content. ACT is a treatment that has
the potential to improve the treatment for veterans with PTSD.
* Mode deactivation therapy (MDT)
MDT shows promise for veterans with combat-related trauma and PTSD (MDT; Apsche et al., 2002).
MDT adapts CBT with mindfulness skills to regulate emotional reactivity, manage stress, and deactivate dysfunctional modes. MDT teaches "multiple paths to mindfulness" (Jennings & Apsche,
2014, p. 1). While MDT was originally developed to work with issues related to
personality disorders, conduct disorders, and childhood trauma (Swart & Apsche, 2014) this
modality can be applied to veterans with PTSD as this approach requires a shorter duration.
The above MBIS reviewed including MBSR, MBCT, DBT, act, and MDT are excellent modalities
which can be integrated with other psychotherapeutic approaches to treat veterans with combatrelated trauma and PTSD.
* Challenges to the use of MBIS
Firstly, consideration needs to be made for participants. For example, prior mental health
conditions, such as generalized anxiety, schizophrenia, bi-polar disorder, depression, or other
psychiatric issues, may make participation in mindfulness meditative practice for PTSD ineffective.
According to Smith (2005), meditation is not appropriate for people who have difficulty
concentrating, are easily distracted, or require a highly structured and familiar training
format. Mindfulness meditation may be contraindicated for people with obsessive-compulsive
disorder or schizophrenia because intense reactions can occur (Dobkin et al., 2011).
Further, Dobkin et al. (2011) inferred that in cases of clients experiencing current and past trauma
or situational life stressors, such as in divorce, transitions, retirement, or loss (e.g., financial
or death), mindfulness meditation may not be appropriate unless led by a clinician with expertise
using interventions for trauma-related experiences. This issue is critical when working with
veterans with combat-related trauma and PTSD.
Caution must be taken in the application of MBIS in group settings. Successful outcome depends
largely on the therapist's understanding of group dynamics. Through human interaction, group
members influence each other and the group as a whole. Careful attention is required to the course
of group development including: (a) dependency issues, (b) group affiliation, and (c) therapist
support (Williams et al., 2008). These key factors provide clarity as to whether MBIS are
responsible for achieving the therapeutic goal or if the outcome is due to the intrinsic therapeutic
effect of group work (Williams et al., 2008).
Fourth there is little consensus as to which type of meditation may be the most efficacious and
under what circumstances.
Lastly, meditation can be integrated with a variety of other CBT approaches in treating veterans
with PTSD. For example, DBT can facilitate exposure treatment facilitating cognitive
restructuring through mindfulness meditative skills training. Mindfulness is at the center of DBT
through awareness and allowing experiences nonjudgmentally rather than avoiding them.
Also, act is an intervention within the CBT modal which emphasizes cognitive processes and
emotional experiences. While CBT uses cognitive restructuring and formal reality testing to correct
faulty beliefs, act focuses on altering the context to enhance the QOL through

mindfulness meditative strategies.

Similar to CBT, MBCT undermines avoidance and treats thoughts as thoughts while focusing on
behaviors and exposure methods. However MBCT places little emphasis on changing the content of
thoughts but rather on changing the relationship and awareness to thoughts, feelings and
bodily sensations through mindfulness meditation.
* Conclusion and future considerations
Concurrent with the operational definition of mindfulness described as "self-regulation of attention,"
"the recognition of mental events occurring in the moment," and "adopting a particular orientation
toward one's experiences in the present moment that is characterized by curiosity, openness,
and acceptance" (Bishop et al., 2004, p. 232), MBIS in the treatment of veterans with PTSD fully
meets this descrpition. The pioneering, multi-component, mindfulness-based treatment programs
discussed in this paper have significance in understanding the relationship between experience,
emotions, behaviors, and the cognitive shifts that occur during the course of treatment for mental
disturbances and psycho-physiological disorders particularly for veterans who struggle with
combat-related trauma and PTSD. The studies indicate that effectiveness of mindful meditative
approaches in a variety of applications seems to be consistent in group settings, individual therapy,
or telehealth/teleconferencing modalities.

Researchers indicate successful treatment of PTSD, anxiety, and depression for veterans with the
application of mixed modality interventions that incorporate mindfulness training such as MBSR,
MBCT, act, and DBT. The meditative model and techniques referenced support the mindfulnessoriented approach for treating veterans with symptoms of PTSD. However, careful monitoring for
the intrinsic therapeutic effect of group work on outcome evaluation is required (Williams et al.,
2008).
Additionally, Yoga meditation, loving-kindness meditation, and mantra meditation and other mindful
interventions can mitigate chronic PTSD symptoms in veterans. These modalities also have potential
in facilitating other currently used therapies for treating veterans with combat-related trauma.
MBIS tend to be delivered in a group intervention format and are likely to be cost-effective.
Additionally, MBIS are acceptable, safe, and improve the clinical condition (Kearney et al., 2012)
and can be taught in the form of education rather than therapy, which reduces the stigma of mental
health treatment (Bormann et al., 2013a).
Mindfulness-based approaches in collaborative care formats show positive effects for Veterans with
PTSD. Further, MBIS coupled with first line treatments are excellent mixed-methods, nonpharmacological, therapeutic approaches for veterans with combat-related trauma and PTSD.

The integration of mindfulness treatments in VA PTSD programs is growing and presents an

opportunity for researchers to evaluate their effect on mental health service use and PTSD
symptoms among veterans (Libby et al., 2012). Future evidence-based investigations would
assist in clarification of MBIS as complementary interventions for veterans with PTSD. Future
research could focus on differentiating the mediating and moderating influence of each process
component in the MBIS coupled with other modalities to understand to what extent
mindfulness techniques contribute to change (Bass et al., 2014). This would assist in understanding
the factors that either interfere with or facilitate the implementation of MBIS for veterans with
PTSD.
Future work could focus on the refinement of mindfulness assessment tools that would be
consistent with the mindfulness skills developed in therapy and in understanding the role that MBIS
play with other treatment other than CBT modalities. Randomized clinical trials with meaningful
comparisons would be useful in showing how MBIS can enhance implementation of existing nonCBT interventions for PTSD among veterans. Only through coordinated first line primary mental
health and physiological care augmented with complementary and integrated modalities such as
MBIS will war veterans attain the level of biopsychosocial interventions they need to adapt to
postdeployment life.
Carol A. Steinberg and Donald A. Eisner Eisner Institute for Professional Studies
Address correspondence to Donald A. Eisner, Ph.D., J.D., Eisner Institute for Professional Studies,
16133 Ventura Blvd, Ste 700, Encino, CA 91436.
psychlaw@hotmail.com
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