Mindfulness-based interventions for veterans withposttraumatic stress disorder.

The wars in Afghanistan and Iraq heighten the need for effectivepsychological treatment forveterans returning from combat who aresuffering from Posttraumatic Stress Disorder (PTSD; seeAmericanPsychiatric Association, DSM-5, 2014). Approximately 25.5% of returningveterans fromOperation Enduring Freedom (OEF) and Operation IraqiFreedom (OIF) present to the VeteransHealth 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 riskfor PTSD because of increased combat exposure whencompared with veterans of past militaryoperations. Veterans with traumaexposure and PTSD often experience co-occurring affectivedisordersincluding anxiety and depression (Owens et al., 2012).

This paper examines the efficacy of mindfulness meditation in thetreatment of veterans who aresuffering from PTSD. The benefits ofmeditation as a modality and future directions are explored

* What is mindfulness meditation?

Meditation may be broadly classified as concentrative ornon-concentrative (e.g., mindfulnessmeditation), depending on themanner in which mental attention is trained. Concentrativetechniquesinclude intense focus on a particular object (e.g., a candle flame orthe sensation ofbreathing); focus is repeatedly brought back to theobject if attention falters. In contrast, in non-concentrativetechniques like mindfulness meditation, individuals cultivate awarenessandacceptance of all mental events. The goal is to observemoment-to-moment shifts in internalexperiences without judging theircontent (Strauss et al., 2011).

The roots of mindfulness meditation can be traced to TibetanBuddhism practices, which weredesigned to evoke a new way ofperceiving. Mindfulness is a 2,500-year-old tradition devoted tomentaltraining. Mindfulness is grounded in human attention and awarenessmindfulness involvesintentionally 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 refineone's awareness.

Understanding one's mind through awareness cultivates kindnessand compassion toward oneself,which then extends to others (Bruce etal., 2010; Siegel, 2007b). Greeson's (2009) review ofmindfulnessresearch and theory supports the claim that mindfulness meditationincreasescompassion. Further, Siegel (2007a) suggested that mindfulnesspractice helps individuals acceptand embrace their minds with kindnessand compassion.

An appropriate operational definition of mindfulness focuses on theelements of cognitive processes(Bishop et al., 2004). These elementsinvolve "self-regulation of attention," "the recognitionofmental events occurring in the moment," and "adopting aparticular orientation toward one'sexperiences in the presentmoment that is characterized by curiosity, openness, andacceptance"(Bishop et al., 2004, p. 232). Mindfulness practice canbe used with other therapeutic skills such aswith mindfulnesscommunicating and listening. Furthermore, learning mindfulness providestheability to attune with others during healing and facilitates thedevelopment of empathy.

* History of mindfulness meditation

MBIS spawned from mindfulness-based stress reduction MBSR, whichbegan in 1979 at theUniversity of Massachusetts Medical Center. Brownet al. (2007) stated, "MBSR is most clearlyrooted in easternphilosophy and psychology, which emphasizes the importance ofexperiential,meditative practice as a primary vehicle for personaldevelopment and transformation" (p. 219). Asa student of Yoga,Vipassana (seeing clearly) meditation, and Zen, Jon Kabat-Zinn (founderofMBSR) included a range of informal and formal practices to cultivatemindfulness. Vipassana is aBuddhist tradition that works well inmainstream settings because it provides specific and directinstructionsfor sustaining attention and awareness. MBSR was developed to helppeople cope withchronic pain issues or stress-related disorders. Thisapproach explored human distress rather thanthe triggers.

Further, MBSR taught individuals to recognize and accept theirthoughts and feelings with anonjudgmental attitude; otherpsychotherapies focused on solutions to help peoplerestructurecognition and coping strategies (Silverton & Kabat-Zinn, 2012). MBSRincluded formaland informal practices for the cultivation ofmindfulness. Meditation is a primary means throughwhich mindfulness iscultivated. MBSR can be described as a psycho-educationalprogramfacilitated on a daily basis over an 8-week period that includes 2.5 to3 hour long classeswith one day of silence in the 6th or 7th week. MBSRcan assist veterans with a variety of physicalhealth conditions as wellas anxiety disorders, depression, and substance abuse issuesthatcommonly co-occur with PTSD. Mindfulness-based treatment for veteranswith PTSD combinesscientific analysis and narrative of mental stateswith calming MBSR and Buddhist strategies.Mindfulness focuses on simplemental awareness and acceptance of openhearted attention from onemomentto the next. It is a "way of being" (Kabat-Zinn, 1994, p. 4)in choosing to think non-judgmentally. MBIS can reduce posttraumaticstress in combat veterans (Rosenthal et al., 2011).

* Rationale for mindfulness meditation as treatment for PTSD

Mindfulness meditation does not require pharmaceuticalinterventions nor does it interfere withmedications. In fact, studiesindicate that meditation is an efficient adjunct to medication andcasemanagement in veterans with symptomatology related to exposure totrauma.

Results in currently used first line interventions for veteranswith PTSD including cognitiveprocessing therapy (CPT; Resick et al.,2007), prolonged exposure (PE) therapy (Foa et al.,2007),stressinoculation training (sit; Foa et al., 1999; Foa et al., 1991), and eyemovement desensitizationand reprocessing (EMDR; Shapiro 2001; Shapiro,1989) indicate that some individuals do not makeclinical gains andthere is a significant drop-out rate (Schottenbauer et al., 2008).

In addition to psychotherapeutic treatments for PTSD practiceguidelines recommendpharmacologic agents including serotonin-reuptakeinhibitors (SSRIS) and serotonin norepinephrinereuptake inhibitors(SNRIS) (Kearney et al., 2012). However, according to Kearny et al.(2012),behavioral interventions and pharmacological treatments reducethe hallmark features of chronicPTSD, but often fail to address thefull psychopathology. Augmenting treatments with mindfulnessmeditationhas the potential for improving care for veterans with PTSD (Hoge,2011). As such,integrating mindfulness meditation with psychotropic andpsychotherapeutic interventions is bestsuited for working with veteranswith PTSD. Veterans may choose this type of intervention becauseit isnonpharmacological and does not focus on trauma (Bormann et al., 2013b).

Another significant reason for utilizing MBIS in working withveterans with PTSD is the neurologicalchanges resulting frommindfulness meditation. For example, Singleton et al. (2014) found

thatparticipation in MBSR therapy increases gray matter concentration in thebrainstem. Holzel etal. (2011) also confirmed increases in gray matterconcentration, signifying that participation inMBSR is related withchanges in parts of the brain associated with learning and memoryprocesses,emotion regulation, and self-referential processing.

Also, MBIS enhance middle prefrontal lobe function, such asself-insight, morality, intuition, andfear modulation (Siegel, 2007a).Davidson (2000) indicated that activation of the middle prefrontallobecorresponds with faster recovery to baseline after being negativelyprovoked. Mindfulnesspractice activates the brain region associatedwith adaptive responses to stressful or negativesituations (Cahn &Polich, 2006). Based on the reviews, mindfulness meditation createslastingneurological benefits for veterans with PTSD for emotionregulation, fear modulation, memoryprocessing, and recovery from traumaexposure.

* Review of mindfulness meditation for veterans with PTSDmindfulness-based stress reduction(MBSR)

A study at the VA Puget Sound Health Care System, Seattle, WAdescribed the utility of MBSR withveterans experiencing PTSD. Kearny etal. (2013a) conducted a randomized controlled pilot studyon the effectsof participation in a mindfulness program for veterans with PTSD.Forty-sevenparticipants were randomized to MBSR or treatment-as-usual(tau). Data were collected from 25intervention group patients and 22patients in the control group at baseline. Assessments occurredatbaseline, 2 months, and 4 months follow-up. The MBSR followed the formatoriginally developedby Jon Kabat-Zinn (1982). The veterans practicedmeditation and had homework assignments.Participants developedattentional skills by placing sustained attention on a specificexperiencesuch as the breath and flexibility of attention by letting goof rumination. Body scan, gentle Yoga,meditation, and informalmindfulness were used with elements of loving-kindness, nonjudgment,andawareness. Participants in the tau group received usual care for PTSD.Findings indicated thatveterans with PTSD who took part in the MBSRreported improvement in mindfulness skills ascompared with thoseassigned to tau. The MBSR group also showed increased mentalhealth-related quality-of-life (QOL). Limitations of the study includedthe small sample and an activecontrol group. Another weakness was thelack of a formal assessment of PTSD at baseline. Also,treatmentfidelity to the MBSR program was not assessed. Lastly, many of theveterans in the taugroup were prescribed benzodiazepines, which couldhave influenced the results (Kearney et al.,2013a).

In a different study, Kearny et al. (2012) assessed mental healthoutcomes of veterans with PTSDwho participated in a MBSR program andreviewed the associated factors including depression,behavioralactivation, experiential avoidance, QOL, and mindfulness. MBSR wasprovided as anadjunct to the usual care of veterans at VA medicalcenter. The veterans' issues included PTSD,chronic pain,depression, and physical disability. The intervention was delivered bygroup to 74male and female veteran participants in an 8-week MBSRcourse. All participants continued theirusual psychiatric andpsychological care during the study. Participants met once per week(2.5hours per session) and practiced mindfulness meditation and Yoga. Themindfulnessinstructions in the class focused on attention and attitude,exercises, discussions, and homeworkassignments. Veterans were asked tobring sustained attention to an aspect of their experience(thought,emotion, or bodily sensation) and flexibility in the ability todisengage from ruminativecycles of thought (Kearny et al., 2012).Openness, loving-kindness, curiosity, and non-judging ofpresent-momentexperience including unpleasant experiences were encouraged. InformalMBSRhomework practices such as mindful eating were encouraged.Clinically significant change frombaseline in PTSD symptoms andfunctional status was calculated at the 2-month and 6-month timepoints.

Results indicated that veterans who participated in MBSRexperienced significant improvements inphysical QOL and mental health,including measures of PTSD, depression, experiential avoidance,andbehavioral activation. A strength of this study was that mindfulnessskills increased over thecourse of the study and increased mindfulnessplayed a role in the positive changes. One weaknessof the study was thelack of a randomized control group. Another limitation was the use ofself-report measures without a clinician interview to substantiateself-reports. Additionally, the studywas conducted with Caucasiansonly. However, the findings from this study provide support forthepotential for teaching MBSR to veterans with PTSD (Kearney et al.,2012).

MBSR significantly reduces self-reported distress, emotional andphysical symptoms, and mood anddisturbance in veterans with PTSD. Thus,based on empirical research one can conclude that MBSRhas a significantrole in the regulation of physical health as well as psychologicalstates in the QOLfor combat-related symptoms and PTSD in veterans.

* Three meditative techniques

Lang et al. (2012) reviewed the theoretical and empirical basis formeditation as an intervention forPTSD. Different mechanisms underliedifferent meditative approaches. Three meditation techniquesexamined inthis review include mindfulness meditation, mantra meditation, andcompassionmeditation. Firstly, Lang et al. described how mindfulnessmeditation can create cognitive changethat can be applied to PTSDveterans who demonstrate attentional bias toward trauma-relatedstimuli.Mindfulness can also be applied to deficits in cognition and the abilityto inhibit irrelevantinformation, both of which explain re-experiencingsymptoms. Additionally, mindfulness changescognitive styles of worryand rumination with greater attention to the present; this isassociatedwith lower PTSD symptom severity in trauma-exposed adults. Assuminganonjudgmental stance counteracts the tendency of people with PTSD tonegatively interpretexperiences and assists them to face fear-provokingstimuli. This key element of mindfulnesscounteracts avoidance, which isa common characteristic of veterans with PTSD.

Secondly, Lang et al. (2012) indicated that mantra meditation islinked to decreasing physiologicalarousal and heightening awareness ofone's thoughts facilitating emotional self-regulation. Thus, itcanserve as an intentional distraction to disturbing thoughts and behaviorsand allows "mindfuldistraction" (p. 768). Additionally,mantra meditation reduces the autonomic fight or flight responseandcounteracts this aspect of PTSD. These factors can be taught to veteranswith PTSD as acoping mechanism when memories are triggeredintentionally during PE therapy.

Thirdly, Lang et al. (2012) also described compassion meditation.Theoretically, this potentiallyleads to a heightened sense of warmthand closeness to others (Lang et al., 2012). This type ofmeditativeapproach has been linked to social connectedness and increases inpositive emotionleading to increases in personal resources, resilience,a sense of mastery, and social support, all ofwhich contribute to lifesatisfaction. Social connectedness can assist veterans with PTSD whofeeldetached and have difficulty with interpersonal relationships.Veterans with PTSD may also have adiminished ability to empathicallyconnect with others and deficits in empathy are reflected inverbalaggression in veterans with PTSD (Lang et al., 2012). As a result,veterans with PTSD canbenefit from an induction of positive emotions.Also, because PTSD is associated with autonomichyperarousal, positiveemotions can reduce anxiety-related reactivity and assist veteransindeveloping resilience and the ability to recover from negativeexperiences.

The three different types of meditative techniques reviewed wereconsidered to reducesymptomatology and improve quality of life (QOL)for people with PTSD. Findings indicate thatmindfulness meditation hasthe best empirical support for treatment of PTSD and may enhance

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

* Mindfulness-based practice and training

Vujanovic et al. (2013) reviewed how mindfulness meditation isadapted in the treatment of PTSDamong military veterans. Vujanovic etal. described difficulties integrating mindfulness-basedpractices andtraining clinicians to develop knowledge and the ability to alleviatepsychologicalproblems including PTSD among veterans. The researcherssuggested part of the problem was dueto the lack of consensus regardingthe definition of mindfulness (e.g. "as a state of mind," or"a traitof mind," and a "type of mental process")(Vujanovic et al., 2013, p. 22). Further, the researcherssuggested thatmindfulness assessments to evaluate effectiveness are always changing;refinementof these instruments would create a reliable method ofmeasurement for efficacy.

One weakness of Vujanovic et al's (2013) review was the lackof adequate research studies ofmindfulness treatment for veterans withPTSD and nonclinical populations. Another weakness wasthe reference toinconsistencies in the practice level. Practice levels improved andspread rapidlyover the past 10 years. Also, the authors'suggestion that the definition of mindfulness is confusingis dated.

* Mindfulness via telehealth

Niles et al. (2012) conducted a study of two telehealthinterventions for veterans with combat-related PTSD. The study comparedmindfulness meditation and psycho-educational treatmentsforcombat-related PTSD using a telehealth approach. There were twoin-person sessions and sixtelephone sessions used in both modalities.There were 33 male veteran participants with combat-related PTSD,between the ages of 23 and 66. Substance abuse was not an exclusioncriterion andparticipants were not required to discontinue ongoingtreatment with other mental health providersduring the 8-week studyperiod. Most participants were taking psychiatric medications, whichwereassessed throughout the study. Results indicated that telehealthtreatments for PTSD usingmindfulness was feasible and associated withhigh satisfaction rates in the treatment of PTSD forveterans.Compliance was very high for homework completion, and veterans engagedin sessionssubstantially more than the protocol requested. The studyprovides evidence that participation inmindfulness intervention viatelephone can reduce symptoms of PTSD more than thepsychoeducationintervention. Weaknesses of this study were the small sample size andthe factthat the participants in the psychoeducation group had greaterPTSD symptoms. Additionally, thebrief treatment would need to beextended in length or paired with other interventions to createlastingeffects (Niles et al., 2012).

* Facets of mindfulness

Boden et al. (2012) investigated changes in facets of mindfulnessmeditation and PTSD treatmentoutcome with military veterans. Theytested the prospective associations between pre-to post-treatmentchanges in facets of mindfulness and PTSD and depression severity attreatmentdischarge among 48 military veterans in residential PTSDtreatment adhering to a cognitive-behavioral framework. All participantsexperienced combat-related trauma. Facets of mindfulnessmeditation weremeasured using the Kentucky Inventory of Mindfulness Skills (KIMS; Baeret al.,2004). The findings indicated that elements of mindfulnessincreased during the course oftreatment. Changes in the facets ofmindfulness were associated with reductions in post-treatmentPTSD anddepression severity. Awareness and nonjudgmental acceptance wererecognized as corecomponents of mindfulness facets and strongpredictors of positive PTSD treatment outcome.Further, CBT for PTSD canfacilitate the development of acting with awareness and

nonjudgmentalacceptance. Limitations of this study were the lack of a control groupand the smallsample. Also, self-reported mindfulness may or may notrepresent actual change (Boden et al.,2012).

* Mindful attention and awareness

Bernstein et al. (2011) evaluated the concurrent relations betweenmindful attention and awarenessand psychopathology among trauma-exposedadults. Participants included 76 adults including 35women with averageage of 30. The investigators also Corepower Yoga Workout evaluated thephenomenological natureof these associations to identify patterns of association withvulnerabilityand resilience. Approximately 93.4% of the sample wasCaucasian, 2.6% was African American,1.3% was Hispanic, and 2.6%identified as Other. All participants smoked cigarettes.Findingsindicated that mindful attention and awareness were significantly andstronglyconcurrently predictive of level of PTSD symptom severity,psychiatric morbidity, anxious arousal,and anhedonic depression.Statistical evaluation of the phenomenological pattern oftheseassociations indicated high levels of mindfulness exclusivelyco-occurred with low levels ofpsychopathology symptoms or high rates ofmental health. Low levels of mindfulness co-occurredwith a wide rangeof symptom levels. Limitations of this study include the methodology,whichprecluded inferring causality. Further, it is not clear whetherthe results can be generalized toexposure in war experiences. However,the study did include evidence of concurrent associationsbetweenmindful 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 controlledtrial of sleep-focused mind-bodybridging (MBB) to help veterans withPTSD and sleep disturbances. MBB incorporates mindfulness-basedcognitive behavior therapy (MBCT) and MBSR to comprise the mindfulnessawarenesstraining program which focuses on mind training in regulatingmental and physical states of theperson. There were 63 participants(male and female veterans 18-70 years old) with self-reportedsleepdisturbances who received either MBB or an active sleep educationcontrol. Bothinterventions were conducted in two sessions, once perweek. A sleep hygiene program taughtparticipants to limit exercise,eating, alcohol and caffeine intake before bed, to use a bedforsleeping, and to establish a regular bedtime. Each MBB session hadobjectives of identifyingcauses of sleep difficulties and reducingdaytime stress.

The study was conducted over 3 weeks and participants had twosessions of standard-of-care sleephygiene (SH) or MBB, which ranconcurrently over two consecutive weeks, one per week for 1 hourfor SHand 1.5 hours for MBB. Awareness skills to help individuals calm themind and relax thebody were taught. Participants used mind-body mappingexercises to write in a free association ofthought patterns, whichhelps identify unrealistic expectations.

This short study evaluated whether MBB could improve symptoms andother co-occurring symptomsin veterans such as PTSD, depression, andhealth-related QOL. Additionally, the study assessedwhether MBB couldincrease mindfulness as an underlying mechanism. Results indicatedthatsleep-focused MBB in two sessions greatly reduced patient-reported sleepdisturbances andPTSD symptoms and increased overall levels ofmindfulness in comparison to those observed in thestandard-of care SHintervention. Mindfulness mechanisms did increase. However there wasnoimprovement in depression symptoms or QOL indices. Results suggestedthat the effectivenessof mindfulness practice facilitated health andwell-being including sleep and reductions in PTSDsymptoms. Using amindfulness-based approach as an adjunct sleep intervention can beconsidered

for future interventions. Limitations of this study includethe shortness of the treatment, the lack ofclinical evaluation forveterans who participated, and self-report data. Another weakness wasthelack of assessment of daily changes in sleep patterns based on sleepdiary data and no follow-upassessments.

* Yoga meditative therapy

Yoga is a meditative approach which incorporates mindfulnesselements. According to a survey byLibby et al. (2012), Yoga therapy forveterans with PTSD is effective when tailored to emphasizeautonomicregulation, mindfulness, and acceptance. The VA's Northeast ProgramEvaluationCenter (NEPEC) responsible for conducting evaluations of theVA Specialized PTSD treatmentprograms required PTSD programcoordinators to complete the survey. Libby et al. suggested thatYogatherapy for veterans with PTSD can be customized to reinforcetherapeutic concepts used inother evidence-based practices for PTSD.

In another study, Emerson et al. (2009) reviewed the application ofYoga practices in treating warveterans suffering from PTSD. Theydescribed how Yoga helps veterans recover from trauma bylearning tocalm down or self-regulate. Emerson et al. indicated that Yoga practicesincludingmindfulness meditation can reduce autonomic sympatheticactivation, muscle tension, and bloodpressure, and improveneuroendocrine and hormonal activity, and decrease physical symptomsandemotional distress, thus increasing QOL. For these reasons, Yoga is apromising addition toother interventions for addressing emotional,cognitive, and physiological symptoms associated withPTSD.

In an article entitled Warriors at Peace by Neal Pollack (2010),combat veterans from the VietnamWar, the Persian Gulf War, OEF, and OIFprovided convincing testimonials for the efficacy of Yoga.The articledescribed symptoms associated with PTSD which included insomnia,nightmares,migraines, anxiety, depression, disturbing memories,disconnectedness, inability tofocus/concentrate, anger, pain,confusion, and irritability. Pollack provided information aboutthesuccess of programs for veterans with PTSD including: There and BackAgain (Charlestown,Massachusetts); Yoga Warriors (Massachusetts); YogaCenter Yoga program at the Justice ResourceInstitute (Brookline,Massachusetts); Integral Yoga Institute (New York, NY); the iRestYogaPrograms offered at Integrative Restoration Institute (San Rafael,California); the Walter ReedArmy Medical Center, (Washington D. C.);the Miami and Chicago Army VA Hospitals; and CampLejeune (NorthCarolina) (Pollack, 2010).

Further, in a recent study published in the Journal of TraumaticStress, researchers identified Yogaas beneficial for veterans withPTSD. The study focused on the effects of breathing-basedmeditation,which balances the autonomic nervous system (Seppala et al., 2014)

The literature reviewed strongly indicates the efficacy of Yoga asa beneficial addition to otherpsychotherapeutic interventions forveterans with PTSD.

* Loving-kindness meditation

The role of mindfulness meditation and conventional interventionsfor PTSD strive to alleviateemotional suffering. Loving-kindness is acrucial ingredient in mindfulness meditation and "isacomplementary and alternative approach that facilitates increasedpositive emotions throughmeditation exercises designed to developfeelings of kindness and compassion for self and others"(Kearneyet al., 2013b, p. 427).

Kearny et al. (2013b) conducted a pilot study with veterans withPTSD to assess feasibility of loving-kindness meditation as anintervention and to gather preliminary evidence on clinicaloutcomes.Forty-two veterans with PTSD (58.1% male; 40% female, and 81.4%Caucasian)participated in a 12week loving-kindness meditation course asan adjunct to their usual care at a VAHospital. The procedures includedmindful breathing, loving-kindness meditation, repetition ofphrases,daily life integration of loving-kindness, and group discussion.Homework assignmentsinvolved lessons learned in sessions andincorporation of loving-kindness meditation at home.Results indicatedincreased self-compassion and mindfulness skills as well as reductionsinsymptoms of PTSD and depression. The high rate of compliance withloving-kindness meditationprovided preliminary support for this kind ofintervention with veterans with PTSD. Limitationsincluded the lack of acontrol group. Improvement might be due to nonspecific effectsofparticipation in group rather than specific effects of loving-kindnessmeditation. Additionally, thesample was composed mainly ofself-referred Caucasians who previously participated with aMBSRprogram; thus, the findings could not be generalized. The follow-up wasat 3-months andlonger follow-up would be needed to assess durability ofimprovements.

In summary, loving-kindness a crucial element of mindfulness canserve clinically meaningfulfunctions in alleviating PTSD symptoms inveterans (Vujanovic et al., 2013).

* Mantra meditation

Mantra meditation involves focusing on a word, phrase, or object toencourage relaxation.Transcendental Meditation (TM) directs attentionto a mantra that is repeated until the repetitionno longer requiresconscious direction (Lang et al., 2012). A related practice is referredto as theMantram Repetition Program (MRP) which uses a sacred word orphrase that is repeatedintermittently.

In recent years, there has been a major effort to make mantrameditation available to veterans withPTSD. For example, "WarriorMind Training" is a course offered in some branches of the U.S.military to decrease combatants' operational stress and PTSD (Langet al., 2012). Anotherexample is evident in the film "OperationWarrior Wellness" created by David Lynch to provide tm toveteranswith PTSD (Lang et al., 2012). In fact, research indicates that thefirst studies ofmeditative modalities for veterans with PTSD involvedmantra meditation. These studies includedtm and mantra repetition,which reduced PTSD symptomatology for veterans with combat-relatedtrauma.

In a randomized clinical trial (RCT) with veterans diagnosed withPTSD, Bormann et al. (2013a)explored the efficacy of the MRP thatteaches three tools for training attention and regulatingemotion. Thefirst tool is considered spiritual concentrative meditation in which amantram (asacred word or phrase) is repeated silently throughout theday. The second tool taught is a slowingdown by thinking or actingintentionally and carefully for self-reflection, training awareness,andsetting priorities. The third tool is a one-pointed attention ormindfulness and involvesawareness of choice to purposely focus on onething. These tools reflect elements of the mindfulnessmeditativeapproach including; attention, awareness, and mindful of themoment-to-momentwithout judgment. The trial was conducted with 146outpatient veterans diagnosed with PTSD andwho were sober for at least2 months prior to joining the study. Participants were confirmedashaving been on "stable types of medication and doses ofpsychotropic medications for at leasttwo months" (p. 261).Participants were randomly assigned to both medication andcasemanagement alone (i.e., treatment-as-usual (TAU), or (b) TAU coupledwith a 6-week psycho-educational group mantram repetition program (MRP +TAU). Participants in this group were askedto record the number of daysper week they practiced repeating mantrams and number of times per

daythat mantram was initiated using portable wristhttp://www.holisticonline.com/Yoga/hol_yoga_benefits.htm counters and dailytracking forms. Therewere 136 veterans (66 in MRP + TAU; 70 in tau) whocompleted posttreatment assessments.Results indicated significantlygreater symptom reductions in self-reported and clinician-ratedPTSDsymptoms in the MRP + TAU compared with tau alone.

Results indicated that twice as many participants, 24% of MRP + TAUsubjects, compared with 12%tau subjects, had clinically meaningfulimprovements in PTSD symptom severity. MRP + TAUsubjects also reportedsignificant improvements in depression, mental health status, andexistentialspiritual well-being compared with tau subjects. A strengthof this study is that veterans may seekthis type of treatment becauseit does not rely on psycho-pharmaceuticals. Another strength is thatMRPdoes not focus on trauma but tends to enhance spiritual well-being. Oneweakness of thisstudy was due to the tau group not meeting weeklyduring the 6-week intervention period and sothe results may beattributed to group social support rather than the MRP intervention. Asecondweakness was that participants were self-selected and open tonovel treatment modalities. Thirdly,the participants were males and thefindings cannot be generalized to women veterans.Additionally, theresearchers 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 ofmantram repetition, which requires thespiritual practice of repeating a sacred word or phrasethroughout theday in the management of symptoms of PTSD. There were 29 participantsrangingin age from 40 to 76 years. In terms of ethnicity, 66% wereCaucasian, 14% were African American,10% were Hispanic, and 10% wereother. All had approximately 13 years of education and served intheVietnam, Korean, or the first Gulf Wars. A two group (intervention vs.control) by two time (pre-and post-intervention) experimental designwas used. PTSD symptoms, psychological distress, QOL,and patientsatisfaction were measured. A 6-week (90 min/week) mantram interventionconsisted ofa psycho-educational approach on the symptoms of PTSD andskills on how to choose and silentlyrepeat a mantram. Veterans werealso taught the concepts of slowing down the thinking process,settingpriorities, and mindfulness as a focusing tool. Mantram participantsalso continued withusual medical care.

The participants in the usual care delayed-treatment control groupcontinued with their usualmedical care and medication. They did nothave group meetings during the 6-week interventionperiod. Findingsindicated that compared to controls, the intervention group demonstratedreducedPTSD symptom severity, psychological distress, and increased QOLand mindfulness. The clinician-assessed scores improved lessdramatically. Results indicated that a spiritual program wasfeasiblefor veterans with PTSD. They reported moderate to high satisfaction.Effect sizes showedpromise for symptom improvement but more research isneeded. Results indicated potential for thistype of innovative,inexpensive alternative approach to treating PTSD. Limitations were thesmallsize sample and the lack of recruitment of veterans returning fromIraq or Afghanistan. As a result,the findings cannot be generalized toveterans with PTSD with experiences in recent war-relatedtrauma(Bormann et al., 2008).

Bormann et al. (2013b) conducted a qualitative analysis of an MRPused for managing PTSDsymptoms in veterans with 65 outpatient veterans.The study was a companion to the Bormann etal. (2008) study and usedthe data collected at that time. Ninety-eight percent of the samplewasmale ranging in age between 39 and 75 and 37% were non-Caucasian. Eightypercent of theparticipants experienced war zone combat trauma and 42%were wounded in combat. The MRPconsisted of six weekly group sessions(90min/wk) on how to choose and use a mantram, slow downthoughts andbehaviors, and develop mindfulness for emotional regulation. Criticalincident

research technique interviews were conducted at 3 monthpostintervention. Interview categoriesincluded triggering events andsymptomatic responses, coping mechanisms, and associatedoutcomes. Atotal of 268 triggering events were collected for analysis from the 65participants whocompleted the MRP. Findings indicated that in a widerange and variety of situations whereconsistent use of mantramrepetition was applied, the outcome was positive and preventedviolenceand harm to others. Additionally, mantram improved interpersonalrelationships withfamily, friends, and strangers. Limitations of thestudy included the sample which was primarilymale, middle-aged, andwith chronic PTSD. The MRP with the meditative technique includingtheone-point mindfulness factor delivered in a psychoeducational format,could provide a holisticapproach for emotional regulation, reducestigma of mental health treatment, and help veteranswho refuse or dropout of other trauma-focused therapies (Bormann et al., 2013b).

* Transcendental meditation (TM)

A pilot study on the effects of transcendental meditation (tm) inveterans of OEF and OIF with PTSDwas conducted by Rosenthal et al.(2011). Participants of OEF and OIF between 25 and 40 years ofage witha history of combat-related PTSD were recruited. Participants practicedtm for 20 minutestwice a day. They were allowed to continue with theirregimen of psychotropic medication. Thestudy was divided into ascreening/baseline visit, tm instruction, an 8-week assessment,datacollection, and a 12 week final checkup. tm was taught over 3consecutive days andparticipants were asked to meditate 20 minutestwice a day for 12 weeks. Eleven veterans wereoriginally screened andseven were enrolled. Three subjects withdrew for various reasonsincludingredeployment. The results were based on the five remainingparticipants.

Findings indicated that subjects reported feeling calmer, lessstressed, less anxious, andimprovement in their sleep. Veteransreported feeling "more alive," "happier," "morefocused,"deeply rested," "having a big weight liftedfrom my shoulders," "having clarity," and "havingmorepeace in life." Participants also reported improvedcommunication with family, friends, andcoworkers and being more engagedin their daily lives. Limitations of this study were the smallsamplesize and the lack of a control group. A placebo effect could not beruled out.

Brooks and Scarano (1985) conducted an earlier randomizedcontrolled trial of the tm technique asa treatment for combat-relatedPTSD among Vietnam War Veterans, which was important inidentifying thepotential role of tm as an adjunct intervention. This study included acomparisonbetween tm and psychotherapy in the treatment of post-Vietnamadjustment. Eighteen maleVietnam veterans were randomly selected toparticipate in one of two treatment groups. One groupwas taught tm overa 4-day period and weekly follow-up meetings over a 3-month period. Theywereinstructed to meditate twice daily for 20 minutes. The participantsassigned to the psychotherapygroup were provided weekly individualtherapy and could have family counseling if wanted. Thepsychotherapywas integrative, using various theoretical approaches includingcognitive,existential, and psychodynamic. Nine dependent variables weremeasured before and after the 3-month period.

Results indicated that the tm group experienced significantimprovement in symptomatologyincluding anxiety, depression, insomnia,and quality of life and stress reactivity. The therapy groupshowed nosignificant improvement on any measure. One weakness of this study wasthe lack of acontrol group. Also, it was not clear if all participantsmet full diagnostic criteria for PTSD. Theauthors did not indicate ifparticipants were allowed to continue with psychotropicmedications.Additionally, due to the small sample size the results could not begeneralized toothers with PTSD (Brooks & Scarano, 1985).

The review of the studies of mantram repetition and tm techniquesfor PTSD has shown somepositive effects and potential. More researchincluding studies with larger sample sizes, controlgroups,heterogeneous participants, and follow-up would be beneficial.

* Integrating mindfulness with other interventions

Several attempts have been made to integrate cognitive behaviortherapy (CBT) with meditation inthe treatment of veterans with PTSDusing 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 andcommitment therapy (ACT; Hayes et al., 1999); and (d)mode deactivationtherapy (MDT; Apsche et al., 2002).

* Mindfulness-based cognitive therapy (MBCT)

MBCT has mindfulness enhancement as a central element (Brown etal., 2007) and includesmonitoring of pleasant and unpleasant events anda variety of exercises for building awareness andcompassion which canbe applied in treating veterans with PTSD. For example, Owens et al.(2012)explored the relationship between mindfulness skills and PTSD forveterans through MBCT as anadjunct to CPT. Findings suggested thatmindfulness skills may help decrease symptoms in veteranswith PTSD. Inanother study of MBCT for combat veterans with PTSD, King et al. (2013)includedmindfulness-based facets including; mindful eating, body-scan,mindful stretching, mindfulnessmeditation, and mindfulness breathingtechniques. The outcomes seen in MBCT adapted for PTSDwere similar toeffects of MBSR. Results indicated reduction in avoidant symptoms acommon issueamong combat veterans. Also, mindfulness attention in anonjudgmental approach throughacceptance led to decrease in self-blameand an increase in a positive worldview.

* Dialectical behavior therapy (DBT)

Central to DBT is the acceptance of change, emotion regulation, anddistress tolerance. Thedialectics involve the desire for change andfear of failure. Veterans with PTSD who require emotionregulation or aneed to develop more appropriate distress tolerance can benefit fromDBT. Forexample, Becker and Zayfert (2001) described a program thatintegrates DBT strategies to facilitatePE therapy. The program utilizedall the DBT techniques and mindfulness skills. The authorsreported thatmindfulness facilitated the PE process by teaching patients toselectively activate,accept, and tolerate the experience of anxiety.The research reviewed supports the idea that DBT isa comprehensivetreatment to assist veterans with distress tolerance. DBT can be adaptedto treatpsychosocial issues by addressing emotion regulation forveterans with PTSD resulting in QOLimprovement.

* Acceptance and commitment therapy (ACT)

ACT produces psychological flexibility through acceptance,commitment, and awareness in thecapacity for change. act can benefitveterans with PTSD in providing mindfulness exercises todemonstrate howthoughts and memories of traumatic experiences can be safelyexperienced(Vujanovic et al., 2013). Orsillo and Batten (2005) reviewed act in thetreatment ofveterans with PTSD as a behavior therapy based onfunctional contextualism. Avoidance of externalor internal cues thatcan trigger re-experiencing of traumatic events is depicted asemotionalavoidance in veterans with PTSD. ACT specifically is directed atdecreasing the veteran'suse of avoidance in coping with unwantedthoughts, feelings or memories, and "at increasing theiracceptanceor willingness to experience private events while engaging in previouslyavoidedbehavioral action" (p. 97). Through mindfulness exercisesindividuals can be taught to be aware of

private events without judgingthem or becoming caught in the content. ACT is a treatment that hasthepotential 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 toregulate emotional reactivity, manage stress, and de-activatedysfunctional modes. MDT teaches "multiple paths tomindfulness" (Jennings & Apsche,2014, p. 1). While MDT wasoriginally developed to work with issues related topersonalitydisorders, conduct disorders, and childhood trauma (Swart & Apsche,2014) thismodality can be applied to veterans with PTSD as thisapproach requires a shorter duration.

The above MBIS reviewed including MBSR, MBCT, DBT, act, and MDT areexcellent modalitieswhich can be integrated with otherpsychotherapeutic approaches to treat veterans with combat-relatedtrauma and PTSD.

* Challenges to the use of MBIS

Firstly, consideration needs to be made for participants. Forexample, prior mental healthconditions, such as generalized anxiety,schizophrenia, bi-polar disorder, depression, or otherpsychiatricissues, may make participation in mindfulness meditative practice forPTSD ineffective.According to Smith (2005), meditation is notappropriate for people who have difficultyconcentrating, are easilydistracted, or require a highly structured and familiar trainingformat.Mindfulness meditation may be contraindicated for people withobsessive-compulsivedisorder or schizophrenia because intense reactionscan occur (Dobkin et al., 2011).

Further, Dobkin et al. (2011) inferred that in cases of clientsexperiencing current and past traumaor situational life stressors, suchas in divorce, transitions, retirement, or loss (e.g., financialordeath), mindfulness meditation may not be appropriate unless led by aclinician with expertiseusing interventions for trauma-relatedexperiences. This issue is critical when working withveterans withcombat-related trauma and PTSD.

Caution must be taken in the application of MBIS in group settings.Successful outcome dependslargely on the therapist's understandingof group dynamics. Through human interaction, groupmembers influenceeach other and the group as a whole. Careful attention is required tothe courseof group development including: (a) dependency issues, (b)group affiliation, and (c) therapistsupport (Williams et al., 2008).These key factors provide clarity as to whether MBIS areresponsible forachieving the therapeutic goal or if the outcome is due to the intrinsictherapeuticeffect of group work (Williams et al., 2008).

Fourth there is little consensus as to which type of meditation maybe the most efficacious andunder what circumstances.

Lastly, meditation can be integrated with a variety of other CBTapproaches in treating veteranswith PTSD. For example, DBT canfacilitate exposure treatment facilitating cognitiverestructuringthrough mindfulness meditative skills training. Mindfulness is at thecenter of DBTthrough awareness and allowing experiences nonjudgmentallyrather than avoiding them.

Also, act is an intervention within the CBT modal which emphasizescognitive processes andemotional experiences. While CBT uses cognitiverestructuring and formal reality testing to correctfaulty beliefs, actfocuses on altering the context to enhance the QOL through

mindfulnessmeditative strategies.

Similar to CBT, MBCT undermines avoidance and treats thoughts asthoughts while focusing onbehaviors and exposure methods. However MBCTplaces little emphasis on changing the content ofthoughts but rather onchanging the relationship and awareness to thoughts, feelings andbodilysensations through mindfulness meditation.

* Conclusion and future considerations

Concurrent with the operational definition of mindfulness describedas "self-regulation of attention,""the recognition ofmental events occurring in the moment," and "adopting aparticular orientationtoward one's experiences in the presentmoment that is characterized by curiosity, openness,andacceptance" (Bishop et al., 2004, p. 232), MBIS in the treatment ofveterans with PTSD fullymeets this descrpition. The pioneering,multi-component, mindfulness-based treatment programsdiscussed in thispaper have significance in understanding the relationship betweenexperience,emotions, behaviors, and the cognitive shifts that occurduring the course of treatment for mentaldisturbances andpsycho-physiological disorders particularly for veterans who strugglewithcombat-related trauma and PTSD. The studies indicate thateffectiveness of mindful meditativeapproaches in a variety ofapplications seems to be consistent in group settings, individualtherapy,or telehealth/teleconferencing modalities.

Researchers indicate successful treatment of PTSD, anxiety, anddepression for veterans with theapplication of mixed modalityinterventions that incorporate mindfulness training such as MBSR,MBCT,act, and DBT. The meditative model and techniques referenced support themindfulness-oriented approach for treating veterans with symptoms ofPTSD. However, careful monitoring forthe intrinsic therapeutic effectof group work on outcome evaluation is required (Williams et al.,2008).

Additionally, Yoga meditation, loving-kindness meditation, andmantra meditation and other mindfulinterventions can mitigate chronicPTSD symptoms in veterans. These modalities also have potentialinfacilitating other currently used therapies for treating veterans withcombat-related trauma.

MBIS tend to be delivered in a group intervention format and arelikely to be cost-effective.Additionally, MBIS are acceptable, safe,and improve the clinical condition (Kearney et al., 2012)and can betaught in the form of education rather than therapy, which reduces thestigma of mentalhealth treatment (Bormann et al., 2013a).

Mindfulness-based approaches in collaborative care formats showpositive effects for Veterans withPTSD. Further, MBIS coupled withfirst line treatments are excellent mixed-methods, non-pharmacological,therapeutic approaches for veterans with combat-related trauma and PTSD.

The integration of mindfulness treatments in VA PTSD programs isgrowing and presents anopportunity for researchers to evaluate theireffect on mental health service use and PTSDsymptoms among veterans(Libby et al., 2012). Future evidence-based investigations wouldassistin clarification of MBIS as complementary interventions for veteranswith PTSD. Futureresearch could focus on differentiating the mediatingand moderating influence of each processcomponent in the MBIS coupledwith other modalities to understand to what extentmindfulnesstechniques contribute to change (Bass et al., 2014). This would assistin understandingthe factors that either interfere with or facilitatethe implementation of MBIS for veterans withPTSD.

Future work could focus on the refinement of mindfulness assessmenttools that would beconsistent with the mindfulness skills developed intherapy and in understanding the role that MBISplay with othertreatment other than CBT modalities. Randomized clinical trials withmeaningfulcomparisons would be useful in showing how MBIS can enhanceimplementation of existing non-CBT interventions for PTSD amongveterans. Only through coordinated first line primary mentalhealth andphysiological care augmented with complementary and integratedmodalities such asMBIS will war veterans attain the level ofbiopsychosocial interventions they need to adapt topostdeployment life.

Carol A. Steinberg and Donald A. Eisner Eisner Institute forProfessional Studies

Address correspondence to Donald A. Eisner, Ph.D., J.D., EisnerInstitute for Professional Studies,16133 Ventura Blvd, Ste 700, Encino,CA 91436.

psychlaw@hotmail.com

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