Just Breathe

Can mindfulness help heal our wounded soldiers?
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Still from Escape Fire. (COURTESY OF AISLE C PRODUCTIONS)

Still from Escape Fire. (COURTESY OF AISLE C PRODUCTIONS)

We’ve written in the past about soldiers learning to use mindfulness on the battlefield. But what about veterans back home?

Tony King, a research assistant professor at the University of Michigan, started thinking about how vets might benefit from “mindfulness based cognitive therapy,” or MBCT, more than a decade ago. The therapy—which involves breathing, movement, and meditation—was originally developed for patients living with chronic and remitted depression. It focused on interrupting the constant spiral of negative thoughts and rumination that makes living with the disease a daily hell.

“Very often, depression can be about the past,” King explains, “ruminating over and over about losses or other terrible things that happened in the past. Anxiety, meanwhile, very often involves ruminating about terrible things that you’re afraid are going to happen in the future. But in the present, very often, there’s actually nothing terrible going on, and the act of recognizing that can be helpful.”

Individual, trauma-focused therapy remains far more effective in treating PTSD in veterans than any group therapy, mindful or otherwise.

MBCT showed great promise in combating depression. A 2010 study, published in the Archives of General Psychiatry, demonstrated that, among patients with remitted depression, a single, eight-week meditation class was just as effective in preventing relapse as 18 months of continued medication.

But King, a one-time novice Zen monastic and practicing student of Buddhism, wondered if the therapy might be adapted for victims of post-traumatic stress disorder.

“PTSD is often associated with avoidant behavior,” he says. “People sometimes construct their entire lives in such a way that they don’t have to be reminded of their trauma. A lot of times, this means constricting, making their world smaller. They have areas of safety. They won’t go certain places—won’t go to the supermarket, won’t watch certain television programs. This does seem to be a reasonable way of coping: if you have horrible memories, and they’re distressing to the point of being incapacitating, of course you want to avoid anything that triggers them. The problem is that this act of avoidance actually increases the symptoms. You learn that you can’t tolerate these things—that they’ll destroy you.”

Shopping in a supermarket is rarely dangerous, of course. But being a soldier in a Baghdad bazaar is. “There’s this transfer of fear onto things that are not dangerous, but they feel dangerous. And it’s a very real, felt sense.”

King and his colleagues decided to compare the efficacy of mindfulness therapy with traditional PTSD therapies offered to veterans. The researchers studied veterans getting two different kinds of therapies in a V.A. PTSD clinic: some received eight weeks of mindfulness therapy, and some received usual forms of group treatment. There were a handful of vets that resisted all the sitting and silent breathing—“I remember a veteran getting quite angry in a session, saying, ‘Why would you do this to me?’, because a memory came up”—but many more took to it. In addition to meditation, psychologists led the vets through “body scans,” stretching regimens, and a mindful eating practice known as “the raisin exercise.”

Some of the Korea and Vietnam veterans had spent more than 40 years keeping themselves obsessively busy, avoiding memories, and never sitting still. “And what do we do in mindfulness meditation?” King says. “We ask them to sit still! For 20 minutes!” But, he adds, “That was the whole idea. We wanted to do something different to break the cycle of avoidance.” As behavioral therapists are fond of saying, “A thought is not a fact.”

At the end of eight weeks, vets who completed the mindfulness group scored about 16 points lower on a standard, 22-item PTSD scale than they had before beginning therapy (the informal “cutoff” on this scale for PTSD diagnosis is 50 to 60). Members of the “treatment as usual” group, meanwhile, did not see their scores change significantly. The results were published online this month by the journal Depression and Anxiety.

King is the first to acknowledge that MBCT is just one tool among many for recovering veterans. In fact, he says, individual, trauma-focused therapy remains far more effective in treating PTSD in veterans than any group therapy, mindful or otherwise.

“If you believe the papers, and there are good papers, individual therapy looks like it’s effective about 75 percent of the time. People come in with PTSD and they come out either 'cured'"—that is, not having PTSD—"or at least substantially better.” One-on-one therapy with combat veterans might lead to a 25- to 50-point drop in PTSD severity, compared to published studies of traditional group therapy, most of which have shown less than 10-point drops. Mindfulness group therapy appears to fall somewhere in between.

Which is just the point. “There are people who, even if they know individual, trauma-focused therapy is effective, may not be ready or willing to do that. My rationale is that we really want to have multiple approaches. We’re very much focused on their everyday life. We’re focused on that supermarket.”

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