Staff Perspective: Mindfulness for PTSD? Maybe It's Best to Sit on the Fence...For Now
As a way of living, mindfulness helps me to wake up to and move out of cycles of destructiveness and suffering.
Claude AnShin Thomas, Soto Zen priest, Vietnam Veteran, author of At Hell’s Gate: A Soldier’s Journey
Bodhidharma [speaking to his student] replied, “The highest subtle way of Buddha cannot be attained without immeasurably long training and almost unbearable effort. It cannot be achieved by puny virtue, shallow wisdom, faint inspiration, or self-conceit.”
The Gateless Gate, p.196, Kōun YamadaRoshi
Several years ago, I attended an all-day Zen retreat with Claude AnShin Thomas (AnShin means “peaceful mind”). After several hours of silent zazen (seated breath awareness meditation), I had the opportunity to meet with AnShin for a private interview. Although we only spoke for a brief period of time, one thing that he said really stuck with me. I can’t remember his exact words, but I remember him saying something like, “The challenge for combat veterans like me who have had the illusion of themis (divine order, fairness, law) shattered is to learn to live with their new reality. Dying is easy. We know how to do that.”
AnShin explained to me that he found a place for himself outside of “civilized” society, among those who are touched by war and violence. In fact, he spends most of his time traveling to areas of the world that are in the midst of war, doing what he can to bear witness to the suffering he finds there. AnShin’s main message is that mindfulness has allowed him to “wake up” to the seeds of anger and violence inside of himself. This, in turn, has allowed him and his students (many of them Veterans and Service members) to change their relationship to their own suffering and to avoid reactively passing that suffering on to others. AnShin is a remarkable man and I felt honored to sit with him that day.
Around the same time that I met AnShin, I was working in a VA hospital as a member of the Trauma Recovery Program. In addition to first-line treatments for PTSD such as Cognitive Processing Therapy (CPT) and Prolonged Exposure Therapy (PE), I was also facilitating mindfulness-based therapies. Typically, these were offered to Veterans and Service members who either did not wish to participate in Evidence Based Psychotherapy (EBP) or those who had completed it and were still struggling. Specifically, I offered a mindfulness practice group where Veterans and I got together for an hour, once a week, to practice seated breath awareness and walking meditation. I also offered eight-week Mindfulness-Based Stress Reduction (MBSR) and Mindfulness Based Cognitive Therapy (MBCT) groups from time to time.
Facilitating mindfulness felt both right and wrong at the same time. It felt right because it was some of the most honest clinical work I’ve ever done. I felt free to be open about that fact that I didn’t have all the answers and that suffering is a part of life, not something that can be simply eliminated by a technique. It also felt right because there was an intimacy and vulnerability about that work that I didn’t experience when doing CPT or PE. In the silence, we were just a bunch of human beings connected by our shared experience, doing our best to focus on the breath, to find a way to be at peace with things as they are.
At the same time, something didn’t feel quite right about facilitating these groups. I was very much still a student of meditation myself. Was I really qualified to be leading a meditation group? Could I honestly call myself a teacher? When a Veteran reported experiencing intrusive memories or strong emotions, I would often advise them to “just notice the experience,” “just sit with it,” “let go and come back to the breath,” or “tune into the body.” Was that ok? At least when I was doing CPT or PE, there were techniques and strategies that I could confidently suggest that were likely to reduce suffering, sometimes quickly. Mindfulness doesn’t work like that. It opens you up to everything in your experience: the good, the bad, the ugly, and sometimes the terrifying. Gradually, you find a spaciousness beneath it all that is big enough to hold all your experience. Old, entrenched patterns of self-defeating behavior soften to habits that become less automatic. But it is a very slow process. It is also an ongoing practice, and these shifts don’t “stick” if the practice is abandoned.
Many Veterans came to group a few times and left. In the several years I ran these groups, there were less than five that stuck with it for more than a few months. I had many more Veterans complete EBP, most experiencing significant benefit. I started to think that maybe I shouldn’t be teaching mindfulness at all. Once, I shared my concerns with one of those few Veterans who stuck it out, and he bluntly said, “You are doing the right thing. Veterans need this.” I believed him (and agreed), but still…
After a while, I decided to take a break from teaching mindfulness in a professional setting to deepen my own practice. I’ve often been asked how I became interested in mindfulness and mindfulness-based therapies. For better or worse, it all started with my own suffering. I was introduced to mindfulness as a depressed teenager by a teacher in high school. The First Noble Truth, “Life is Suffering,” rang true for me, as did the prospect that meditation could help relieve some of that suffering. However, it wasn't until my 30’s that I was able to maintain a consistent meditation practice. Burned out and depressed after leaving an incredibly stressful job, I bought Jon Kabat-Zinn’s book, Full Catastrophe Living and followed the eight-week MBSR protocol on my own. Then I completed MBSR with a wonderful teacher. In fact, I completed MBSR twice. These experiences were truly life changing, and helped me to start and maintain a consistent mindfulness practice. Inspired by these experiences, I attended a week-long MBCT teacher training and then realized that I needed the support of a group and a teacher to support my ongoing practice. This led me to find my Zen sangha (practice community) and current sensei, Bruce Seiryu (“Clear Stream”) Blackman. Since that time, I have sat zazen for hundreds and hundreds of hours. Just recently Sensei Blackman has given me the title of “Hoshi” or “Dharma Holder,” signifying that I am now a Zen teacher in training.
To be honest, I’m still not sure if I should be teaching mindfulness as a treatment for PTSD to Veterans and Service members. It’s also unclear to me if mindfulness should be offered as a general treatment for PTSD by most clinicians. The most up-to-date scientific literature and VA and DoD Guideline for the Management of PTSD (2017) are also “ambivalent” about the answer to this question. For example, the guideline states that there isn’t sufficient evidence to recommend or not recommend MBT as a treatment for PTSD. Even though there is a growing body of literature suggesting that MBT likely has some benefit for Veterans and Service memberss diagnosed with PTSD (Lang, 2017), I know from my own experience that the benefits of mindfulness practice take time to manifest themselves. Mindfulness practice can also be stressful and even physically and emotionally painful. You can feel like you are alone in a rowboat in the middle of the ocean during a hurricane at times. Without a qualified teacher with many years of training and practice under their belt, it can be tough to weather those storms. Mindfulness practice generally requires sustained commitment before meaningful and fundamental changes happen, and continued practice is required to maintain these changes. Plus, it is very difficult to maintain a practice without the long-term support of a community and that doesn’t fit well with the recovery-based, time-limited nature of EBP. Changes certainly can happen, but, as Sensei Bruce often says, “They are the side effects of your practice.”
I think it is human nature to view things as black-and-white. If we are not careful, the debate around mindfulness practice as a treatment for PTSD can be approached the same way. It’s important to value the experience of people like AnShin as well as the emerging data supporting mindfulness-based interventions. It’s also important to honor the 2,500+ year Buddhist traditions that have cultivated and refined mindfulness and meditation. These practices are deeply rooted in their own unique psychologies, ethics, and cultures. How many clinicians who have an interest in mindfulness truly appreciate this larger context when considering the utility of introducing mindfulness to their clients? Maybe it’s not a question of if mindfulness could be helpful to veterans and service members, but who is best equipped to teach them and under what conditions.
While these questions are being resolved, I highly recommend that you start your own meditation practice. If you like the idea of mindfulness as a treatment, you really ought to find out for yourself what the practice is really about. As any mediation teacher worth their salt will tell you, there really is no substitute for practice.
You may also want to watch the recording of Dr. Santanello's and Dr. Matt Sacks' CDP Presents webinar " Mindfulness-based Interventions for Service Members and Veterans"
The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.
Andrew Santanello, Psy.D., is a licensed, clinical psychologist and Military Behavioral Health Psychologist at the Center for Deployment Psychology (CDP) at the Uniformed Services University of the Health Sciences in Bethesda, Maryland.
References
Department of Veterans Affairs and Department of Defence (2017). VA/DoD Clinical Practice
Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder. Retreived from: https://www.healthquality.va.gov/guidelines/MH/ptsd/
Lang, A.J. (2017). Mindfulness in PTSD treatment. Current Opinion in Psychology, 14, 40–43.
Nishijima, G. W. & Bailey, J. (2009). To Meet the Real Dragon. New York: Dogen Sangha
Publications.
Thomas, C. A. (2013). At Hell’s Gate: A Soldier’s Journey. New York: Shambhala.
Yamada, K. The Gateless Gate. New York: Wisdom Publications.
As a way of living, mindfulness helps me to wake up to and move out of cycles of destructiveness and suffering.
Claude AnShin Thomas, Soto Zen priest, Vietnam Veteran, author of At Hell’s Gate: A Soldier’s Journey
Bodhidharma [speaking to his student] replied, “The highest subtle way of Buddha cannot be attained without immeasurably long training and almost unbearable effort. It cannot be achieved by puny virtue, shallow wisdom, faint inspiration, or self-conceit.”
The Gateless Gate, p.196, Kōun YamadaRoshi
Several years ago, I attended an all-day Zen retreat with Claude AnShin Thomas (AnShin means “peaceful mind”). After several hours of silent zazen (seated breath awareness meditation), I had the opportunity to meet with AnShin for a private interview. Although we only spoke for a brief period of time, one thing that he said really stuck with me. I can’t remember his exact words, but I remember him saying something like, “The challenge for combat veterans like me who have had the illusion of themis (divine order, fairness, law) shattered is to learn to live with their new reality. Dying is easy. We know how to do that.”
AnShin explained to me that he found a place for himself outside of “civilized” society, among those who are touched by war and violence. In fact, he spends most of his time traveling to areas of the world that are in the midst of war, doing what he can to bear witness to the suffering he finds there. AnShin’s main message is that mindfulness has allowed him to “wake up” to the seeds of anger and violence inside of himself. This, in turn, has allowed him and his students (many of them Veterans and Service members) to change their relationship to their own suffering and to avoid reactively passing that suffering on to others. AnShin is a remarkable man and I felt honored to sit with him that day.
Around the same time that I met AnShin, I was working in a VA hospital as a member of the Trauma Recovery Program. In addition to first-line treatments for PTSD such as Cognitive Processing Therapy (CPT) and Prolonged Exposure Therapy (PE), I was also facilitating mindfulness-based therapies. Typically, these were offered to Veterans and Service members who either did not wish to participate in Evidence Based Psychotherapy (EBP) or those who had completed it and were still struggling. Specifically, I offered a mindfulness practice group where Veterans and I got together for an hour, once a week, to practice seated breath awareness and walking meditation. I also offered eight-week Mindfulness-Based Stress Reduction (MBSR) and Mindfulness Based Cognitive Therapy (MBCT) groups from time to time.
Facilitating mindfulness felt both right and wrong at the same time. It felt right because it was some of the most honest clinical work I’ve ever done. I felt free to be open about that fact that I didn’t have all the answers and that suffering is a part of life, not something that can be simply eliminated by a technique. It also felt right because there was an intimacy and vulnerability about that work that I didn’t experience when doing CPT or PE. In the silence, we were just a bunch of human beings connected by our shared experience, doing our best to focus on the breath, to find a way to be at peace with things as they are.
At the same time, something didn’t feel quite right about facilitating these groups. I was very much still a student of meditation myself. Was I really qualified to be leading a meditation group? Could I honestly call myself a teacher? When a Veteran reported experiencing intrusive memories or strong emotions, I would often advise them to “just notice the experience,” “just sit with it,” “let go and come back to the breath,” or “tune into the body.” Was that ok? At least when I was doing CPT or PE, there were techniques and strategies that I could confidently suggest that were likely to reduce suffering, sometimes quickly. Mindfulness doesn’t work like that. It opens you up to everything in your experience: the good, the bad, the ugly, and sometimes the terrifying. Gradually, you find a spaciousness beneath it all that is big enough to hold all your experience. Old, entrenched patterns of self-defeating behavior soften to habits that become less automatic. But it is a very slow process. It is also an ongoing practice, and these shifts don’t “stick” if the practice is abandoned.
Many Veterans came to group a few times and left. In the several years I ran these groups, there were less than five that stuck with it for more than a few months. I had many more Veterans complete EBP, most experiencing significant benefit. I started to think that maybe I shouldn’t be teaching mindfulness at all. Once, I shared my concerns with one of those few Veterans who stuck it out, and he bluntly said, “You are doing the right thing. Veterans need this.” I believed him (and agreed), but still…
After a while, I decided to take a break from teaching mindfulness in a professional setting to deepen my own practice. I’ve often been asked how I became interested in mindfulness and mindfulness-based therapies. For better or worse, it all started with my own suffering. I was introduced to mindfulness as a depressed teenager by a teacher in high school. The First Noble Truth, “Life is Suffering,” rang true for me, as did the prospect that meditation could help relieve some of that suffering. However, it wasn't until my 30’s that I was able to maintain a consistent meditation practice. Burned out and depressed after leaving an incredibly stressful job, I bought Jon Kabat-Zinn’s book, Full Catastrophe Living and followed the eight-week MBSR protocol on my own. Then I completed MBSR with a wonderful teacher. In fact, I completed MBSR twice. These experiences were truly life changing, and helped me to start and maintain a consistent mindfulness practice. Inspired by these experiences, I attended a week-long MBCT teacher training and then realized that I needed the support of a group and a teacher to support my ongoing practice. This led me to find my Zen sangha (practice community) and current sensei, Bruce Seiryu (“Clear Stream”) Blackman. Since that time, I have sat zazen for hundreds and hundreds of hours. Just recently Sensei Blackman has given me the title of “Hoshi” or “Dharma Holder,” signifying that I am now a Zen teacher in training.
To be honest, I’m still not sure if I should be teaching mindfulness as a treatment for PTSD to Veterans and Service members. It’s also unclear to me if mindfulness should be offered as a general treatment for PTSD by most clinicians. The most up-to-date scientific literature and VA and DoD Guideline for the Management of PTSD (2017) are also “ambivalent” about the answer to this question. For example, the guideline states that there isn’t sufficient evidence to recommend or not recommend MBT as a treatment for PTSD. Even though there is a growing body of literature suggesting that MBT likely has some benefit for Veterans and Service memberss diagnosed with PTSD (Lang, 2017), I know from my own experience that the benefits of mindfulness practice take time to manifest themselves. Mindfulness practice can also be stressful and even physically and emotionally painful. You can feel like you are alone in a rowboat in the middle of the ocean during a hurricane at times. Without a qualified teacher with many years of training and practice under their belt, it can be tough to weather those storms. Mindfulness practice generally requires sustained commitment before meaningful and fundamental changes happen, and continued practice is required to maintain these changes. Plus, it is very difficult to maintain a practice without the long-term support of a community and that doesn’t fit well with the recovery-based, time-limited nature of EBP. Changes certainly can happen, but, as Sensei Bruce often says, “They are the side effects of your practice.”
I think it is human nature to view things as black-and-white. If we are not careful, the debate around mindfulness practice as a treatment for PTSD can be approached the same way. It’s important to value the experience of people like AnShin as well as the emerging data supporting mindfulness-based interventions. It’s also important to honor the 2,500+ year Buddhist traditions that have cultivated and refined mindfulness and meditation. These practices are deeply rooted in their own unique psychologies, ethics, and cultures. How many clinicians who have an interest in mindfulness truly appreciate this larger context when considering the utility of introducing mindfulness to their clients? Maybe it’s not a question of if mindfulness could be helpful to veterans and service members, but who is best equipped to teach them and under what conditions.
While these questions are being resolved, I highly recommend that you start your own meditation practice. If you like the idea of mindfulness as a treatment, you really ought to find out for yourself what the practice is really about. As any mediation teacher worth their salt will tell you, there really is no substitute for practice.
You may also want to watch the recording of Dr. Santanello's and Dr. Matt Sacks' CDP Presents webinar " Mindfulness-based Interventions for Service Members and Veterans"
The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.
Andrew Santanello, Psy.D., is a licensed, clinical psychologist and Military Behavioral Health Psychologist at the Center for Deployment Psychology (CDP) at the Uniformed Services University of the Health Sciences in Bethesda, Maryland.
References
Department of Veterans Affairs and Department of Defence (2017). VA/DoD Clinical Practice
Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder. Retreived from: https://www.healthquality.va.gov/guidelines/MH/ptsd/
Lang, A.J. (2017). Mindfulness in PTSD treatment. Current Opinion in Psychology, 14, 40–43.
Nishijima, G. W. & Bailey, J. (2009). To Meet the Real Dragon. New York: Dogen Sangha
Publications.
Thomas, C. A. (2013). At Hell’s Gate: A Soldier’s Journey. New York: Shambhala.
Yamada, K. The Gateless Gate. New York: Wisdom Publications.