It’s Wednesday afternoon, and I’m sitting, cross-legged, on a meditation cushion in the dayroom at a Veteran’s hospital. There are 13 Veterans sitting around the room; some of them are outpatients and some of them are participants in a residential PTSD program. Some of them are sitting on cushions, but most of them are in chairs. Another psychologist and a few psychology interns are there, too. We are all sitting in silence. About seven minutes into the final period of practice in our mindfulness group, the thought that I knew was coming finally presents itself, front and center, in my mind. I observe the thought as it materializes and resist the urge to find an answer. The thought just sits there, hovering in my consciousness, challenging me to look beyond a simple “yes” or “no.” Time goes by, my cell phone vibrates against my leg, signaling that it is time to ring the bell, ending this period of practice. As the Veterans in group begin to share their experiences of practicing together, the thought is still with me. It demands an answer and yet there just doesn’t seem to be anyone or anything that can provide the information that would satisfy the question. As group ends, I thank everyone for coming to practice with me and encourage each person to work toward developing and maintaining a daily mindfulness practice. I call this my “used car salesman” routine. That usually gets a laugh or two. A few Veterans in group make a point to catch me after the session to say that they enjoyed practicing, and thank me for leading the group. The thought jumps right to the front of my mind yet again:
“Should I be teaching Veterans to meditate?”
Over the course of my career, I have been fortunate to have the opportunity to lead many different mindfulness groups for Veterans in both outpatient and residential settings. Some of these groups were essentially meditation groups in which participants learned and practiced different types of meditation (e.g., mindfulness of the breath, walking meditation). Others were more traditional therapy groups that included mindfulness exercises. One of the first groups that I facilitated was in a residential program at a VA hospital about ten years ago. We had lost some staff and were in the middle of a major shift in programming, so I was asked to develop a group for the schedule. This weekly, “drop in” meditation group included basic instruction in the mechanics of sitting meditation and a brief (20 minute) period of silent meditation. Several Veterans attended the group on a regular basis, and a few seemed to really connect with the practice. In fact, I ran into two Veterans from this first group in the last year, and both of them told me that they have continued their practice and have joined meditation groups in the community. At the time, I had training in Acceptance and Commitment Therapy (which includes mindfulness-based interventions) and a strong personal mindfulness practice which was bolstered by completing two Mindfulness-Based Stress Reduction (MBSR) courses in my personal life, but I was still concerned that my competence to deliver mindfulness-based interventions with fidelity was not where it needed to be. I definitely didn’t consider myself to be an expert. So, I attended a week-long teacher training workshop in Mindfulness-Based Cognitive Therapy (MBCT) for Depression. It was a rare and wonderful training experience, and it was really a great opportunity for me to learn the “nuts and bolts” of MBCT. Completing the training also helped me to feel a little more confident in my ability to teach mindfulness and encouraged me to continue, but I could not completely resolve a lingering doubt:
Should I be teaching Veterans to meditate?
Another important consideration was the fact that I was delivering mindfulness-based interventions exclusively to Veterans with a diagnosis of PTSD. Was this appropriate? As a clinician who strongly values evidence-based psychotherapy, I was providing both Cognitive Processing Therapy (CPT) and Prolonged Exposure (PE) therapy as a first line treatment as recommended by VA/DoD guidelines. However, was it consistent with my value to offer adjunctive, mindfulness-based interventions that have limited (albeit promising) empirical support (e.g., Hoffman, Sawyer, Witt, & Oh, 2010; Khoury et al., 2013) to this population that is deserving of the very best that we have to offer? Many Veterans have informed me that they found the mindfulness skills that they learned in group to be quite helpful in coping with symptoms of PTSD, depression, anger, and even urges to use substances. Also, I knew that mindfulness had made a big difference in my life. Mindfulness practice is my “go to strategy” for managing work-related stress and fending off vicarious traumatization. Beyond that, mindfulness practice has been the only thing that I have found to be consistently helpful in managing the chronic bouts of depression that have plagued me since I was a pre-teen. By sitting in the stillness and quiet with my breath, I’ve learned how to interrupt the rumination that transforms mood shifts into depressive episodes and to let go of even the darkest thoughts, no matter how “true” they may seem at the time. I don’t think that it would be hyperbole to say that mindfulness has been a real lifesaver for me. Luckily, it’s been years since my last major depressive episode, but I know that, if I don’t keep up with my practice, another major depressive episode is probably not far away. In short, mindfulness is very good for me, but does that mean it’s good for my clients? How much should I take into account my personal experiences with the benefits of mindfulness in my clinical decision making? I worried that this may be risky at best and unethical at worst.
From there, the questions get even more difficult to answer. Who is qualified to be a mindfulness teacher? What are the “minimum requirements?” Is it really enough to satisfy a set of arbitrary “minimum requirements” or is there something more that distinguishes a genuine teacher from a well-intentioned, but ultimately unqualified mindfulness-enthusiast? It doesn’t seem right for “just anybody” to be a meditation teacher. I have been lucky to work with several Zen teachers over the past few years, and they are all amazing people. My current sensei practiced with his teachers for over 20 years before he was given permission to start a community and teach on his own. He has a “presence” about him that is hard to describe. Most yoga instructors need at least 200 hours of intensive instruction before they are certified as teachers. Good yoga instructors don’t teach from a manual and typically seem to intuitively know just the right adjustments to make for their students to really help them “embody” the various yoga postures. To become a certified MBSR instructor, one must complete a long and intensive training and evaluation process. There is also some evidence that specialized training and experience that therapists have in mindfulness-based therapies may be a key, moderating variable that affects the “power” of mindfulness-based interventions to reduce symptoms of anxiety and depression (Khoury, et al., 2013). Although I have some training and supervision in mindfulness-based therapies, I’m not a “certified” MBSR teacher. I haven’t been given “permission” to teach by a recognized and legitimate authority on mindfulness. I don’t have a piece of paper saying that I’ve fulfilled all the requirements necessary to teach mindfulness in a competent manner. I am most definitely not “enlightened” or particularly “advanced” in my own practice, whatever that means. When is someone really qualified to teach even basic mindfulness skills? Even if they are “qualified,” does that mean that they have the right “presence” or temperament to teach?
Should I be teaching Veterans to meditate?
This particular question is especially resistant to any sort of logical answer. In this respect, it is somewhat like a Zen koan. Koans have a long and storied history as a teaching tool used by Zen teachers, beginning in China around the beginning of the Middle Ages. Koans tend to be misunderstood as seemingly unsolvable riddles that demand a really creative response (e.g., Bart Simpson clapping the fingers and palm of one hand together in response to the koan,“What is the sound of one hand clapping?”). However, koans aren’t puzzles, per se, and when given to a student by a teacher, they aren’t given to test the student’s cleverness. Rather, these brief phrases, questions, or stories are designed to encourage the student to let go of his or her normal way of processing and understanding life through discriminative thought. They push the student beyond thought and into their lived experience of each moment. Attempting to “solve” a koan with logic and reason will only lead to more confusion. As a student of Zen, I’m becoming somewhat of an expert in failing to provide my teacher with an adequate response to my koan. I think that this is probably a sign of progress. Out of the frustration of confusion comes a sense that there is something orienting and important about the state of mind that results from finally “giving up” on the effort to “figure things out.” I’m not sure if koans are really ever “solved.” In fact, I think that is the source of their effectiveness. Instead of offering a simple solution to life’s problems, they help to “wake us up” so that we can cut through the veil of our endless thinking. This allows us to actually see what is most important and then reorient ourselves toward whatever that happens to be.
In my professional life, the question, “should I be teaching Veterans to meditate?” has been something of a koan on which I’ve been working for a long time. I’ve found that the “answer” to the koan changes depending on the context. There is no such thing as the “mindfulness police,” and a therapist teaching a client to pay attention to their breathing or do a few light yoga poses isn’t likely to get a “cease and desist” letter from the Dalai Lama. So, if you want to offer mindfulness to a Veteran or Service member as part of your treatment plan, how do you decide if and when this is appropriate?
In part two of this blog, we will discuss some of the considerations about motivation, competence, and best practice guidelines that you might find useful when making the decision to offer mindfulness-based interventions. There will even be a fancy Venn diagram!
Between now and then, you might want to “sit with” the question, “should I be teaching Veterans and/or Service members to meditate?” As Jon Kabat-Zinn is fond of saying, “place the question on the workbench of your mind.” Don’t try to find a definitive answer. Rather, let the koan do its work. Note any new questions or considerations that arise.
Thanks for reading! Stay tuned for part two!
Editor’s note: If you would like to learn more about mindfulness, Dr. Santanello will be leading a webinar on the subject, 11 May from 12:00 to 1:30 p.m. Eastern. For more information or to sign up click here.
Andrew Santanello, Psy.D is a licensed, clinical psychologist and CBT trainer at the Center for Deployment Psychology.
Hoffman, S.G., Sawyer, A.T. Witt, A.A. & Oh, Diana. (2010). The effect of mindfulness-based therapy on anxiety and depression: A meta-analytic review. Journal of Consulting and Clinical Psychology,78, 169-183.
Khoury,B., Lecomte, T., Fortin, G. et al. (2013). Mindfulness-based therapy: A comprehensive meta-analysis. Clinical Psychology Review, 33, 763-771.