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. Author manuscript; available in PMC: 2021 Aug 5.
Published in final edited form as: Mindfulness (N Y). 2020 Feb 6;11(4):964–974. doi: 10.1007/s12671-020-01326-5

Increasing Mindfulness Skills of Veterans With PTSD Through Daily Mindfulness Training Incorporated Into an Intensive Treatment Program

Michelle L Miller 1, Jenna M Bagley 1, Patricia Normand 1, Michael B Brennan 1, Rebecca Van Horn 1, Mark H Pollack 1, Philip Held 1
PMCID: PMC8340911  NIHMSID: NIHMS1688185  PMID: 34367355

Abstract

Objectives

Mindfulness training is frequently included as part of an integrative care approach to treating PTSD in veterans. However, the utility and acceptability of daily group mindfulness training in an intensive treatment program (ITP) for PTSD have not been explored. The study objectives were to determine: (a) whether mindfulness skills significantly increased from pre- to post-treatment and (b) if daily group mindfulness training was acceptable to veterans.

Methods

Veterans (N = 170 outpatients, age M = 40.7 (SD 9.3), 67.6% male) in this prospective study were consecutively enrolled in a 3-week ITP that included daily mindfulness group sessions. Mindfulness skills were assessed using the Five Facet of Mindfulness Questionnaire (FFMQ) at intake and post-treatment. Acceptability was assessed using an anonymous post-treatment program satisfaction survey.

Results

Paired t tests demonstrated significant increases in overall mindfulness skills from pre- to post-treatment (t(169) = − 6.33, p < 0.001, d = 0.49). Small to medium effect sizes were observed across subscales: describing, (t(169) = − 5.91, p < 0.001, d = 0.38); acting with awareness, (t(169) = − 3.70, p < 0.001, d = 0.29); nonjudging, (t(169) = − 7.54, p < 0.001, d = 0.58); and nonreactivity, (t(169) = − 4.84, p < 0.001, d = 0.41). Most veterans (n = 125, 74.4%) found daily mindfulness training moderately to very helpful.

Conclusions

Veterans’ mindfulness skills significantly increased over the course of a 3-week ITP, and mindfulness training was found acceptable. Mindfulness training can be delivered daily as part of an ITP for veterans with PTSD, and mindfulness skills can meaningfully increase over the course of 3 weeks. A significant limitation is the lack of control condition.

Keywords: Mindfulness, Intensive treatment, Massed treatment, Veterans, Posttraumatic stress disorder

Posttraumatic stress disorder (PTSD) is one of the most prevalent mental health problems among US veterans (Kessler et al. 2005), afflicting approximately 23% of veterans who served in support of the most recent military operations in Afghanistan and Iraq (Fulton et al. 2015). Untreated PTSD has a significant negative impact on social functioning, long-term health outcomes, and general quality of life (Pagotto et al. 2015; Schnurr et al. 2009). In order to address this widespread problem, evidence-based treatments (EBTs), such as cognitive processing therapy (CPT; Resick et al. 2016), are often utilized and have been shown to be effective for the treatment of PTSD in veterans in both residential programs and traditional outpatient settings (Chard et al. 2010; Voelkel et al. 2015). Research has demonstrated that EBTs can be effectively delivered in an intensive format and may be non-inferior to traditionally delivered formats (Beidel et al. 2017; Ehlers et al. 2014; Lande et al. 2011; Zalta et al. 2018; see Held et al. 2019 for review). To provide participants with additional skills to manage distress, ITPs for PTSD may combine traditional evidence-based psychotherapies with integrative care approaches, such as mindfulness training (Harvey et al. 2017).

Mindfulness-based programs, such as mindfulness-based stress reduction (MBSR; Kabat-Zinn 1990), are seen as particularly encouraging additions in the treatment of PTSD in various populations, including military veterans (Bremner et al. 2017; Davis et al. 2019; Omidi et al. 2013; Polusny et al. 2015). Mindfulness is a practice that emphasizes deliberate, nonjudgmental awareness of one’s experience in the present (Bishop et al. 2004). Mindfulness training targets several core symptoms of PTSD, including avoidance, emotional reactivity, hyperarousal, and emotional numbing (Boyd et al. 2018; Delizonna et al. 2009; see Vujanovic et al. (2011) for a theoretical review).

Mindfulness-based programs have been shown to improve skills across mindfulness domains and reduce PTSD symptom severity in veteran populations (Jasbi et al. 2018; Polusny et al. 2015; Stephenson et al. 2017), including when offered as a weekly adjunct to CPT in residential PTSD treatment programs (Owens et al. 2012; Held et al. 2017). In a randomized control study, Jasbi et al. (2018) delivered eight weekly group sessions of mindfulness-based cognitive therapy (MBCT) to veterans with PTSD. Participants who participated in the mindfulness program experienced greater improvement in symptoms of PTSD, depression, anxiety, and stress compared to controls. In another study, Owens et al. (2012) implemented mindfulness groups delivered once per week in a 7-week residential PTSD treatment program for veterans. The authors examined the five facets of mindfulness utilizing the Five Facet Mindfulness Questionnaire (FFMQ; Baer et al. 2006), including observing, describing, acting with awareness, nonjudging of inner experience, and nonreactivity to inner experience. While overall mindfulness skills did not improve significantly over the course of residential treatment, veterans reported greater improvements in certain facets of mindfulness skills (e.g., acting with awareness) as well as decreased levels of PTSD and depressive symptoms at post-treatment. It is possible that the modest improvements in mindfulness skills may be the result of mindfulness training being delivered far less frequently (i.e., once per week) in comparison to the evidence-based PTSD treatment veterans receive either daily or multiple times per week (e.g., Owens et al. 2012; Held et al. 2017). It is currently unknown if mindfulness-based programs can be adapted for a daily delivery to veterans in ITPs.

In order to derive the benefits of increased mindfulness skills and decreased psychological distress, daily mindfulness practice (15–45 min) has been recommended (Hayes and Smith 2005; Segal et al. 2002). In weekly mindfulness trainings, which recommend daily home practice, the amount of formal training, rather than informal mindfulness practice, has been found to be responsible for increases in mindfulness gains and subsequent symptom reduction (Carmody and Baer 2008). However, recent literature suggests that neither formal training nor informal mindfulness practice dosage reliably measures changes in mindfulness skills or mental health related outcomes (Carmody and Baer 2009; Creswell 2017; Khoury et al. 2013). While mindfulness skills taught over a brief period of time could improve dissemination and conserve resources, it is unknown whether mindfulness skills can improve when taught daily over a shorter, more condensed time period to veterans with PTSD. The aims of this mixed methods study were to determine (a) whether mindfulness skills significantly increased from pre- to post-intensive PTSD treatment and (b) if daily group mindfulness training was acceptable to veterans. Based on prior research in residential PTSD treatment, we hypothesized that the facets of describing, acting with awareness, nonjudging of inner experience, and nonreactivity to inner experience would all increase from pre- to post-treatment and that veterans would find the mindfulness training program satisfactory.

Methods

Participants

The present sample originally consisted of 182 military service members or veterans (hereafter referred to as veterans) who completed a 3-week ITP for PTSD between August 2017 and December 2018. The timeframe was restricted to these dates to match the time when changes in mindfulness were assessed. To be included in this study, participants had to complete both the pre- and post-treatment mindfulness assessments. Of the veterans who began the ITP, 10 did not complete treatment due to reasons including administrative discharge due to disruptive behaviors (n = 1), violation of the code of conduct (n = 3), choosing to leave as a result of interpersonal conflict that occurred within the cohort (n = 2), not feeling ready for the program at that time (n = 1), and not feeling that the treatment was helpful (n = 3). Additionally, one participant did not complete the pre-treatment mindfulness assessment and one completed treatment but did not complete the post-treatment mindfulness assessment. The final sample consisted of 170 veterans; for participant characteristics, see Table 1.

Table 1.

Demographics and military characteristics

Variable n % M SD Range
Age 40.7 9.3 24–70
Male 115 67.6
Ethnicity
Not Latino 130 76.5
Latino 39 22.9
Refused 1 0.6
Race
White 112 65.9
African American 34 20
Asian 2 1.2
American Indian/Alaskan Native 4 2.4
Native Hawaiian/Pacific Islander 1 0.6
Other 16 9.4
Marital status
Single 39 22.9
Married/domestic partner 89 52.4
Divorced/separated 41 24.1
Widowed 1 0.6
Military service status*
Service branch
Air force 15 8.8
Army 106 62.4
Coast guard 2 1.2
Marines 29 17.1
Navy 18 10.6
Post 9/11 service 156 91.8
Discharged 167 98.2
Active duty 3 1.8
FFMQ subscale scores
Describing Pre-treatment 20.66 6.17 8–40
Post-treatment 23.09 6.63
Acting with awareness Pre-treatment 20.27 4.83 9–38
Post-treatment 21.86 6.00 8–40
Nonjudging of inner experience Pre-treatment 20.48 5.71 8–40
Post-treatment 24.10 6.59
Nonreactivity to inner experience Pre-treatment 17.38 4.57 7–34
Post-treatment 19.38 5.03 7–32
Total Pre-treatment 103.46 17.49 53–158
Post-treatment 113.31 22.18 49–189
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*

For military status, discharged, discharged/retired/medically retired; active duty, active duty/reserves/inactive ready reserve/national guard; FFMQ, Five Facet Mindfulness Questionnaire scores

N = 170

Based on independent samples t tests of pre-treatment data, the excluded veterans were not significantly different in mindfulness scores (assessed with the FFMQ), depressive symptom severity (assessed with the PHQ-9; Kroenke et al. 2001), severity of alcohol use (assessed with the AUDIT; Saunders et al. 1993), or age. However, there were significant differences in PTSD symptom severity (assessed with the PCL-5; Blevins et al. 2015) at pre-treatment, (t(180) = 2.05, p = 0.04), with excluded veterans (n = 12) displaying higher severity of PTSD symptoms (M = 62.17, SD = 8.56) compared to completers (n = 170, M = 55.28, SD = 11.40; for comparison among all scores, see Table 2). For full review of ITP participants, see Zalta et al. 2018).

Table 2.

Pre-treatment differences between completers and excluded veterans

Completers M(SD) Excluded veterans M(SD) p
Intake variables
Age 40.71 (9.25) 41.67 (8.29) 0.71
PCL-5 55.28 (11.40) 62.17 (8.56) 0.02
PHQ-9 17.57 (5.04) 18.25 (4.58) 0.63
AUDIT-C 2.62 (2.93) 3.17 (3.76) 0.63
FFMQ Subscale Scores
Describing 20.66 (6.17) 23 (5.6) 0.21
Acting with awareness* 20.27 (4.83) 19.64 (6.76) 0.76
Nonjudging of inner experience* 20.48 (5.71) 21.23 (6.65) 0.71
Nonreactivity to inner experience 17.38 (4.57) 16.93 (5) 0.77
FFMQ Total 103.46 (17.49) 104.22 (22.69) 0.91
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PCL-5, posttraumatic stress disorder checklist for DSM-5; PHQ-9, patient health questionnaire; AUDIT-C, alcohol use disorders identification test. PCL-5 assessed PTSD symptoms; PHQ-9 assessed depressive symptoms; AUDIT-C assessed severity of alcohol use; FFMQ, Five Facet Mindfulness Questionnaire. Bolded = significant at p < 0.05

Completers n = 170, non-completers n = 12,

*

n = 11

The majority of the 170 participants who completed the program and were included in this study were identified as White (n = 112, 65.9%), male (n = 115, 67.6%), and on average 41 years old (SD = 9.3). Nearly every participant was honorably discharged from military service (n = 167, 98.2%), with the majority having served in the military after the September 11, 2001 terrorist attacks (91.8%).

Procedures

Inclusion and Exclusion Criteria

In order to participate in the ITP, veterans had to endorse a history of military trauma (e.g., specific combat trauma or military sexual trauma) and to have met the diagnostic criteria for PTSD, verified by the Clinician Administered PTSD Scale for DSM-5 – past month version (CAPS-5; Weathers et al. 2013). Before enrolling in the IOP, veterans completed two 60–90-min clinical intake evaluations consisting of a semi-structured psychosocial interview and the CAPS-5. These evaluations were conducted by a licensed psychologist, postdoctoral psychology fellow, social worker, or licensed professional counselor. In addition to clinician-administered interviews, veterans completed a battery of self-report assessments during intake evaluations and again after completing the ITP. Exclusion criteria included active suicidality or homicidality, suicide attempt in the past 3 months, serious self-harm behaviors, if they require medical detox or medical observation as a result of their substance use, current mania or eating disorders, history of psychosis, and/or any treatment-interfering medical, legal, or other psychosocial issues.

Intensive Treatment Program

The 3-week ITP (13 treatment days) for veterans with PTSD was housed in a mental health clinic designed for veterans housed within a large Midwestern academic medical center. The ITP uses a co-ed cohort model. Included in this study, there were 16 cohorts, with sizes ranging from 8 to 12 participants (median size = 11). The primary treatment components of the ITP include individual and group CPT, mindfulness training called mindfulness-based resiliency training (MBRT), and several adjunctive components (for full review of all ITP components, see Zalta et al. 2018). Veterans were assigned to one of two treatment tracks based on their index trauma (combat trauma or military sexual trauma) with both cohort types receiving the same mindfulness training. All study procedures were approved by the Institutional Review Board at Rush University Medical Center. Awaiver of consent was obtained because all assessments were collected as part of routine clinical care procedures.

Mindfulness Based Resiliency Training

The mindfulness training, called Mindfulness Based Resiliency Training (MBRT), closely follows the mindfulness-based stress reduction (MBSR) curriculum (Kabat-Zinn 1990) with a few modifications to fit the overall structure of the 3-week ITP. For example, the mindfulness training content that focused on exploring difficult emotions was taught earlier in the curriculum than traditional MBSR in order to augment the trauma-focused CPT that veterans were concurrently completing. MBSR was chosen as the foundation for the mindfulness program as it is a reproducible, evidence-based mindfulness curriculum that has been found efficacious in samples of veterans with PTSD (Vujanovic et al. 2011). Mindfulness training was taught by five qualified MBSR teachers/MBSR teachers in training (two per group) and designed to help participants learn to decrease reactivity and increase distress tolerance during the treatment program. Mindfulness training in the ITP consisted of 13 daily sessions (each session 80 min long), with 1 session functioning as a shortened retreat, as compared to the traditional 2.5-h weekly session per week and 7-hour retreat format used in MBSR. Sessions included a combination of didactics, discussion, and meditation training with brief home practice. The yoga (mindful movement) component that is typically part of MBSR was included as a separate hour for time management as well as to allow for participants’ family members to attend this portion during the third week of the program. Participants were asked to complete up to 15 min of both formal and informal mindfulness meditations for home practice, including the new skills learned in class that day. Smartphone mindfulness apps, including Mindfulness Coach (US Department of Veterans Affairs 2019) and Calm (Calm.com, Inc., 2019), were encouraged, and home practice was assessed the following day but not formally tracked. Mindfulness training session content is displayed in Table 3.

Table 3.

Mindfulness-based resiliency training curriculum

Session Content In class practice time Type of practice
1 Introductions and class guidelines
Definition of mindfulness
Physiology of stress
Learning to identify zones of comfort, challenge, and “too much”
2 Defining stress and resiliency 10 min Raisin meditation
Mindfulness and meditation as tools to increase capacity to bear stress
How to integrate thoughts, emotions, and sensations into mindfulness using triangle of mindfulness
3 Identification of individual habitual patterns of reacting to stress 15 min Awareness of breath (AOB) meditation
Harmful ways of reacting to stress
Pausing-responding vs. reacting
How mindfulness decreases stress response
4 Working with discomfort 15 min Body scan
Using a mindfulness tool for “too much”
5 How to notice the pleasant 15 min Sitting meditation with AOB, walking meditation
Noticing thoughts, emotions, and sensations that accompany a pleasant event
Mixed moments of both pleasant and unpleasant
6 Recognizing and working with the unpleasant and difficult emotions 15–20 min Body scan or sitting, meditation with AOB and sounds
Working with mindfulness tools in extremely high affect (“too much”) moments
7 The influence of perception and mindset on stress 15 min Body scan or sitting meditation
Flexibility in moments of stress
8 Mini retreat day of meditation practices 80 min Sitting meditation with AOB, sounds, and thoughts; walking meditation; body scan
9 Judgment, compassion, and self-compassion 15 min Sitting meditation with AOB, sounds, and thoughts
Mindfulness, universality, and self-kindness as components of compassion for self and others
Offering self-comfort
10 Self-compassion as an antidote for shame or guilt 15 min Sitting meditation with AOB, sounds, and thoughts, and open presence
Introduction of kindness and forgiveness meditations
11 Interpersonal mindfulness and difficult communication 15 min Sitting meditation with AOB, sounds, and thoughts, and open presence
Flexibility and compassion as tools to work with difficult communications
12 Flexibility in working with change as well as practicing self-care 15 min Body scan or sitting, meditation with AOB, sounds, and thoughts, and open presence
Patterns of reaction vs openness and flexibility
Nourishment - what we take in matters
13 Review of the class and resources for ongoing practice 15 min Body scan
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Measures

Demographics

Veterans provided basic demographic information, such as age, sex, race, employment status, and education level, as well as information about their military service, such as service branch, service era (pre- or post- the September 11, 2001 terrorist attacks), number and location of deployments, and military discharge status during the intake evaluation (see Table 1).

Mindfulness

The Five Facet Mindfulness Questionnaire (FFMQ; Baer et al. 2006) is a 39-item measure of mindfulness across several domains that was administered at intake and again post-treatment. Items are rated on a 5-point Likert-type scale (“never or very rarely true” to “very often or always true”). The facets of mindfulness measured include describing, acting with awareness, nonjudging of inner experience, and nonreactivity to inner experience, along with an overall score. The describing domain assesses ability to label internal experiences; the acting with awareness domain assesses attention to present-moment activities; the nonjudging of inner experience domain assesses ability to refrain from evaluating one’s internal experiences; and the nonreactivity to inner experience domain assesses ability to allow internal experiences to come and go. The Observing subscale was not included due to poor psychometric properties (cf. Held et al. 2017). The total score was calculated by adding the sum of all subscales except the Observing subscale. The FFMQ has demonstrated good construct validity and reliability (Baer et al. 2008), including in veterans (Niles et al. 2013). Internal consistency (Cronbach’s α) was good across domains: describing, α = 0.89–0.91(intake, post-treatment); acting with awareness, α = 0.82–0.89 (intake, post-treatment); nonjudging of inner experience, α = 0.86–0.89 (intake, post-treatment); nonreactivity to inner experience: α = 0.82–0.86 (intake, post-treatment); and for the total overall score, α = 0.89–0.94 (intake, post-treatment).

Program Satisfaction

Following the completion of the ITP, participants were asked to complete an anonymous feedback survey composed of open-ended qualitative and Likert scale questions assessing program satisfaction. The survey assessed satisfaction with all elements of the ITP. For this sample, a 5-point Likert scale was utilized to assess satisfaction with mindfulness training, with answers ranging from “not at all helpful” to “very helpful.” Open-ended responses were used to assess veterans’ experience of mindfulness training, what they liked the most about mindfulness training, and what they liked the least about mindfulness training. An additional question inquired about any additional comments concerning mindfulness training and/or the yoga (mindful movement) component.

Data Analyses

For this mixed methods study, SPSS® 21.0 (IBM Corporation, Armonk NY, USA) was used for data analysis. There were no missing data. Paired t tests were used to compare participants’ intake scores to their post-treatment scores on the describing, acting with awareness, nonjudging of inner experience, and nonreactivity to inner experience subscales. The data from the two treatment tracks (combat trauma and military sexual trauma [MST]) were combined for overall analyses, yet independent sample t tests were also used to determine if there was any significant differences in mindfulness domain change scores across treatment between MST and combat trauma cohorts. Satisfaction with mindfulness training was reported as a percentage. Bivariate correlations were conducted with other potential demographic variables but were omitted due to lack of statistical significance. Cohen’s d was utilized to describe size of effect sizes, with d < 0.20 considered small, d ≥ 0.50 considered medium, and d ≥ 0.80 considered a large effect size (Cohen 1988). To identify key themes of the qualitative feedback, four study authors (MM, JB, PH, PN) independently reviewed all of the participants’ qualitative responses on the satisfaction survey of their experience of mindfulness training and compared to elucidate the most common themes. A formal qualitative analysis was not completed because the focus was program evaluation.

Results

Intake to Post-Treatment Change in Mindfulness Skills

Paired t tests showed a statistically significant differences in FFMQ subscale scores from intake to post-treatment with overall small to medium effect sizes for describing, (t(169) = − 5.91, p < 0.001, d = 0.38); acting with awareness, (t(169) = − 3.70, p < 0.001, d = 0.29); nonjudging of inner experience, (t(169) = − 7.54, p < 0.001, d = 0.58); nonreactivity to inner experience (t(169) = − 4.84, p < 0.001, d = 0.41); and overall total score, (t(169) = − 6.33, p < 0.001, d = 0.49). When assessing change in FFMQ subscale scores from intake to post-treatment between MST and combat cohorts, there was a statistically significant difference in the nonjudging of inner experience domain, (t(168) = − 2.06, p = 0.04, d = 0.33), with individuals in MST cohorts (M = 4.97, SD = 6.28) displaying slightly greater nonjudging of inner experience skill improvements compared to those in combat trauma cohorts (M = 2.91, SD = 6.14). No statistically significant differences in FFMQ score changes from intake to post-treatment between MST and combat cohorts were observed for any other mindfulness domain. An α level of 0.05 was used to determine statistical significance.

Satisfaction With Mindfulness Training

The majority of participants (n = 168, 98.8%) completed the optional anonymous post-treatment satisfaction survey. Of the 168 veterans that have completed post-treatment satisfaction surveys after completing the ITP, 77 (45.8%) rated the mindfulness training as “very helpful”; 27 (16.1%) as “quite helpful”; 21 (12.5%) as “moderately helpful”; 22 (13.1%) as “slightly helpful”; and 18 (10.7%) veterans rated it as “not at all helpful.” Three veterans selected that they did not remember if the mindfulness training was helpful. Overall, the majority (n = 125, 74.4%) reported that they found mindfulness training to be “moderately to very helpful.”

Four main themes were identified when examining veterans’ comments about their experiences: group content (curriculum, practical applications), new coping skills (emotional regulation, nonjudgement), logistics (time/frequency/length, flexibility/engagement in exercises), and application to veterans (see Table 4 for specific comments from the veterans). In regard to group content, veterans commented on specific parts of the curriculum such as meditation exercises or didactics, describing how and where they could integrate it into their own life (e.g., when in stressful or emotional situations). Some feedback suggested enjoying or not enjoying the meditation practice, while some veterans mentioned specific exercises from the mindfulness training curriculum that they found useful (e.g., the raisin exercise). Veterans described enjoying learning new coping skills, such as awareness of the breath or body as grounding techniques to return to the present moment, which helped them to practice emotional regulation and nonjudgement of internal experiences. Veterans had more negative comments about group logistics, such as the length of the group and time of day in which group was held. Some veterans also commented that they felt that the group curriculum was inflexible and struggled with the mandatory participation in group. Lastly, veterans commented on the need for more veteran-specific exercises or choice of language; veterans described that some of the abstract metaphors and exercises taken from the MBSR curriculum were less relatable and useful to integrate into their skill set. Comments on the yoga (mindful movement) component were similar to the other questions, with some veterans enjoying the length, timing, and poses, while others found it to be too long, unnecessary, or unhelpful.

Table 4.

Primary themes and sample responses about participants’ experience of mindfulness training from the anonymous program satisfaction survey

Theme Sample Responses
Group content
Curriculum

  • I really enjoyed meditating and the deep breathing exercises. I even loved learning about other techniques like RAIN

  • Learning to be still, the breathing moments and the useful handouts they provided

  • They never did explain how or why meditation helps. Tie every mindful lesson to the ‘why’ for veterans
Practical applications

  • A good skill to learn and apply to help with stress, anxiety, depression, and other distressing emotions and behaviors

  • The one thing that I will take away would be the grounding stone.

    I was able to use it to focus my energy and attention whenever I become irritable or angry
New coping skills
Emotional regulation

  • I have learned skills that can allow me to calm down and respond rather than react

  • I liked how I learned good techniques to be able to compensate and de-escalate myself

  • I believe that learning to slow down my reactions to things that upset or anger me will really help to start rebuilding relationships with my family and friends
Nonjudgement

  • I liked learning about how to recognize my emotions and allow them to be, without judging myself or trying so hard not to feel certain ways

  • The meditation process helped me to stop judging myself
Logistics
Time/frequency/length

  • I loved the mindfulness portion of this program,

    I just wish it did not last so long at the end of the day [when] I was already tired

  • I felt that the time for MBRT should be changed. I felt that it was quite a bit at the end of the day and could have benefitted from it more at the beginning to the day to assist me in starting my day and getting in the right mindset

  • I found this to be a little longer than it needed to be… 45 min [would be] plenty of time
Flexibility/engagement in exercises

  • The sessions were slow paced. It seemed difficult to keep the group engaged
Application to veterans
Veteran-specific language

  • The mindfulness class felt like it was more pertinent to civilians and not veterans

  • It is too fluffy… explaining how we can feel these events coming before they become overwhelming to us (and use) mindfulness to reduce or stop this from happening would be key
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Discussion

The findings from the current sample support the notion that mindfulness skills can be learned in only 3 weeks as part of an intensive PTSD treatment program, in which mindfulness training groups are one of the several treatment components. While the utility of mindfulness training as an adjunctive component in treatment of PTSD symptoms is increasingly being studied, research has typically examined mindfulness training delivered weekly over 7–8 weeks, in residential or outpatient settings (Owens et al. 2012; Stephenson et al. 2017). This study demonstrates that incorporating daily mindfulness training with daily evidence-based psychotherapy for PTSD as part of an ITP is generally acceptable. This study suggests that daily mindfulness programs are effective, but more research is needed, given the study’s lack of control condition and randomization.

Veterans reported improved mindfulness skills in nearly every domain from intake to post-treatment. Specifically, veterans’ ability to describe their experiences, act with awareness, as well as be nonjudgmental and nonreactive to inner experiences improved significantly from pre- to post-treatment. Importantly, these improvements appear to be clinically meaningful, given the overall modest, small to medium effect size. These findings are consistent with existing research from residential programs that incorporate mindfulness programs and have shown increases in the describing, acting with awareness, and nonjudging of inner experience mindfulness facets post-treatment (Owens et al. 2012). Despite the shorter program duration, the effect sizes for the daily mindfulness training increases in the 3-week ITP were significantly larger than those reported for weekly sessions, over a 7-week residential PTSD treatment program (Held et al. 2017). These differences in mindfulness skill increases may be due to the total amount and frequency of mindfulness training groups. The 3-week ITP examined in the present study included 13 mindfulness group sessions, which were delivered on a daily basis, compared to 7 weekly mindfulness groups over the course of a residential PTSD treatment program (Held et al. 2017). It is possible that daily mindfulness training enhances the ability to acquire or improve mindfulness skills compared to longer programs where mindfulness skills were taught less frequently. Future research should determine if the total amount of mindfulness training, the frequency of mindfulness training, or a combination of both factors drives change in the overall mindfulness skills.

The benefits of mindfulness practice have been well established, benefits that include fostering psychological well-being, improving the ability to cope with daily distress and chronic health conditions, and improving functional quality of life (Brown and Ryan 2003; Grossman et al. 2004). Daily mindfulness training has now been shown to help veterans improve mindfulness skills in a shorter amount of time than previously studied. Further, mindfulness training may have augmented trauma-focused treatment by providing an opportunity to build a skill set that improved veterans’ ability to maintain frequency and consistency of trauma work on a daily basis. While these results suggest an opportunity to more quickly improve veterans’ mental and physical health, they are preliminary and require rigorous, controlled testing.

Of note, veterans in MSTcohorts demonstrated significantly greater mean improvement in the nonjudging of inner experience mindfulness domain compared to those in combat cohorts. Individuals in the MST cohorts may have utilized their mindfulness training skills more specifically for self-blame posttraumatic cognitions. Interpersonal violence is often associated with ruminative, problematic beliefs about the self (Valdez and Lilly 2017), and MST survivors endorse significantly stronger self-blame cognitions compared to non-MST survivors, regardless of PTSD symptom severity (Carroll et al. 2018). Mindfulness may have provided a useful tool to reduce negative beliefs about the self in MST cohort members. However, it is not possible to draw conclusions on why or how different types of index traumas may have affected improvement in nonjudging of inner experience skills as CPT, the trauma-focused therapy conducted concurrently with mindfulness training, primarily focuses on reducing problematic posttraumatic cognitions. Future research may benefit from exploring what unique benefit mindfulness may add to reducing self-blame posttraumatic cognitions when also accounting for interventions that directly target self-blame, such as CPT.

Overall, veterans reported moderate to high satisfaction with the daily mindfulness groups offered in the 3-week ITP. Veterans described that learning mindfulness skills was particularly helpful for them, as these skills served as a tool to mitigate and accept the distress they were experiencing. Veterans reported the most satisfaction with learning new coping skills, whereas satisfaction with all aspects of mindfulness training was somewhat mixed, with some veterans enjoying learning mindfulness skills a great deal and others struggling with the presentation of the mindfulness exercises. For example, some veterans described discomfort with the choice of language used in the mindfulness training, describing it as a stark change from the more traditionally masculine culture in which they feel most comfortable. The most negative feedback centered on group logistics; some of the veterans provided the feedback that having to sit with their thoughts and feelings directly after trauma-focused therapy sessions was particularly difficult. Veterans generally reported lower satisfaction with mindfulness groups compared to trauma-focused individual and group psychotherapy components (cf. Zalta et al. 2018). Future research should examine whether logistical changes to mindfulness programming during an ITP (e.g., schedule mindfulness training prior to trauma-focused psychotherapy rather than after, modifying the duration of the mindfulness sessions, etc.) can have a positive impact on veterans’satisfaction with this program component and their ability to learn mindfulness skills.

Limitations and Future Research

Several limitations should be noted. First, a significant limitation was the lack of any control condition. Veterans who participated in the ITP received several different interventions in addition to mindfulness groups, including CPT group psychotherapy, individual CPT sessions, and psychoeducation. Thus, it was not possible to determine if other interventions contributed to the increases in mindfulness skills because veterans were required to attend all programming components. Further, the current study was limited to pre-post data collected after the 3-week program and did not assess the extent that the skills were used following intervention. Relatedly, data from the present study were drawn from routine program evaluation, not a randomized controlled trial comparing the 3-week ITP to another intervention or waitlist control condition. Thus, we were not able to establish the direct impact of the mindfulness training on veterans’ improved mindfulness skills or the impact of mindfulness skills on general treatment outcomes. Second, although the 80-min-long mindfulness groups occurred daily, the time that participants spent practicing mindfulness skills outside of the group was not recorded. Consequently, we were unable to determine the role that mindfulness practice outside of session played in the veterans’ reports of increased mindfulness skills from pre- to post-treatment. Third, the measures included in this study did not account for other mental health variables that could have affected mindfulness scores, such as depressive, anxiety, or PTSD symptomology. More, concerns have been raised over validity of the five-factor structure of the FFMQ (Gu et al. 2016). Due to questions over its reliability and validity (Baer et al. 2006; Bergomi et al. 2013; Rudkin et al. 2018), the FFMQ observing subscale was omitted. Yet, omitting a subscale may have limited our understanding of how certain mindfulness skills change over the course of the ITP. Fourth, in contrast to the overall positive responses on the satisfaction quantitative scale, much of the qualitative feedback the veterans provided in their anonymous satisfaction surveys following ITP completion was polarized, indicating either very high or very low satisfaction with mindfulness training. Of note, many veterans left minimal comments for each question (e.g., “loved it” or “meditation”), and it is likely that only those who had strong negative or positive opinions of mindfulness training left more detailed qualitative responses, similar to other satisfaction surveys (Riiskjær et al. 2012). Similarly, there was limited information on the yoga component of the curriculum, and participants either had strong negative or positive opinions about this component. Future studies should examine each mindfulness training component in a more nuanced way. Lastly, the anonymous nature of the satisfaction survey administered at the end of the ITP prevented us from determining the association between mindfulness group satisfaction ratings and mindfulness skill increases over the course of the program.

Mindfulness skills can significantly increase over the course of a 3-week ITP for PTSD, and veterans generally find daily mindfulness training acceptable. As such, the present findings suggest that daily mindfulness training can be incorporated into intensive PTSD treatment programs. Future research should involve dismantling ITPs to determine which treatment components (trauma-focused psychotherapy vs. mindfulness training) contribute to increases in mindfulness skills. Given the highly polarized satisfaction ratings reported by the veterans in this study, future research should continue to address veterans’ feedback and examine whether there are certain types of individuals who may benefit from the addition of mindfulness programming, and for whom additional practice in acceptance skills or other skills to cope with difficult cognitions may be beneficial above and beyond trauma-focused psychotherapy. Lastly, future research should also assess the extent to which continued practice of mindfulness skills following program completion affects the overall treatment gains. Overall, daily mindfulness training has been shown to be possible and beneficial, and future research should evaluate the extent to which it improves treatment of PTSD and other comorbid psychological disorders.

Acknowledgments

We thank the Wounded Warrior Project for their support of the Road Home Program and the resulting research. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health or Wounded Warrior Project.

Funding Information

Philip Held receives grant support from the Boeing Company and the Robert R. McCormick Foundation. Mark H. Pollack receives support from the Wounded Warrior Project and research funding from National Institutes of Health.

Footnotes

Conflict of Interest The authors declare that they have no conflict of interest.

Ethical Approval The study procedures have been approved by the appropriate ethics committee and have been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments. A waiver of consent was obtained from the Rush University Medical Center IRB because all assessments were collected as part of routine care procedures.

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