**Transcript of Cyberseminar**

**Timely Topics of Interest**

**PTSD: Complementary Health Approaches**

**Presenters:  David Kearney, M.D.; Jill Bormann, RN, PhD**

**April 18, 2013**

**PTSD: Complementary Health Approaches**

**April 18, 2013**

*This is an unedited transcript of this session. As such, it may contain omissions or errors due to sound quality or misinterpretation. For clarification or verification of any points in the transcript, please refer to the audio version posted at http://www.hsrd.research.va.gov/cyberseminars/catalog-archive.cfm or contact:**ralph.depalma@va.gov*

Dr. Ralph DePalma:It’s a pleasure today to have Jill Bormann, registered nurse and PhD who is a research scientist at the VA San Diego facility and Dr. David J. Kearney who is a staff member at Puget Sound Washington. The topic today is complimentary health approaches to PTSD. 

Moderator:Thank you Dr. DePalma and we’re going to have Dr. David Kearney speaking first so at this time I’ll turn it over to you Dr. Kearney.

Dr. David Kearney:Thank you very much; I really appreciate the opportunity to say a few words. What I would like to do is just give an overview of what we’ve done at VA Puget Sound. For the past five years we’ve had a program where we’ve offered mindfulness as a hospital wide program to all Veterans who can either self refer or be referred by a provider either for reasons of wanting to work with a particular problem like chronic pain or PTSD, or just because they may want to develop greater self awareness and wellness as well.

So I’ll say a few words. And first I’d like to just point out that there’s been a great explosion of interest in mindfulness programs over the past several years. You can see that this is really an exponential growth curve in terms of publications and the literature about mindfulness. And you know this is really encouraging; it wouldn’t have been that long ago when a mindfulness program would have been considered sort of a fringe intervention and outside the mainstream, but I really think that this is entered the mainstream of medicine. There are many academic medical centers nationwide that mindfulness programs or mindfulness centers, other organizations like the Kaiser System offer mindfulness programs widely. Even national health service in the UK now offers mindfulness as part of the standard of care for people with three or more episodes of major depression because there is some good data that it prevents relapse of depression, which I’ll talk about.

So the first question is “What is mindfulness”? Like we hear of this word; frequently people will say, “I wasn’t mindful, I lost my car keys”, you know is that really what we’re talking about when we talk about mindfulness? Well so I just wanted to say a few words about that.

So mindfulness fundamentally is a quality of attention and it -- it refers to a present moment attention and this photograph is actually from a mindfulness meditation center, spirit rock, outside of San Francisco where some well known mindfulness teachers are located and this is what you’re greeted by as you enter a mindfulness retreat, which is really the primary message. “Yield to the present”. So and that can mean a lot of things. This is a quote from William James back in 1890 when he wrote about the importance of attention and mental health. So he says, “The faculty of voluntarily bringing back a wandering attention over and over again is the very root of judgment, character and will. No one is compos sui, meaning master of oneself if you haven’t not. An education which should improve this facet would be the education par excellence, but it is easier to define this ideal then to give practical instruction for bringing it about. 

So he was really onto something but he actually lived in an era before mindfulness meditation programs or instruction were widely known because that’s really what mindfulness practice works with is the faculty of voluntarily bringing back a wandering attention over and over again. And there are a number of studies indicating that this is associated with well being. So in one form you could consider this tendency to be off, you know churning over events in the past which we could refer to as rumination that that’s what’s associated with relapse of depression. One of the factors associated with relapse of major depression. So we’re teaching people the ability to not ruminate; the ability to let go of this tendency or these habit patterns to turn over problems in the past or to worry about the future. So there’s a certain skill that’s developed in mindfulness meditation classes and that’s one way of framing it. 

So we can consider that mindfulness is a synonym for awareness that we’re talking about developing greater awareness. Awareness that our mind is off in the future or the past. It’s a particular kind of awareness so Jon Kabat Zinn has written a great deal about mindfulness and started, you know arguably as the father of the modern mindfulness movement. He defines mindfulness as the awareness that emerges by paying attention on purpose, in the present moment and without judgment. So it’s this particular kind of attention -- so in mental health self focus attention can be associated with poor health status. If it’s a critical sort of self judging type of attention. We’re talking about an open, curious, non-judging stance of attention in the present moment, which leads to greater self awareness. It’s fundamentally a way of being, a way of going through life, a way of processing and greeting experience is how it’s defined. 

There is both a quality of attention and flexibility of attention that is worked with in mindfulness. So the -- where we place our attention often helps to define out perception of reality. In one model of mindfulness it’s described that there’s intention, attention and attitude. So people are asked to bring forth their intention for being there, what is it they hope to achieve or the direction that they’re hoping to go, you know whether it be to live with less fear or avoidance, to cope better with chronic pain. And then we work with attention and this flexibility of attention through meditation exercises and group discussion. So non-judging patience, non-striving beginners mind so there’s these words are used to describe a certain quality of attention. 

Dan Siegel who is from UCLA has written extensively about mindfulness and in his book *The Mindful Brain* which is a very good book, he uses the acronym COEL so to describe the qualities of mindful attention; so curiosity, openness, acceptance and love. So curiosity it’s difficult to be judging if you’re curious. Curiosity is sort of a way of working with a critical, judging style of attention. Those don’t co-exist very easily. So people are often asked to bring an attitude of curiosity even to difficult experience like if they’re feeling shame or guilt or a feeling of sadness to be open to that and to try and understand it in a certain way, which requires openness, acceptance of what is here and a basic sense of kindness or love. So kindness and self compassion are taught throughout mindfulness classes.

So when we think about how developing greater mindful awareness reduces stress and suffering there’ve been a number of theories proposed. So fundamentally even the title of my talk, I wrote *You are not your trauma*; you know working with Veterans with post traumatic stress disorder. It promotes a de-identification with a quote “Storyline”. So you know often people sort of frame who they are in rather narrow terms. Mindfulness sort of opens this up. Mark Williams who is an Oxford Psychiatrist has written about why mindfulness intervention seem to be almost universally beneficial in terms of affect or stress; there’s a sense of well being that’s developed through mindfulness interventions across multiple studies and why -- how could that possibly be. And he writes that this is a universal human vulnerability to language that language tends to sort of concretize an experience in a way that’s often not helpful.

So mindfulness programs teach people to see thoughts of thoughts. So they’re bringing awareness over and over again to thoughts, ideas, beliefs and also awareness of automatic reaction patterns. Self compassion is developed through mindfulness classes. There is one I think really well done and rather remarkable study of mindfulness based cognitive therapy by Kiken is the author where they looked at actually the mechanisms through which -- going through a mindfulness course led to a decrease in the rate of depressive symptoms and depressive relapse. And they showed that in their study it wasn’t that maladaptive thoughts or dysfunctional beliefs or attitudes decreased; actually in their study they -- the group that received mindfulness teaching actually had an increase in those. They were probably more aware that they had limiting beliefs and thoughts and so forth. But they held them in a different way that they -- they no longer had that affect of leading to depression and that in a statistical model it was shown that self compassion actually mediated this response that enhanced self compassion changed the relationship of a person to maladaptive thoughts, limiting beliefs and depression. That they no longer led to depression. 

So it’s not so much that the -- the experience has changed, it’s more that it’s working with the relationship to experience it and how we identify with the experience is what’s taught in mindfulness. The experience of the present moment decreased rumination; this has been shown in the depression literature through mindfulness interventions. Its rumination is associated with depressive relapse so this is quite important. And moreover it teaches ability to distinguish the primary experience through -- from reactivity so often people are lost and reaction patterns and lose track of what’s beneath that. Like what value that’s a service of or what they really want. There is an increased clarity of emotional state taught in mindfulness programs. 

So an acronym that’s commonly used is MBSR; so that stands for mindfulness based stress reduction and this is perhaps the most widely available mindfulness program offered clinically worldwide. So I wanted to say a few words about that because that’s the program that we’ve offered at RVA and that applies. There are hundreds of studies in the literature about mindfulness based stress reduction. So this is an eight week intensive introduction to mindfulness that began at the University of Massachusetts in 1979 by Jon Kabat Zinn. It’s pretty intensive compared to interventions; we typically employ clinical practice two and half hours a week for eight weeks. People are asked to do 30 to 45 minutes a day of homework practice in the form of meditation or other sort of informal mindfulness practices. They’re asked to pay attention to daily activities, to encounters with other people and there’s a way of prophesying it in the group. There are very experienced teachers in mindfulness who facilitate groups of 15 to 25 people.

So MBSR is sort of the mother of all mindfulness programs in a way in healthcare. It’s led to more specific interventions that are tailored to specific clinical situations like mindfulness based cognitive therapy is a intervention for depression. I highly recommend the teacher manual for this if you want to read a good book that explains in a more clinical sense how mindfulness is taught and how it works. There -- it’s really well done. Mindfulness based relapse prevention is an example of focusing more on triggers or relapse of working with that. DBT is -- has an element of mindfulness; it’s grounded in mindfulness although it’s not specifically teaching meditation practices and there are other elements taught as well. Acceptance and commitment therapy is also another way of teaching elements of mindfulness. There are mindfulness based childbirth and parenting programs, mindfulness based teen applications; so there’s more and more an effort to make sort of mindfulness programs more specific to certain populations of people. 

So in general mindfulness emphasizes a context of thought whereas cognitive therapy will place a greater emphasis on the content of thought. So in a mindfulness program you know if the person sat down and said after the meditation if they notice that their thoughts were off in the future or that they were worrying about what their job was going to turn out like, that there’s some conflict they’ve had. The teacher would really work with them to say, “Great, how great it is that you can notice that this is where your mind has gone. That you can hold that in awareness and you can see that your mind is going off in this pattern”. There wouldn’t necessarily be an attempt to do any reality testing of the content of path that were put out there or to sort of go through the content. And I think this is a fundamental way in which mindfulness classes differ from cognitive therapy. And mindfulness practice we also work a lot with physical symptoms so that the feeling in the body, or working with people with chronic pain, having them feel the sensations of chronic pain and so forth. There’ve been more than 100 experimental studies of mindfulness based applications. There is evidence -- good evidence in favor of prevention of depressive relapse. There’s good evidence with the active control condition for irritable bowel. There are multiple studies of cancer quality of life; there are studies of chronic pain. In general depressive symptoms and anxiety symptoms across multiple studies improve not necessarily people treating people with major depression, but people without the history of major depression who have depressive symptoms or anxiety symptoms. 

When we talk about rumination and the setting of major depression the idea is that negative thinking leads to a potential relapse of depression through the low mood that’s activated by negative thinking can lead to modes of mind that are very difficult to step out of. So a person is taught through mindful awareness to recognize this mode of thinking and not to sort of step into it in the same way. This is an outcome slide from one of the trials of mindfulness based cognitive therapy, the intent to treat analysis shown the cumulative proportion of patients not relapsing. So these patients all had multiple episodes of major depression, received state of the art psychotherapy and anti-depressant medications and the ones who went through an eight week course of NBCT had a markedly reduced rate of relapse of major depression with 60 weeks follow-up. And this has also been replicated in another study. There is very strong evidence in favor of NBCT. 

This is just to make you aware that there’s a literature on neuro imaging for mindfulness and this is one slide from that literature. So in this study in the functional MRI paradigm dispositional mindfulness was associated with greater pre-frontal cortex activation and reduced amygdala activity during affect labeling. So this is how we understand mindfulness to work; it helps to provide greater emotional regulation through increased pre-frontal cortex activity, it helps to regulate the amygdala. This may be of particular importance for PTSD. In PTSD the primary symptom clusters include re-experiencing, avoidance patterns, emotional numbing, hyper arousal and as we know upwards of 50% of patients may respond to evidence based treatments. But that leaves a lot of people who don’t respond to existing treatments and also people who might prefer perhaps a contemplative practice or another form of practice. 

So what I’m about to talk about is the role of mindfulness in PTSD and this  is mostly speculative at this point so I just want to emphasize that the data we have are rather limited and I’m just going to go through the data that exists. But there’s some nice theoretical fits here as to why mindfulness might be helpful for people with PTSD. And primarily it’s that mindfulness practice is continually going for an approach oriented attitude rather than avoidance; so distressing thoughts or feelings. In mindfulness practice a person would be asked to sort of explore that, to be curious and open rather than avoiding those thoughts and feelings, which are you know part of the mechanism of emotional constriction, numbing, deadening that occurs in PTSD. 

Mindfulness has been postulated to be a form of exposure therapy, a very gradual subtle form of exposure therapy. Decreased rumination might play a role in PTSD; there’s evidence that more severe rumination worsens PTSD symptoms so perhaps that will lead to decreased PTSD symptoms .And then of course there’s this potential for enhanced functionality despite stable symptoms. So even if symptoms don’t decrease there’s the possibility that people can have greater freedom or functionality through enhanced mindfulness. There’s a phrase in mindfulness teaching that it’s freedom within suffering, not freedom from suffering. So in the face of difficulty it leads to enhanced ability to go through life. 

So initially we did a before and after study of 92 Veterans, all comers who took par in an MBSR program, mindfulness based stress reduction program at RBA. And in -- we wanted to do this just to see if Veterans would participate in a program like this, would there be high drop out rates? Is this something that they’re interested in? Would symptoms get worse? You know if you ask people to close their eyes and meditate for 45 minutes you know, might that even be harmful. And basically we found that there were medium to large effects across multiple variables for PTSD symptoms improved over time, depression improved over time, behavioral activation. People were more functional in the face of adversity. The mental components summary score improved. You can measure mindfulness skills and this improved with a large effect size. And about 48% of Veterans had a reliable change, using the reliable change index for PTSD symptoms and attendance was very, very good. About three-fourths attended at least half the classes. This got us to do a small randomized controlled pilot study, you can see here the room of Veterans -- it’s just a typical VA conference room. This is where we hold our classes. 

So with a small grant we randomized 47 Veterans to -- with PTSD to MBSR and usual care or just usual care alone. And we looked at PTSD symptoms using the TCL, some measures of functional status including behavioral activation and SF8, depression and mindfulness skills. And what we found in our small pilot study is that for the MBSR arm there wasn’t a significant difference in PTSD symptoms as measured at PCL. It really didn’t have much of an effect on PTSD symptoms but that functional status improved across multiple different ways of measuring it. This is the mental component summary score of functionality and well being using the FS8 showing significant improvement post MBSR which persisted at form up follow up. When we did complete our analyses which 84% of Veterans who are randomized MBSR showed up for at least four classes. We then found medium to large affect sizes for depression, quality of life, mindfulness skills but not PTSD symptoms. So there’s the discussion that most Veterans -- this is acceptable to and it’s associated with improvement and functional status and depression and mindfulness over all, but maybe not PTSD. 

In a post hoc analysis there’s -- in the literature is written about like what constitutes a clinically meaningful intervention and it’s -- people have written that it would include both symptom change and quality of life improvement. So we looked at that and requiring a reliable change in both symptoms and quality of life. If we define that post hoc as a clinically significant change it was highly favorable for MBSR. So post MBSR there was no difference; the idea with mindfulness intervention is that you teach people a practice that it continued to use over time and that it snowballs we hope. And that there were 27% of people in MBSR who had both reliable change and symptoms of PTSD and quality of life versus zero percent in usual care. There were no people in usual care who met those criteria; we found that encouraging.

Of note the other study that’s been published in the literature comes from the Boston VA, Barbara Niles, the National Center for PTSD in Boston, FBU. They developed a tele-health intervention for Veterans with PTSD. It’s based on a lot of the teaching of MBSR through working with an experienced MBSR teacher. They developed a tele-health intervention where they met with vets individually twice and then six individual phone calls. And then a small randomized control pilot study, tele-health mindfulness was associated with temporary reductions in PTSD symptoms which waned follow-up and they were not significant at that point. But people were satisfied and it suggests that continued mindfulness practice is necessary for those effects.

Just a brief note that in our center MBSR is part of the electronic record that you can -- people can refer using the consult menu. It’s a really nice mechanism; it’s become part of our culture here at RVA that this is part of medical care. So overall studies are limited; there are two large trials underway by the VA that have been funded and should be available within the next year or so. Our initial pilots randomized controlled studies showed improved quality of life and functionality reduced depression for complete but not PTSD symptoms. And this actually sort of fits with what we teach; we’re not really attempting to reduce PTSD symptoms. It’s not a trauma focused intervention. We’re teaching functionality in the face of difficulty and adversity. 

There’s also this encouraging literature on tele-health mindfulness and my overall impression that mindfulness and my overall impression that mindfulness programs are acceptable and actually beyond acceptable -- I would say they’re actually popular in and very much appreciated by Veterans. We’re talking about PTSD but the literature is stronger for other conditions such as pain and depression which are often co-morbid with PTSD. 

So I’d like to end with a quote by Walk Whitman which is “I am larger and better than I thought. I did not think I held so much goodness”. Thank you very much.

Moderator:Thank you very much Dr. Kearney; that was a great presentation and without further ado I’d like to turn it over to our second presenter Dr. Jill Bormann. 

Dr. Jill Bormann:All right, thank you very much. I will see if I can get this up and running.  I want to thank David very much for his presentation. It serves as a nice segue into my topic today which is Mantram Repetition. And we were funded through the nursing research initiative and the study that we did was between July of 2005 and June of 2009 and I really want to bring up that point because things were very different in 2005, just that short time ago in terms of this kind of research. And so I was really very fortunate to get funded through the VA, although prior to that I’d been funded through the National Institute of Health and had done a randomized clinical trial in the HIV area. So I want to just give thanks to the Center of Excellence for stress and mental health here at the VA San Diego Health Care System and also the nursing research initiative for this study. And I’m going to focus primarily on this one study of Veteran’s with PTSD, but that doesn’t mean that -- that we haven’t done other studies. So I want to start out with a polling question and I’m hoping that -- what do I have to do here to do this? 

Moderator:The poll question -- you’re all set and the poll question is open and it’s on the attendees pages now; so for our attendees please just click the circle that best corresponds to your answer. The question is “Have you heard of the Mantram repetition program before”? The answer options are “yes”, “no” or “maybe, I’m not sure”. And it looks like already 80% of our audience has voted; so we’ll give people just one more second or two and then we’ll share the results. Okay it looks like the answers have stopped streaming in so I’m going to close the poll now and share the results. And Jill you should be able to see those now if you want to talk --

Dr. Jill Bormann:Now I can; yes. So 31% have heard of the Mantram Repetition before and 64 have not and maybe 5% aren’t sure. Okay great. That kind of helps me a little bit know my audience. Let’s see here if I can get this back open again. I’m having a little trouble managing -- let’s get this up here. 

Moderator:There you go; you’re all set.

Dr. Jill Bormann:All right. So anyway the first thing that people ask me is “How come I’m using the word “Mantram” and not “Mantra”? Well this is a great cartoon that says, “I’m pretty sure that I don’t want to work, I just want to bang on the drum all day. It’s not a mantra”. And I think a lot of people have the idea that mantra is a word or phrase that you repeat regardless of what it is, often an affirmation or some type of motto. And that’s how our society is using the term “Mantra”. So in doing this work I have really taken the work of a spiritual teacher by the name of Eknath Easwaran and he founded the Blue Mountain Center of Meditation. 

I was introduced to this work in 1988, that’s about 25 years ago and being a nurse and always interested in spirituality and health I was curious of whether or not a person could take sort of a portable type of practice rather than a sitting meditation and I know that the mindfulness based stress reduction uses many different types of mindfulness and therefore it’s sort of more comprehensive approach and it’s a much more intensive approach then what we’ve done with the mantram repetition program. 

So mantram repetition really is based in ancient wisdom traditions and if you looked back over the centuries you would probably find that in every faith tradition there is some type of repetition of a word, like Catholics will repeat the rosary. There is a Jesus prayer, there’s all these different types of spiritual words or phrases that have been repeated and purported to help a person become calm. So in our program we had with HIV patients tried to teach a sitting meditation but what I found clinically over time is that people really stopped meditating as far as sitting meditation, but a lot of them kept using the mantram. And part of that is because it’s a portable skill and so in terms of our program we have basically three tools that we teach. And the first is choosing a word or phrase, a mantram -- word or phrase with spiritual meaning and it’s meant to be repeated silently so that it’s virtually portable and you can use it any time, any where, no one knows you’re using it. And the idea is to begin training your attention back to that word or phrase. 

So similar to what Dr. Kearney was saying about mindfulness and noticing thoughts and then letting them go and noticing thoughts and letting them go we use a little different approach by focusing on that word or phrase. The idea being that there is something powerful or something that’s indescribable about these particular words and phrases that speaks to something within us at a deeper level. Now when you’re talking about research and science it’s very difficult to bridge that area where you begin talking about spirituality. But there are studies now that are actually measuring and quantifying spiritual well being and so that’s really kind of the target of mantram repetition. 

We also talk about slowing down and setting priorities. One cannot be truly mindful or truly present unless they slow down a little bit and everything in our society teaches us to speed up. And we also then teach one pointed attention. Now the interesting thing about this is that Eknath Easwaran who came to the United States back in the 60’s, the early 60’s he was teaching this one point of attention, which is very virtually much the same as mindfulness as described by you now, Jon Kabat Zinn. So there’s a lot of overlap here and one of the things that I think that makes the mantram repetition program unique is that we really embrace the idea of spirituality. Now I’m not talking about religious and there’s a fine line there between religion and dogma and being part of an institution, being part of a community versus ones own spirituality, which has been defined as search for the sacred. Spirituality is finding meaning and purpose in life, feeling a sense of comfort from a faith, tradition and that kind of thing. 

So when we teach mantram repetition in this program right now we offer it over an eight week period of time about one and a half hours each week and we -- traditionally offered it in the group setting. We are doing a study now looking at it individually and I’ll talk more about that later but the training attention is kind of a synergy between the idea of repeating this word or phrase quietly to yourself at any time, any place whenever you’re not using your mind for something that you really are focused on like work or driving or you know doing your taxes or whatever. But you use it as sort of a respite. The mantram is used as kind of a respite place to be.

Slowing down involves setting priorities and one pointed attention; so they all kind of work together. And it’s been coined a portable stress buster, which I guess from the lay perspective that’s probably a much easier thing to swallow. You know you can say to somebody, “Hey I’m taking a class on how to learn how to have a portable stress buster” versus saying, “I’m going to a mantram repetition class”. There’s a lot of people that are shy or skeptical or find it somewhat offensive to use that term. However in the last 10 years or so, actually really about 12, I think we started teaching mantram repetition courses in the year 2000. At that time I was doing a post-op fellowship through the VA and I’m not the only one that’s doing this kind of work; there’s been some other studies that were published before me looking at the difference between spiritual and secular meditation or looking at other types of mantram repetition. 

So there’s a slow but steady growing area of research. So my objective today is really to describe the outcomes of a mixed methods clinical trial. Just looking at the efficacy of mantram repetition in Veterans with PTSD and this is a published study -- it’s not in print yet, but it is online available and because it’s a mixed method study we also just submitted the qualitative responses and that’s a study that should come out in the journal of rehab, research and development. I’m not sure when that will be available but these two studies kind of go together in terms of the subjects and the reports of the qualitative and quantitative findings. 

Our research question really does this program reduce psychological distress in the treatment group compared to controls and can this program improve quality of life and spiritual well being? That’s kind of overall in a nutshell. This research had a mixed method’s design so it was a randomized clinical trial. We recruited Veterans and randomized them into two groups and you can see here the usual care in this case were those Veterans that were really waiting to get into some other more evidence based treatments. And so in the meantime they were on meds and cash management. 

Originally the study was designed to have an eight week group but in 2005 at our PTSD clinic they had modules that were 12 weeks and human subjects committee did not feel that it was ethical to keep people from having a treatment longer than six weeks so we actually had to truncate our intervention and so we offered it six weeks of usual care versus mantram plus the usual care and then those that were in the mantram class crossed over -- I mean in the usual care crossed over to the mantram class. And then we did the qualitative interviews.

Now the unfortunate thing about this type of design unlike Dr. Kearney’s wonderful research with follow-up, we couldn’t really do a follow-up because everyone in the study has had the intervention; however we did get some very good data on qualitative interviews indicating that it was sustainable up to three months and people still reported improvements. 

So I’m just going to talk today about the pre and the post test of these two groups. Our inclusion criteria are listed here. I think some of the strengths was that we used the CAPS, the clinician administered PTSC scale, the gold standard for measuring symptoms. People had to have a score of greater than 45 to be in the study, they had to be positive for the criteria for PTSC. We ruled out things like abusing drugs or actively abusing psychotic disorders and actively suicidal. Now it’s unfortunate again, but when you do an efficacy study you really need to kind of focus in because you’re looking to see if there’s any improvements. So we had to narrow our inclusion criteria; however many of you that work with patients with PTSC know that nearly everyone is suicidal at some point in time and many of them do use drugs. 

So I have another polling question and I’d like to ask Molly to put that up now in terms what percentage of Veterans self report that they identify as spiritual? And I included different percentages, 10%, 25%, 50%, 75% and 85%.

Moderator:Great thank you Dr. Bormann, we’ve already had 50% of our audience vote and the answers are still streaming in so we’ll give people just a few more seconds to make their vote. All right, it looks like we have 75% of our audience has voted and the answers have stopped streaming in so at this time I’m going to close the poll and share the results. Dr. Bormann you should be able to see those now. 

Dr. Jill Bormann:Okay, let’s see what we have over here. All right. So just looking -- it looks like the largest number, which is about 38% rated 75 -- that’s 75% of Veterans would say that they are spiritual or identify as spiritual and then from there it kind of goes down kind of like a bell curve and actually this is a very smart audience because in fact in our results we did find that the majority of Veterans, about 75 did report that they identified as spiritual. And if we could go to the next slide, let’s see here if I can go back to the next slide here. This is the baseline demographics or these are the baseline demographics and you’ll see that the majority of people in this study were Vietnam era, Korean era. They had long term duration of PTSD symptoms, up to 33 years of symptoms and then down in the right hand corner you can see that in both the controls and the mantram group that nearly 75% did report that they identified with spiritual -- we kind of thought that this would be a confounding variable or that there would be a co-variant in that those people who identified as spiritual religious would have better outcomes. So it turned out not to be the case that that was not necessarily a contributing factor to improvement. 

These are the actual results showing just the means of the CAPS total score and you can see definitely -- now remember this is only six weeks, one hour a week so compared to the mindfulness say stress reduction it’s a very quick you might say, and not as intense of an intervention. Definitely you can see that the control group also improved in those six weeks. At post treatment everyone came in with PTSD so at post treatment using the CAPS we found that 30% no longer met the criteria versus 13% in the control group. However if you’re going to define clinically meaningful as a 10 point decrease in the CAPS as well as the total score of less than 45 then our numbers are a little less impressive. But again it’s hard to say whether this is really meaningful if patients don’t continue to use the practice and so forth.

We also did self reports so there’s the results of the PTSC checklist. Again these are somewhat small effect sizes; we use the brief symptom inventory and found significant decreases on the depression subscale. And in terms of quality of life, enjoyment and satisfaction which is kind of similar to an SF 36 type of scale we found greater improvements in the mantram group than in the control group. We also measured mindfulness using the mindfulness attention awareness scale and found greater improvements in the mantram versus the controls. Now all these results are intent to treat. We had very low drop out; however in both groups we had only 7% dropout. So we started with 146 and we had 136 completers and then we also measured the spiritual well being. This scale is one that has been published quite a bit. There’s been some reliability and validity and it’s broken down into some other subscales, but all the scales were pretty much the same as what you see here. And just to show an example of what a lot of the rest of our data looked like and that’s in this slide you can see pre-treatment where people started and they were virtually the same at pre-treatment even though it looks here like the mantram was -- had a higher score to begin with. And then when people went to the -- at the end of six weeks they showed improvements and the control group then flipped over and you can see there’s a little decay in the mantram group but yet the control group also received a benefit. So it sort of indicates to us that there is something going on there. 

The qualitative interviews that we asked -- they were done over the phone and we took the 71 people who were in the first six weeks that took the mantram program. We were able to contact 65 of them over the phone at post treatment and we simply asked them a question “Can you think of a time that you’ve used something you learned from the program and can you give us an example”? And we used a technique called the critical incidents research method. It’s been used in nursing, it’s actually been used more in business and in evaluating programs and the idea is to really focus in and target on just the kind of the kernel of what the person is saying and identifying incident and then how they responded to that incident. 

Now for the purpose of this presentation I don’t have a lot of those results because I didn’t know that I would have time or not but these are just some really simple examples of quotes that Veterans have reported. It’s giving me something to do when it feels like there’s no hope. So for example when people are ruminating or they’re having depressive thoughts, you know we encourage them to use the mantram to refocus that attention and that, in some ways, is the same as raising ones awareness in creating that detachment. So in terms of mindfulness and that idea that you are separate, you are not your mind. It’s your mind that’s ruminating but you aren’t necessarily don’t have to identify with that. So there’s some cognitive types of things that are similar to the mindfulness stress reduction that we talk about. 

The overwhelming response when people use mantram is they become relaxed. They feel -- they always say, “I calmed down”; “I used mantram to calm down”. And “Slowing down helps me to be in the moment”, that’s another really important aspect of the program and helps them analyze their thoughts, helps them focus. 

Now just as an aside some of you might have the question, “Well in terms of the PTSD criteria of the three, now four with the new DSM5 aspects of the PTSD symptoms we overwhelmingly found that the mantram program really improved hyper arousal and all of our qualitative data verified that. People when they were irritable, in a crowd they would use the mantram to calm down. If they had road rage they would use the mantram not to react; so that whole idea of that instant reactivity or as some people feel like they have a short fuse. The idea with mantram repetition is you practice it when you don’t need it so that when these situations come up it’s readily available to you and your mind. And so that’s another example of how people reported it.

As with any study there were very -- there quite a few limitations to this randomized clinical trial. We did not have an active control group that met every week and so we could argue that perhaps the improvements just became because of a sport group. It was not generalizable although we tried to recruit women and younger Veterans; we just had a lot of difficulty doing that. And of course we limited the diagnoses of patients; we didn’t look at those with co-morbidities, particularly TBI. And we didn’t look at people that had acute PTSD symptoms. I think in this study we only had five Veterans from the OEF, OIF conflict and part of the reason for that was that our study was done during the day and it was very difficult for those Veterans to get into the classes. We did, however pilot three of them over the telephone. And we did teach in another study of caregivers -- we actually have taught mantram repetition in eight sessions with the beginning session in person and then the in between six sessions over the phone on conference calls and then the final session in person. And that was done with caregivers -- family caregivers of Veterans with dementia. And we found significant improvements in terms of quality of life and reductions and depression and so forth.

So what are the next steps? Well as Dr. Kearney mentioned there are two other studies that were funded by clinical services research and development that are studying mindfulness based stress reduction. We were also one of the lucky ones I guess you might say that received funding to do a clinical trial and we’re comparing individual delivered mantram repetition to individual present centered therapy and that we’re moving into the second year of that study. Our primary outcomes are PTSD using CAPS as well as some other measures such as spiritual well being, post traumatic growth, depression, quality of life. We’re also doing a demonstration project and we’re collecting some heart rate variability data on mantram repetition compared to just a generic educational PTSD group. We’ve written a study on brain imaging and we’re sort of waiting on funding to see whether we could compare Veterans that have post traumatic stress and what goes on before and after. And then we have received some funding through the office of patient center care and cultural transformation and we’re putting together what we call tool kits and focusing on health care workers. We’ve had -- one of my doctoral students just completed a study looking at mantram repetition for burn out in health care workers and that program was actually delivered over a live meeting. And so that’s -- we’re kind of moving in that direction as well.

Hopefully if you are available this summer on June 27, I don’t know the exact time of day yet but we’re going to try to present a 90 minute VeHU presentation, for those of you that don’t know that’s the Veterans Electronic Help University. And that will be an overview and a kick off to some of these programs. 

So on that note I think I’ll turn it over to questions --

Moderator:Great --

Dr. Jill Bormann:Hoping to do more programs for women and the teleconference delivery and facilitator training. But I’ll turn it over then to Molly.

Moderator:Great, thank you very much Dr. Bormann. Well for those of you that joined us after the top of the hour and are wondering how to submit questions or comments simply use the control panel on the right hand side of your screen; there’s a write in section. You can type in any questions or comments for the presenters and we’re going to get to them right now in the order that they are received. You’re line is going to remain muted -- actually Jill can you leave up that last slide just so we have something to look at?

Dr. Jill Bormann:Sure.

Moderator:Okay no problem. So at this time we do have 10 pending questions and we’ll go ahead and get started. The first one is for David, what was the name of the mindfulness CVT book by Kukan that you talked about?

Dr. David Kearney:That was actually an article. They published an article in 2010, I think it’s *How Does MBCT work* I think is the title. But if you just look for that on Med Line it’s a really nice article. But the -- the MBCT teacher manual is a really great book to read about mindfulness; so if you just look up mindfulness based cognitive therapy and the authors are Williams, Teasdale and Sigel. There’s a second edition and that’s a very good book.

Moderator:Excellent thank you. And we’ll just switch between presenters. This one came in for Jill. I’ve taken Jill’s mantram program and used it with patients with co-morbid diagnosis and have had success. Patients report a decrease in PTSD, depression and anxiety symptoms; so thank you very much.

Dr. Jill Bormann:Yes, as a matter of fact we have done some facilitator trainings in the last three years and have probably about 20 sites across the nation that have some providers that are doing some type of mantram repetition and it’s quite adaptable to a lot of different groups.

Moderator:Excellent thank you. And the next question that came in, this is for David. Is -- are practitioners using videos to see patients on tele-health for mindfulness?

Dr. David Kearney:Really good question. It’s something that we’ve talked about recently; you know there’s this effort in the VA to reach patients in outlying areas via video, tele-conferencing. I think it’s a great idea. We haven’t done that yet but you know I think it sounds feasible you could have a teacher at a VA teach a group of patients who meet somewhere else in a tele-conference room. We use this for things like dermatology in the VA that a lot of care is for -- medical care is provided that way. So I think a lot of potential for that. 

Moderator:Thank you. This next question I believe this came in when Jill was speaking. How long were the interviews, the length of the interview? Did the participants have any other narratives associated with the mantram repetition?

Dr. Jill Bormann:Yes, as a matter of fact the -- the quotes that I showed on these slides are not very well representative of all of the interviews that we collected. They would talk anywhere from five to 25 minutes, probably an average of maybe 10 minutes. And we asked them if they could think of a time when they used their mantram for example and they would list that and we’d say, well you know a few probes like, “Well what happened then” or “What did you do” or “Did it work for you” or not and those kind of questions. And then we’d say, “Can you think of another time”? And so we have anywhere from one example up to 15 examples of using mantram from one person, you know what I mean? So there was a range that some people had up to 15 different uses versus you know an average of seven or whatever it was. So they were very rich interviews and we, you know, it’s hard to --

Moderator:Great --

Dr. Jill Bormann:Share all that. 

Moderator:No problem; thank you for the reply. We do have still a very large and interested audience. The questions are streaming in. This one is for Dr. Kearney, which QOL, which quality of life survey did you use in your studies?

Dr. David Kearney:So we use the SF8, you know which is the shortened version of the SF36, you know just because there was a lot of instrument burden on our subjects, they filled out a lot of different measures. But ideally I think a person should use SF36 and there are even recommendations that that’s the preferred quality of life instrument in the setting of PTSD. So in future studies that’s what we propose. I think it’s important to measure quality of life in addition to symptoms. That’s an important piece of this type of work I think.

Moderator:Thank you for that reply. We do have a question that came in directed at both of you. To both presenters have any Veterans with mild TBI, PTSD overlap been observed, any differences?

Dr. Jill Bormann:I can’t say that we have -- that I’ve seen anybody with TBI who have been through a program but we don’t really know that for sure. I suppose if we went back and double checked medical records. When we actually allowed people into the study we did do a cognitive -- we did the mini -- what is it? The mini neuro psychiatric interview and tried to rule out any cognitive deficits. So I couldn’t say for sure.

Dr. David Kearney:So I know we’ve had Veterans with TBI go through MBSR, you know it’s not an exclusion criteria; we regularly include them. I know several that are personally taught and observed in these classes and they can do it. I think it can be more of a challenge because really we’re teaching ways of regulating attention and concentration and these are particular challenges for people with TBI. But I know some Veterans who have taken my classes multiple times with TBI and that’s the way they’ve chosen to work with those challenges. We’re about to analyze data on neuro psychology testing so we’re finishing up a project of Golf War Veterans, we’re doing formal neuro psyche testing. So we hope to have some information about attention and memory in this -- in regards to mindfulness in the near future. 

Moderator:Thank you for that reply. I do believe this one came in David while you were also speaking, but you guys can correct me if I’m wrong. Are there opportunities for training this approach through VA or VA Puget Sound?

Dr. David Kearney:Yeah so similar to Jill, so we also have a grant through the Office of Patients Under Care to develop a tool kit for dissemination of programs for Veterans and we’re creating a Veteran tailored version of MBSR. And we’re also developing a teaching program for providers -- for teachers of mindfulness to help them teach in the VA. So if the person wanted to contact me I’d be happy to say more about that. 

Moderator:Thank you for that reply. The next question what kind of training venues within the VA are available for mindfulness and mantram training?

Dr. Jill Bormann:Well I can just speak to the mantram program and that’s that we are hoping to launch another set of live meetings which is a way to sign up to TMS and actually do some modules on your own, but then also come together. And I’m not sure exactly when that’s going to be done or started up, I’m hoping in August. But we do have a VHA mantram program list serve and if people want to e-mail me and my e-mail is there on the screen, you can e-mail me and ask to be added to the VHA mantram list serve and we can get some of that information out to you. But we’re hoping to do it more on a regular basis but right now we’re in the stages of modifying and getting things up and running. We don’t want to release anything until we know its quality that we want.

Dr. David Kearney:For mindfulness -- for mindfulness there’s stress reduction; that’s a specific format for achieving mindfulness and there have been professional teacher training guidelines developed through the University of Massachusetts, which is where this initially began. And they’re pretty extensive; it usually takes about three years or so. There’s a couple of week long training programs and personal practice. So it’s the model for MBSR is that the teacher you know, is really speaking from his or her own experience and personal understanding and embodies certain qualities of mindfulness as a way of teaching as well. So what we’ve done in our VA is we have outside experienced teachers come in and teach on a contract basis and we’re involved in a dissemination project within our vision where the model is that we’re going to pair an experienced community MBSR teacher with a staff psychologist who is interested in mindfulness as well and team teach in that way as a way of disseminating. And we hope that that will be successful and a potential model for the future. 

There are other people who teach mindfulness in RVA and nationally like in a survey recently performed through occupation center care there are practitioners who teach some really basic mindfulness practices and it sort of -- you know a more abbreviated, sort of mindfulness light version and that’s a good thing also. And -- but for mindfulness training within the VA it’s still a work in progress I think is the short answer and I just described how we do it locally.

For NBCT the bar is set a little lower in terms of the number of training programs and personal practice and so forth so it -- those trainings are a little shorter so if a mental health provider wanted to teach mindfulness based cognitive therapy for people’s depression based on some really great literature; I think it’s a five day training they can do and then have an ongoing mindfulness practice and you know, they can teach MBCT’s how that’s structured.

Moderator:Thank you both for those replies. I just want to let our audience and Dr. Bormann know there are several people that are asking how they can sign up for facilitator training on mantram repetition and when it would be offered. It sounds like your answer was to contact you off line and they’ll be put on a list serve; is that correct?

Dr. Jill Bormann:That’s the best way right now. We right now have not scheduled any facilitator trainings for the fall yet. The ideal way to do it is face to face in a two-day intensive; that’s what we’ve done in the past and that’s only for people who have already been practicing mantram and slowing down and want pointed attention. Then we’ve had three successful trainings over the past three years, but with the cap on travel we haven’t really figured out a way to do it face to face or to do it not face to face because part of the training is to have people actually teach classes in front of everybody and share that experience. So I would recommend that if you’re interested in mantram related work to go ahead and e-mail me and I will see that you get added to our VHA list serve and it’s that list serve that will be coming out with many announcements of things. And we’ll try to do it in a way that’s advanced so people can plan.

Dr. David Kearney:And similarly if people are interested in teaching mindfulness I’d be happy to get an e-mail from you and I’m working with patients -- we’re developing ways of training teachers so it’d be great to have a list of people interested in that.

Moderator:Great thanks for making yourselves available off line. This one is for Dr. Kearney. About how long did it take for MBSR to become part of the culture at your VA? Any tips for facilitating this process?

Dr. David Kearney:So we’ve been doing this for about five years and initially I did it through grants I wrote. Our initial funding was through the Gates Foundation actually, just a small grant through them. They’re interested in global health and I framed PTSD as a global health problem, which it actually sort of is. But one thing -- one tip I would make is to include it in the electronic medical record; that’s why I showed that slide. It makes it so easy for people to refer to a program. You know just one click away, we -- we receive referrals from all the services in the hospital. Encourage people not to silo it into one service line or one department within the hospital and these problems overlap for many people and so we’ve structured ourselves to be patient centered in that way. 

But really my experience has been if you build it, they will come. Like it really -- I think it’s we initially put up posters and I gave some talks about this but once the patients start coming, they start educating their providers is my experience. They start talking about this and then they’re providers become a littler more interested in this or it becomes part of the language and there’s a snowball effect. So I really think that if you set up a reasonable framework where it’s easy to refer people and the classes are well taught that -- you know it starts to just gradually proceed where patients often sort of turn around and talk to their providers about it; so those are my thoughts for now. 

Moderator:Thank you; this question is for Dr. Bormann. What is present centered therapy that is being investigated along with mantram?

Dr. Jill Bormann:Present centered therapy is somewhat of an evidence based therapy based on problem solving and it was used in some of the studies that Dr. Paula Schnurr was the PI and it was used and I think originally thought as a very good control group for long exposure for other trauma focused therapies. So if you were to do a list search and look up Dr. Paula Schnurr and that’s S-C-H-N-U-R-R that’s one way. And then there’s actually a book chapter that’s been written, Melissa Wassenberg, or Wattenburg -- excuse me Melissa Wattenburg has written a chapter on presence centered therapy and she’s our consultant for our research study and does our supervision. And so it’s a -- it’s a type of individual or group therapy that encourages people to talk about what’s happening in their lives in the current moment. Like what kinds of stressors are you dealing with now; it doesn’t focus on trauma. But it’s a very supportive kind of therapy.

Dr. David Kearney:And there’s evidence that it has an effect for PTSD and it’s -- to the status of an active treatment.

Dr. Jill Bormann:Yes, it’s like an active treatment definitely. It’s a high bar; let’s put it that way for a control group.

Moderator:Thank you for that reply. This one is for Dr. Kearney; can you speak to the importance of the clinician’s level of mindfulness? That is does the clinicians own mindful practice matter?

Dr. David Kearney:Very great question and I think it matters, I think it matters a great deal. And there’s even some evidence that -- I think there’s an article, a therapist who receives mindfulness training that their clients do a little better than the study of that. It makes intuitive sense that if you’re more available, you’re more aware, you’re less distracted that your clinical encounters will go better. And also there’s an element of self care for providers, you know there are programs for mindful awareness among health care providers with before and after studies showing evidence of reduced burn out, increased empathy, greater job satisfaction. So I think it’s -- for me it’s made a huge difference in my quality of life as a physician. My -- you know being available to patients, listening.

Moderator:Thank you for that reply.

Dr. David Kearney:Thank you.

Dr. Jill Bormann:And I would -- I would ditto that for the mantram program that people who teach it really need to be using it and it’s meant to be a habit. It’s meant to become a part of your life and something that you use for the rest of your life. So that we encourage people -- and I think mantram sometimes is a jumping starting point or a beginning point for people who then maybe later go on and do more intensive types of meditation or a return to other types of maybe even spiritual practices; that’s what we have found in some of our participants. But definitely it helps to be a provider to -- if you’re going to teach it you have to be able to do it, embrace it.

Moderator:Thank you both for those replies. I know we are just a little bit past the hour; we do have seven pending questions and is still a large audience that’s engaged. Do you both have time to answer the remaining questions?

Dr. Jill Bormann:Sure.

Dr. David Kearney:Yeah, I think so. 

Moderator:Great thank you, we’ll move right along. To both Dr. Bormann and Kearney my question has to do with OEF/OIF Veterans. It seems like this population is more difficult to engage in general. Moreover in my experience this population is more difficult to engage in mindfulness practices from a clinical perspective. Can you speak to the possibility of providing mindfulness based interventions for the OEF/OIF Veterans specifically?

Dr. Jill Bormann:Yes I’ll speak to that in the regards to one of our service man, actually he’s a nurse and he’s also in the army reserves and he was very interested in mantram. He doesn’t think we should call it mantram. He thinks we should call it a rapid focus tool or like a portable stress buster or some other name. He thinks that the name is a real turn off to the younger Veterans. And the other thing that I think is important is the availability of clinics. I don’t think we’re going to be very successful in getting younger Veterans into treatment if we can’t offer after hours or on weekend’s kind of care. I think that -- I’m not sure if there’s anything else that we can do to get people involved other than if they were say students going back to school and you could offer them something that would help them concentrate to study or help them be a better parent for example, to develop patience or anger management. Those are the kind of things that maybe younger Veterans would be interested in. 

Dr. David Kearney:So -- yeah my sense would be that we really don’t know and you know that’s an important question and we’ll probably learn more about this through the studies that are ongoing. We’re engaged in a qualitative study right now interviewing Veterans. But you know my sense is that we have had many OIF/OEF Veterans go through MBSR, probably some do and some don’t want to take part in a group like that. So along the way in doing this I’ve heard many people express what seem to me to be sort of preconceptions and its how we hold it like we really don’t know the answer to that. Even at our facility we have a program in loving kindness meditation, which we piloted and now it’s available as a clinical intervention. 

So we just as an experiment decided to not change the name of that because that’s what it’s called in the literature and in the tradition in which it came. And we’ve had many Veterans go through that class; it doesn’t seem to be a barrier to participation. So I look forward to finding out the answer and you know, I can see where the question comes from. There’s so many OIF/OEF Veterans --

Moderator:Thank you for that reply --

Dr. David Kearney:Okay --

Moderator:Oh I’m sorry; go ahead I didn’t mean to cut you off.

Dr. David Kearney:Oh okay, I was going to say that I’m sure some of them would be interested in groups like this and that’s been our experience. If individual tele-health or some other version of this was more accessible to them then we need to meet that need both in our studies and in the slides that Jill presented. The average age of the participants is in the 50’s, which does say something that are results might not be generalizable to all Veterans. 

Dr. Jill Bormann:I would want to add too that we’re having a better time if we offer it individually then to the younger vets then if we offer it in a group. We have found here in San Diego that a lot of the OEF/OIF Veterans do not want to participate in groups. But if you offer something individually they’re much more likely to sign up for it; that’s been our experience.

Moderator:Thank you for that reply. Did you want to add something Dr. Kearney?

Dr. David Kearney:No, no I don’t.

Moderator:Okay, great. What general advice would the presenters give to researchers interested in complimentary/integrative topics for VA funding?

Dr. Jill Bormann:Well I know the health services research and development is looking to try to create a new portfolio. It’s in the works I believe, I can’t guarantee or know when that might happen but I do know that there are people who have been submitting grants in yoga for example, or mindfulness based stress reduction grants to health services research and -- or even to rehab research .And I think those studies are -- and if they have high merit and some pilot data that show feasibility and whatnot I think they can be funded. So I would say for researchers to you know, write your grant and -- or pair up with others who have had success and submit.

Dr. David Kearney:Yeah I would echo that. I think it’s a great time to be interested in these topics that the grants are reviewed, just as other grants are and treated very fairly. And partnering with people who are experienced at some of the methods is very important as well.

Moderator:Thank you. This one is for Dr. Bormann. Can you give us some examples of some of the mantrams? How are they selected for each participant?

Dr. Jill Bormann:Well that’s a great question, it always comes up and unlike other types of meditation like transcendental meditation you are assigned a mantram or a mantra in that tradition and it’s assigned by a teacher and you don’t get to choose what it is, and you’re not supposed to say it out loud or share it with anyone. In our program and based on Eknath Easwaran you choose your own mantram word or phrase, but it’s -- there’s some certain criteria that we like people to follow and that is it’s not something you make up in your own mind, not something you just decide you’re going to say; that’s more like a mantra used in a secular way. Some examples Mahatma Gandhi he used “Rama, Rama” and that means joy within from the Hindu tradition. Om mani padme hum is a common mantram from Buddhism. So hum, is I am that and that’s from a -- also a Hindu tradition. Shalom or Om shanti om, or Om Frama, Jesus Jesus or Come Lord Jesus. Cura Lason, Christi e lason, My God and my All -- I’m just sort of rambling down a list. 

Now for research purposes we encourage Veterans to choose from that list but you will always find some that don’t want anything to do with any of those words. And so then you just try to work with them to come up with something they are willing to use and we have to be very careful when we report results that we’re actually reporting on those Veterans who have actually selected. So we’ve gotten a little bit better at asking our Veterans what mantrams they are choosing. Some people will choose a verse from the Bible or from other scripture and some will maybe choose a verse or something like the Lord’s Prayer or other kind of scripture. But it’s -- its pretty open in terms of really allowing people to choose something that they want. And we encourage them to do a test drive, in other words try a mantram for a couple of weeks and see if it has the right sound, if it has the right resonance, if it’s kind of working for you. But don’t get too hung up on the meaning of the word. Does that answer your question?

Moderator:Well they can write in if it does not. 

Dr. Jill Bormann:Okay, I’m sorry.

Moderator:The second part is --

Dr. Jill Bormann:Yeah we do have a list for our research --

Moderator:No problem --

Dr. Jill Bormann:I have a handout that I can share with people.

Moderator:Oh great, thank you. Kind of a follow up to that but from a different audience member. Our mantram of focus for the in the moment mindfulness?

Dr. Jill Bormann:Yes as a matter of fact saying a mantram does bring you into the moment. But in terms of meditative practices they’ve been classified as a concentrative or object focus practice, which is mantram or open monitoring focus, which is more like the mindfulness that David was talking about where you kind of are just aware of one thing to another, moment by moment. And then there’s transcendent concentration which is that of transcendental mediation where you kind of rise above your thoughts. And I think mantram repetitions, slowing down, one point of attention when they’re used synergistically are using a little bit of both. A little bit of concentrative meditation to raise awareness and then allow a person to make a choice as well as the point of attention is like open monitoring or choosing and using some intention. So a lot of what the program embraces is it’s a tool, it’s a rapid focus tool that allows you to pause, kind of take stock and then you can go on from there and make a decision what you want to do. 

So it has a lot of the similarities of a mindfulness based stress reduction but it doesn’t -- it doesn’t teach a whole bunch of different things and we purposely have tried to narrow it for research purposes to just be three tools that we can really get a handle on and talk about and measure. And our correlations do show that they’re highly correlated and that in health care providers. People up to three months after taking a course are still using their mantram or slowing down anywhere from like about 80% of the folks that we measured. 

Dr. David Kearney:Yeah I’ll just add that so like in mindfulness based stress reduction you know there’s this focus on working with the breath. So it’s a way of regulating attention. So it’s a way of shifting attention out of thoughts and emotions back to the breath and the body. So that would be another way of having this intentional shift that’s portable, that studies people use over the longer term; they can come back to their breath in any situation. So there are different ways of working with different forms of meditation.

Dr. Jill Bormann:Yeah and in fact I think that it depends on the individual of what they find most appealing and we haven’t done any studies on trying to match what types of meditation for what types of groups. But certainly the breath is with you all the time, it’s completely portable, it does enhance that body -- sort of a mind/body connection. With mantram it’s a word that’s meant to kind of tap into something spiritual as well and so those are kind of the unique I think similarities and differences.

Dr. David Kearney:Yeah and ideally it would be great to have you know ways of matching interventions for what people want, what they most gravitate towards. 

Moderator:Thank you both. Another attendee asked, we are starting a Chi Don program for our PTSD patients here in Lake City, Florida. I would like to assess their progress with a good tool. Of the tools you mentioned what might you suggest as the most valid and quickest to administer? I would like to measure improvement and reduction of PTSD symptoms primarily?

Dr. Jill Bormann:Well I think the PTSD check list which is a 17 item, that’s probably the most commonly used, wouldn’t you say David?

Dr. David Kearney:Yeah and it’s the easiest. If you do the CAPS which is a clinical administered PTSD scale that takes longer, that’s about 45 minutes long or so. So the 17 item self report measure of PTSD symptoms, PTSD check list is widely used and validated. 

Dr. Jill Bormann:And by the way you can get that checklist -- I think it’s on the National Center for PTSD website and there’s three versions. There’s the PTSD checklist for military, for civilians and then specific. And then the specific version you write in what your trauma is and you can go on that website its open and free and you can download and use that measure; it’s really pretty good.

Dr. David Kearney:Yeah.

Moderator:Thank you both. The next question; we’re down to our last three or four and there is a request Dr. Kearney, can you speak up just a little bit when answering the questions. So this one is a comment and question. We are using tele-health to teach Veterans Tai Chi EZ a modified stressed reduction modality. I am very interested in studying the outcomes. Any researcher interested in Tai Chi that you know of?

Dr. Jill Bormann:I know of someone but they’re not in the VA and that’s not so great. But the Tai Chi EZ I believe is from Roger Jonke (ph) is that the person that you are -- is that the same Tai Chi that you’re doing? I think -- I think it’s crucial to pair up with someone who can do research and knows the research avenue because it’s a full time job if you’re going to try to conduct research. But I don’t know of anybody off hand, off the top of my head.

Dr. David Kearney:Me neither; no.

Moderator:Thank you both and we’re down to the last two. This one is for both of you, are the trainers for EB treatment for PTSD (PE/CPT) suggesting that there’s value in these complimentary alternative treatments? If not, why not? What would you suggest as rationale for taking these alternative trainings?

Dr. Jill Bormann:Well I think the first answer would be for all those vets who don’t want to participate in PE or CPT there are Veterans who, for whatever reason David mentioned that too, that they just don’t want that type of therapy. I think then complimentary therapies are excellent. I think as far as evidence goes the reason that those two have been rolled out in the VA’s because of the amount of research that’s been done. And in these other modalities there’s just not been as much scientific research conducted. But I think that a lot of the complimentary therapy community are people who are very passionate about all these different modalities whether it’s yoga or Tai Chi or Chi Gong or mindfulness or whatever that there’s a lot of passion for that and I think making it available to our Veterans is important.

Dr. David Kearney:Yeah I think it’s really to meat the needs of Veterans who may or may not want to go through PE or CPT. And also only maybe half of the people have clinically meaningful responses to those interventions whether or not other modalities such as these might play a role for people that don’t respond. That’s an open question; we’re pretty far away from knowing that. So you know we need a lot more evidence. Just to point out one thing though like even CPT was rolled out; there’s good evidence behind individual CPT that group CPT has never been studied until just recently. There is evidence for that now but there is -- the evidence base for multiple interventions is a state of growth and flux and you know -- I’m not so sure that the, I pointed out that mindfulness is not a trauma focused intervention. Like we don’t directly address PTSD or teach toward PTSD, and maybe we should. But the way that it was studied in our studies and I think in ongoing studies as well it’s more of a general intervention related to wellness and functionality. So it may play a different role in the treatment of PTSD rather than specifically working with PTSD symptoms; it’s working with functionality in the face of suffering and pain and difficulty. 

Moderator:Thank you. And this one is for Dr. Kearney. I know you’ve touched on this through a couple questions but we’ll just see if you have anything to add; how do you get Veterans to buy into the MSBR? It is offered at our VA yet rarely utilized?

Dr. David Kearney:Oh that’s really interesting. We don’t advertise at all; we haven’t for a few years. We could have a new group every month if we had the ability to do that. We expanded this year to two campuses, soon to be a third campus within our vision. So the way -- I occasionally have people contact me from the DOD or the VA and tell me you know, experiences like that. So one thing as we orient people -- so it’s easy to refer people we use the electronic consult referral mechanism. We have a nice orientation; there’s actually a 45 minute Bill Moyer’s documentary film that came out in the early 90’s where Bill Moyer took MBSR and they filmed him asking questions as he goes through it. So we actually show that 45 minute film as an orientation so they know exactly you know, what they’re getting into. They have a clear picture in their mind of what that will be. And we do a group orientation and we answer questions.

And then the third thing we do is we have very experienced teachers that it’s -- they’re not teaching you know from a manual. They’re teaching from their own deep understanding of mindfulness. We have a group of community teachers who really devoted a lot of their life to teaching mindfulness and the analogy I use is that if you wanted to teach Chi Gong in the VA it’s possible you could have a VA staff member who is really great at Chi Gong and teaching Chi Gong. But it’s kind of unlikely -- it’s an art form and there’s a deep practice there. So in the same way we’ve chosen to work with mindfulness teachers who really have you know, long standing interest in understanding in teaching mindfulness. So -- so that’s a long answer to a question which is we -- that just hasn’t been our experience that we don’t have trouble having Veterans have buy in to MBSR.

Moderator:Great thank you. And that is the final question that come in -- came in. So I’d like to give you each an opportunity to make any concluding comments. Dr. Kearney would you like to go first?

Dr. David Kearney:Sure, I think that you know when you hear our two presentations the common thread is really the importance of attention. That these are different ways of working with attention that there’s evidence to support. I also -- it’s really the comments I was just making that I sometimes think that the barriers to dissemination of meditation based programs are actually more within the VA staff and leadership then they are within patients themselves; that’s been my experience. I think Veterans are very open to you know creative ways of working with suffering and difficulties. So I just wanted to share that with people. 

And then the final comment I’d make is I think in the handouts I sent some links to some video presentations of ours, so like one of them is a 30 minute documentary film where we follow Veterans as they -- with PTSD who progress through love and kindness mediation classes. And most of the discussion really centers around mindfulness; that’s another form of teaching mindfulness which we really didn’t go into today. But I would just encourage people to check that out, that there are former Navy Seals, Vietnam Veterans who talk about their experiences and they’re in there talking about the importance of self compassion and kindness. I think is a really good image of what Veterans are capable of. 

Thank you for the opportunity to present today.

Moderator:Thank you for sharing your expertise and Dr. Bormann?

Dr. Jill Bormann:Yeah again I really want to thank everyone for the opportunity to present; it was especially fun to present with David since we had met and share a lot of the same passion I think for each of these modalities. I would -- I would just offer that if people want more information that you can just Google the word “Mantram” and find a whole wealth of things. I do think that the VA is looking to try to find ways to find certification and quality control for any new modalities that come in the door and there are committees that are working on that within the VA. But as David said I think that it’s going to be a slow process perhaps and I think that anything that we can do to offer our Veterans that they’re interested in, and they truly are, then I think we ought to try the best we can to do that. 

But I too, thank you for the invitation.

Dr. Depalma:This is Dr. Depalma I’d really like to thank you both for this really inspirational message and I know that Dr. Atkins and HSR & D is interested in establishing more work in this important area. Again thank you.

Dr. David Kearney:You’re welcome.

Dr. Jill Bormann:You’re welcome.

Moderator:Excellent. Well again I’d like to thank you all and I’d like to thank our audience for joining us today. Feel free to join us for the next cyber seminar on TBI and that’s on screening and evaluation of headaches and endocrine disorders and that’s going to be on Thursday the 25th at the same time, 2 PM Eastern. And with that as you exit today’s session for attendees please wait just a second while the feedback survey pops up and please do give us your feedback it helps gear where our program heads. So thanks again to everyone and this does conclude today’s cyber seminar.

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