You Are Not Your Trauma: 

Teaching Mindfulness to 

Veterans with Posttraumatic 

Stress Disorder (PTSD)

Title slide - part 1

David Kearney, M.D.

Associate Professor of Medicine, University of 

Washington 

Director, Mindfulness-Based Stress Reduction (MBSR) 

Program 

VA Puget Sound Health Care System
There has been an explosion of academic interest in 

Mindfulness

Williams, Kabat-Zinn, Contemporary Buddhism, Vol. 12, No. 1, May 2011
What is Mindfulness? 

Mindfulness Involves Attention 

William James, Principles of Psychology (1890), on 

the importance of attention in mental health:

“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 if he have it not. An education which 

should improve this faculty would be the education 

par excellence. But it is easier to define this ideal 

than to give practical instruction for bringing it 

about.”

 

compos sui: “master of one’s self”
What is Mindfulness?

• Mindfulness is synonymous with “awareness”

• It is a particular kind of awareness

– “Paying attention, on purpose, in the present moment, 

and without judgment” (Kabat-Zinn) 

• Involves both a quality of attention and flexibility 

of attention

• Non-judgment, patience, non-striving, ‘beginner’s mind’ 

• COAL: (Segal)

– Curiosity, 

– Openness, 

– Acceptance

– Love
How Does Mindfulness Reduce Stress?

• Promotes ‘de-identification’ with ‘storyline’

– Mindfulness proposed to be of benefit across multiple 

conditions due to the ‘universal human vulnerability’ to 

language (Williams)

– ‘Thoughts are thoughts’ and may not represent reality

• Develops awareness of automatic reaction 

patterns
How Does Mindfulness Reduce Stress?

• Promotes self-compassion – Self-compassion ‘uncouples relationship to maladaptive thoughts’ (Kuyken, 2010)

• Grounds experience in the present moment

– Decreased rumination = decreased risk of depressive 

relapse 

– Teaches ability to distinguish primary experience, vs. 

thoughts & emotions that arise from that experience 

(reactivity)

• Increases clarity of emotional states
Mindfulness-Based 

Stress Reduction (MBSR)

• 8-week intensive introduction to mindfulness 

practice

– Began at U Mass in 1979; widely available

• 2.5 hour class 1x/week, 45 mins daily 

mindfulness practice, all-day retreat week 6

• Formal & informal mindfulness practices: 

meditation, paying attention to daily activities, 

gentle yoga

• “Attitudinal Foundations” = non-judging, patience, 

trust, non-striving, beginner’s mind, acceptance, 

letting go
Mindfulness Programs Used in Health Care

• MBSR: mindfulness-based stress reduction

• MBCT: mindfulness-based cognitive therapy

• MBRP: mindfulness-based relapse 

prevention

• DBT: dialectical behavioral therapy

• ACT: Acceptance and commitment therapy

• Other clinical applications: obesity, eating 

disorders, childbirth
Mindfulness vs. Cognitive Therapy

• In general, mindfulness emphasizes context

of thought whereas cognitive places greater 

emphasis on content of thought.

– Mindfulness: Thoughts are treated as an object of attention, 

‘thoughts are just thoughts’, which are automatic and do not 

necessarily represent a concrete reality. 

– Mindfulness practice is not limited to thoughts – feelings and 

physical sensations are also held in mindful awareness.
What Does the Literature Say?

• More than 100 experimental studies of 

MBSR/MBCT have been published

• Conditions for which there is supportive evidence: 

- Depressive sx - MDD relapse 

- Psoriasis - Irritable bowel

- Chronic Pain - Cancer QOL 

- Fibromyalgia - Stress in the workplace

- Anxiety sx
EPISODE

Negative 

thinking 

Non-negative 

thinking 

REMISSION

POTENTIAL 

RELAPSE OF 

DEPRESSION

LOW MOOD

Reactivation of 

negative thinking RELAPSE 

NO RELAPSE

 Negative thinking 

patterns “nipped in the bud”

Negative thinking 

patterns re-established 

Mechanisms of Mindfulness: Decreased Rumination

Segal, Williams, Teasdale (2002) Mindfulness-Based Cognitive Therapy for Depression
Rate of Depressive Relapse for Treatment as Usual (TAU) and 

Mindfulness-Based Cognitive Therapy (MBCT)

Teasdale et al, Prevention of Relapse/Recurrence in Major Depression by Mindfulness-Based 

Cognitive Therapy, Jo Cons Clin Psych 68(4): 615-623, 2000.
Neural Correlates of Dispositional Mindfulness During Affect Labeling 

Dispositional mindfulness was associated with greater prefrontal 

cortical activation and reduced amygdala activity during affect 

labeling c/w control task

. Creswell JD, Way BM, Eisenberger NI, Lieberman MD. Neural Correlates of Dispositional Mindfulness 

During Affect Labeling. Psychosomatic Medicine 69:560-565 (2007)
Clinical Features of PTSD

• PTSD symptom clusters: 

– painful reexperiencing

– phobic avoidance of situations and memories

– emotional numbing

– hyperarousal

• Despite treatment, many patients have continued 

symptoms, and would prefer to manage symptoms 

without medications. 
How Mindfulness Practice Might Influence PTSD

• Mindfulness meditation practice encourages a kind, open, 

curious attitude in relation to experience (including 

difficult or painful experiences)

• Potential influence on PTSD symptoms

– Might decrease avoidance behaviors: Mindfulness 

fosters approach, rather than avoidance, of distressing 

thoughts and feelings

– Increased self-compassion might lead to reduced 

anger, shame and guilt. 

– Mindfulness may be a form of exposure therapy 

(Baer 2003)

– Decreased rumination might lead to decreased PTSD sx

– Also, potential for enhanced functionality despite 

stable symptoms
Mindfulness and PTSD: Pilot Studies

• Before-and-after study of Veterans who enrolled in MBSR 

(N=92)

• There were significant improvements in (d = effect size)

– PTSD symptoms (d = -0.64)

– Depression (d = -0.70)

– Behavioral activation (d = 0.62)

– SF-8 mental component summary score (d = 0.72)

– mindfulness (d = 0.78)

– 48% of Veterans had reliable change in PTSD symptoms.

– 74% attended at least 4 class session (of 9 possible)

Kearney et al, Journal of Clinical Psychology 2011
Mindfulness and PTSD: Pilot Studies

• A randomized controlled exploratory trial with two arms. 

– 47 Veterans with PTSD randomized to usual care or usual care plus 

MBSR. 

– Study measures obtained at baseline, 2 months (after completion 

MBSR) and 4 months later. 

• Aims

– Aim 1: Assess safety and feasibility 

– Aim 2: Apply PTSD symptom severity, depression , QOL

• Measures 

– PTSD Symptoms. PCL

– Functional Status. Short Form-8V 

– Depression. PHQ-9 

– Behavioral Activation. Behavioral Activation Scale (BAS)

– Five Facet Mindfulness Questionnaire (FFMQ)

Kearney et al, Journal of Clinical Psychology 2012;68:101-116
Mindfulness for Veterans with PTSD: Pilot Studies

• MBSR vs. Treatment as Usual for PTSD (N=47) 

• ITT analyses: no reliable effects on PTSD sx, mental HRQOL 

improved post-treatment but NS at 4 months.

• Completer analyses (≥ 4 classes attended): medium to large between group effect sizes for depression, mental HRQOL, and 

mindfulness skills, but not PTSD symptoms. 

– 84% of Veterans randomized to MBSR attended ≥ 4 classes 

Kearney et al, Journal of Clinical Psychology 2012;68:101-116
Mindfulness for Veterans with PTSD: Pilot Studies

• MBSR vs. TAU for PTSD Results (N=47)

• Clinically Meaningful Change = Symptoms and QOL 

improve 

– Post-hoc analysis

– The proportion of subjects with reliable change in both PTSD 

symptoms and mental health-related QOL was significantly 

greater for MBSR at 4-months (27.3% vs. 0%; p = 0.016)

Kearney et al, Jo Clin Psych, 2012;68:101-116

0

5

10

15

20

25

30

Post-MBSR

4-Month F/U

MBSR

TAU
Mindfulness for Veterans with PTSD: Pilot Studies

• A telehealth mindfulness intervention has been developed 

for Veterans with PTSD

• Telehealth mindfulness treatment involves two in-person 

sessions followed by six telehealth sessions.

– Taught individually

– 6-week follow-up

• In a small pilot RCT (N=33) telehealth mindfulness 

treatment was associated with temporary reductions in 

PTSD symptoms as compared to psychoeducation 

Niles et al, Psychological Trauma: Theory, Research, Practice, and Policy 2012;4:538-547 
Mindfulness for Veterans with PTSD: Pilot Studies

• Telehealth mindfulness was associated with temporary 

reductions in PTSD symptoms

• High compliance and satisfaction with intervention

• Suggests continued mindfulness practice necessary for effect

Niles et al, Psychological Trauma: Theory, Research, Practice, and Policy 2012;4:538-547 
Mindfulness Interventions for PTSD

• Studies are limited

– Large studies of MBSR for PTSD are underway

– Initial pilot study of MBSR showed evidence of improved 

QOL/functionality, and reduced depression for completers, 

but not PTSD symptoms

• MBSR is not a trauma-focused intervention

– Telehealth mindfulness produced transient reductions in 

PTSD symptoms

• Mindfulness programs appear acceptable and safe to 

Veterans 

– Literature supports use for other conditions common 

among Veterans: pain, depression
“I am larger and better than I thought. I 

did not think I held so much 

goodness.” 

Walt Whitman
Thank you!
Efficacy of Mantram Repetition 

on PTSD Symptoms in Veterans

Jill E. Bormann, PhD RN

Steve Thorp, Ph

Ariel Lang, PhD

Julie Wetherell, PhD

Samantha Hurst, PhD

Shah Golshan, PhD

Madeline Gershwin, MA, RN

Ann Kelly, MN, APRN

Wendy Belding, MA

Patricia Bone, BS, RN

July 2005 – June 2009
Acknowledgements Department of Veterans Affairs 

 Office of Research & Development

 Health Services Research & Development 

 Nursing Research Initiative (04-041)

Center of Excellence for Stress and Mental Health

VA San Diego Healthcare System

This material represents the work of the authors and the content does not represent 

the views of the Department of Veterans Affairs or the United States Government.
Polling Question

 Have you heard of the “Mantram 

 Repetition Program” before?

 YES

 NO

 Maybe, not sure

Mantram Repetition Program

Meditation-based tools for emotional regulation* 

Ancient, universal practice, cross-cultural

Three “portable” primary skills taught:

1. “Mantram” = word/phrase with spiritual meaning, 

repeated silently, frequently to train attention throughout the day

2. Slowing down & setting priorities

3. One-pointed attention/mindfulness

 

*Adapted from 8 Point Program (E. Easwaran)
Training Attention

“Rapid” Relaxation Response

1. Mantram Repetition

2. Slowing Down

3. One-Pointed Attention

“Portable Stress Buster”
Growing Research Evidence
Today’s Objective

Describe outcomes of a mixed-methods clinical trial 

testing the efficacy of the Mantram Repetition 

Program for PTSD symptoms in Veterans. 

Bormann, J. E., Thorp, S. R., Wetherell, J. L., Golshan, S. & Lang, A. J. (2012, March 12).

Meditation-based mantram intervention for Veterans PTSD: A randomized trial. 

Psychological Trauma: Theory, Research, Practice and Policy. (4)2 

Advance online publication. doi: 10.1037/a0027522

Bormann, J. E., Hurst, S., Kelly, A. (in press). Responses to a mantram repetition program

from Veterans with posttraumatic stress disorder: A qualitative analysis. JRRD.

Meditation-Based Mantram Intervention for Veterans PTSD: A Randomized Trial.

Journal of Rehabilitation Research & Development.
Research Questions

1. Does the Mantram Repetition Program (MRP) 

 significantly reduce psychological distress

 compared to controls?

2. Does MRP improve quality of life and spiritual 

 well-being?
Design 

Mixed-Methods Randomized Controlled Trial

Veterans 

with PTSD

6-week 

Mantram 

+ Usual 

Care* (n=71)

6-week 

Usual 

Care*

only (n=75)

R 

Crossover to

Mantram 

+ Usual Care

Qualitative 

Interviews 

3 months

posttreatment

*Usual Care = meds & case management for 6 weeks
Inclusion/Exclusion 

Outpatient veterans 18 years or older

Assessed having PTSD using CAPS*

Not actively abusing drugs

No psychotic or personality disorders

Not actively suicidal

Treatment naïve except for PTSD orientation

* Clinician Administered PTSD Scale

 
Polling Slide

 What percentage of Veterans self-report they 

identify as “spiritual”?

 10%

 25%

 50%

 75%

 85%
Baseline Demographics

Mantram 

(n=71) 

M (SD)

Control

(n=75) 

M (SD)

Age (range 25-84) 56 (10.31) 58 (9.86)

Months of combat 12 (8.50) 13 (11.63)

Years duration of PTSD 33 (11.23) 36 (10.75)

 n % n %

Males 68 (99) 74 (96)

Ethnicity

 White 40 (56) 45 (60)

 African-American 20 (28) 16 (21)

 Hispanic 3 (4) 8 (11)

 Other 8 (11) 6 (8)

Identifies as ... 

 Spiritual 52 (75) 57 (78)

 Religious 60 (85) 58 (77)
Clinician Administered PTSD Scale 

(CAPS) Total Scores

F(1,144) = 4.12, p = .044

60

65

70

75

80

85

Pre-treatment Post-treatment

Mantram = 71

Control = 76
Percentage of Veterans at 

Post-treatment Without PTSD Diagnosis

Clinically meaningful

10 point decrease + total score < 45

 24% 12% CAPS =

No

PTSD 

χ2 (1) = 5.75, p = .016
PTSD Checklist

F (1,144) = 4.15, p = .043

52

54

56

58

60

62

64

66

Pre-treatment Post-treatment

Mantram = 71

Control = 75
BSI-18 Depression Subscale

F (1,144) = 7.90, p < .0001
Quality of Life Enjoyment 

& Satisfaction

F(1,134)= 9.33, p = .003

 

34

35

36

37

38

39

40

Pre-treatment Post-treatment

Mean Scores

Mantram = 71

Control = 75
F(1,134) = 9.91, p = .002, ηp2 = .07

*Mindfulness Attention Awareness Scale
F (1,144) = 23.85, p < .0001

Spiritual Wellbeing (FACIT-Sp)

10

15

20

25

30

35

Pre-treatment Post-treatment

Mantram = 71

Control = 75
Mantram Improves SWB

40

42

44

46

48

50

52

54

Pre-Treatment (Week 1) Post-Treatment (Week 6) 6-Week Follow-Up (Week

12)

Control (N = 65)

Mantram (N = 65)

F (1,127) = 27.56, p < .0001

Mantram (N=64) 

6 weeks

Mantram

6 weeks

Mantram
Qualitative Interviews in Veterans

65 veterans interviewed

over phone at 3-months 

post-treatment
Veterans with PTSD

“It’s given me something to do when it feels like 

there’s no hope--mantram repetition.”

“Helped me become relaxed.”

“Slowing down with the mantram helps to be in the 

 moment.”

“Made me analyze my actions & thoughts and helped 

me focus on more important issues in my life.”
Limitations 

 No active control to account for

 unspecified effects of group support

 Not generalizable to:

- women Veterans

- younger Veterans

- PTSD with co-morbidities/TBI

- acute PTSD symptoms
Next Steps 1. CSR&D funded clinical trial comparing individual 

 Mantram to individual Present Centered Therapy

2. Demonstration project collecting heart rate 

 variability data

 3. Brain imaging study awaits funding

4. Office Patient Centered Care & Cultural Transformation 

 Innovation Grant – Toolkits & healthcare worker courses 

SAVE THE DATE: Thursday, June 27th

VeHU presentation (time TBD)
Future Plans

Teach more providers & disseminate

Webinars/Live Meetings

 2-Day Facilitator Training

Teleconference Delivery for Family 

Caregivers

Programs for Women Veterans & Families
Questions?

jill.bormann@va.gov

www.jillbormann.com
A link to a brief (6-minute) talk on mindfulness programs for Veterans by David Kearney, MD. This talk 

gives a brief summary of what is taught in mindfulness courses, and why these courses are of 

importance to Veterans.

http://www.youtube.com/watch?v=3hDHVAH1ksc&feature=plcp&context=C4a38670VDvjVQa1PpcFOv4

q851C-iIwhxfKMaGicHCLqXxnCCRqg

The link below is to a 30-minute documentary film, which follows five Veterans with PTSD as they 

progress through a Loving-Kindness Meditation class series. The classes are intended to teach kindness 

and compassion for self and others. These classes were offered as part of a research project at the 

Seattle VA, which came about as a result of working with Veterans with trauma. By cultivating positive 

emotions, Loving-Kindness Meditation might represent a method of working with emotional numbing 

and deadening that occur with chronic PTSD. The loving-kindness meditation classes met once weekly 

for 12 weeks, and were co-taught by David Kearney, MD and Carolyn McManus, PT, MA, MS. The film 

follows five veterans from the beginning to the end of one of a 12-week loving-kindness meditation 

courses.

http://www.seattlechannel.org/videos/video.asp?ID=3171005