A compassionate approach to post-traumatic stress disorder

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  • Dr Ariel Lang of the VA San Diego Healthcare System in San Diego, California, is a clinical psychologist seeking new ways to treat the debilitating condition, post-traumatic stress disorder (PTSD), in US veterans. Her latest project explores the potential of a contemplative approach, Compassion Meditation, which may help patients to cultivate positive emotional experiences and build social connections – both of which can be a struggle for individuals with PTSD. Her aim is to use this type of meditation to complement existing PTSD treatments.

    In the US, at any given time, up to twenty percent of military veterans experience post-traumatic stress directly related to their combat activities. As many as a third of veterans may suffer at some point in their lifetime. Post-Traumatic Stress Disorder (PTSD) can have devastating effects upon relationships, general functioning and quality of life.

    A personal and social issue
    PTSD is recognised as a maladaptive response to a traumatic event, characterised by re-experiencing (through flashbacks or nightmares), avoidance (of triggers, reminders or trauma-related thoughts), hyperarousal (such as constant stress, anger and inability to concentrate), negative thoughts (e.g., guilt or blame), and a lack of positive thoughts or interest in positive activities. Problems with social functioning, such as reduced empathic connection and impaired ability to contribute to relationships, are also common.

    Patients may not be comfortable with existing therapies, do not engage with them, or find that they do not completely resolve their PTSDQuote_brain

    Dr Ariel Lang, a clinical psychologist and expert in anxiety and trauma-related disorders, is particularly interested in novel therapeutic interventions for mental illness, and aims to increase the range of effective therapies that are available. This has led her to investigate complementary and alternative treatments for PTSD.

    Current mainstream treatments focus on medications (such as antidepressants) and group-based or one-to-one psychotherapy (‘talking therapy’), such as ‘exposure therapy’ – gradually exposing patients to memories of their trauma in a safe and controlled manner – and cognitive therapies to help patients to view the trauma in a more realistic and adaptive way. These treatments can be very effective. However, some patients may not be comfortable with them, do not engage with them, or find that they do not completely resolve their PTSD. Thus, there is a need for additional therapies to add to the ‘toolkit’ from which patients and psychotherapists can select, to provide the best chance of successful intervention in all cases.

    In addition, existing therapies tend to focus on ameliorating negative emotions, thereby putting less direct emphasis on two key features of PTSD: lack of positive feelings and lack of social connection. PTSD sufferers frequently articulate feeling ‘cut off’ from their loved ones and the wider community, a big problem when we consider that social support is a key predictor of recovery and protects against stress, depression and even suicide risk. For this reason, Dr Lang and her collaborators are evaluating an alternative technique, Cognitively Based Compassion Training (CBCT), a form of ‘Compassion Meditation’ known to promote both positive emotions and social functioning.

    A compassionate approach
    Meditation takes many different forms which, research suggests, may act in different ways in resolving disorders such as PTSD. Compassion Mediation is a contemplative practice derived from Buddhist philosophy but implemented through an entirely secular programme accessible to the general population regardless of faith or belief.

    The main aim of Compassion Meditation is to foster compassion for, and connectedness to, other individuals, wishing both oneself and others freedom from suffering. As Dr Lang puts it, “Humans are fundamentally social creatures, and thus relating constructively and positively with others is central to anyone’s wellbeing.”

    Previous studies of Compassion Meditation and the related practice, ‘Loving Kindness Meditation’, have shown enhanced positive emotion, associated with better coping, greater resilience and reduced fear and anger. Compassion Mediation has also been linked to increased social connectedness, which Dr Lang hopes could engender more positive relationships, social support and ultimately better quality of life for those with PTSD.

    Social support is a key predictor of recovery and protects against stress, depression and even suicide riskQuote_brain

    Dr Lang suggests that Compassion Meditation may prove attractive to veterans who prefer complementary treatment approaches. This might make them more likely to engage with the programme, potentially resulting in a greater chance of successful treatment. At present, despite significant interest in complementary approaches amongst both professionals and the public, few empirical studies have been conducted to test their efficacy in treating mental health conditions.

    The Compassion Meditation protocol used by Dr Lang and colleagues was developed by Geshe Lobsang Negi, director of the Emory-Tibet Partnership, a union of Western and Indo-Tibetan Buddhist traditions based in Atlanta, Georgia. It comprises a semi-structured programme of eight sessions led by a trained therapist. During the course, patients are led from a basic meditative practice, focusing on breathing and observation of their own thoughts and feelings, to an analytical practice leading to an understanding of compassion for oneself, appreciation of others, and finally to active compassion for others. The technique is designed to produce enduring changes to mental patterns and habits.

    Engagement and effectiveness
    The first goal of Dr Lang’s work is to demonstrate that the CBCT programme could feasibly be implemented with veterans with PTSD. Thus, her present study, with funding from the US government’s National Institutes of Health, aims firstly, to develop and refine a manualised protocol appropriate for use and further evaluation in the veteran community; secondly, to determine whether Compassion Meditation is acceptable to veterans; and thirdly, to assess whether it has a positive effect on their mental health.

    Initial results are encouraging, suggesting that veterans who sought out this type of treatment consider Compassion Meditation favourably, rendering it a potentially feasible approach. Furthermore, preliminary analysis suggests that it may help reduce PTSD symptoms, i.e., it is clinically effective. Veterans taking part in the study described an increased sense of peace and resilience, and observed differences in the way they think about themselves and others. The next step for Dr Lang and her colleagues will be to move to randomised controlled trials to assess statistically whether Compassion Meditation has significant benefits to sufferers of this incapacitating disorder.

  • What problems or limitations are there with existing methods of treatment for PTSD?
    Medications for PTSD are not universally effective, and many veterans, particularly those from the recent conflicts in Iraq and Afghanistan, prefer non-pharmacologic approaches. Like medications, the empirically-supported psychotherapies are not effective for everyone. Although many people fully recover with these approaches, a majority are left with residual symptoms and impairment. Others never try these approaches because they do not like the idea of focusing on memories of or thoughts about the trauma.

    Why might Compassion Meditation be particularly appropriate for resolving these issues among veterans?
    I do not expect that Compassion Meditation will fully resolve these issues. It is likely to be a niche intervention, i.e., it will be a good match for certain patients but not something that everyone chooses to do. My vision is that some day there will be an array of effective ways of recovering from PTSD so that patients and clinicians can work together to find the right path to recovery for everyone who has faced PTSD.

    My vision is that some day there will be an array of effective ways of recovering from PTSDQuote_brain

    What have you found in your preliminary studies on the feasibility and effectiveness of Compassion Meditation as a treatment for PTSD?
    Compassion Meditation was received well by participants and was associated with clinically and statistically significant reductions in symptoms of depression and PTSD. I did not observe changes in positive emotion or social support, but it is possible that methodological issues contributed to the lack of findings and further work is already underway.

    How did your treatment protocol develop during the study? What changes were made and why?
    We revised the language of the intervention to resonate with military veterans and to be accessible to anyone, regardless of prior experience with meditation. In addition, the materials were tailored to PTSD, with explanation of the rationale for using meditation to combat PTSD and trouble-shooting of challenges that may arise.

    How do you intend to take this research forward in the near future?
    A randomised trial is underway, comparing Compassion Meditation to relaxation, to determine whether the contemplative practice is likely contributing to recovery. In addition, we are testing alternative means of delivering the classes (e.g., using technology to bring classes to Veterans’ homes).

  • Research Objectives
    Dr Lang’s research primarily involves assessment of and psychotherapy for anxiety and trauma-related disorders. She is particularly interested in novel interventions and increasing engagement in psychotherapy. Her recent work has emphasised the use of complementary and alternative techniques.

    Funding

    • National Institutes of Health (NIH)
    • VA Center of Excellence for Stress and Mental Health

    Collaborators

    • Dr Lobsang Negi and Mr Timothy Harrison of Emory University
    • Drs Pollyanna Casmar, Samantha Hurst, Shahrokh Golshan and Michael Essex of the VA San Diego

    Bio
    Dr Lang received her MA and PhD in Clinical Psychology from the University of California Los Angeles and MPH from San Diego State University. She is Associate Director of the VA San Diego Center of Excellence for Stress and Mental Health and Professor In Residence, University of California San Diego Department of Psychiatry.

    Contact
    Ariel J. Lang, PhD, MPH
    Veterans Medical Research Foundation
    3350 La Jolla Village Dr. (MC 111N1)
    San Diego
    CA 92161
    USA

    E: ajlang@ucsd.edu
    T: +1 858 552 8585 x5359
    W: https://www.cesamh.org/
    http://profiles.ucsd.edu/ariel.lang

  • A compassionate approach to post-traumatic stress disorder
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