Running Head: MINDFULNESS IN FEMALE VETERANS WITH PTSD 1

Mindfulness in Female Veterans with PTSD: A Review of Effectiveness

Jack Nickles

Northeastern University

3,076

Citation Style: APA

MINDFULNESS IN FEMALE VETERANS WITH PTSD 2

Abstract

Females soldiers who experience military combat are increasing after federal laws removed

restrictions barring them from combat arms units. With this increase, female soldiers will be

exposed to the stressors and war and thus the potential for PTSD. Previous PTSD research has

found mindfulness based practices to be highly effective, however, the large majority of the

research conducted so far has been on male soldiers. Studies that have included women have

used specific mindfulness techniques like MBSR, MBCT and CBCT to effectively treat PTSD

symptoms. More research, especially in women-only studies with larger sample sizes, are needed

to validate these findings.

MINDFULNESS IN FEMALE VETERANS WITH PTSD 3

Mindfulness in Female Veterans with PTSD: A Review of Effectiveness

Introduction

Post Traumatic Stress Disorder is an increasingly common diagnosis with over 70% of

the United States population experiencing at least one traumatic event in their lifetime and about

half of that subset experiencing four or more (Shalev, Liberzon & Marmar, 2017; Benjet et al.,

2016; Karam et al., 2014). Of that 70%, 12% will go on to develop PTSD (Shalev et al., 2017).

Prevalence within North America is estimated to be between 2.5 and 3.5% (Benjet et al., 2016).

The disorder itself is characterized by a persistence of recurring flashbacks and reminders of the

traumatic event (TE) itself. These intrusions typically degrades the sufferer’s mood and

cognition (King et al., 2013), increase negative affect (Engelmann & Steil, 2017), disturb sleep

patterns (Wisner, 2015) and increase the perceived sense of an imminent threat

(hypervigilance) (Shalev et al., 2017; Karam et al., 2014). Beyond the intrusions, those

diagnosed also experience an extreme avoidance of possible traumatic triggers, ie situations and

objects in the environment that may call to mind the TE, dissociation, depersonalization and

derealization (Boyd, Lanius & McKinnon, 2017).

Traumatic events that most commonly develop into PTSD include: sexual assault and

rape, childhood abuse (physical or sexual), accidents and injuries and exposure to a combat

theatre (Benjet et al., 2016; Boyd et al., 2017). Within the overall population there are specific

demographic groups that experience higher rates of PTSD. Primarily, those who have

experienced multiple TE’s (the severity of the TE is directly correlated with the severity of the

PTSD), those currently living in economically disadvantaged areas (specifically those who

receive little to no healthcare), those who are younger (below mean age of 16), women, military
MINDFULNESS IN FEMALE VETERANS WITH PTSD 4

personnel and those with comorbid mental disorders (primarily bipolar and ADHD) (Benjet et

al., 2016; Karam et al., 2014).

Diagnostic Criteria Relating to Military Personnel​. Despite studies reporting high percentages

of PTSD within active military and veterans, the numbers reflected are actually significantly

deflated and quite possibly flawed (Hoge, Riviere, Wilk, Herrell & Weathers, 2014). In 2013 the

APA’s newest edition of their Diagnostic and Statistical Manual (DSM) was released, updating

the previous DSM-IV-TR. DSM-V alters the definition of PTSD by classifying it under trauma

and stressors instead of an anxiety disorder (Hoge et al., 2014). With the change in classification,

the criteria for diagnosis changed by adding three symptoms and rewording eight of the original

seventeen symptoms (Hoge et al., 2014). In 2014, Hoge and colleagues looked at the reliability

of the DSM-V’s PTSD diagnosis compared to the previous edition. They found that 30% of

soldiers that met the criteria for the DSM-IV-TR did not meet the updated criteria and another

30% met the criteria for DSM-V but not the previous edition (Hoge et al., 2014). These findings

reveal the lack of consistency in the DSM’s ability to diagnose PTSD. Undoubtedly, there are

soldiers who haven’t received care, or have received the wrong care due to this incomplete

understanding of objective testing methods.

Women, PTSD and the Military. ​One of the most under researched areas in the field of

traumatic disorders is gender differences within military populations (Afari et al., 2015). This is

surprising because women in general are an at risk population for PTSD (Karem et al., 2014).

Compared to men, women are 20% more likely to be diagnosed with PTSD after an episode of

physical abuse and 3% more likely after an traumatizing accident (Shalev et al., 2017). In

addition to these baseline statistics, members of the military report PTSD symptoms at a
MINDFULNESS IN FEMALE VETERANS WITH PTSD 5

substantially higher rate than other populations. 25% of all chronic PTSD cases are from

deployed soldiers (Shalev et al., 2017). 30% of soldiers who returned from Operation Enduring

Freedom and Operation Iraqi Freedom (OEF/OIF) were diagnosed (Thomas et al., 2010). Thus,

women in the military are at an extreme risk for developing this disorder (Street, Gradus,

Giasson, Vogt & Resick, 2013); Street and colleagues found that women who serve may be up to

twice as likely compared to their male counterparts. These statistics grow increasingly more

severe when situational factors like sexual assault, which occurs in 1 out of every 20 female

soldiers, are accounted for (Kimerling, 2017).

The population of female soldiers has significantly increased over the past decade with

women now comprising over 15% of all active duty positions (Afari et al., 2015). At the time of

OEF/OIF (2001-2014) women were not legally permitted to be a part of any combat unit. Only

10% of all those deployed were women (Afari et al., 2015). This 10% comprises a large portion

of combat support roles which regularly receive both direct and indirect hostile action. Seventy

four percent of women deployed during OEF/OIF reported having had one or more combat

experiences such as receiving fire, caring for the wounded or seeing a dead body (Afari et al.,

2015). These statistics reveal that although females during the war experienced far less combat

compared to males, they report equal and sometimes elevated levels of PTSD (Afari et al., 2015).

Legislation passed in 2016 removed restrictions on females in combat units (Pellerin,

2015). The first women are just now being trained for jobs in infantry and armor divisions which

will exacerbate the diagnosis of PTSD and inflate the number of women who report PTSD

symptoms.
MINDFULNESS IN FEMALE VETERANS WITH PTSD 6

Typical Treatment and need for Alternative treatment. ​Common treatment options for

veterans diagnosed with PTSD are cognitive behavioral therapies including prolonged exposure,

non exposure and cognitive processing therapy (Shalev et al., 2017). Despite many studies

showing a general reduction in PTSD severity using these techniques, the majority of

participants still retained their diagnosis during post treatment trials (Steenkamp, Litz, Hoge &

Marmar, 2015).

Additionally, a large portion of the diagnosed population turns towards pharmacological

options for their treatment (Hoskins et al., 2015). Despite many pharmaceutical options being

produced and prescribed, Hoskins et al. (2015) found effect sizes to be significantly less than

psychological interventions. Furthermore, researchers also found multiple problems with

pharmacological treatment options such as taking PTSD medications with a comorbid clinical

depression diagnosis and not maintaining a structured self administration regiment (Hoskins et

al., 2015). WHO now recommends pharmacological treatment options for PTSD as a secondary

option only after psychological remedies have failed to show results (Hoskins et al., 2015).

With many of the mainstream treatment options showing need for further improvement,

an alternative treatment for Post Traumatic Stress Disorder is needed. Mindfulness, a concept

originating in ancient Eastern culture, has presented itself as an effective option for diagnosed

veterans. Jon Kabat-Zinn defines mindfulness as “the awareness that emerges through paying

attention on purpose, in the present moment, non judgmentally to the unfolding of experience

moment by moment” (Kabat-Zinn, 2003). Mindfulness takes a present centered approach that

aims to improve the mental well being of the participant. Instead of actively recalling and

re-exposing one to the TE that plagues the participant, mindfulness aims to simply accept those
MINDFULNESS IN FEMALE VETERANS WITH PTSD 7

thoughts as they come. Previous meta analyses have shown mindfulness to be a effective for

those diagnosed with PTSD (Banks, Newman & Saleem, 2015). Specifically, mindfulness has

shown improvements in stress reduction, avoidance symptoms and feelings of guilt and shame

(Banks et al., 2015).

Effectiveness of Mindfulness Approaches in Female Veteran Populations

Multiple Applications of Mindfulness. ​There are specific techniques that fall under the broad

definition of mindfulness, that have been applied effectively to veterans (Martinez et al., 2012;

King et al., 2013; Lang, 2017; Hoge et al., 2014). By far the most common approach is

Mindfulness Based Stress Reduction (MBSR) therapy which consists of an intensive 8-week,

group-centered, multi-faceted approach (Possemato et al. 2016). Mindfulness Based Cognitive

Therapy (MBCT) is a similarly common treatment option that derives from MBSR but contains

cognitive components meant for patients with concurrent depression (King et al., 2013). Meta

mindfulness, also referred to as loving kindness or compassion mindfulness (CM), aims to

cultivate compassion for self and others and attempts to increase positive emotion as well as

social connectedness in patients (Lang, 2017). Low levels of these two characteristics, in the

aftermath of a TE are strong predictors of PTSD, need for extended treatment, and the increased

risk of suicide (Lang, 2017).

 MINDFULNESS IN FEMALE VETERANS WITH PTSD 8

Type of Study Treatment Treatment Focus Number Results

Method of
Women
in the
Study

Possemato et al., Randomized MBSR Reduction in general 8/62 Similar symptom reduction
2016 clinical trial symptoms with to typical MBSR studies
expedited treatment but with increased
approach reduction in comorbid
depression

Lang, 2017 Nonrandomized CBCT Increase in positive 7/36 Overall drop in PTSD from
emotion (PE) and session 1 to session 10
improved social reached statistical
functioning (SF) significance. Change in PE
and SF did not but
qualitative data supports
improvement in these two
areas.

Kearney et al., 2017 Longitudinal MBSR Examine mental health 22/92 48% of participants showed
and quality of life before clinically significant
and after MBSR improvement
treatment

Wisner, 2015 Qualitative MBSR Stress and sleep 3/9 No statistical change in pre
Study difficulties and post measures of stress
and sleep difficulties

King et al., 2013 Nonrandomized MBCT General PTSD 14/37 MBCT participants had an
control study symptoms, especially average 11 point decrease
negative cognitions on the CAPS scale

Engelmann & Steil, Case Study MBCT Patient's self view 7/10 9 out of 10 participants did
2017 (negative beliefs) not meet the diagnostic
criteria for PTSD after
completion of the therapy

MBSR for female veterans with PTSD

Mindfulness Based Stress Reduction therapy, the most widely researched method to date

(Shalev et al., 2017), has shown effectiveness in reducing symptoms of PTSD in both male and
MINDFULNESS IN FEMALE VETERANS WITH PTSD 9

female veterans (Possemato et al., 2016; Shalev et al., 2017). However, one of the many major

drawbacks of MBSR is a large time commitment (Possemato et al., 2016). Typical treatments

start at a minimum of 8 weeks with groups meeting for 2.5 hours each session and at least one

session that lasts the entire day (Possemato et al., 2016). A 2013 study revealed that full length

MBSR treatments may be less effective than originally reported (Possemato et al., 2016).

Kearney et al (2012) studied 47 veterans with PTSD, splitting them into randomized groups with

one group receiving full length MBSR therapy and the other a combination of support therapy

and medication. The results showed that there was little difference in post treatment symptoms

between the two groups. Alternative MBSR programs have been studied that cut the length of the

full therapy. Possemato and colleagues (2016) created a truncated program specifically tailored

to primary care patients lasting 4 weeks and 1.5 hours per session. The study included 8 females

veterans and results showed similar effectiveness to basic MBSR studies but with longer lasting

additive effects such as a statistically significant reduction in depression which is often comorbid

with the disorder in review (Possemato et al., 2015). Statistical significance in this study was

measured on the PTSD Checklist (PCL) and required a drop of at least 10 points between pre and

post tests. The PCL is a 20 question self report test. Each question has a 1-4 scale and total

symptom severity score can be reached by summing all questions (Possemato et al., 2015).

One of the primary symptoms of PTSD is trouble sleeping. In a survey of 338 veterans,

40% indicated that they had trouble sleeping as a result of a TE during combat (Gwin et al.,

2012). In 2015, Wisner conducted a small study of student veterans who met the criteria for

PTSD and reported difficulties sleeping. The study, consisting of 9 student veterans, a third

being female, used MBSR therapy to manage elevated stress levels and sleep problems caused
MINDFULNESS IN FEMALE VETERANS WITH PTSD 10

by PTSD. Students met hourly for 6 weeks during a semester. During the meetings, a licensed

social worker lead the group in mindfulness practices consisting of guided meditations, debrief

discussions, and a question and answer portion. No significant differences in the data between

the pre and post measures on stress were found however students reported multiple benefits from

the MBSR classes including increased sense of mindfulness, increased sense of belonging and

attentional control (Wisner, 2015). Participants knew that the therapy was working because

although the stressors themselves did not decrease (mindfulnesses’ purpose is not to eliminate

symptoms) their ability to recognize and cope with the stress did.

MBCT for Female Veterans with PTSD

Mindfulness Based Cognitive Therapy was designed to for patients with PTSD who also

experience comorbid mental health issues. Thirty to fifty percent of those with PTSD are also

diagnosed with depression and the numbers stay consistent in veteran populations (Duncan et al.,

2007; Shalev et al., 2017). King and colleagues (2013) designed the pilot study that looked at the

effectiveness of MBCT as a new alternative treatment for combat related PTSD. The results

confirmed this novel form of therapy to be effective in reducing PTSD symptoms between the

pre and post tests administered to participants with MBCT. MBCT participants averaged an 11

point decrease on the Clinically Administered PTSD Scale (CAPS) and seventy-five percent of

participants in the MBCT therapy reported clinically significant improvements, compared to

34% in the control group (King et al., 2013).

A 2017 study conducted by Engelmann looked at cognitive restructuring and imagery

modification (CRIM), two specific techniques within the MBCT skill set. The revised DSM-V

diagnostic criteria for PTSD includes a negative cognition component which is what CRIM
MINDFULNESS IN FEMALE VETERANS WITH PTSD 11

actively attempts to combat. Negative cognitions are central to PTSD because they create vicious

“cognitive symptomatic” cycles which continually afflict the the diagnosed population

(Engelmann & Steil, 2017). CRIM address these cognitions by changing a negative core belief a

sufferer has about themselves. Participants are instructed to cognitively restructure the traumatic

event with it resulting in an alternate, positive outcome (Engelmann & Steil, 2017). Engelman’s

study consisted of three sessions each lasting an hour and a half with 10 participants, 7 being

women. In the first session, the negative cognition was identified (ie “I am worthless and weak”)

and the following two treatment sessions were spent restructuring the thought by using imagery

modification to imagine the event ending in a more positive outcome. The results collected at the

end of the final session showed significant reductions in PTSD symptoms in both clinician rated

and self reported measures (Engelmann & Steil, 2017). Mean CAPS scores dropped from 72 to

28, removing 9 out of 10 participants from meeting the diagnostic criteria for PTSD (Engelmann

& Steil, 2017). Overall CRIM works by addressing dysfunctional negative self concepts which

many veterans who return from deployment have.

CBCT for female veterans with PTSD

Cognitively based compassion training is a newly emerging form of treatment for

veterans with PTSD. Its aim is to increase compassion towards self and others by encouraging

reappraisal, altering typical mental patterns, and increasing present moment practices like

focused attention and open monitoring (Lang, 2017). The increase in compassion that results

from these techniques is directly related to an increase in positive emotion (PE) and social

functioning (SF). PE counteracts PTSD in that people with high positive emotion are able to

thinking flexibly and utilize psychological resources in order to cope (Lang, 2017). Poor SF has
MINDFULNESS IN FEMALE VETERANS WITH PTSD 12

been labeled as a predictor for PTSD and additionally predicts an increased need for treatment

and suicide in veterans (Lang, 2017). Conversely, higher SF is linked to close social support

which has been shown to be a primary contributor to symptom reduction (Lang, 2017).

In a 2017 study looking at the effectiveness of CBCT modified for veterans, researchers

took 36 veterans, 20% who were female, and put them through a 10 session program

incorporating didactics, mindfulness meditation, and ending in a question and answer portion.

The study began by recalling a time and a place where the participant felt safe and then applied

the positive effect generated by the exercise in other areas of the participant’s life. Specifically in

cultivating compassion by meditating on ideas such as gratitude towards others and the basic

human desire to be free from suffering and judgement (Lang, 2017). The results of the study

showed a significant difference in PTSD symptoms from session 1 to session 10 with a mean of

15 points dropped on the PCL scale (Lang, 2017). Based on qualitative data collected post study,

CBCT increased positive emotion (Lang, 2017) however quantitative data did not reflect a

change in social connectedness. The researchers attribute this nonfinding to the idea that social

change takes far longer than the 10 weeks the study spanned. Long term follow up would be

beneficial to see these potential changes.

Limitations

There are a number of limitations in the studies contained in this review. First no study

has yet been conducted exclusively with female veterans in the treatment of PTSD with

mindfulness. Many studies include women, however they are a small portion of the total sample

size. The standard for inclusion in this review was a minimum of an 85%:15% male to female

ratio. In many cases it is difficult to generalize the overall findings to women specifically
MINDFULNESS IN FEMALE VETERANS WITH PTSD 13

because they represent a small portion of the total sample sizes. Without randomized and

controlled studies looking specifically at female veterans with PTSD using mindfulness, the

current data being reported is low in validity and accuracy. Next, the sample sizes used in these

studies varied from ​n=9​ up to ​n=36​, however, most fell in the 10 to 15 participant range. These

low sample sizes provide less credibility to the results that were found. Last, a recent study (King

et al., 2013) has notes that some veteran participants felt uncomfortable during the therapy which

has led to elevated drop out rates. This may suggest that while mindfulness based PTSD

treatment has shown to be effective, it is not the right method of treatment for all veterans.

Future Directions

Throughout the studies included in this review, researchers noted areas that could have

been improved upon in their mindfulness practices. First, veteran participants found that

mindfulness therapy was most effective when it was labeled as “training” compared to alternate

labels such as meditative practices or mindfulness therapy (Possemato et al., 2017). Second,

veteran participants reported that their MBSR training would be most effective if the groups

were separated by sex and that no non military personnel be included (excluding family and

close friends). This may have to do with a sense of belonging and the ability for those in therapy

to form close social relationships without fear of judgement (Martinez et al., 2015). Furthermore,

while collecting data, Wisner (2015) found that a significant portion of the veterans interviewed

for the study reported that they did not know where to seek help or what resources were available

to them. Lastly, a majority reported that it would be “embarrassing” or viewed as “weak” if they

sought out mental health care for their condition (Wisner, 2015). This shows that the direction of
MINDFULNESS IN FEMALE VETERANS WITH PTSD 14

future mindfulness studies need to be improved, as well as an increase in the awareness and

support for veterans with PTSD.

Conclusion

Mindfulness has been shown to be an effective treatment option for veterans with PTSD.

The literature up to the present contains numerous different approaches and applications of

mindfulness to treat this disorder such as MBSR, MBCT, and CBCT. Past studies however are

limited in that they focus primarily on males and provide little to no specific data for the

treatment of female soldiers. These studied have included small samples of women, however, the

results are hard to generalize to the female veteran population as a whole. In 2016, federal law

was passed allowing women into combat units. This change will drastically increase the number

of women who are on the front lines and, as a result, the number of women who will be

diagnosed with PTSD. Treatment options for this population must be studied and validated

before the influx occurs.

Acknowledgements

I am especially thankful for Molly Sands, Vanessa Castro and Dr. Derek Isaacowitz for

helping me write my first research proposal and literature review last summer. That practice

helped in completing this project. Lastly I would like to thank Dr. Irina Todorova who teaches

Clinical Applications of Mindfulness, the class that inspired me to choose this topic.
MINDFULNESS IN FEMALE VETERANS WITH PTSD 15

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