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Mindfulness ISSN 1868-8527 MindfulnessDOI 10.1007/s12671-014-0340-0

Feasibility and Acceptability of a BriefMindfulness Program for Veterans inPrimary Care with Posttraumatic StressDisorder

Wilfred Pigeon, Christy Allen, KylePossemato, Dessa Bergen-Cico & ScottTreatman

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ORIGINAL PAPER

Feasibility and Acceptability of a Brief Mindfulness Programfor Veterans in Primary Care with Posttraumatic Stress Disorder

Wilfred Pigeon & Christy Allen & Kyle Possemato &

Dessa Bergen-Cico & Scott Treatman

# Springer Science+Business Media New York (outside the USA) 2014

Abstract Mindfulness-based stress reduction programs haveimproved psychological health for clinical populations in-cluding veterans with posttraumatic stress disorder (PTSD).Veterans with PTSD who seek services in Department ofVeterans Affairs primary care are especially in need ofbrief treatments that can alleviate PTSD symptoms. Aclinical demonstration project was carried out to assessthe feasibility and acceptability of a brief mindfulnessprogram consisting of four weekly 1.5-h class sessions.Veterans enrolled in primary care with diagnostic or sub-threshold PTSD were recruited. The brief mindfulnessintervention was feasible to deliver, and veterans weregenerally satisfied with the program. Despite good reten-tion once a class session was attended, a large number ofveterans provided a variety of reasons for not attendingthe program at all. Veteran feedback that can be addressedto improve the brief mindfulness program is discussed,including enhancing initial attendance.

Keywords Meditation .Mindfulness . PTSD . Primary care .

Veterans

Introduction

Posttraumatic stress disorder (PTSD) is a common and oftendebilitating psychiatric diagnosis with an 8 % prevalence rateamong the general population (Kessler et al. 1995) and among11–12 % of patients receiving services in civilian (Stein et al.2000) and Department of Veterans Affairs (VA) primary care(PC) clinics (Magruder et al. 2005). Among recent combatveterans of the wars in Iraq and Afghanistan, also referred toas Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn (OEF/OIF/OND) veterans, as manyas 58 % who are PC patients may have PTSD (Seal et al.2010). Subthreshold PTSD, defined as reporting a traumaticstressor, at least one re-experiencing symptom, and eitherthree avoidance or two arousal symptoms from the DSM-IVdiagnostic criteria, is common in VA PC (Grubaugh et al.2005; Zlotnick et al. 2004). Beyond mere prevalence, PTSDis strongly linked to physical health problems treated in PC(Ouimette et al. 2004; Schnurr and Spiro 1999) and to havingmultiple impairments, including elevated pain and diminishedphysical function (Gillock et al. 2005). Both older (Vietnamera) and more recent veterans with PTSD have significantlyincreased cardiovascular-related morbidity rates compared totheir veteran peers without PTSD (Andersen et al. 2010;Boscarino 2008). Furthermore, PTSD is often comorbid withother psychiatric disorders, especially depression and alcoholuse disorders (Hankin et al. 1999; Stein et al. 2000).

The joint VA/Department of Defense Clinical PracticeGuidelines for PTSD suggest that PC is an “ideal setting” toengage individuals with PTSD in the treatment process (TheManagement of Post-Traumatic Stress Working Group 2010).There are barriers to the treatment of PTSD in PC. Forinstance, cognitive behavioral and exposure therapies con-stitute major advances in the treatment of PTSD, but thereis a shortage of providers trained to deliver evidence-basedPTSD treatments (Frueh et al. 2006). Additional barriers

W. Pigeon (*)Center of Excellence for Suicide Prevention, Canandaigua VAMedical Center, 400 Fort Hill Avenue, Canandaigua,NY 14424, USAe-mail: wilfred_pigeon@urmc.rochester.edu

C. Allen :K. PossematoCenter for Integrated Healthcare, Syracuse VA Medical Center,Syracuse, NY, USA

D. Bergen-CicoDepartment of Public Health, Syracuse University, Syracuse,NY, USA

S. TreatmanEmployee Health Services, Crouse Hospital, Syracuse, NY, USA

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include the following: practitioner concerns about iatrogeniceffects of PTSD treatments (Becker et al. 2004); patientresistance to cognitive behavioral therapies (Foy et al.1996; Zayfert and DeViva 2004); decreased treatment seek-ing due to stigma of PTSD (Hoge et al. 2004); and treat-ment refusal among veterans with PTSD due to negativeperceptions about service accessibility, delivery, and efficacy(Desai et al. 2005).

In health care systems where regular PTSD screening hasbeen implemented in PC (e.g., VA health care), the disorder isbeing detected more often (Kimerling et al. 2006). Withincreasing frequency, both civilian and military health caresystems have integrated mental health professionals into thePC setting. Nonetheless, even in the VA, a large study ofveterans from the Iraq and Afghan wars found that thosewho received PTSD diagnoses in PC were significantly lesslikely to receive adequate PTSD treatment compared to thosediagnosed in specialty treatment settings (Spoont et al. 2010),suggesting that patients may have difficulty following throughon referrals made to PTSD services outside of the PC setting.Medical chart review data has also revealed that approximatelytwo thirds of veteran PC patients with PTSD refused, or wereambivalent about, accepting referrals from their PC providersfor specialized PTSD treatment (Possemato 2011).

As a potential response to these barriers, both research andclinical practice suggest that briefer interventions are betteraccepted by patients and providers in PC settings (e.g., Gunnand Blount 2009; McDaniel and LeRoux 2007). Mindfulness-based stress reduction (MBSR) is one treatment that could beadapted to the PC environment to enhance treatment engage-ment for patients with PTSD. MBSR is a structured 8-weekprogram, developed by John Kabat-Zinn, which incorporatesquiet sitting meditation, body scanning, and moving medita-tion to teach participants how to cultivate and apply mindful-ness skills (Kabat-Zinn 2009, 2003). Mindfulness is both astate of awareness and a way of being, which is cultivatedthrough structured meditation practice to promote psycholog-ical and physical health (Bergen-Cico and Cheon 2013).Meditation is the core of mindfulness and is indeed the“scaffolding” that leads to mindfulness becoming an inte-gral part of living and being (Kabat-Zinn 2009, 2003;Shapiro et al. 2006). In addition to sitting meditation,gentle yoga and psychoeducation related to awareness ofthoughts and judgments are integral components of MBSR(Kabat-Zinn 2009). Shapiro et al. (2006) theorize that thereare three fundamental components of mindfulness: inten-tion, attention, and attitude; and these components whichare cultivated through MBSR practice are hypothesized tomediate changes in psychological and physical symptoms.

Further, MBSR promotes self-regulation and toleratinganxiety and distress. Anxiety is associated with forward fo-cused thinking and worry, whereas depression is characterizedby ruminating on the past; neither are present moment focused

(Ehring et al. 2008). In contrast, mindfulness-based practicescultivate nonjudgmental awareness of the present moment andare associated with reductions in anxiety and depression (Baer2003; Brown and Ryan 2003; Kabat-Zinn 2003, 2009). Infact, the efficacy ofMBSR in reducing anxiety and depressionhas been demonstrated in a variety of populations (Kabat-Zinnet al. 1992; Koszycki et al. 2007; Ramel et al. 2004).

It has been suggested that MBSR may be particularly well-suited, therefore, to treat symptoms of PTSD (Kearney et al.2012; Vujanovic et al. 2009). Support for this assertion in-cludes the effectiveness of MBSR in reducing anxiety inindividuals with medical problems linked to PTSD (Bédardet al. 2003; Tacon et al. 2003) and in treating conditions thatare commonly comorbid with PTSD, including anxiety(Kabat-Zinn et al. 1992; Koszycki et al. 2007) and depression(Ramel et al. 2004). Further, rationale for introducing individ-uals with PTSD to MBSR is the possibility that cultivation ofmindfulness skills can improve emotional regulation and pro-vide awareness and acceptance skills in the face of emotionaltriggers, reminders of trauma, and the states of distress thatmay accompany them (Follette and Vijay 2009; Vujanovicet al. 2009). For instance, in a cross-sectional study of 239trauma-exposed adults with elevated PTSD symptom severity,Vujanovic et al. (2009) reported that the mindfulness con-structs of acting without judgment and acting with awarenesswere significantly associated with lower PTSD severity.Finally, there is also evidence that mindfulness practice maylead to reductions in physiological arousal, a core symptom ofPTSD (Baer 2003).

Notably, significant improvement in PTSD symptoms hasbeen observed among veterans engaging in mindfulness-basedcognitive therapy (MBCT; King et al. 2013) and MBSR(Kearney et al. 2012; Niles et al. 2012). Kearney et al. (2012)reported statistically significant reductions in both PTSD anddepression severity in an uncontrolled trial of a standardMBSRprogram delivered to 92 veterans (74 % with PTSD); theimprovements were sustained at a 6-month follow-up. Nileset al. (2012) conducted a small randomized trial of veteranswith PTSD (n=33), comparing a telephone-based mindfulnessintervention (two sessions in person and six sessions overthe phone) to PTSD psychoeducation delivered in the sameformat. In this study, the mindfulness condition was asso-ciated with greater reductions in both self-reported andclinician-assessed PTSD symptoms, at posttreatment, but theseimprovements were not sustained through the 6-week follow-up (Niles et al. 2012).

Given the time commitment (approximately 26 h over eight2.5-h weekly group sessions and one all day retreat) needed toengage in traditional MBSR (e.g., Follette and Vijay 2009;Kabat-Zinn 2003), briefer formats of MBSR have been devel-oped and found to be efficacious (Bergen-Cico et al. 2013;Carmody and Baer 2009; Klatt et al. 2009; Tang et al. 2007;Zeidan et al. 2010). Carmody and Baer (2009) examined

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published MBSR studies and did not find a significant corre-lation between total class hours and effect sizes; the mostsignificant gains in MBSR have been observed to occur inthe first 4 weeks of the 8-week MBSR curriculum (Bergen-Cico and Cheon 2013). In nonclinical samples, brief coursesof MBSR have led to significant improvements in quality oflife in four sessions (Mackenzie et al. 2006) and five sessions(Jacobs and Nagel 2003); mindfulness and self-compassion infive sessions (Bergen-Cico et al. 2013); and perceived stress insix sessions (Klatt et al. 2009).

A brief mindfulness intervention, therefore, is a potentiallyviable and effective treatment alternative for PC patients withPTSDwho are less receptive to currently recommended PTSDtreatments and/or have limited access to such care. An addi-tional rationale for offering the 4-week program to the currentveteran population was the widespread geography of par-ticipants and the related transportation challenges theyoften face. Accordingly, we undertook a clinical demon-stration project with the primary aim of assessing thefeasibility and acceptability of a primary care brief mind-fulness program (PC-bMP) developed to augment PTSDtreatment options for veterans in PC.

Method

Participants

Participants were recruited from PC clinics at a VA MedicalCenter for this clinical demonstration project. Specifically,veterans who completed a required annual PC PTSD screen(Prins et al. 2003) and screened positive for PTSD (scored≥2)were identified.

In order to be considered eligible for the study, participantshad to meet criteria for subthreshold PTSD or diagnostic-levelPTSD related to military service, as measured by the ClinicianAdministered PTSD Scale (CAPS) for the past month (Blakeet al. 2000). Subthreshold PTSD is defined as reporting atraumatic stressor, at least one re-experiencing symptom, andeither three avoidance or two arousal symptoms, is common inVA PC (Grubaugh et al. 2005; Zlotnick et al. 2004). Exclusioncriteria included veterans who met one or more of thesecriteria: (a) gross cognitive impairment as measured by theBlessed Orientation-Memory-Concentration (Katzman et al.1983); (b) moderate to severe traumatic brain injury (asmeasured by the VA TBI assessments present in patients’medical charts); (c) a suicide attempt or desire to commitsuicide in the previous 2 months; (d) engaged in psycho-therapy or mental health counseling in the previous2 months that was received outside of VA PC; (e) changein dosage, or began a new, psychotropic medication in theprevious 2 months; or (f) had a desire to begin PTSDtreatment in specialty mental health treatment.

Procedure

Participants provided informed consent prior to inclusion inthe project (verbal consent during a phone screen and writtenconsent in person), which was approved by the localInstitutional Review Board and Research and Developmentcommittees. Following identification of potential participants,the PC provider or their OEF/OIF/OND case managerreviewed the case. If appropriate, a letter from the provideror case manager was sent to the veteran informing them thatthey had been referred to the study, which was briefly de-scribed in the letter. Experienced assessors subsequentlyscreened these veterans over the phone for military traumaexposure, defined as “highly stressful and traumatic events aspart of military service including combat, serious injuries, andphysical and sexual assaults” and the presence of currenttraumatic stress, defined as “stress symptoms related to theseexperiences, such as distressing dreams, avoiding thinkingabout them, avoiding places that would remind them of theirexperiences, or feeling constantly on guard or watchful.”

Veterans who met these initial eligibility criteria andwished to participate in the study were scheduled for an in-person assessment. Seventy-eight veterans enrolled in thestudy and were further assessed for eligibility by study asses-sors using the past month and past week versions of the CAPS(Blake et al. 2000). All assessors received formal CAPStraining including face-to-face didactics, role play, and prac-tice with administration and coding.

Following the eligibility assessment, participants wererandomized to receive our brief mindfulness program or acontrol condition consisting of treatment-as-usual in PCand, following completion of the 8-week posttreatmentassessment, the option of participating in the mindfulnessprogram. Participants were assessed at baseline, immediatelyposttreatment, 4-week posttreatment, and 8-week posttreat-ment and reimbursed $20–$30 per assessment based on thelength of each assessment for a total of up to $100 for com-pleting all assessments, but were not reimbursed for attendinggroup sessions.

Participants randomized to the PC-bMP attended weeklyin-person 1.5-h class sessions for four consecutive weeks. ThePC-bMP curriculum was originally developed by the instruc-tor in response to feedback from past and prospective MBSRparticipants that they could/would not commit to an 8-weekprogram due to work and family obligations. The 4-weekcurriculum has been taught twice yearly to approximately 12participants per program since 2011.

The curriculumwas condensed while still allowing for corepractices of the 8-week MBSR program (body scan, yoga,sitting meditation including “choiceless awareness” and“metta”, walking meditation) to be experienced in class.Each class session centered around a weekly theme, introduc-tion to various mindfulness skills, and discussions of weekly

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practice in the real world and using mindfulness to circumventthe unhealthy cycle of stress reactivity.

Home practice was a core component of the program,particularly given the brevity of the intervention. Each partic-ipant was given a copy of the book Full Catastrophe Living:Using the Wisdom of Your Body and Mind to Face Stress,Pain, and Illness (Kabat-Zinn 2009) and two audio CDscontaining the facilitator’s renditions of several prerecordedguided meditations such as the following: “BreathAwareness,” “Loving Kindness,” “Body Scan,” “SittingMeditation (5, 10, and 30 minute meditation with ∼85 %silence),” and “Mindful Yoga.” The instructor offered asupplemental CD of “minimeditations” ranging from2 min to nearly 12 min.

The “2-min chill out meditation” (with ∼50 % silence) wasassigned to daily practice to give participants an easy oppor-tunity to “drop in” to the moment.

Group participants were given weekly home assignmentsthat included selected readings, audio guided meditations,walking meditations, and other exercises. Handouts weredesigned to track the curriculum. They also received weeklylogs with prompts to record thoughts, reflections, and obser-vations that arose as they practiced mindfulness skills bothformally and informally on their own as well as to record thedaily amount of time engaged inmindful exercises. An outlineof each class and weekly home assignments is presented inTable 1.

At the VA facility where this study was conducted, therewas a lack of available space for the mindfulness programduring the time periods needed. Therefore, we sought a loca-tion that was spacious enough and would make veterans feelcomfortable. The groups were ultimately conducted withinone block of the VA hospital using another medical center’sfacilities.

Fidelity was measured by anMBSR practitioner and teach-er who attended the PC-bMP sessions. The fidelity raterobserved at least one of each session to rate: (a) facilitatoradherence to program delivery according to the PC-bMPtreatment manual curriculum developed for this study; (b)tracking of the number of minutes and ratio of time engagedin meditation, body scan, yoga and dialogue; and (c) whetherthe instructor conducted inquiry in ways that elicited howparticipants experienced their practice and how they workedwith difficulties in the context of mindful practices. Thefidelity rater also observed participant receptivity to mindful-ness practice and attitudinal foundations of mindfulness.

All cohorts of the PC-bMP were taught by the same expe-rienced MBSR teacher. Both the PC-bMP instructor and thefidelity rater completed all three foundational trainings inMBSR through the University of Massachusetts Center forMindfulness in Medicine, Health Care and Society but havenot obtained their teacher certification. The fidelity rater has7 years of formal mindfulness practice and has been teaching

MBSR for 6 years; the instructor has 21 years of daily per-sonal meditation practice and 18 years of teaching experience.

Measures

The demographics and military background is an unvalidated,self-report instrument constructed and used by the study teamfor prior studies of veterans with PTSD assessed basic demo-graphic information (e.g., sex, age, education, employment,and income) and military background including deploymenthistory (e.g., length, number, and locations), militaryrank/positions, branch of service, active/reserve status, anddates of service.

The CAPS is the “gold standard” measure of PTSD. Afterconfirming exposure to a traumatic event that involved actualor threatened death or serious injury to self or others and wasexperienced with intense fear, helplessness, or horror, thescale assesses the 17 core symptoms of PTSD using an inter-view format (Blake et al. 1995). Each symptom is scoredseparately on a five-point (0–4) scale for both frequency andintensity. The CAPS has sound psychometric properties in-cluding excellent diagnostic utility. The past month version ofthis measure was used to verify the presence of a traumaticevent, measure PTSD severity, and document rates of full andsubthreshold PTSD in the sample at baseline. The CAPS hasgood internal consistency with Cronbach’s α ranging from0.89 to 0.95 (Blake et al. 2000); internal consistency in thecurrent sample was α=0.93.

The Client Satisfaction Questionnaire (CSQ-8) is an 8-itemself-report measure developed to assess patient satisfactionwith medical and mental health treatment (Attkisson andGreenfield 2004). Items use a 4-point likert scale and sum toa total score of 8–32. The CSQ-8 is reliable and correlates wellwith measures of global improvement, and higher scores arerelated to treatment completion and symptom reduction. TheCSQ-8 was administered at the 4-week posttreatment assess-ment. The CSQ-8 has good internal consistency withCronbach’s α ranging from 0.83 to 0.93 (Sederer et al. 1996);internal consistency in the current sample was α=0.88.

The Experiences in Treatment Questionnaire (EiTQ) is anunvalidated, self-report instrument constructed for this pro-ject. It contains 32 items with some items rated as “yes or no”and others rated on a 0–3 scale ranging from “not at all” to “alot, ” to assess participant experiences related to barriers tocare (e.g., transportation problems, location), treatment (e.g.,confidentiality, comfort with group leader, frequency of ses-sions), and research assessments (e.g., length, nature of ques-tions). This instrument is intended to provide some feasibilitydata as well as feedback to enhance procedures in future work.

Finally, brief structured phone interviews were conductedwith participants who chose not to attend PC-bMP. The inter-viewer asked participants to rate 22 statements (from 1=“dis-agree strongly” to 5=agree strongly”) drawn from common

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barriers to treatment in general (e.g., “I do not have the time toattend treatment”) and barriers specific to this study andveterans with PTSD (e.g., “I do not go to places or do thingsthat remind me of past traumas”) which precluded them fromattending group sessions. It also included three open-endedquestions pertaining to their understanding of the group, whatcould have encouraged their participation, and what changesthey might recommend to improve the program.

Data Analyses

Although our primary focus is to describe the brief mindful-ness program that was developed and our experience indelivering this intervention, some descriptive statisticsare provided, and simple, exploratory analyses wereundertaken to further assess feasibility and acceptance. UsingSPSS 20.0, bivariate correlations were conducted between

sociodemographic/clinical variables and group participation,number of sessions attended, and total number of hoursengaged in mindfulness practice outside of the sessions. Wealso performed a bivariate correlation between scores onthe CSQ-8 and change in PTSD severity as measured bythe CAPS (1-week version).

Results

Of the 78 veterans enrolled in the study, 62 (80 %) wereeligible and randomized (n=36 to PC-MBSR; n=26 to thecontrol condition). As detailed in Table 2, the majority ofparticipants were male and identified as white, represented avariety of military branches and deployment experiences, andapproximately half met diagnostic-level PTSD criteria, theother half meeting subthreshold PTSD criteria.

Table 1 Structure of brief MBSR program

Group #: theme Session content Weekly assignment

#1: There is more right with you thanwrong with you

• Introduction to program (format, expectations,ground rules)

• Brief exercise: “TheWell” (Why are we here?;Aspirations)

• What is mindfulness? (foundation, intentionand commitment, integrating into daily living,dealing with stress)

• Raisin meditation• Body Scan—20 min• Brief sit with breath awareness

• 20 min body scan daily and mini-sitting*• Using breath awareness in stressful situations• Use 2-min Chill Out* at least once daily• Mindful eating• Mindfulness of routine activities• Daily log of minutes spent on various mindful activities• Readings: “Incline your Mind’ an introduction tomindfulness by the group facilitator; Chapters 1–3 from“Full Catastrophe Living” by Jon Kabat-Zinn

#2: Perception and creative responding • Review past week (issues with meditations,seeing change, difficulties)

• 20 min sitting – breath awareness, physicalsensations, sounds

• Stress reactivity vs. response (Stress reaction101, usingmindfulness to short circuit reaction,real life scenarios)

• Yoga and awareness

• Alternate stretching/mini-body scan* with 20 min sitting• Use 2-min Chill Out*, once or more daily• Capturing pleasant and unpleasant moments• Using the breath to slow things down• Awareness of what we take in (food, substances, violence,sounds, etc.)

• Daily log of minutes spent on various mindful activities• Readings: Thoughts on Thoughts’ by the group facilitator;“Why Meditate’ NY times article.

#3: Communication, expression offeelings, maintaining one’s centerin interpersonal relationships

• Brief sitting• Review of past week• Communication styles, separating fact fromstory, awareness of emotional reaction, focuson content

• Mindful listening exercise• Introduce Metta meditation

• Alternate “Metta” with any other 20 min meditation• 2-min Chill Out* at least once daily• Awareness of difficult communications (observingreactivity, story spinning, physical reactions, using thebreath to try to minimize reactivity)

• Observation of dietary intake (reading labels, underlyingemotions/feelings for eating, slowing things down)

• Daily log of minutes spent on various mindful activities• Readings: Cultivating Self-Compassion” and “Mindfulnessand Mastery” by the group facilitator.

#4: Making this practice your own • Yoga followed by body scan• Review of past week• Introduce walking meditation• Brief sitting, loving-kindness• Resources for continued practice• Closing activity

• Final Reading: “Continue Down the Mindful Path”

*=Follow along on mini-meditation CD

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Group Participation

Of the thirty-six participants randomized to PC-bMP, 20(56%) attended at least one session. Six PC-bMP groups wereheld over the course of 2012 and 2013 with 5–8 participantsassigned to each group. Weekly session attendance rangedfrom 2 to 6 individuals. Ninety-five percent (19/20) of PC-bMP participants who attended one session completed allfollow-up assessments, and 80 % (16/20) met our definitionof treatment completion (attending ≥3 sessions).

Program attendance was not correlated with any demo-graphic variable, PTSD severity, other clinical variables, ortime elapsed from baseline assessment to the first groupsession, which ranged from 5 to 89 days with a mean of35.8 (SD=28.5) days excluding one outlier who chose todefer starting the program for 181 days. However, participantswho endorsed passive suicidal ideation (“wished to be dead orwished to go to sleep and not wake up”) on the Columbia-Suicide Severity Rating Scale (C-SSRS) (Posner et al. 2006)within the 2 months prior to their baseline assessment were

likely to attend fewer sessions (r=−0.27, p<0.05). Asexpected, these participants were also less likely to com-plete the PC-bMP (r=−0.28, p<0.05).

Finally, study staff called participants (from both condi-tions) who did not attend any PC-bMP session and asked whatspecific barriers stopped then from attending sessions; 19participants were reached (13 from the PC-bMP conditionand 6 from the control condition). The most commonlyendorsed barriers were “I do not have time to attendtreatment” n=13, “Talking about my problems is toodifficult for me” n=9, “I do not go to places or do thingsthat remind me of my past traumas” n=9, and “I was notsure what treatment would involve” n=6. Two participantsendorsed “I do not like or want to try meditation.”Participants were also asked open-ended questions. Whenasked what they understood about the purpose of thegroup, more than half (n=11) thought it would focusspecifically on PTSD and trauma memories, three thoughtit would be a discussion-based process group, and twomentioned learning mindfulness skills. When asked,“Could we have done anything that would have madeyou decide to participate?” the most common response(n=8) focused on having more flexible time for thegroups that would fit into busy work and school sched-ules. Three participants also noted that the groups weretoo far away from their homes. When asked, “If wewanted more veterans to participate in this group in thefuture what changes would you recommend?” participantsmost often suggested having the groups closer to theirhomes (n=6). Additional suggestions included offeringmultiple groups per day (n=2), using online or app-based resource to do the interventions remotely (n=2),offering more incentives, such as giving gift cards forcoming to the groups (n=2).

Outside Class Participation

Participants submitted home practice logs to the PC-bMPfacilitator, during the last three classes. Logs were availablefrom 18 participants. The mean number of hours of homepractice, including formal practice of both guided and unguid-ed meditations as well as informal practice (e.g., mindfuleating, mindfulness of routine activities), engaged in was5.4 h (SD=5.8) following session one, 6.5 h (SD=9.3) fol-lowing week 2, and 5.7 h (SD=9.3) following week 3. Thetotal mean number of hours of mindfulness activities over3 weeks was 17.6 h (SD=24.3), with a wide range of 0.5 to87.7 h and a mix of approximately 40 % formal and 60 %informal practice. Years of education were positively correlat-ed with total minutes of practice (r=0.55, p<0.05). Greaterage (r=0.47, p=0.06) and a higher PTSD severity score atbaseline (r=0.47, p=0.06) trended toward being significantlycorrelated with total minutes of practice. About half of the

Table 2 Sample characteristics

Characteristics (N=62) n (%)

Mean age (SD) 46.4±16.3

Age range 21–71

Gender

Male 54 (87.1 %)

Female 8 (12.9 %)

Race/Ethnicity

Black/African American 9 (14.5 %)

Hispanic (non-White) 2 (3.2 %)

White 51 (82.3 %)

Married/living with a partner 44 (70.0 %)

Employed 23 (36.8 %)

Military branch

Army 39 (62.9 %)

Marines 13 (21.0 %)

Navy 8 (12.9 %)

Air Force 3 (4.8 %)

Coast Guard 2 (3.2 %)

Military Deployments

OEF/OIF/OND 36 (58.07 %)

Gulf War I 8 (12.9 %)

Vietnam 20 (32.3 %)

Other 10 (16.1 %)

Mean CAPS Score 44.7±15.0

Diagnostic PTSD 30 (48.4 %)

Subthreshold PTSD 32 (51.6 %)

OEF/OIF/OND Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn, CAPS Clinician Administered PTSD Scale (pastmonth version)

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participants (52%) reported doing all of the assigned readings,and only one participant reported not doing any readings.

Satisfaction

Twenty participants randomized to PC-bMP attended at leastone session, and 19 of these participants completed the CSQ-8. Their mean satisfaction score was 24.1 (SD=5.53) on ascale of (8–32), which corresponds to an average item ratingof 3.0 on a 1–4 scale where higher scores indicate greatersatisfaction.

Individual CSQ-8 item responses included that the PC-bMP was rated as “excellent” or “good” by 100 % ofattenders. Eighty-four percent (n=16) of attenders thoughtthat “almost all” or “most” of their needs were met, while16 % (n=3) felt “only a few” were met. When asked howsatisfied they were with the amount of help they received,58 % (n=11) were very or mostly satisfied, 21 % (n=4)were indifferent, and 21 % (n=4) were dissatisfied. Ninetypercent (n=17) of attenders reported that the programhelped them deal more effectively with their problemswhile 11 % (n=2) felt PC-bMP did not really help.Fifty-three percent (n=10) reported that they “got the kindof services they wanted,” and 58 % (n=11) reported thatthey would recommend the program to a friend in need ofsimilar help. In an exploratory analysis, the scores on theCSQ-8 were not associated with change in PTSD severityas assessed by the CAPS (r=0.08; p=61).

Participants also completed an unvalidated measure (theEiTQ) designed for this project to further assess satisfactionrelated to different areas of the pilot project at 8-week post-treatment. Responses were received from 36 participantsacross both conditions. Overall, participants reported beingsatisfied with the research assessments. When asked aboutfeeling uncomfortable with the kinds of questions asked,56 % (n=20) indicated “not at all,” 42 % (n=15) indicated“a little,” 3 % (n=1) indicated “a lot.” When asked if theassessment made them feel worse, 67 % (n=24) indicated notat all, and 33 % (n=12) indicated a little. When asked if theassessment helped them feel understood, 31 % (n=11)indicated not at all, 58 % (n=28) indicated “somewhat,”11 % (n=4) indicated a lot. Among PC-MBSR partici-pants completing the EiTQ (n=19), all attendees rated thequality of the services they received as “good” or “excellent,”and over three quarters reported that some or all of their needshad been met. Eighty-nine percent (n=17) reported that theservices they received helped them to deal more effectivelywith their problems. No one reported finding the group ses-sions too frequent, but a minority (n=4, 21 %) reportedfinding them too infrequent. Most participants (n=16, 84 %)reported that MBSR sessions helped them to feel better. Mostparticipants (n=15, 79 %) were comfortable with what theydisclosed to their facilitator and felt that they could be open

and confide in the instructor. All attendees felt the instructorunderstood and respected their cultural background.

Discussion

Overall, we found the PC-bMP to be feasible to implement.The protocol was able to be carried out for six groups withoutany significant issues in completing all planned activities.Veterans were able to attend without significant adverse ef-fects and with little cost or effort to either them or the VA. Interms of provider feasibility, the facilitator was able to follow astandardized curriculum, which engaged participants for 6 hof group mindfulness-based practice. Participants also en-gaged in an average of approximately 5–6 h of mindfulnesspractice per week during the program.

The brief mindfulness program was also generally well-accepted by veterans as indicated by total mean scores on theCSQ-8 averaging 3.0 on a 1–4 scale. Individual items fromthis scale also provided support for satisfaction at high levelsfor the majority of items. Informing future work is that only53 % reported they received the kind of services they wanted,which was lower than we would expect given higher rates ofsatisfaction in other areas. Other feedback received fromparticipants suggests that our procedures did not properlyprepare the veterans for PC-bMP. Addressing this shortcom-ing will be of critical import in refining the program.

Several additional lessons were learned from this clinicaldemonstration project. Institutional support, including both adedicated space within PC or within the VA facility as well asthe availability of a VA provider to facilitate mindfulnessprograms, is an important consideration in making futurerenditions of this program successful. As is the case in deliv-ering many group interventions, having enough participants tohold groups frequently and at different times of the day islikely to enhance group attendance given the feedback re-ceived from participants. The instructor and the fidelity raterof the PC-bMP groups concluded after the first cohort that agreater and explicit emphasis on engaging in practice (timespent in body scan and meditation) and limiting dialog wouldbe beneficial, and this change was implemented in subsequentgroup cohorts.

One major limitation of this study was that space for theprogram was not available at the VA facility where the studywas conducted. We cannot, therefore, infer that findingswould be similar if the group was conducted in or adjacentto a VA PC clinic. Similarly, the mindfulness program was notfacilitated by a VA PC staff. Instead, the study findings arebased on PC veterans who attended a brief mindfulness pro-gram that took place outside the VA and was not conducted byVA PC clinicians. We also did not systematically gatherqualitative feedback from veterans (e.g., in focus groups),

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which could have added information to the self-report andstructured interview feedback we did receive. For instance, afocus group could have probed to determine discrepancies onthe high ratings of CSQ-8 items related to treatment and togetting needs met, compared to lower ratings on getting thekinds of service they wanted. Another limitation is that somebut not all research staff had personal experience with MBSR,which limited the richness of the communication that could beused to describe our brief mindfulness program to participants.

The other limitation of this study was the sizable number ofveterans (44 %) who were randomized to receive PC-bMP butfailed to attend any session. Fifty-six percent of participantsrandomized to the PC-bMP condition attended at least onesession, and 80 % of this subsample completed treatment. Toput this in context, historically, dropout rates from PTSDtreatments are reported to be around 50 % (Schottenbaueret al. 2008); one study reported that 68 % of veterans droppedout of treatment in a VA PTSD clinic (Garcia et al. 2011). Inone VA clinic, 151 of 365 eligible patients (41 %) who werereferred to an existingMBSR orientation session attended thatsession (Kearney et al. 2012) and 74 % of 92 veterans whoenrolled in their uncontrolled study of standard MBSR subse-quently met their definition of completion (attended ≥4 of 9total group sessions). In the Niles et al. (2012) randomized trialof a phone-based mindfulness program, 13 of 17 programparticipants (76%) completed treatment. Thus, the current studyretention rate (80 %) once treatment was initiated is consistentwith or better than prior work while the initial dropout rate isunfortunately no better than that achieved in clinical settingsand raises the question as to whether a brief program can reachany more veterans than a standard MBSR program.

One possible reason for the initial rates of attendance wasthat the time elapsed between the baseline assessment and thefirst group that the participant was able to attend variedwidely. We did not find, however, that days elapsed betweenbaseline and group were related to whether or not the partic-ipant attended the group. It is possible that class and workschedules may have shifted during the wait time. The mostconsistent veteran feedback received with respect to groupattendance was related to time constraints and timing of thegroups. This may be a limitation of any group treatment thattargets busy individuals.

In addition, the fidelity rater and the PC-bMP instructornoted that despite verbal and written descriptions of the groupat the informed consent session, some veterans arrived at theirfirst session with some misconceptions. Notably, some partic-ipants expected this to be a “talking group.” Indeed, this wasalso a common misconception among veterans who chose notto attend any group sessions, as many indicated that they wereuncomfortable with the idea of “talking about their traumaticexperiences” or with talking in a group as a therapeuticapproach. This misconception may have partly arisen becausethe research interviews were largely focused on assessment of

traumatic events and PTSD symptoms. While this was neces-sary to verify a PTSD diagnosis with the CAPS, it also mayhave led participants to expect that group sessions would alsobe focused on talking about past traumas.

Although we did adjust our procedures to augment thestudy description that occurred during the consent processby including a brief flyer highlighting mindfulness compo-nents and a letter from the PC-bMP instructor, these are stillrather impersonal. Instead, establishment of a more personalconnection with a health care provider by discussing thereferral to PC-bMP in a patient-centered manner would, inretrospect, have been a far more appropriate approach.

To fully address any misperceptions about PC-bMP, and tolay the foundation for a therapeutic relationship, an initialorientation and overview of the program are recommendedprior to the first formal session (as described in Kearney et al.2012). Providing an introduction to the instructor before thefirst group session has obvious advantages. In addition,discussing the concept that the program is not directed at justthe body (as a type of asana exercises) or only at the mind (asjust a form of talk therapy), but that it encompasses the personin their entirety and is an opportunity to engage in the personalgrowth process could have been beneficial. Similarly, address-ing any concerns that PC-bMP is “just a yoga class” or “justgroup therapy,” would allay any such concerns. As suggestedfor MBSR programs, discussing ground rules and addressingany questions or concerns at an orientation session also allowthe first class to be more focused on mindfulness practice.

In sum, findings from this clinical demonstration projectindicate that it is feasible to deliver a four-session mindfulnessprogram to veterans with PSTD. The project also suggests thatveterans were able to complete the program once they started,that they engaged in outside practice, that the mindfulnessskills were helpful in several domains of their lives, and thatthey were reasonably satisfied with the program overall.Several forms of feedback, however, suggest that the programmust be improved, not the least of which is the imperative toimprove rates of initial attendance in the program followingreferral, before any dissemination efforts are considered. Inparticular, providing a more patient-centered orientation to thebrief mindfulness program is, we believe, likely to beimpactful in this regard. Finally, the literature on briefmindfulness programs is relatively nascent, what constitutesa mindfulness-based program has been raised (Kabat-Zinn2003), and reservations about brief formulations have beenexpressed. Whether brief mindfulness programs, both ingeneral and for patients with PTSD, have a place inclinical practices clearly remains to be established.

Acknowledgments This work was supported by clinical demonstrationfunds from the VA Office of Mental Health Services. The authors’ viewsor opinions do not necessarily represent those of the Department ofVeterans Affairs or the United States Government.

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Conflict of Interest The authors declare that they have no conflicts ofinterest.

References

Andersen, J., Wade, M., Possemato, K., & Ouimette, P. (2010).Association between posttraumatic stress disorder and provider-diagnosed disease among Iraq and Afghanistan veterans.Psychosomatic Medicine, 72(5), 498–504. doi:10.1097/PSY.0b013e3181d969a1.

Attkisson, C. C., & Greenfield, T. K. (2004). The UCSF ClientSatisfaction Scales: I. The Client Satisfaction Questionnaire-8. InM. Maruish (Ed.), The use of psychological testing for treatmentplanning and outcome assessment (3rd ed.). Mahwah: LawrenceErlbaum Associates.

Baer, R. A. (2003). Mindfulness training as clinical intervention. Aconceptual and empirical review. Clinical Psychology: Scienceand Practice, 10(2), 125–143. doi:10.1093/clipsy/bpg015.

Becker, C. B., Zayfert, C., & Anderson, E. (2004). A survey of psychol-ogists’ attitudes towards and utilization of exposure therapy forPTSD. Behaviour Research and Therapy, 42, 277–292. doi:10.1016/S0005-7967(03)00138-4.

Bédard, M., Felteau, M., Mazmanian, D., Fedyk, K., Klein, R.,Richardson, J., Parkinson, W., & Minthorn-Biggs, M. B. (2003).Pilot evaluation of a mindfulness-based intervention to improvequality of life among individuals who sustained traumatic braininjuries. Disability and Rehabilitation, 25, 722–731. doi:10.1080/0963828031000090489.

Bergen-Cico, D., & Cheon, S. (2013). The mediating effects of mindful-ness and self-compassion on trait anxiety.Mindfulness. doi:10.1007/s12671-013-0205-y.

Bergen-Cico, D., Possemato, K., & Cheon, S. (2013). Examining theefficacy of a brief mindfulness based stress reduction (brief MBSR)program on psychological health. Journal of American CollegeHealth, 61(6), 348–360.

Blake, D. D., Weathers, F. W., Nagy, L. M., & Kaloupek, D. G. (1995).The development of a Clinician-Administered PTSD Scale. Journalof Traumatic Stress, 8(1), 75–90.

Blake, D. D., Weathers, F. W., Nagy, L. M., Kaloupek, D., Klauminzer,G., Charney, D. S., Keane, T. M., & Buckley, T. C. (2000).Clinician-Administered PTSD Scale (CAPS) Instruction Manual.Boston: National Center for PTSD.

Boscarino, J. A. (2008). A prospective study of PTSD and early-age heartdisease mortality among Vietnam veterans: implication for surveil-lance and prevention. Psychosomatic Medicine, 70, 668–676. doi:10.1097/PSY.0b013e31817bccaf.

Brown, K. W., & Ryan, R. M. (2003). The benefits of being present:mindfulness and its role in psychological well-being. Journal ofPersonality and Social Psychology, 84(4), 822–848. doi:10.1037/0022-3514.84.4.822.

Carmody, J., & Baer, R. A. (2009). How long does amindfulness-based stress reduction program need to be? Areview of class contact hours and effect sizes for psycholog-ical distress. Journal of Clinical Psychology, 65(6), 627–638.doi:10.1002/jclp.20555.

Desai, R. A., Stefanovics, E. A., & Rosenheck, R. A. (2005). The role ofpsychiatric diagnosis in satisfaction with primary care: data from theDepartment of Veterans Affairs.Medical Care, 43(12), 1208–1216.doi:10.1097/01.mlr.0000185747.79104.90.

Ehring, T., Frank, S., & Ehlers, A. (2008). The role of rumination andreduced concreteness in the maintenance of posttraumatic stressdisorder and depression following trauma. Cognitive Therapy andResearch, 32(4), 488–506.

Follette, V. A., & Vijay, A. (2009). Mindfulness for trauma and posttrau-matic stress disorder. In D. Fabrizio (Ed.), Clinical handbook formindfulness (pp. 299–317). New York: Springer.

Foy, D. W., Kagan, B., McDermott, C., Leskin, G., Sipprelle, R., & Paz,G. (1996). Practical parameters in the use of flooding for treatingchronic PTSD. Clinical Psychology & Psychotherapy, 3, 169–175.

Frueh, B. C., Cusack, K. J., & Wells, C. (2006). Clinicians’ perspectiveson cognitive-behavioral treatment for PTSD among persons withsevere mental illness. Psychiatric Services, 57(7), 1027–1031. doi:10.1176/appi.ps.57.7.1027.

Garcia, H. A., Kelley, L. P., Rentz, T. O., & Lee, S. (2011). Pretreatmentpredictors of dropout from cognitive behavioral therapy for PTSD inIraq and Afghanistan war veterans. Psychological Services, 8(1), 1–11. doi:10.1037/a0022705.

Gillock, K. L., Zayfert, C., Hegel, M. T., & Ferguson, R. J. (2005).Posttraumatic stress disorder in primary care: prevalence and rela-tionships with physical symptoms and medical utilization. GeneralHospital Psychiatry, 27(6), 392–399. doi:10.1016/j.genhosppsych.2005.06.004.

Grubaugh, A. L., Magruder, K. M., Waldrop, A. E., Elhai, J. D., Knapp,R. G., & Frueh, B. C. (2005). Subthreshold PTSD in primary care:prevalence, psychiatric disorders, healthcare use, and functionalstatus. Journal of Nervous and Mental Disease, 193(10), 658–664.doi:10.1097/01.nmd.0000180740.02644.ab.

Gunn, W. B., & Blount, A. (2009). Primary care mental health: a newfrontier for psychology. Journal of Clinical Psychology, 65(3), 235–252. doi:10.1002/jclp.20499.

Hankin, C. S., Spiro, A., III, Miller, D. R., & Kazis, L. (1999). Mentaldisorders and mental health treatment among U.S. Department ofVeterans Affairs outpatients: the veterans health study. TheAmerican Journal of Psychiatry, 156(12), 1924–1930.

Hoge, C. W., Castro, C. A., Messer, S. C., & Koffman, R. L. (2004).Combat duty in Iraq and Afghanistan, mental health problems, andbarriers to care. The New England Journal of Medicine, 351(1), 13–22. doi:10.1056/NEJMoa040603.

Jacobs, B., & Nagel, L. (2003). The impact of a brief mindfulness-basedstress reduction program on perceived quality of life. InternationalJournal of Self Help and Self Care, 2(2), 155–168.

Kabat-Zinn, J. (2003). Mindfulness-based interventions in context: past,present, and future. Clinical Psychology: Science and Practice,10(2), 144–156. doi:10.1093/clipsy/bpg016.

Kabat-Zinn, J. (2009). Full catastrophe living: using the wisdom of yourbody and mind to face stress, pain and illness. NewYork: Delacorte.

Kabat-Zinn, J.,Massion, A.O., Kristeller, J., Peterson, L. G., Fletcher, K. E.,Pbert, L., & Santorelli, S. F. (1992). Effectiveness of a meditation-based stress reduction program in the treatment of anxiety disorders.American Journal of Psychiatry, 149(7), 936–943.

Katzman, R., Brown, T., Fuld, P., Peck, A., Schechter, R., & Schimmel,H. (1983). Validation of a short orientation-memory-concentrationtest of cognitive impairment. The American Journal of Psychiatry,140(6), 734–739.

Kearney, D. J., McDermott, K., Malte, C., Martinez, M., & Simpson, C.L. (2012). Association of participation in a mindfulness programwith measures of PTSD, depression, and quality of life in a veteransample. Journal of Clinical Psychology, 68(1), 101–116. doi:10.1002/jclp.20853.

Kessler, R. C., Sonnega, A., Bromet, E., Hughes, M., & Nelson, C. B.(1995). Posttraumatic stress disorder in the National ComorbiditySurvey. Archives of General Psychiatry, 52(12), 1048–1060.

Kimerling, R., Ouimette, P., Prins, A., Nisco, P., Lawler, C., Cronkite, R.,&Moos, R. H. (2006). Utility of a short screening scale for DSM-IVPTSD in primary care. Journal of General Internal Medicine, 21(1),65–67. doi:10.1111/j.1525-1497.2005.00292.x.

King, A. P., Erickson, T. M., Giardino, N. D., Favorite, T., Rauch, S. A.M., Robinson, E., Kulkarni, M., & Liberzon, I. (2013). A pilot studyof group mindfulness-based cognitive therapy (mbct) for combat

Mindfulness

Author's personal copy

veterans with posttraumatic stress disorder (ptsd). Depress. Anxiety,30, 638–645. doi:10.1002/da.22104.

Klatt, M. D., Buckworth, J., & Malarkey, W. B. (2009). Effects of low-dose mindfulness-based stress reduction (MBSR-ld) on workingadults. Health Education & Behavior, 36(3), 601–614. doi:10.1177/1090198108317627.

Koszycki, D., Benger, M., Shlik, J., & Bradwejn, J. (2007). Randomizedtrial of a meditation-based stress reduction program and cogni-tive behaviour therapy in generalized social anxiety disorder.Behaviour Research and Therapy, 45, 2518–2526. doi:10.1016/j.brat.2007.04.011.

Mackenzie, C. S., Poulin, P. A., & Seidman-Carlson, R. (2006). A briefmindfulness based stress reduction intervention for nurses andnurses aides. Applied Nursing Research, 19(2), 105–109. doi:10.1016/j.apnr.2005.08.002 pp. 105-9.

Magruder, K. M., Frueh, B. C., Knapp, R. G., Davis, L., Hamner, M.B.,Martin, R.H…. Arana, G.W. (2005). Prevalence of posttraumaticstress disorder in Veterans Affairs primary care clinics. GeneralHospital Psychiatry, 27(3), 167–179. doi:10.1016/j.genhosppsych.2004.11.001

McDaniel, S. H., & LeRoux, P. (2007). An overview of primary carefamily psychology. Journal of Clinical Psychology in MedicalSettings, 14(1), 23–32. doi:10.1007/s10880-006-9050-7.

Niles, B. L., Klunk-Gillis, J., Ryngala, D. J., Silberbogen, A. K.,Paysnick, A., & Wolf, E. J. (2012). Comparing mindfulness andpsychoeducation treatments for combat-related PTSD using atelehealth approach. Psychological Trauma: Theory, Research,Practice and Policy, 4(5), 538–547. doi:10.1037/a0026161.

Ouimette, P., Cronkite, R., Henson, B. R., Prins, A., Gima, K., & Moos,R. H. (2004). PTSD and health status among female and malemedical patients. Journal of Traumatic Stress, 17(1), 1–9. doi:10.1023/B:JOTS.0000014670.68240.38.

Posner, K., Brent, D., Lucas, C., Gould,M., Stanley, B., Brown, G….Mann,J. (2006).Columbia-suicide severity rating scale (C-SSRS).NewYork:Columbia University/New York State Psychiatric Institute.

Possemato, K. (2011). The current state of intervention research forposttraumatic stress disorder within the primary care setting.Journal of Clinical Psychology in Medical Settings. doi:10.1007/s10880-011-9237-4.

Prins, A., Ouimette, P., Kimerling, R., Cameron, R.P., Hugelshofer, D.S.,Shaw-Hegwer, J. … Sheikh, J.I. (2003). The primary carePTSD screen (PC-PTSD): Development and operating char-acteristics. Primary Care Psychiatry, 9(1), 9–14. doi:10.1185/135525703125002360

Ramel, W., Goldin, P. R., Carmona, P. E., & McQuaid, J. R. (2004). Theeffects of mindfulness meditation on cognitive processes and affectin patients with past depression. Cognitive Therapy and Research,28(4), 433–455. doi:10.1023/B:COTR.0000045557.15923.96.

Schnurr, P. P., & Spiro, A., III. (1999). Combat disorder, posttraumaticstress disorder symptoms, and health behaviors as predictors ofself-reported physical health in older veterans. Journal ofNervous and Mental Disease, 187(6), 353–359. doi:10.1097/00005053-199906000-00004.

Schottenbauer, M. A., Glass, C. R., Arnkoff, D. B., Tendick, V., & Gray,S. H. (2008). Nonresponse and dropout rates in outcome studies onPTSD: review and methodological considerations. Psychiatry,71(2), 134–168. doi:10.1521/psyc.2008.71.2.134.

Seal, K. H., Maguen, S., Cohen, B., Gima, K. S., Metzler, T. J., Ren,L….Marmar, C.R. (2010). VA mental health services utilization inIraq and Afghanistan veterans in the first year of receiving newmental health diagnoses. Journal of Traumatic Stress, 23(1), 5–16.doi:10.1002/jts.20493

Sederer, L. I., Dickey, B., & Hermann, R. C. (1996). The imperative ofoutcomes assessment in psychiatry. In L. I. Sederer & B. Dickey(Eds.), Outcomes assessment in clinical practice (pp. 1–7).Baltimore: Williams & Wilkins.

Shapiro, S. L., Carlson, L. E., Astin, J. A., & Freedman, B. (2006).Mechanisms of mindfulness. Journal of Clinical Psychology,62(3), 373–386. doi:10.1002/jclp.20237.

Spoont, M., Murdoch, M., Hodges, J., & Nugent, S. (2010). Treatmentreceipt by veterans after a PTSD diagnosis in PTSD, mental health,or general medical clinics. Psychiatric Services, 61(1), 58–63. doi:10.1176/appi.ps.61.1.58.

Stein, M. B., McQuaid, J. R., Pedrelli, P., Lenox, R., & McCahill, M. E.(2000). Posttraumatic stress disorder in the primary care medicalsetting. General Hospital Psychiatry, 22(4), 261–269. doi:10.1016/S0163-8343(00)00080-3.

Tacon, A. M., McComb, J., Caldera, Y., & Randolph, P. (2003).Mindfulness meditation, anxiety reduction, and heart disease: a pilotstudy. Family and Community Health, 26(1), 25–33.

Tang, Y. Y., Ma, Y., Wang, J., Fan, Y., Feng, S., Lu, Q., Yu, Q., Sui, D.,Rothbart, M. K., Fan, M., & Posner, M. I. (2007). Short-termmeditation training improves attention and self-regulation.Proceedings of the National Academy of Sciences, 104(43),17153–17156.

The Management of Post-Traumatic Stress Working Group. (2010). VA/DoD Clinical Practice Guideline for Management of Post-Traumatic Stress. Washington: Veterans Health Administration,Department of Defense.

Vujanovic, A. A., Youngwirth, N. E., Johnson, K. A., & Zvolensky, M. J.(2009). Mindfulness-based acceptance and posttraumatic stresssymptoms among trauma-exposed adults without Axis I psychopa-thology. Journal of Anxiety Disorders, 23(2), 297–303. doi:10.1016/j.janxdis.2008.08.005.

Zayfert, C., & DeViva, J. C. (2004). Residual insomnia following cogni-tive behavioral therapy for PTSD. Journal of Traumatic Stress,17(1), 69–73. doi:10.1023/B:JOTS.0000014679.31799.e7.

Zeidan, F., Johnson, S. K., Gordon, N. S., & Goolkasian, P. (2010). Effectsof brief and sham mindfulness meditation on mood and cardiovascu-lar variables. Journal of Alternative and Complementary Medicine,16, 867–873. doi:10.1089/acm.2009.0321.

Zlotnick, C., Rodriguez, B. F., Weisberg, R. B., Bruce, S. E., Spencer, M.A., Culpepper, L., & Keller, M. B. (2004). Chronicity in posttrau-matic stress disorder and predictors of the course of posttraumaticstress disorder among primary care patients. The Journal of Nervousand Mental Disease, 192(2), 153–159.

Mindfulness

Author's personal copy