Thirteen years ago, inspired by his own practice, David Kearney, a gastroenterologist at the Veterans Affairs Medical Center in Seattle, Washington began offering classes in mindfulness and meditation to veterans with posttraumatic stress disorder (PTSD). The vets found the sessions using Sharon Salzberg’s lovingkindness meditation particularly helpful. So helpful, in fact, that Kearney organized a clinical study to test just how well lovingkindness meditation could relieve symptoms of PTSD. In April, he published the results online in the Journal of the American Medical Association. His conclusion: a 12-week course of lovingkindness meditation was just as effective as Cognitive Processing Therapy (CPT), the gold standard treatment for PTSD. For Kearney, who recently retired after 25 years at the VA, the study was confirmation that meditation and mindfulness can be valuable resources for mental health professionals and patients alike.
I reached Kearney at home in Seattle. We talked about how his study of lovingkindness meditation for PTSD came about and what it may mean for the way mental illness is treated in the future.
How was your study of lovingkindness meditation conducted? We divided about 190 VA patients with PTSD into two groups: a lovingkindness group and a CPT group. The groups met once a week for 12 weeks. After that, we used a standard test measuring the severity of PTSD symptoms to evaluate the participants. When we compared the results from the lovingkindness group to the CPT group, there was no difference in the scores.
What would the participants do in the lovingkindness sessions? The lovingkindness groups were led by experienced meditation teachers. We followed Sharon Salzberg’s practice of silently repeating phrases of good will for ourselves and others. Classically, four phrases are used, beginning with yourself: “May I be safe. May I be happy. May I be healthy. May my life unfold with ease.” As you practice, you begin to extend the phrases to others, from those who have helped you to the difficult people in your life. Participants would practice in class for 30—35 minutes, and follow with a discussion. They were also asked to practice at home.
How have combat vets related to meditation? Veterans are very open to learning meditation practices—it’s actually popular. They don’t see it as spiritual practice, but more in terms of I’m just looking for something that helps me live with suffering.
How did it go when the vets started doing lovingkindness practice? It was challenging for them at first. In classic lovingkindness practice, self is placed first, because that should be the easiest. But for people with PTSD, allowing yourself to receive kindness can be very difficult. They feel they’re not deserving of kindness or it’s selfish. They also found it difficult to extend lovingkindness to others, because they would commonly say they just didn’t think that other people had good will toward them. They even struggled when we asked them to think of a neutral person, someone you might see at the bus stop, or a cashier at the grocery store. People with PTSD don’t regard people as being neutral. They’re either a threat or not a threat.
How did you handle those kinds of obstacles? We’d remind them that it was fine if they didn’t have feelings of kindness or compassion while practicing—they weren’t doing the practice wrong. We simply wanted them to notice whatever came to mind, including feelings of shame or anger, with an attitude of friendliness, kindness, and curiosity.
How common is PTSD among vets? Very common. It’s estimated that as many as 25 percent of veterans who were deployed to Iraq or Afghanistan suffer from PTSD. When I started mindfulness sessions at the VA, the majority of the veterans in our groups had PTSD, and many of them said that the practice was helpful. That was surprising. When I trained to be a mindfulness facilitator, we were told not to include people with PTSD in our groups.
You weren’t supposed to teach mindfulness to people with PTSD. Why not? I was trained in the Mindfulness-Based Stress Reduction techniques developed by Jon Kabat-Zinn. I spoke to him about this. I think for him it was simply a matter of being cautious, given how little was known at the time about applying mindfulness practice to mental illness. But we certainly weren’t going to turn vets away because they had PTSD.
Are you a meditator? Yes, for many years.
Do you have a Buddhist practice? I’ve learned from a lot of Buddhist teachers. The Spirit Rock tradition of Jack Kornfield, Sylvia Boorstein, and Sharon Salzberg has been particularly important to me personally.
Is that how you learned about lovingkindness meditation? I read Sharon Salzberg’s book Lovingkindness and went on a seven-day lovingkindness meditation retreat at Spirit Rock. It had a real impact.
How so? In the days following the retreat, I was aware of being more open and interested in others, of appreciating the humanity and basic goodness of people, even those I didn’t necessarily like. There’s a line in the Metta Sutta that invokes the aspiration of “omitting none” from our openheartedness, and I felt like the retreat helped me to take a step in that direction. To quote Sylvia Boorstein, one of the teachers on the retreat: “We’re not asking you to like other people, we’re just asking you to love them.” I think the retreat helped me better understand the possibilities involved in those words.
What made you think that lovingkindness meditation could be particularly helpful for PTSD? PTSD is characterized by distressing emotions, images, and memories, often accompanied by what psychologists call hindsight bias, the belief that you could have done something differently to avoid the traumatic event. I thought lovingkindness practice might be able to help people with PTSD relearn self-compassion in the face of negative emotions like guilt and self-blame.
In your study, you compared lovingkindness meditation to Cognitive Processing Therapy (CPT), which you describe as a “trauma-focused” treatment. What do you mean by that? Trauma-focused treatments like CPT work directly with memories or beliefs that arise from trauma. CPT is an intervention that uses techniques called cognitive restructuring and emotional reprocessing to help people examine the impact of trauma on their life and the fixed or overgeneralized beliefs that might have resulted from the trauma.
What kinds of fixed or overgeneralized beliefs? That the world is unsafe or that I can’t be close to people because other people can’t be trusted.
In contrast, you describe lovingkindness meditation as a “non-trauma focused” treatment. How so? With lovingkindness meditation, there’s no intentional uncovering of trauma-related memories. Instead, the goal is to teach people skills they can use in daily life to disengage from cycles of rumination and self-criticism about their past or worry about the future. Both approaches are valuable, but trauma-focused treatment can be very difficult for some people. We need alternatives.
The symptom severity scores for people in the lovingkindness and CPT groups both improved by about 8 to 10 points. What does that mean? It means that both approaches resulted in a clinically measurable improvement, but the effects were often modest—about 40 percent of people in each group had a reduction of symptoms. That’s what we typically see with veterans because they’ve usually been through so much trauma. In our study, half the cases of PTSD were war-related and the average veteran in our group had been through at least 10 different categories of potentially PTSD-causing trauma.
Yet, for many of them, their symptoms improved. Why do you think lovingkindness meditation worked as well as it did? Lovingkindness practice holds a mirror up to the mind so that these fixed beliefs of being unworthy of love, or that the world is unkind, or that people can’t be trusted are brought to the surface. Lovingkindness meditation is a tool they can use to be in contact with difficult emotions without judgement. It can be a gentle antidote to many aspects of PTSD. For example, instead of avoidance and suppression, which are hallmarks of PTSD, a person is taught to “stay with” whatever arises in practice with an attitude of curiosity, openness, kindness, and acceptance.
In the future, do you think lovingkindness meditation could become a treatment for forms of mental illness other than PTSD? That’s possible. The VA has been very open to funding research projects like ours and, within the VA system, it’s very common for veterans with PTSD to participate in mindfulness programs as part of their routine care. Apart from PTSD, there have been studies showing that mindfulness practice can have benefits for depression. Another study showed that lovingkindness meditation could help certain manifestations of schizophrenia. But, until there are more studies, we just don’t know. We’re in the early phases of a new set of interventions based on kindness and compassion for people with mental illness. It would be wonderful if our study became a jumping off point for more research.
Read Kearney’s full study in the Journal of the American Medical Association here.
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