E d ito r ia l
Mindfulness in the Military
W L do a 2,500 year-old monk and a modern-day ninth-generation military woman have in common? Besides some common thread of humanity, on the sur face it may not seem like much. Like the military, mindfulness has a deep-seated history. Rooted in Buddhist psychology, mindfulness made its way into modern-day American society in various forms in the 1960s and 1970s when Eastern teachers began settling in the United States, and westerners who had studied in the East brought what they had learned back to the States. Jon Kabat-Zinn began teaching a secular ized mindfulness-based stress reduction course at the University of Massachu setts Medical School in the late 1970s, which importantly, was adapted for clinical contexts and could be studied. Over the past 35 years, this and other mindfulness-based interventions have begun to build an evidence base that suggests utility in disorders r a n g i n g ___________________________________ from anxiety and depression to smok Johnson and colleagues have brought ing and other substance use disorders mindfulness to the military. (1-3). Over the past decade, some of the first “contemplative neuroscience” studies have emerged in the literature and begun unpacking how m in d fulness might affect not only our brains but our (related) stress physiology (for example, in 2003, mindfulness-based stress reduction was shown to boost antibody titers to vaccine administration) (4, 5). And now, in a study reported in this issue of the Journal, Johnson and col leagues have brought mindfulness to the military (6). This is a particularly interesting context because instead of helping a population with disorders return to health (e.g., military personnel who have developed posttraumatic stress disorder), Johnson et al. provided mindfulness training to healthy individuals to help them develop resilience. In brief, Mindfulness-Based Mind Fitness Training, which was developed specifically for military environments by Dr. Elizabeth Stanley, ninth-generation U.S. Army, com bines mindfulness practice with a didactic and skills training component on autonomic nervous system regulation. In theory, this combination is supposed to train individuals to behaviorally “tune” their autonomic nervous system to be more dynamically re sponsive to stress. This is important because although the military uses stress in oculation training to put soldiers in real-world simulations to better prepare them for actual combat, stress inoculation does not provide recovery training—that is, how to “turn off’ their nervous system once the stressor has passed; stress inoculation teaches troops to function well during stress but not howto recover to baseline afterward. Stress inoculation training also leads to decrements in cognitive functioning (e.g., working memory capacity) and even dissociation as a maladaptive coping strategy, with as sociated degradation in military performance (7-9). Mindfulness-Based Mind Fitness Training was developed to fill this gap. By training soldiers how to monitor their own bodies for autonomic activation and to This article is featured in this month’s AJP Audio A m J P s y c h ia try
777:8, A u g u s t 2 0 1 4
a jp .p s y c h ia try o n lin e .o rg
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EDITORIAL
use mindful awareness to tune this activation down efficiently and appropriately, they can learn to work adaptively in situations such as stress inoculation and combat, effectively both increasing their dynamic response range and preventing them from burning out (or acting out) during prolonged stress exposure. Stanley’s group previously published preliminary studies suggesting that this may indeed be the case. In active military cohorts who received Mindfulness-Based Mind Fitness Training before deployment, working memory capacity was preserved after deployment, and, as expected, it degraded in soldiers who did not receive the mindfulness intervention (10). In addition, perceived stress levels decreased among military cohorts who received the intervention compared with controls (11). Johnson et al. take this one step further in this new study by examining both physiological and neural changes associated with Mindfulness-Based Mind Fitness Training. They randomly assigned 281 Marines to receive either training as usual or training as usual plus 20 hours of mindfulness training over an 8-week period during predeployment preparation. They then measured physiological markers of resilience before, during, and after a stress inoculation challenge, which consisted of real-time scenarios of counterinsurgency operations (e.g., village patrol, complex ambush). In a subset of individuals (20 from each group), they also used functional MRI to assess neural response to an emotional face processing task in brain regions associated with interoceptive awareness (e.g., the insula) and attentional control (e.g., the anterior cingulate cortex). Marines who received the mindfulness training intervention attended a majority of the training sessions (92%), which may not be surprising given the context, and they reported a mean total of about 2.5 hours of practice outside of the classroom over the 8-week period. Marines who received the intervention showed a significant increase in heart rate in anticipation to the stress challenge, which was nonsignificantly higher during the challenge. Interestingly, their rate of recovery was significantly faster than the control group’s. Breathing rate recovery was similarly faster in the intervention group relative to the control group. The intervention group also showed lower concentrations of neuropeptide Y (a marker of autonomic system activation) after stress inoculation, which was significantly correlated with heart rate during response and recovery periods (R2=0.25 during both periods). However, the authors did not find similar correlations for epinephrine levels. Also, Marines who received mindfulness training showed less activation to emotional faces in the right insula and the anterior cingulate cortex. Changes in the right anterior insula were correlated with changes in a self-reported measure, the Re sponse to Stressful Experiences Scale, from before mindfulness training to after the stress inoculation challenge. This study is noteworthy for its taking place in an active military training setting, the use of stress inoculation training as a real-world stressor (as compared with bringing participants into a lab), the linkage of physiological markers, and a grounded theoretical basis for what the mindfulness training intervention would target. What is less clear is how exactly the changes in brain activity line up. One might hypothesize that these should correlate with the physiological markers as well, if indeed individuals are processing interoceptive stimuli, as suggested. Fur thermore, the authors focused their neuroimaging analyses on brain regions defined a priori, which is good for testing specific hypotheses but may miss potentially relevant targets. For example, the dorsal anterior cingulate has been shown to regulate the posterior cingulate cortex, which correlates with improved performance (12); these regions have been shown to be functionally coupled in 804
a jp .p s y c h ia try o n lin e .o rg
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experienced meditators (13). Additionally, the lack of an active control group raises the question of whether the addition of 20 hours of group training plus homework could nonspecifically help individuals become more cohesive or more bonded within their group, yielding similar changes in physiology. Given the promising results of this study, what is next for this field? A dizzying array of mindfulness-based interventions are being developed and rolled out at present, likely in response to the pervasive nature of many disorders, the need for improved treatments, the current popularity of mindfulness among the public (in 2007, 9.4% of the U.S. population reported using meditation in the past year [14]), and the growing evidence base for such treatments. Only a few of these modalities have been standardized (e.g., mindfulness-based stress reduction and mindfulnessbased cognitive therapy for depression). As exemplified by Crane et al„ it is critical that standards for maintaining fidelity and competency are developed and utilized (15, 16). This will help researchers isolate variables to more clearly establish efficacy and mechanisms in an already inherently difficult-to-study intervention (for exam ple, it is hard to tell if someone is meditating just by looking at them). Standards of this type, like those governing the chemical composition of medications, will also help protect our patients by ensuring that they are getting the evidence-based mindfulness intervention that they signed up for. R e fere n ces 1. Goyal M, Singh S, Sibinga EM, Gould NF, Rowland-Seymour A, Sharma R, Berger Z, Sleicher D, Maron DD, Shihab HM, Ranasinghe PD, Linn S, Saha S, Bass EB, Haythornthwaite JA: Meditation programs fo r psychological stress and w ell-being: a systematic review and meta-analysis. JAMA Intern Med 2014; 174:357-368 2. Bowen S, W itkiewitz K, Clifasefi SL, Grow J, Chawla N, Hsu SH, Carroll HA, Harrop E, Collins SE, Lustyk MK, Larimer ME: Relative efficacy of mindfulness-based relapse prevention, standard relapse prevention, and treatm ent as usual for substance use disorders: a randomized clinical trial. JAMA Psychiatry (Epub ahead of print, March 19, 2014) 3. Brewer JA, M allik S, Babuscio TA, Nich C, Johnson HE, Deleone CM, Minnix-Cotton CA, Byrne SA, Kober H, Weinstein AJ, Carroll KM, Rounsaville BJ: Mindfulness training fo r smoking cessation: results from a ran domized controlled trial. Drug Alcohol Depend 2011; 119:72-80 4. Davidson RJ, Kabat-Zinn J, Schumacher J, Rosenkranz M, Muller D, Santorelli SF, Urbanowski F, Harrington A, Bonus K, Sheridan JF: Alterations in brain and im m une function produced by mindfulness m editation. Psychosom Med 2003; 65:564-570 5. Davidson RJ, McEwen BS: Social influences on neuroplasticity: stress and interventions to prom ote w ell being. Nat Neurosci 2012; 15:689-695 6. Johnson DC, Thom NJ, Stanley EA, Haase L, Simmons AN, Shih PB, Thompson WK, Potterat EG, M inor TR, Paulus MP: Modifying resilience mechanisms in at-risk individuals: a controlled study o f mindfulness training in Marines preparing fo r deployment. Am J Psychiatry 2014; 171:844-853 7. Morgan CA 3rd, Doran A, Steffian G, Hazlett G, Southwick SM: Stress-induced deficits in w orking m em ory and visuo-constructive abilities in Special Operations soldiers. Biol Psychiatry 2006; 60:722-729 8. Lieberman HR, Tharion WJ, Shukitt-Hale B, Speckman KL, Tulley R: Effects of caffeine, sleep loss, and stress on cognitive performance and m ood during US Navy SEAL training. Psychopharmacology (Berl) 2002; 164: 250-261 9. Lieberman HR, Bathafon GP, Falco CM, Kramer FM, Morgan CA 3rd, Niro P: Severe decrements in cognition function and mood induced by sleep loss, heat, dehydration, and undernutrition during simulated combat. Biol Psychiatry 2005; 57:422-429 10. Jha AP, Stanley EA, Kiyonaga A, Wong L, Gelfand L: Examining the protective effects of mindfulness training on w orking m em ory capacity and affective experience. Emotion 2010; 10:54-64 11. Stanley EA, Schaldach JM, Kiyonaga A, Jha AP: Mindfulness-Based Mind Fitness Training: a case study of a high-stress predeploym ent m ilitary cohort. Cogn Behav Pract 2011; 18:566-576 12. Wen X, Liu Y, Yao L, Ding M: Top-down regulation of default mode activity in spatial visual attention. J Neurosci 2013; 33:6444-6453 13. Brewer JA, Worhunsky PD, Gray JR, Tang YY, Weber J, Kober H: Meditation experience is associated w ith differences in default mode network activity and connectivity. Proc Natl Acad Sci USA 2011; 108:2025420259 14. Barnes PM, Bloom B, Nahin RL: Complementary and alternative medicine use am ong adults and children: United States, 2007. Natl Health Stat Report 2008; 12:1-23 15. Crane RS, Kuyken W, W illiams JM, Hastings RP, Cooper L, Fennell MJ: Competence in teaching mindfulnessbased courses: concepts, developm ent, and assessment. Mindfulness (NY) 2012; 3:76-84
Am J Psychiatry 171:8, August 2014
ajp.psychiatryonline.org
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EDITORIAL
16. Crane RS, Eames C, Kuyken W, Hastings RP, Williams JM, Bartley T, Evans A, Silverton S, Soulsby JG, Surawy C: Development and validation of the Mindfulness-Based Interventions: Teaching Assessment Criteria (MBI: TAC). Assessment 2013; 20:681-688
JUDSON BREWER, M .D., Ph .D. From the Departments o f Medicine and Psychiatry and the Center fo r Mindfulness, University o f Massachusetts Medical School, Worcester; and the Department o f Psychiatry, Yale University School o f Medicine, New Ftaven, Conn. Address correspondence to Dr. Brewer ([email protected]). Editorial accepted fo r publication April 2014 (doi: 70.7 7 76/appi.ajp.2014.14040501). Dr. Brewer reports no financial relationships with commercial interests.
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ajp.psychiatryonline.org
Am J Psychiatry 171:8, August 2014
Copyright of American Journal of Psychiatry is the property of American Psychiatric Publishing, Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Mindfulness in the Military
W L do a 2,500 year-old monk and a modern-day ninth-generation military woman have in common? Besides some common thread of humanity, on the sur face it may not seem like much. Like the military, mindfulness has a deep-seated history. Rooted in Buddhist psychology, mindfulness made its way into modern-day American society in various forms in the 1960s and 1970s when Eastern teachers began settling in the United States, and westerners who had studied in the East brought what they had learned back to the States. Jon Kabat-Zinn began teaching a secular ized mindfulness-based stress reduction course at the University of Massachu setts Medical School in the late 1970s, which importantly, was adapted for clinical contexts and could be studied. Over the past 35 years, this and other mindfulness-based interventions have begun to build an evidence base that suggests utility in disorders r a n g i n g ___________________________________ from anxiety and depression to smok Johnson and colleagues have brought ing and other substance use disorders mindfulness to the military. (1-3). Over the past decade, some of the first “contemplative neuroscience” studies have emerged in the literature and begun unpacking how m in d fulness might affect not only our brains but our (related) stress physiology (for example, in 2003, mindfulness-based stress reduction was shown to boost antibody titers to vaccine administration) (4, 5). And now, in a study reported in this issue of the Journal, Johnson and col leagues have brought mindfulness to the military (6). This is a particularly interesting context because instead of helping a population with disorders return to health (e.g., military personnel who have developed posttraumatic stress disorder), Johnson et al. provided mindfulness training to healthy individuals to help them develop resilience. In brief, Mindfulness-Based Mind Fitness Training, which was developed specifically for military environments by Dr. Elizabeth Stanley, ninth-generation U.S. Army, com bines mindfulness practice with a didactic and skills training component on autonomic nervous system regulation. In theory, this combination is supposed to train individuals to behaviorally “tune” their autonomic nervous system to be more dynamically re sponsive to stress. This is important because although the military uses stress in oculation training to put soldiers in real-world simulations to better prepare them for actual combat, stress inoculation does not provide recovery training—that is, how to “turn off’ their nervous system once the stressor has passed; stress inoculation teaches troops to function well during stress but not howto recover to baseline afterward. Stress inoculation training also leads to decrements in cognitive functioning (e.g., working memory capacity) and even dissociation as a maladaptive coping strategy, with as sociated degradation in military performance (7-9). Mindfulness-Based Mind Fitness Training was developed to fill this gap. By training soldiers how to monitor their own bodies for autonomic activation and to This article is featured in this month’s AJP Audio A m J P s y c h ia try
777:8, A u g u s t 2 0 1 4
a jp .p s y c h ia try o n lin e .o rg
803
EDITORIAL
use mindful awareness to tune this activation down efficiently and appropriately, they can learn to work adaptively in situations such as stress inoculation and combat, effectively both increasing their dynamic response range and preventing them from burning out (or acting out) during prolonged stress exposure. Stanley’s group previously published preliminary studies suggesting that this may indeed be the case. In active military cohorts who received Mindfulness-Based Mind Fitness Training before deployment, working memory capacity was preserved after deployment, and, as expected, it degraded in soldiers who did not receive the mindfulness intervention (10). In addition, perceived stress levels decreased among military cohorts who received the intervention compared with controls (11). Johnson et al. take this one step further in this new study by examining both physiological and neural changes associated with Mindfulness-Based Mind Fitness Training. They randomly assigned 281 Marines to receive either training as usual or training as usual plus 20 hours of mindfulness training over an 8-week period during predeployment preparation. They then measured physiological markers of resilience before, during, and after a stress inoculation challenge, which consisted of real-time scenarios of counterinsurgency operations (e.g., village patrol, complex ambush). In a subset of individuals (20 from each group), they also used functional MRI to assess neural response to an emotional face processing task in brain regions associated with interoceptive awareness (e.g., the insula) and attentional control (e.g., the anterior cingulate cortex). Marines who received the mindfulness training intervention attended a majority of the training sessions (92%), which may not be surprising given the context, and they reported a mean total of about 2.5 hours of practice outside of the classroom over the 8-week period. Marines who received the intervention showed a significant increase in heart rate in anticipation to the stress challenge, which was nonsignificantly higher during the challenge. Interestingly, their rate of recovery was significantly faster than the control group’s. Breathing rate recovery was similarly faster in the intervention group relative to the control group. The intervention group also showed lower concentrations of neuropeptide Y (a marker of autonomic system activation) after stress inoculation, which was significantly correlated with heart rate during response and recovery periods (R2=0.25 during both periods). However, the authors did not find similar correlations for epinephrine levels. Also, Marines who received mindfulness training showed less activation to emotional faces in the right insula and the anterior cingulate cortex. Changes in the right anterior insula were correlated with changes in a self-reported measure, the Re sponse to Stressful Experiences Scale, from before mindfulness training to after the stress inoculation challenge. This study is noteworthy for its taking place in an active military training setting, the use of stress inoculation training as a real-world stressor (as compared with bringing participants into a lab), the linkage of physiological markers, and a grounded theoretical basis for what the mindfulness training intervention would target. What is less clear is how exactly the changes in brain activity line up. One might hypothesize that these should correlate with the physiological markers as well, if indeed individuals are processing interoceptive stimuli, as suggested. Fur thermore, the authors focused their neuroimaging analyses on brain regions defined a priori, which is good for testing specific hypotheses but may miss potentially relevant targets. For example, the dorsal anterior cingulate has been shown to regulate the posterior cingulate cortex, which correlates with improved performance (12); these regions have been shown to be functionally coupled in 804
a jp .p s y c h ia try o n lin e .o rg
A m J P s y c h ia try 1 7 1:8, A u g u s t 2 0 1 4
EDITORIAL
experienced meditators (13). Additionally, the lack of an active control group raises the question of whether the addition of 20 hours of group training plus homework could nonspecifically help individuals become more cohesive or more bonded within their group, yielding similar changes in physiology. Given the promising results of this study, what is next for this field? A dizzying array of mindfulness-based interventions are being developed and rolled out at present, likely in response to the pervasive nature of many disorders, the need for improved treatments, the current popularity of mindfulness among the public (in 2007, 9.4% of the U.S. population reported using meditation in the past year [14]), and the growing evidence base for such treatments. Only a few of these modalities have been standardized (e.g., mindfulness-based stress reduction and mindfulnessbased cognitive therapy for depression). As exemplified by Crane et al„ it is critical that standards for maintaining fidelity and competency are developed and utilized (15, 16). This will help researchers isolate variables to more clearly establish efficacy and mechanisms in an already inherently difficult-to-study intervention (for exam ple, it is hard to tell if someone is meditating just by looking at them). Standards of this type, like those governing the chemical composition of medications, will also help protect our patients by ensuring that they are getting the evidence-based mindfulness intervention that they signed up for. R e fere n ces 1. Goyal M, Singh S, Sibinga EM, Gould NF, Rowland-Seymour A, Sharma R, Berger Z, Sleicher D, Maron DD, Shihab HM, Ranasinghe PD, Linn S, Saha S, Bass EB, Haythornthwaite JA: Meditation programs fo r psychological stress and w ell-being: a systematic review and meta-analysis. JAMA Intern Med 2014; 174:357-368 2. Bowen S, W itkiewitz K, Clifasefi SL, Grow J, Chawla N, Hsu SH, Carroll HA, Harrop E, Collins SE, Lustyk MK, Larimer ME: Relative efficacy of mindfulness-based relapse prevention, standard relapse prevention, and treatm ent as usual for substance use disorders: a randomized clinical trial. JAMA Psychiatry (Epub ahead of print, March 19, 2014) 3. Brewer JA, M allik S, Babuscio TA, Nich C, Johnson HE, Deleone CM, Minnix-Cotton CA, Byrne SA, Kober H, Weinstein AJ, Carroll KM, Rounsaville BJ: Mindfulness training fo r smoking cessation: results from a ran domized controlled trial. Drug Alcohol Depend 2011; 119:72-80 4. Davidson RJ, Kabat-Zinn J, Schumacher J, Rosenkranz M, Muller D, Santorelli SF, Urbanowski F, Harrington A, Bonus K, Sheridan JF: Alterations in brain and im m une function produced by mindfulness m editation. Psychosom Med 2003; 65:564-570 5. Davidson RJ, McEwen BS: Social influences on neuroplasticity: stress and interventions to prom ote w ell being. Nat Neurosci 2012; 15:689-695 6. Johnson DC, Thom NJ, Stanley EA, Haase L, Simmons AN, Shih PB, Thompson WK, Potterat EG, M inor TR, Paulus MP: Modifying resilience mechanisms in at-risk individuals: a controlled study o f mindfulness training in Marines preparing fo r deployment. Am J Psychiatry 2014; 171:844-853 7. Morgan CA 3rd, Doran A, Steffian G, Hazlett G, Southwick SM: Stress-induced deficits in w orking m em ory and visuo-constructive abilities in Special Operations soldiers. Biol Psychiatry 2006; 60:722-729 8. Lieberman HR, Tharion WJ, Shukitt-Hale B, Speckman KL, Tulley R: Effects of caffeine, sleep loss, and stress on cognitive performance and m ood during US Navy SEAL training. Psychopharmacology (Berl) 2002; 164: 250-261 9. Lieberman HR, Bathafon GP, Falco CM, Kramer FM, Morgan CA 3rd, Niro P: Severe decrements in cognition function and mood induced by sleep loss, heat, dehydration, and undernutrition during simulated combat. Biol Psychiatry 2005; 57:422-429 10. Jha AP, Stanley EA, Kiyonaga A, Wong L, Gelfand L: Examining the protective effects of mindfulness training on w orking m em ory capacity and affective experience. Emotion 2010; 10:54-64 11. Stanley EA, Schaldach JM, Kiyonaga A, Jha AP: Mindfulness-Based Mind Fitness Training: a case study of a high-stress predeploym ent m ilitary cohort. Cogn Behav Pract 2011; 18:566-576 12. Wen X, Liu Y, Yao L, Ding M: Top-down regulation of default mode activity in spatial visual attention. J Neurosci 2013; 33:6444-6453 13. Brewer JA, Worhunsky PD, Gray JR, Tang YY, Weber J, Kober H: Meditation experience is associated w ith differences in default mode network activity and connectivity. Proc Natl Acad Sci USA 2011; 108:2025420259 14. Barnes PM, Bloom B, Nahin RL: Complementary and alternative medicine use am ong adults and children: United States, 2007. Natl Health Stat Report 2008; 12:1-23 15. Crane RS, Kuyken W, W illiams JM, Hastings RP, Cooper L, Fennell MJ: Competence in teaching mindfulnessbased courses: concepts, developm ent, and assessment. Mindfulness (NY) 2012; 3:76-84
Am J Psychiatry 171:8, August 2014
ajp.psychiatryonline.org
805
EDITORIAL
16. Crane RS, Eames C, Kuyken W, Hastings RP, Williams JM, Bartley T, Evans A, Silverton S, Soulsby JG, Surawy C: Development and validation of the Mindfulness-Based Interventions: Teaching Assessment Criteria (MBI: TAC). Assessment 2013; 20:681-688
JUDSON BREWER, M .D., Ph .D. From the Departments o f Medicine and Psychiatry and the Center fo r Mindfulness, University o f Massachusetts Medical School, Worcester; and the Department o f Psychiatry, Yale University School o f Medicine, New Ftaven, Conn. Address correspondence to Dr. Brewer ([email protected]). Editorial accepted fo r publication April 2014 (doi: 70.7 7 76/appi.ajp.2014.14040501). Dr. Brewer reports no financial relationships with commercial interests.
806
ajp.psychiatryonline.org
Am J Psychiatry 171:8, August 2014
Copyright of American Journal of Psychiatry is the property of American Psychiatric Publishing, Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
