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Journal of Interpersonal Violence 2017, Vol. 32(14) 2139 –2165
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Article
Impact of Meditation on Mental Health Outcomes of Female Trauma Survivors of Interpersonal Violence With Co-Occurring Disorders: A Randomized Controlled Trial
Mo Yee Lee, PhD, RSW,1 Amy Zaharlick, PhD, MSW,1 and Deborah Akers, PhD3
Abstract This study was a randomized controlled trial that examined the impact of meditation practice on the mental health outcomes of female trauma survivors of interpersonal violence who have co-occurring disorders. Sixty- three female trauma survivors were randomly assigned to the meditation condition and the control condition. Treatment conditions consisted of a 6-week meditation curriculum that was influenced by Tibetan meditation tradition and focused on breathing, loving kindness, and compassion meditation. Clients in the meditation condition made significant changes in mental health symptoms (t = 5.252, df = 31, p = .000) and trauma symptoms (t = 6.009, df = 31, p = .000) from pre-treatment to post- treatment, whereas non-significant changes were observed among the
1The Ohio State University, Columbus, OH, USA 2Miami University, Oxford, OH, USA 3Independent Researcher
Corresponding Author: Mo Yee Lee, Professor, College of Social Work, The Ohio State University, 1947 College Road, Columbus, OH 43220, USA. Email: [email protected]
591277 JIVXXX10.1177/0886260515591277Journal of Interpersonal ViolenceLee et al. research-article2015
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control condition clients. There were significant group differences between clients in the meditation condition and in the control condition on their mental health symptoms, F(1, 54) = 13.438, p = .001, and trauma symptoms, F(1, 54) = 13.395, p = .001, with a generally large effect size of eta squared .127 and .146, respectively. In addition, significantly more clients in the meditation condition achieved reliable change in mental health symptoms (35.5% vs. 8.3%) and trauma symptoms (42.3% vs. 4.8%) than clients in the control condition. Significance of the study is discussed with respect to the empirical evidence of meditation practice as a complementary behavioral intervention for treating female trauma survivors of interpersonal violence who have co-occurring disorders.
Keywords meditation, female trauma survivors, substance use disorders, mental health, co-occurring disorders, randomized controlled trial
Introduction
Co-occurring substance use and mental disorders among female trauma survi- vors of interpersonal violence has gained increased attention in the past two decades primarily because of the magnitude of violence in the lives of women, impact of violence on women’s mental health (Jordan, Campbell, & Follingstad, 2010), and concern for effective services for this population (Flynn & Brown, 2008; Goodman & Epstein, 2008). Research has consistently demonstrated a relationship between mental health disorders, substance use, and trauma among women (McHugo et al., 2005). Female trauma survivors of interpersonal vio- lence usually develop different coping strategies that can include denying the abuse, blocking memories, minimizing importance or severity of their abuse, or believing that they have done something that deserves the act of violence (Waldrop & Resick, 2004). Trauma as a result of interpersonal violence also disrupts the emotional regulation ability of an individual. To cope with the overwhelming negative emotions, especially when initial coping mechanisms fail to contain the traumatic experience, survivors might engage in high-risk behaviors to numb their painful emotions that could include self-inflicted vio- lence, or being suicidal, and so on (Dutton, Goodman, & Bennett, 1999; Finkelhor, 2008). Consequently, exposure to interpersonal violence including childhood abuse has been identified as a risk factor for a wide range of mental health and substance use problems in women (Dube, Anda, Felitti, Edwards, & Croft, 2002; Follingstad, 2009) and increases the risks of major depression, post-traumatic stress disorder (PTSD), substance use, and also other diagnostic co-occurring disorders (CODs; D. G. Kilpatrick et al., 2003).
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The role of exposure to trauma in initiation and maintenance of substance use disorders has been supported in different studies (Logrip, Zorrilla, & Koob, 2012). One explanation for the CODs in survivors of interpersonal violence is the “self-medication” hypothesis (Khantzian, 1997), which pro- poses that people drink to cope with negative emotions and stressors. For instance, alcohol, which is a Central Nervous System (CNS) depressant, acutely improves or ameliorates trauma arousal symptoms including diffi- culty falling and staying asleep, difficulty concentrating, irritability, hyper- vigilance, and an exaggerated startle response (Frewen & Lanius, 2015). Studies show that women often connect their involvement with substance abuse to a traumatic life event or stressor (Keyes, Hatzenbuehler, & Hasin, 2011), and a history of abuse drastically increases the likelihood that a woman will abuse alcohol and other drugs (Covington, 2002). In addition, substance abusers may expose themselves to high-risk situations to sustain their addic- tion and, therefore, are more likely to experience higher levels of physical, sexual, and psychological trauma (El-Bassel, Gilbert, Wu, Go, & Hill, 2005).
Clinical Challenges
Current treatment of this population has clearly recognized the problems in traditional treatment where mental health and substance abuse treatment is separated with little attention to trauma assessment or treatment. To address the need for better service integration across mental health, substance abuse, trauma-specific and other related service for female trauma survivors, Substance Abuse and Mental Health Services Administration (SAMHSA) launched a 5-year study in 1998, Women, Co-occurring Disorders, and Violence Study (WCDVS), to explore the interrelation between violence, trauma, and co-occurring mental health and substance use disorders among women, which represent the first major federal effort to address systems- level integrated care (Cocozza et al., 2005). WCDVS also provided recom- mendations for “trauma-integrated services” for these women, demonstrating that women with a history of trauma and CODs would benefit greatly from more holistic, integrated services and programs (Moses, Reed, Mazelis, & D’Ambrosio, 2003). Receipt of comprehensive services is also found to be significantly associated with a reduction in post-treatment substance use for female survivors of interpersonal violence (Andrews, Cao, Marsh, & Shin, 2011). Seeking Safety, a treatment program based on cognitive-behavioral approaches and trauma-informed care, has been established as an evidence- based practice at the National Registry of Evidence-Based Programs and Practices (NREPP) for women (now including all populations) with co- occurring substance use disorders and a PTSD diagnosis (Najavits, 2007).
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Although these efforts have made significant improvements at both the treatment level and system level (Flynn & Brown, 2008), effective clinical treatment to this population still presents challenges because symptoms of clients with CODs tend to be more severe (Kessler, Chiu, Demler, Merikangas, & Walters, 2005). National Comorbidity Survey Replication (NCS-R) results showed that severity of mental health problems was strongly related to comorbidity; 9.6% of respondents with 1 diagnosis, 25.5% with 2 diagnoses, and 49.9% with 3 or more diagnoses were classified as serious (Kessler et al., 2005). Clients with co-occurring substance use disorder and PTSD or major depressive disorders also have significantly poorer outcomes than clients with single disorder (Najt, Fusar-Poli, & Brambilla, 2011) and higher relapse rate (P. J. Brown, Read, & Kahler, 2003). In addition to addressing the psy- chological impact of substance abuse and trauma, survivors of interpersonal violence are also dealing with neurobiological changes associated with trauma (Frewen & Lanius, 2015) and neuropharmacological changes related to substance use disorders (Fromme, Katz, & D’Amico, 1997). One major challenge is the extensive overlapping of trauma symptoms and substance withdrawal syndromes. Jacobsen, Southwick, and Kosten (2001) suggest that although CNS depressants such as alcohol and opioids initially lead to a calming effect on trauma symptoms, the physiologic arousal resulting from withdrawal may have an additive effect with arousal symptoms associated with trauma. The resulting hyperaroused state may serve as a conditioned reminder of traumatic events and thus precipitate exacerbation of trauma symptoms. When clients find the additional arousal resulting from alcohol/ substance withdrawal intolerable, they are more prone to use alcohol and/or other substances as a way to self-medicate. As such, attempts to stop using substance may inadvertently initiate a cycle that perpetuates continued sub- stance use and relapse among clients with CODs (Jacobsen et al., 2001).
Another major treatment challenge at a clinical level relates to the reduced abilities of clients to respond to and live in the present. Substance abuse leads to diminished cognitive functions (Gould, 2010) as well as reduced ability to maintain self-awareness (Verdejo-García & Pérez-García, 2008) and self-reg- ulate their emotion (Sher & Grekin, 2007). Craving is directed toward the future with the addicted mind focused on their next “fix” (Marlatt, 2002). In addition, emotional dysfunction of trauma survivors of interpersonal violence can be partly perceived as the consequences of the survivor being trapped in past traumas and not able to live in the present. One major treatment challenge is how to enhance clients’ capacity to recognize and attend to current experi- ences as well as to differentiate them from trauma-based or addiction-influenced emotional and behavioral responses so that they can make choices that are responsive and beneficial to their current needs and situations.
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Relevance of Meditation as a Complementary Behavioral Treatment
Meditation is a set of practices that has been in existence for more than 4,000 years, with roots in Buddhist, Ayurvedic, and other contemplative traditions. There are many different traditions of meditation, although overall it has two distinctive intentions: (a) to cultivate the ability to create a mindful existence in a non-judgmental and non-attached manner primarily through mindfulness- based meditation (Kabat-Zinn, 2012) and (b) to cultivate an attitude of love and compassion (Schmidt, 2004) through loving kindness and compassion meditation (Lee, Ng, Leung, & Chan, 2009). The positive impact of medita- tion on mental health and substance use outcomes has been well documented. Meditation is associated with positive mental health outcomes in clients with PTSD (Vujanovic, Niles, Pietrefesa, Schmertz, & Potter, 2011), borderline personality disorders (Sauer & Baer, 2012), depressive disorders (Bieling et al., 2012), and anxiety symptoms (Arch et al., 2013). Meditation has been increasingly adopted to treat clients with substance use problems (Dakwar & Levin, 2009). Marlatt and his colleagues have developed a mindfulness-based relapse prevention (MBRP) approach in treating substance use problems with positive outcomes (Bowen et al., 2009). Mindfulness meditation, a meta-cog- nitive skill learned through meditation practice, has been shown to help clients develop the coping skill of non-reaction to a cognitive urge through the “act of inaction,” being in the moment, observing, and accepting, without analyzing, judging, or reacting (Marlatt, 2002). Mindfulness-based meditation has also found to be effective in treating child abuse survivors (Kimbrough, Magyari, Langenberg, Chesney, & Berman, 2010).
Explanations of these positive outcomes have been understood in terms of the impact of meditation on physiological, neurological, psychological, and emotional processes.
Physiological processes. Meditation is a stress-reducing phenomenon that brings about “the relaxation response” by inducing favorable brain waves and lowering the physiological and biochemical byproducts of stress (Ben- son, 1975; Lazar et al., 2000). Studies found that mindfulness-based medita- tion was a stress-reducing phenomenon that brought about “the relaxation response” by inducing more left sided Electroencephalographic (EEG) activ- ity and lowering the physiological and biochemical byproducts of stress, leading to a lowered respiration rate, a decreased heart rate, lowered blood pressure (Lazar et al., 2000), reduced cortisol levels (Kim, 2012), increased level of antibodies (Davidson et al., 2003), and enhanced immune system functioning (Thaddeus et al., 2008).
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Neurological processes. Brain imaging studies further specify the neurological impact of mindfulness-based mediation practice on the brain. Meditation practice has shown to generate measurable neural activation patterns (David- son et al., 2003). For instance, meditation practice activates frontal and pre- frontal regions of the brain and is associated with significant increases in hippocampal and parahippocampal formation, significant activation in amygdala and hypothalamus (Lazar et al., 2000; Short et al., 2007), and increased endoge- nous dopamine release (Kiaer et al., 2002). Mindfulness-based stress reduction training has found to affect regional functional connectivity within auditory/ salience and medial visual intrinsic connectivity networks (L. A. Kilpatrick et al., 2011). In other words, mindfulness-based meditation practice positively acti- vates or affects brain regions that are associated with attention, concentration, sensory processing, emotion memories, drives, inhibition, and motivation. In addition, these positive impacts persist beyond the period of meditation prac- tice (Lutz, Greischar, Rawlings, Ricard, & Davidson, 2004).
Psychological processes. Theories on self-regulation have long recognized the importance of self-awareness and attention in maintaining and enhancing psychological and behavioral functioning. Self-determination theory as pro- posed by Deci and Ryan (2008) posits that open awareness is essential in facilitating the choice of behaviors that are consistent with one’s needs, val- ues, and interests. Different psychological processes have been postulated to explain the positive impact of mindfulness-based meditation on emotional and behavioral regulation. First, mindfulness meditation practice fosters a switch from “doing” to “being” modes (Segal, Williams, & Teasdale, 2002) and therefore facilitates openness to current experience (Teasdale, Segal, & Williams, 2003). Systems perspectives and cybernetic theories describe how the self-regulation process occurs through the operation of feedback mecha- nisms (Bateson, 1979; Becvar & Becvar, 2013). In human beings, attention to internal and external stimuli constitutes the necessary input for a person to initiate the self-regulating feedback processes for positive regulation (Carver & Scheier, 1981). Second, when awareness becomes object of meditation, a “mental gap” is introduced between awareness and its objects, and therefore, between the stimulus–response relationships that shape automatic responding (K. W. Brown, Ryan, & Creswell, 2007). This process of decentering (Bieling et al., 2012) could result in the recognition that “mind” contains, but is not identical to thoughts, feelings, or experiences that a person has (Nydahl, 2008). Mindfulness-based meditation, by fostering openness to current expe- rience and a process of cognitive decentering, allows the individual to con- sciously attend to thoughts, emotions, and action tendencies that are consistent with their basic needs and values, making a person more likely to regulate
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behavior in a way that fulfills personal needs as defined by the current life context and needs (K. W. Brown & Ryan, 2003; Hodgins & Knee, 2002) rather than being driven by self-relevant cognition (K. W. Brown et al., 2007). As such, mindfulness-based meditation practice should assist a person to accept thoughts as they are and “let them go” instead of reacting to them, which should result in increased adaptive behavior and psychological well-being.
Emotion and emotional regulation. Loving kindness meditation and compassion meditation teach empathy skills training in two different aspects of empathic awareness: sensitivity to one’s own affect and sensitivity to another’s affect, and development of compassion for oneself and others (Damdul, Lee, Zahar- lick, & Akers, 2013). Different from mindfulness meditation that is directed toward being in the moment and not reacting to emotions and thoughts, loving kindness and compassion meditation seek to fully experience the emotional episode. The brain-imaging studies showed that loving kindness and compas- sion meditation was associated with enhanced affective processing in terms of increased pupil diameter and activation of limbic regions (insula and cingu- lated cortices; Lutz, Brefczynski-Lewis, Johnstone, & Davidson, 2008), and stronger functional connectivity from the frontal regions to the brain’s emo- tional regions (Brefczynski-Lewis, Lutz, Schaefer, Levinson, & Davidson, 2007). There is initial empirical evidence of the positive impact of compas- sion/loving kindness meditation on emotions and emotional regulation (Bref- czynski-Lewis et al., 2007; Lutz et al., 2008). In addition, studies have also found that experienced practitioners of Tibetan Buddhist compassion medita- tion techniques are capable of altering brain functioning in ways that have been shown to be associated with positive emotions, as well as enhanced immune system functioning (Thaddeus et al., 2008).
Meditation practice, by cultivating the ability to create a mindful existence in a non-judgmental and non-attached manner and an attitude of love and compassion in life, should enhance clients’ abilities to disengage from auto- matic thoughts, habits, and unhealthy behavior patterns that are oftentimes seen in trauma survivors (Linehan, 2015). In other words, meditation practice should be helpful for female trauma survivors with co-occurring mental health and substance use disorders to accomplish the following treatment tasks and goals and complement other trauma-informed treatments: (a) enhancing clients’ ability to be aware of the triggers of craving, observe and accept the urge, let it go without giving in or repressing the urge for substance use; (b) enhancing clients’ emotional regulation abilities and reducing nega- tive thoughts; (c) enhancing clients’ ability to stay physiologically calm so that they have increased ability to engage beneficially in treatment to successfully
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process and integrate their trauma experiences and no longer need to depend on alcohol for managing their negative emotions; (d) enhancing clients’ abil- ity to stay physiologically calm so that they have increased ability to tolerate and address substance withdrawal syndromes, trauma symptoms, or nega- tive emotions during treatment; and (e) fostering clients’ capacity to recog- nize and attend to current experiences as well as to differentiate them from trauma-based or addiction-influenced emotional and behavioral responses so they can make choices that are responsive and beneficial to their current needs and situations.
Method
Objective
This was an efficacy study that used a randomized controlled trial to exam- ine the impact of meditation practice on the mental health outcomes of female trauma survivors of interpersonal abuse who have COD. The study hypothesized that meditation practice would lead to a reduction in the pri- mary study outcome on mental health symptoms and secondary study out- come on trauma symptoms.
Participants
Research participants were recruited from a substance abuse treatment and housing program for homeless women and their children in a Midwestern cos- mopolitan city. The selection criterion included clients who had experienced interpersonal abuse and clients who have CODs. Clients with co-occurring conditions of schizophrenia and severe depression or who were actively sui- cidal were excluded from participation. This exclusion is based on literature that shows meditation can be counter-therapeutic for these clients. A univer- sity Institutional Review Board reviewed and approved the study. Participation was voluntary, and formal consent was obtained from all participants.
Recruitment flyers were posted at the treatment facility where all clients were invited to attend an introduction session in which researchers explained the project. A total of 67 clients signed up for the study and completed required consent forms. Four clients were assessed as not eligible because of co-occurring psychiatric conditions involving psychosis. The remaining 63 clients were randomly assigned to the treatment (meditation) or the control condition using the randomly permuted blocks procedure to ensure close bal- ance of the numbers in each group during the trial (Fleiss, 1986). A computer- generated list of random numbers was created based on a 1:1 allocation using
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random block sizes of 2. Thirty-two clients were randomly assigned to the meditation condition and 31 to the control condition. Five clients from the control condition dropped out from the study prior to data collection, yielding a final count of 32 clients in the meditation condition and 26 in the control condition. Because of group size considerations, two separate meditation groups were formed, the first cohort included 17 clients and the second cohort, 15 clients. One client in the control condition left the agency prior to the post-treatment assessment. Another client in the meditation study with- drew from the study prior to the post-treatment assessment because of a med- ical condition that necessitated hospitalization (Figure 1). There were no significant differences between those who had dropped out or left the study and those who had completed the study on their demographic variables and Diagnostic and Statistical Manual of Mental Disorders (DSM) diagnoses.
Treatment Conditions
Treatment consisted of a 6-week meditation curriculum that was influenced by Tibetan meditation tradition with the first 2 weeks devoted to breathing meditation, the second 2 weeks to Nying-je (loving kindness), and the final 2 weeks to Tonglen (compassion). Breathing meditation focused on training for mindfulness and calmness. Loving kindness and compassion taught empathy skills, in terms of sensitivity to one’s own affect and sensitivity to another’s affect, and the development of compassion for oneself and others (Damdul et al., 2013). The meditation class met twice every day for 1 hr, 5 days a week consecutively for 6 weeks for a total of 60 hr. Geshe Kalsang Damdul, the assistant director of the Institute of Buddhist Dialectics in Dharamsala, India (which is under the direct administration of His Holiness the Dalai Lama), developed the meditation curriculum and provided the meditation instruc- tion. At the beginning of each class, Geshe Damdul provided some informa- tion on the technique for that day, usually from 5 to 10 min of instruction, followed by 20 to 40 min of silent meditation. He then asked for questions, which he answered until the end of the allotted time.
Participants in both the meditation and control condition groups received all regular services provided by the agency such as group therapy, individual coun- seling, and treatment related to their substance use. The difference between the two groups was that the control group did not participate in the meditation classes.
Treatment Adherence
Meditation is a private practice that does not readily lend itself to external observation and evaluation. To ensure treatment adherence, participants in
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the meditation condition were encouraged to practice meditation during and after the study periods. During each meditation session, the instructor also allowed time for participants to share their experiences, questions, and learn- ing pertaining to their practice. Participants in the meditation condition were asked to complete a meditation checklist to measure the frequency of their meditation practices. The meditation checklist asked “How often do you practice meditation?” and “For how long do you meditate each time?” Based on the meditation checklist records, 92% of the participants practiced medita- tion more than 1 time each day, and 8% practiced once every day. In addition, 89% practiced meditation for more than 1 hr and 11% practiced meditation for 30 to 60 min. The observed meditation practice pattern was likely to be influenced by the structure of the treatment condition. Participants met twice for an hour during the weekdays and practiced meditation together in a group
32 assigned to the meditation condition
4 were excluded because of co-morbid psychiatric conditions
67 signed up for the study
31 assigned to the controlled condition
63 underwent randomization
25 completed the pre- treatment evaluation
31 completed the post- treatment evaluation
32 completed the pre- treatment evaluation
26 completed the pre- treatment evaluation
1 left the agency
1 withdrew as a result of medical condition
5 withdrew from the study
Figure 1. Screening, randomization, and completion of the pre- and post- assessments.
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format. The instructor also encouraged participants to practice meditation on their own for 30 min during weekends when the group was not meeting. Participants in the control condition were encouraged to continue their routine treatment provided by the agency but not to engage in meditation or related prac- tices during the 6-week intervention period. Treatment fidelity was not measured in this study because Geshe Kalsang Damdul, the only meditation instructor of this study, also developed the 6-week meditation curriculum. However, we had recorded and transcribed the meditation instruction of all sessions for purposes of developing treatment fidelity procedures and measures for future research.
Outcomes
Assessment of participants’ primary outcome on mental health symptoms and secondary outcome on trauma symptoms were made at pre-treatment and post-treatment.
Mental health symptoms. Mental health symptoms were measured by The Symptom Distress Scale (SDS) of the Ohio Department of Mental Health (ODMH) Adult Consumer Form, which is a self-report instrument adopted by the ODMH Consumer Outcomes System to evaluate mental health out- comes among consumers (the ODMH, 2005). The scale consists of 15 items, including Symptom Checklist -10 (SCL-10), which asks respondents to rate their mental health symptoms on a 5-point Likert-type scale. The score for SDS was obtained by summing all individual items. The total scores range from 15 to 75 with a higher score indicating a greater level of symptom dis- tress. The Reliable Change score of SDS is calculated at 11, meaning a differ- ence of 11 between the pre- and post-treatment scores is indicative of reliable change that is not a result of chance (the ODMH, 2006). Based on psycho- metric information from a group of 888 individuals who completed the Adult Consumer Form, SDS demonstrated excellent internal consistency (Cron- bach’s α = .97). The component SCL-10 of the scale also showed adequate discriminant validity with the Beck Depression Inventory and all but two of the Minnesota Multiphasic Personality Inventory scales as well as construct validity (Brophy, Norvell, & Kiluk, 1988). The reliability measure Cron- bach’s alpha for SDS with the current sample was .910.
Trauma symptoms. Trauma symptoms were measured by the Modified PTSD Symptom Scale (MPSS), which is a 17-item instrument developed by Falsetti, Resnick, Resick, and Kilpatrick (1993) to measure the frequency and severity of current PTSD symptoms occurring during the past 2 weeks in respondents. MPSS has three subscales: Re-experiencing subscale, Avoidance/Numbing
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subscale, and Arousal subscale. Because the items correspond directly to Diag- nostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; American Psychiatric Association, 1994) PTSD symptoms, MPSS can be scored dichotomously to determine whether diagnostic criteria for PTSD are met (Falsetti, 1997). MPSS Total Score ranges from 0 to 119 with higher scores indicating more severe PTSD symptoms. MPSS has demon- strated excellent reliability: Cronbach’s alpha was .96 for treatment sam- ple and .97 for community sample (Falsetti et al., 1993) as well as excellent validity (Falsetti, 1997; Falsetti, Resick, Resnick, & Kilpatrick, 1992; Wilson & Keane, 1997). The reliability measure for MPSS with the current study sample was .920.
Statistical Method
Data collected from various instruments were checked and coded for data processing and statistical analyses. To measure treatment effectiveness, the study used paired-sample t tests to examine changes in scores from pre- treatment to termination for each treatment condition. In addition, the study calculated a Reliable Change Index (RCI) for all measurements as well as percentages of clients who had achieved reliable change. To measure com- parative treatment effectiveness between the meditation and control condi- tions, the study used ANCOVA of post-test outcomes controlling for the impact of differences in ethnicity and pre-test scores.
Results
Participants
Data analyses were based on 32 participants in the meditation condition and 26 participants in the control condition. All participants were female. The age of the program participants ranged from 22 to 56 years (M = 38.6, SD = 8.6). Program participants were predominantly White American (58.6%) with 41.4% as non-White. Regarding educational attainment, 10.3% were college graduates, 53.4% had received some college education, 20.7% were high school graduates, and 15.5% did not finish high school. Regarding the mari- tal status of program participants, 53.4% were single, 24.1 % divorced, 15.5% separated, and 6.9% widowed. No participants were married. There were no significant differences between the two groups on demographic characteris- tics including age, educational attainment, and marital status. However, there was significant difference between the two groups in terms of their ethnicity. In the meditation condition, 71.9% were White American and in the control condition, 42.3% were White American (Table 1).
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All participants had DSM-IV diagnoses in substance-related disorders. Of the 58 participants, 39.7% had a diagnosis of cocaine dependence, 32.8% alco- hol dependence, 15.5% opioid dependence, 6.9% polysubstance dependence, 3.4% cannabis dependence, and 1.7% amphetamine dependence. In addition to the substance use–related diagnoses, 27.6% of the participants had Axis I diag- noses of bipolar disorders, 32.8% depression disorders, 12.1% anxiety disor- ders, and 12.1 % PTSD. Other diagnoses included eating disorders, schizoaffective disorder, and somatoform disorder. There were no significant differences between the two groups in terms of their diagnoses (Table 1).
All participants had trauma-related experiences: 82.5% had experienced physical abuse (52.4% in childhood, 31.0% teenager, and 42.9% adult), 78.9% sexual abuse (66.9% in childhood, 26.7% teenager, and 26.7% adult), and 82.5% emotional abuse (74.5% in childhood, 44.7% teenager, and 40.4% adult). The study also collected information regarding participants’ childhood experience. Of the participants, 43.9% had experienced parental divorce or separation, 80.7% were children of alcoholics, and 59.6% had witnessed domestic violence between parents. There were no significant differences between the two groups on their trauma-related experiences or other childhood experiences, including parental divorce, parental violence, and family alcoholism (Table 1).
Baseline Characteristics
Table 2 shows the results for the meditation and control conditions. Clients in both groups experienced mental health symptoms as measured by the Symptom Distress Scale (SDS). Mean SDS scores for clients in the meditation condition and control condition were 32.06 (SD = 10.66) and 28.82 (SD = 9.74) respec- tively. For trauma symptoms, mean MPSS Total Score for clients in the medita- tion condition and control condition were 52.85 (SD = 25.25) and 40.57 (SD = 25.70). There were no significant differences in the initial scores of SDS and MPSS between the two conditions.
Treatment Efficacy
To measure treatment efficacy, the study used paired-sample t tests to exam- ine changes in scores from pre-treatment to termination for each treatment condition. For clients who had attended the meditation curriculum, findings showed significant reduction in overall PTSD symptoms (t = 6.009, df = 31, p = .000) from pre-treatment to post-treatment (Table 2). In addition, there were significant reductions in mental health symptoms (t = 5.252, df = 31, p = .000). Non-significant changes in all evaluated dimensions were observed among clients in the control condition from pre-treatment to post- treatment (Table 2).
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Lee et al. 2155
The study also calculated the RCI for all measurements using the method suggested by Jacobson and Truax (1991). The RCI of SDS is 11 and MPSS is 10 (Table 3). For clients in the meditation condition, 35.5% achieved reliable change in their mental health symptoms and 42.3% of clients achieved reli- able change in their trauma symptoms. Compared with clients in the medita- tion condition, only 8.3% and 4.8% of clients in the control condition achieved reliable change in their mental health and trauma symptoms. In addition, no clients in the meditation condition experienced reliable negative change in their mental health or trauma symptoms, whereas 23.8% of clients in the control condition experienced reliable negative change in their trauma symptoms (Table 3). There were also significant differences between clients in the meditation condition and the control condition in their pattern of reli- able change pertaining to mental health symptoms and trauma symptoms with significantly more clients in the meditation condition achieving reliable change in their mental health and trauma symptoms than clients in the control condition (Table 3).
Treatment Effectiveness of the Meditation Condition and the Control Condition
This study used ANCOVA of pre-test post-test improvement on the SDS and MPSS as dependent variables respectively in two analyses. Because of differ- ences between the two groups in race (White vs. non-White) and also pre- treatment scores, the initial score and the race variable (White vs. non-White) were entered as covariates in each ANCOVA model. We also entered the two- way and three-way interactions among the covariates and treatment variable. These interactions were removed from the final models. We also tested the homogeneity of regression slopes between the covariates and the dependent variables of treatment improvement across the treatment and control groups. There were no significant differences found in the interaction of the covari- ates and the treatment improvement outcomes.
Regarding mental health symptoms, findings indicate there was a signifi- cant group difference between clients in the meditation condition and the control condition in their SDS scores, F(1, 54) = 13.438, p = .001. The mean score of the meditation condition (23.89) was significantly lower than the mean score of the control condition (28.11) at post-treatment controlling for the impact of differences in ethnicity and pre-test SDS score between the two groups, with an effect size of Eta Squared .127.
Regarding trauma symptoms, findings indicate there were significant group differences between clients in the meditation condition and the control condition in MPSS Total Scores, F(1, 54) = 13.395 p = .001, controlling for
2156 Journal of Interpersonal Violence 32(14)
the impact of differences in ethnicity and pre-test MPSS scores between the two groups. The mean score of the meditation condition was significantly lower than the mean score of the control condition with respect to total MPSS Total Score (26.78 vs. 36.85), with an effect size of Eta Squared .146.
Discussion
Mindfulness and meditation techniques have been increasingly adopted in treatment of trauma survivors and/or clients with substance use problems mostly because of the recognition of the role of neurobiological changes related to trauma and substance use. Current treatment usually includes mindfulness-based interventions or yoga as influenced by the works of Bessel van der Kolk (Trauma-Sensitive Yoga); Marsha Linehan (Dialectic Behavioral Therapy); Garland Marlatt (Mindfulness-Based Relapse Prevention); John Kabat-Zinn (Mindfulness-based Stress Reduction); John Teasdale, Zindel Segal, and their associates (Mindfulness-Based Cognitive Therapy for Depression); and so on. This randomized, controlled trial provides empirical evidence of a Tibetan-based meditation practice that includes not only mind- fulness-based breathing meditation but also loving kindness meditation and compassion meditation as a complementary behavioral intervention for improving mental health outcomes in female trauma survivors of interpersonal
Table 3. Reliable Change on Mental Health and Trauma Symptoms.
RCI
Meditation Condition
Control Condition
χ2 df p n % n %
Mental health symptoms: SDS
11 31 24 5.53 1 .019
Positive change greater than RCI
35.5 8.3
No change 64.5 91.7 Trauma symptoms:
MPSS 10 26 21 12.95 2 .002
Positive change greater than RCI
42.3 4.8
No change 57.7 71.4 Negative change
greater than RCI 0.0 23.8
Note. RCI = Reliable Change Index; SDS = Symptom Distress Scale; MPSS = Modified PTSD Symptom Scale.
Lee et al. 2157
abuse with CODs. Findings based on paired-sample t tests showed a signifi- cant reduction in the primary outcome on mental health symptoms and sec- ondary outcome on trauma symptoms from pre-treatment to post-treatment in clients who had attended the meditation classes (Table 2). Non-significant changes in all evaluated dimensions were observed among clients in the con- trol condition (Table 2). In addition, there were significant differences between clients in the meditation condition and the control condition in their pattern of achieving reliable change pertaining to mental health symptoms and trauma symptoms. Overall, 35.5% and 42.3% of clients in the meditation condition achieved reliable change, whereas only 8.3% and 4.8% of clients in the control condition achieved reliable change in their mental health and trauma symptoms (Table 3).
To compare treatment effectiveness of the meditation condition and the control condition, the study used ANCOVA of post-test outcomes of medita- tion and control conditions controlling for the impact of differences in ethnic- ity and pre-test scores between the two groups. Findings indicate there were significant group differences between clients in the meditation condition and the control condition in their mental health and trauma symptoms. The effect sizes were generally large with similar level of positive effect of meditation practice on mental health symptoms (.127) and trauma symptoms (.146).
In sum, findings of the study offered empirical support to the hypotheses that meditation practice would lead to a reduction in mental health symp- toms and a reduction in trauma symptoms. Limitations of this efficacy study need to be acknowledged. First, the sample size was relatively small. Second, although there were no significant differences between the medita- tion and the control condition on demographic characteristics including age, educational attainment, and marital status, as well as childhood and trauma-related experiences including parental divorce, parental violence, family alcoholism, and physical, sexual, and/or emotional abuses, there were significantly more African American clients in the control condition than the meditation condition. Because of these differences, the study con- trolled for the impact of ethnicity and pre-treatment score differences in conducting all data analyses when comparing the two groups. Third, although only two clients withdrew from the study prior to post-treatment, there was still a slight problem of measurement attrition. In addition, five clients from the control condition dropped out from the study prior to data collection process. Finally, no substance use outcomes were included in this study. Because this study was conducted at a residential treatment cen- ter for substance use women, absolute abstinence was required for all cli- ents for them to stay in this treatment facility. As such, measurement of substance use outcomes was not included in the current study.
2158 Journal of Interpersonal Violence 32(14)
Conclusion
Interpersonal violence has pervasive and devastating impacts on individuals, particularly on their affect modulation ability. It is not uncommon for trauma survivors of interpersonal violence to turn to mind-altering substances to cope with their negative emotions and numb their feelings. One major chal- lenge for female trauma survivors with CODs is learning how to live benefi- cially in the present and not detrimentally under the shadow of the past trauma. Clinical challenges encountered by these clients in the treatment pro- cess revolve primarily around the ability to differentiate responses that clients can regulate emotions and behaviors based on current needs and life con- texts. Because trauma is also registered in the “body,” clients need to have the ability to stay psychologically and physiologically calm so that they can ben- eficially process and integrate their trauma experiences in the treatment pro- cess (van der Kolk, 2002). Meditation practice, with its intentions to cultivate a mindful existence and positive emotions, should have beneficial impact on trauma survivors with COD for enhancing their capacity to attend to the pres- ent, to stay calm, and to better regulate their emotions. In doing so, clients will have a better chance of benefiting from treatment, integrating their trauma experiences.
Consistent with a strengths perspective (Saleebey, 2008), meditation prac- tice also empowers clients in the process of their recovery (Lee et al., 2009). Clients can practice meditation at their own pace, anytime and anywhere, on a regular basis once they learn how to do it. Meditation does not require costly equipment, facilities, or professional assistance, nor does it require clients to share their trauma experiences with others. Meditation also initiates cognitive change at the meta-cognitive level. Instead of directly addressing and focusing on the “content” of trauma or substance use, meditation trains individuals to “discipline” their mind. In other words, meditation allows a person to change one’s relationship to thoughts without directly focusing on the problems (Marlatt, 2002). By training clients to attend to the present, enhancing clients’ ability to stay physiologically calm, and increasing posi- tive emotions, meditation practice allows clients to unfold their internal and personal resources to address the problems of trauma, substance abuse, and other mental health problems (Lee, Zaharlick, & Akers, 2011). It helps clients to build and strengthen self-resources and capacities and echoes the concerns of “self before trauma” (Briere, 2002; Linehan, 2015).
It is important to evaluate the effectiveness of meditation as a complimen- tary behavioral intervention and examine the associated mechanisms and pro- cesses that contribute to its effectiveness so that treatment is based on an informed position. Although findings of this study provide empirical evidence
Lee et al. 2159
of the feasibility of this 6-week meditation program as a complementary behavioral intervention for treating female trauma survivors of interpersonal violence who have CODs, the structure of this meditation program was rela- tively intensive and the study was conducted at a substance abuse treatment facility for women. As such, feasibility of this meditation program will still need to be further tested in diverse treatment settings with different levels of treatment intensity. For instance, without sacrificing the content of the 6-week meditation curriculum, can the program be offered in different formats such as weekend retreats or using a hybrid model combining in-class and online practice? Specific recommendations for future large scale effectiveness stud- ies include (a) the use of a larger sample size from multiple research sites including diverse treatment settings and using different formats of program offerings, (b) the inclusion of physiological stress markers in measuring out- comes, (c) examination of the impact of meditation on substance use out- comes, (d) longitudinal study design to examine the long-term impact of meditation practice on outcomes, (e) the development of a valid fidelity mea- sure for the meditation curriculum and meditation practice, (f) the use of trained instructors to conduct the meditation curriculum to control for the “Geshe effect,” that is, the therapist effect, and (g) the use of multiple research methods, including both quantitative and qualitative research strategies, to identify the mechanisms of change associated with meditation practice.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research is supported by the Ohio Department of Mental Health (now OhioMHAS), Grant 60012277.
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Author Biographies
Mo Yee Lee, PhD, is Professor at the College of Social Work, The Ohio State University. Her scholarship focuses on intervention research using a solution-focused, strengths-based, and systems perspective as well as utilizing integrative body-mind- spirit approaches including meditation in treatment. She co-authored “Integrative Body-Mind-Spirit Social Work: An empirically based approach to assessment and treatment”, “Solution-focused treatment with domestic violence offenders: Accountability for change,” and “Integrative Families and Systems Treatment (I-FAST): A strengths-based common factors approach”, published by The Oxford University Press.
Amy Zaharlick, PhD, is Emeritus Professor in the Department of Anthropology, The Ohio State University, with specialization in sociocultural, linguistic, and applied
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anthropology and has a Master degree in social work with an emphasis in the clinical behavioral health field. Much of her recent research has focused on the effectiveness of meditation practices for treating female trauma survivors with a prolonged history of interpersonal abuse, and to explore the utility, cultural adaptability, and appropri- ateness of using meditation, a primarily Eastern-based practice, as an intervention with clinical populations in the U.S.
Deborah Akers, PhD, is an applied cultural anthropologist, an author, and a researcher. She has served as a Visiting Scholar at the Institute of Buddhist Dialectics in northern India where she has established a field school in the Tibetan refugee com- munity in exile. Among the countries where she has lived and conducted fieldwork are Dubai, United Arab Emirates; Jeddah, Saudi Arabia; as well as Tibetan monaster- ies in Dharamsala, India, and Katmandu, Nepal.
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