Compassion Meditation Training for Emotional Numbing Symptoms Among Veterans with Post-Traumatic Stress Disorder

Abstract

For the 8 million American adults suffering from post-traumatic stress disorder (PTSD), emotional numbing can impair the quality of interpersonal relationships that are themselves critical for the remediation of PTSD.^1

–4 Yet, although reducing emotional numbing and restoring interpersonal connectedness may improve response to treatment, few therapies specifically target the interpersonal deficits that accompany PTSD. CBCT^® (Cognitively-Based Compassion Training), a secular group-format intervention designed to cultivate compassion for self and others,⁵ may be one such novel and effective approach to restore emotional well-being after initial PTSD treatment. The aims of this study were (1) to examine the acceptability of CBCT among veterans who continued to report social disconnection and emotional numbing symptoms after completing empirically supported PTSD treatment and (2) to make preliminary estimates of the impact of CBCT on emotional numbing symptoms.

Methods

Twenty veterans (ages 30–72 years) initially completed a pre-CBCT assessment. All participants had previously completed at least 8 weeks of empirically supported PTSD treatment, but nonetheless continued to report emotional numbing symptoms. Participants reported an average of 5.80 (SD = 2.31) lifetime traumatic events, with 90% reporting combat exposure, 70% assault, and 20% sexual assault. Of those who agreed to participate in CBCT, 8 (40%) never presented for the intervention. Thus, 10 weeks of CBCT was administered (Table 1) to 12 male veterans (ages 31–69 years). Veterans completed pre- and postintervention assessments of self-reported PTSD symptoms using the PTSD Checklist (PCL).⁶ An emotional numbing composite score was calculated from the PCL numbing items (i.e., 9–11). Participant satisfaction was measured using the Client Satisfaction Questionnaire (CSQ-8)⁷ administered after the final CBCT class. Preliminary estimates of acceptability/feasibility were measured by retention, attendance, and self-report of compassion meditation practices.

Table 1.

Cognitively-Based Compassion Training Protocol Overview (Six Core Modules Taught Over the Course of 10 Weeks)

Foundational Practice: Resting in a Moment of Nurturance.

By recalling a situation associated with feelings of safety, security, and comfort, and learning to sustain this over time, the foundational practice promotes the physiological and psychological conditions in which mental insight and learning can occur. This also deepens the motivation to train in compassion due to an increased awareness of the value of nurturance and care in one's own life.

Module I: Attentional Stability and Clarity.

This module supports an increased capacity for inner focus and introspective awareness by practicing holding one's attention on the feelings of the breath or other benign sensations in the present moment.

Module II: Insight into the Nature of Mental Experience.

Open monitoring (nonappraisal) practice is employed to observe the nature of thoughts, feelings, and emotions, and to gain insight into the automatic reactivity and projections common to mental experience.

Module III: Self-Compassion.

With greater insight into mental patterns, the participant here examines causes of dissatisfaction present in one's own life despite one's innate aspiration for well-being and freedom from distress. Seeing one's difficulties within a broader context and perspective (cognitive reappraisal) can bring a sense of kindness and relief in the face of inevitable imperfections, vulnerabilities, and adversities. With an increasing sense of self-efficacy, the participant commits to emerging from misleading and harmful mental patterns over time.

Module IV: Impartiality Toward Others.

Turning the focus from self to others, the participant examines how distorted views of others can cause harm. Module IV counters learned habits of bias or partiality through reflection on the basic human orientation toward well-being and freedom from distress. Seeing that all individuals are alike in this way, one visualizes people in the categories of friend (positive), stranger (indifferent), and adversary (negative), with the goal of seeing the superficiality of the categories as well as increasing identification with others. These insights increase an inclusive sense of closeness with others while reducing indifference and excessive liking or disliking.

Module V: Gratitude and Affection.

All individuals benefit from a complex social system that provides numerous resources and benefits. Recognition of this interdependence, in particular the high degree of dependence on countless others, decreases perceptions of interpersonal distance and social isolation and leads to a sense of gratitude and closeness to others, whether familiar, unknown, or perhaps adversarial. The practice guides the participant in extending gratitude, as well as an accompanying sense of affection or warmheartedness, to an ever-widening circle of others, both known and unknown.

Module VI: Empathetic Concern and Engaged Compassion.

Enhanced feelings of affection, coupled with an empathic awareness of their suffering and its causes, naturally give rise to the wish for others to be free from suffering and its causes—which in CBCT is the definition of compassion. The participant is guided through a meditation designed to move from simply wishing others to be free of unhappiness to actively committing to assistance in their pursuit of well-being and freedom from harm and distress. Consistent training strengthens a compassionate motivation and, over time, helps it to become both more inclusive and spontaneous.

Headings are bold for emphasis

Weekly sessions were 2 h long, taught by two coteachers to participants as a group.

CBCT, cognitively-based compassion training.

Results

Among veterans who presented for at least one session, CBCT was rated as highly acceptable and useful, and retention was high, with 83% completing the intervention (i.e., 10 out of 12 veterans attended at least 5 sessions; M = 7.90 sessions, SD = 0.99). Veterans engaged frequently in meditation practice, reporting, on average, 92.58 min of weekly meditation (SD = 44.62) and 7.91 occasions per week (SD = 2.56). At preintervention, veterans endorsed a high degree of internal motivation for treatment on a 1–7 scale (M = 6.67, SD = 0.57) and confidence in CBCT (M = 6.28, SD = 0.91). At the end of the intervention, veterans reported a high degree of satisfaction with the program (CSQ-8: M = 28.89, SD = 3.33; possible scores ranged from 8 to 32). Veterans reported significantly decreased PTSD symptoms from preintervention (M = 63.44, SD = 11.43) to postintervention (M = 53.68, SD = 14.70; Z = −2.67, p = 0.008, d = 0.74). Emotional numbing symptoms significantly decreased from preintervention (M = 3.59, SD = 1.09) to postintervention (M = 2.93, SD = 0.86; Z = −2.12, p = 0.034, d = 0.64).

Discussion

Overall, the findings of this small pilot are encouraging for future intervention research, particularly considering that most of the veterans had already received a variety of treatments, including trauma-focused therapy. Veterans who started the class maintained a high level of engagement and satisfaction with CBCT. Analyses also revealed theory and hypothesis-consistent outcomes with respect to decreases in emotional numbing and PTSD symptoms after CBCT. Although it was not clear that increased compassion was the mechanism of change (or will be in future studies), it is worth noting that a rationale to increase compassion was considered appropriate and reasonable. However, given the high dropout rate in the intent-to-treat sample (n = 20), it will be important for future studies to clarify reasons for failure to initially engage with CBCT (e.g., avoidance, insufficient rationale, or logistical barriers to attendance).

Although these preliminary findings are promising in that 100% of participants reported a decrease in PTSD symptoms and 78% reported a decrease in numbing symptoms specifically, the pre–post change estimates should be interpreted with caution given that the small sample size may not be generalizable to the larger population of veterans suffering from residual emotional numbing. Furthermore, small sample sizes may inflate estimates of effect size.⁸ Likewise, there were no significant associations between frequency of meditation practice and the outcomes tested, which may have been both an issue of sample size and restricted range in the practice variables, as most of the veterans engaged frequently in the practices. Finally, history of PTSD and trauma exposure were measured by self-report (rather than structured clinical interview), and index traumas could not be verified using VA medical records. Notwithstanding these limitations, this pilot provides preliminary support for compassion meditation as an adjunctive intervention worthy of further study for addressing residual emotional numbing, and highlights the importance of whole-person treatment for veterans with histories of PTSD.

Footnotes

Acknowledgments

The authors thank Nathan Mascaro for his clinical expertise during study design, Stephen Blount for coteaching the CBCT courses, Carol Beck for administrative help in setting up the CBCT courses, and the Emory CBCT Program for much support along the way. Finally, the authors thank the veterans who were willing to participate in the CBCT groups. The study was funded by a NARSAD Young Investigator Award through the Brain & Behavior Research Foundation (J.S.M.) and a Mind and Life 1440 Award (J.S.M. and J.N.K.).

Author Disclosure Statement

No competing financial interests exist.

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