SpirituallySpiritually --Based Based MantramMantramRepetition to Manage PTSD in Repetition to Manage PTSD in

Veterans: A Qualitative Analysis of Veterans: A Qualitative Analysis of Uses & OutcomesUses & Outcomes

Jill E. Bormann, PhD RNJill E. Bormann, PhD RN1,2

Samantha Hurst, PhDSamantha Hurst, PhD3

Steve Thorp, PhDSteve Thorp, PhD1,3

Dale Glaser, PhDDale Glaser, PhD1,2

1 VA San Diego Healthcare SystemVA San Diego Healthcare System2 San Diego State UniversitySan Diego State University3 University of California San DiegoUniversity of California San Diego

VA HSR&D Nursing Research Initiative (04-041-1)

Background & SignificanceBackground & Significance

Incidence of PTSD in military is increasing!Incidence of PTSD in military is increasing!1212--20% of Iraq vets have PTSD20% of Iraq vets have PTSD

Multiple deployments to Iraq & AfghanistanMultiple deployments to Iraq & Afghanistan

Very few complementary Very few complementary or or ““ spirituallyspiritually --basedbased ””therapies availabletherapies available

Institute of Medicine (2010) .Returning Home from I raq and Afghanistan: Preliminary Assessment of Read justment Needs of Veterans, Service Members, and Their Famil ies National Academic Press, Washington, DC,1-173.

HogeHoge , Castro, Messer et al., (2004); , Castro, Messer et al., (2004); HogeHoge , , AuchterlonieAuchterlonie , Milliken, (2006); , Milliken, (2006); Owens, Baker, Owens, Baker, KasckowKasckow et al, (2005).et al, (2005).

MantramMantram RepetitionRepetition““MantramMantram”” = word/phrase with = word/phrase with spiritual spiritual meaning,meaning, repeated silently, frequently to repeated silently, frequently to train attention throughout the daytrain attention throughout the day

Innovative, portable, immediately available, Innovative, portable, immediately available, inexpensive, invisible, noninexpensive, invisible, non--pharmacological, pharmacological, nonnon--toxic ~ toxic ~ ““no known side effects! no known side effects! ””

Ancient, universal practice, cross-culturalAdapted for health education

Why Why ““ mantrammantram ””not not ““ mantra?mantra? ””

To distinguish from secularized To distinguish from secularized

usage of usage of ““mantramantra””

Reflects teachings of Eknath Easwaran

Is Is NOT NOT Transcendental Meditation (TM) Transcendental Meditation (TM) ––

a sitting mantra meditationa sitting mantra meditation

Rama, ShalomRama, Shalom Om Mani Om Mani PadmePadme HumHum

My God and my allMy God and my all Come Lord JesusCome Lord Jesus RibonoRibono shelshel olamolam

Ave Maria, So HumAve Maria, So Hum O O WankaWanka TankaTanka , Allah, Allah

1. 1. MantramMantram RepetitionRepetition2. Slowing Down2. Slowing Down3. One3. One--Pointed AttentionPointed Attention

Training AttentionTraining Attention

3 of 8 points from Eknath Easwaran, Blue Mountain Ce nter

MantramMantram InterventionInterventionComponents Components

EducationEducation�� PTSD PTSD

–– EtiologyEtiology–– SymptomsSymptoms

Skill BuildingSkill Building1) How to choose1) How to choose2) Ways to use 2) Ways to use mantrammantram forfor

symptom managementsymptom management3) Slowing Down 3) Slowing Down 4) One4) One--pointed attentionpointed attention

6 weeks (90 minutes per week group format)6 weeks (90 minutes per week group format)

How itHow it ’’s taught . . .s taught . . .1. Practice repeating 1. Practice repeating anytime, anywhereanytime, anywhere

2. Practice when you 2. Practice when you ““dondon’’t need itt need it””–– waiting in lineswaiting in lines

–– at a stoplightat a stoplight

–– before sleeping at night, when relaxedbefore sleeping at night, when relaxed

3. Use it when you 3. Use it when you ““do need itdo need it””–– Interrupt/redirect obsessive thoughtsInterrupt/redirect obsessive thoughts

–– Slow reactivity to disturbing actionsSlow reactivity to disturbing actions

Prior Research EvidencePrior Research Evidence

Can Can mantrammantram repetition help repetition help manage symptoms of PTSD?manage symptoms of PTSD?

Research QuestionResearch Question

StudyStudy AimsAims

1. Identify types of situations and ways1. Identify types of situations and ways

that that mantrammantram repetition is used. repetition is used.

2. Evaluate if 2. Evaluate if mantrammantram repetition isrepetition is

helpful or not helpful.helpful or not helpful.

�� Sample from larger RCT Sample from larger RCT

�� Contacted 65 who completed Contacted 65 who completed mantrammantram

�� Telephone interviews 3 mo. postTelephone interviews 3 mo. post--txtx

�� Critical Incident Research Interviewing Critical Incident Research Interviewing Technique Technique (not briefing)(not briefing)

�� Constant Comparative AnalysisConstant Comparative Analysis

�� Organize in taxonomyOrganize in taxonomy

MethodsMethods

Data AnalysesData Analyses

�� Identify triggering eventIdentify triggering event

�� Responses to events (symptoms)Responses to events (symptoms)

�� Coping strategies usedCoping strategies used

�� Outcomes reported Outcomes reported

Interview QuestionsInterview QuestionsCritical Incident Research MethodCritical Incident Research Method

““Can you think of a time that you used theCan you think of a time that you used themantrammantram to manage your PTSD symptoms?to manage your PTSD symptoms?””

““Can you tell me about any other situationsCan you tell me about any other situations(unrelated to PTSD)(unrelated to PTSD) in which you used thein which you used themantrammantram? ?

. . . repeat till no more answers. . . repeat till no more answers

Sample CharacteristicsSample Characteristics65 Veterans65 Veterans M (SD)M (SD) rangerange

Mean age (SD)Mean age (SD) 56 (5.5)56 (5.5) 39 to 7539 to 75

Years of combatYears of combat 1 (0.7)1 (0.7) 0.5 to 20.5 to 2

n (%)n (%)

MaleMale 64 (98)64 (98)

OIF/OEF veterans OIF/OEF veterans 3 (5) 3 (5)

EthnicityEthnicity

WhiteWhite

African AmericanAfrican American

LatinoLatino

OtherOther

41 (63)41 (63)

17 (26)17 (26)

3 (5)3 (5)

4 (6)4 (6)

CharacteristicsCharacteristicsEducation (> high school)

Partner Status - SingleMarried/cohabitatingSeparated/Divorced

Employed > 35hrs/week

Income > $30,001

Wounded

23 (35)

4 (6)32 (49)29 (45)

6 (9)

36 (55)

27 (42)

Spiritual/ReligiousSpiritual/Religious

Spiritual (not religious)

Religious (not spiritual)

Both Spiritual and Religious

Neither

7 (11)

10 (15)

44 (68)

4 (6)

Identifies as… n %

Triggering EventsTriggering Events• Media violence• Reminiscence• Social Interactions• Interpersonal relationship difficulties• Driving• Sleep disturbance caused by mantram prior to sleep• Health problems• Dealing with Death • Sounds from Environment• VA group discussions• Personal issues

65 Veterans reported65 Veterans reported268 268 ““Triggering EventsTriggering Events””

Responses to Events

n (%) � Re-experiencing 56 (18)� Avoidance 16 (5)� Hyper-arousal 222 (70)� Depression 13 (4)� Survivor Guilt 7 (2)� Pain 3 (1)

317 Responses/Symptoms317 Responses/Symptoms

HyperarousalHyperarousaln n = 222= 222

�� 109 irritable angry outbursts (49%)109 irritable angry outbursts (49%)

�� 56 anxiety/panic (25%)56 anxiety/panic (25%)

�� 17 inability to calm down/relax (8%)17 inability to calm down/relax (8%)

Coping Strategies

� Use mantram effectively� Mastering mantram practice� Use mantram inconsistently--little or no effect� Use medications� Use other spiritual practices (meditation, prayer)� Use breathing exercises� Use other therapy (i.e., CBT)� Use anger management� NOT use mantram for trigger� Use alcohol� Use sleep to avoid thinking

302 Ways of coping302 Ways of coping

nn21721724201411

742111

(%)(%)(72)(72)(8)(7)(5)(4)(2)(1)

(0.7)(0.1)(0.1)(0.1)

80%

�� relax / be calmrelax / be calm

�� think clearly and rationallythink clearly and rationally

�� divert attention away from problemdivert attention away from problem

�� let go of angerlet go of anger

�� to focusto focus

�� neutralize ("let go of") anxiety/bad neutralize ("let go of") anxiety/bad feelings feelings

Outcomes of Use Outcomes of Use ((continued) continued)

379 Outcomes379 Outcomesn %n %

143143 (38)(38)

46 (12)46 (12)

2828 (7)(7)

2626 (7)(7)

2626 (7)(7)

2323 (6)(6)

50%50%

27%27%

Outcomes of Use�� refine skills of refine skills of mantrammantram classclass 22 (6)22 (6)�� sleepsleep 22 (6)22 (6)�� "come back" from flashback"come back" from flashback 13 (3)13 (3)�� let go of fearlet go of fear 9 (2)9 (2)�� slow downslow down 7 (2)7 (2)�� communicate thoughts/feelings more effectively communicate thoughts/feelings more effectively 6 (2)6 (2)�� feel in touch spirituallyfeel in touch spiritually 4 (1)4 (1)�� let go of or relieve painlet go of or relieve pain 2 (0.5)2 (0.5)�� control blood pressurecontrol blood pressure 2 (0.5)2 (0.5)

n %n %

Mantram for Sleep

What kinds of situations or events prompt you to use your mantram?

“Almost every night, because I have trouble going to sleep. If I use my mantram, I can get to sleep.”

Response to Environment/Flashback

“I have a problem with fire because I was involved in a fire. And a couple of times, when I’ve lighted the outside grill, the flash got me, you know! I used the mantram to settle myself down. I lose the fire flash, and I come back to normal.”

To Manage Anger“Well, once in awhile, I get involved with

my wife of 40 years and I lose my temper. And I right away can get the mantram to help me out of that situation and it blends things real well; and I have a little trouble with my voice control because of a stroke that I had and the mantram helps me get over that.

To Manage PTSD Sx“Any time I get agitated. Any time I have

any PTSD triggers . . . driving. . . situations in relationships . . . anywhere I feel uncomfortable. Those types of things . . . in crowds when I am not comfortable in crowds . . . If I wake up in the night from a dream or nightmare . . . I wake up in sweat . . .I say my mantramand I relax.

Not a cure-allSame vet from previous slide:

“It doesn’t always work all the time, though. But most of the time it will work, you know, in other words, it’s taken away a lot of that mental anguish that I usually carry.”

Summary/Conclusions

Mantram intervention is a beneficial complement to usual care for managing a variety of PTSD related symptoms in older Veterans with long-term PTSD.

Most effective for symptoms ofhyperarousal.

Vet 10: “Seems to me whenever I need it, I just use it and it helps me.”

Vet 13: “Thank you for calling me. Using my mantram a lot.”

Vet 23: “Use it most every morning to prepare…to get in better mood for day. . . Use it in stressful times like talking with the bank. It helps.”

Interviews 1-year Post-Intervention

Vet 24• Use it every night before sleep. . .

• When waking during night. Helps to get rid of awfulthoughts. Helps to focus and just go to sleep. . .

• Use it in the morning when really sleepy; to get focusedand get up and get started . . .

• Use to relax when in shower. . .

• When getting upset, like strange thoughts. . .

• Use it when driving; cut off by young kids who werelaughing at me. Used mantram to keep from going after them

• Costco woman rolled her cart into me in line, bloodpressure went up; used mantram and I turned away andgot in another line. Really wanted to yell at her, but didn’t.

• Or with my wife, we get mad at each other over any littlething, when wife, I feel is over reacting, then do themantram . . .

Vet 24 - continued

“Use mantram often but depends on situation. Situations I use in are when upset with wife or for disagreements. I sit back and use mantram to calm self and not get angry. Also when driving or being harassed, like when cut off or followed too closely…helps to calm down and not get angry.”

Vet 26

Questions?Questions?

Thank you!Thank you!

www.jillbormann.com

jill.bormann@va.gov

The views in this material are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs or the United States Government.