Loving-Kindness Meditation for PTSD
David J. Kearney, Carol A. Malte, Carolyn McManus, Michelle E. Martinez, Ben Felleman, and Tracy L. Simpson explain how loving-kindness meditation increases positive emotions and reduce the emotions that underlie post-traumatic stress. It's a powerful tool now being used by veterans and their family members to deal with PTSD.
Self-criticism, rumination, and thought suppression are frequently associated with posttraumatic stress disorder (PTSD; Bennett & Wells, 2010), as is depression (Krupnick et al., 2008). There is evidence that self-compassion is negatively associated with self-criticism, rumination, thought suppression, anxiety, and depression, and positively associated with healthy psychological functioning, including life satisfaction and social connectedness (Neff, Rude, & Kirkpatrick, 2007). A small body of literature has assessed the role of self-compassion in PTSD....
Loving-kindness meditation is a complementary and alternative medicine (CAM) approach that facilitates increased positive emotions through meditation exercises designed to develop feelings of kindness and compassion for self and others.
Loving-kindness practice has its roots in the Buddhist tradition, but can also be applied as a nonreligious practice. The phrase loving-kindness derives from the Pali word metta, which can be translated as “love” or “loving-kindness,” akin to the Greek word “agape.” The words loving-kindness describe an emotional state that is not a feeling of sentimental love. Rather, it can be described as an unconditional friendliness, benevolence, and goodwill. In the Buddhist record, loving-kindness meditation was originally taught as a way of working with fear, which is the predominant emotional experience in PTSD.
Indeed, one of the core features of PTSD is thought to be a phobic fear response to reminders of a traumatic event and to the memories associated with that event, which in conjunction with information processing problems, lead to pervasive fear and poor functioning (Foa & Riggs, 1993).
In loving-kindness meditation practice, a person sits quietly and calls to mind a particular person (e.g., a good friend) for whom they have positive regard, and silently repeats phrases of positive intention for that person. The phrases invoke a desire for safety, happiness, health, and ease or peace for them.
Classically, four phrases are used, such as “may you be safe,” “may you be happy,” “may you be healthy,” and “may your life unfold with ease” (Salzberg, 1995). The participant is asked to notice the feelings and thoughts evoked by the phrases.
Next, the person brings to mind other individuals or categories of people, including oneself, a neutral person, and those who have caused difficulty or harm, changing the phrases as needed (for example, “may I be safe” becomes “may you be safe” (Salzberg, 1995). Although loving-kindness meditation can be considered to be a form of practice that cultivates a mindful way of being, the repetition of phrases of positive intention, as taught in loving-kindness meditation, is distinct from mindfulness meditation practices, which typically involve bringing nonjudgmental attention to the breath, body, or other aspects of experience.
Increasing evidence supports loving-kindness meditation as a technique for enhancing positive emotions and health generally . Fredrickson, Cohn, Coffey, Pek, and Finkel (2008) randomized 139 individuals to loving-kindness meditation or a waitlist control, and found that those randomized to loving-kindness meditation reported greater positive emotions and were less depressed than the no loving-kindness meditation group, even though both groups reported a similar frequency of negative emotions. Positive emotions persisted after meditation sessions ended, and loving-kindness meditation practice produced an increase in positive emotions on subsequent days, regardless of whether the person practiced meditation on that day (Fredrickson et al., 2008).
Other studies in support of loving-kindness meditation include a pilot study for chronic low back pain, which compared subjects who underwent loving-kindness meditation to standard care and found that those in loving-kindness meditation reported lower pain ratings, less anger, and less psychological distress (Carson et al., 2005)
An additional study indicated that a single brief session of loving-kindness meditation training led to increased self-esteem and social connectedness relative to a control condition (Hutcherson, Seppala, & Gross, 2008), and another study found that three sessions of loving-kindness meditation led to the association of positive affect with previously neutral stimuli (Hunsinger, Livingston, & Isbell, 2012). Also, in a case series in which loving-kindness meditation was taught to people with schizophrenia, loving-kindness meditation appeared beneficial for persistent negative symptoms (Johnson et al., 2009).
The United States Department of Veterans Affairs (VA) has successfully disseminated evidence-based treatments for PTSD, including prolonged exposure (; Schnurr et al., 2007) and cognitive processing therapy (CPT; Karlin et al., 2010). Despite receiving treatment for PTSD, however, many people continue to experience persistent PTSD symptoms (Schottenbauer, Glass, Arnkoff, Tendick, & Gray, 2008), and other difficulties including disrupted interpersonal relationships, shame, and guilt (Lee et al., 2001). Consensus recommendations have advocated the need for further research on nontraditional delivery systems and group-based interventions for mental health conditions to significantly expand the availability of cost-effective therapies (Hollon et al., 2002). Loving-kindness meditation is designed to be delivered in a group format, thus reaching 12–15 patients at once rather than a single patient at a time as is typical with both PE and CPT (though the latter may be offered in small groups). Given the large number of veterans with PTSD, additional cost-effective treatments are needed to address residual symptoms and psychiatric comorbidity, such as depression.
Additionally, many patients would prefer to manage symptoms of anxiety and depression through means other than medications, and qualitative research among veterans suggests that dissatisfaction with reliance on prescription medications and neglect of social and spiritual aspects of health serve as motivating factors for use of complementary medicine modalities (Kroesen, Baldwin, Brooks, & Bell, 2002). The cultivation of positive emotions through loving-kindness meditation could be hypothesized to be particularly helpful for the constrictive symptoms characteristic of chronic PTSD, which can present as feelings of chronic alienation, emotional numbness, and deadness.
Providing a technique through which positive emotions are repeatedly brought forward, as in loving-kindness meditation practice, might provide an innovative pathway to address these numbing and constrictive symptoms.
The high rate of compliance with loving-kindness meditation provides preliminary support for the acceptability of loving-kindness meditation among veterans; larger studies are needed to confirm these findings. The apparent acceptability of loving-kindness meditation is consistent with the larger body of literature on CAM-use among veterans, which indicates that veterans use CAM at high rates. Dissatisfaction with reliance on prescription medications and neglect of social and spiritual aspects of health have been identified as factors leading to CAM-use among veterans...
Loving-kindness meditation is postulated to represent another form of teaching mindfulness and acceptance. Recently, there has been increased interest in mindfulness and acceptance-based approaches to PTSD (Kearney, McDermott, Malte, Martinez, & Simpson, 2012a, 2012b; Kimbrough, Magyari, Langenberg, Chesney, & Berman, 2010; Niles et al., 2012; Orsillo & Batten, 2005; Walser & Westrup, 2007), though data from large-scale randomized controlled trials are lacking.
A commonly cited operational definition of mindfulness is “the awareness that emerges by way of paying attention on purpose, in the present moment, and nonjudgmentally to the unfolding of experience moment by moment” (Kabat-Zinn, 2002, p. 732). Mindfulness instructions encourage an approach-oriented attitude, rather than avoidance, of distressing thoughts and feelings, which for people with PTSD, may have the potential to lead to reductions in avoidance behaviors over time (Vujanovic, Niles, Pietrefesa, Schmertz, & Potter, 2011). Whereas traditional mindfulness practices are thought to facilitate acceptance through nonjudgmental observation of the breath, thoughts, emotions, and bodily sensations, the use of personally meaningful phrases setting the intention of safety, happiness, health, and ease for oneself and others appears to constitute a viable alternative that merits further evaluation.
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(Foa & Riggs, 1993).