Integrative Therapy Approaches for Posttraumatic Stress Disorder: A Special Focus on Treating Veterans

Mindfulness is widely used in both healthy and diagnostically diverse clinical populations, which results in an increasing assortment of mindfulness-based interventions (MBIs) (13). Mindfulness is the process of paying attention in a particular way, on purpose, in the present moment, nonjudgmentally (14). Although there is a prior history of mindfulness teachers and practitioners in the West, mindfulness-based stress reduction (MBSR), an eight-week program of intensive mindfulness training originally intended to treat stress and chronic pain, is often credited with introducing mindfulness into health care, professional and education settings, and Western culture at large (15, 16). The recent explosion of interest in mindfulness is due in part to the timely confluence of two distinct epistemologies: that of an ancient Buddhist contemplative practice, and that of modern, empirically driven science, including the fields of medicine, health psychology, cognitive therapy, and neuroscience (17).

To operationalize mindfulness in empirical research, researchers have proposed a two-component model (18). The first component is the self-regulation of attention on one’s immediate experience, which allows one to note mental events in the present moment. The second component is the foundational qualities the practitioner brings to this attention: namely, a sense of kindness, curiosity, and acceptance of whatever arises. An understanding of the importance of both of these components is essential, because mindfulness is often incorrectly assumed to be either a “relaxation skill” or simply “concentration training.”

Clinical practice suggests that the multidimensional benefits of mindfulness training may uniquely address the vulnerability and maintenance factors of PTSD. Present-centered awareness and nonjudgmental acceptance may function as indirect exposure to trauma-related stimuli (internal and external) and reduce behavioral avoidance and physiological arousal while fostering emotion regulation and behavioral activation (19). An enhanced capacity for present-moment awareness diminishes the worry and catastrophic thinking associated with a mind focused on the future or the negative and regretful ruminations of a mind lost in the past.

Through direct experience, mindfulness training promotes a deep understanding that cognitions and beliefs are mental phenomena rather than facts. Hyperarousal and the behavioral components of PTSD are also positively affected, or dampened, by MBIs. Neuroscience findings, in both structural and functional magnetic resonance imaging, show that mindfulness training results in changes in the amygdala, hippocampus, and prefrontal cortex—structures directly involved with threat assessment, memory, activation of the fight-or-flight response, and discrimination between past and present (20, 21).

The mechanistic benefits of mindfulness are multidimensional in nature and include sensory, affective, and cognitive processes (22). These benefits include improvements in anxiety, depression, and psychological stress (23, 24); changes in immunological markers (25); lengthening of telomeres, reflecting cellular aging improvements (26, 27); and both structural and functional neuroimaging changes (28). Among veterans, MBIs have been found to decrease depression, anxiety, and suicidal ideation (29). The Veterans Affairs Evidence Synthesis Program concluded that the strongest evidence for positive effects of MBIs includes mental health, quality of life, well-being, somatic health, anxiety, depression, and chronic pain (30).

Recent reviews of clinical trials have found that MBIs may be useful in reducing PTSD symptoms, although most studies have not used contemporary methodological standards (31, 32). Additionally, trials have used several different MBI protocols and heterogeneous samples with varying levels of mean symptom severity. In the largest randomized controlled trial to date, Polusny et al. (33) investigated group-delivered MBSR, as compared with a nonspecific psychotherapy, in the treatment of PTSD. Results indicated that MBSR, as compared with the control, resulted in a greater reduction in PTSD symptom severity. However, the effect size was small, and several potentially confounding variables limit conclusions (e.g., MBSR nearly doubled the session time of the control; pretreatment PTSD severity was higher in the MBSR group than the control group).

Several benefits may result from using MBIs to augment evidence-based, trauma-focused psychotherapies that do not already emphasize mindfulness (19). First, mindfulness can assist with engagement, given that it is frequently a welcomed approach by veterans who are unable to tolerate or unwilling to engage with another modality. Second, mindfulness practices can facilitate preparation for engagement in trauma-focused psychotherapies, because learning to accept and tolerate the sensations, emotions, and thoughts as they arise may help patients to tolerate trauma content. Third, mindfulness approaches may boost adherence to treatment as patients make mindful choices to persevere through exposure and trauma processing. Finally, an MBI following the completion of a trauma-focused therapy for PTSD can help maintain commitment to further developing skills learned in treatment and provide additional relief from a sense of unease in the body that may remain.

It is important to note that not all MBIs are equivalent. A single mindfulness session is not an equivalent “dose” to that of MBIs supported by research (e.g., MBSR involves weekly 2.5-hour classes and daily practice of 30–45 minutes for eight weeks). Successful administration of a specific MBI requires a fully trained mindfulness teacher with a history of and ongoing commitment to his or her own personal mindfulness practice. Furthermore, clinicians teaching mindfulness to veterans are encouraged to directly address differences between military culture and the shift to a mindfulness-based approach. During deployments, service members may disconnect from affective experiences rather than become lost in feeling to deal with immediate threats and extreme stressors. In contrast, mindfulness encourages people to open up to an experience and shift from “doing” to “being.”

The word yoga means “union” or “to yoke” in Sanskrit, signifying the alignment of mind, body, and spirit that can be achieved through its practice. Although there are many different styles, yoga practice typically involves a combination of physical postures (asana), controlled breathing (pranayama), meditation (dhyana; intentional cultivation of awareness in the present moment), and yogic ethics and philosophy (e.g., yamas and niyamas). The relative emphasis on each of these components varies depending on the specific tradition being practiced.

The practice of yoga has been associated with improvements in depression, anxiety, and stress (34, 35). Yoga is also associated with physical health benefits, such as improved cardiovascular health, pulmonary function, and exercise capacity (36–38). Thus, preliminary research suggests that yoga is associated with good physical and mental health, with few to no side effects (39).

There have been several mechanisms proposed for the benefits of yoga, including decreasing oxidative stress (40) and change in cortisol levels (41), as well as increasing vagal tone (42), heart rate variability (43), levels of gamma-amino butyric acid (GABA) (7), and brain-derived neurotrophic factor (44). Yoga has also been associated with improvements in immune functioning (41) and down-regulation of the hypothalamic-pituitary-adrenal axis (7).

With respect to PTSD, it has been hypothesized that yoga’s benefits are attributable to restored balance in the autonomic nervous system (7). Yoga also appears to increase both parasympathetic nervous system (PNS) and GABA activity (7), addressing the overactivity of the sympathetic nervous system and underactivity of the PNS that often characterize PTSD. Yoga can also enhance interoceptive awareness (45), which has been linked with improvements in the emotion-regulation capacities that are often disrupted by PTSD (46). Furthermore, the effects of yoga may also be mediated by increased mindfulness and self-compassion (47), which can help trauma survivors approach symptoms with acceptance and potentially decrease reactivity and avoidance behaviors (48).

For clinicians, it is important that yoga is considered a possible adjunctive intervention for PTSD, as opposed to a foundational or stand-alone treatment. Although yoga may be particularly useful for individuals who find using movement to practice mindfulness helpful, yoga does not require rigorous physical activity or flexibility. Trauma-sensitive variations also exist, as do variations that emphasize restorative practices while minimizing movement to support participants with physical limitations (e.g., “chair yoga,” which allows the person to be sitting throughout the yoga session). However, these variations require that the yoga instructor has experience working with these techniques and populations (e.g., seated practices and trauma-sensitive yoga) (49). Although one session may be beneficial, multiple sessions of yoga are optimal to see the additive benefits.

Although many studies have assessed the effects of exercise on general health and well-being, only a select few have researched the effects on mental health, including anxiety and depression, and even fewer have assessed the effects on PTSD symptoms. Hall and colleagues (50) reviewed physical activity in relation to PTSD. They found that studies evaluating physical activity as a direct correlate or predictor of PTSD had inconsistent findings; however, some preliminary intervention studies reviewed suggested a positive effect of physical activity on PTSD symptoms such as anxiety and depression. For example, Rosenbaum et al. (51) found that a 12-week exercise program plus usual care reduced PTSD and depressive symptoms as well as improved quality of sleep, compared with a control group, among veterans and service workers with PTSD. Other research has shown a reduction in symptoms of PTSD, anxiety, and depression with the use of stationary biking (52) or aerobic exercises (53).

Several mechanisms have been proposed for the positive effect of exercise, which can be divided in two categories: psychological and biological. Psychological variables include increased autonomy, improved physical well-being, enhanced quality of life, and increased self-esteem and mood (54, 55). Biological variables include several growth factors (e.g., brain-derived neurotrophic factor) and neurotransmitters (e.g., β-endorphins, vascular endothelial growth hormone, fibroblast growth factor 2, insulin-like growth factor) that have been implicated in the role of exercise-induced neurogenesis and its positive psychological effects (56–59).

The standard dosing of exercise for physical health benefit according to the American College of Sports Medicine has typically been 150 minutes per week of moderate-intensity exercise, or approximately 30 min on five days per week (60). Studies with PTSD have yielded similar results for exercise recommendations (61, 62). It also is recommended that people receive medical clearance before starting an exercise regimen and that they begin any exercise program slowly and gradually increased. Too often, people can become motivated to make a lifestyle change and then set unrealistic goals that are difficult to achieve. Setting smaller, more achievable exercise goals (e.g., walking a few days per week for 20–30 minutes) is important, as is encouraging participants to continue with their usual treatment. For some people, using phone applications or wearable devices (e.g., actigraphy and GPS watches) helps them track their progress and motivates them to increase their weekly exercise, although a 2013 survey of Fitbit users found that only one-third of participants continued to wear theses devices after six months (63). Given the importance of exercise to boost mental and physical health, and given promising data specific to PTSD, clinicians should attempt to speak with all of their patients about increasing their physical activity.

According to a recent survey conducted by the Wounded Warrior Project, obesity has emerged as a significant, growing health concern among returning veterans, particularly those with PTSD symptoms and depression (4). Maguen et al. (64) found that 75% of post-9/11 veterans were overweight or obese at baseline and that those with PTSD symptoms and depression “were at greatest risk of being either obese without weight loss or overweight or obese and continuing to gain weight” (p. 563). For veterans, one of the riskiest times for weight gain is immediately following discharge; this is a very stressful time, and stress is linked to poor diet (65). Thus, the transition from the active, structured military lifestyle to an unstructured, often sedentary civilian one can be a struggle for former service members who are trying to maintain healthy weight and physical fitness levels.

A review of observational studies found conflicting results regarding the association between PTSD and binge-eating disorder or binge-eating behavior, with several studies reporting significant associations between PTSD and binge-eating disorder or binge-eating behaviors and several reporting no such associations (50). PTSD has also been associated with emotional eating or eating as a response to experiencing negative affect (66). Although a direct correlation between dietary intake and PTSD cannot be established without further research, current studies may suggest a role for eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), or fatty acids that are omega−3 fats, in the treatment of PTSD symptoms such as depression.

A review conducted by McNamara (67) evaluated the role of omega−3 fatty acids in the etiology, treatment, and prevention of depression. Greater habitual intake of EPA+DHA was found to be associated with reduced risk for developing depressive symptoms and mild depressive disorder. This is further supported by the finding that lower levels of omega−3 fatty acids are present in patients with major depressive disorder (68).

Although it is unknown whether supplements help with PTSD symptoms, one study found that a 12-week omega−3 fish oil (70% DHA and 7% EPA) supplementation improved PTSD symptoms among female medical-assistance team workers (69). A possible mechanism of omega−3 fish oil on mental health, similar to yoga and exercise, may be increased serum brain-derived neurotrophic factor levels (70), which are associated with reduced depression severity. There is also some evidence that plants may have anxiolytic effects (71). In particular, kava and galphimia have the most evidence, with promising data for passionflower, gotu kola, chamomile, skullcap, roseroot, ginkgo, ashwagandha, echinacea, Iranian borage, lemon balm, and milk thistle. Further evidence is warranted to better understand the potential role of herbal remedies for anxiety.

To encourage overall brain health (e.g., neurogenesis) through nutrition, clinicians should consider several important recommendations for their patients, on the basis of research conducted in the fields of dementia and cardiovascular disease. For example, patients should be encouraged to consume two servings per week of green leafy vegetables (e.g., kale, spinach, broccoli, collards), five ounces per week of nuts (which contain healthy fats, fiber, and antioxidants), one cup of berries two times per week (e.g., blueberries, strawberries), one-half cup of beans three times per week (because they are high in fiber and protein and low in calories and fat), three servings per day of whole grains (they are high in fiber and have beneficial B-vitamins), a serving of fish at least once a week, and two servings weekly of white-meat chicken or turkey (72). Patients should also be encouraged to eat red meat, butter and stick margarine, cheese (no more than two ounces per week), pastries and other sweets, and fried foods and fast foods (ideally no more than once per week) only in moderation (72).

Acupuncture, qigong, and Tai Chi are Eastern disciplines originating in China. Chinese scholars believe acupuncture and qigong to be somewhere between 2,000 and 5,000 years old, with Tai Chi having emerged more than 600 years ago. There is increasing evidence that these modalities may be beneficial for common comorbidities of PTSD (e.g., pain, sleep, migraines) as well as depression and anxiety.

Acupuncture, typically administered over several sessions, is the insertion of needles into the specific acupoints of the body that are thought to activate the body’s innate healing mechanism and restore balance (homeostasis). Evidence suggests the clinical efficacy of acupuncture to modulate the limbic system (73), improve sleep quality (74), decrease cortisol levels (75), release endogenous opioids (76), decrease inflammation (77), and regulate neurotransmitters (78). Reviews of the literature suggest that acupuncture may also help to improve headaches, anxiety, sleep disturbance, depression, and chronic pain (79–82). For example, battlefield acupuncture is a single-limited procedure using the ear acupuncture technique, or placement of five semipermanent gold needles in specific locations of the ear. This treatment has been shown to be feasible, acceptable, and associated with reduced pain among veterans (83–85). Preliminary evidence also suggests that acupuncture may be beneficial for PTSD symptoms (86, 87).

Qigong is a mind-body discipline, an energy cultivation method for therapeutic and health promotion (88), and the foundation of traditional Chinese medicine (89). In recent years, studies have shown the benefits of qigong for reducing oxidative stress (90), improving blood lipid metabolism (91), and preventing bone loss (92), as well as improving mood and sleep (93), cognitive function (94), and emotional regulation (95–97). Only a few studies have examined the use of qigong for PTSD, but one found that qigong was associated with reduction in PTSD symptoms (98).

There are varying standards for qigong practice. The general recommended dosing is 30–60-minute sessions daily or two to three times per week in a group setting to enhance therapeutic response. Individuals are encouraged to practice on their own daily for at least 30 minutes to gain positive benefits. A randomized study of 41 participants found that practicing qigong for 30 minutes was sufficient to provide psychological benefits on mood and emotions (99).

The emphasis of qigong is on the breath and coordination between the mind and body, which makes this modality available to a broad range of participants. However, there are numerous styles of qigong with varying degrees of rigor; thus, clinicians must assess patients’ abilities to select a qigong style most appropriate for them. Although outdoor practice in a clean, peaceful, and natural environment may be preferred, there is no evidence to suggest indoor practice is less effective. To find a qualified instructor, one should seek a referral from acupuncturists or qigong organizations and associations (100).

Tai Chi is a form of martial arts that involves more weight bearing and strength training than yoga and a wider range of coordinated movements than other aerobic exercises. The practice of Tai Chi involves focusing the mind solely on the movements of the form, which helps to bring about a state of mental calm and clarity. Studies show that those who practice Tai Chi have improved balance, reduced fear of falling, and decreased risk of falls. A study of 17 veterans with PTSD who had four sessions of Tai Chi reported having fewer intrusive thoughts, less difficulty concentrating, and less physiological arousal (101).

Art therapy has a long history of being used as an adjunct treatment for veterans. The American Art Therapy Association documented its use in 1945 to treat veterans, and, since then, veterans have reported experiencing emotional relief from the creative expression facilitated by a trained art therapist. Art therapy provides an impetus to uncover, process, and integrate memories and emotions that might otherwise remain inaccessible or too difficult to vocalize (102–104). The art in art therapy offers a unique opportunity not found in traditional talk therapy. Engaging in the creative process with art materials offers the unique opportunity for a therapeutic dyad (therapist-client or art-client), which patients consistently report to be helpful across clinical populations (103, 105).

Emerging data on how traumatic memories are stored in the brain suggests that art therapy may assist in retrieving traumatic memories (103, 105). For example, neuroimaging studies have implicated prefrontal regions of the brain, including subcortical regions, in the pathophysiology of traumatic stress as well as during recall of traumatic memories (106). Nonverbal expressive therapies, such as art, activate these regions and access preverbal memories (107).

Art therapy may also be useful for veterans, because this sensory-based therapeutic intervention has been shown to help veterans engage in treatment (104, 108). For example, the creation of masks (i.e., papier-mâché depictions of patients’ emotional and physical state) has been credited with “revealing things beyond the reach of the most high-tech neuroimaging machine” for veterans (109; caption under image 3). Adjunctive art therapy may also help in decreasing symptoms of PTSD. One study found that art therapy in conjunction with cognitive processing therapy improved combat veterans’ trauma processing, because it promoted “healthy distancing, enhanced trauma recall, and increased access to emotions” (108; p. 169). Other studies have found that art therapy helps PTSD patients to organize and integrate their traumatic memories, improve their social relationships, and reduce feelings of avoidance (i.e., intrusive thoughts and emotional numbing; 102, 103). Thus, art therapy has been recommended as an adjunct treatment for PTSD and is currently used in the Veterans Administration to treat veterans (102–104). Researchers have also recommended that therapists conduct individual art therapy sessions with veterans to encourage authentic participation and provide a more personalized experience, as well as to avoid mixing military ranks, which often occurs in group settings and can stifle participation (104).

Largely, evidence suggests that art therapy may help to relieve PTSD symptoms among veterans and, more broadly, traumatized adults; however, the data remain largely qualitative and hampered by methodological limitations (102, 103, 108, 110). Although future studies are required to better understand the unique benefits of art therapy for specific clinical populations, art therapy appears to provide stress relief, improve quality of life, and support successful treatment outcomes for veterans.

Compared with previous conflicts, the post-9/11 military long has been identified as having unique circumstances. Unlike the conscript military of the Vietnam War, when rotational tours of duty for enlisted personnel were generally limited to one year, the current era has an all-volunteer military with many service members who experienced multiple and often long (in excess of 24 months in a single deployment), stressful deployments—the outcomes of which resulted in complex physical and psychological injuries (111). The aggregate of these adverse health consequences is seen in complex comorbid conditions, such as PTSD, traumatic brain injury, depression, substance abuse, chronic pain, and headaches, among others.

Managing these complex comorbid conditions in environments where health care resources are limited and existing clinical care has little variability, few first-line treatment options, and even fewer nonpharmacotherapy options is challenging at best and leaves many veterans demotivated to address their own health care. The concomitant, and often overlapping, symptoms associated with PTSD and these comorbid conditions suggest the need for integrative modalities as a comprehensive adjunctive treatment model. Given the multitude of symptom combinations that may be manifested by a veteran with PTSD, it follows that stand-alone treatments may not be effective to treat all the potential symptom combinations present with this highly individualized disorder (9). Thus, including integrative therapies in support of the gold-standard conventional treatments for PTSD provides increased opportunities to target comorbid symptoms not addressed by conventional treatments; increases opportunities to promote self-management and self-care skills (112); and provides opportunities to absorb, process, and retain gains achieved with exposure-based and cognitive-based therapies.

Despite the limited number of rigorous scientific studies examining the efficacy of integrative modalities, a growing literature shows much promise for their additive benefit to conventional treatments for PTSD. For example, long-term practice of mindfulness has yielded positive neurological changes associated with hyperarousal, memory, and threat assessment among individuals with PTSD (20, 21). Furthermore, mindfulness may provide veterans the opportunity to be better prepared for trauma-focused therapies, increase treatment compliance, and enhance mind-body awareness, while decreasing the effects of chronic physiologic arousal and hypervigilance. Physical activity and nutrition address the often-comorbid conditions to PTSD, including chronic pain, obesity, and depression. Exercise affects neurogenesis—a direct impact on overall brain health (53, 113).

Yoga also holds promise for PTSD, given its roots in mindful movement and its effect on the autonomic nervous system, or its ability to correct imbalances known to be associated with PTSD (7). Similarly, acupuncture may play a role in reregulating the autonomic nervous system after trauma (114) as well as treating the pain often experienced by combat veterans (74, 82). Qigong and Tai Chi may also assist in managing PTSD symptoms, given their positive effects on intrusive thoughts, concentration, and psychological arousal among veterans (86, 87, 98). Finally, art therapy, one of the oldest integrative health modalities applied to the treatment of veterans, has been associated with a reduction in symptoms of PTSD (102, 103, 108).

In sum, there is a burgeoning literature on the effectiveness of integrative health models as adjunctive treatments for PTSD, in addition to decades of collective clinical experience and patient testimony supporting their use. Moreover, these modalities show few to no negative side effects, as compared with side effects of psychopharmacology for PTSD. Thus, it is recommended that clinicians treating PTSD become familiar with local reputable resources with well-trained practitioners who offer these adjunctive integrative modalities to support their clinical work.

However, there remains insufficient evidence to conclude that integrative therapies as stand-alone treatments are effective in the treatment of PTSD. Thus, there is a need for further systematic and robust clinical trials to investigate the dosing, timing, and sequencing of these therapies, as well as the heterogeneity of previously reported treatment effects, to understand who might benefit from which modality and why. These data are needed to better guide clinicians on how to recommend these modalities and to whom.