Trauma-Sensitive Mindfulness for War Refugees: Communication of Preliminary Findings

Round 1

Reviewer 1 Report

The article was exceptionally well written with good sound neurological information as a framework. I feel that this method has much potential and can be used in various situations. The author has captured the essence of this and clearly noted the worthiness of this technique. Well Done.

Author Response

Dear Reviewer 1

Thank you for your feedback. I have noted that the recommendations were for minor spell checks. These have been attended to.

Regards,

Veronica

Reviewer 2 Report

Mindfulness therapy is nowadays one of the most popular interventions used by a psychologist in almost every field. Hence, the issue discussed by the authors is current and important.

Review articles should be based on a systematic review of the available literature on the subject with a systematic search in Google Scholar, Web of Science, PsycARTICLES, SocINDEX, etc. The lack of a systematic review based on the systematic search makes the work not very reliable and, in my opinion, unsuitable for publication. Especially as in the literature there have already been attempts to present a mindfulness literature review – thus the paper also lacks originally (example in 2013 Khoury et al., published a meta-analysis about mindfulness psychotherapy; Allen et al. did similar work in 2006; Banks et al., 2015 and Boyd et al., in 2018 reviewed its effectiveness applied for PTSD patients and many other papers have already described similar issue).

Detail Comments:

There is an unusual beginning for the theoretical manuscript as the authors started the introduction with a description of the Syrian refugees' dramatic situation. Although it is important, this was not the suggested aim of the paper. The introduction is very short and should be more related to the discussed subject. The structure of the paper should be here presented.

The paper needs a clearly described aim with a scientific explanation for exploring the literature from this field.

There are at least 33 definitions of mindfulness (see Niellson et al., 2016) what was the criterium to choose definitions by Knight, or Kabat – Zin and ignoring the rest of them? Why you only focused on Mindfulness meditation definitions?

The authors very briefly described mindfulness interventions e.g. the mentioned IBMT or MBSR without explaining  what they are and how they differ – which in my opinion should be the key of this paper from the point of view of the title of the paper

Moreover, I do not understand what you have presented in tables 1 and 2 elements taken from the systematic  review made by Nocon et al. especially as she did not review mindfulness interventions

The discussion section is for discussing the issue presented in the main body of the text, however, the authors did not meet this criteria, they have presented new definitions irrelevant to the discussed subject e.g. by Brown and Ryan, or some information is important and relevant however have not been presented in the body of the text lines 471-478

Similar comment to the conclusion section

The references are old and need to be refreshed (most are older than 4-5 years ago)

Small editorial errors should be corrected

Throughout the paper, the authors sometimes used an informal language style typical for popular science e.g. lines 95-100

some expressions used in the text lack proper references e.g. lines 95-100; 155-9; 362-368

Editorial errors should be corrected “Error! Bookmark not defined„ - Line 347  

Author Response

Dear Reviewer 2

Thank you for your feedback and input. They have been most welcomed. Please find attached the responses to the review.

Regards,

Veronica

Author Response File: Author Response.docx

Reviewer 3 Report

traumacare-1933339-peer-review-v1

This article is an interesting and thorough introduction to trauma-sensitive-mindfulness (TSM) and is an excellent summary of the history of mindfulness and its application to anxiety and potentially to war-trauma-related PTSD in refugees. In describing the actual effects of mindfulness on mind and brain states, it would be of value to contrast this with what is known about the effects of evidence-based treatments such as CBP or CPT, which are actively used to treat war trauma-related PTSD in the US Veterans with much success:

“Mindfulness-based interventions teach us how to pay more attention to what is happening in us and around us so that we can be more aware of emotions and behaviour instead of feeling like emotions and thoughts dominate our behaviour.  Through  mindfulness intervention, the identification of when emotional states or feelings of distress are most intense is achievable. Tolerance helps us accept the moment until our emotions  pass or reduce in intensity and we are better able to use other skills.”

For example, with CBT or CPT, do we also become more aware of thoughts and emotions and do these therapeutic approaches allow us to separate ourselves and not be driven or be triggered by these intrusive thoughts and related emotions? Similarly, in acceptance and commitment therapy (ACT), what is our relationship to thoughts and emotions? This reviewer thinks it would be of value to compare and contrast how these evidence-based therapies differ or are similar to TSM. Are there major differences? What are they? How is TSM potentially of more value in a refugee camp setting than evidence-based CBT, CPT, ACT or other well-examined therapies. Or do they really offer the same result ultimately? Or is it really the relationship forged between therapist and war-traumatized refugee that is the most important factor in the future outcome of that individual.    

“A further conceptualisation of mindfulness proposed a two-component model. One component involves self-regulation of attention to the experience of the present moment,  and the other involves adopting an orientation of openness and acceptance toward one’s experience [7]. Therefore, these interventions teach mindfulness skills to increase intentional attention, develop a different relationship with one’s thoughts and practice different strategies in relation to distressing thoughts and emotions in a non-judgemental way.”

“Mindfulness-based interventions teach us how to pay more attention to what is happening in us and around us so that we can be more aware of emotions and behaviour instead of feeling like emotions and thoughts dominate our behaviour. Through mindfulness intervention, the identification of when emotional states or feelings of distress are most intense is achievable. Tolerance helps us accept the moment until our emotions pass or reduce in intensity and we are better able to use other skills.”

Again, how does the above statement about mindfulness differ fundamentally from the outcomes of CBT, CPT, ACT or other evidence-based therapies--therapies that are in regular use as part of the treatment plans for war-traumatized veterans suffering from PTSD? Is there a fundamental difference between civilians and children exposed to war trauma versus veterans in the underlying changes in mind and brain and the associated PTSD they experience?

The authors make a careful and thorough investigation into the extant literature, but given that war trauma and associated PTSD, as highlighted by the authors, certainly has the same underlying neural basis, and the same brain structures, circuits and nuclei are involved in arousal and hyperarousal, nightmares, flashbacks, sustained fight or flight response, etc., it is unclear that war traumatized refugees would not express the same or very similar symptoms to war veterans returning home, many to questionable living circumstances, with high levels of homelessness. There is a tremendous literature on veterans experiencing PTSD in the United States for example, available at the National Library of Medicine and associated PubMed database, and the US Veterans Administration has launched a variety of Whole Health Strategies (https://www.va.gov/wholehealth/

), and the work of individuals such as Ben Kligler, MD, MPH, Executive Director for the Office of Patient Centered Care and Cultural Transformation, Veterans Health Administration, where a variety of conventional, complementary and integrative health strategies are implemented, including mindfulness-based approaches, CBT, CPT, insight meditation, body scan techniques (https://www.youtube.com/watch?v=UINFbJLuSPg). Importantly, the US Veterans Health Administration approaches trauma from a multiple systems approach, where a variety of techniques might be provided, including mindfulness-based stress reduction, tai chi, qigong, acupuncture, body scan, group therapy approaches, meaning-based therapies, yoga, combined with conventional medical care. And in this paradigm, care is also individualized to each person, is patient-centered, and values based. The point of this reviewer, and as the authors point out, many of the manifestations of war trauma-related PTSD have a significant somatic component, and many behavioral therapists believe this must be addressed through multiple interventions, including mind-body approaches like trauma-sensitive mindfulness, mindfulness-based stress reduction, tai chi, gigong, bodyscan, guided imagery, art and music therapy, along with other evidence-based approaches like CBT or CPT. So this reviewer would like to ask these authors if they imagine a single intervention or a “program” of mind-body interventions that is personalized to each individual, and would address from a multifactorial perspective the vagus nerve response, the autonomic nervous system tonic changes in the body, the brain circuits and pathways discussed that are altered due to PTSD-related war trauma, etc. Importantly, there are 18 national demonstration projects funded with millions of dollars from the US Veterans Administration to collect data and evidence on these multifactor therapeutic approaches to war trauma and PTSD, and that literature is expanding quickly.  

This reviewer was also surprised that the historic and enormous lifetime body of work on trauma, especially trauma and associated PTSD in children, of Bessel van Der Kolk, MD, is not cited in this review. Given his enormous contribution to this field, including developing validated international diagnostic criteria for assessing childhood PTSD and examining a variety of therapies to treat adults and children experiencing trauma-related PTSD, and his continued research in this specific area and on a variety of therapeutic approaches, including many mind-body and other approaches (including MDMA, yoga, neurofeedback, hypnosis, eye movement desensitization and reprocessing, brief eclectic psychotherapy, etc.)—it is difficult for this reviewer to understand why this work has been left out. Given that Bessel van der Kolk has also written extensively on the risks of re-traumatization that can occur with particular therapeutic approaches, it appears again that his work is highly relevant to the discussion in this monograph.

Line 5 and 6: please specify more information, (e.g., what department and what school are you located in at the University of Johannesburg).

Figure 1: 4th panel on the right please correct the date for Dialectical Behavior Theory, assuming it is 1993, NOT 81993)

Line 219-220: The following statement about the structure known as the amygdala seems naïve in that many brain circuits, brain nuclei and other brain regions are involved in the stress response and associated anxiety and fear. The amygdala is associated with negative emotional affect and association, emotion regulation, fear conditioning (especially auditory fear conditioning), danger salience, and many other phenomenon, but may also be involved in positive reward mechanisms (PMID: 15082318) and thus a decrease in the volume of the amygdala does not provide definitive evidence for decreases in fear, anxiety and stress. “Decreases in brain cell volume in the amygdala, were also evident, which is responsible for fear, anxiety and stress.”  The authors should be cautious not to make overly simplistic statements about incredibly complex brain structures that are deeply integrated and interconnected with numerous other brain regions, circuits and nuclei that never function in isolation. There are even reports of increases in amygdala volume that is associated with an MBSR program and that is not bilateral (PMID: 33249071). So again, we should be cautious about overly simplistic statements when referring to incredibly complex bilateral brain structures. We should also make sure that we have done our scholarship in terms of examining the current PubMed and Embase and other major database for the most recent publications in this field, especially in the neurosciences, which has advanced at an incredibly fast pace over the last 30 years.

Similarly, the statement about the hippocampus governing learning and memory is a tremendous oversimplification, and once again there are literally thousands of research monographs pointing out the many subtleties of the hippocampus role in place-based spatial memory, memory consolidation, short term memory, pattern separation; but also in emotion regulation, fear, anxiety (PMID: 32700828) and stress, and many of these functions belong to unique structures within the hippocampus (dorsal, intermediate and ventral) (PMID: 20152109). “The study reported that eight weeks of mindfulness-based stress reduction (MBSR) was found to increase cortical thickness in the hippocampus, which governs learning and memory,” Thus, an observed increase in volume may have many implications for hippocampal function and how MBSR may be modifying these hippocampal functions and their relationship to many other brain structures and circuits is totally unclear.

Line 345: Please fix reference here: “Brown et al. [Error! Bookmark not defined.] point out that mindfulness awareness”

Line 370-372: “According to Siegel [38] (p. 113), “Neuroplasticity is the term used to describe the capacity for creating new neural connections and growing neurons in response to experience.” It occurs throughout the lifespan as we are consistently exposed to experiences.” The reality is that modern neuroscience has demonstrated a VERY limited capacity in adults for the creation of new neurons and new neuron generation is restricted to just a few places like the hippocampus and the olfactory bulb, and even that is still debated in the current literature, for example with intense exercise training in rats. Hebbian rewiring does appear in adults and is much more broad with respect to brain structures. So to suggest broadscale new neuron generation is at odds with modern neuroscientific investigation.

Line 499: “indicated that CBT and IPT showed capable results that need further replication.” Not sure what capable results refers to and perhaps this is specific to South African English. Do the authors mean effective?

Finally, although the review of the origins of mindfulness is interesting, the historical background leaves out significant parts of this history, such as the explosion of interest in Eastern philosophies and associated mind-body practices in the 1960s with the arrival of the countercultural revolution (including Qigong, Tai Chi, Transcendental Meditation, Chakra Meditation, numerous Yoga traditions, breathwork and other breathing techniques, various martial arts forms from many East Asian cultures, Buddhist meditation and other practices, etc.). Also the arrival of roshis, gurus, senseis, Buddhist monks, and many other expert practitioners and scholars from these Asian cultures to Western shores; and the travel of many Westerners to these cultures to apprentice and learn these many techniques and bring them to the US and Europe in the 1960s. One need only mention books like The World’s Religions (Houston Smith), The Web that Has No Weaver (Ted Kaptchuk), The Relaxation Response (Herbert Benson), The Natural Mind (Andrew Weil), Zen and the Art of Motorcycle Maintenance (Robert M. Pirsig), The Book (Alan Watts), all the work of D.T. Suzuki who is a titanic figure in bringing Eastern philosophies to the West  long before Jon Kabat-Zinn, The Tibetan Book of the Dead (W.Y Evans-Wentz), The Dancing Wu Li Masters (Gary Zukav), Light on Yoga (B.K.S. Iyengar)—this is just a fraction of the literally thousands of books and monographs published on many mind-body practices long before the arrival of Mindfulness-Based Stress Reduction. Similarly, the tremendous influence of Eastern philosophy and practices on individuals like Carl Jung, Herman Hesse and other monumental figures shaping modern Western culture suggests that it may be best to leave out Figure 1 and avoid altogether the history of mindfulness given the extremely thin timeline presented. Or perhaps it is best just to leave the discussion in the text of clinical applications of mindfulness with the already brief mention of the origin of mindfulness. It is also important to note that Jon Kabat-Zinn himself learned about mindfulness from Zen masters who came to the US, thus even his ideas come purely from traditional Asian sources (this is noted in his books and tapes), thus the influence of the East has continued for many decades and continues to this day both in Europe and the United States. Perhaps the timeline could just focus on direct incorporation into clinical practice settings in psychology.

Line 118-120: “The diagram (Figure 1) below provides a timeline which indicates the transition of mindfulness from its origins to the present application of the practice.” Again, this is an oversimplification. Traditional Asian philosophy, practices and medicines continue to thrive not just in conventional psychology but throughout European and US culture in their ORIGINAL forms, and innumerable psychologists and psychiatrists continue to benefit from the traditional and ancient practices of Zen meditation, Taoist practices, qigong, tai chi, breathwork, yoga, traditional Chinese medicine, Reiki, Insight Meditation, Transcendental Meditation and many other healing modalities.  So again, it is best to stick to clinical adaptations of these traditional mind-body practices such as “mindfulness.”

Author Response

Dear Reviewer 3,

Thank you for your feedback and input. It has been most welcomed. Please find attached the responses to the review comments.

Regards,

Veronica

Author Response File: Author Response.docx

Round 2

Reviewer 2 Report

The authors stated in their response that the introduction section has been corrected following my comments. With regret, I must say that the comparison of the original and current versions shows that very little has been changed in it. It still insufficiently introduces the subject. Next comments were also briefly introduced e.g. the authors presented the systematic review results made by Nocon et al. and I suggested deleting it and making a more systematic review however the authors only widened the study aim, however without changing the title which suggests “review of mindfulness interventions”. Also, editorial errors are still in the paper.

Author Response

Dear Reviewer,

Thank you for the feedback. Please find attached the responses. The corrections can be viewed in the track changes document

Author Response File: Author Response.docx

Reviewer 3 Report

Second Review MDPI Traumacare Manuscript 19333

Figure 1 Panel 5, Please correct “Linehan, 81993’ TO “Linehan, 1993”

Line 201: Please change “Referring to the fourth noble truth” to “Referring to the fourth noble truths”

Line 376-377: Please replace “Van der Kolk supports a variety of therapeutic approaches”  with “Van der Kolk’s research has explored a variety of therapeutic approaches”

Line 386: Please correct: “[Error! Bookmark not defined.]”

Line 434: Replace “ie increased perception of internal states” with “e.g., increased perception of internal states”

Author Response

Thank you for the English language and style are fine/minor spell check reviews. These have now been attended to.

Editorial corrections for the following have been attended to:

Figure 1 Panel 5,  “Linehan, 81993’ CHANGED TO “Linehan, 1993”

Line 201:  “Referring to the fourth noble truth” CHANGED to “Referring to the fourth noble truths”

Line 376-377: “Van der Kolk supports a variety of therapeutic approaches” REPLACED with “Van der Kolk’s research has explored a variety of therapeutic approaches”

Line 386:  “[Error! Bookmark not defined.]” REPLACED with Brown et al. [9]

Line 434:  “ie increased perception of internal states” REPLACED with “e.g., increased perception of internal states”

Author Response File: Author Response.docx