It is Tuesday afternoon, at three o’clock and four unlikely students of “mindfulness meditation” are relearning how to breathe. Instruction in being more mindful is everywhere these days, particularly in the Bay Area. So I could have been sitting through a similar training in Berkeley with a group of 60-something women with crinkling faces, flowing gray hair, and a history of New Age enthusiasms. Or I could have been on Valencia Street in San Francisco, epicenter of that city’s techie take-over, where whiz kids in their twenties and thirties are coping with long hours in Silicon Valley at a studio with a website called stressreductionatwork.com.
The 12-week mindfulness training I am attending takes place in a distinctly different setting, however. It’s held in a corner conference room in Building Number 8, the Behavioral Health Building, at The San Francisco VA Health Care System at Fort Miley and led by clinical psychologist Susanna Fryer and psychology intern Ian Ramsey. The group of veterans in their fifties and sixties who’ve come to Fort Miley are not here only for an intellectual or spiritual exercise. For some of these men, becoming better able to control their thoughts and anxieties through mindfulness is literally a matter of life or death.
Dressed in spanking fresh jeans, and starched white shirt, Harvey holds himself steel rod straight. He speaks deliberately, each word clipped, sharpened as if surrounded by a barbed wire and warning signs advising people to keep their distance. His cross to bear is Obsessive Compulsive Disorder (OCD), also depression and ten years of being homeless.
Ronald, an African American veteran is almost his opposite, supple, fluid, and easy with jokes. Yet, he has experienced similar struggles with homelessness, poverty drugs, and divorce
James has suffered for years from a panic disorder. He will find himself in a supermarket or on a bus and suddenly, he is overwhelmed with anxiety. He feels he has to get out or he will quite literally die. There have been times when he has run out of the room screaming in fear. These panic attacks have been with him since he was 22 and was raped during a hazing ritual on a ship when he was in the Navy. He is now in his late fifties. For over thirty years he has self-medicated with drugs and alcohol. He lost job after job and lived on the streets.
Finally, there is Jose who is a Vietnam vet who has PTSD and is plagued by nightmares and has trouble with sleeping. A divorce tipped him over the edge and after 20 years managing without treatment, he went into a spiral of alcohol abuse that led to homelessness before he finally came to the The Veterans Health Administration (VHA) for help.
All of these men struggle just to get from day to day. When they talk about intrusive thoughts, it’s not about the boss who wants them to work morning noon and night or what diet they should choose, Paleo or gluten free. The things that are a struggle for me – impatience standing in line at the supper market or a ten minute wait on hold with some clerk at my doctor’s office, are not just some of life’s minor, albeit often infuriating, frustrations. For these men, they are triggers that can send them over a line into a tailspin from which it can take years to recover.
When they talk about difficult relationships, “negative people,” as Ronald describes them, they are talking about a whole lot of people who have ripped them off (or who maybe they have ripped off) who have knives, and guns, and needles, and bottles into which they can disappear for months at a time.
In many media articles on the Veterans Health Administration, reporters talk about veterans’ frustration with wait times. Those of us who do not have these problems, naturally assume, ‘oh these guys were frustrated because they had to wait weeks, months to get help.’ And maybe that was the case. But I have learned that, to someone with PTSD, or a traumatic brain injury, or panic disorder or all three, an intolerable wait can be 15 minutes, not 15 weeks. It could be standing in line for five minutes not waiting for an appointment for five months.
Susanna Fryer, who facilitates mindfulness-based stress management groups at the SFVAHCS explains that her work is largely based on pioneering program development by mindfulness advocates including Jon Kabat- Zinn, Zindel Segal and others. The Fort Miley programs, (programs which are available at many VHAs across the country) which combine mindfulness and cognitive-behavior therapy principles, usually have eight to ten veterans per group. Unlike private sector programs run on a fee-for-service basis, the VHA’s will continue even if some vets drop out. Not all veterans who are referred to the mindfulness program have mental illnesses, Fryer adds. Some with heart disease, for example, or dealing with cancer treatment, may be referred to lower their stress levels. Others may be in chronic pain.
Whatever their reason for coming, mindfulness training is part of an integrated approach that includes other therapies. The men in the room may have done Cognitive Behavioral Therapy for Psychosis, or PTSD or depression or anxiety. They have done group therapy or had an in-patient hospitalization. Some are also taking psychiatric medications.
The mindfulness stress management group, Fryer explains, can complement other treatments. In sessions that build upon one another, veterans learn, and begin to practice, skills that can be used in their daily lives to help them stay connected socially, manage stress, and create healthy habits that will help them be less reactive in ways that can lead to problems at home or at work.
The idea here is to begin accepting the thoughts that intrude as you concentrate on breath in, breath out, eating a raisin, or learning not to focus on people whom you can hear talking through the open window. The goal is to help patients learn to distinguish between the points of the triangle that Fryer always draws on the conference room’s whiteboard before she begins each session. At the apex of the triangle is the word “thoughts.” At the base, the line connecting to the left edge leads to a point at the base where she writes the word “feelings” Across the bottom another line links feelings to “behavior.” Thoughts produce feelings –- anxiety, depression, anger — which in turn lead to behaviors that can be destructive and dangerous – to ourselves and others. Mindfulness techniques which teach people to tune in to their present-moment experiences can help people understand that a thought is not reality and that feelings don’t have to lead to destructive behavior.
For example, in one of the sessions I attend, she asks the men to imagine a situation. “You’re walking down the street and someone cuts you off. What might be the thought that runs through your head?”
“Get out of my space,” Ronald says. “What a jerk, I should have brought my gun.”
“I should tell him off,” Harvey volunteers.
“This person doesn’t know you,” Ian Ramsey suggests.
“Let’s workshop each of these thoughts,” Fryer proposes. “What are you feeling when you think, ‘get out of my space?’”
“Agitated, angry, I feel nervous when people get in my space, nauseous even.” Ronald explains.
“Retaliation,” Harvey adds.
“Like you’re entitled?” Fryer probes,” This is my space.”
The men continue to explore, discussing the rudeness they see everywhere today in San Francisco, the sense that they constantly need to be on the defensive, and even to act to defend themselves. As they go deeper, they recognize and discuss the stress response, the lingering impact it has on their mind and body. After further discussion, Fryer asks them to consider the cycle – something happens, a thought emerges, and then influences what they feel and do. “With mindful awareness of your thoughts,” she reminds them,” you have other choices.”
“That’s what I like about this class,” James says,” I’ve got choices I never had before. I get to think about things not just react. I was at the pharmacy and had to wait and line and got all agitated, now I can breathe through it, instead of reacting like I used to, storming off, furious.”
Fryer introduces the acronym HALT, to discuss common stress triggers and what happens when people are Hungry, Angry, Lonely, or Tired and about how to apply the mindfulness skills from the group to cope when you’re in an agitated state. The men nod in agreement. Jose says that sometimes he now says a prayer to relax himself. Harvey goes back to the visualization they have all learned, where you let negative thoughts, like leaves, float down stream, until they are far, far away.”
Fryer affirms their progress, explaining how the quick, judging brain works to send us off on a negative spiral, making assumptions about the person who cut us off, didn’t respond to our needs, or wasn’t quick enough to get us our meds. “At the end of the day, we don’t even know if people meant what we think they meant?”
“Or even if they did, is our response worth it?” Ramsey asks.
The group continues discussing how to work with thoughts in a mindful space to cultivate non-judgmental awareness. “This being human is a guest house. Every morning a new arrival. A joy, a depression, a meanness, some momentary awareness comes as an unexpected visitor. Welcome and entertain them all. Even if they are a crowd of sorrows” Fryer reads from a poem by Rumi called the “The Guest House” commonly recited in mindfulness circles.
Ronald returns to the struggle of waiting on lines, for example, at the check out counter of the supermarket. After eight sessions of mindfulness work – not only in these weekly hour -long sessions but through homework and practicing mindfulness techniques– he explains that he is trying to get patient with his impatience. He is making strides.
“That’s why we call it practice,” Ramsey says. “That’s why we are here.”
Journalist Suzanne Gordon is writing a book about VA healthcare. Check her website, www.suzannegordon.com