The Effect of meditation in combination with psychotherapy in the context of PTSD. An explorative qualitative study

The Effect of meditation in combination with psychotherapy in the context of PTSD. 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An explorative qualitative study Melina Schwab, Ulrich W. Weger, Terje Sparby This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6369237/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract There is ongoing research on the effect of meditation in the context of post-traumatic stress disorder (PTSD) and possible effects are the subject of controversial debate. The studies predominantly provide evidence of a beneficial effect, but possible risk factors also appear to be associated with meditation interventions. The impact of meditation on the process of psychotherapeutic trauma treatment has not been addressed in any research publication to date. For the first time the present explorative qualitative study examines the combination of meditation, psychotherapy and PTSD. Using guided interviews, 11 people were interviewed about their experiences, including PTSD sufferers and psychotherapists. The qualitative analysis extracted six overarching themes based on the content: Background, deductively identified effects, PTSD symptom groups, inductively constructed effects, negative effects/challenges, dealing with negative effects/challenges and effects of psychotherapeutic process. Descriptions of transformative processes and mechanisms of action that imply both positively and negatively perceived effects were identified. The study aims to suggest that more sensitivity is needed in the use of meditation in the context of PTSD, both for those affected themselves and for clinicians who use meditation in a psychotherapeutic setting. Furthermore, to our knowledge, this is the first scientific study that provides experientially based insight into the use of meditation in combination with psychotherapy. Biological sciences/Psychology Health sciences/Health care/Health services Meditation psychotherapy PTSD trauma Figures Figure 1 Figure 2 1 Introduction "The wound is the place where the light enters you." Rūmī (as quoted in Barks, 2004, p. 82). The beneficial effect of meditation on mental health has been extensively researched in recent decades (Grossman et. al., 2004; Boccia et al., 2015; Tran et al. 2022). There is ample evidence of the effectiveness of meditation and mindfulness, particularly for mental illnesses such as depression and anxiety disorders (Parmentier et. al., 2019; Carpena et al. 2019). There is also a recognisable clinical interest among experts in the effects of meditation on post-traumatic stress disorder (PTSD). However, there are, as we will show, gaps in the research and potential effects are the subject of controversial debate. The studies predominantly provide evidence in favour of a beneficial effect of meditation on PTSD. For example, the attention processes that are trained through meditation practices are said to lead to a general reduction in emotional and physiological arousal and improved emotion regulation (Lang et al., 2012). Furthermore, there is a growing number of studies suggesting that regular practice, particularly of mindfulness meditation, leads to a reduction in PTSD symptoms (Heffner et. Al. 2016; Davis. Et al. 2018; Possemato et. Al. 2022). Focussing on the present moment seems to restore a sense of control and safety to those affected and reduce dissociative and overwhelming feelings (cf. e.g. Lee et. Al., 2017). There are also signs of changes in the ability to relate to others and a reduction in feelings of isolation caused by the trauma (Myers et. Al. 2015). The increasing number of publications on the feasibility and effectiveness of meditation programmes for veterans affected by PTSD is particularly striking. A meta-analysis published in 2016 by Heffner et. al. summarised the study results. Using data from six multi-site mental health services of the Department of Veterans Affairs in the USA, various meditation programmes were examined for their effect sizes before and after implementation in comparison with standard programmes. The results show mean effect sizes in the following areas: severity of PTSD symptoms =.32, general mindfulness =.41 and non-reactivity to inner experiences =.37. The specific meditation programmes and the termination of the programme were identified as potential moderators of the effect sizes. For example, mantra-based programmes show significant effects on the level of general trait mindfulness, whereas mindfulness-based programmes show stronger effects on non-reactivity toward inner experiences (Heffner et. al., 2016). Current global political conflicts emphasise the urgent need for further research in the field of post-traumatic stress disorder. Initial studies suggest increasing prevalence rates of PTSD in war zones (Karatzias et al., 2023). Previous research also emphasise the need for high-quality qualitative studies to deepen understanding and identify unanswered questions (Hilton et al. 2016). Qualitative research not only gives an overview of the spectrum of experiences, but also contributes to understanding contextual factors and identifying individual aspects that may influence the effectiveness of meditative approaches in combination with PTSD. This allows for more specific recommendations and individual tailoring of meditation interventions. In contrast to these predominantly positive results, researchers warn of possible risks and negative effects of meditation in clinical settings. Lindahl and Britton (2017; 2019) criticises the inadequate investigation of potentially challenging, stressful or difficult experiences. In a research project, Lindahl and Britton examined a subgroup of a sample of 120 meditation practitioners and meditation experts with years of daily practice for affective changes related to re-experiencing traumatic content. Some of the practitioners understood the traumatic content in relation to the tantric soteriology of purification, which is a normative framework that gives traumatic content positive significance. In contrast, those affected by a history of trauma did not understand the traumatic re-experiencing as purification and sought additional psychotherapeutic or psychiatric treatment (Lindahl and Britton?? See above, 2017). These results show the need for further differentiation of the effect of meditation in relation to the treatment of people with PTSD. While the study is limited in its representativeness, it nevertheless also points to possible risk factors, such as an increased experience of dissociation through the use of meditation in the context of PTSD. Meditation research may be understood as having gone through different phases (cf. Chowdhury et. al. 2023). While the first phase focused on beneficial effects while disregarding potential negative effects, the second wave focusses specifically on different types and the prevalence of potential negative effects (Anonymized, 2024). The assessment of potential adverse effects is complex and emphasises the need for a differentiated and multidimensional approach (Britton et. al. 2021). Goldberg et al. (2022) suggest that so-called MRAEs ( meditation-related adverse effects ) need to be recorded in their full range of severity. In their study, the research team found that individual trauma experiences can possibly influence the response to meditation. Those who had gone through stressful childhood experiences had a 25.8% chance of re-experiencing trauma in connection with their meditation practice. The results suggest that the effect of meditation in the context of PTSD needs to be investigated specifically with regard to uncovering the potential influence of individual traumatic experiences and reactions on meditative practices. A comprehensive understanding and sufficient information about possible risk factors is necessary, both for those affected and for clinicians (Goldberg et al., 2022). Meditation practices, which have been handed down over thousands of years in different traditions, also have different views about how to categorise, interpret and cope with challenging experiences. These views may contrast with the Western cultural understanding of illness and health (Lindahl, 2017), though traditional views also include ideas such as “meditation sickness” (Ahn, 2020), indicating that there is an understanding of challenging aspects of mediation practice in the traditions that current research has yet to integrate. People who experience psychological trauma are confronted with experiences that lie outside their normal system of meaning, which overwhelm the nervous system and existing coping strategies, and consequently impair psychosocial functioning (Lepak & Carson, 2021, p. 429). According to the Western perspective and the current findings of the American Psychiatric Association (2023), post-traumatic stress disorder (PTSD) can develop as a result of experiencing an incisive traumatic event or a series of such events. These events are often perceived as harmful or life-threatening, whether emotionally or physically. Examples include serious accidents, terrorist attacks, wartime experiences, natural disasters or violence. The diagnosis of PTSD is characterised by the globally established DSM-5® diagnostic system through characteristic groupings of symptoms : (1) re-experiencing in vivid form (e.g. flashbacks), (2) avoidance behaviour as expressed in thoughts and feelings or associated with the traumatic event, (3) perception of a present threat (e.g. excessive vigilance), (4) increased emotional reactivity (e.g. dissociations), (5) negative self-beliefs (e.g. a feeling of worthlessness), (6) difficulties in social relationships (Falkai et al. 2018). In cases of complex PTSD, the experiences have usually occurred repeatedly over a period of years, and the manifestations of symptoms such as negative self-beliefs and difficulties in social relationships are more pronounced (cf. Kazlauskas et al. 2018). The effects can occur in people of different ethnic backgrounds and at any age. The prevalence rate for adolescents between the ages of 8 and 13 is 8%, and in the U.S. total population 3.5% are diagnosed with PTSD each year. Women are about twice as likely as men to be diagnosed, as are ethnic minorities (American Psychiatric Association, 2023). Links to Eastern traditions and meditation can be found early in the history of psychology and psychotherapy. Important figures such as Carl Gustav Jung, co-founder of analytical psychology, were in contact with Daisetzu Teitaro Suzuki, who contributed significantly to the spread of Zen Buddhism in the West. Pioneers such as Charlotte Selver recognized the growth potential inherent in mindful awareness of the here and now and integrated it into therapeutic work (Huppertz, 2003; Bohus & Huppertz, 2006). With their increasing popularity from the 1960s onwards, traditional meditation practices found their way exponentially into psychology and psychotherapy. Well-known mindfulness-based therapy approaches such as MBSR ( Mindfulness-Based Stress Reduction), MBCT ( Mindfulness-Based Cognitive Therapy ) and ACT (Acceptance and Commitment Therapy) have established themselves as effective methods for various mental illnesses. There is ample evidence of their effectiveness (Dawson et. al. 2020; Querstret et. al. 2020; Pseftogianni et. al. 2023), though the specific mechanisms of action do not appear to be clearly understood (Bohus & Huppertz, 2006; Alsubaie et. al. 2017). In the context of PTSD, psychotherapy plays an important role in alleviating symptoms and processing the trauma experienced. Initial approaches for the integration of meditative practices into trauma treatment exist, but these are limited in their representativeness and generalisability (Vujanovic et. al., 2011; Lee et. al. 2017). In addition, the necessary competencies of psychotherapists seem to be neglected (Waelde et. al. 2016). To our knowledge, no research currently exists that addresses the specific effects meditation may have on the psychotherapeutic process in the context of PTSD. The mechanisms of action are also unknown. There may be a strong potential benefit inherent in the combination of meditation and psychotherapy, and yet it remains unanswered whether specific synergy effects can be identified. When reviewing the scientific debate on trauma-related disorders, it quickly becomes clear how delicate this topic is, involving for example the potential for re-traumatization during therapy, and that the potential risk factors for the use of meditation need to be sufficiently clarified. However, it is possible that accompanying psychotherapy can lead to a reduction in negative effects. Preece hypothesizes that psychotherapeutic trauma treatment may be necessary when meditation-based techniques are used as interventions for PTSD (Preece, 2011). As already discussed, it seems essential that both clinicians and the affected persons themselves receive sufficient education and a comprehensive understanding (Goldberg et al., 2022). The research gap identified above led to formulation of four research questions that are to be investigated in this study. To our knowledge, this is the first time explorative qualitative research examines the combination of meditation and psychotherapy in the treatment of PTSD. Qualitative research offers a person-centred approach that is likely to do justice to the complex nature of trauma and the individual experiences of the people affected. The research questions are: What is the effect of meditation on PTSD? Can changes in PTSD symptoms be observed through the practice of meditation? Can risks or challenging effects be identified when practicing meditation in the context of PTSD? What effects does meditation have on the psychotherapeutic process in the context of PTSD? 2 Study design and method The qualitative research design was developed based on the work of Mayring and Flick et al. (2013, 2019). The choice of an explorative qualitative design was motivated by the very limited state of knowledge. The criteria for participant recruitment were developed according to the logic of criterion-guided sampling, with the aim of achieving heterogeneity (Schreier, 2019). Two main groups were approached: persons in psychotherapeutic treatment and psychotherapists, as both provide vital perspectives on the psychotherapeutic process. The participants were acquired through a combination of online research, personal contacts and the snowball method. Potential participants were contacted over email. The participants were selected according to the main criterion of being affected by PTSD and having practised meditation regularly for at least one year. Participation in current psychotherapeutic treatment was another criterion. The psychotherapists recruited had experience in dealing with PTSD patients who practise meditation and/or had in-depth knowledge of meditation themselves. People with physical or mental impairments that could make the interviews more difficult were excluded from the study. The participants received sufficient information about the study project, the process and data protection, including pseudonymisation. Over a period of three months, the interviews were conducted either in person or via the video conferencing software "Zoom". The study was approved by the ethics committee of Witten/Herdecke University (No. 225/2022) and the study was conducted in accordance with the relevant guidelines and regulations. 2.1 Description of the sample A total of N= 11 participants took part in the qualitative interviews. The affected PTSD patients ( N= 7) experienced one or more traumatic events in their childhood or adulthood. Of these, 85.7% identified themselves as female and 14.3% as male, with an age range of 24 to 71 years ( M= 45.57 years, SD= 18.08). The diagnosis was made at the beginning of therapeutic counselling and the patients had been in therapy for an average of M=13 .57 years ( SD=8 .75 ). Of these, 71.5% were in behavioural therapy (BT) and 28.5% in therapy based on depth psychology (DP). The accompanying therapists had additional training in trauma therapy (e.g. Eye Movement Desensitization and Reprocessing (EMDR )). All participants had been practising various forms of mindfulness meditation for an average of M= 11 years ( SD=9 .2 years): 71.4 % mixed forms of various forms of mindfulness meditation, 14.3% metta meditation, and 14.3% mantra meditation. 71.4% favoured guided meditation. In terms of practice, 42.9% indicated individual practice (I), 14.3% group practice (G) and 42.9% a combination of individual and group practice (I+G). Support from meditation teachers was received by 42.9%, while 57.1% stated no support. The experts (licensed psychotherapists) had many years of experience with PTSD patients, on average M= 18.75 years ( SD=8 .8). The gender ratio in this group of participants was heterogeneous, with 50% identifying as female and 50% as male. The average age was M=52 .25 years ( SD=12 .5). In addition to their many years of meditation experience averaging 20 years (SD=5.84), 25% of the psychotherapists were trained in BT and 75% in DP, were also certified MBSR/MBCT teachers, or had published books/articles on meditation. 2.2 Data collection Geertz, an anthropologist and proponent of explorative questioning, argues in favour of immersing oneself in the complexity of phenomena: “(...) the analysis of culture is not an experiment in searching for hidden motives, but an experiment in understanding meanings" (Geertz, 1973, p. 93) The semi-structured qualitative interview, which is particularly widespread in social research, endeavours to gain a more comprehensive understanding and deeper insights into a research topic. In contrast to fully structured interviews, in which the questions are determined in advance, the semi-structured interview offers greater flexibility and room for exploration. Based on the research purpose, the aim was to collect rich data that delves deeper into the phenomenology of experiences (May & Mruck, 2020; Flick, 2008). An interview guide was designed to provide orientation for asking questions relevant to the research questions. This guideline is divided into sections A (affected persons, 19 questions) and B (experts, 17 questions). The focus was on personal experiences with meditation in relation to post-traumatic stress disorder. In addition to the effects on the psychotherapeutic process, the interviews also considered potential challenges and risks. Open questions helped to encourage the participants to provide unknown perspectives and a trusting atmosphere offered the participants the opportunity to freely share their individual, subjective experiences. The interviewer reacted flexibly to follow-up on spontaneously arising topics of conversation (Flick, 2008; Flick et al., 2013). To support the sense of safety of those in the affected group, personal trauma was not discussed. The interviews were originally conducted in German. 2.3 Data processing and analysis After creating RTF transcripts using the "f4-transcription" software, the interview management transferred the data to the MAXQDA programme (VERBI SOFTWARE, 2022). From then on, the systematic data analysis was based on structured qualitative content analysis, following the procedure described by Mayring (2015; 2020). According to the bibliometric results of Carrera-Fernández et. al. (2014), qualitative content analysis is one of the most widely used text analytical methods. This analysis method enables large verbal data to be reduced into categories that are representative in terms of content. The text analysis focuses on constructing a category system oriented towards the research questions. Mayring developed a strictly rule-based procedure of analysis based on the techniques of summarisation , explication and structuring. The present analysis followed on the "process model" designed by Mayring (for more details: Mayring, 2015, pp. 70-72). Accordingly, the interview guide offered the opportunity to form initial deductive categories, but the focus of the analysis was on the actual data available. Only text passages relating to the effect of meditation in post-traumatic stress disorder in combination with psychotherapy were analysed). The smallest units that could be coded were parts of sentences as whole units of meaning. The extracted text passages were rewritten in a descriptive form to create paraphrases. Different units of meaning were combined to form an inductive category system. In contrast to the purely deductive approach, inductive category formation offers openness during implementation, which minimises bias and preconceptions on the part of the researchers. Furthermore, a lack of concrete theories and concepts necessitates the predominantly inductive approach (cf. e.g. Mayring, 2015). Categories were gradually developed from the initial material and the level of abstraction was successively increased. The aim of inductive category formation was to summarise relevant aspects of the research topic as precisely as possible. A comparison was made between the source material and the categories formed by means of a repeated review. The criterion of saturation determines the end point of the data analysis. Saturation is reached when no new data or insights are added with regard to the phenomenon being researched. In this research work, saturation could be achieved within the predefined sample size and within the scope of the survey content (Schreier, 2019). 2.4 Quality of the study The views on what constitutes high-qualitative research vary depending on the research tradition, theoretical approach, methodology, and research question. This diversity is due to the flexible and context-dependent nature of qualitative studies (Patton, 2014). Despite diverse views, there is consensus regarding principles that ensure quality. These include care in collecting and analysing data, critical reflection on one's own assumptions and transparency in documenting the research process (cf. e.g. May & Mruck, 2020). The researcher endeavoured to fulfil the fundamental principle of intersubjective comprehensibility (Steinke, 2022). Before the study was conducted, a research design was developed, different methodological approaches were discussed, and an interview guide was developed. Clear transcription rules were drawn up. To ensure reliability, the set of rules and the systematic approach to the analysis were applied uniformly in all interviews. The determination of interrater reliability helped to determine the degree of reliability using a second independent coder. 3 Results The analysis of the eleven collected interviews led to the generation of six superordinate clusters based on the research questions, each of which is characterised by different topics, referred to as “subcodes”. The key findings of the qualitative analysis are presented below and provide an in-depth insight into the interview data obtained. Table 1 below provides an overview of the key results and frequency of codes (for all other results tables, see appendix). When affected participants are cited in the following, reference will be made to “P” for the participant number, and then the paragraph of the transcript (for example, “P1, para. 12”, refers to the 12 th paragraph of the transcript of the interview with participant number 1). Psychotherapists will be referred to similarly, replacing “P” with “T”. Table 1 Code system with superordinate clusters and associated subcodes List of codes Frequency Nominations Total 416 Background 21 Meaningfulness 8 Calming 13 Deductively identified effects PTSD symptom groups 136 Less re-experiencing 13 Less avoidance behaviour 12 Less perception of present threat 28 Change in affect regulation 23 Less negative self-beliefs 37 Less difficulties in social relationships 23 Inductively constructed effects 134 Calming of the autonomic nervous system 15 Expanding scope of action 28 Trauma disidentification 32 Anchoring in the awareness of the present 26 Self-regulation 33 Negative effects/challenges 58 Increased symptom awareness 22 Increased states of dissociation 15 Overwhelming confrontation 21 Dealing with negative effects/challenges 27 Support 16 Discontinuing the meditation 4 Changing the appraisal 7 Effects of the psychotherapeutic process 40 Differentiated introspective 10 Meta-level (metacognition, metaemotion) 9 Resource activation 14 Theme actualisation 7 Table 2 Cluster: Inductively constructed effects Topic Characteristics Example quotes Inductively constructed effects (Description of the effects of meditation on PTSD) Calming of the autonomic nervous system Breathing deepens, lowered heart rate, physical relaxation. The autonomic nervous system changes to parasympathetic activity. (...) I often have this kind of pressure in my chest, which eases, so the chest and stomach area, it eases. I relax. My body relaxes and I think I breathe more calmly. Expanding scope of action Increased mindfulness opens up the conscious perception of trauma-related processes. The scope of action expands. (...) like an interested observation, but not like totally accepting everything or something, but being able to consciously choose what I accept of something. Um and the other thing is really to be able to react more calmly in precarious situations or conflictual situations. Trauma disidentification The ability to take the position of an observer in relation to trauma-related thoughts, feelings and behaviours and to actively follow them. And then this intermediate step happens, like a (...) like a contemplation of it [the trauma-related experience]. I can then simply look at it calmly and, for example, this self-deprecating thought or this negative emotion towards myself. Anchoring in the awareness of the present The ability not to be overwhelmed by trauma-related bodily sensations, feelings and images and to focus one's awareness of the here and now. And I believe that this pull is weakening. So that the part [of me] that can stay here, in what is happening here right now, will have more support. In a way guardians who come, who protect me and somehow make it possible to deal with the now and not go into the past. Self-regulation The ability to deal productively with and regulate emerging trauma-related feelings, thoughts and impulses. (...) that in situations (...) that perhaps affect or trigger the traumatic experience, that this has become an anchor point that I can consciously use. For example, to calm myself down a bit from a strong, violent physical reaction. 3.1 Background The main category background focusses on the underlying need for meditation in the context of post-traumatic stress disorder. Within the background category, two central subcategories were identified. See table 3 in the appendix for an overview. 3.1.1 Meaningfulness. In relation to meaningfulness, the interviewees expressed a common need for a deeper meaning and a more comprehensive contextualisation of the traumatic experience. They did not wish to view their experience in isolation, but rather to embed it into a broader narrative. In accordance with this, they wanted to find a deeper meaning for themselves and their subjective suffering. One affected person stated: And meditating is more about how I place myself in this world, also and how [I place myself in relation to] let's say the meaningfulness, which I have always doubted (P5, para. 84). Meditation is an opportunity for this participant to not only reconsider their own position in the world, but also to question and understand the inherent meaning of their existence. The meaningfulness that is explored through meditation became a means of overcoming doubts and uncertainties about the meaning of one's own life. 3.1.2 Calming. Longing and searching for a way to relax and regulate the heightened inner state of arousal emerged as another topic. This may be described as a key need discovered within this study. Meditation was identified as a decisive supporting factor here, with the test subjects describing the experience of calm and emotional regulation triggered by this as a significant resource. This quote from an interviewed therapist illustrates the emerging need for calming: People who still have a heightened arousal, yes, they actually often wish for a method with which they can calm down a little (T1, para. 6). This refers to the need for a method that enables people to relax and regulate their persistent inner arousal. The example quote thus also emphasises the role that meditation plays in fulfilling this need. 3.2 Deductively identified effects of the PTSD symptom groups Within the main category deductively identified effects of PTSD symptom groups, changes in DSM-5 symptoms through the use of meditation in PTSD could be derived. The symptom groups are categorised into five themes. See table 4 in the appendix for an overview. 3.2.1 Less re-experiencing. Within the data analysis, the category of less re-experiencing manifests itself as a significant result of meditative practice. This subcode refers to the reduction of re-experiencing traumatic events in the form of thoughts, images or feelings as well as improved differentiation between past and present. The interviewees emphasised improved psychological coping through the use of meditation. One affected person illustrates this experienced symptom reduction: I definitely have the feeling that I have fewer flashbacks from everyday life as a result. And if I do have a triggering situation or something happens that puts me back into an experience, I can deal with it much better, in terms of finding my bearings or briefly orientating myself and telling myself that I'm no longer in the situation (P2, para. 32). The quote points to a developed ability to deal with stressful situations in a different way. The reason for this appears to be a conscious anchoring in the present and a better differentiation between the past and the current reality. 3.2.2 Less avoidance behaviour. The less avoidance behaviour category reflects a decrease in the avoidance of situations associated with the traumatic event. At the same time, there may be an increased awareness of the avoidance process and increased self-confidence in dealing with challenging situations. In the words of one participant: I often find myself in situations like this, where I have the feeling that God, I don't really want to go there now, but I actually have to do it. Then I often take the time for myself again, meditate, collect myself a bit, get through the situation more clearly and dare to go into it (P6, para. 32). This quote directly conveys that meditation enables the person to tackle challenges with increased clarity and a higher degree of self-confidence. The description of consciously dealing with avoided situations indicates that meditation serves as a supportive mechanism that reduces avoidance behaviour and promotes more active coping with such challenges. 3.2.3 Change in affect regulation. The identified category change in affect regulation reflects the observed changes in the area of affect regulation. The changes include several modifications in the way PTSD sufferers deal with and regulate their emotions. These include a reduction of the generally heightened emotional reactivity due to PDSD, a decrease in the tendency to dissociate and feelings of numbness, and an increased awareness of one's own emotional experience. In addition, meditation is said to lead to greater acceptance, processing and integration of emotions. Here is a quote that exemplifies what acceptance consists of: (...) I experience that I can perhaps somehow hold on to difficult emotions and difficult body sensations. It's no longer so unbearable for me, but I can approach it and somehow allow it (T4, para. 39). This quote refers to the process of improved processing ability, greater inner stability, and a more conscious confrontation with one's own emotions. 3.2.4 Less perception of present threat. The category less perception of present threat stands out as a significant result of meditation. The interviewees describe that the number of situations that are perceived as threatening can be reduced. At the same time, this is accompanied by an increased awareness of the process that leads to something being perceived as a threat. Those affected experience an increased feeling of security and control. This can be illustrated by the following quote: (...) I find more peace within myself when I meditate regularly and always have the feeling that there is still a small protective layer between me and the world. And if I don't do it so much that I have the feeling that everything is immediately super threatening and super stressful (...) (P2, para. 44). The description that without regular meditation everything is perceived as immediately threatening emphasises the influence of meditation practice on the symptom of the perception of present threat. 3.2.5 Less negative self-beliefs. A further change in the perceived symptoms emphasises the category of less negative self-beliefs. Within the main cluster of deductively identified effects of the PTPS symptom groups, it has the highest coding rate. This category describes a reduction in negative judgements, particularly with regard to feelings of worthlessness or guilt. Here too, both affected persons and therapists report that there is an increasing awareness of negative self-beliefs. In addition, meditation can increase compassion towards oneself and one’s trauma-related experience. The sense of self-worth undergoes a positive development. The following example can be quoted: (...), because I also have a lot to do with guilt about myself and for a very, very long time I simply related a lot of what happened only to myself. And meditation definitely helps me to deal with myself in a much more loving way or rather to have a feeling of self-care or compassion (P5, para. 28). This quote clearly shows that the person experiences a change in the perception of negative self-beliefs through regular meditation. Particularly in relation to feelings of guilt, there is a reduction in self-centredness and a shift towards a more loving approach to oneself. 3.2.6 Less difficulties in social relationships. The interviewees reported changes in the area of interpersonal interaction through the use of meditation in the context of PTSD. These changes are contained in the subcode of less difficulties in social relationships. A notable observation was the increased ability to better perceive and understand the needs and boundaries of others and to express one’s own boundaries in relation to others. The results indicate that in the area of interpersonal interactions, past experiences or traumas are more clearly separated from current relationship experiences. This ability enables those affected to be less influenced by past experiences and to concentrate more on their current relationships. The qualitative statement by one interviewee describes these changes as follows: (...) when I meditate I am in such (...) condition that I realise how I am feeling and can also communicate better, for example. For example, if I’m touched or something like that and I don't want that right now or something. And that definitely makes it much easier for me to maintain a relationship (P2, para. 52). The respondent illustrates how the practice of meditation enables her to develop a heightened self-awareness and to integrate this into her interpersonal relationships. 3.3 Inductively constructed effects The inductively constructed effects refer to the meditation aspects of the meditation process that may have a beneficial impact on post-traumatic stress disorder. Five central categories were identified within the present sample. See table 2 in the appendix for an overview of the categories. 3.3.1 Calming of the autonomic nervous system. An important element discovered in the data analysis was the calming of the autonomic nervous system . Participants and therapists reported a deepening of breathing, accompanied by a lower heart rate and general physical relaxation. It was shown that meditation can influence the autonomic nervous system and bring about a change towards parasympathetic activity. These effects could be of particular importance for people with PTSD, as they are often confronted with increased tension and impaired regulation of the autonomic nervous system. This interview quote illustrates the observed effects of meditation on the autonomic nervous system: (...) I often have this kind of pressure on my chest, which eases. So the chest and stomach area, it eases. I relax. The body relaxes and I think I also breathe more calmly (P3, para. 18). The person describes their experience of noticeable physical relief during meditation. The reduction of pressure on the chest, accompanied by a general relaxation and calmer breathing, reflects the observed effects that were emphasised by the interviewees during the data collection. 3.3.2 Expanding scope of action. The subcategory expanding scope of action refers to a process that can unfold through increased mindfulness during meditation. The interviewees described that a conscious perception of the processes associated with the trauma is made possible through the use of meditation. Those affected are able to observe these processes with interest and without automatically identifying with them. Instead, they can consciously decide which thoughts and emotions they want to pay attention to. This ability to make conscious choices opens up a wider scope for action, which manifests itself in more possibilities for action and reactions, and hence generally represents increased autonomy. This quote from the collected data describes this effect: (...) like an interested observation, but not like totally accepting everything or something, but being able to consciously choose what I accept something from. Um and the other thing is really to be able to react more calmly in precarious situations or conflictual situations. (P1, para. 35). This illustrates how a conscious choice of thoughts and emotions can create the ability to shape reactions more consciously and purposefully, rather than acting automatically or impulsively. In difficult or conflictual situations, those suffering from PTSD and practising meditation may be able to respond more calmly. 3.3.3 Trauma disidentification. This category can be introduced by the following vivid quote: And that's where this intermediate step happens, like a contemplation of it [the trauma-related experience]. I can then simply look at it calmly, for example, this self-deprecating thought or this negative emotion towards myself (P4, para. 53). The interviewees emphasised the ability to detach themselves from identification with the trauma-related patterns and to adopt an observational stance. Trauma disidentification as a subcode therefore refers to the ability to take an observational position in relation to the trauma-related thoughts, feelings and behaviours and to actively observe them. This skill of disidentification acquired through meditation can help PTSD patients create a certain distance from the symptomatic self-deprecating thoughts or negative emotions about themselves. 3.3.4 Anchoring in the awareness of the present. The category of anchoring in the awareness of the present generated in the analysis describes an elementary ability that almost all interviewees reported unanimously: Not allowing oneself to be flooded by trauma-related bodily sensations, feelings and images and instead focussing one's awareness on the here and now. Through meditation, PTSD sufferers can develop the skills to reduce the magnetic pull of the past and consciously direct their attention to present experiences. The following example can be quoted: And I believe that this pull is weakening. So that the part [of me] that can stay here, in what is happening here right now, will have more support. In a way guardians who come, who protect me and somehow make it possible to deal with the now and not go into the past. (P1, para. 41). Through meditation, participants can experience a stronger anchoring in the present moment and conscious awareness can enable them to distance themselves from trauma-related experiences. 3.3.5 Self-regulation. The highest coding rate belongs to the category of self-regulation . The subcode describes the ability of PTSD patients to deal independently with the emerging trauma-related feelings, thoughts and impulses and to calm the nervous system. Through meditation, they can learn various self-regulation strategies to change and calm their reactions to trauma-related stimuli. It is important to note that this category can also include other aspects of self-regulation, such as emotional regulation or impulse control. (...) that in situations that perhaps affect or trigger the traumatic experience, this has become an anchor point that I can use consciously. For example, to calm myself down a little from a strong, violent physical reaction (P3, para. 14). This quote emphasises that through meditation, participants develop the ability to consciously use anchor points, for example a meditation object like the breath, to calm themselves down in situations that can affect or trigger their traumatic experience. Learning such self-regulation strategies helps those affected to respond more strongly to trauma-related symptoms and gain greater control over their physical reactions. 3.4 Negative effects/challenges The main category of negative effects/challenges associated with meditation for PTSD includes potentially negative side effects or challenges that may arise during or after the use of meditation practices. Three central themes were defined within the cluster. See table 5 in the appendix for an overview. 3.4.1 Increased symptom awareness. Within the data analysis, the category of increased symptom awareness emerged with a high coding rate among the overarching theme of negative effects/challenges. The interviews showed that meditation practice promotes increased mindfulness, which influences the way in which those affected experience their symptoms. By engaging more consciously and intensively with their thoughts, feelings and bodily sensations, this can lead to an increased awareness of their own symptoms. One participating PTSD patient describes this experience as follows: For example, I have experienced that when I perceive my body, I don't have a good relationship with it. I say to myself, I don't know it at all and when I perceive it, it often shocks me (P5, para. 90). The person suddenly came across aspects of their body that were previously not consciously recognised or that were associated with negative emotions. This process reflects an inner conflict in which the heightened awareness promoted by meditation leads to an increased sensitivity to the symptoms while at the same time creating a sense of alienation or rejection of one's own body. This discrepancy between heightened awareness and aversion toward the perceived symptoms can trigger a cycle (symptom amplification) and possibly intensify the suffering experienced. 3.4.2 Increased states of dissociation. Another theme that emerged was increased states of dissociation when making use of meditation. Focussing on the breath or similar aspects can lead to those affected focussing strongly on themselves and introspecting deeply. In some cases, this can create such a sense of being overwhelmed that dissociation, that is, the tendency to disconnect from one’s feelings, thoughts or even behaviours away from oneself, is intensified. As described by one participant: (...) but closing my eyes and concentrating so much on myself, on my breathing etc. and so on, that this kind of drifting only intensifies (...). So, this dissociative tendency, which I also know from myself, gets more space as a result (P1, para. 74). Hence, paradoxically, meditation, which normally serves to promote mindfulness, can reinforce dissociative tendencies. 3.4.3 Overwhelming confrontation. The theme overwhelming confrontation also emerged during the analysis. The intense focus on the intrapsychic event, without external regulation options, can cause a sudden renewed immersion in the traumatic experience. The interviewees reported triggered flashbacks or re-traumatization and feelings of panic or helplessness. This example quote from one of the interviews illustrates this effect: (...) from this, traumatic experience flowed into me with great speed, because what happened in the moment of meditation is that you are completely with yourself, and also very isolated sometimes (...) And then there's a chance that you fall into it [the traumatic experience], somehow, and then go through it again and experience it again (P3, para. 82). The experience suggests a potential challenge during meditation practice. Isolation without external regulation harbours the risk that traumatic memories can emerge uncontrollably and with high intensity. 3.5 Dealing with negative effects/challenges Within this theme, three possible solutions were identified for dealing with possible side effects and risks that can occur in connection with the use of meditation for PTSD. See table 5 in the appendix for an overview. 3.5.1 Support. The theme of support consists of different forms of personal support and regulation options, which can be of crucial importance for PTSD patients practicing meditation. Various methods were suggested by the interviewees. Guided meditations by meditation teachers or trained professionals are an essential component. The presence of an experienced psychotherapist with knowledge of meditation can also play a valuable role. These facilitators can not only provide guidance for meditation, but also create an open and supportive environment in which patients can evaluate their experiences and individual challenges during meditation. One therapist interviewed emphasized the importance of this supportive aspect: I would definitely say that one should accompany the patient and not leave them alone, so to speak. I think that's the most important thing right now. And it can be a matter of saying, “I'm on board for now and we'll wait and see” (T4, para. 54). The therapist emphasized the need for a supportive structure that creates trust and enables patients to feel safe and stable during their meditation practice. 3.5.2 Discontinuing the meditation. When dealing with potentially negative effects and challenges, discontinuing the meditation is an important suggested solution. The main claim inherent in the theme is that it is advisable to end the meditation session if excessive stress or negative effects are experienced. Stopping meditation serves to protect the patient from further excessive strain, such as re-experiencing. The therapists interviewed emphasized that meditation sessions should only be carried out when sufficient regulatory options are available to deal appropriately with any negative reactions that occur. The timing of the meditation sessions should be chosen carefully, based on the individual's stability and existing coping mechanisms. In the words of one therapist: I would actually check again if such negative effects exist, is the person safe enough for it? Stabilised enough for it? And if not, I would advise against meditation and actually do other stabilisation exercises (T1, para. 72). The therapist interviewed recommends prioritizing other therapeutic approaches for stabilizing and coping with stress before continuing meditation, if the patient shows negative effects. 3.5.3 Changing the appraisal. As part of the data evaluation, a further recommendation emerged. The theme of interpretive change describes the possibility of changing how one views the meaning of the negatively perceived effects. Instead of viewing these as purely negative effects, they can be categorized as opportunities for personal growth and as integral components of the healing process. By attributing a new meaning to them, even difficult experiences during meditation can be interpreted as important components of therapeutic progress. In the interview, one affected person described such a change in judgement: So, that means that it's not allowed to be , how should I put it, all that ! I'm allowed to cry, it's allowed to bother me, it's allowed to come up. It's not bad! I thought that this was good and it's not so dramatic and then to distinguish oneself from it: Yes, it's an old memory and I'll help you to regain your security (P5, para. 94). Changing the attribution of meaning helped the participant to classify the emotions as possibilities for inner processing and to see them as part of the path to stabilisation and healing. 3.6 Effects of Meditation on the Psychotherapeutic process The overarching theme effects of meditation on the psychotherapeutic process provides information on specific effects through four identified subthemes. See table 6 in the appendix for an overview. 3.6.1 Differentiated introspection. The differentiated introspection theme describes the development of inwardly directed mindfulness and self-observation when using meditation in combination with psychotherapy for treating PTSD. This aspect is characterised by an increased ability to consciously perceive, recognise, and control intrapsychic processes. The increased awareness of inner processes cultivated by meditation enabled those affected to explore their PTSD symptoms in more detail and to improve the articulation of their experiences during the psychotherapeutic process. This interview statements exemplifies this effect: (...) the meditation helped me a lot to start noticing symptoms at all. Because before it was super difficult for me to name what was going on or how I was feeling. Naming emotions or something like that is super difficult for me (...) I would then have the feeling that I can say much better what exactly is going on and then work better with it (P6, para. 58). The patient describes how the meditation practice helped her to find increased clarity and precision in the identification and verbal expression of her feelings and inner states. This led to her gaining an improved ability to communicate what she experienced during the psychotherapeutic sessions, thereby laying a more solid foundation for the therapeutic work. 3.6.2 Meta-level (metacognition, metaemotion). Within the data analysis, the theme of meta-level consists of the ability to be aware that one is having thoughts and emotions. Through the combination of meditation and psychotherapeutic intervention, those affected developed increased metacognitive and metaemotional competence, which enabled them to analyse their thoughts and feelings from a more distanced perspective. The therapists interviewed reported that this process supported easier identification and modification of maladaptive trauma patterns during the psychotherapeutic sessions. One therapist explained this process vividly: And also, the ability not to actually judge it immediately, but to be able to move it around a bit and look at it from different angles: What did someone actually experience and how could it be seen and where could it come from (T2, para. 88)? This ability to view one’s internal states from different perspectives and to create distance from one's own experiences opens a space of neutrality within the psychotherapeutic process. This space then enables a less biased analysis of one's own experiences and the factors influencing trauma patterns. 3.6.3 Resource activation. This category can be vividly introduced and illustrated with this quote: Well, but what is activated somehow is perhaps a (...) capacity to work on that or to go back to what I have somehow experienced. So, by the fact that the meditation practice leads to no longer being so involved, at the same time there is more space to turn to it again (P1, para. 65). The participant describes an increased capacity for coping and a reduction in immediate emotional involvement that can arise through meditation practice. This coping capacity is what is meant by resource activation . Within the main cluster, this subcode has the highest coding rate. Within the psychotherapeutic process, those affected can draw on the familiar effects of meditation, such as self-regulation and the ability to act, and thus tackle and process painful issues as they emerge. Meditation can thus offer PTSD patients an opportunity to constructively and gently address the traumatic content by enabling them to access helpful resources. Hence the psychotherapeutic trauma processing and integration can be promoted. 3.6.4 Theme actualisation. The theme actualisation highlights how experiences during meditation can serve as a starting point for deeper psychotherapeutic work. The interviewees report that these experiences act as important points of reference and can lead to better clarification and processing within the therapeutic relationship. For example: I mean, my therapist has known me for some time now, and can say: Look, does that remind you of anything? Was that there? Is there something that's coming up again? (P4, para. 78). This example quote illustrates how meditation experiences may initiate in-depth discussion and reflection on potentially meaningful content that may be relevant in the context of therapy. The meditation experiences can thus enrich and promote the psychotherapeutic process. 3.7 Interrater reliability As part of the qualitative data analysis, a second independent coder calculated the interrater reliability using MAXQDA software (VERBI SOFTWARE, 2022). The analysis revealed a total of 240 matches and 23 non-matches between the independent ratings of the coded content, resulting in a total of 263 coded segments. This yielded an overall interrater reliability of 91.25% (see appendix, Table 7 ). The high reliability indicates a consistent and reliable assessment of the coded data. The research team paid particular attention not only to the calculation of interrater reliability but also addressed coding differences. The researchers held extensive discussions about the coding discrepancies and then refined the coding system accordingly. 4 Discussion The investigation of meditation in combination with psychotherapy in the context of PTSD led to a deeper understanding of the effects and risks involved in the process. Within the main category of background, the research highlighted a fundamental need among participants for a deeper meaning and comprehensive contextualisation of their traumatic experiences. At the same time, those affected had a need to regulate and calm their heightened internal arousal. These results shed light on the possible role of meditation in the context of PTSD. The practice of meditation appears to be an important coping mechanism for those affected in relation to the challenges they face. In the following, the main results will be summarized and discussed. Hypotheses for further study will also be suggested. 4.1 Perceived changes in the DSM-5 criteria for PTSD As already described in detail, the Diagnostic and Statistical Manual for Mental Disorders, 5th edition, defines post-traumatic stress disorder by several symptom groups (American Psychiatric Association, 2022). The integration of the DSM-5 criteria facilitated a standardised assessment and enabled reliable and comparable evaluations of potential changes. Precise findings on specific change characteristics were obtained in the present study. Previous studies have indicated that meditation may explicitly affect PTSD symptoms positively (Heffner et. al., 2016; Lang et. al., 2012 Davis. et al. 2018; Possemato et. al. 2022). These findings formed an important basis for the present study and were supported by evidence. The subjects in all symptomatic groupings expressed perceived changes in various aspects as a result of meditation. These changes were characterised by a reduction in the symptom of re-experiencing traumatic events and a reduction in the avoidance of trauma-associated situations. In addition, the perception and regulation of feelings were reported to improve. The test subjects experienced an increased sense of security and control, which indicates that meditation can influence the symptom of perceived threat. The impact on negative self-beliefs was particularly strong, as indicated by having the highest coding value. The analysis highlighted meditation as an important positive influencing factor. The affected participants reported a growing compassion towards themselves and a positive development in self-esteem. In addition, meditation appears to have a positive influence on the ability to relate to others based on a perception of needs and boundaries. Table 4 in the appendix provides an overview of the perceived changes in the respective categories. Different types of meditation exist, and these involve different mental activities (cf. Anonymized, 2022). In this study, no specific statements can be made about the effect of different meditation techniques on PTSD symptoms. However, research indicates that the change in self-esteem acts as a moderating factor for PTSD symptoms when performing loving-kindness meditation (Kearney, 2013). The majority of the subjects studied (85.7%) practised mindfulness meditation that integrated the meditation object mettā , that is, the attitude and feeling of loving-kindness. The largest score change in the symptomatic grouping less negative self-beliefs may indicate a correlation and explain the magnitude of this change. Future research may further differentiate the effect of different meditation techniques on the clinical picture and uncover moderators. The deductively identified results in the present study emphasise two main themes in the effect of meditation on PTSD symptoms: First, an important differentiation process between past and present takes place; those affected learn to draw a dividing line between past traumatic experiences and present experiences. Second, meditation practice contributes to an increased awareness of the symptoms experienced, which enables them to better understand and regulate their symptoms. In addition to the scientific perspective, the findings are of particular clinical relevance. As a complementary treatment, meditation may play an important role in alleviating PTSD symptoms. 4.2 Model of the effect mechanisms of meditation in PTSD The qualitative research approach allowed for nuanced data collection that included reports on individual transformations of response patterns that occurred as a result of regular meditation practice. Although previous research provides evidence for the effectiveness of meditation in PTSD, there are few descriptions of the complex change processes (Bohus & Huppertz, 2006; Alsubaie et. al. 2017). As a response to this, we developed a model that may help to understand and identify the exact mechanisms of action. The model outlines possible changes to the classic stimulus/response process that may occur as meditation is used in the context of PTSD. See Figure 1 for an overview of the model. As soon as a trauma memory is activated by a stimulus or trigger, corresponding trauma-related physical sensations, feelings, thoughts or judgements are triggered and evoke a reaction. For example, a person who has experienced violence might suddenly tremble, feel an increased heart rate and experience flashbacks during boxing training at the gym due to the trainer's raised voice (stimulus/trigger), which forces them to leave the room (reaction). The effects of calming of the autonomic nervous system , trauma disidentification, anchoring in awareness of the present and self-regulation (see the green box of Figure 1) that arose during the inductive analysis describe how meditation can affect PTSD. The study showed that these effects have a positive influence on thoughts, feelings, etc. (see the blue arrow of Figure 1) when the trauma memory is activated. This is followed by a fundamental change in the classic stimulus/reaction sequence. The interviewees suggested that an intermediate step occurs before the normal reaction follows. In this intermediate step, the inductively identified effects (e.g. trauma disidentification ) have an impact on bodily sensations, thoughts, feelings and appraisals. This changes the scope for action (see the purple cloud of Figure 1) and the affected person can react differently as a result. Overall, this process indicates that those affected learn to modify their reactions to triggers and consciously regulate themselves through the skills acquired from meditation practice. Jon Kabat-Zinn, the founder of the Mindful-Based Stress Reduction (MBSR) programme and a well-known pioneer of mindfulness meditation in the West, suggested as early as 1990 that regular meditation practice creates a space of awareness and mindfulness, allowing practitioners to respond differently to their experiences (Kabat-Zinn, 1990). A similar idea can be found in Lang et. al (2012), who argued that meditation leads to better emotion regulation when confronted with traumatic stressors. It appears to be of significant relevance that it is not the trauma-related triggers that dissolve; rather it is the way in which these are dealt with that changes. The question of whether meditation can possibly reduce the overall number of episodes of trauma memory activation through effects such as calming of the autonomic nervous system represents an important field for further research. The following two-part hypothesis was generated based on the model described here: 1. Meditation disrupts the trauma-related stimulus/response process through the effects of calming of the autonomic nervous system, trauma disidentification, anchoring in the awareness of the present and self-regulation. 2. This process of disruption expands the scope of action of those affected by PTSD so that they may experience greater autonomy and ultimately be free of PTSD. 4.3 Negative effects/challenges and possible solutions The qualitative analysis of the effects of meditation on post-traumatic stress disorder (PTSD) revealed both positive effects (see 4.1, 4.2) and challenging aspects. The inclusion of questions relating to risks in our questionnaire responds to Lindahl's (2017) criticism of the inadequate illumination of potentially challenging, stressful or difficult experiences in current research. Three central themes emerged that need to be discussed in the context of the use of meditation for PTSD. That the theme with the highest coding rate was increased symptom awareness may indicate that meditation indeed may lead to a challenging increase in the awareness of symptoms. Those affected become aware of parts of their bodies or aspects of their emotions that were previously not consciously recognised or even split off. This process can trigger internal tension, as the increased awareness of symptoms is accompanied by a rejection or alienation from one's own body. This discrepancy can cause a symptom-reinforcement cycle and possibly worsen the suffering. Furthermore, the theme of increased states of dissociation indicates a potential tendency toward increased dissociation. In some cases, the focus on introspective experiences (e.g. by concentrating on breathing) can be so overwhelming that the patient’s established pattern of splitting feelings, thoughts or behaviours away from themselves may increase. Hence the present study brings to light a paradoxical effect. Focussing on internal processes can lead to increased awareness of symptoms, which may be reported as an increase in experienced symptoms. This can potentially be detrimental if it only leads to reinforcing dissociative tendencies. Some studies mention the phenomenon of the so-called "mindfulness paradox" (cf. e.g. Shapiro et. al. 2018). On the one hand, there is evidence that the increase and intensification of symptoms are limited to a short initial phase. However, the participants had been practising for an average of M= 11 years ( SD=9 .2 years). On the other hand, Anonymized (2019) points out that challenging experiences must be viewed in the context of developmental processes that may unfold over decades. Our study provides a cross-section at one point in time; future long-term studies with developmental trajectories of those affected by PTSD may create a clearer picture of patterns and trajectories. In her research, Marianne Bentzen, co-founder of the theory of neuroaffective developmental psychology (NADP), builds a bridge between brain development, trauma theory and evolutionary psychology. In her most recently published work "Neuroaffective Meditation" (2021), she suggests that trauma leads to a paradoxical neuroaffective activation with a state of maximum arousal (sympathetic activity) and simultaneous maximum immobility (parasympathetic activity). Through the findings of Newberg et al. (2002), who discovered that both systems can be highly active together during spiritual (opening) states in the brain organisation, Bentzen drew an exciting connection: the similar brain activation during meditation seems to put the nervous system of traumatised people back into survival mode. It is possible that the neuroaffective states are important markers and explanations for the negative effects experienced. She suggests actively moving out of the states of highest activation during meditation and gradually levelling the nervous system into the new experience with regulatory options such as stretching (movements) (Bentzen et al., 2021). Regulatory options therefore appear to play a central role in the context of PTSD sufferers. The third theme, overwhelming confrontation , which had similarly high coding rates as increased symptom awareness, indicated that the intense focus on the inner experience without external regulation options can lead to a renewed immersion in traumatic experiences. Our study indicates that one needs to be cautious when using meditation in the context of PTSD, even though meditation holds potential for strong potential benefits. The analysis revealed various solutions that may positively counter the detrimental effects. Figure 2 gives an overview of possible influencing factors. Support appears to be a very important factor for dealing with risks or side effects and is the theme with the highest coding rate. Support refers to the help that the therapist can provide through different regulation options. Guided meditations by trained professionals are perceived as particularly helpful. The presence of a psychotherapist or meditation teacher with meditation experience, someone who goes beyond practical guidance to create an environment for reflection and categorisation of the challenges, is an equally supportive coping approach. The autonomic nervous system may be seen as being positively impacted by providing connection and reassurance through the voice or presence of a trusted person. In addition, the theme of discontinuing the meditation emphasises that it may be advisable to end the meditation session in the event of excessive stress or the occurrence of negative effects. The decision to carry out meditation should be based on individual stability and existing coping mechanisms in order to protect patients from further excessive strain. One psychotherapist interviewed recommends a graduated approach in line with Bentzen. Changing the appraisal is another possible solution. This involves not viewing challenges that arise exclusively as negative effects, but rather perceiving them as opportunities for personal growth and interpreting them as an integral part of the healing process. This reinterpretation seems to help patients to categorise difficult experiences during meditation as important components of their therapeutic progress. In current meditation research, the extent to which negative experiences are essential for growth is being considered and the inclusion of the traditional contemplative perspective seems fundamental (Anonymized, 2023; Anonymized., 2024). It needs to be underlined that reactions and effects are always individual experiences. Nevertheless, the present work makes it clear that both positive and negative effects can be identified across individuals. Further research is essential to minimise potential risks. From the discussion above, the following hypothesis was generated: Three specific possible solutions, support, discontinuation the meditation and changing the appraisal, positively counters the negative effects and challenges experienced by people using in meditation as part of PTSD-treatment. 4.4 Effects of meditation on the psychotherapeutic process for PTSD The present study explored how meditation specifically affects the psychotherapeutic process. The theme of differentiated introspection focuses on important aspects that are particularly relevant for therapy. By increasing the ability for inner self-observation and mindfulness, intrapsychic processes can be perceived, identified and regulated more consciously. As a result, those affected seem to be able to examine and verbalise their PTSD symptoms more precisely during the psychotherapeutic process. A randomised controlled trial published in 2020 identified increased introspective insight as a potentially fundamental mechanism of action for mindfulness-based and other psychological interventions (Nyklíček et al., 2020). Our analysis confirmed this and showed how introspection can positively influence the course of therapy and the treatment of symptoms. Furthermore, research indicates that mindfulness-based therapies contribute to the development of metacognitive awareness, which does not resolve the content of the symptoms, but rather changes the relationship to the experienced content (cf. Teasdale et. al., 2002). The study uses the category of the meta-level to show that the combination of meditation and psychotherapeutic intervention can lead to the development of increased metacognitive and meta-emotional competence. This enables a distanced perspective on trauma-related thoughts and feelings. Hypothetically, it is precisely this internal distancing that could explain the altered relationship to the symptomatic content. In addition, metacognitive skills appear to make a relevant contribution to the depth and effectiveness of psychotherapeutic treatment. The therapists interviewed described how metacognitive and meta-emotional skills make it easier to identify and modify maladaptive trauma structures within therapy. That resource activation is a primary and essential active principle of psychotherapy has been empirically and extensively documented (Grawe & Grawe-Gerber, 1999; Grawe, 2004; Beesdo-Baum 2011; Willutzki & Teismann, 2013; Fiedler 2017). The focus is on a person's existing abilities and possibilities, which make a significant contribution to change processes (cf. e.g. Willutzki & Teismann, 2013). Resource activation is also important for trauma treatment, as those affected may have little to no access to their protective capacities. Resource activationindicates that meditation practice promotes an increased coping capacity and a reduction in immediate emotional involvement. Thus, PTSD patients seem to draw on the effects of meditation, such as self-regulation and agency, within the psychotherapeutic process and thereby address the underlying painful issues. In addition to resource activation, Grawe has identified so-called problem actualisation as a further effective factor of psychotherapy (Grawe, 2004). This principle of real-life experience means that implicit patterns of meaning are actualised in therapy and made tangible. At the same time, they stimulate an essential process of change. Meditation can possibly be classified as an important support option to promote the process of problem actualisation. The final theme of theme actualisation emphasises the potential use of meditation experiences as a way into relevant themes within psychotherapy, as these experiences may exemplify psychological patterns connected to PTSD. Meditation appears to make a valuable contribution to bringing out and actualising hidden (unconscious) themes. Within the therapeutic relational experience, meditation experiences can therefore act as a catalyst for extended clarification and processing. Research on psychotherapeutic processes is a highly complex phenomenon. It deals with the question of impact factors, mechanisms and changes that take place during psychotherapy and within the therapeutic relationship. This complexity is due to the large number of variables, such as the therapeutic approach, individual characteristics, relationship characteristics, and duration of treatment. Taking this complexity into account is important when ensuring the quality of psychotherapy (Orlinsky et. al, 2004; Lutz et. al., 2019). The themes of differentiated introspection, meta-level, resource activation and theme actualisation offer guidance for understanding how meditation may work in combination with psychotherapy in the context of PTSD treatment. Further research is vital to understand the specific mechanisms and uncover possible mediators and moderators. Based on the research by Lee et al., the competencies of psychotherapists in accompanying meditation with PTSD sufferers are also a promising field of research. The findings open up new possibilities for the application and implementation of meditation within clinical trauma treatment. The following hypothesis was generated based on the above discussion: In the context of PTSD, meditation can positively influence the effectiveness of the psychotherapeutic process through the following effects: Differentiated introspection, meta-level, resource activation and theme actualisation In the popular work "Trauma-Sensitive Mindfulness", David A. Treleaven (2018) pointed out that people suffering from trauma seem particularly attracted to the potential benefits of meditation practices. This study has investigated the ways in which meditation may impact the therapeutic process. While meditation is a promising tool for several reasons, potential risks must also be considered. These risks may be inherent in the process. For example, meditation may uncover underlying aspects of traumatic experiences, which may represent an opportunity for therapy, but could also be overwhelming and lead to re-traumatization. Hence, the therapists may play a vital role in adequately preparing and supporting those affected to avoid these risks and to ensure that the approach provides overall benefit. Declarations Informed Consent All participants gave written informed consent. Author Contribution Melina Schwab and Terje Sparby contributed to developing the research question and methodology. Melina Schwab conducted the interviews. Melina Schwab and Terje Sparby conducted the analysis. Melina Schwab author wrote the initial draft. Terje Sparby and Ulrich W. Weger reviewed and edited the draft. All authors approved the submitted version. Data Availability The interview transcripts are not publicly available in order to protect the identities of the participants. Requests may nonetheless be directed to the corresponding author and the IRB at Witten/Herdecke University. References Ahn, J. Y. Meditation sickness. In Oxford University Press eBooks . 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The Theoretical and Empirical Basis for Meditation as an Intervention for PTSD. Behav. Modif. 36 (6), 759–786. https://doi.org/10.1177/0145445512441200 (2012). Lee, K. C. et al. (eds) (George),,& Buddhist counselling: Implications for mental health professionals. Spirituality in Clinical Practice , 4 (2), 113–128. (2017). https://doi.org/10.1037/scp0000124 Lepak, M. M. & Carson, G. D. Presence psychotherapy: A novel integrative trauma treatment model for thorough memory reconsolidation. J. Psychother. Integr. 32 (4), 426–442. https://doi.org/10.1037/int0000273 (2022). Lindahl, J. R. & Britton, W. B. I have this feeling of not really being here: Buddhist meditation and changes in sense of self. J. Conscious. Stud. 26 (7–8), 157–183 (2019). Lindahl, J. R., Fisher, N. E., Cooper, D. J., Rosen, R. K. & Britton, W. B. The varieties of contemplative experience: A mixed-methods study of meditation-related challenges in Western Buddhists. PLoS ONE . 12 (5), e0176239. https://doi.org/10.1371/journal.pone.0176239 (2017). Lutz, W., Neu, R. & Rubel, J. Evaluation and effect assessment in psychotherapy (1st ed.). Hogrefe. (2019). https://doi.org/10.1026/02912-000 MAXQDA. software for qualitative data analysis, 1989–2023, VERBI Software. Consult. Sozialforschung GmbH, Berlin, Germany. Mayring, P. Qualitative Content Analysis: Basics and Techniques (12th, revised edition). Beltz. (2015a). Mayring, P. Qualitative Content Analysis: Basics and Techniques (12th, revised edition). Beltz. (2015b). Mayring, P. Qualitative content analysis. In G. Mey & K. Mruck (Eds.), Handbook of Qualitative Research in Psychology (pp. 495–511). Springer Fachmedien Wiesbaden. (2020). https://doi.org/10.1007/978-3-658-26887-9_52 Mayring, P. & Fenzl, T. Qualitative content analysis. In N. Baur & J. Blasius (Eds.), Handbook of methods in empirical social research (pp. 633–648). Springer Fachmedien. 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Fifty years of psychotherapy process-outcome research: Continuity and change. In Bergin and Garfield's Handbook of Psychotherapy and Behaviour Change (5th Edition, pp. 307–390). Wiley. (2004). Parmentier, F. B. R. et al. Mindfulness and Symptoms of Depression and Anxiety in the General Population: The Mediating Roles of Worry, Rumination, Reappraisal and Suppression. Front. Psychol. 10 , 506. https://doi.org/10.3389/fpsyg.2019.00506 (2019). Patton, M. Q. Qualitative Research & Evaluation Methods: Integrating Theory and Practice (SAGE, 2014). Possemato, K. et al. Randomised Clinical Trial of Brief Primary Care-Based Mindfulness Training Versus a Psychoeducational Group for Veterans With Posttraumatic Stress Disorder. J. Clin. Psychiatry . 84 (1), 44829 (2022). Preece, R. Preparing for Tantra: Creating the Psychological Ground for Practice (Snow Lion, 2011). Pseftogianni, F., Panagioti, M., Birtwell, K. & Angelakis, I. Mindfulness interventions for obsessive-compulsive and related disorders: A systematic review and meta-analysis of randomised controlled trials. Clin. Psychol. Sci. Pract. 30 (3), 233–243. https://doi.org/10.1037/cps0000132 (2023). Querstret, D., Morison, L., Dickinson, S., Cropley, M. & John, M. Mindfulness-based stress reduction and mindfulness-based cognitive therapy for psychological health and well-being in nonclinical samples: A systematic review and meta-analysis. Int. J. Stress Manage. 27 (4), 394–411. https://doi.org/10.1037/str0000165 (2020). Schreier, M. Case selection. In G. Mey & K. Mruck (Eds.), Handbook of Qualitative Research in Psychology: Volume 2: Designs and Procedures (pp. 19–39). Springer Fachmedien. (2020). https://doi.org/10.1007/978-3-658-26887-9_19 Shapiro, S., Siegel, R. & Neff, K. D. Paradoxes of Mindfulness. Mindfulness 9 (6), 1693–1701. https://doi.org/10.1007/s12671-018-0957-5 (2018). Steinke, I. in A Companion to Qualitative Research . (eds Flick, U. & von Kardoff, E.) (SAGE, 2004). Steinke, I. Quality criteria of qualitative research. In U. Flick, E. von Kardorff, & I. Steinke (Eds.), Qualitative Research: A Handbook (14th ed., original edition). Rowohlts Enzyklopädie im Rowohlt Taschenbuch Verlag. (2022). Teasdale, J. D. et al. Metacognitive awareness and prevention of relapse in depression: Empirical evidence. J. Consult. Clin. Psychol. 70 (2), 275–287. https://doi.org/10.1037/0022-006X.70.2.275 (2002). Tran, U. S. et al. Self-reported mindfulness accounts for the effects of mindfulness interventions and nonmindfulness controls on self-reported mental health: A preregistered systematic review and three-level meta-analysis of 146 randomised controlled trials. Psychol. Bull. 148 (1–2), 86–106. https://doi.org/10.1037/bul0000359 (2022). Treleaven, D. A. Trauma-sensitive mindfulness: Practices for safe and transformative healing (First edition) (W. W Norton & Company, 2018). Vujanovic, A. A., Niles, B., Pietrefesa, A., Schmertz, S. K. & Potter, C. M. Mindfulness in the treatment of posttraumatic stress disorder among military veterans. Prof. Psychology: Res. Pract. 42 (1), 24–31. https://doi.org/10.1037/a0022272 (2011). Waelde, L. C., Thompson, J. M., Robinson, A. & Iwanicki, S. Trauma Therapists' Clinical Applications, Training, and Personal Practice of Mindfulness and Meditation. Mindfulness 7 (3), 622–629. https://doi.org/10.1007/s12671-016-0497-9 (2016). Willutzki, U. & Teismann, T. Resource activation in psychotherapy (Hogrefe, 2013). Additional Declarations No competing interests reported. Supplementary Files Appendix.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6369237","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":457956416,"identity":"384c08f0-6af1-486b-9d46-5f96aaec78e5","order_by":0,"name":"Melina Schwab","email":"","orcid":"","institution":"Witten/Herdecke University","correspondingAuthor":false,"prefix":"","firstName":"Melina","middleName":"","lastName":"Schwab","suffix":""},{"id":457956417,"identity":"b76abc47-3163-4da2-a74f-f7a8e4a1cca7","order_by":1,"name":"Ulrich W. Weger","email":"","orcid":"","institution":"Witten/Herdecke University","correspondingAuthor":false,"prefix":"","firstName":"Ulrich","middleName":"W.","lastName":"Weger","suffix":""},{"id":457956418,"identity":"38268a5b-cf26-45cc-bd0d-d9a55b39b163","order_by":2,"name":"Terje Sparby","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA/UlEQVRIiWNgGAWjYJACAwjFw8DwAUixsRNQzoOshXEGSAszEVrgTGYwj5AWe/beBwUfGOry+GefPSZt82ubPB8zA+OHjzl4bOE5bmA4g+FwscS5vDTp3L7bhm3MDMySM7fh0SKRxmDMw3AgseEMj5l0bs9tRqAWNmZefFrknzEY/2GoS5wP0mLZc9uesBYJNgZjoJcTN4C0MPy4nUhYy5k0BsMeg8PFhmf4ki17G24ntzEzNuP1C3v7MTaDHxV1eXJneA/e+PHntu389uaDHz7i0QIEbAbAyEwAMlgkGNtAAowNeNUDAfMDIAHSwvyB4Q8hxaNgFIyCUTASAQDjG0hPp7pZtwAAAABJRU5ErkJggg==","orcid":"","institution":"Rudolf Steiner University College","correspondingAuthor":true,"prefix":"","firstName":"Terje","middleName":"","lastName":"Sparby","suffix":""}],"badges":[],"createdAt":"2025-04-03 12:23:07","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6369237/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6369237/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":83051332,"identity":"4f851dcc-af6c-409b-914b-2d72caad308b","added_by":"auto","created_at":"2025-05-19 12:41:45","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":56398,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eModel of the effect mechanisms of meditation in PTSD\u003c/em\u003e. Meditation in particular impacts the bodily sensations, feelings, thoughts, and appraisals through different processes such as calming of the autonomic nervous system. This affects the stimulus/reaction pattern and expands the scope of action.\u003c/p\u003e","description":"","filename":"Picture1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6369237/v1/5122f54a9759b7035825ac61.jpg"},{"id":83050362,"identity":"14903d77-c714-40b7-ab72-e878ca6ba46a","added_by":"auto","created_at":"2025-05-19 12:33:45","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":51723,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eInfluence of possible solutions on negative effects/challenges\u003c/em\u003e. This figure gives an overview of different ways to meet challenges that may arise when usnig medtiation in the context of PTSD.\u003c/p\u003e","description":"","filename":"Picture2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6369237/v1/a159be9ae33734312f94b834.jpg"},{"id":98621866,"identity":"95cfc21f-23eb-4221-b311-c88a6e5accd7","added_by":"auto","created_at":"2025-12-19 16:26:42","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1217057,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6369237/v1/6adb016f-7d6d-43d5-ae2f-ed58fa96ed79.pdf"},{"id":83050359,"identity":"fefb741b-3941-469a-9c90-924be845eb61","added_by":"auto","created_at":"2025-05-19 12:33:45","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":39797,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix.docx","url":"https://assets-eu.researchsquare.com/files/rs-6369237/v1/aa43e0f43215705c4aeb9594.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"The Effect of meditation in combination with psychotherapy in the context of PTSD. An explorative qualitative study","fulltext":[{"header":"1 Introduction","content":"\u003cp\u003e\u003cem\u003e\"The wound is the place where the light enters you.\" Rūmī (as quoted in Barks, 2004, p. 82).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe beneficial effect of meditation on mental health has been extensively researched in recent decades (Grossman et. al., 2004; Boccia et al., 2015; Tran et al. 2022). There is ample evidence of the effectiveness of meditation and mindfulness, particularly for mental illnesses such as depression and anxiety disorders (Parmentier et. al., 2019; Carpena et al. 2019). There is also a recognisable clinical interest among experts in the effects of meditation on post-traumatic stress disorder (PTSD). However, there are, as we will show, gaps in the research and potential effects are the subject of controversial debate. The studies predominantly provide evidence in favour of a beneficial effect of meditation on PTSD. For example, the attention processes that are trained through meditation practices are said to lead to a general reduction in emotional and physiological arousal and improved emotion regulation (Lang et al., 2012). Furthermore, there is a growing number of studies suggesting that regular practice, particularly of mindfulness meditation, leads to a reduction in PTSD symptoms (Heffner et. Al. 2016; Davis. Et al. 2018; Possemato et. Al. 2022). Focussing on the present moment seems to restore a sense of control and safety to those affected and reduce dissociative and overwhelming feelings (cf. e.g. Lee et. Al., 2017). There are also signs of changes in the ability to relate to others and a reduction in feelings of isolation caused by the trauma (Myers et. Al. 2015). The increasing number of publications on the feasibility and effectiveness of meditation programmes for veterans affected by PTSD is particularly striking. A meta-analysis published in 2016 by Heffner et. al. summarised the study results. Using data from six multi-site mental health services of the Department of Veterans Affairs in the USA, various meditation programmes were examined for their effect sizes before and after implementation in comparison with standard programmes. The results show mean effect sizes in the following areas: severity of PTSD symptoms =.32, general mindfulness =.41 and non-reactivity to inner experiences =.37. The specific meditation programmes and the termination of the programme were identified as potential moderators of the effect sizes. For example, mantra-based programmes show significant effects on the level of general trait mindfulness, whereas mindfulness-based programmes show stronger effects on non-reactivity toward inner experiences (Heffner et. al., 2016). Current global political conflicts emphasise the urgent need for further research in the field of post-traumatic stress disorder. Initial studies suggest increasing prevalence rates of PTSD in war zones (Karatzias et al., 2023). Previous research also emphasise the need for high-quality qualitative studies to deepen understanding and identify unanswered questions (Hilton et al. 2016). Qualitative research not only gives an overview of the spectrum of experiences, but also contributes to understanding contextual factors and identifying individual aspects that may influence the effectiveness of meditative approaches in combination with PTSD. This allows for more specific recommendations and individual tailoring of meditation interventions.\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn contrast to these predominantly positive results, researchers warn of possible risks and negative effects of meditation in clinical settings. Lindahl and Britton (2017; 2019) criticises\u0026nbsp;the inadequate investigation of potentially challenging, stressful or difficult experiences. In a research project, Lindahl and Britton examined a subgroup of a sample of 120 meditation practitioners and meditation experts with years of daily practice for affective changes related to \u0026nbsp;re-experiencing traumatic content. Some of the practitioners understood the traumatic content in relation to the tantric soteriology of purification, which is a normative framework that gives traumatic content positive significance. In contrast, those affected by a history of trauma did not understand the traumatic re-experiencing as purification and sought additional psychotherapeutic or psychiatric treatment (Lindahl and Britton?? See above, 2017). These results show the need for further differentiation of the effect of meditation in relation to the treatment of people with PTSD. While the study is limited in its representativeness, it nevertheless also points to possible risk factors, such as an increased experience of dissociation through the use of meditation in the context of PTSD.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMeditation research may be understood as having gone through different phases (cf. Chowdhury et. al. 2023). While the first phase focused on beneficial effects while disregarding potential negative effects, the second wave focusses specifically on different types and the prevalence of potential negative effects (Anonymized, 2024). The assessment of potential adverse effects is complex and emphasises the need for a differentiated and multidimensional approach (Britton et. al. 2021). Goldberg et al. (2022) suggest that so-called MRAEs (\u003cem\u003emeditation-related adverse effects\u003c/em\u003e) need to be recorded in their full range of severity. In their study, the research team found that individual trauma experiences can possibly influence the response to meditation. Those who had gone through stressful childhood experiences had a 25.8% chance of re-experiencing trauma in connection with their meditation practice. The results suggest that the effect of meditation in the context of PTSD needs to be investigated specifically with regard to uncovering the potential influence of individual traumatic experiences and reactions on meditative practices. A comprehensive understanding and sufficient information about possible risk factors is necessary, both for those affected and for clinicians (Goldberg et al., 2022). Meditation practices, which have been handed down over thousands of years in different traditions, also have different views about how to categorise, interpret and cope with challenging experiences. These views may contrast with the Western cultural understanding of illness and health (Lindahl, 2017), though traditional views also include ideas such as “meditation sickness” (Ahn, 2020), indicating that there is an understanding of challenging aspects of mediation practice in the traditions that current research has yet to integrate.\u003c/p\u003e\n\u003cp\u003ePeople who experience psychological trauma are confronted with experiences that lie outside their normal system of meaning, which overwhelm the nervous system and existing coping strategies, and consequently impair psychosocial functioning (Lepak \u0026amp; Carson, 2021, p. 429). According to the Western perspective and the current findings of the American Psychiatric Association (2023), post-traumatic stress disorder (PTSD) can develop as a result of experiencing an incisive traumatic event or a series of such events. These events are often perceived as harmful or life-threatening, whether emotionally or physically. Examples include serious accidents, terrorist attacks, wartime experiences, natural disasters or violence. The diagnosis of PTSD is characterised by the globally established DSM-5® diagnostic system through characteristic groupings of symptoms\u003cem\u003e:\u0026nbsp;\u003c/em\u003e(1) \u003cem\u003ere-experiencing\u0026nbsp;\u003c/em\u003ein vivid form (e.g. flashbacks), (2) \u003cem\u003eavoidance behaviour\u0026nbsp;\u003c/em\u003eas expressed in thoughts and feelings or associated with the traumatic event, (3) \u003cem\u003eperception of a present threat\u0026nbsp;\u003c/em\u003e(e.g. excessive vigilance), (4) \u003cem\u003eincreased emotional reactivity\u0026nbsp;\u003c/em\u003e(e.g. dissociations), (5) \u003cem\u003enegative self-beliefs\u0026nbsp;\u003c/em\u003e(e.g. a feeling of worthlessness), (6) \u003cem\u003edifficulties in social relationships\u0026nbsp;\u003c/em\u003e(Falkai et al. 2018). In cases of complex PTSD, the experiences have usually occurred repeatedly over a period of years, and the manifestations of symptoms such as negative self-beliefs and difficulties in social relationships are more pronounced (cf. Kazlauskas et al. 2018). The effects can occur in people of different ethnic backgrounds and at any age. The prevalence rate for adolescents between the ages of 8 and 13 is 8%, and in the U.S. total population 3.5% are diagnosed with PTSD each year. Women are about twice as likely as men to be diagnosed, as are ethnic minorities (American Psychiatric Association, 2023).\u003c/p\u003e\n\u003cp\u003eLinks to Eastern traditions and meditation can be found early in the history of psychology and psychotherapy. Important figures such as Carl Gustav Jung, co-founder of analytical psychology, were in contact with Daisetzu Teitaro Suzuki, who contributed significantly to the spread of Zen Buddhism in the West. Pioneers such as Charlotte Selver recognized the growth potential inherent in mindful awareness of the here and now and integrated it into therapeutic work (Huppertz, 2003; Bohus \u0026amp; Huppertz, 2006). With their increasing popularity from the 1960s onwards, traditional meditation practices found their way exponentially into psychology and psychotherapy. Well-known mindfulness-based therapy approaches such as MBSR (\u003cem\u003eMindfulness-Based Stress Reduction),\u0026nbsp;\u003c/em\u003eMBCT (\u003cem\u003eMindfulness-Based Cognitive Therapy\u003c/em\u003e) and ACT \u003cem\u003e(Acceptance and Commitment Therapy)\u0026nbsp;\u003c/em\u003ehave established themselves as effective methods for various mental illnesses. There is ample evidence of their effectiveness (Dawson et. al. 2020; Querstret et. al. 2020; Pseftogianni et. al. 2023), though the specific mechanisms of action do not appear to be clearly understood (Bohus \u0026amp; Huppertz, 2006; Alsubaie et. al. 2017).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn the context of PTSD, psychotherapy plays an important role in alleviating symptoms and processing the trauma experienced. Initial approaches for the integration of meditative practices into trauma treatment exist, but these are limited in their representativeness and generalisability (Vujanovic et. al., 2011; Lee et. al. 2017). In addition, the necessary competencies of psychotherapists seem to be neglected (Waelde et. al. 2016). To our knowledge, no research currently exists that addresses the specific effects meditation may have on the psychotherapeutic process in the context of PTSD. The mechanisms of action are also unknown. There may be a strong potential benefit inherent in the combination of meditation and psychotherapy, and yet it remains unanswered whether specific synergy effects can be identified. When reviewing the scientific debate on trauma-related disorders, it quickly becomes clear how delicate this topic is, involving for example the potential for re-traumatization during therapy, and that the potential risk factors for the use of meditation need to be sufficiently clarified. However, it is possible that accompanying psychotherapy can lead to a reduction in negative effects. Preece hypothesizes that psychotherapeutic trauma treatment may be necessary when meditation-based techniques are used as interventions for PTSD (Preece, 2011). As already discussed, it seems essential that both clinicians and the affected persons themselves receive sufficient education and a comprehensive understanding (Goldberg et al., 2022).\u003c/p\u003e\n\u003cp\u003eThe research gap identified above led to formulation of four research questions that are to be investigated in this study. To our knowledge, this is the first time explorative qualitative research examines the combination of meditation and psychotherapy in the treatment of PTSD. Qualitative research offers a person-centred approach that is likely to do justice to the complex nature of trauma and the individual experiences of the people affected. The research questions are:\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003eWhat is the effect of meditation on PTSD?\u003c/li\u003e\n \u003cli\u003eCan changes in PTSD symptoms be observed through the practice of meditation?\u003c/li\u003e\n \u003cli\u003eCan risks or challenging effects be identified when practicing meditation in the context of PTSD?\u003c/li\u003e\n \u003cli\u003eWhat effects does meditation have on the psychotherapeutic process in the context of PTSD?\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"2 Study design and method","content":"\u003cp\u003eThe qualitative research design was developed based on the work of Mayring and Flick et al. (2013, 2019). The choice of an explorative qualitative design was motivated by the very limited state of knowledge. The criteria for participant recruitment were developed according to the logic of criterion-guided sampling, with the aim of achieving heterogeneity (Schreier, 2019). Two main groups were approached: persons in psychotherapeutic treatment and psychotherapists, as both provide vital perspectives on the psychotherapeutic process. The participants were acquired through a combination of online research, personal contacts and the snowball method. Potential participants were contacted over email. The participants were selected according to the main criterion of being affected by PTSD and having practised meditation regularly for at least one year. Participation in current psychotherapeutic treatment was another criterion. The psychotherapists recruited had experience in dealing with PTSD patients who practise meditation and/or had in-depth knowledge of meditation themselves. People with physical or mental impairments that could make the interviews more difficult were excluded from the study. The participants received sufficient information about the study project, the process and data protection, including pseudonymisation. Over a period of three months, the interviews were conducted either in person or via the video conferencing software \"Zoom\". The study was approved by the ethics committee of Witten/Herdecke University (No. 225/2022) and the study was conducted in accordance with the relevant guidelines and regulations.\u003c/p\u003e\n\u003ch2 id=\"_Toc143768921\"\u003e2.1\u0026nbsp; \u0026nbsp; \u0026nbsp;Description of the sample\u003c/h2\u003e\n\u003cp\u003eA total of \u003cem\u003eN=\u0026nbsp;\u003c/em\u003e11 participants took part in the qualitative interviews. The affected PTSD patients (\u003cem\u003eN=\u0026nbsp;\u003c/em\u003e7) experienced one or more traumatic events in their childhood or adulthood. Of these, 85.7% identified themselves as female and 14.3% as male, with an age range of 24 to 71 years (\u003cem\u003eM=\u0026nbsp;\u003c/em\u003e45.57 years, \u003cem\u003eSD=\u0026nbsp;\u003c/em\u003e18.08). The diagnosis was made at the beginning of therapeutic counselling and the patients had been in therapy for an average of \u003cem\u003eM=13\u003c/em\u003e.57 years (\u003cem\u003eSD=8\u003c/em\u003e.75 ). Of these, 71.5% were in behavioural therapy (BT) and 28.5% in therapy based on depth psychology (DP). The accompanying therapists had additional training in trauma therapy (e.g. \u003cem\u003eEye Movement Desensitization and Reprocessing\u003c/em\u003e (EMDR )). All participants had been practising various forms of mindfulness meditation for an average of \u003cem\u003eM=\u0026nbsp;\u003c/em\u003e11 years (\u003cem\u003eSD=9\u003c/em\u003e.2 years): 71.4 % mixed forms of various forms of mindfulness meditation, 14.3% metta meditation, and 14.3% mantra meditation. 71.4% favoured guided meditation. In terms of practice, 42.9% indicated individual practice (I), 14.3% group practice (G) and 42.9% a combination of individual and group practice (I+G). Support from meditation teachers was received by 42.9%, while 57.1% stated no support.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe experts (licensed psychotherapists) had many years of experience with PTSD patients, on average \u003cem\u003eM=\u0026nbsp;\u003c/em\u003e18.75 years (\u003cem\u003eSD=8\u003c/em\u003e.8). The gender ratio in this group of participants was heterogeneous, with 50% identifying as female and 50% as male. The average age was \u003cem\u003eM=52\u003c/em\u003e.25 years (\u003cem\u003eSD=12\u003c/em\u003e.5). \u0026nbsp; In addition to their many years of meditation experience averaging 20 years (SD=5.84), 25% of the psychotherapists were trained in BT and 75% in DP, were also certified MBSR/MBCT teachers, or had published books/articles on meditation.\u0026nbsp;\u003c/p\u003e\n\u003ch2 id=\"_Toc143768922\"\u003e2.2\u0026nbsp; \u0026nbsp; \u0026nbsp;Data collection\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eGeertz, an anthropologist and proponent of explorative questioning, argues in favour of immersing oneself in the complexity of phenomena: “(...) the analysis of culture is not an experiment in searching for hidden motives, but an experiment in understanding meanings\" (Geertz, 1973, p. 93) The semi-structured qualitative interview, which is particularly widespread in social research, endeavours to gain a more comprehensive understanding and deeper insights into a research topic. In contrast to fully structured interviews, in which the questions are determined in advance, the semi-structured interview offers greater flexibility and room for exploration. Based on the research purpose, the aim was to collect rich data that delves deeper into the phenomenology of experiences (May \u0026amp; Mruck, 2020; Flick, 2008). An interview guide was designed to provide orientation for asking questions relevant to the research questions. This guideline is divided into sections A (affected persons, 19 questions) and B (experts, 17 questions). The focus was on personal experiences with meditation in relation to post-traumatic stress disorder. In addition to the effects on the psychotherapeutic process, the interviews also considered potential challenges and risks. Open questions helped to encourage the participants to provide unknown perspectives and a trusting atmosphere offered the participants the opportunity to freely share their individual, subjective experiences. The interviewer reacted flexibly to follow-up on spontaneously arising topics of conversation (Flick, 2008; Flick et al., 2013). To support the sense of safety of those in the affected group, personal trauma was not discussed. The interviews were originally conducted in German.\u003c/p\u003e\n\u003ch2 id=\"_Toc143768924\"\u003e2.3\u0026nbsp; \u0026nbsp; \u0026nbsp;Data processing and analysis\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eAfter creating RTF transcripts using the \"f4-transcription\" software, the interview management transferred the data to the MAXQDA programme (VERBI SOFTWARE, 2022). From then on, the systematic data analysis was based on structured qualitative content analysis, following the procedure described by Mayring (2015; 2020). According to the bibliometric results of Carrera-Fernández et. al. (2014), qualitative content analysis is one of the most widely used text analytical methods. This analysis method enables large verbal data to be reduced into categories that are representative in terms of content. The text analysis focuses on constructing a category system oriented towards the research questions. Mayring developed a strictly rule-based procedure of analysis based on the techniques of \u003cem\u003esummarisation\u003c/em\u003e, \u003cem\u003eexplication\u0026nbsp;\u003c/em\u003eand \u003cem\u003estructuring.\u0026nbsp;\u003c/em\u003eThe present analysis followed on the \"process model\" designed by Mayring (for more details: Mayring, 2015, pp. 70-72). Accordingly, the interview guide offered the opportunity to form initial deductive categories, but the focus of the analysis was on the actual data available. Only text passages relating to the effect of meditation in post-traumatic stress disorder in combination with psychotherapy were analysed). The smallest units that could be coded were parts of sentences as whole units of meaning. The extracted text passages were rewritten in a descriptive form to create paraphrases. Different units of meaning were combined to form an inductive category system. In contrast to the purely deductive approach, inductive category formation offers openness during implementation, which minimises bias and preconceptions on the part of the researchers. Furthermore, a lack of concrete theories and concepts necessitates the predominantly inductive approach (cf. e.g. Mayring, 2015). Categories were gradually developed from the initial material and the level of abstraction was successively increased. The aim of inductive category formation was to summarise relevant aspects of the research topic as precisely as possible. A comparison was made between the source material and the categories formed by means of a repeated review. The criterion of saturation determines the end point of the data analysis. Saturation is reached when no new data or insights are added with regard to the phenomenon being researched. In this research work, saturation could be achieved within the predefined sample size and within the scope of the survey content (Schreier, 2019).\u003c/p\u003e\n\u003ch2 id=\"_Toc143768926\"\u003e2.4\u0026nbsp; \u0026nbsp; \u0026nbsp;Quality of the study\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eThe views on what constitutes high-qualitative research vary depending on the research tradition, theoretical approach, methodology, and research question. This diversity is due to the flexible and context-dependent nature of qualitative studies (Patton, 2014). Despite diverse views, there is consensus regarding principles that ensure quality. These include care in collecting and analysing data, critical reflection on one's own assumptions and transparency in documenting the research process (cf. e.g. May \u0026amp; Mruck, 2020). The researcher endeavoured to fulfil the fundamental principle of intersubjective comprehensibility (Steinke, 2022). Before the study was conducted, a research design was developed, different methodological approaches were discussed, and an interview guide was developed. Clear transcription rules were drawn up. To ensure reliability, the set of rules and the systematic approach to the analysis were applied uniformly in all interviews. The determination of interrater reliability helped to determine the degree of reliability using a second independent coder.\u0026nbsp;\u003c/p\u003e"},{"header":"3 Results","content":"\u003cp\u003eThe analysis of the eleven collected interviews led to the generation of six superordinate clusters based on the research questions, each of which is characterised by different topics, referred to as \u0026ldquo;subcodes\u0026rdquo;. The key findings of the qualitative analysis are presented below and provide an in-depth insight into the interview data obtained. Table 1 below provides an overview of the key results and frequency of codes (for all other results tables, see appendix). When affected participants are cited in the following, reference will be made to \u0026ldquo;P\u0026rdquo; for the participant number, and then the paragraph of the transcript (for example, \u0026ldquo;P1, para. 12\u0026rdquo;, refers to the 12\u003csup\u003eth\u003c/sup\u003e paragraph of the transcript of the interview with participant number 1). Psychotherapists will be referred to similarly, replacing \u0026ldquo;P\u0026rdquo; with \u0026ldquo;T\u0026rdquo;.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1\u0026nbsp;\u003c/strong\u003e\u003cem\u003eCode system with superordinate clusters and associated subcodes\u003c/em\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"416\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eList of codes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFrequency\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003eNominations Total\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e416\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eBackground\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cem\u003eMeaningfulness\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cem\u003eCalming\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eDeductively identified effects PTSD symptom groups\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e136\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cem\u003eLess re-experiencing\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cem\u003eLess avoidance behaviour\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cem\u003eLess perception of present threat\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cem\u003eChange in affect regulation\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cem\u003eLess negative self-beliefs\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e37\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cem\u003eLess difficulties in social relationships\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eInductively constructed effects\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e134\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cem\u003eCalming of the autonomic nervous system\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cem\u003eExpanding scope of action\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cem\u003eTrauma disidentification\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cem\u003eAnchoring in the awareness of the present\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cem\u003eSelf-regulation\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e33\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eNegative effects/challenges\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e58\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cem\u003eIncreased symptom awareness\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cem\u003eIncreased states of dissociation\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cem\u003eOverwhelming confrontation\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eDealing with negative effects/challenges\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cem\u003eSupport\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cem\u003eDiscontinuing the meditation\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cem\u003eChanging the appraisal\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eEffects of the psychotherapeutic process\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cem\u003eDifferentiated introspective\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cem\u003eMeta-level (metacognition, metaemotion)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cem\u003eResource activation\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cem\u003eTheme actualisation\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2\u003c/strong\u003e\u0026nbsp;\u0026nbsp;\u003cem\u003eCluster: Inductively constructed effects\u003c/em\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTopic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristics\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 319px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eExample quotes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 0px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eInductively constructed effects\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e(Description of the effects of meditation on PTSD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 0px;\"\u003e\n \u003cp\u003e\u003cem\u003eCalming of the autonomic nervous system\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 0px;\"\u003e\n \u003cp\u003eBreathing deepens, lowered heart rate, physical relaxation. The autonomic nervous system changes to parasympathetic activity.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 0px;\"\u003e\n \u003cp\u003e(...) I often have this kind of pressure in my chest, which eases, so the chest and stomach area, it eases. I relax. My body relaxes and I think I breathe more calmly.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u003cem\u003eExpanding scope of action\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003eIncreased mindfulness opens up the conscious perception of trauma-related processes. The scope of action expands.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 319px;\"\u003e\n \u003cp\u003e(...) like an interested observation, but not like totally accepting everything or something, but being able to consciously choose what I accept of something. Um and the other thing is really to be able to react more calmly in precarious situations or conflictual situations.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u003cem\u003eTrauma disidentification\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003eThe ability to take the position of an observer in relation to trauma-related thoughts, feelings and behaviours and to actively follow them.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 319px;\"\u003e\n \u003cp\u003eAnd then this intermediate step happens, like a (...) like a contemplation of it [the trauma-related experience]. I can then simply look at it calmly and, for example, this self-deprecating thought or this negative emotion towards myself.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u003cem\u003eAnchoring in the awareness of the present\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003eThe ability not to be overwhelmed by trauma-related bodily sensations, feelings and images and to focus one\u0026apos;s awareness of the here and now.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 319px;\"\u003e\n \u003cp\u003eAnd I believe that this pull is weakening. So that the part [of me] that can stay here, in what is happening here right now, will have more support. In a way guardians who come, who protect me and somehow make it possible to deal with the now and not go into the past.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u003cem\u003eSelf-regulation\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003eThe ability to deal productively with and regulate emerging trauma-related feelings, thoughts and impulses.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 319px;\"\u003e\n \u003cp\u003e(...) that in situations (...) that perhaps affect or trigger the traumatic experience, that this has become an anchor point that I can consciously use. For example, to calm myself down a bit from a strong, violent physical reaction.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003ch2\u003e3.1 \u0026nbsp; \u0026nbsp; Background\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eThe main category \u003cem\u003ebackground\u0026nbsp;\u003c/em\u003efocusses on the underlying need for meditation in the context of post-traumatic stress disorder. Within the background category, two central subcategories were identified. See table 3 in the appendix for an overview.\u003c/p\u003e\n\u003cp\u003e3.1.1 Meaningfulness. In relation to \u003cem\u003emeaningfulness,\u0026nbsp;\u003c/em\u003ethe interviewees expressed a common need for a deeper meaning and a more comprehensive contextualisation of the traumatic experience. They did not wish to view their experience in isolation, but rather to embed it into a broader narrative. In accordance with this, they wanted to find a deeper meaning for themselves and their subjective suffering. One affected person stated:\u003c/p\u003e\n\u003cp\u003eAnd meditating is more about how I place myself in this world, also and how [I place myself in relation to] let\u0026apos;s say the meaningfulness, which I have always doubted (P5, para. 84).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMeditation is an opportunity for this participant to not only reconsider their own position in the world, but also to question and understand the inherent meaning of their existence. The meaningfulness that is explored through meditation became a means of overcoming doubts and uncertainties about the meaning of one\u0026apos;s own life.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e3.1.2 Calming. Longing and searching for a way to relax and regulate the heightened inner state of arousal emerged as another topic. This may be described as a key need discovered within this study. Meditation was identified as a decisive supporting factor here, with the test subjects describing the experience of calm and emotional regulation triggered by this as a significant resource. This quote from an interviewed therapist illustrates the emerging need for calming:\u003c/p\u003e\n\u003cp\u003ePeople who still have a heightened arousal, yes, they actually often wish for a method with which they can calm down a little (T1, para. 6).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis refers to the need for a method that enables people to relax and regulate their persistent inner arousal. The example quote thus also emphasises the role that meditation plays in fulfilling this need.\u003c/p\u003e\n\u003ch2\u003e3.2 \u0026nbsp; \u0026nbsp; Deductively identified effects of the PTSD symptom groups\u003c/h2\u003e\n\u003cp\u003eWithin the main category \u003cem\u003edeductively identified effects of PTSD symptom groups,\u0026nbsp;\u003c/em\u003echanges in DSM-5 symptoms through the use of meditation in PTSD could be derived. The symptom groups are categorised into five themes. See table 4 in the appendix for an overview.\u003c/p\u003e\n\u003cp\u003e3.2.1 Less re-experiencing. Within the data analysis, the category of \u003cem\u003eless re-experiencing\u0026nbsp;\u003c/em\u003emanifests itself as a significant result of meditative practice. This subcode refers to the reduction of re-experiencing traumatic events in the form of thoughts, images or feelings as well as improved differentiation between past and present. The interviewees emphasised improved psychological coping through the use of meditation. One affected person illustrates this experienced symptom reduction:\u003c/p\u003e\n\u003cp\u003eI definitely have the feeling that I have fewer flashbacks from everyday life as a result. And if I do have a triggering situation or something happens that puts me back into an experience, I can deal with it much better, in terms of finding my bearings or briefly orientating myself and telling myself that I\u0026apos;m no longer in the situation (P2, para. 32).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe quote points to a developed ability to deal with stressful situations in a different way. The reason for this appears to be a conscious anchoring in the present and a better differentiation between the past and the current reality.\u003c/p\u003e\n\u003cp\u003e3.2.2 Less avoidance behaviour. The \u003cem\u003eless avoidance behaviour\u0026nbsp;\u003c/em\u003ecategory reflects a decrease in the avoidance of situations associated with the traumatic event. At the same time, there may be an increased awareness of the avoidance process and increased self-confidence in dealing with challenging situations. In the words of one participant:\u003c/p\u003e\n\u003cp\u003eI often find myself in situations like this, where I have the feeling that God, I don\u0026apos;t really want to go there now, but I actually have to do it. Then I often take the time for myself again, meditate, collect myself a bit, get through the situation more clearly and dare to go into it (P6, para. 32).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis quote directly conveys that meditation enables the person to tackle challenges with increased clarity and a higher degree of self-confidence. The description of consciously dealing with avoided situations indicates that meditation serves as a supportive mechanism that reduces avoidance behaviour and promotes more active coping with such challenges.\u003c/p\u003e\n\u003cp\u003e3.2.3 Change in affect regulation. The identified category \u003cem\u003echange in affect\u003c/em\u003e \u003cem\u003eregulation\u0026nbsp;\u003c/em\u003ereflects the observed changes in the area of affect regulation. The changes include several modifications in the way PTSD sufferers deal with and regulate their emotions. These include a reduction of the generally heightened emotional reactivity due to PDSD, a decrease in the tendency to dissociate and feelings of numbness, and an increased awareness of one\u0026apos;s own emotional experience. In addition, meditation is said to lead to greater acceptance, processing and integration of emotions. Here is a quote that exemplifies what acceptance consists of:\u003c/p\u003e\n\u003cp\u003e(...) I experience that I can perhaps somehow hold on to difficult emotions and difficult body sensations. It\u0026apos;s no longer so unbearable for me, but I can approach it and somehow allow it (T4, para. 39).\u003c/p\u003e\n\u003cp\u003eThis quote refers to the process of improved processing ability, greater inner stability, and a more conscious confrontation with one\u0026apos;s own emotions.\u003c/p\u003e\n\u003cp\u003e3.2.4 Less perception of present threat. The category \u003cem\u003eless perception of present threat\u0026nbsp;\u003c/em\u003estands out as a significant result of meditation. The interviewees describe that the number of situations that are perceived as threatening can be reduced. At the same time, this is accompanied by an increased awareness of the process that leads to something being perceived as a threat. Those affected experience an increased feeling of security and control. This can be illustrated by the following quote:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e(...) I find more peace within myself when I meditate regularly and always have the feeling that there is still a small protective layer between me and the world. And if I don\u0026apos;t do it so much that I have the feeling that everything is immediately super threatening and super stressful (...) (P2, para. 44).\u003c/p\u003e\n\u003cp\u003eThe description that without regular meditation everything is perceived as immediately threatening emphasises the influence of meditation practice on the symptom of the perception of present threat.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e3.2.5 Less negative self-beliefs. A further change in the perceived symptoms emphasises the category of \u003cem\u003eless\u003c/em\u003e \u003cem\u003enegative self-beliefs.\u0026nbsp;\u003c/em\u003eWithin the main cluster of \u003cem\u003edeductively identified effects of the PTPS symptom groups,\u0026nbsp;\u003c/em\u003eit has the highest coding rate. This category describes a reduction in negative judgements, particularly with regard to feelings of worthlessness or guilt. Here too, both affected persons and therapists report that there is an increasing awareness of negative self-beliefs. In addition, meditation can increase compassion towards oneself and one\u0026rsquo;s trauma-related experience. The sense of self-worth undergoes a positive development. The following example can be quoted:\u003c/p\u003e\n\u003cp\u003e(...), because I also have a lot to do with guilt about myself and for a very, very long time I simply related a lot of what happened only to myself. And meditation definitely helps me to deal with myself in a much more loving way or rather to have a feeling of self-care or compassion (P5, para. 28).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis quote clearly shows that the person experiences a change in the perception of negative self-beliefs through regular meditation. Particularly in relation to feelings of guilt, there is a reduction in self-centredness and a shift towards a more loving approach to oneself.\u003c/p\u003e\n\u003cp\u003e3.2.6 Less difficulties in social relationships. The interviewees reported changes in the area of interpersonal interaction through the use of meditation in the context of PTSD. These changes are contained in the subcode of \u003cem\u003eless difficulties in social relationships.\u0026nbsp;\u003c/em\u003eA\u003cem\u003e\u0026nbsp;\u003c/em\u003enotable observation was the increased ability to better perceive and understand the needs and boundaries of others and to express one\u0026rsquo;s own boundaries in relation to others. The results indicate that in the area of interpersonal interactions, past experiences or traumas are more clearly separated from current relationship experiences. This ability enables those affected to be less influenced by past experiences and to concentrate more on their current relationships. The qualitative statement by one interviewee describes these changes as follows:\u003c/p\u003e\n\u003cp\u003e(...) when I meditate I am in such (...) condition that I realise how I am feeling and can also communicate better, for example. For example, if I\u0026rsquo;m touched or something like that and I don\u0026apos;t want that right now or something. And that definitely makes it much easier for me to maintain a relationship (P2, para. 52).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe respondent illustrates how the practice of meditation enables her to develop a heightened self-awareness and to integrate this into her interpersonal relationships.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003e3.3 \u0026nbsp; \u0026nbsp; Inductively constructed effects\u003c/h2\u003e\n\u003cp\u003eThe \u003cem\u003einductively constructed effects\u0026nbsp;\u003c/em\u003erefer to the meditation aspects of the meditation process that may have a beneficial impact on post-traumatic stress disorder. Five central categories were identified within the present sample. See table 2 in the appendix for an overview of the categories.\u003c/p\u003e\n\u003cp\u003e3.3.1 Calming of the autonomic nervous system. An important element discovered in the data analysis was the \u003cem\u003ecalming of the autonomic nervous system\u003c/em\u003e. Participants and therapists reported a deepening of breathing, accompanied by a lower heart rate and general physical relaxation. It was shown that meditation can influence the autonomic nervous system and bring about a change towards parasympathetic activity. These effects could be of particular importance for people with PTSD, as they are often confronted with increased tension and impaired regulation of the autonomic nervous system. This interview quote illustrates the observed effects of meditation on the autonomic nervous system:\u003c/p\u003e\n\u003cp\u003e(...) I often have this kind of pressure on my chest, which eases. So the chest and stomach area, it eases. I relax. The body relaxes and I think I also breathe more calmly (P3, para. 18).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe person describes their experience of noticeable physical relief during meditation. The reduction of pressure on the chest, accompanied by a general relaxation and calmer breathing, reflects the observed effects that were emphasised by the interviewees during the data collection.\u003c/p\u003e\n\u003cp\u003e3.3.2 \u003cstrong\u003eExpanding scope of action.\u0026nbsp;\u003c/strong\u003eThe subcategory \u003cem\u003eexpanding scope of action\u0026nbsp;\u003c/em\u003erefers to a process that can unfold through increased mindfulness during meditation. The interviewees described that a conscious perception of the processes associated with the trauma is made possible through the use of meditation. Those affected are able to observe these processes with interest and without automatically identifying with them. Instead, they can consciously decide which thoughts and emotions they want to pay attention to. This ability to make conscious choices opens up a wider scope for action, which manifests itself in more possibilities for action and reactions, and hence generally represents increased autonomy. This quote from the collected data describes this effect:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e(...) like an interested observation, but not like totally accepting everything or something, but being able to consciously choose what I accept something from. Um and the other thing is really to be able to react more calmly in precarious situations or conflictual situations. (P1, para. 35).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis illustrates how a conscious choice of thoughts and emotions can create the ability to shape reactions more consciously and purposefully, rather than acting automatically or impulsively. In difficult or conflictual situations, those suffering from PTSD and practising meditation may be able to respond more calmly.\u003c/p\u003e\n\u003cp\u003e3.3.3 Trauma disidentification. This category can be introduced by the following vivid quote:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAnd that\u0026apos;s where this intermediate step happens, like a contemplation of it [the trauma-related experience]. I can then simply look at it calmly, for example, this self-deprecating thought or this negative emotion towards myself (P4, para. 53).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe interviewees emphasised the ability to detach themselves from identification with the trauma-related patterns and to adopt an observational stance. \u003cem\u003eTrauma disidentification\u0026nbsp;\u003c/em\u003eas a subcode therefore refers to the ability to take an observational position in relation to the trauma-related thoughts, feelings and behaviours and to actively observe them. This skill of disidentification acquired through meditation can help PTSD patients create a certain distance from the symptomatic self-deprecating thoughts or negative emotions about themselves.\u003c/p\u003e\n\u003cp\u003e3.3.4 Anchoring in the awareness of the present. The category of \u003cem\u003eanchoring in the awareness of the present\u0026nbsp;\u003c/em\u003egenerated in the analysis describes an elementary ability that almost all interviewees reported unanimously: Not allowing oneself to be flooded by trauma-related bodily sensations, feelings and images and instead focussing one\u0026apos;s awareness on the here and now. Through meditation, PTSD sufferers can develop the skills to reduce the magnetic pull of the past and consciously direct their attention to present experiences. The following example can be quoted:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAnd I believe that this pull is weakening. So that the part [of me] that can stay here, in what is happening here right now, will have more support. In a way guardians who come, who protect me and somehow make it possible to deal with the now and not go into the past. (P1, para. 41).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThrough meditation, participants can experience a stronger anchoring in the present moment and conscious awareness can enable them to distance themselves from trauma-related experiences.\u003c/p\u003e\n\u003cp\u003e3.3.5 Self-regulation. The highest coding rate belongs to the category of \u003cem\u003eself-regulation\u003c/em\u003e. The subcode describes the ability of PTSD patients to deal independently with the emerging trauma-related feelings, thoughts and impulses and to calm the nervous system. Through meditation, they can learn various self-regulation strategies to change and calm their reactions to trauma-related stimuli. It is important to note that this category can also include other aspects of self-regulation, such as emotional regulation or impulse control.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e(...) that in situations that perhaps affect or trigger the traumatic experience, this has become an anchor point that I can use consciously. For example, to calm myself down a little from a strong, violent physical reaction (P3, para. 14).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis quote emphasises that through meditation, participants develop the ability to consciously use anchor points, for example a meditation object like the breath, to calm themselves down in situations that can affect or trigger their traumatic experience. Learning such self-regulation strategies helps those affected to respond more strongly to trauma-related symptoms and gain greater control over their physical reactions.\u003c/p\u003e\n\u003ch2\u003e3.4 \u0026nbsp; \u0026nbsp; Negative effects/challenges\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eThe main category of \u003cem\u003enegative effects/challenges\u0026nbsp;\u003c/em\u003eassociated with meditation for PTSD includes potentially negative side effects or challenges that may arise during or after the use of meditation practices. Three central themes were defined within the cluster. See table 5 in the appendix for an overview.\u003c/p\u003e\n\u003cp\u003e3.4.1 Increased symptom awareness. Within the data analysis, the category of \u003cem\u003eincreased symptom awareness\u0026nbsp;\u003c/em\u003eemerged with a high coding rate among the overarching theme of negative effects/challenges. The interviews showed that meditation practice promotes increased mindfulness, which influences the way in which those affected experience their symptoms. By engaging more consciously and intensively with their thoughts, feelings and bodily sensations, this can lead to an increased awareness of their own symptoms. One participating PTSD patient describes this experience as follows:\u003c/p\u003e\n\u003cp\u003eFor example, I have experienced that when I perceive my body, I don\u0026apos;t have a good relationship with it. I say to myself, I don\u0026apos;t know it at all and when I perceive it, it often shocks me (P5, para. 90).\u003c/p\u003e\n\u003cp\u003eThe person suddenly came across aspects of their body that were previously not consciously recognised or that were associated with negative emotions. This process reflects an inner conflict in which the heightened awareness promoted by meditation leads to an increased sensitivity to the symptoms while at the same time creating a sense of alienation or rejection of one\u0026apos;s own body. This discrepancy between heightened awareness and aversion toward the perceived symptoms can trigger a cycle (symptom amplification) and possibly intensify the suffering experienced.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e3.4.2 Increased states of dissociation. Another theme that emerged was \u003cem\u003eincreased states of dissociation\u0026nbsp;\u003c/em\u003ewhen making use of meditation. Focussing on the breath or similar aspects can lead to those affected focussing strongly on themselves and introspecting deeply. In some cases, this can create such a sense of being overwhelmed that dissociation, that is, the tendency to disconnect from one\u0026rsquo;s feelings, thoughts or even behaviours away from oneself, is intensified. As described by one participant:\u003c/p\u003e\n\u003cp\u003e(...) but closing my eyes and concentrating so much on myself, on my breathing etc. and so on, that this kind of drifting only intensifies (...). So, this dissociative tendency, which I also know from myself, gets more space as a result (P1, para. 74).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHence, paradoxically, meditation, which normally serves to promote mindfulness, can reinforce dissociative tendencies.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e3.4.3 Overwhelming confrontation. The theme \u003cem\u003eoverwhelming confrontation\u0026nbsp;\u003c/em\u003ealso emerged during the analysis. The intense focus on the intrapsychic event, without external regulation options, can cause a sudden renewed immersion in the traumatic experience. The interviewees reported triggered flashbacks or re-traumatization and feelings of panic or helplessness. This example quote from one of the interviews illustrates this effect:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e(...) from this, traumatic experience flowed into me with great speed, because what happened in the moment of meditation is that you are completely with yourself, and also very isolated sometimes (...) And then there\u0026apos;s a chance that you fall into it [the traumatic experience], somehow, and then go through it again and experience it again (P3, para. 82).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe experience suggests a potential challenge during meditation practice. Isolation without external regulation harbours the risk that traumatic memories can emerge uncontrollably and with high intensity.\u003c/p\u003e\n\u003ch2\u003e3.5 \u0026nbsp; \u0026nbsp; Dealing with negative effects/challenges\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eWithin this theme, three possible solutions were identified for dealing with possible side effects and risks that can occur in connection with the use of meditation for PTSD. See table 5 in the appendix for an overview.\u003c/p\u003e\n\u003cp\u003e3.5.1 Support. The theme of \u003cem\u003esupport\u0026nbsp;\u003c/em\u003econsists of different forms of personal support and regulation options, which can be of crucial importance for PTSD patients practicing meditation. Various methods were suggested by the interviewees. Guided meditations by meditation teachers or trained professionals are an essential component. The presence of an experienced psychotherapist with knowledge of meditation can also play a valuable role. These facilitators can not only provide guidance for meditation, but also create an open and supportive environment in which patients can evaluate their experiences and individual challenges during meditation. One therapist interviewed emphasized the importance of this supportive aspect:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eI would definitely say that one should accompany the patient and not leave them alone, so to speak. I think that\u0026apos;s the most important thing right now. And it can be a matter of saying, \u0026ldquo;I\u0026apos;m on board for now and we\u0026apos;ll wait and see\u0026rdquo; (T4, para. 54).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe therapist emphasized the need for a supportive structure that creates trust and enables patients to feel safe and stable during their meditation practice.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e3.5.2 Discontinuing the meditation. When dealing with potentially negative effects and challenges, \u003cem\u003ediscontinuing the meditation is\u0026nbsp;\u003c/em\u003ean important suggested solution. The main claim inherent in the theme is that it is advisable to end the meditation session if excessive stress or negative effects are experienced. Stopping meditation serves to protect the patient from further excessive strain, such as re-experiencing. The therapists interviewed emphasized that meditation sessions should only be carried out when sufficient regulatory options are available to deal appropriately with any negative reactions that occur. The timing of the meditation sessions should be chosen carefully, based on the individual\u0026apos;s stability and existing coping mechanisms. In the words of one therapist:\u003c/p\u003e\n\u003cp\u003eI would actually check again if such negative effects exist, is the person safe enough for it? Stabilised enough for it? And if not, I would advise against meditation and actually do other stabilisation exercises (T1, para. 72).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe therapist interviewed recommends prioritizing other therapeutic approaches for stabilizing and coping with stress before continuing meditation, if the patient shows negative effects.\u003c/p\u003e\n\u003cp\u003e3.5.3 Changing the appraisal. As part of the data evaluation, a further recommendation emerged. The theme of interpretive change describes the possibility of changing how one views the meaning of the negatively perceived effects. Instead of viewing these as purely negative effects, they can be categorized as opportunities for personal growth and as integral components of the healing process. By attributing a new meaning to them, even difficult experiences during meditation can be interpreted as important components of therapeutic progress. In the interview, one affected person described such a change in judgement:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSo, that means that it\u0026apos;s not \u003cem\u003eallowed to be\u003c/em\u003e, how should I put it, \u003cem\u003eall that\u003c/em\u003e! I\u0026apos;m allowed to cry, it\u0026apos;s allowed to bother me, it\u0026apos;s allowed to come up. It\u0026apos;s not bad! I thought that this was good and it\u0026apos;s not so dramatic and then to distinguish oneself from it: Yes, it\u0026apos;s an old memory and I\u0026apos;ll help you to regain your security (P5, para. 94).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eChanging the attribution of meaning helped the participant to classify the emotions as possibilities for inner processing and to see them as part of the path to stabilisation and healing.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003e3.6 \u0026nbsp; \u0026nbsp; Effects of Meditation on the Psychotherapeutic process\u003c/h2\u003e\n\u003cp\u003eThe overarching theme \u003cem\u003eeffects of meditation on the psychotherapeutic process\u003c/em\u003e provides information on specific effects through four identified subthemes. See table 6 in the appendix for an overview.\u003c/p\u003e\n\u003cp\u003e3.6.1 Differentiated introspection. The \u003cem\u003edifferentiated introspection\u0026nbsp;\u003c/em\u003etheme describes the development of inwardly directed mindfulness and self-observation when using meditation in combination with psychotherapy for treating PTSD. This aspect is characterised by an increased ability to consciously perceive, recognise, and control intrapsychic processes. The increased awareness of inner processes cultivated by meditation enabled those affected to explore their PTSD symptoms in more detail and to improve the articulation of their experiences during the psychotherapeutic process. This interview statements exemplifies this effect:\u003c/p\u003e\n\u003cp\u003e(...) the meditation helped me a lot to start noticing symptoms at all. Because before it was super difficult for me to name what was going on or how I was feeling. Naming emotions or something like that is super difficult for me (...) I would then have the feeling that I can say much better what exactly is going on and then work better with it (P6, para. 58).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe patient describes how the meditation practice helped her to find increased clarity and precision in the identification and verbal expression of her feelings and inner states. This led to her gaining an improved ability to communicate what she experienced during the psychotherapeutic sessions, thereby laying a more solid foundation for the therapeutic work.\u003c/p\u003e\n\u003cp\u003e3.6.2 Meta-level (metacognition, metaemotion). Within the data analysis, the theme of \u003cem\u003emeta-level\u0026nbsp;\u003c/em\u003econsists of\u003cem\u003e\u0026nbsp;\u003c/em\u003ethe ability to be aware that one is having thoughts and emotions. Through the combination of meditation and psychotherapeutic intervention, those affected developed increased metacognitive and metaemotional competence, which enabled them to analyse their thoughts and feelings from a more distanced perspective. The therapists interviewed reported that this process supported easier identification and modification of maladaptive trauma patterns during the psychotherapeutic sessions. One therapist explained this process vividly:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAnd also, the ability not to actually judge it immediately, but to be able to move it around a bit and look at it from different angles: What did someone actually experience and how could it be seen and where could it come from (T2, para. 88)?\u003c/p\u003e\n\u003cp\u003eThis ability to view one\u0026rsquo;s internal states from different perspectives and to create distance from one\u0026apos;s own experiences opens a space of neutrality within the psychotherapeutic process. This space then enables a less biased analysis of one\u0026apos;s own experiences and the factors influencing trauma patterns.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e3.6.3 Resource activation. This category can be vividly introduced and illustrated with this quote:\u003c/p\u003e\n\u003cp\u003eWell, but what is activated somehow is perhaps a (...) capacity to work on that or to go back to what I have somehow experienced. So, by the fact that the meditation practice leads to no longer being so involved, at the same time there is more space to turn to it again (P1, para. 65).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe participant describes an increased capacity for coping and a reduction in immediate emotional involvement that can arise through meditation practice. This coping capacity is what is meant by \u003cem\u003eresource activation\u003c/em\u003e. Within the main cluster, this subcode has the highest coding rate. Within the psychotherapeutic process, those affected can draw on the familiar effects of meditation, such as self-regulation and the ability to act, and thus tackle and process painful issues as they emerge. Meditation can thus offer PTSD patients an opportunity to constructively and gently address the traumatic content by enabling them to access helpful resources. Hence the psychotherapeutic trauma processing and integration can be promoted.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e3.6.4 Theme actualisation. The \u003cem\u003etheme actualisation\u0026nbsp;\u003c/em\u003ehighlights how experiences during meditation can serve as a starting point for deeper psychotherapeutic work. The interviewees report that these experiences act as important points of reference and can lead to better clarification and processing within the therapeutic relationship. For example:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eI mean, my therapist has known me for some time now, and can say: Look, does that remind you of anything? Was that there? Is there something that\u0026apos;s coming up again? (P4, para. 78).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis example quote illustrates how meditation experiences may initiate in-depth discussion and reflection on potentially meaningful content that may be relevant in the context of therapy. The meditation experiences can thus enrich and promote the psychotherapeutic process.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003e3.7 \u0026nbsp; \u0026nbsp; Interrater reliability\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eAs part of the qualitative data analysis, a\u0026nbsp;second independent coder\u0026nbsp;calculated the interrater reliability using MAXQDA\u0026nbsp;software\u0026nbsp;(VERBI SOFTWARE, 2022). The analysis revealed a total of 240 matches and 23 non-matches between the independent ratings of the coded content, resulting in a total of 263 coded segments. This yielded an overall interrater reliability of 91.25% (see appendix, Table 7\u003cem\u003e).\u0026nbsp;\u003c/em\u003eThe high reliability indicates a consistent and reliable assessment of the coded data. The research team paid particular attention not only to the calculation of interrater reliability but also addressed coding differences. The researchers held extensive discussions about the coding discrepancies and then refined the coding system accordingly.\u003c/p\u003e"},{"header":"4 Discussion","content":"\u003cp\u003eThe investigation of meditation in combination with psychotherapy in the context of PTSD led to a deeper understanding of the effects and risks involved in the process. Within the main category of \u003cem\u003ebackground,\u0026nbsp;\u003c/em\u003ethe research highlighted a fundamental need among participants for a deeper meaning and comprehensive contextualisation of their traumatic experiences. At the same time, those affected had a need to regulate and calm their heightened internal arousal. These results shed light on the possible role of meditation in the context of PTSD. The practice of meditation appears to be an important coping mechanism for those affected in relation to the challenges they face. In the following, the main results will be summarized and discussed. Hypotheses for further study will also be suggested.\u003c/p\u003e\n\u003ch2\u003e4.1 \u0026nbsp; \u0026nbsp; Perceived changes in the DSM-5 criteria for PTSD\u003c/h2\u003e\n\u003cp\u003eAs already described in detail, the Diagnostic and Statistical Manual for Mental Disorders, 5th edition, defines post-traumatic stress disorder by several symptom groups (American Psychiatric Association, 2022). The integration of the DSM-5 criteria facilitated a standardised assessment and enabled reliable and comparable evaluations of potential changes. Precise findings on specific change characteristics were obtained in the present study. Previous studies have indicated that meditation may explicitly affect PTSD symptoms positively (Heffner et. al., 2016; Lang et. al., 2012 Davis. et al. 2018; Possemato et. al. 2022). These findings formed an important basis for the present study and were supported by evidence. The subjects in all symptomatic groupings expressed perceived changes in various aspects as a result of meditation. These changes were characterised by a reduction in the symptom of re-experiencing traumatic events and a reduction in the avoidance of trauma-associated situations. In addition, the perception and regulation of feelings were reported to improve. The test subjects experienced an increased sense of security and control, which indicates that meditation can influence the symptom of perceived threat. The impact on negative self-beliefs was particularly strong, as indicated by having the highest coding value. The analysis highlighted meditation as an important positive influencing factor. The affected participants reported a growing compassion towards themselves and a positive development in self-esteem. In addition, meditation appears to have a positive influence on the ability to relate to others based on a perception of needs and boundaries. Table 4 in the appendix provides an overview of the perceived changes in the respective categories.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDifferent types of meditation exist, and these involve different mental activities (cf. Anonymized, 2022). In this study, no specific statements can be made about the effect of different meditation techniques on PTSD symptoms. However, research indicates that the change in self-esteem acts as a moderating factor for PTSD symptoms when performing loving-kindness meditation (Kearney, 2013). The majority of the subjects studied (85.7%) practised mindfulness meditation that integrated the meditation object \u003cem\u003emettā\u003c/em\u003e, that is, the attitude and feeling of loving-kindness. The largest score change in the symptomatic grouping \u003cem\u003eless negative self-beliefs\u0026nbsp;\u003c/em\u003emay indicate a correlation and explain the magnitude of this change. Future research may further differentiate the effect of different meditation techniques on the clinical picture and uncover moderators.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe deductively identified results in the present study emphasise two main themes in the effect of meditation on PTSD symptoms: First, an important differentiation process between past and present takes place; those affected learn to draw a dividing line between past traumatic experiences and present experiences. Second, meditation practice contributes to an increased awareness of the symptoms experienced, which enables them to better understand and regulate their symptoms. In addition to the scientific perspective, the findings are of particular clinical relevance. As a complementary treatment, meditation may play an important role in alleviating PTSD symptoms.\u003c/p\u003e\n\u003ch2\u003e4.2 \u0026nbsp; \u0026nbsp; Model of the effect mechanisms of meditation in PTSD\u003c/h2\u003e\n\u003cp\u003eThe qualitative research approach allowed for nuanced data collection that included reports on individual transformations of response patterns that occurred as a result of regular meditation practice. Although previous research provides evidence for the effectiveness of meditation in PTSD, there are few descriptions of the complex change processes (Bohus \u0026amp; Huppertz, 2006; Alsubaie et. al. 2017). As a response to this, we developed a model that may help to understand and identify the exact mechanisms of action. The model outlines possible changes to the classic stimulus/response process that may occur as meditation is used in the context of PTSD. See Figure 1 for an overview of the model.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAs soon as a trauma memory is activated by a stimulus or trigger, corresponding trauma-related physical sensations, feelings, thoughts or judgements are triggered and evoke a reaction. For example, a person who has experienced violence might suddenly tremble, feel an increased heart rate and experience flashbacks during boxing training at the gym due to the trainer\u0026apos;s raised voice (stimulus/trigger), which forces them to leave the room (reaction). The effects of \u003cem\u003ecalming of the autonomic nervous system\u003c/em\u003e, \u003cem\u003etrauma disidentification, anchoring in awareness of the present\u0026nbsp;\u003c/em\u003eand \u003cem\u003eself-regulation\u0026nbsp;\u003c/em\u003e(see the green box of Figure 1) that arose during the inductive analysis describe how meditation can affect PTSD. The study showed that these effects have a positive influence on thoughts, feelings, etc. (see the blue arrow of Figure 1) when the trauma memory is activated. This is followed by a fundamental change in the classic stimulus/reaction sequence. The interviewees suggested that an intermediate step occurs before the normal reaction follows. In this intermediate step, the inductively identified effects (e.g.\u0026nbsp;\u003cem\u003etrauma disidentification\u003c/em\u003e) have an impact on bodily sensations, thoughts, feelings and appraisals. This changes the scope for action (see the purple cloud of Figure 1) and the affected person can react differently as a result. Overall, this process indicates that those affected learn to modify their reactions to triggers and consciously regulate themselves through the skills acquired from meditation practice.\u0026nbsp;\u003cbr\u003e Jon Kabat-Zinn, the founder of the Mindful-Based Stress Reduction (MBSR) programme and a well-known pioneer of mindfulness meditation in the West, suggested as early as 1990 that regular meditation practice creates a space of awareness and mindfulness, allowing practitioners to respond differently to their experiences (Kabat-Zinn, 1990). A similar idea can be found in Lang et. al (2012), who argued that meditation leads to better emotion regulation when confronted with traumatic stressors. It appears to be of significant relevance that it is not the trauma-related triggers that dissolve; rather it is the way in which these are dealt with that changes. The question of whether meditation can possibly reduce the overall number of episodes of trauma memory activation through effects such as \u003cem\u003ecalming of the autonomic nervous system\u003c/em\u003e represents an important field for further research.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe following two-part hypothesis was generated based on the model described here:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e1. \u003cem\u003eMeditation disrupts the trauma-related stimulus/response process through the effects of calming of the autonomic nervous system, trauma disidentification, anchoring in the awareness of the present and self-regulation.\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e2. \u003cem\u003eThis process of disruption expands the scope of action of those affected by PTSD\u003c/em\u003e \u003cem\u003eso that they may experience greater autonomy and ultimately be free of PTSD.\u003c/em\u003e\u003c/p\u003e\n\u003ch2\u003e4.3 \u0026nbsp; \u0026nbsp; Negative effects/challenges and possible solutions\u003c/h2\u003e\n\u003cp\u003eThe qualitative analysis of the effects of meditation on post-traumatic stress disorder (PTSD) revealed both positive effects (see 4.1, 4.2) and challenging aspects. The inclusion of questions relating to risks in our questionnaire responds to Lindahl\u0026apos;s (2017) criticism of the inadequate illumination of potentially challenging, stressful or difficult experiences in current research. Three central themes emerged that need to be discussed in the context of the use of meditation for PTSD. That the theme with the highest coding rate was \u003cem\u003eincreased symptom awareness\u0026nbsp;\u003c/em\u003emay indicate that meditation indeed may lead to a challenging increase in the awareness of symptoms. Those affected become aware of parts of their bodies or aspects of their emotions that were previously not consciously recognised or even split off. This process can trigger internal tension, as the increased awareness of symptoms is accompanied by a rejection or alienation from one\u0026apos;s own body. This discrepancy can cause a symptom-reinforcement cycle and possibly worsen the suffering. Furthermore, the theme of \u003cem\u003eincreased states of dissociation\u0026nbsp;\u003c/em\u003eindicates a potential tendency toward increased dissociation. In some cases, the focus on introspective experiences (e.g. by concentrating on breathing) can be so overwhelming that the patient\u0026rsquo;s established pattern of splitting feelings, thoughts or behaviours away from themselves may increase.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHence the present study brings to light a paradoxical effect. Focussing on internal processes can lead to increased awareness of symptoms, which may be reported as an increase in experienced symptoms. This can potentially be detrimental if it only leads to reinforcing dissociative tendencies. Some studies mention the phenomenon of the so-called \u0026quot;mindfulness paradox\u0026quot; (cf. e.g. Shapiro et. al. 2018). On the one hand, there is evidence that the increase and intensification of symptoms are limited to a short initial phase. However, the participants had been practising for an average of \u003cem\u003eM=\u0026nbsp;\u003c/em\u003e11 years (\u003cem\u003eSD=9\u003c/em\u003e.2 years). On the other hand, Anonymized (2019) points out that challenging experiences must be viewed in the context of developmental processes that may unfold over decades. Our study provides a cross-section at one point in time; future long-term studies with developmental trajectories of those affected by PTSD may create a clearer picture of patterns and trajectories. In her research, Marianne Bentzen, co-founder of the theory of neuroaffective developmental psychology (NADP), builds a bridge between brain development, trauma theory and evolutionary psychology. In her most recently published work \u0026quot;Neuroaffective Meditation\u0026quot; (2021), she suggests that trauma leads to a paradoxical neuroaffective activation with a state of maximum arousal (sympathetic activity) and simultaneous maximum immobility (parasympathetic activity). Through the findings of Newberg et al. (2002), who discovered that both systems can be highly active together during spiritual (opening) states in the brain organisation, Bentzen drew an exciting connection: the similar brain activation during meditation seems to put the nervous system of traumatised people back into survival mode. It is possible that the neuroaffective states are important markers and explanations for the negative effects experienced. She suggests actively moving out of the states of highest activation during meditation and gradually levelling the nervous system into the new experience with regulatory options such as stretching (movements) (Bentzen et al., 2021). Regulatory options therefore appear to play a central role in the context of PTSD sufferers. The third theme, \u003cem\u003eoverwhelming confrontation\u003c/em\u003e, which had similarly high coding rates as \u003cem\u003eincreased symptom awareness,\u0026nbsp;\u003c/em\u003eindicated that the intense focus on the inner experience without external regulation options can lead to a renewed immersion in traumatic experiences.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOur study indicates that one needs to be cautious when using meditation in the context of PTSD, even though meditation holds potential for strong potential benefits. The analysis revealed various solutions that may positively counter the detrimental effects. Figure 2 gives an overview of possible influencing factors.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSupport\u0026nbsp;\u003c/em\u003eappears to be a very important factor for dealing with risks or side effects and is the theme with the highest coding rate.\u0026nbsp;\u003cem\u003eSupport\u003c/em\u003e refers to the help that the therapist can provide through different regulation options. Guided meditations by trained professionals are perceived as particularly helpful. The presence of a psychotherapist or meditation teacher with meditation experience, someone who goes beyond practical guidance to create an environment for reflection and categorisation of the challenges, is an equally supportive coping approach. The autonomic nervous system may be seen as being positively impacted by providing connection and reassurance through the voice or presence of a trusted person.\u0026nbsp;\u003cbr\u003eIn addition, the theme of \u003cem\u003ediscontinuing the meditation\u003c/em\u003e emphasises that it may be advisable to end the meditation session in the event of excessive stress or the occurrence of negative effects. The decision to carry out meditation should be based on individual stability and existing coping mechanisms in order to protect patients from further excessive strain. One psychotherapist interviewed recommends a graduated approach in line with Bentzen.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eChanging the appraisal\u0026nbsp;\u003c/em\u003eis another possible solution. This involves not viewing challenges that arise exclusively as negative effects, but rather perceiving them as opportunities for personal growth and interpreting them as an integral part of the healing process. This reinterpretation seems to help patients to categorise difficult experiences during meditation as important components of their therapeutic progress. In current meditation research, the extent to which negative experiences are essential for growth is being considered and the inclusion of the traditional contemplative perspective seems fundamental (Anonymized, 2023; Anonymized., 2024). It needs to be underlined that reactions and effects are always individual experiences. Nevertheless, the present work makes it clear that both positive and negative effects can be identified across individuals. Further research is essential to minimise potential risks.\u003c/p\u003e\n\u003cp\u003eFrom the discussion above, the following hypothesis was generated: \u003cem\u003eThree specific possible solutions, support, discontinuation the meditation and changing the appraisal, positively counters the negative effects and challenges experienced by people using in meditation as part of PTSD-treatment.\u003c/em\u003e\u003c/p\u003e\n\u003ch2\u003e4.4 \u0026nbsp; \u0026nbsp; Effects of meditation on the psychotherapeutic process for PTSD\u003c/h2\u003e\n\u003cp\u003eThe present study explored how meditation specifically affects the psychotherapeutic process. The theme of \u003cem\u003edifferentiated introspection\u0026nbsp;\u003c/em\u003efocuses on important aspects that are particularly relevant for therapy. By increasing the ability for inner self-observation and mindfulness, intrapsychic processes can be perceived, identified and regulated more consciously. As a result, those affected seem to be able to examine and verbalise their PTSD symptoms more precisely during the psychotherapeutic process. A randomised controlled trial published in 2020 identified increased introspective insight as a potentially fundamental mechanism of action for mindfulness-based and other psychological interventions (Nykl\u0026iacute;ček et al., 2020). Our analysis confirmed this and showed how introspection can positively influence the course of therapy and the treatment of symptoms. Furthermore, research indicates that mindfulness-based therapies contribute to the development of metacognitive awareness, which does not resolve the content of the symptoms, but rather changes the relationship to the experienced content (cf. Teasdale et. al., 2002). The study uses the category of the \u003cem\u003emeta-level to\u0026nbsp;\u003c/em\u003eshow that the combination of meditation and psychotherapeutic intervention can lead to the development of increased metacognitive and meta-emotional competence. This enables a distanced perspective on trauma-related thoughts and feelings. Hypothetically, it is precisely this internal distancing that could explain the altered relationship to the symptomatic content. In addition, metacognitive skills appear to make a relevant contribution to the depth and effectiveness of psychotherapeutic treatment. The therapists interviewed described how metacognitive and meta-emotional skills make it easier to identify and modify maladaptive trauma structures within therapy.\u003c/p\u003e\n\u003cp\u003eThat resource activation is a primary and essential active principle of psychotherapy has been empirically and extensively documented (Grawe \u0026amp; Grawe-Gerber, 1999; Grawe, 2004; Beesdo-Baum 2011; Willutzki \u0026amp; Teismann, 2013; Fiedler 2017). The focus is on a person\u0026apos;s existing abilities and possibilities, which make a significant contribution to change processes (cf. e.g. Willutzki \u0026amp; Teismann, 2013). Resource activation is also important for trauma treatment, as those affected may have little to no access to their protective capacities. Resource activationindicates that meditation practice promotes an increased coping capacity and a reduction in immediate emotional involvement. Thus, PTSD patients seem to draw on the effects of meditation, such as self-regulation and agency, within the psychotherapeutic process and thereby address the underlying painful issues.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn addition to resource activation, Grawe has identified so-called problem actualisation as a further effective factor of psychotherapy (Grawe, 2004). This principle of real-life experience means that implicit patterns of meaning are actualised in therapy and made tangible. At the same time, they stimulate an essential process of change. Meditation can possibly be classified as an important support option to promote the process of problem actualisation. The final theme of \u003cem\u003etheme actualisation\u0026nbsp;\u003c/em\u003eemphasises the potential use of meditation experiences as a way into relevant themes within psychotherapy, as these experiences may exemplify psychological patterns connected to PTSD. Meditation appears to make a valuable contribution to bringing out and actualising hidden (unconscious) themes. Within the therapeutic relational experience, meditation experiences can therefore act as a catalyst for extended clarification and processing.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eResearch on psychotherapeutic processes is a highly complex phenomenon. It deals with the question of impact factors, mechanisms and changes that take place during psychotherapy and within the therapeutic relationship. This complexity is due to the large number of variables, such as the therapeutic approach, individual characteristics, relationship characteristics, and duration of treatment. Taking this complexity into account is important when ensuring the quality of psychotherapy (Orlinsky et. al, 2004; Lutz et. al., 2019). The themes of \u003cem\u003edifferentiated introspection, meta-level, resource activation\u0026nbsp;\u003c/em\u003eand \u003cem\u003etheme actualisation\u0026nbsp;\u003c/em\u003eoffer guidance for understanding how meditation may work in combination with psychotherapy in the context of PTSD treatment. Further research is vital to understand the specific mechanisms and uncover possible mediators and moderators. Based on the research by Lee et al., the competencies of psychotherapists in accompanying meditation with PTSD sufferers are also a promising field of research. The findings open up new possibilities for the application and implementation of meditation within clinical trauma treatment.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe following hypothesis was generated based on the above discussion: \u003cem\u003eIn the context of PTSD, meditation can positively influence the effectiveness of the psychotherapeutic process through the following effects: Differentiated introspection, meta-level, resource activation and theme actualisation\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eIn the popular work \u0026quot;Trauma-Sensitive Mindfulness\u0026quot;, David A. Treleaven (2018) pointed out that people suffering from trauma seem particularly attracted to the potential benefits of meditation practices. This study has investigated the ways in which meditation may impact the therapeutic process. While meditation is a promising tool for several reasons, potential risks must also be considered. These risks may be inherent in the process. For example, meditation may uncover underlying aspects of traumatic experiences, which may represent an opportunity for therapy, but could also be overwhelming and lead to re-traumatization. Hence, the therapists may play a vital role in adequately preparing and supporting those affected to avoid these risks and to ensure that the approach provides overall benefit.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eInformed Consent\u003c/h2\u003e \u003cp\u003e All participants gave written informed consent.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eMelina Schwab and Terje Sparby contributed to developing the research question and methodology. Melina Schwab conducted the interviews. Melina Schwab and Terje Sparby conducted the analysis. Melina Schwab author wrote the initial draft. Terje Sparby and Ulrich W. Weger reviewed and edited the draft. All authors approved the submitted version.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe interview transcripts are not publicly available in order to protect the identities of the participants. Requests may nonetheless be directed to the corresponding author and the IRB at Witten/Herdecke University.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAhn, J. Y. Meditation sickness. In \u003cem\u003eOxford University Press eBooks\u003c/em\u003e. (2020). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1093/oxfordhb/9780198808640.013.45\u003c/span\u003e\u003cspan address=\"10.1093/oxfordhb/9780198808640.013.45\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlsubaie, M. et al. 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Trauma Therapists' Clinical Applications, Training, and Personal Practice of Mindfulness and Meditation. \u003cem\u003eMindfulness\u003c/em\u003e \u003cb\u003e7\u003c/b\u003e (3), 622\u0026ndash;629. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s12671-016-0497-9\u003c/span\u003e\u003cspan address=\"10.1007/s12671-016-0497-9\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e (2016).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWillutzki, U. \u0026amp; Teismann, T. \u003cem\u003eResource activation in psychotherapy\u003c/em\u003e (Hogrefe, 2013).\u003c/span\u003e\u003c/li\u003e \u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Meditation, psychotherapy, PTSD, trauma","lastPublishedDoi":"10.21203/rs.3.rs-6369237/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6369237/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eThere is ongoing research on the effect of meditation in the context of post-traumatic stress disorder (PTSD) and possible effects are the subject of controversial debate. The studies predominantly provide evidence of a beneficial effect, but possible risk factors also appear to be associated with meditation interventions. The impact of meditation on the process of psychotherapeutic trauma treatment has not been addressed in any research publication to date. For the first time the present explorative qualitative study examines the combination of meditation, psychotherapy and PTSD. Using guided interviews, 11 people were interviewed about their experiences, including PTSD sufferers and psychotherapists. The qualitative analysis extracted six overarching themes based on the content: \u003cem\u003eBackground, deductively identified effects, PTSD symptom groups, inductively constructed effects, negative effects/challenges, dealing with negative effects/challenges\u003c/em\u003e and \u003cem\u003eeffects of psychotherapeutic process.\u003c/em\u003e Descriptions of transformative processes and mechanisms of action that imply both positively and negatively perceived effects were identified. The study aims to suggest that more sensitivity is needed in the use of meditation in the context of PTSD, both for those affected themselves and for clinicians who use meditation in a psychotherapeutic setting. Furthermore, to our knowledge, this is the first scientific study that provides experientially based insight into the use of meditation in combination with psychotherapy.\u003c/p\u003e","manuscriptTitle":"The Effect of meditation in combination with psychotherapy in the context of PTSD. An explorative qualitative study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-19 12:33:40","doi":"10.21203/rs.3.rs-6369237/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"bf336577-5d3e-405d-abf9-a4fd54325d1c","owner":[],"postedDate":"May 19th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":48668258,"name":"Biological sciences/Psychology"},{"id":48668259,"name":"Health sciences/Health care/Health services"}],"tags":[],"updatedAt":"2025-12-10T03:08:52+00:00","versionOfRecord":[],"versionCreatedAt":"2025-05-19 12:33:40","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6369237","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6369237","identity":"rs-6369237","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}