Mindfulness interventions for clients with brain injury

What is mindfulness?

Mindfulness is all about becoming aware of your internal states (e.g. thoughts, emotions and physical sensations) and your environment (e.g. what you can see, hear and smell).  It involves consciously attending to your senses and observing information flowing through them in a detached manner. It helps us to be present in the here and now rather than be distracted by thoughts of the past and future.

Why is it likely to be useful with brain injured survivors?

Turning on the frontal lobes and turning off automatic pilot

The frontal lobes act as the ‘executive director’ of the brain and co-ordinate “executive skills”. Executive skills are basically structured thinking skills, which are required to make sense of and function in an otherwise unpredictable, unstructured social environment and enable us to act in a goal directed manner. These structured thinking skills include planning; organisation; problem solving; the ability to synthesise and integrate complex information and make predictions about likely outcomes; allocation of attentional resources and persevering with a goal when distracted with an option which will provide more immediate gratification.

Without these executive functioning skills, we would essentially be acting in response to our social environment on an ‘automatic pilot’ level. This would mean that our behaviours would be driven by factors in our environment which provide us with immediate gratification; we would be unlikely to be able to over-ride unhelpful habitual responses and we would not be able to consciously control our behaviours to conform to social norms and conventions. On this automatic pilot level our lives would essentially be chaotic without any clear direction.  A framework called the “supervisory attentional system” (SAS, Normal and Shallice, 1986) was developed to conceptualise how executive functions over-ride our “automatic pilot” to facilitate goal directed action.

The SAS is an “attentional monitoring system” which over-rides “automatic pilot”, by allocating attentional resources in a goal directed manner. The SAS serves three functions (i) formulation of planned action goals; (ii) implementation of plan and (iii) monitoring when things are going wrong and adjusting our actions accordingly, which may involve inhibiting habitual responses.

The SAS is “turned off” during routine automatic tasks which do not require our conscious attention (e.g. making a cup of tea) but the SAS is required for tasks which (i) involve planning or decision making (ii) involve components of trouble shooting (iii) the person makes mistakes in the task or they require novel sequences to compensate for their problems/disabilities (iii) they are dangerous or theoretically difficult (Normal & Shallice, 1986).

Mindfulness may help to turn back off automatic pilot and conscious processing back on. This may be achieved by the support worker prompting the brain injured survivor to regularly monitor their stream of consciousness (e.g. thoughts, feelings, actions and information from different senses) and re-direct their channel of consciousness in a goal directed manner (e.g. re-focus their attention from thoughts to what they can see in the environment). This can also be achieved in functional tasks (e.g. making a cup of tea) by directing their attention to information coming through their senses relevant to performing the task.

This mindfulness approach can be used to stimulate the person’s arousal/attention at regular intervals. This is consistent with self alert training (SAT) which was an intervention developed by Robertson et al. (1995) to remediate the sustained attention deficits of a group of stroke patients. Robertson et al (1995) asked participants to perform a variety of routine tasks, whilst the experimenter re-directed attention to the task by combining a loud noise with an instruction to attend. After training, participants showed clinically significant improvements on a number of untrained behavioral tasks. This SAT method has also been shown to be effective in treating attention deficit hyperactivity disorder symptoms (Salomone, et al., 2015).

Consistent with the hypothesis that mindfulness can improve attentional mechanisms, studies have shown that it can alter brain functioning in non-brain injured individuals. Mrazek (2012) showed mindfulness training increased working memory capacity; interestingly it was also found that his participants reported less distracted thoughts during the tasks. Furthermore, Holzel (2011) showed, using a series of fMRI scans, that after an 8 week mindfulness based training plan, participants showed an increase in concentration of gray matter in the left hippocampus, posterior cingulate cortex, temporo-parietal junction and cerebellum; areas of the brain associated with attention, memory and executive functioning.

Managing worry

Following a brain injury a person can become depressed or worried. When we are worried or depressed, we worry too much about the past and future and become wrapped up in our thoughts, losing perspective. As a result negative thoughts can become magnified, making the person feel worse.  Furthermore, if the brain injury survivor has a consistent running negative commentary in their head they are unable to attend to pertinent information and this can affect their thinking skills (e.g. concentration and memory).

Mindfulness helps you to detach yourself from these thoughts and re-focus your mind in a goal directed manner. Through mindfulness techniques you may watch your mind and experiences as a passive, non-judgmental observer. This way you learn to gain perspective by watching your experiences with acceptance. The goal of mindfulness is not to turn the thoughts off but to become aware of negative, unhelpful thoughts and when they occur accept them in a non-judgmental way and then re-direct your mind.

There is an ever-richer pool of literature showing the benefits of mindfulness based therapy in many areas of psychology and the treatment of mental health. A meta-analysis by Goyal (2014) showed moderate evidence in the positive treatment of anxiety and depression, and low evidence in the treatment of stress.

Conclusions

Mindfulness has growing popularity in the area of mental health but there is currently a paucity of research evaluating its efficacy in brain injury.  This is despite a robust theoretical rationale for its clinical utility. The interventions are also likely to be cost effective as they can be carried out by a support worker/ assistant psychologist under the guidance of a qualified consultant clinical neuropsychologist. At Neuromindworks we are currently evaluating its efficacy in the context of our clinical work (single case studies).

References

Hölzel, B. K., Carmody, J., Vangel, M., Congleton, C., Yerramsetti, S. M., Gard, T., & Lazar, S. W. (2011). Mindfulness practice leads to increases in regional brain gray matter density. Psychiatry Research: Neuroimaging, 191(1), 36-43.

Goyal, M., Singh, S., Sibinga, E. M., Gould, N. F., Rowland-Seymour, A., Sharma, R., … & Haythornthwaite, J. A. (2014). Meditation programs for psychological stress and well-being: a systematic review and meta-analysis. JAMA internal medicine, 174(3), 357-368.

Mrazek, M. D., Franklin, M. S., Phillips, D. T., Baird, B., & Schooler, J. W. (2013). Mindfulness training improves working memory capacity and GRE performance while reducing mind wandering. Psychological Science, 0956797612459659.

Norman, D, A., &  Shallice, T. (1986).  Attention to action. Springer US, 1986.

Robertson I. H., Tegnér R., Tham K., Lo A., Nimmo-Smith I. (1995). Sustained attention training for unilateral neglect: theoretical and rehabilitation implications. J. Clin. Exp. Neuropsychol. 17, 416–430. 10.1080/01688639508405133

Salomone, S., Fleming, G. R., Shanahan, J. M., Castorina, M., Bramham, J., O’Connell, R. G., & Robertson, I. H. (2015). The effects of a Self-Alert Training (SAT) program in adults with ADHD. Frontiers in human neuroscience, 9.