Contact: Dr Birgit Gurr Prinicipal Clinical Neuropsychologist

Neuropsychology Service Dorset HealthCare, University NHS Foundation Trust

Poole Community Clinic, Shaftesbury Road, Poole BH15 2NT
birgit.gurr@dhuft.nhs.uk

Caroline Rice-Varian
caroline.ricevarian@dhuft.nhs.uk
01202 308080
Mindfulness and Brain Injury Rehabilitation

Mindfulness-Based Stress Reduction (M.B.S.R.)
by Caroline Rice-Varian
Clinical Specialist Occupational Therapist
Mindfulness Instructor

There is more right with you than
wrong with you.

Jon Kabat-Zinn

Definition:
Paying attention
on purpose
in the present moment
and non-judgmentally
Jon Kabat-Zinn (Full Catastrophe Living,
1990)

Overview:

What is Mindfulness
Why Mindfulness and Brain Injury
Mindfulness and Cognitive Improvement
Mindfulness and Neurobiology
MBSR
Feedback from a MBSR group
Future directions

When we are being mindful, we are choosing to
notice the details of our experiences, just as they
are in this moment and without judging or trying to
change them in the first instance

Sarah Silverton, The Mindfulness Breakthrough.
Watkins Publishing, 2012

MindfulnessTraining
teaches a way of being rather than
doing.
allowing us to step back from
automatic behaviours and habitual
thought patterns

Summary of Research
Mindfulness can be used within brain
injury rehab
Mindfulness improves quality of life
and mental health in people with a
brain injury
Mindfulness has been shown to
improve challenging behavior in
people with LD (soles of the feet)
Mindfulness improves aspects of
attention
Mindfulness causes distinct patterns
of brain activation and structural
changes; consistent with reported
experience


Siegels hypothesis
Mindfulness effects (outcomes) are
mediated by middle frontal region of
the brain (Siegel 2007)
Outcomes are paralleled by secure
parent-child attachment and effective
psychotherapy
Outcomes of mindfulness are related
to the emotional and psychosocial
difficulties caused by TBI
Mindfulness promotes attunement
with others and with our own
experience


Mindfulness and Cognitive Improvement

Chiesa, Calati and Serrettis (2011) systematic review found:

Mindfulness mediation practice improved selective attention and
unfocused sustained attention

Mindfulness could enhance working memory capacity and some
executive functions
However:
Many studies had methodological limitations

Study designs, durations and populations were different

Conclusions:
That mindfulness meditation could enhance cognitive functions, but
available evidence should be considered with caution

Further studies investigating more standardized mindfulness meditation
programs are needed.


The neurobiology of Mindfulness
Findings:
Recent studies have investigated brain morphology before and after an 8-week MBSR program. The
results demonstrated:

Increases in grey matter in the left hippocampus, the posterior cingulate cortex, the temporo-parietal
junction and the cerebellum for those who did MBSR relative to waiting-list controls (Hlzel BK,
Carmody J, Vangel M, et al, 2011)

Reductions in stress correlated positively with decreases in right basolateral amygdala grey matter
density (Hlzel BK, Carmody J, Evans KC, et al., 2010)
However:
Changes in the brain owing to mindfulness meditation could be a direct effect on the brain or could be
mediated in whole or in part by an indirect mechanism (e.g. therapeutic relationship)
Research is in its infancy and more is needed to determine the cause of neurological change

Conclusions:
Research is inconclusive and unclear
Further research is needed



Other Mindfulness and Acceptance Based
Therapies:
Person-Centred CT for distressing psychosis (Chadwick et al)
Relapse Prevention for Substance Misuse (Marlatt and Donovan,
2005)
Integration of Mindfulness into other effective therapeutic
approaches (eg 1-1 therapy)

MBSR
Foundation of the programme the practice of mindfulness
8 week structure
Group delivery
Practice assignments each week
Addressing chronic problem (stress, pain, etc.)
Relationship to suffering can change by turning towards pain and difficulty,
and being present with what is here
Working with a variety of illnesses, physical and psychological
Relating to the universal nature of suffering whatever the particular form
shows up as (use of more general term stress)
Therapy in the older sense of healing?
Steady focus on the landscape of generic suffering
Specificity towards the stress of living with chronic illnesses and how it
affects our experience
Paying attention, noticing, allowing build up of mindfulness experience to
illuminate insight
Large group
2.5 3 hours per session



Learning through meditation
practice to approach our
experience in new ways
Moment by moment non-judgmental
awareness of body sensations, thoughts and
emotions
Formal meditation practice - bodyscan,
mindful movement, sitting practice, 3
minute breathing space.
Informal practice - awareness of present
moment experience during daily life


Session 1
Themes
There is more right with
you than wrong with you

Difficulties are workable

The present moment is
the only time anyone ever
has to perceive, learn,
grow or change


Session 2
Themes
Perception and thinking
outside the box

How people see their
particular stressors

Relationship to stress

Session 3
Themes
There is pleasure and
power in being present
Yoga as a practice of
mindfulness
Noticing and questioning
the conditioned tendency
of the mind
Pleasant vs. unpleasant
moments

Session 4
Themes
Conditioning and
perception shape our
experience

Physiological and
psychological bases of
stress reactivity

Session 5
Themes
Awareness of the
conditioned patterns of
escape from difficulty
Connect mindfulness with
perception/appraisal
Paying attention to the
capacity to respond
rather than to react to
stressful situations
Honour the full range of
emotions

Session 6
Themes
Stressful communications

Interpersonal mindfulness

Cultivating the capacity to
be more flexible

Final Words
Every Day Susan Coolidge (with changes to the wording by Jody Mardula):

Every breath a fresh beginning, Listen my heart to the glad refrain.
And, in spite of old sorrow,
And older sinning
Troubles forecasted, and possible pain,
Take heart with each breath, and begin again.

Buddhist Teaching
Mindfulness-based
approaches have developed
from Buddhist teachings,
which originated around
500BC. With its roots in
Buddhism, mindfulness has a
number of branches, the main
ones being MBSR and
MBCT.
MBSR
Mindulness-Based
Stress Reduction was
developed to help
clients who were
experiencing a range
of different health
conditions.
MBCT
Mindfulness-Based
Cognitive Therapy for
depression relapse
prevention (2000)
was given NICE
guideline approval in
2010 (UK).
MBSR
Other mindfulness-
based approaches
have developed out
of MBSR.
ACT and DBT
Acceptance and
Commitment Therapy,
and Dialectical
Behaviour Therapy.
MBSR
has been adapted
for other health
problems.
MBCT
can also be offered to
a mixed general
public group.
MBCT
has been adapted for
other health problems
such as cancer and
chronic fatigue.
Centre for Mindfulness Research and
Practice - Bangor
Founded within the school of psychology
Training and research activity based on MBSR and MBCT
Developed programme of 8 week courses in MBSR
Developed programme of 8 week courses in MBCT for
depression
Developed Teacher Development Training Programmes (CPD)
Developed MA/MSc Masters Training Programme
Programme of research days and Conferences

Session 7
Themes
Integrating mindfulness
practice more fully and
personally into daily life
Purposefully reflect on
lifestyle choices that are
adaptive and self-
nourishing, as well as
those that are
maladaptive and self-
limiting


Session 8
Themes
Keeping up the
momentum of intention
and commitment

Review of supports to
help integrate the
learning from this
programme over time

Factors in the selection and set up of the
CBIS MBSR Pilot Group
Clients
How selected
Stage of recovery
Group set up????
Measures quant and qual pre post
Process factors

Group Participants/Clients
Group Participants were selected from the current CBIS service
All participants attended a pre-group meeting to experience a mindfulness exercise and ask any questions about the MBSR 8 week
course
All participants knew the MBSR Instructor either as a co-facilitator in a previous group or one-to-one psychological therapy (CAT) or as
their OT
All participants were psychologically minded and has access to psychological support from CBIS team or in one case a CMHT
Group participants had a range of time of injury from 13 months post injury to six years post injury
One group participant was a member of the brain injury staff (in line with JK-Z ethos of members of staff experiencing MBSR as part of
their training)
The range of injury group participants experienced were from a mild head injury to moderate/severe brain injury
All group participants (with injuries) had experienced some mindfulness either in group or individual therapy
All group participants had shown a commitment to their rehabilitation and recovery
The Perceived Stress Scale (PSS) was chosen to test the outcome of the group at pre and post the 8 week MBSR group
The qualitative feedback questionnaire was completed post the 8 week MBSR group
Support for Group Participants:
Access to Psychology or on-going individual psychological therapy. In one case access to a CMHT.
Support for the Mindfulness Instructor:
Team Support and interest: Specialist Mindfulness Supervision as per the guidance for my level of expertise/training
with a mindfulness supervisor weekly telephone or face to face supervision



Practicalities of running an MBSR group
The venue a bit cold! Supplied mats and brought
blankets
CDs purchased for group members
CBIS MBSR booklet compiled week by week in order to
tailor make the programme
Admin support
Psychology support and help with analysis of results quant
and qual.

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7
28
25
40
21
0
5
10
15
20
25
30
35
40
45
A B C D E F G
S
c
o
r
e

Client
Bar Chart showing difference between Pre and Post
Course Perceived Stress Scale Scores
Pre-Course
Score
Post-Course
Score
3.37
0.95
1.41
1.26 1.34
1.71
2.62 2.69
-1.16
-1.01
2.16 2.19
3.98
1.1
-2
-1
0
1
2
3
4
5
A B C D E F G
Z
-
S
c
o
r
e

Client
Bar Chart showing difference in Perceived Stress
Scale Z-Score
Pre-Course
Z-Score
Post-Course
Z-Score
0
1
2
3
4
5
6
7
8
9
10
A B C D E F G
S
c
o
r
e

Client
Bar Chart showing Client Scores from Qualitative
Feedback Questionnaire
Qualitative
Score
Sources:
Information for these slides is taken from the following sources:
1. Blacker, M., Meleo-Meyer, F., Kabat-Zinn, J. and Santorelli, S., 2009.
Stress Reduction Clinic Mindfulness-Based Stress Reduction (MBSR)
Curriculum Guide. Center for Mindfulness in Medicine, Health Care and
Society, University of Massachusetts Medical School.
2. Segal, Z. V., Williams, J. M. G. and Teasdale, J. D., 2002. Mindfulness-
based cognitive therapy for depression: A new approach to preventing
relapse. New York: Guilford Press.
3. Crane, R. S., 2009. Mindfulness-Based Cognitive Therapy. The CBT
Distinctive Features Series. London: Routledge.
4. Silverton, S., 2012. The Mindfulness Breakthrough. Watkins Publishing.
5. Kabat-Zinn, J., 1996. Full Catastrophe Living. London: Piatkus.

What did I get out of coming? What did I
learn?

To think far more mindfully and control feelings of confusion. I
have learnt so much by attending.
To take a breath and try to think more about me. If I look after
myself I will be more able to look after others.
I have learnt a new valuable skill to help me lead a more
balanced, happy and fulfilling life.
Focussing on what is happening now. It has taught me to reign
my mind in. Over thinking can make things worse.

In the past few weeks a lot of
things have been going
wrong; ie family health; family
members dyeing and we are
also getting married in 3
weeks I am confident I
would never have coped at all
without the classes.

There have only been 2
occasions when my original
reasons for coming on the
course deserted me! I have
learnt so much by
attending. I can now
remember what is in my
kitchen cupboards!

C.B.I .S.
Poole Community Health Clinic
Shaftsbury Road
Poole Dorset BH15 2NT