The idea that meditation can positively impact one's mood and quality of life finds support, albeit limited, in the scientific literature. And since mood and quality of life can suffer greatly after significant damage to the brain, meditation is a potentially useful treatment in brain injury rehabilitation. But because of the particular learning styles and cognitive impairments that characterize the brain-injured patient, it needs to be made more accessible before it can become a practical and effective mode of treatment.
In many respects, meditation is a natural complement to brain injury rehabilitation.
Brain-injured individuals are, in general, more susceptible to the side effects of medications. Medications that cause minor drowsiness in a person without a brain injury might cause sedation in a person with a brain injury. Medications that are mildly stimulating to a person without a brain injury might cause agitation in a person with a brain injury. It’s not uncommon for a person with a significant brain injury to take ten or more medications a day, so any treatment which avoids side effects and drug-drug interactions is a treatment worth considering.
Also, many people fail to respond to medications, or choose to limit medications as a matter of principle. Meditation, being a distinct mode of treatment, may prove to be useful in these cases.
And, importantly, meditation is action-based. It’s learning by doing. When you’re learning after a brain injury, there’s great value in learning something through active doing.
We tend to think of memory as a single thing, but actually, we have more than one kind of memory. We have a memory for learning new facts and a memory for learning how to do stuff. After a brain injury, it’s often the case that the memory for learning new facts is severely impaired while the memory for learning how to do stuff is still functional.
For example, a brain-injured person can be taught how to pack a lunch by doing the action over and over, even though he may not be able to tell you in words how to go about packing a lunch. The poorer the memory for learning new facts, the more the memory for learning how to do stuff becomes important. Meditation is something that you do over and over and over, making it a good fit, in theory, with brain injury rehabilitation’s emphasis on learning by doing.
In other ways, meditation isn’t a very good fit for a person with a brain injury. For one thing, meditation, at least in the most formal sense of the term, in the sense of a daily solitary sitting practice, is a complex activity. It’s the coordinated action of several more basic actions -- breathing awareness, body awareness, mind awareness -- and this is too complex for some brain-injured individuals.
For another thing, a formal sitting meditation practice requires a certain attention span. Many people with brain injuries simply don’t have long attention spans. It’s difficult, or in some cases impossible, to focus on one thing for longer than a few seconds, especially when the frontal lobes have sustained significant damage.
And frankly, the very idea of meditation itself can be hard to grasp. Even the word “meditation” can be difficult to get a handle on. What does it mean, and how do you explain it to someone with a brain injury. It seems exotic, hard to wrap the mind around, difficult to relate to.
So in 2008 I started a group at Touchstone with the goal of exploring how to make meditation more accessible to someone with a brain injury. Because of the cognitive demands I just mentioned -- it’s complex, it requires sustained attention, it’s abstract and hard to relate to -- meditation, as it’s traditionally conceived, excludes a certain segment of the population. I wanted to see if I could make meditation as cognitively inclusive as possible, in other words, to exclude as few people as possible from the benefits of a meditative practice.
Some will bristle at the very suggestion that ancient meditation traditions can or should be modified. They say, “Tough. There are always going to be people who, for whatever reason, just won’t be able to meditate. Meditation isn’t for them. I won’t bend my rules. Technique is technique, and I won’t have my traditions altered or diluted in any way.” This is a valid attitude to have. Meditation traditions are, in some cases, thousands of years old. It hasn’t stuck around this long by being changed to suit the fads and fashions of the day, to accommodate the taste of every individual practitioner.
But this “my way or the highway” attitude will exclude a lot of people. As part of the process of becoming certified as an instructor of meditation, I had to give a five-minute presentation of the basics of meditation to a group of my classmates after which they asked me questions, posing as hypothetical pupils, to test my knowledge of meditation and my ability to field questions on the spot.
One of the questions that was posed to me was, “How long should I meditate?” I answered, “In the beginning, developing the discipline of setting aside some time each day to meditate is more important than the number of minutes you’re meditating. If you need to start with one minute a day, start with one minute a day. It’s just important that you start. As you get more practice, you can increase the amount of time you meditate each day.”
When the exercise was over, the teacher of the group gave me feedback on my performance. He told me that he wouldn’t recommend anything shorter than a five-minute meditation practice. In essence, he was saying, “If you can’t do five minutes at a time, then don’t even bother. It wouldn’t be worth it.”
For someone without a brain injury, this may be good advice, but for someone with a brain injury, setting a minimum time limit of five minutes is tantamount to excluding them from the practice of meditation entirely. I have many patients for whom five minutes, because of their neurological impairments, is simply too much to ask. You might as well ask a man to jump over the moon.
A helpful analogy is to view meditation as a kind of building you have to climb up five steps to enter. Some people can climb five steps and some people can’t. Recognizing this limitation on the part of some people, as a meditation instructor I can respond in one of two ways. I can stand at the entrance of the building and say, “If you can’t climb these first five steps, then don’t even bother.” Or I can make the building more accessible by putting in a wheelchair ramp. If I make meditation more accessible -- by starting at one minute of meditation a day, then working up to five minutes a day or more over time -- what harm have I done?
I believe that there is a persuadable segment of the population that, over time, can be introduced to meditation. Do I remain rigid, standing up for my principles, knowing that I will exclude certain people forever from a potentially useful treatment modality, or do I bend a little, meeting them where they are, making accommodations such as lowering the minimum time requirement when they are just getting started? So the first thing I can do as a meditation instructor is to relax the minimum time requirement for a daily sitting practice, and recommend gradually increasing it over time. In other words, BUILD A RAMP.
Another thing that makes a formal sitting meditation practice difficult for brain-injured people is its complexity. Even in its simplest form, meditation requires the simultaneous coordination of several more basic actions. In addition to the maintenance of a sitting posture, a person needs to cultivate both an awareness of breathing and an awareness of the mind’s movements, also known as mindfulness. So another way of making a meditation practice more accessible to a person with a brain injury is to BREAK IT DOWN into its component actions -- body awareness, breath awareness, mindfulness -- practice each skill first on its own, then add in another component once the basic skills have been learned.
It was important for me to communicate the intention of the group to the patients I was teaching. If they didn’t have a clear idea of what they could expect to get out of the group, the experience would have limited impact. I didn’t want to call it a mindfulness group or a meditation group. There isn’t enough in those names for someone with a brain injury, particularly a significant brain injury, to grasp. The name needed to communicate the goal of the group in words they could relate to. The name also needed to highlight the active, learning-by-doing nature of the group. I called it Peaceful Habits.
For an hour each Thursday morning, keeping these principles of accessibility in mind, I led a small group of patients at Touchstone in meditation and meditation-like exercises. Some mornings I included very low-functioning patients, patients with poor language skills, very little memory function and brief attention spans. Other mornings I restricted the group to only higher-level patients, those with a greater ability to sustain attention and functional language skills.
During each group session I also invited Touchstone staff members to participate. I wanted to get as broad a cognitive sample as possible. There were people across the spectrum of brain injury -- mild, moderate and severe -- and people without a history of brain injury. Starting from the goal of being as cognitively inclusive as possible and working forward from there, I instructed the group in basic skills such as breath awareness, guided relaxation and mindfulness training.
Together my patients and I would practice a variety of exercises over and over. Given the importance of learning-by-doing, there was always a “doing” aspect to these exercises group. Over time, I found that the more concrete the exercise, the more the patients were engaged by the experience.
What do I mean by “concrete”? “Concrete” in the sense of “tangible”. “Concrete” in the sense of all the stuff around you you can see, smell, touch and feel, as opposed to abstract or purely intellectual activity. If you want to connect with an audience of brain-injured people, it’s important to be concrete, to use concrete images and concrete language. They may have difficulty with more abstract ideas.
For example, earlier in this essay, instead of talking about the difference between pharmacologic and non-pharmacologic treatments, I used more concrete language. I spoke in terms of “magic wand” and “long hard road” approaches, both very concrete images that are easier to relate to, easier to get a handle on, easier to wrap the mind around.
A sentence by John Dewey is probably the best description of “concrete” I have come across. He wrote, “Some things are grasped only by first calling to mind more familiar things.” This is the key, I believe, to teaching meditation to people with significant brain injuries. It can only be arrived at through more concrete means, through calling to mind more familiar things.
Of the three basic components of meditation I alluded to earlier -- body awareness, breath awareness and mindfulness -- mindfulness is the least concrete. It’s the most slippery of the three, the most difficult to relate to. Mindfulness can be thought of as bringing one’s attention to the present moment, to whatever is presently happening.
The breath is often used in mindfulness training. Being with the feeling of the breath, noticing it as you breathe, this is mindfulness of breath. But anything can be used in this way: a chanted mantra, an image, an idea, a feeling. To practice mindfulness with an idea, for instance, the idea “everything is impermanent”, one simply brings one’s mind to that idea and stays with it. When the mind wanders from that idea, mindfulness brings the mind back to it.
Mindfulness is the skill of bringing one’s attention to something, an idea, the breath, a feeling, whatever, over and over and over. Like any other neurological function, it can be strengthened through repetition.
But ideas can be too abstract for a person with a brain injury to practice mindfulness on. For some, even the breath can be difficult to relate to for an extended period of time. It’s too elusive. Instead, I wanted to use exploring more concrete objects for the mindfulness exercises, familiar things, things anyone could relate to. I found tea to be useful in this regard. Tea -- now there’s something anyone can grasp. Everyone knows what to do with it.
I began starting the hour by preparing tea for the group. Especially with lower-functioning patients, the drama of tea preparation -- the boiling kettle, the aroma, the pouring into cups -- was the best shot I had for holding their attention for more than a few minutes, remember, no easy task for a brain -injured audience.
While I had their attention, I’d mention the magic wand and the long hard road. I’d talk about how healing isn’t always something a doctor does to a patient, a pill he gives to a person. I’d talk about how healing is also something a person does to himself, for himself. Once the tea was brewed and poured, we’d practice being mindful.
I’d guide them through an exploration of their cup of tea using their senses. We’d look at the tea, trying to figure out what color it was. We’d listen to the tea and talk about how tea was mostly silent, but how it conjured a quiet spell of bubbling and sipping sounds in the space all around it. We’d feel the warm cups in our hands, the warm tea down our throats. We’d talk about the three stages of tea-tasting: the smell, the taste and the after-taste. Smell is often impaired after a brain injury, and usually there would be at least one patient in the group without a sense of smell, so we'd talk about that. Sense by sense, through practical exploration, I taught them to the skill of mindfulness.
Other days, we’d listen to music or birdsong. Patients who were unable to sit still for long periods of time in silence would sit for ten or even fifteen minutes when music or birdsong was playing. Adding these external supports to the practice of mindfulness was like adding training wheels to a bicycle. The music and the tea gave them something concrete to hold on to, supporting and lengthening their practice.
So the third way I was able to make meditation more accessible was by adding TRAINING WHEELS to the practice of mindfulness. For some, these external supports could be removed later, like training wheels, when the time came and they could stay up on their own. Others always needed the training wheels, and that was OK too.
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