The Impact of the Mindfulness Attention Meditation (MAP) with a Mixed Brain injury Population to Improve Emotional Regulation Enhance Awareness

Special Article – Cognitive Rehabilitation

Phys Med Rehabil Int. 2016; 3(6): 1101.

The Impact of the Mindfulness Attention Meditation (MAP) with a Mixed Brain injury Population to Improve Emotional Regulation Enhance Awareness

Azulay J* and Mott T

Department of Neuropsychology & Cognitive Rehabilitation, JFK Johnson Rehabilitation Institute, USA

*Corresponding author: Joanne Azulay, Department of Neuropsychology & Cognitive Rehabilitation, JFK Johnson Rehabilitation Institute, 2048 Oak Tree Rd, Edison NJ 08820, USA

Received: October 04, 2016; Accepted: October 27, 2016; Published: November 01, 2016


Objective: To evaluate the effectiveness of mindfulness group intervention designed specifically for brain injury. This is an expansion from our previous pilot study of an mTBI cohort to a mixed and more severe brain injury population.

Design: A convenience sample of 25 participants was recruited from clinical referrals over a two -year period. Participants completed outcome measures pre and post treatment intervention.

Setting: Post-acute brain injury rehabilitation center within a suburban medical facility.

Participants: Participants included twenty-five individuals; 10 post stroke; 5 TBI (moderate-severe); 7 Autoimmune; and 3 “Other” with a post injury period greater than 10 months. Thirteen participants were male and twelve were female, ranging in age from 18 to 62 years.

Main Outcome Measures: Main outcome measures included the Difficulties in Emotion; Regulation Scale (DERS), Freiberg Mindful Inventory (FMI) and several neuropsychological; (NP) measures of attention and memory. Secondary Measures from the previous study were also repeated and included: Perceived Quality of Life Scale (PQOL), Perceived Self-Efficacy; Scale (PSE), and a self–report symptom and problem solving inventory (PSI).

Results: Clinically meaningful improvements were noted on measures of emotional regulation (Cohen’s d = 0.67) moment-to-moment awareness (Cohen’s d = 0.70) and on measures of central-executive aspects of working memory and regulation of attention (PASAT Cohen’s d =.27, CPTA Cohen’s d =.40). As with our previous study, improvements were also found on quality of life measures (Cohen’s d=.43) and perceived self- efficacy (Cohen’s d = 0.50).

Conclusion: A Mindfulness Attention Program (MAP) designed for brain injury (BI) can positively impact emotional regulation with a mixed brain injury population. This study demonstrated the efficacy of a unique but simple intervention to target emotional regulation with a mixed brain-injured population. Improved performance on a measure associated with emotional regulation may be related to treatment directed at improving (nonlocal) awareness, confident self-acceptance (self efficacy), and the practice of repeatedly refocusing attention. The improvement of these three factors may be a crucial outcome of treatment post brain injury in order to facilitate a reduction in habitual physical and intellectual triggers that allow for measured responses over impulsive reactions; thereby minimizing emotional dysregulation more typically associated with brain injury and chronic disability. Additional research using a randomized control trial on the comparative effectiveness of the MAP with a larger sample base is warranted.

Keywords: Mindfulness; Emotional Regulation; Brain injury; Attention; Awareness; Rehabilitation; Self-efficacy; Mindfulness Attention Program (MAP)


Self-regulation of emotion, cognition, and ultimately, behavior are mediated by the prefrontal cortex and commonly disrupted to some degree after brain injury. In general, self-regulation is complicated because it is mediated by a complex interaction of neurological processes that encompass ; 1) self-awareness that a response is being activated; 2) previously developed beliefs and knowledge that help to shape the response, and: 3) sufficient self-efficacy and self control to modulate the emotional triggers/reactions adequately. It also requires a metacognitive process involving a non-localized awareness (of people around you; your body; your thoughts) and cognitive choices (i.e. to attend versus distract) that culminate in anticipatory behavior or lack of behavior that is either effective or maladaptive [1-3]. Thus, its complexity makes it one of the more challenging cognitive functions to adequately ameliorate after brain injury.

The control of emotions is probably the most difficult of voluntary regulatory processes since emotions are typically intense activations of feelings that can explode and interrupt an ongoing behavior [4]; and after a brain injury, can drastically disrupt cognition and engender a host of responses that are no longer appropriate to the situation. The research literature emphasizes emotional dysregulation as one of the primary disruptive deficits of brain injury; impacting cognition, relationships and productivity. Thus, the ability to tailor emotional states after brain injury becomes crucial to functioning. “Emotion regulation” refers to the strategies used to influence, experience, and modulate emotions [4]. These strategies may include responses such as redirecting attention, withdrawal, suppression and/or cognitive reappraisal of a stressful situation [5]. As mentioned earlier, a significant component of emotional regulation is awareness, especially a selfawareness that one is in danger of becoming emotionally disregulated. The ability to “observe the self” (self-observe) and make moment-bymoment adjustments to maintain emotional equilibrium requires a level of attentional flexibility that allows one to process the extrinsic and intrinsic experiences in a balanced and fluid way [6]. The metacognitive process of awareness at the basic level encompasses the ability to be aware of our own thoughts, recognize irrational thoughts and the impact that thoughts and emotions can have on our physiology. It includes self-awareness of metacognitive beliefs or knowledge (beliefs about our cognition) as well as self-monitoring and self-control of cognition while performing an activity. The awareness process is only successful if the attention functioning component is flexible enough to continuously reevaluate the different sensations of the individual and adjust accordingly. This working attention as a function of the central executive component of working memory, or `working attention” becomes an essential component to emotional regulation. Furthermore, accepting/adapting to the changes in ones functioning and feeling confident about managing symptoms adequately becomes an important aspect towards utilizing past experiences in shaping anticipatory strategy application [7].

Therefore, the alchemy of awareness, attention control and self -efficacy constitutes three elements necessary for emotional regulation. Unfortunately, one of the challenges after brain injury is the deficit or reduction of attentional skills including the maintenance of multiple elements in working memory such as attention to the salient situation, attending to a level of self-awareness/metacognition that there is a potential emotional reaction on the horizon and the ability to shift attention in a manner that is self-adaptive (ie step back from the situation or do nothing). Conversely, numerous studies to date have underscored the importance of emotion in directing attention to potentially relevant information in our environment [8,9]. Clearly there is a constriction of balance between the emotion/ attention feedback loops. Consequently, sensitivity and awareness to slight shifts in emotional and physical homeostasis can become indicators to attend to some necessary change.

Robertson and Garavan [10] suggest ongoing activation of the right frontal-thalamic-parietal sustained attention system is required to actively, endogenously maintain higher order goal states in working memory. When the sustained attention system is compromised, habits, or environmental conditions may oppose and displace higher order goals, resulting in cue-dependent or distracted behavior that is a hallmark of patients with attentional and executive deficits. Therefore, sustained attention is viewed as crucial to supporting various processes including the regulatory process of emotion [11,12].

Self-Regulation Interventions after Traumatic Brain Injury

The manifestations of impaired self-regulation and executive functions in individuals with BI include a variety of integrative skill sets that impact ones ability to inhibit, shift attention, integrate and self monitor towards consequent emotional self-control during activities. The few interventions that are available often require multiple-steps, substantial cognitive demands as well as considerable treatment resources. Despite the significance and scope of the problem, and given the complex interface of these executive elements, it is not surprising that the approaches are limited in their function or unwieldy in their approach. Kennedy and Coleho [2] identify obstacles to many of the interventions that preclude successful application. These include inaccurate self-feedback (lack of awareness), inability to anticipate task demands, and poor application to novel situations. With awareness being a significant aspect in the modulation of emotional regulation, an intuitive requisite for effective treatment would incorporate group treatments that allow for peer feedback and a collaborative approach to shared challenges. However, there are only a handful of group treatment studies that collectively address the relevant aspects of cognition we have identified as necessary to emotional regulation.

Rath et al [13] compared a group therapy approach that focused on emotional self-regulation and strategic thinking for problem solving with conventional cognitive rehabilitation in adults with mild to severe TBI. Important to this module was instruction on inhibiting impulsive responses that can flood the cognitive system, using a self-regulation worksheet. More importantly, participants analyzed their emotional responses by documenting their reactions and the precursors that triggered the reaction, then “reframing’’ by mentally rewinding the situation to observe how it could be avoided. The innovative treatment group made gains over those made by the conventional group on several measures of impairment and everyday activities associated with problem solving and self-appraisal of problem solving. The study did not measure emotional regulation per se but the outcome of improved problem solving abilities and its relationship to emotional regulation.

In a more comprehensive, randomized study using a more intensive group treatment protocol for brain injury, improvement was also found on measures of cognitive and emotional regulation [14]. The treatment combined increasing awareness of emotional triggers and the subsequent derailment of cognitive processes as well as training of strategies to improve emotional equilibrium post disruption. Improvements with quality of life and self-efficacy were noted, however, the intervention required intense coordinated manpower and resources that limited the treatment feasibility (e.g., typically at least 15 therapists, 12 hours of individual and group treatments per week over 16 weeks). Equally, Goal Management Training (GMT; [15,16,17]) is based on the theory of sustained or vigilant attention and has shown some efficacy for management of improving goal directed behaviors and the treatment encompasses some of the self-awareness training towards improved strategy usage. Although, it has been shown to be an effective intervention but it requires learning to self-monitor, which can be difficult to learn as per experienced group leaders [18].

With a relative paucity of treatment geared at addressing emotional regulation or even impacting the underlying elements that support the ability to regulate ones emotions effectively, there would seem to be a strong need to implement and assess the impact of treatments tailored specifically to the chronic BI symptom constellation, with a particular focus on improved self-awareness, central aspects of working attention, and an increased sense of self-efficacy that would support active strategy application. Potentially, controlling the focus and flexibility of attention to an improve awareness of one’s self (one’s impulses, habitual thoughts and physical reactions/experiences) may decrease over reacting to emotional stimuli, and create a sense of selfefficacy in responding to daily life challenges.

Mindfulness-Based-Stress Reduction (MBSR) is a group-based intervention that was developed by Jon Kabat-Zinn [19]. Initially designed for patients with chronic pain; it has now been widely implemented in a variety of medical and psychiatric populations such as those with chronic fatigue, pain, psoriasis, anxiety and cancer [20- 26]. Despite earlier studies that revealed mindfulness intervention ineffective with a brain injury population [27], we discovered efficacy by significantly modifying the presentation and the emphasis of treatment focus of a mindful intervention. Our initial pilot study revealed that a modified mindfulness intervention could influence cognitive, emotional and somatic symptoms that made it very relevant to an mTBI population. In fact, our research demonstrated that improved attention, self efficacy, quality of life, and problemsolving abilities were all achieved through a very simple activity/ intervention that had few cognitive demands [28]. The success achieved with the symptoms of brain injury with a mild TBI cohort led us to consider expanding the population to a more impaired and diversified population as well as expanding our hypothesis to include changes in self-regulation of emotion, which reflected the repeated informal reports of patients participating in the intervention.

In sum, there exist a small number of interventions geared to addressing self-regulation as it relates to emotion secondary to brain injury. It is our belief that the complexity of the components essential to change has historically forced interventions to be therapeutically demanding in either resources or cognitive load.

Thus, the aims of our the current study were (1) to determine whether the simplicity of our treatment, a Mindfulness Attention Program (MAP), could be efficacious with a more diversified and impaired brain injury population, and (2) to determine the effects of treatment on self-reported challenges of emotional regulation after brain injury, in addition to the earlier assessed areas of psychological and neuropsychological functioning including self-efficacy, life satisfaction, attention, memory, and problem solving. We hypothesize that a mindful attention program (MAP) delivered in a group format would result in an increase in emotional regulation, self-efficacy and perceived quality of life. We also hypothesized that there would be an improvement in social problem solving secondary to reduced emotional reactivity along with objective improvements in attention and new learning secondary to training in attentional focus.


Participants, recruitment and eligibility

The study was conducted in a post-acute brain injury rehabilitation center within a suburban rehabilitation hospital. A convenience sample of 25 participants was recruited from clinical referrals over the course of two years. The study was reviewed and approved by the JFK Health System Institutional Review Board. Inclusion criteria was as follows: 1) 18-62 years of age; 2) medical documentation of a brain injury both traumatic and non-traumatic in origin; 3) at least 3 months post injury; 4) being medically stable; 5) having sufficient language functioning to participate in a treatment conducted in English; 6) willingness and ability to participate in and travel to a 10- week treatment with agreement to do daily homework assignments. Specific exclusion criteria included 1) active substance abuse; and 2) psychiatric symptoms that prohibited a participant’s ability to benefit from treatment.


People who sustained some form of brain injury who were participating, or had previously participated, in a post-acute brain injury rehabilitation program were referred for the study by their treating clinicians. Each potential participant was initially assessed for eligibility by one of the investigators on this study. Those who met inclusion criteria and gave their written informed consent completed neuropsychological measures of attention and new learning in addition to a number of self-report measures 1-2 weeks prior to beginning the 10-week treatment program. All measures were administered again within 2 weeks of completion of the program. Treatment dropouts were incorporated through an intent-to-treat analysis, although there were no dropouts in this particular cohort. A total of five groups were run over a two- year period with 4-6 BI individuals per group. The groups generally ran consecutively with breaks during the holiday season secondary to the need for consistent attendance.

Outcome measurement

Difficulties in Emotion Regulation Scale (DERS) [29], is a selfreport questionnaire, designed to assess multiple aspects of emotion deregulation. It consists of 36 items and six subscales including: (i) non-acceptance of emotional responses, (ii) difficulties of engaging in purposive behaviors, (iii) impulsivity, (iv) lack of emotional awareness, (v) limited access to emotion regulation strategies, and (vi) lack of emotional clarity.

The Freiberg mindfulness inventory: We assessed participants’ self-reported levels of mindfulness using the Freiberg Mindfulness Inventory [30] with items such as

“When I notice an absence of mind, I gently return to the experience of the here and now,” on a Likert scale ranging from almost always to almost never.

Perceived Quality of Life (PQOL): The PQOL was initially developed as a cognitive appraisal of patient’s life satisfaction after intensive medical care [31]. The modified PQOL has been used with adults who have chronic neurologic disability including stroke and TBI. The PQOL measures the degree to which the individual is satisfied with his/her functioning on a 10-point scale ranging from extremely dissatisfied to extremely satisfy.

Perceived Self-Efficacy (PSE): Perceived self-efficacy for the management of symptoms was adopted from a measure developed for people with chronic disability [32] and modified specifically for use with TBI. Each item is preceded by the question How confident are you that you can … with responses on a 1to 10 point Likert scale from not at all confident to totally confident. We used the total PSE score and examined effect sizes for subscales assessing self-efficacy for the management of cognitive, emotional and social problems.

Neurobehavioral Symptom Inventory (NSI): The Neurobehavioral Symptom Inventory (NSI) is a self-report rating scale of 22 symptoms that are characteristic of brain injury [33]. Participants rated each symptom according to the level of resultant functional disruption how much the symptom has disturbed them in the past two weeks, using a five-point rating scale from 0 (none) to 4 (very severe). The NSI has been shown to reflect cognitive, affective and somatic/sensory clusters of symptoms [34]. In the present study we analyzed the total score and also examined effect sizes for each of the symptom clusters.

Neuropsychological measures: A brief neuropsychological battery was administered, to assess the central-executive aspects of attention and the ability to acquire new information. These measures were chosen based on the cognitive deficits typically associated with BI as well as the current literature regarding positive cognitive changes associated with mindfulness in a healthy population. The central-executive aspects of attention were assessed with the Continuous Performance Test of Attention (CPTA) [34] and the Paced Auditory Serial Addition Test (PASAT) [35]. The CPTA is an auditory continuous performance test with five conditions reflecting varied processing loads, and has previously been described in more detail [36]. The raw scores were based on the total number of errors, which were corrected for age and education. The PASAT is another measure of auditory processing speed and working memory. Rote verbal learning and subsequent recall were assessed with the total score from the learning trials on the California Verbal Learning Test- II, Alternate Form [37] with the assumption that improved attention functioning may lead to improved recall.

Social Problem-Solving Inventory-Revised Short Form SPSIR: S): A self-report measure of problem-solving [38] was administered to assess changes in problem solving orientation and problem solving skills. This measure looks at problem solving awareness and style with statements such as…”I am too impulsive when making decisions,” that are measured from 0 (not at all like me) to 5 (extremely true of me). Raw scores from the Positive Problem Orientation and Negative Problem Orientation subscales were combined to form a single measure, with higher scores indicating more positive problem solving orientation. Problem solving skills were assessed with raw scores obtained on the SPSI-R: S.


The intervention consisted of a 10-week group (one, 2 hour session per week) initially modeled after Kabat-Zinn’s MBSR program, but modified and progressed to what we call a mindfulness attention program (MAP); a program that focused more on continued attention training on non-local awareness and provided significant meditation guidance in the practice of moving towards physical pain, emotional pain and uncomfortable experiences to enhance adjustment to medical trauma and to more fully accommodate the needs of a brain injured population.

The meditative guidance over time evolved to a non-local awareness that is characterized by an intentional awareness of internal and external states and the ability to flexibly focus on each. Because brain injury can often have a negative and/or repeated focus (often referred to as perseveration). Our intervention stressed some of the Pantanjali Yoga Sutras that speak about using and moving to a general awareness through meditation which allows brain injured patients to move more readily through perseverations and instead observe the mind’s tendency to perseverate. This self -realization of observing the injured brain’s new tendencies is fostered by guidance of balancing the sensory experiences both of the internal and the external state creating a process of attention training and ultimately improved focus.

In addition, each two-hour session incrementally allotted proportionately more time to the meditative practice as patients acclimated until the majority of the session time was focused on meditation. The classes began with initially short, guided meditation sessions, starting with 15 minutes and eventually ending up with 45 minutes. These were followed by the processing of challenges to the practice, understanding the philosophy behind the practice and the context of the experiences while meditating. The patients’ discussion of changes to their core functioning secondary to brain injury became an integral part that is linked to the compassionate element of the meditative experience; i.e. the acceptance, observance and method of response. This approach is a stark contrast to the normative rehabilitative practice in brain injury, which is typically focused on deficit assessment and improvement. In addition, yoga practices that are typically floor exercises were modified over the course of treatment to chair yoga positions. Systematic relaxation of the body is also practiced in a chair rather than on the floor to accommodate physical disabilities/limitations.

Each of the last 45 minutes of the two-hour sessions introduced a new meditative practice that was emphasized over a two-week period to accommodate challenges with new learning. As mentioned in our earlier study, modifications were made to specifically meet cognitive challenges such as reduced recall, disorganization, poor topic maintenance and attention dysregulation. We expanded the number of treatment sessions from 8 to 10 and reduced group sizes to an average of 6 rather than 25, to allow for the increased time patients required for us to explain concepts, repeat procedures, reinforce learning and process their experiences with the practice. We also provided heavily guided sessions (3.5-4 sessions) of more sophisticated techniques, for the exploration of emotional and physical pain, as brain injury related problems with abstract reasoning sometimes make these concepts more difficult to grasp and apply. Each client received a memory notebook system for meditation that outlined weekly homework sessions, guidance regarding the approach towards meditation, 1 week trackers for pleasant and unpleasant events and homework logs so that patients could attend to the time of day they practiced, the frequency of practice and log obstacles in the completion in order to achieve an understanding and an accurate recall of these own individual practice. Each group was run by two leaders, both of whom were neuropsychologists with training in Mindfulness based meditations among other types of meditation. This tailored treatment was then manualized to ensure treatment consistency across groups and leaders for each group; both leaders specialized in brain injury rehabilitation and have been actively practicing and teaching meditation for greater than 9 years with a brain injury population.



Table 1 provides the full demographics of the sample. In summary, the sample was 47% female, 64% Caucasian, with 40 % stroke survivors 20% moderate severe TBI and 28 % autoimmune disorders. More than half of the participants were married (48%), and 81% had greater than a high-school education. Religious affiliation was designated as Christian in the vast majority of the group (75%). Most participants (87%) had time post-injury of greater than 12 months and none were earlier than 7 months. Most listed their employment status as disabled at the time of treatment (68.2%). All of the participants had received some form of concurrent rehabilitation during their participation in the study, with the majority (85.8%) receiving limited (individual neuropsychology only) treatment through a neuropsychology clinic.

Citation: Azulay J and Mott T. The Impact of the Mindfulness Attention Meditation (MAP) with a Mixed Brain injury Population to Improve Emotional Regulation Enhance Awareness. Phys Med Rehabil Int. 2016; 3(6): 1101. ISSN : 2471-0377