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November/December 2014 Issue

Mindfulness-Based Approaches to Traumatic Brain Injuries
By Kate Jackson
Social Work Today
Vol. 14 No. 6 P. 18

Research suggests that a simple approach may make a world of difference to military personnel and veterans experiencing the symptoms and aftereffects of traumatic brain injury.

Labeled a "signature injury" of the wars in Afghanistan and Iraq, traumatic brain injuries (TBIs) are among the leading causes of injury to American soldiers, yet approximately 80% of such injuries are not sustained in combat. More often they occur during training and participation in sports and other leisure activities.

When working with military personnel and veterans who have experienced a mild TBI, social workers are likely to provide education, coping strategies, and resources including referrals to different types of medical care, counseling, and support groups. Increasingly, however, research suggests that they can make a significant difference by referring patients to mindfulness-based stress reduction programs (most of which involve some form of meditation) or by incorporating these techniques into their own practices.

What Is TBI?
TBI is the consequence of either a blunt trauma to the head or the force of acceleration or deceleration that causes the brain to move inside the skull, resulting in disturbance or damage to the neural cells, which in turn can cause altered consciousness and difficulty processing information. Upon such an impact or force, an individual may lose consciousness and experience confusion, amnesia, and seizures. These injuries may have physical, cognitive, emotional, and behavioral repercussions, all of which may be compounded or amplified by comorbidities, including psychological health issues. In the case of veterans, for example, individuals with TBI may also experience PTSD, either related to the injury or to preexisting trauma.

While PTSD isn't necessarily a corollary to a TBI, they often coincide. According to Donald Marion, MD, MSc, special consultant to the Defense and Veterans Brain Injury Center (DVBIC), "The association between PTSD and postconcussion syndrome can be confusing since there are some symptoms in common, such as fatigue, sleep difficulties, and memory problems. However, avoidance behavior and flashbacks are uniquely PTSD symptoms, and headaches and dizziness are typical of concussion and not of PTSD. Most importantly, PTSD can and often does occur without physical trauma to the head, while concussion is defined as being caused by trauma to the head."

TBIs are classified as mild (concussion), moderate, severe, or penetrating—a categorization that pertains to the severity of the trauma causing the injury, not to the degree of the symptoms or complications associated with the TBI. These may include headache and other pain, blurred vision, memory deficits, fatigue, irritability, balance and coordination problems, agitation, nausea, vomiting, dizziness, sleep disturbances, poor attention, and mood disturbances.

According to Joanne Azulay, PhD, a neuropsychologist at JFK Johnson Rehabilitation Institute, a professor of neuroscience at Seton Hall University, and an assistant professor of rehabilitation at Robert Wood Johnson Medical School in New Jersey, individuals with TBI not only experience emotional lability, but "can go from zero to 10 in anxiety and depression." They often are hypersensitive to sound, light, and even touch, becoming "thin skinned across their senses so that everything can be an irritation and seem overwhelming," she explains. They may begin to avoid any kind of event that creates overstimulation, for example driving at night. Their challenge is not only to adjust to the physical symptoms of TBI, she explains, but also to the physical experience that is new to them and to a new way of thinking and experiencing the world. "Meditation is a good match because it's about changing nothing and is rather about accepting."

More than 307,000 military service members have been diagnosed with TBI since 2000, according to the DVBIC. Congress established a component of the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury, DVBIC, in 1992 to provide comprehensive care for military personnel in collaboration with the Department of Defense and the U.S. Department of Veterans Affairs (VA) as well as with other partners. According to the DVBIC, 83% of TBIs are categorized as mild, making mild TBI the most common form of brain injury among U.S. Armed Forces personnel.

Multidisciplinary Approach
Many patients will recover from symptoms within weeks of injury and may not require treatment, while for others symptoms may be persistent. The course of symptoms and of treatment is variable and may be complicated by other injuries and coexisting, preexisting psychological health issues. Each patient requires thorough assessment and an individualized plan of treatment.

First line approaches to combatting the physical and cognitive repercussions of TBI as well as comorbid psychiatric problems traditionally have included psychotherapeutic and pharmacologic interventions. More recently, however, a variety of approaches have been researched and employed as adjunctive therapies by military, veteran, and civilian practitioners to help individuals with mild TBIs cope with an array of troubling symptoms.

"In the west we use a lot of medications, which are valuable in acute and short term settings, but may be problematic for chronic treatment," says Heechin Chae, MD, director of National Intrepid Center of Excellence (NICoE) Satellite Fort Belvoir Community Hospital and site director of the DVBIC Clinic. He says mind-body medicine in general—meditation, yoga, and tai chi, for example—are all good approaches to reducing symptoms and distress and are becoming widely embraced. In the Department of Defense, says Chae, "there is huge demand for these techniques. Work from our investigators has shown close to 40% to 50% of patients with these symptoms want to try these techniques." NICoE Satellite is a Department of Defense organization devoted to education and research about TBI and psychological health conditions and to providing affected service members with clinical care that is individualized, holistic, and interdisciplinary. Its integrative health care program helps clinicians and other service providers learn the techniques of complementary practices such as acupuncture, nutritional medicine, biofeedback, yoga, acupuncture, and mind-body practices that are effective adjuncts to traditional treatments.

According to the Defense Centers of Excellence, "Mind-body interventions seek to engage mind-body connection and spirituality as part of the healing process. Mindfulness meditation is the most common practice and is used as adjunctive treatment for stress management, anxiety, PTSD, depression, and pain."

Mindfulness and Meditation
Mindfulness is a state of awareness that results from consciously paying attention, and meditation is a means to bring about mindfulness. Jon Kabat-Zinn, PhD, a leading expert in this type of mind-body medicine, developed the Mindfulness-Based Stress Reduction (MBSR) program at the University of Massachusetts Medical Center's Stress Reduction Clinic, of which he is founding director. Professor of medicine emeritus at the University of Massachusetts Medical School, he's also founding executive director of the school's Center for Mindfulness in Medicine, Health Care, and Society. Begun in 1979, his renowned program is now offered in numerous centers around the world. It's the topic of Kabat-Zinn's book, Full Catastrophe Living, and is the basis of numerous research projects examining its usefulness in healing, including those made possible by grants from the National Institutes of Health's National Center for Complementary and Alternative Medicine.

Mindfulness-based cognitive therapy is a variant of the program that marries a meditative practice with cognitive therapy techniques that lets participants process thoughts and feelings. Kabat-Zinn's MBSR program typically involves eight weekly sessions including a variety of meditative practices such as sitting meditations, mindful yoga, and mindful walking, each emphasizing attitudes of acceptance, patience, and nonjudgmental attention. Research consistently indicates a number of benefits to participation in these programs, including a reduction in medical and psychological symptoms. And research is beginning to demonstrate its similar efficacy in the treatment of complaints associated with TBI, revealing a reduction in anxiety, stress, and isolation, for example, along with improvements in memory, attention, and other cognitive functions.

Kabat-Zinn's MBSR program was the basis for a pilot study examining its effect on symptoms of chronic mild TBI/postconcussive syndrome, by a team of researchers led by Azulay. Participants were men and women ages 18 to 62 with mild TBI of at least seven months' duration. The researchers modified Kabat-Zinn's MBSR program to make it more applicable to a population of individuals with TBI, in particular adding an emphasis on processing the experiences. "We spent an hour teaching meditation and an hour getting feedback and helping participants connect the dots about what they were experiencing," Azulay says. It's not the intervention, per se, that is effective, she explains. It's a tool that allows for the processing of what she calls "strings of painful experiences." "The processing is necessary because without it it's too hard to wrap your head around the experience," she explains.

"Most surprising because we didn't expect it was that their attention and memory function changed significantly," says Azulay. Learning to meditate affected their ability to maintain their attention, and because their attention improved, their memory also improved." Interestingly, physical symptoms didn't change, she explains, but emotional symptoms did. "They complained less about frustration, irritability, and anxiety, and while their headaches and sensory symptoms hadn't diminished, they'd learned to deal with them better. "We spent a lot of time moving toward psychological and physical pain," she says, with participants learning to explore and embrace it and thus be desensitized by the fear of pain."

In addition to an increased ability to sustain attention and improved working memory, participants experienced gains in self-efficacy, problem solving, and perceived quality of life. Other benefits were realized in self-regulation. Meditators were better able to cope with their emotions and regulate themselves. If an individual became anxious, for example, Azulay explains, he might be able to "step back and go into a meditative understanding and give himself time or space to respond or not respond at all," and to avoid making decisions based on fear.

In addition to this study, Chae notes that there have been many small studies that have shown efficacy for the use of mindfulness/meditation with individuals with TBI, but there are challenges to studying these techniques. "The limiting factor in larger studies has been funding to support the research," he explains. "It's much easier to get funding for drug trials than lifestyle measures. It's also logistically more difficult to study this type of intervention compared to a drug trial." Nevertheless, existing studies and experiential accounts point to numerous rewards of mindfulness-based programs.

"TBI is a complex diagnosis involving many components," says Chae. "One significant component is the stress response after having this type of injury. Mindfulness meditation appears to have a strong relaxing and stress reduction quality for patients, which is tremendously beneficial for overall recovery from injury." Meditation, he adds, has been shown to help counteract the stress response and the effects of cortisol. "High levels of cortisol can adversely affect important cognitive structures in the brain, which affects overall recovery from brain injury."

Charli Prather, MSW, LCSW, RYT 200 hrs, of Charli Prather Counseling, a licensed clinical social worker and registered combat-sensitive yoga and meditation teacher, has worked as a clinical contractor during vacations to the Wounded Warrior Project Odyssey program through Courage Beyond, an endeavor to help veterans and service members overcome combat stress. She's also taught meditation in her private practice as provider for Tricare, a health program serving uniformed service members and their families. Prather observes that mindfulness training is useful in helping people with TBI adapt to pain. "For pain control, it can induce a relaxation response that can reduce activity in the sympathetic nervous system—the fight or flight response—and increase activity in the parasympathetic nervous system—responsible for rest and digest activities."

According to Prather, "Learning how to control breathing can balance the nervous system and impacts the vagal response and heart rate variability," which, she says, can help control responses to pain, emotional balance, communication, and anger. The focus on breathing in mindfulness meditation practice also targets specific challenges associated with the experience of having a TBI. "Meditation," she says, "can assist the individual in reducing hyperarousal with the intentional use of breath and attention." Its emphasis on being present in the moment also makes it helpful for slowing the release of traumatic memories.

"Meditation has a definite value; the question is how to adapt it to the population at hand," says Chae. "It will be interesting to see how this evolves for this population over time as more research comes out." Mindfulness, observes Azulay, "is like the hammer in the toolbox—a very simple piece, but you have to have it to negotiate life on its own terms."

— Kate Jackson is an editor and freelance writer based in Milford, PA, and a frequent contributor to Social Work Today.

How Social Workers Can Help
Charli Prather, MSW, LCSW, RYT 200 hrs, of Charli Prather Counseling, a licensed clinical social worker and registered combat-sensitive yoga and meditation teacher, advises practitioners interested in learning more about working with patients with traumatic brain injury to consult first with those with greater experience. "Talk to other social workers who are already working with veterans and find out which programs they find most helpful in understanding combat stress. There are a variety of online courses, but these, she adds, "won't provide you with the information or modalities that you need to work ethically and competently with post 9/11 veterans." Prather recommends starting with the 40-hour program offered through the Center for Deployment Psychology.

Joanne Azulay, PhD, a neuropsychologist at JFK Johnson Rehabilitation Institute, a professor of neuroscience at Seton Hall University, and an assistant professor of rehabilitation at Robert Wood Johnson Medical School in New Jersey, encourages social workers to appreciate the ways in which their own practice of mindfulness and meditation may inform and improve their ability to help others. She points to literature arguing that practitioners who learn mindfulness become more compassionate to their patients. She advises social workers to "get their feet wet" by experiencing mindfulness themselves. From there, they can study mindfulness meditation practices and become certified, but she cautions that patients with brain injury may be best served by specialized programs in hospitals.

— KJ