Clinical Handbook of Mindfulness (119 page)

with their families. Anecdotal reports included the following quotes: “The

deep breathing was so soul searching and relaxing. It makes me more aware

of myself.” “I appreciate taking the time during the day when it’s stressful,

to learn ways to come back to a state of equilibrium.” and “I know how to

control myself when I feel nervous and angry.” This continued popularity in

the face of job demands underscores the importance to both caregivers and

care receivers of creating ongoing opportunities within the work schedule

and environment to engage in stress-reduction programs.

Informal Caregivers

Mindfulness groups offered to family and friend caregivers can also pro-

vide skills and support. Informal caregivers frequently report stress and

stress-related illness, and yet informal caregivers often find it hard to care for

themselves. Mindfulness groups encourage self-care in the context of care

provision. The groups are one and one-half hours long and generally in the

early evening at the facility providing care for the institutionalized elders.

Many group members reported a decrease in somatic complaints and

an increased satisfaction in the caregiving role. Caregivers can be “in the

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moment” with their loved one, rather than worrying about the past or future.

As one group member responded: “I feel less anxious about stresses than

I formerly did. I think about ‘riding the waves’ instead of getting anxious

about them or ‘fighting’ the waves. I feel less responsible for my husband’s

well-being.”

Group members also reported learning new ways to cope with stress, such

as using deep breathing when feeling upset. Experiencing the “groupness”

was also important, as shared by this member: “I think what was most helpful

was the energy you received from the group. Everyone seemed to want to

be there and wanted to participate and learn.”

Practical Issues

Teacher Requirements

MBSR teaches informal and formal practices that, if employed regularly, can

lead to profound life changes. Below are listed some of the practices taught

and the adaptations made for frail elders and their caregivers. Clinicians

desirous of initiating mindfulness training with older adults and their care-

givers should have an established mindfulness practice, MBSR instructor

training, and geriatric experience. Practitioners may also consider partner-

ing with persons who have complementary expertise. It is not possible in

the span of this chapter to detail the varied accommodations to the interven-

tions based on the individual or group needs and abilities. What cannot be

substituted is the mindfulness practice of the teacher. The most important

intervention we can offer is ourselves, who we are in each moment, being

present with the other, feeling our connection, and verbally and non-verbally

conveying this felt sense.

Mindful Eating

Mindfulness in daily living is frequently taught initially by an eating aware-

ness. Group members are given a few raisins and asked to slowly eat them

while observing physical sensations, thoughts and feelings. They observe the

raisins, without judgment. Participants may find an increased awareness of

sensations, just by slowing down and paying attention. There may be elders

who are not able, for a variety of reasons, to follow all of your instructions.

They may have swallowing difficulties or medical conditions that prohibit

certain foods. Consider different foods, or even different activities, in order

to include as many residents as possible in the experience. Elana Rosenbaum,

who has worked with cancer patients in the hospital, describes using ice

chips for a mindful experience
(Rosenbaum, 2005).

Group Discussion

Group discussion with residents in the nursing home will have a natural focus

on the very real and immediate pain and distress of medical conditions and

institutional living. Residents may feel disempowered and unable to control

any aspect of their lives. In MBEC groups, we discuss and learn new ways of

being with pain and distress. Residents find that they still have abilities, con-

trol over their perceptions, and increased choices in how they respond to

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439

situations. Group discussion often starts with a resident complaining about

having to wait for care provision, or other residents, or the food, or pain.

Rather than focus on resolving these issues, we discuss how what we prac-

tice and learn in the group might apply to these situations. If a resident is

upset because he had to wait to get a glass of water, for example, we might

discuss what he could do while he waited. He could take a deep breath, or

practice meditation or stretches. This shift in focus enables residents to feel

increased control over situations where they previously felt victimized and

dependent. In qualitative reports, the group experience was reported to be

the most valued aspect by group members. They reported: “I’ve always liked

this [group] since I started
. . .
being quiet, relaxed
. . .
a special feeling.” And,

“I feel uplifted. I realize we all have pain. We talk about how we are getting

along. It is important to be with other people.”

Caregivers also, report the group experience to be helpful. Sharing com-

mon stressors is often an initial theme. As the group progresses, however,

caregivers begin to share how they use mindfulness skills to cope with these

stressors. In addition, caregivers who work together provide support and

reminders to practice on the job.

Diaphragmatic Breathing and Breath Awareness

I often tell group members that anyone can participate in the group as long

as they are breathing. In a setting where the focus is on disability, it is helpful

for residents to remember what they still can do. Mindful meditation often

begins with an awareness of the breath, not trying to change the breath,

just noticing if it is fast or slow, even or ragged, deep or shallow. A deep,

belly breath is intentional and directed. With a soft belly, participants are

encouraged to deeply fill the belly, ribs and upper chest with air, and then,

very slowly release it. Both residents and caregivers report that the deep belly

breath is the intervention most utilized. It only takes a few moments and can

be utilized anytime, anywhere. The deep belly breath can also provide the

space we need to respond thoughtfully in moments of intensity.

Deep breathing can be challenging for nursing home residents with breath-

ing problems. I use it as an opportunity to talk about expanding our bound-

aries. Mindfulness classes encourage participants to explore their limits,

knowing when we can expand them and when we need to respect them.

I use deep breathing as an example of how we can stretch a little further

each day, with regular practice.

Meditation

Seated meditation practice may initially appear foreign to an elder and care-

giver population. The instructor can offer guidance and encouragement.

Shorter practice times are also important, and yet, participants should be

encouraged to gradually expand their practice. I have found that residents

with cognitive and physical limitations are able to participate in the experi-

ence of meditation. On the dementia unit, many group members sat quietly,

with their eyes closed, for periods of time following a simple explanation

and demonstration.

Rose was an 84-year-old nursing home resident who was physically frail,

with minimal family involvement and a life-long psychiatric history. Her

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fixed paranoid delusions often kept her from sleeping as she was convinced

there was a network of people plotting to harm her. I knew Rose well, and

during the group closely monitored her for potential negative impact. She

attended the group faithfully and reported that the chairs in the group

were more comfortable than other chairs. (In fact, they were the same

chairs she sat in for eating and other activities.) Rose often fell asleep in

group and declared that it was the only place she found peace. She also

said the meditation practice reminded her of her Jewish roots, when she

used to light candles on Friday night
.

Gentle Yoga and Mindful Movement

Despite significant physical disability, elders report enjoying simple yoga

stretches. Chair and bed adaptations can include the basics of yoga stretches

and poses. Instruction for the poses can be given verbally, demonstrated by

the instructor and hands-on assistance given as needed. In addition, staff care-

givers are often out of shape and do not care for their own bodies. For res-

idents and staff with limited physical experience, yoga provides wonderful

opportunities to experience their bodies in a new way.

I adapt the poses to bed and chair, and focus on the groups’ abilities, not

disabilities. For example, when stretching our arms, I might say that those

who cannot use one or both arms, to just stretch the arm that is available

to them. If they cannot move their arms at all, I ask them to focus on their

breathing and imagine they are stretching with us. Residents never express

any distress that they cannot participate in all the exercises; to the contrary,

they are pleased to be included.

Standing and walking meditation may not be an option for nursing home

residents in wheelchairs. A “wheeling” meditation can be suggested for these

residents. I often use mindful movement with elders on the dementia unit,

combining movement, music, imagery, and play. While seated, we imagine

we are walking, moving our feet up and down in a walking motion. I ask

people where they would like to go. Some might say Central Park, or Broad-

way, or the beach. I ask what we would see, smell, feel, and hear there. We

might swing our arms and turn our heads. Music may ease the movements.

For residents who are rarely able to leave a facility, this experience provides

some release and remembrance.

Guided Imagery

When introduced skillfully, this practice does not serve to escape the present

moment, but provides a powerful metaphor to illuminate the process of

shifting to a mindful awareness. I found that many elders responded to the

use of imagery, especially of nature, or to address pain. Guided imagery

tapes calmed even some residents on the dementia unit. While not able to

understand all of the words, these residents understood the tone, pacing

and simple, concrete language. An exercise as easy as breathing into the

pain, and gently releasing it with the out breath, may offer relief. On the

other hand, it may not. What is important is to accept whatever arises with

equanimity.

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Body Scan

The body scan uses guided imagery to observe the body without judgment.

Elders with disabilities may be acutely aware of their body’s limitations. The

body scan allows us to observe our bodies as they are, without needing to

change anything. Again, a lack of comprehension of all the instructions does

not prevent those with dementia from participating. Caregivers may also

have unpleasant feelings about their bodies, and this exercise can increase

their self-acceptance and compassion.

Homework

Nursing home residents in my groups rarely participated in the homework

assignments of a formal practice. They did, however, report using the skills

of deep breathing and reframing outside of class. Some residents had diffi-

culty operating CD or tape players. Staff would set up the equipment and

encourage residents. Staff also were not able to consistently practice formal

skills. Many held two jobs or provided caregiving at home for family after

work. In caregiver classes, I emphasized in class skills that could be prac-

ticed while waiting in line, driving, or on the bus or subway. Formal and

informal caregiver classes also discussed specific stresses of caregiving and

strategized ways to cope with them.

Other Considerations

There are logistical and practical problems that you may want to consider as

you plan your group. The following are some of the issues that came up as I

developed and led groups over the past 13 years (McBee, 2008).

Environment

Mindfulness groups in institutional environments can present environmental

difficulties. Often, there are no quiet or secluded spots to hold meditation

groups. In the nursing home, I hold groups in one corner of a large din-

ing/recreation room. We hear loudspeakers and alarms; confused residents

may wander into the group; and once, a doctor even entered the group and

pulled a resident’s wheelchair out while the group was in progress! When

I find it especially challenging, I remind myself that this is the environment

that many residents are in 24 hours a day, seven days a week. If they can