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(p. 1) Wisdom Mind: Conceptual Foundations and Preparing to Deliver the Program 

(p. 1) Wisdom Mind: Conceptual Foundations and Preparing to Deliver the Program
Chapter:
(p. 1) Wisdom Mind: Conceptual Foundations and Preparing to Deliver the Program
Author(s):

Colette M. Smart

DOI:
10.1093/med-psych/9780197510001.003.0001
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date: 14 June 2021

Background to the Development of Wisdom Mind: Words From the Author

The idea for Wisdom Mind was born out of my clinical experiences and also my personal background in mindfulness meditation. While working as a full-time clinical neuropsychologist in a major suburban hospital, I held many roles. One included running a memory disorders clinic one day a week, assessing older adults and diagnosing them with dementia and various forms of late-life cognitive impairment. Another role I had was working in the outpatient neurorehabilitation department, where other clinical neuropsychologists and I were running mindfulness-based stress reduction (MBSR) groups for adults with persistent postconcussive syndrome (PCS). Through running several iterations of these groups, we learned valuable information about how to tailor Jon Kabat-Zinn’s (1990) protocol specifically to accommodate the cognitive challenges faced by persons with PCS. This tailoring was influenced by our knowledge of cognitive rehabilitation, specifically how to support adaptation to cognitive impairment through both restitution (i.e., improving function through repeated training) and compensation (i.e., finding strategies or “work-arounds” for cognitive difficulties). This tailoring not only supported individuals’ full participation in the program but also led to positive changes in their cognitive and psychological functioning, even after many of them had participated in several previous therapies and were considered “plateaued” in their treatment progress (Azulay et al., 2013).

It was a pivotal conversation with a behavioral neurologist at the memory disorders clinic that finally pushed me to figure out how to bring together these two different sets of experiences—diagnosing older (p. 2) adults with cognitive impairment and providing treatment in the form of MBSR for persons with PCS. Frustrated with having limited treatment options beyond medications with uncertain efficacy, this neurologist implored me: “You’re a psychologist; surely you have other treatment options for our patients that you can come up with?” And I thought, you know, you are right—we should be able to do better for these older adults. Cognitive rehabilitation, still a developing field, had been primarily focused on younger and middle-aged adults with various forms of acquired brain injury. While there was an existing literature on cognitive interventions for older adults, at the time this tended to focus on cognitive training (which typically focuses more on “drill and practice” of lower-level cognitive skills) as distinct from cognitive rehabilitation (which is more holistic and integrates a variety of strategies and supports and also includes emotional functioning). I questioned why we could not offer cognitive rehabilitation to older adults—and whether mindfulness training was one way to achieve this end.

The reason I chose to focus this work on subjective cognitive decline (described in more detail later in this chapter) was twofold. First, from co-leading the brain injury groups, I knew that trying to teach mindfulness to persons with full-blown dementia could be very difficult, and I thought that there would be more immediate traction by focusing on older adults in the earliest stages of cognitive decline. Second, I saw some interesting parallels between persons with subjective cognitive decline and those with PCS. Both of these are (and to some extent continue to be) “controversial” diagnoses—controversial because often the complaints or concerns of the affected individual are not detectable on standardized clinical testing. This failure to detect what the individual knows to be true in their experience can create further anxiety and distress and feelings of being invalidated. It also struck me that, in both cases, regardless of whether any objective evidence could be found for cognitive impairment, both groups of individuals were living with these symptoms that were adversely affecting their functioning and their quality of life. It seemed that mindfulness—with its focus on acceptance and self-compassion—could be beneficial in both of these populations. Moreover, mindfulness had the potential to help individuals learn to regulate their attention in a way that might help them not to overfocus on symptoms but to allow a wider scope of experiences into their everyday awareness. It had also been shown to enhance cognitive functioning, (p. 3) particularly attention, in healthy individuals, yet there was virtually no literature at that point to show whether it could improve cognitive functioning in individuals who were actually living with cognitive impairment.

And so it was my commitment to supporting older adults, as well as the positive experiences I had had teaching mindfulness to persons with PCS, that led me to develop this protocol. In fact, it was the impetus for me to leave full-time clinical practice and move to an academic-clinical position where I could devote significant time and resources to developing this work and researching its impact.

Background on Late-Life Cognitive Decline

Current research indicates that, with the rapid aging of the global population and with the coming of age of the “baby boomer” generation, there will be an exponential increase in the number of older adults at risk for significant cognitive decline and dementia. More specifically, in 2015, an estimated 46.8 million people were living with dementia worldwide, with the total estimated cost of care being $818 billion. The number of affected persons is anticipated to double every 20 years, with a projected increase to 74.7 million by 2030 (Alzheimer’s Disease International, 2015). Although the field of dementia science has focused heavily on pharmacological treatments, as of yet there is no cure and no single agent has been shown to reliably slow or prevent pathological cognitive decline (Tuokko & Smart, 2018). As such, there has been a recent movement toward greater focus on primary prevention (Imtiaz et al., 2014; Smart et al., 2017). Primary prevention includes promoting cognitive wellness in healthy older adults; for the purposes of this program, this includes older adults who are experiencing the effects of normal aging as well as those who may be at the very earliest stages of risk for decline.

This latter group—those at risk—has recently been discussed in the literature under the classification label of subjective cognitive decline, or SCD. SCD refers to a state whereby older adults complain of changes in their cognitive abilities yet appear normal on standardized clinical assessment (Jessen et al., 2014). Although these older adults may have (p. 4) been previously considered to be “worried well,” longitudinal evidence suggests that SCD is a risk factor for the later development of cognitive decline and dementia, including Alzheimer’s disease (Rabin, Smart, & Amariglio, 2017). More specifically, a recent meta-analysis estimated the risk of developing dementia in persons with SCD to be 2.07, with an annual conversion rate of 2.66%. In studies that had follow-up periods greater than 4 years, 14.1% of participants with SCD developed dementia and 26.6% declined to mild cognitive impairment (MCI; Mitchell et al., 2014). These figures indicate that persons with SCD represent a key target population for primary prevention interventions that can enhance current well-being as well as potentially reduce or slow the rate of future cognitive decline. Even for older adults who are not experiencing preclinical dementia, SCD may be related to comorbid conditions such as depression, anxiety, chronic pain, and other medical comorbidities (Rabin et al., 2017). Each of these are conditions that can adversely affect cognition and emotional well-being in older adults, and therefore they warrant clinical attention. A recent systematic review and meta-analysis indicated that persons with SCD may benefit from cognitively focused non-pharmacological interventions, although larger trials with longer-term follow-up are needed to fully appreciate the true preventive benefits against cognitive decline (Smart et al., 2017).

Mindfulness training could serve as a promising non-pharmacological prevention intervention in older adults, with some studies suggesting that long-term practitioners of meditation show less age-related neurodegeneration than non-meditating peers (Luders, 2014). There is some preliminary evidence that mindfulness training may be of benefit to older adults, although this field is in its relative infancy compared to the application of mindfulness in younger and middle-aged samples (e.g., Gard, Hölzel, & Lazar, 2014; Luders, 2014). The potential benefits of mindfulness training for older adults are several; for one, the dissemination of the intervention—and its maintenance thereafter—likely incurs lower costs than cognitive-enhancing medications. Moreover, studies on healthy individuals demonstrate that the practice of mindfulness can positively impact cognition and emotion (Sedlmeier et al., 2012) as well as brain structure and function (Fox et al., 2014, 2016) in healthy populations. Mindfulness meditation has been studied in a wide variety of clinical populations with different symptoms and concerns. A recent review that specifically focused on persons with neurological (p. 5) disorders suggested that mindfulness shows promise in various neurological samples, although interventions seem to be more efficacious when tailored to the particular needs and symptoms of the population rather than taking a one-size-fits-all approach (Smart, 2019).

The Current Protocol

This Facilitator Guide provides a mindfulness treatment protocol designed specifically for cognitively healthy older adults with and without SCD. The protocol, Wisdom Mind, is based broadly on Kabat-Zinn’s (1990) MBSR program, but with specific tailoring for older adults, including both developmental and cognitive tailoring. The overarching structure of the program is similar to MBSR, in terms of the 8-week format with weekly groups and a daylong retreat. However, as the author had learned from her experiences teaching the brain injury groups, presenting MBSR “as is” to individuals with cognitive issues was not going to be maximally effective without considering the participants’ cognitive difficulties. Moreover, most of the existing literature on MBSR at that time (and still at the current time) was focused on younger or middle-aged adults. As someone who had worked extensively with older adults, the author knew that a deep understanding and appreciation for this particular period of lifespan development was a necessary ingredient in making mindfulness effective in this population. As such, while the current protocol is heavily influenced by MBSR from a structural point of view, it clearly stands alone as a unique protocol, with additional practices and material specific to the older adult population. This is similar to the many other MBSR or other mindfulness protocols that have been specifically tailored to different populations and stand alone as their own programs. That said, the author would like to extend her very sincere appreciation to Jon Kabat-Zinn and his trailblazing efforts in bringing mindfulness to the health care setting—this tailored protocol truly would not be possible without those efforts. His influence looms large and continues to permeate the various forms of mindfulness programming that we see for various patient populations and age groups being made available today.

Through generous funding from the Alzheimer’s Society of Canada, the author and her colleagues conducted a single-blind, randomized (p. 6) controlled trial (n = 36), including healthy older adults with and without SCD, comparing the impact of Wisdom Mind with an existing program of psychoeducation on cognitive aging (Troyer, 2001; Wiegand et al., 2013). Outcomes were evaluated via self-report, cognitive electrophysiology with computerized cognitive testing, and structural magnetic resonance imaging (sMRI).

In one set of analyses, all participants receiving Wisdom Mind showed an increase in percent brain volume on sMRI following the intervention, as well as greater stability in moment-to-moment regulation of attention based on a cognitive task. Persons with SCD specifically showed a concomitant enhancement in the P300, an event-related potential associated with attention capacity. Both Wisdom Mind and the control condition of psychoeducation were associated with a decrease in cognitive complaints and an increase in memory self-efficacy (Smart et al., 2016).

In another set of analyses, the investigators looked at cognitive electrophysiology indices of performance monitoring, specifically the ERN event-related potential. This allowed the researchers to test the mindfulness principle of learning to respond, not react. Participants receiving Wisdom Mind showed enhanced performance monitoring as measured by an increase in the ERN, as well as a trend toward faster reaction times on the task used to generate the ERN, confirming the investigators’ hypotheses. Similar to the first set of analyses, all participants, regardless of intervention condition, showed a reduction in self-report of anxiety and self-judgment of one’s own mental function as measured by a self-report mindfulness questionnaire (Smart & Segalowitz, 2017).

In a recent review of the literature focused specifically on the application of mindfulness in neurological populations, a majority of studies focused on psychosocial and emotional outcomes, to the relative exclusion of cognitive variables (Smart, 2019). This is striking, given the literature in healthy individuals showing that mindfulness meditation can positively impact performance on cognitive and direct neural measurements. Moreover, the approach of cognitive rehabilitation broadly refers to a holistic treatment approach that simultaneously attends to a client’s mood, cognitive function, and psychosocial function, with treatment goals that are grounded in real-world experiences (Tuokko & Smart, 2018). What makes Wisdom Mind distinctive is that it was explicitly designed (p. 7) as a form of cognitive rehabilitation, addressing mood and cognitive variables, as well as the broader developmental context of older adults. The findings from the initial validation studies of Wisdom Mind indicate that while both mindfulness and psychoeducation can lead to subjective improvements in psychological functioning in older adults, only mindfulness training was associated with objective improvements in brain and behavior. More detail is provided later in this chapter in terms of how Wisdom Mind draws on the practices and principles of cognitive rehabilitation, particularly within an older adult context.

Who Is This Treatment For?

Wisdom Mind is a group-based protocol that was designed for—and validated with—cognitively healthy older adults (i.e., those 65 years and older) with and without significant cognitive concerns or SCD. Wisdom Mind is not validated for persons with documented, clinically significant levels of cognitive impairment, and such individuals should be screened out prior to group enrollment. In other words, it is not recommended that persons with MCI or dementia be intermixed with healthy older adults in Wisdom Mind. On one hand, those with greater cognitive impairment may struggle to keep up; conversely, healthy older adults may become fearful to see the level of cognitive impairment exhibited by these other group members. Providing mindfulness training to persons with more pronounced cognitive impairment will require a different approach in terms of which practices are presented and when. Other published work has examined the application of mindfulness to persons with MCI (e.g., Larouche et al., 2015; Wells et al., 2013) and dementia (Chan et al., 2017), and you are directed to these works for guidance on how to serve such individuals.

Cognitive Screening

Ideally, a thorough neuropsychological screen of each participant should be conducted to determine eligibility prior to group enrollment. The original assessment battery we used is detailed in Smart and Krawitz (2015) and was fairly extensive. If time and resources preclude such an (p. 8) assessment, then at least one, preferably two, norm-referenced tests of verbal memory will ensure that all participants can learn and retain new information and will reduce the likelihood of including persons with amnestic MCI. The Dementia Rating Scale-2 (Jurica, Leitten, & Mattis, 2001) also provides a broad-based screen of cognitive functions and can be used to rule out persons with MCI and dementia (i.e., those who show decreased performance in one or more domains at the level of 1.5 standard deviations below norms).

Clinical neuropsychological screening may not be feasible for all clinical settings, particularly those that do not have access to a clinical neuropsychologist to conduct such testing. At a minimum, a screen of instrumental activities of daily living and overall cognitive status will help to rule out dementia. For example, the Mini-Mental State Examination (MMSE) is a paper-and-pencil test that is scored out of 30 (Folstein, Folstein, & McHugh, 1975). A cut-score of 24 is often set for dementia (Creavin et al., 2016), although some authors have suggested this cut-score needs to be higher (e.g., 27) in more highly educated individuals (O’Bryant et al., 2008; Spering et al., 2012).

Needless to say, all participants should be able to speak and comprehend the dominant language of the group. Wisdom Mind has only been validated in English-speaking individuals, but other clinicians may wish to translate and adapt this program for participants whose primary language is not English. For example, this Guide contains scripts for all of the guided meditations (see Appendix); if the groups are not being conducted in English, then these scripts could be translated to the dominant language of the group and then the guided meditations re-recorded in that language.

Mental Health Screening

In terms of mental health functioning, a screen of participants (e.g., assessing symptoms of depression and anxiety) will provide further information on participant characteristics, as well as providing a way to track outcomes after treatment. It is not necessary to rule out persons with depression and anxiety, as mindfulness training is known to positively impact symptoms of such disorders. Additionally, SCD can often occur (p. 9) in the context of depression or anxiety. That said, it may be prudent for group facilitators to employ some other exclusion criteria, ruling out persons with conditions such as active psychosis, mania, or substance use, or those who are unwilling or unable to participate in a structured group. Group facilitators should also be aware that participants with comorbid mental health concerns such as depression or anxiety may take longer to learn practices (e.g., due to slowed processing speed) or require additional support as compared to participants without such concerns.

In choosing symptom measures, it is important to choose those that are validated specifically with older adult populations, such as the Geriatric Depression Scale (Yesavage et al., 1983) and the Adult Manifest Anxiety Scale-Elderly Version (Lowe & Reynolds, 2006). More detailed information on neuropsychological and psychological screening of older adults is provided in Tuokko and Smart (2018).

Outcome Measures

In terms of outcome measures, it is ultimately up to the particular group facilitators what they want to track for their particular participants. Considering what has already been published on mindfulness, including the original Wisdom Mind validation studies (Smart et al., 2016; Smart & Segalowitz, 2017), constructs to consider include mindfulness, depression, anxiety, and memory self-efficacy. It should be noted that, given this group is designed for cognitively intact older adults, it is unlikely that change would be detected on standardized neuropsychological testing. That said, if group facilitators are in a position to do longer-term tracking of their participants, they may wish to repeat some of the cognitive screening measures to show stability (or lack of decline) following the intervention.

Overview of the Program

In presenting the program, it is useful to begin with the title of the program itself—Wisdom Mind. Cognitively healthy older adults—and particularly those with SCD—are often quite concerned about declines in their cognitive abilities, leading them to judge and compare (p. 10) themselves to who they once were or to their same-aged peers. One of the anticipated outcomes of this program is to enhance current cognitive abilities; however, rather than focusing on this directly as a goal, the emphasis is placed on tapping into the wisdom that is inherent within all of us, which often increases naturally as we age (Jeste & Oswald, 2014). Encouraging participants to cultivate what is already within them immediately communicates a message of acceptance and loving-kindness, which is a central “attitude” of mindfulness (Kabat-Zinn, 1990). Moreover, this approach of non-striving and letting go of outcomes—another attitude of mindfulness—paradoxically allows participants to work on their cognitive ability without increasing stress and anxiety (Smart & Segalowitz, 2017).

Facilitator Qualifications

Facilitators administering this program should be familiar with the dissemination of mindfulness training programs. As the program is broadly based on MBSR (Kabat-Zinn, 1990), ideally individuals would be trained in this modality, although those trained in mindfulness-based cognitive therapy (Segal, Williams, & Teasdale, 2012) could also deliver the program. Most important is that facilitators must have their own regular mindfulness practice; this will allow them to be able to authentically respond to participants’ questions about meditation and to know when modifications to the practice instructions may be necessary.

Ideally, group facilitators should also have some background and experience working with older adults. This includes familiarity with the developmental concerns of older adults (e.g., changes in physical function, grief and loss) as well as a basic working knowledge of the types of cognitive changes that occur in normal aging. Having this knowledge is essential to being able to respond to questions about mindfulness that may be unique to this population and will also allow group facilitators to situate and contextualize mindfulness within the lives of older adults. Some of this material will be presented in the relevant chapters of this Facilitator Guide. Chapter 10, “Common Cognitive Slip-Ups,” details some of the typical cognitive concerns or “slip-ups” that participants might bring to the group. For those seeking a more comprehensive (p. 11) overview of this material, Tuokko and Smart (2018) contains specific chapters on cognitive and emotional changes in healthy aging and SCD.

Finally, as part of the tailoring of standard MBSR for this population, this Guide highlights specific considerations in how to make mindfulness training accessible for individuals with age-related cognitive challenges, including presenting information in multiple modalities. This will be particularly useful for group facilitators who do not have prior experience in leading groups for persons with cognitive difficulties.

Tailoring

Wisdom Mind was devised by the author, a clinical neuropsychologist with now over 20 years of personal meditation practice (primarily in the Zen and Tibetan Buddhist traditions) and well over 15 years’ experience teaching and mentoring students of mindfulness-based meditation practices in both healthy and clinical contexts. The author also has extensive experience working clinically with older adults, as well as a strong background in cognitive rehabilitation. This experience and training allowed for the specific tailoring of the program to meet the developmental needs and cognitive concerns of older adults. In the discussion of tailoring that follows, specific examples are provided.

Developmental Tailoring

Wisdom Mind presents many of the usual concepts of mindfulness training, but with particular respect to the developmental concerns of older adults. For example, it is common for older adults to notice subtle declines in their thinking abilities as they age, and for persons with SCD, these declines can become a significant source of concern or worry (Jessen et al., 2014). Moreover, in a modern, youth-obsessed culture that prioritizes speed and efficiency, these normative cognitive declines can seem even more pronounced to older adults. The concept of Wisdom Mind is to place emphasis on cultivating something that is already believed to be inherent in the aging process—that is, wisdom. This message is presented as a developmentally relevant way (p. 12) of contextualizing the message of acceptance and non-judgment, a core component of the MBSR program (Kabat-Zinn, 1990).

According to Erikson’s developmental theory, the task of older adulthood is to navigate the conflict of ego integrity versus despair (Erikson, 1968). Commensurate with this, Wisdom Mind participants are introduced to mindfulness practice as a way to make space for feelings of grief, loss, or regret in the final phase of life; to cultivate self-compassion for one’s life choices; and to propagate wisdom to younger generations.

The practices are also presented in a framework that addresses concerns about cognitive aging, and this is done in two ways:

  • First, participants are provided with psychoeducation about the relationship between attention and memory, as memory concerns are perhaps the most commonly reported concerns in older adults. Participants learn that lapses in attention (which can be normative) can make it more difficult to encode new information and remember it later. Therefore, by practicing mindfulness, participants should be able to pay better attention and thereby take in and remember more information. This connection between memory complaints and attention was previously illustrated by the work of Sohlberg and Mateer (2001), whereby attention training was found to decrease memory complaints in persons with acquired brain injury. The efficacy of this approach in the current context was further supported by outcome data indicating that older adults participating in Wisdom Mind showed a decrease in self-reported cognitive complaints and an increase in memory self-efficacy (Smart et al., 2016).

  • Second, the incidence of cognitive slip-ups is normalized as part of the aging process; later in the program, the practice of loving-kindness is contextualized in terms of having self-compassion toward these slip-ups. More information is provided in Chapter 10. “Common Cognitive Slip-Ups.”

Developmental psychology literature indicates that older adults tend to have a bias toward the experience of positive emotions, the so-called positivity bias (Reed, Chan, & Mikels, 2014). That said, regulating one’s emotions to maintain a positive mood requires cognitive resources, resources that may be limited in older adulthood. In other words, expending cognitive resources to regulate one’s mood can take a toll on (p. 13) the completion of other cognitive tasks for older adults (Peters et al., 2007). A practice called “Emotional Weather” is introduced later in the program (see Chapter 5), whereby participants are invited to simply be with a challenging emotional experience without reacting to it or trying to change it. The rationale behind this is to provide an emotion regulation practice that can also decrease cognitive load in contexts where participants face both a cognitive and an emotional challenge.

Finally, participants are provided with psychoeducation on the concept of cognitive reserve (Stern, 2012), or the “mental bank account,” and given information on how one can enhance cognitive reserve as a buffer against cognitive decline through taking up novel and challenging activities or increasing socialization. This is connected to mindfulness practice, such that participants might experience greater enjoyment from such activities by bringing a “beginner’s mind” of curiosity, openness, and non-judgment.

Cognitive Tailoring

Judd (1999) has coined the term “neuropsychotherapy” to refer to the need to adapt psychotherapeutic interventions to persons with cognitive impairment. In the case of cognitively healthy older adults with and without SCD, this means tailoring with respect to normal cognitive aging. This includes (but is not limited to) slowed processing speed, difficulties with working memory, new learning and episodic memory retrieval, and prospective memory (Tuokko & Smart, 2018). In practical terms, this translated to the following adaptations in Wisdom Mind:

  • Slowed processing speed and working memory difficulties—Care is taken to pace the material; to offer ideas in simple, straightforward language; and to provide frequent check-ins to ensure that the material has been processed and understood.

  • New learning and episodic memory retrieval difficulties—Significant repetition is used in the program. Each session begins with a recap of the previous session. Likewise, each session concludes with an inquiry into the “take-home points” of that particular session, which the group facilitator writes as bullet points on a whiteboard. Participants are encouraged to write these bullet points down in their (p. 14) Workbook as an easy summary, as well as any bullet points that are personally salient to them in terms of the content discussed during that session. Attention is also drawn to the fact that participants will receive information in multiple modalities (i.e., group discussion, Workbook, audio recordings) in order to facilitate new learning of information.

  • Prospective memory—Prospective memory is described as “remembering to remember.” This means working proactively with participants in the session to derive a specific plan for how they will schedule and remember to do their daily home practice. Participants are encouraged to bring their day planner, calendar, etc., to each session. Time is spent at the end of the first three sessions helping participants to schedule their practice, as well as finding ways to cue a reminder for practice (e.g., alarm on cellphone).

Tailoring With Respect to Practices

As noted earlier, Wisdom Mind was explicitly designed to be in alignment with forms of cognitive rehabilitation. This means that while the program is broadly based on the same format as MBSR, intentional decisions were made about the sequence of practices with respect to the cognitive status of older adults as well as neuropsychological theory. For example, hierarchical theories of attention suggest that sustained attention is a foundational skill on which is built selective attention (i.e., freedom from distractibility), divided attention, and working memory (Sohlberg & Mateer, 2001). As such, Sitting Practice is presented whereby participants train first in Focused Attention (FA; i.e., concentrating on the breath with a narrow placement of attention, on the breath in the abdomen). In later sessions, this is followed by training in Open Monitoring (OM; i.e., an open state where one is receptive to whatever arises in one’s sphere of awareness) (Lutz et al., 2008).

Based on prior experience teaching mindfulness to persons with acquired brain injury (Azulay et al., 2013), the author observed that persons with cognitive impairment often found sitting meditation practice to be more challenging than other practices. This is due not only to cognitive factors but also to physical limitations associated with the injury (e.g., chronic pain). Older age increases the likelihood of chronic (p. 15) illness, which may likewise make it challenging to sit for long periods of time, at least in the beginning when practices are introduced. In light of this, the Sitting Practice is incrementally increased over the weeks of the program, from 10 minutes to 20 minutes to 40 minutes. In order to ensure that a sufficient “dose” of mindfulness training is being engaged, shorter Sitting Practices are augmented with other practices such as the Body Scan or Mindful Yoga. Participants are also presented with basic information on neuroplasticity, particularly the maxim “use it or lose it,” reinforcing the notion that the more they practice mindfulness skills, the more benefit they are likely to get from the training. Given older adults’ focus on positive emotions previously described, group facilitators should explore ways to make the practice intrinsically or even extrinsically reinforcing for participants so that they are more likely to engage in the at-home practice.

Also of note with regard to sequencing of practices is the fact that participants are trained in both FA and OM before explicit instructions are given in practices that involve an emotional component (i.e., loving-kindness and Emotional Weather). As previously discussed, cognition and emotion can compete for limited resources in older adulthood, and all things being equal, older adults will tend to use available resources to regulate their emotions toward a positive state rather than focus on completing a cognitive task (Peters et al., 2007). Training participants in FA and OM as “cold cognitive” tasks first means that they develop some proficiency in these practices before the added challenge of emotionally charged practices is introduced.

When the Wisdom Mind program was originally conducted, the author led participants through Mindful Yoga as outlined in Kabat-Zinn’s (1990) book, as she is not a yoga teacher and did not feel comfortable modifying these teachings. However, one update that has been made to the current iteration of Wisdom Mind is that instead of using Kabat-Zinn’s (1990) yoga sequences, two unique Mindful Yoga series have been created specifically for this program. These sequences were created by Kristen Silveira, MSc, a doctoral student in clinical neuropsychology and a registered yoga teacher who has experience tailoring yoga to populations with different cognitive and physical needs. In the Wisdom Mind yoga series, explicit modifications are made for individuals who may have physical limitations (e.g., options to use a chair when (p. 16) appropriate), and the pacing is appropriate for older adults who may have challenges in processing speed. Photographs of the poses are provided in this Facilitator Guide and also in the corresponding Participant Workbook, which augment the instruction given in guided audios. .

Intervention Structure and Format

Session Structure

Wisdom Mind is an 8-week program consisting of weekly group meetings that can be held in a community setting, with 8 to 10 participants per group to allow for a manageable discussion. The group sessions are 2 hours long, with a break offered around the midway point (i.e., at 1 hour) for participants to visit the bathroom, stretch, or move to alleviate any discomfort from prolonged sitting, and to take a break in focusing their attention. Each group session begins with a brief guided practice (about 10 minutes) to mark the transition from daily life to the more contemplative space of the group. This is followed by a check-in about the previous week’s practice and review of any questions or observations on the prior week’s material. Participants are then presented with the particular didactic material for that week; this is followed by a demonstration of the current week’s practice, and an opportunity for questions about the practice to be answered. The final minutes of the group are spent reviewing the take-home points of the session, and participants are asked to share out loud their recollections of the group and to take notes in their Workbook, reflecting the take-home points in their own words.

Participants are encouraged to review their Workbook over the course of the week, including making note about any questions that arise from the practice as well as tracking practice frequency. If a question arises that participants want addressed sooner than the following session, invite them to email the group facilitator directly. In keeping with the MBSR format, a full-day retreat is held between weeks 7 and 8, again in a community setting, where participants are invited to bring their own lunch to engage in a mindful meal.

(p. 17) Materials

Each group session is held in a quiet space, preferably during the day in a place with natural lighting. Provide straight-backed chairs, comfortable enough for participants to sit in for 2 hours and supportive enough so they can sit in a meditative posture. (Invite participants to sit with cushions at home if they prefer.) Ask participants to obtain and bring a yoga mat to each session for the various floor-based practices, such as Body Scan or Mindful Yoga. We recommend that you have a whiteboard or flip chart to take notes from the session in real time and summarize key points of discussion and learning.

Participants should purchase or be given the separate Participant Workbook for this program so they can take notes during the session, (p. 18) review the notes between sessions, and track their daily practice. In the first several sessions, encourage participants to bring their calendar or day planner to schedule in time for daily practice while in the session, as daily home practice is a core part of the program. As an accompaniment to this Facilitator Guide, . Although all of the meditation practices are recorded and available for download to facilitators and participants, you may wish to record the meditation practices in your own voice; for this purpose, the scripts for these meditation practices are included in Appendix at the end of this Facilitator Guide. Table I.1 lists the practices and the session of this program where they are introduced.

Table I.1 List of Meditation Practices

Program session

Practice

1

1a: Body Scan—Introduction

1b: Body Scan—Practice Instruction

1c: Mindful Eating

2

2a: Ordinary Magic

2b: Short Sitting (Focused Attention I)

3

3a: Slips and Falls

3b: Mindful Yoga—Introduction

3c: Mindful Yoga I—Practice Instruction

3d: Longer Sitting (Focused Attention II)

4

4a: Mindful Yoga II—Practice Instruction

5/6

5a: Long Open Monitoring (Sitting Practice Extended)

5b: Aimless Wandering

5c: Emotional Weather—Introduction

5d: Emotional Weather—Practice Instruction

7

7a: Loving-Kindness—Introduction

7b: Loving-Kindness—Practice Instruction

Finally, as noted earlier, while this program is broadly based on MBSR, it has enough unique elements to have it stand alone as its own mindfulness training program. That said, when the original Wisdom Mind intervention was delivered, participants were assigned certain chapters of Kabat-Zinn’s Full Catastrophe Living (1990) as supplemental reading, as that book is a highly accessible resource on the basic principles of mindfulness. It is up to group facilitators to decide whether they wish to assign those chapters. A reference to the optional purchase of Full Catastrophe Living is made in the Participant Workbook.