INT J LANG COMMUN DISORD, NOVEMBER–DECEMBER 2012,

VOL. 47, NO. 6, 673–684

Research Report
Effects of Mindfulness Meditation on three individuals with aphasia
Ellen Orenstein†, Alexandra Basilakos‡ and Rebecca Shisler Marshall‡
†Dekalb Medical Center, Atlanta, GA, USA
‡Communication Sciences & Special Education, University of Georgia, Athens, GA, USA

(Received July 2011; accepted May 2012)

Abstract
Background: There is evidence to suggest that people with aphasia (PWA) may have deficits in attention stemming
from the inefficient allocation of resources. The inaccurate perception of task demand, or sense of effort, may
underlie the misallocation of the available attention resources. Given the lack of treatment options for improving
attention in aphasia, Mindfulness Meditation, shown to improve attention in neurologically intact individuals,
may prove effective in increasing attention in PWA.
Aims: The purpose of the present study was to determine if Mindfulness Meditation improves divided attention
or language in PWA and if it affects the overall sense of effort.
Methods & Procedures: A multiple baseline single-subject design was used to determine the effects of Mindfulness
Meditation on divided attention for three PWA. Divided attention was measured using a non-linguistic divided
attention task. Visual inspection of the data was used to determine changes in performance (sense of effort, reaction
time and accuracy, language) over time.
Outcomes & Results: High performance observed on the attention measures suggests that PWA have varying degrees
of attentional impairment that may surface when certain demands are presented. There were no observable changes
in the performance on the sense of effort or language measures; however, measures of reaction time may indicate
Mindfulness Meditation improved efficiency of task completion.
Conclusions & Implications: All three participants reported that Mindfulness Meditation was easy to learn and
carry out on a daily basis, and reported feeling more ‘relaxed’ and ‘peaceful’ after Mindfulness Meditation training
than before. With the knowledge that PWA can learn meditative practices, and with such successful findings in
neurologically intact individuals, it is important to continue evaluating the benefits of Mindfulness Meditation in
PWA.
Keywords: aphasia, attention, mindfulness meditation, sense of effort

What this paper adds

What is already known on the subject?
A growing body of research has shown that Mindfulness Meditation may improve attention in neurologically intact
individuals. Further evidence suggests that the linguistic deficits of PWA may be related to an attention deficit.
More information regarding treatment options for attention deficits in aphasia is needed, as improving attention
may subsequently improve language abilities in this population.

What this paper adds

The study was a first attempt to explore how Mindfulness Meditation influences attention in people with aphasia.
The current study showed little effect of Mindfulness Meditation. However, the participants’ performance questions
whether attention deficits in aphasia are universal.

Introduction (Erickson et al. 1996, Marshall et al. 1997, Murray

2000, Murray et al. 1997a, 1997b, 1998). This has
Research has determined that people with aphasia been shown particularly when a rapid shift between
(PWA) often present with deficits in divided attention stimuli is required and when inhibition of unwanted

Address correspondence to: Rebecca Shisler Marshall, 570 F Aderhold Hall, Communication Sciences & Special Education, University of
Georgia, Athens, GA 30602, USA; e-mail: rshisler@uga.edu
International Journal of Language & Communication Disorders
ISSN 1368-2822 print/ISSN 1460-6984 online  c 2012 Royal College of Speech and Language Therapists
DOI: 10.1111/j.1460-6984.2012.00173.x
674 Ellen Orenstein et al.
stimuli is necessary (Erickson et al. 1996, Marshall et al. measure that allows a PWA to rate the amount of effort
1997, Murray 2000, Murray et al. 1997a, 1997b, 1998). believed to be expended on a task, therefore avoiding
Additionally, there is growing evidence demonstrating the potential confound of linguistic deficits to describing
that the capacity of attention itself may be decreased, task difficulty. Clark and Robin (1995) found that when
or the ability to allocate attentional resources may be comparing SOE ratings with individual performance,
inefficient in PWA (Erickson et al. 1996, McNeil et al. individuals with brain damage demonstrate difficulty
1991, Murray et al. 1997a, 1997b, 1998, Tseng et al. accurately measuring the amount of effort needed for
1993). It is thought that these reductions in attentional task completion. However, it is not known whether
abilities contribute to the linguistic deficits that PWA aphasia type or severity may influence participant ratings
experience (McNeil et al. 1991, Murray 2000, Murray of SOE.
et al. 1997a, 1997b, 1998, Tseng et al. 1993). Treatments that specifically target these possible
Though the source of attention deficits observed attention deficits may be beneficial for PWA. There are
in PWA is still debated, there are three possible only a limited number of available treatments targeting
contentions: (1) a possible overall decrease in attention attention processes, as current treatments mainly focus
capacity, (2) a deficit in the allocation of attention on linguistic deficits (Helm-Estabrooks 2002). When
resources and/or (3) a deficit in evaluating the cognitive compared with the linguistic deficits in PWA, attention
demands of a task (Erickson et al. 1996, Murray et al. deficits are often overlooked (Murray 2002). If deficits
1997b, 1998, Peach et al. 1994, Weiner et al. 2004). in attention contribute to the linguistic deficits observed
McNeil et al. (1991) described attention as having in aphasia, directly targeting attention in therapy may
two properties. The first defines attention as a unit of maximize recovery (Murray 2002). Attention, and
limited resources, while the second defines it as a system how it may be targeted for purposes of treatment in
responsible for allocating these same resources across aphasia, is a valid and necessary research area and
functional cognitive demands. A breakdown can occur may further treatment efforts (Helm-Estabrooks 2002,
at either of these levels where there may be a deficit Murray 2002).
in the mental capacity or a deficit in the allocation Recent research has revealed that attention and
process (McNeil et al. 1991). In other words, a deficit in cognitive performance can be increased using methods
attentional capacity may result in fewer resources being such as meditation (Moore and Malinowski 2009, Jha
available to support language. A deficit in allocation, et al. 2007, Lazar et al. 2000, Tang et al. 2007). The
however, may result in the failure of a healthy attention results of these studies have suggested that Mindfulness
processing system to allocate its resources efficiently Meditation (MM) improves cognitive flexibility (Moore
(McNeil et al. 1991). Murray et al. (1997b) suggested and Malinowski 2009), enhances the components of
that PWA might have an impairment in determining the attention system (Jha et al. 2007), increases cortical
which stimuli require attentional priority. Data support- thickness (Lazar et al. 2000), improves responding on
ing deficits in capacity have also been found as for measures of attention, and results in more efficient
inefficient allocation (Murray et al. 1997b, Peach et al. attentional processing (Tang et al. 2007).
1994, Slansky and McNeil 1997). There is a current trend in healthcare settings to
With regards to the third possible source of attention implement complementary and/or alternative treatment
deficits listed above, the evaluation of task demands, strategies as an adjunct intervention for a variety of
literature in the field has found that PWA may have an communication disorders (for a review in the field
inaccurate perception of task demand. Clark and Robin of speech–language pathology, see Laures and Shisler
(1995) found that an inaccurate sense of effort (SOE) 2004). A specific approach that has been studied
might have caused individuals to fail to allocate the for its ability to augment attention and ameliorate
amount of attention resources needed for demanding negative affect is that of MM. Kabat-Zinn (1994) states,
attention tasks. Subsequently, inaccurate SOE may ‘Mindfulness means paying attention in a particular
lead to reductions in performance. In other words, way; on purpose, in the present moment, and nonjudg-
an individual with brain damage may not be able to mentally’ (p. 4). Specifically, during MM practise, the
perceive accurately the difficulty of a task, and therefore individual is seated in an upright posture and attempts
fail to expend the appropriate amount of resources to to focus on his/her breathing (Teasdale et al. 1995).
complete the task. It is speculated that the perception As focus begins to move away from the breath and
of task demand, or SOE, is a possible source for onto other thoughts or feelings, the practitioner is
decreased performance on tasks that require divided taught to acknowledge and accept the redirection of
attention (Clark and Robin 1995, Murray et al. 1997a, thought, to ‘let go’ of the new thought, and to redirect
Tseng et al. 1993). SOE can be defined as a partici- attention back to his/her breathing (Kabat-Zinn 1982,
pant’s perception about how difficult a task was to Teasdale et al. 1995). The practitioner is taught to
complete. Although subjective, SOE is a non-linguistic use this same strategy throughout the day in order to
Effects of Mindfulness Meditation on three individuals with aphasia 675
Table 1. Participant characteristics

Auditory Months
Participant Gender Age (years) Aphasia type Aphasia severity comprehension percentile post-onset Handedness
LN Female 49 Borderline Wernicke’s Mild 37 61 Right
JJ Male 59 Wernicke’s Moderate 16 36 Right
MW Male 51 Anomic Mild 15 96 Right
Note: Type of aphasia and auditory comprehension percentile were as determined on the ADP.

maintain focus on the present moment to increase their and aphasia were initially included in the study. One
general levels of awareness about a task (Teasdale et al. participant withdrew for unknown reasons; therefore,
1995). Although MM instruction is verbal, learning the data are reported for three individuals (mean age =
actual technique is ‘experiential’ and up to the individ- 53 years). All participants were recruited from the
ual to be able to acknowledge and redirect shifting University of Georgia Speech and Hearing Clinic based
attention (Zylowska et al. 2009). Therefore, it can be on the previous diagnosis of aphasia where they received
communicated in ways that even individuals with mild- weekly treatment for language deficits. Inclusion criteria
to-moderate comprehension deficits can learn MM. included a diagnosis of aphasia according to the
Although, it may be more challenging for some PWA, Aphasia Diagnostic Profile (ADP; Helm-Estabrooks
depending on the particular deficits. 1990); passing a hearing screening bilaterally at 45
MM has been documented to improve attention, dB for 500, 1000, 2000 and 4000 Hz; no meditation
cognition and emotion for neurologically intact individ- experience; and the ability to participate in a 9–13-week
uals (Tang et al. 2007, Valentine and Sweet 1999). study. A summary of the participants’ characteristics can
Findings regarding the effects of MM in clinical be found in table 1. All participants consented to partici-
populations (e.g., ADHD) indicate that MM may be pation in the study; and all protocol and procedures
a beneficial adjunct treatment strategy for attention were approved by the Institutional Review Board of the
deficits (Zylowska et al. 2009). With previous research in University of Georgia.
MM demonstrating improved performance on attention
tasks (Valentine and Sweet 1999), this study aimed to
determine if MM is successful for increasing attention Measures
performance for PWA. If so, it may prove to be a useful
complementary therapy for post-stroke deficits. Given Baseline measures of divided attention, SOE and linguis-
that aphasia is defined by deficits in language, this study tic variables were taken during Phase A1 prior to
also intended to follow any effects that MM may have the initiation of MM training. As soon as partici-
on language. In order to explore possible effects on pant performance on the dual task was stable for five
language, specific linguistic measures were conducted consecutive sessions, Phase B commenced and MM
both pre- and post-treatment. training began. MM training was withdrawn in Phase
A2, when participants reached 30 min of MM practise
and demonstrated stability with the dual task.
Method Phase A1 was the preliminary assessment of divided
Experimental design attention, SOE and linguistic variables. The divided
attention task was a non-linguistic dual-task procedure
A multiple baseline single-subject ABA design across that was modelled after Erickson et al. (1996). This
individuals was used for this study in order to control for task was chosen because it implemented non-linguistic
possible threats to internal validity (e.g., practise effects; variables (i.e., card sorting and tone monitoring) to
Kazdin 1982) and to show the effects of implementing allow for the assessment of divided attention without
MM as a treatment for three PWA. Because the design the possible confound of linguistic deficits. It measured
was ABA (maintenance), the baseline phase where MM divided attention via a dual-task procedure that involved
was not administered was considered the ‘control’. Due the simultaneous identification of the designated target
to the nature of MM and the anticipated benefits, we tone and the completion of a card-sorting task. The
did not have a ‘withdraw’ phase. card-sorting task involved sorting cards from the Blinkc
game card deck either by shape, number or colour, as
designated by the experimenter. Cards were continu-
Participants
ously sorted for the duration of the presentation of
Four individuals between the ages of 45 and 59 tones, which was 5 min. Individuals were instructed
years with a history of left-hemisphere brain damage to sort cards the entire time the sounds were playing
676 Ellen Orenstein et al.
at a rate with which they felt comfortable. Data were reach the same criteria, with at least three additional
collected on the accuracy and number of cards sorted in sessions. In Phase B, MM training was completed
addition to the accuracy and reaction time (RT) of the prior to administering the divided attention task each
tone identification task. Since participants identified the session. In a quiet and dimly lit room each participant
target tones by pressing the space bar on the experimen- was individually instructed to notice distractions, pain,
tal computer, RT was recorded as soon as they responded boredom and other feelings that arose while practising
to the tone. To determine if practise in MM altered the breathing technique. As these thoughts occurred,
SOE ratings, SOE measures were collected. Following participants were instructed to return the focus to their
the divided attention task, each participant completed a breath or other bodily sensations (e.g., the awareness of
rating of his/her perceived SOE needed to complete the the chair beneath them or their feet on the ground). The
task, where 5 was the greatest amount (top anchor) of length of the training increased gradually beginning with
effort and zero was the least amount of effort expended 5 min of practise and building to 30 min of guided MM
(bottom anchor; Erickson et al. 1996, Murray et al. over a minimum of four sessions. Participants were asked
1997a). Participants could mark a ‘X’ anywhere on a if they understood MM instructions, and were given an
vertical line at the point they considered to most closely opportunity to ask questions regarding the meditation.
represent their expended effort. The experimenter instructed the participants to practise
The examiner along with another judge determined meditation at home for gradually increased increments
a numerical value for the participant’s mark using a of time, based on the number of instruction sessions.
template with ratings labelled in increments of 0.5. Participants were asked to document the amount of
Informal language measures were collected pre- and daily home practice in a log given to them by the
post-treatment to assess the effects of MM on language. experimenter. Take-home instructions and guidelines
Expressive language was assessed by measuring the were given verbally and in the form of written handouts.
correct information units (CIU) of the participants Treatment continued until no visual trends were evident
according to a modified procedure described by Nicholas for the accuracy of the tone identification task and card-
and Brookshire (1993). A CIU analysis is a standard- sorting task on at least three data points.
ized scoring method used to analyse the informative- Movement to Phase A2, or the maintenance phase,
ness and efficiency of connected speech in adults with was determined by reaching 30 min of MM practice
aphasia. A connected speech sample was obtained with and visible stability for at least three points for both
four stimuli taken from the BDAE (Goodglass et al., accuracy on the tone identification task and card-sorting
2001): (1) description of the ‘cookie theft’ picture, (2) a task. Phase A2 then consisted of the completion of five
narrative of a six-sequence picture story, (3) the answer sessions in order to determine if the effects of treatment
to one question regarding personal information, and remained stable. During this phase, direct MM training
(4) the description of a procedural event. Total word ceased but data collection for performance on the
count, time and CIU counts were used to calculate the divided attention task and SOE continued. Participants
following measures: (a) words per minute (WPM), (b) were instructed to continue practising MM for at least
per cent of words that were correct information units 30 min each day on their own, documenting the time
(% CIUs), and (c) correct information units per minute spent meditating.
(CIUs/min) (Nicholas and Brookshire 1993).
Receptive language was assessed by using partial
Materials
subtests of the BDAE. The first section evaluated word
discrimination and consisted of eight stimuli in which Ten non-target pure tones and one target complex tone
the participants were asked to identify stimuli non- with multiple harmonics were created using ToneGen,
verbally (e.g., ‘Show me your elbow’). The second a downloadable software program which allows the
section consisted of following three, one-step verbal user to create pure tones and harmonics with varying
commands (e.g., ‘Look at the ceiling’). In the third frequencies and amplitudes. Non-targets consisted of
section the participant answered ‘yes/no’ questions (e.g., pure tones presented at the frequencies 550, 580, 620,
‘Will a cork sink in water?’). Each item tested was scored 680, 720, 780, 820, 920 and 980 Hz.1 The target sound
as either correct or not by the experimenter, obtaining was a complex harmonic consisting of the frequen-
a total per cent accuracy for the receptive portion of the cies 500, 1000, 1500, 2000, 2500 and 3000 Hz. The
language measure. target sound was easily differentiated from the non-
Phase B introduced the training of MM. Movement target tones. Tones were generated randomly on a laptop
to Phase B was determined by reaching a minimum of computer using Super Lab Pro for Windows version
five baseline sessions for the first individual, stability 2.0.1 at a rate of onset every 2500 ms with duration
for both accuracy and the tone identification task and of 500 ms, for a total of 24 events/min. A total of
card-sorting task. Each subsequent participant had to 103 tones were presented over a 5-min period with a
Effects of Mindfulness Meditation on three individuals with aphasia 677
ratio of one target tone to every six non-target tones. task. Inspection of RT for tone identification indicates
There were a total of 14 targets and 89 non-targets. A the average RT decreased slightly in Phase A2 when
preview of the tones was presented to the participants compared with phases A1 and B. Increased RTs have
each session to determine adequate loudness—that is, been related to greater activation of brain areas responsi-
adequate loudness was achieved when the experimenter ble for attentional processing (Honey et al. 2000).
was assured by the participants that they could hear the Therefore, increased RTs may imply an increase in
presented tones. Individuals were instructed to press the resources allocated to complete the task.
space bar on the laptop every time they heard the target Upon visual inspection of LN’s SOE ratings over
tone, and to respond to the target tone as quickly and three phases (figure 5), no clear or obvious trends are
accurately as possible. All sessions were recorded using a evident. In addition, the SOE ratings do not appear to
digital video camcorder. correspond with the performance on any of the four
dependent variables examined. That is, LN did not
rate the task as less effortful when her performance was
Results
high, nor did she rate the task as more effortful when
The present study sought to answer the following performance decreased. Likewise, she did not rate a high
questions regarding the effects of MM on PWA: (1) performance with high effort (i.e., as difficult) or a poor
Does performance on a divided attention task improve performance with a low rating (i.e., as easy). LN had
following MM training?; and (2) Does MM alter a high percentage of tones identified and cards sorted
the monitoring of task demands and overall SOE? If while maintaining a relatively fast RT. However, she had
deficits in divided attention contribute to the language more false-positives in the baseline, which suggests she
deficits seen in aphasia (Alexander 2006, Erickson et al. had a lack of attention to the target and was potentially
1996, Helm-Estabrooks 2002, Murray 1999, Tseng over-generalizing her response (for false-positive results,
et al. 1993) and MM improves divided attention (Levy see figure 6). Taken together, LN demonstrates improve-
et al. 2001, Valentine and Sweet 1999), then it can be ment in the task through decreased false-positives in
reasonably predicted that language may improve after addition to increased RT.
practising MM. Language testing for LN revealed a 10% decrease
All dependent variables were recorded and graphed in performance on the receptive language score from
each session. Movement between phases was dependent 84% pre-treatment to 74% post-treatment (table 2).
on relative observable stability of at least three data WPM increased slightly from 0.91 to 0.97 pre- and
points for the accuracy of the tone identification task, post-treatment, respectively, indicating an increase in
card-sorting task and total number of cards sorted. the amount of words produced during the sample. Per
The following variables were recorded each session and cent CIUs decreased from 65% pre-treatment to 59%
graphed: (1) per cent accuracy for sorting cards, (2) post-treatment, indicating slightly less accuracy of the
number of target tones correctly identified, (3) total content in the language sample. Likewise, CIUs/min
number of cards sorted, (4) RT for the identification of decreased slightly with 0.64 pre-treatment and 0.62
target tones, and (5) SOE rating. post-treatment, indicating a slight reduction in the
Overall, the high performance observed on the accuracy and efficiency of content expressed (table 2).
attention measures suggests that PWA have varying
degrees of attentional impairment that may surface
JJ
when certain demands are presented. There were no
observable changes in the performance on the SOE As displayed in figure 2, all dependent variables collected
measure; however, measures of RT may indicate MM’s during the divided attention task remained relatively
improved efficiency of task completion. The following stable through the duration of the study. Performance on
describes patterns observed for each individual in more both the card-sorting task and target tone identification
detail. task reached maximum accuracy within the first few
sessions of baseline.
JJ’s perceived SOE appears to remain relatively stable
LN
throughout the study (figure 5). However, there is a
For the first participant (LN), all dependent variables slight decrease in SOE during Phase A2 compared with
collected during the divided attention task remained Phases A1 and B. When comparing the ratings for SOE
relatively stable through the duration of the study with the other dependent variables during all phases
(figure 1). Performance on both the card-sorting task of the study (i.e., per cent accuracy, number of tones
and target tone identification task reached maximum identified, number of cards sorted and RT), it is evident
accuracy within the first few sessions. Due to her high that a higher SOE was reported when performance
accuracy, it is important to note LN’s RTs for this accuracy decreased, especially during session nine. That
678 Ellen Orenstein et al.

Figure 1. Performance variables for LN.

Table 2. Pre- and post-treatment language scores

Pre-treatment Post-treatment
Receptive language Percentage Receptive language Percentage
Participant score (%) WPM CIUs CIUs/min score (%) WPM CIUs CIUs/min
LN 84 0.91 65 0.64 74 0.97 59 0.62
JJ 68 0.97 61 0.61 61 1.65 65 0.89
MW 90 1.28 86 1.07 87 1.17 84 1.0
Note. WMP, words per minute; CIU, correct information unit.
Effects of Mindfulness Meditation on three individuals with aphasia 679

Figure 2. Performance variables for JJ.

is, JJ’s effort rating increased when the number of 61% post-treatment (table 2). WPM increased from
tones identified decreased, the number of cards sorted 0.97 to 1.65 pre- and post-treatment, respectively,
decreased and RT increased. As a result, it may be indicating a larger number of words produced during the
concluded that JJ has an accurate perception of task sample. Per cent CIUs increased slightly from 61% to
demand. JJ sacrificed the number of cards sorted for 65% post-treatment, indicating an overall improvement
accuracy on target tone identification. His RTs were also in accurate content conveyed in the sample. An increase
slower with fewer false-positives, which suggest he was was also noted in post-treatment testing for CIUs/min
concentrating on accuracy, which led to slower process- with pre-treatment resulting in 0.61 CIUs/min and
ing and therefore slower RTs. post-treatment resulting in 0.89 CIUs/min indicating an
Language testing for JJ revealed a 7% decrease in increase in the amount of meaningful context expressed
the receptive language score from 68% pre-treatment to (table 2).
680 Ellen Orenstein et al.

Figure 3. Performance variables for MW.

MW for MW fluctuated at the start of baseline and then

stabilized before the commencement of treatment.
When assessing performance on the divided attention
During Phases B and A2, RT remained relatively
task pre- and post-treatment, it is evident from visual
stable, resulting in no observable pattern following the
observation of the figures that performance remained
implementation of MM.
relatively stable throughout the duration of the study
MW began the study with relatively high ratings on
(figure 3). With the exception of session 24 on the
the SOE scale during Phase A1 (figure 5). SOE is variable
target tone identification task (figure 3), performance
in Phase B but a general decrease is evident. Phase A2
on this task remained variable but relatively accurate
then exhibits variability across all five sessions. With
throughout the study reaching maximum performance.
regards to SOE representing task performance, MW’s
Performance on both the card-sorting task and target
ratings were generally consistent with his performance
tone identification task reached maximum accuracy
(figures 3 and 5). For instance, in sessions 14 and 24,
within the first few sessions resulting in a minimal
MW demonstrated greater awareness of the degree of
amount of room for improvement (figure 3). RT
extended effort when performance decreased. As a result,
Effects of Mindfulness Meditation on three individuals with aphasia 681

Figure 4. Reaction times for the target tone identification task for participants across phases and sessions.

it may be concluded that MW has an accurate perception course of the study. His level of aphasia was also the least
of task demand. Overall, MW sacrificed card sorting for severe of the three participants.
tone identification and had few false-positives with a Language testing for MW revealed a 3% decrease in
faster RT. There was no observable difference over the the receptive language score from 90% pre-treatment to

Figure 5. Sense of effort (SOE) ratings for participants across phases and sessions.
682 Ellen Orenstein et al.

Figure 6. False-positives, card sorting and tone identification for the PWA in Marshall and Basilakos (2010) (BW, RH, ST, BI, PH and HG)
and the current study (LN, JJ and MW).

87% post-treatment (table 2). WPM decreased from decreased. Reduced RT and maintenance of accuracy
1.28 to 1.17 pre- and post-treatment, respectively, suggests increased processing efficiency, potentially due
indicating fewer words expressed during the sample. Per to MM. It is possible that the other individuals in the
cent CIUs decreased slightly from 86% pre-treatment to study needed more practice with MM techniques before
84% post-treatment, indicating slightly less accuracy of changes in processing speed could be demonstrated on
the content in the language sample. Likewise, CIUs/min the experimental task.
decreased slightly with 1.07 pre-treatment and 1.0 post- While LN’s RT data reveal that MM may have
treatment, indicating a slight reduction in the accuracy played a role in processing speed, it is not apparent in the
and efficiency of content expressed (table 2). other participants and therefore no specific conclusions
can be drawn. Chiesa and Serretti (2010) reviewed
studies that tested whether MM could improve attention
Discussion abilities. Their review found that long-term meditation
There were no observed changes in performance on the practice as well as different meditative techniques could
divided attention task in language or in relaxation as potentially affect certain aspects of attentional process-
a result of the implementation of MM. In addition, ing. Changes in executive attention (which encompasses
measures of SOE revealed a relatively intact evaluation dual-task performance) may occur more specifically
of task demand. All three participants exhibited high with concentrative practices, not Mindfulness-based
performance on the divided attention task with no meditation (Jha et al. 2007). Differences in the effects of
obvious changes observed as a result of the implemen- meditation practices or in the length of time an individ-
tation of MM. ual has been meditating can inform future investigation
Performance on the divided attention task was regarding PWA.
particularly interesting given the consistent findings that In terms of accuracy, all three individuals performed
PWA have decreased divided attention (Erickson et al. close to 90% accuracy on the card-sorting task;
1996, Murray et al. 1997b, 1998, Peach et al. 1994). therefore, it could be argued that the participants
Visual analyses of card sorting and target tone variables focused attention on accuracy while neglecting speed.
on the divided attention tasks revealed no changes as a This could lead to a longer RT with increased accuracy.
result of MM. However, results from LN’s RT data reveal Unfortunately, Erickson et al. (1996) did not collect
that MM may have played a role in processing speed. RTs, so speed of performance versus accuracy cannot be
Although LN’s performance on the tone identification compared between the two studies. A separate study by
task was high, her RT decreased and her false-positives Marshall and Basilakos (2010) administered the same
Effects of Mindfulness Meditation on three individuals with aphasia 683
task and did collect RTs. In this study, ten PWA were no other study has implemented the use of MM to
given the 5-min dual task without MM treatment. The modulate the performance of an attention task in PWA.
individuals in Marshall and Basilakos’ study performed The findings in attention were limited to RT; though,
at a lower rate of accuracy (average accuracy for tone having three participants with aphasia demonstrate
identification was 65%); however, the RTs were at the high-accuracy performance on attention tasks questions
lower end of the range (mean = 1550 ms; SD = 430.88; about whether all PWA present with attention deficits.
range = 750–2069 ms) in comparison with the current There are several limitations to note that may have
study at first baseline testing (mean = 1778; SD = impacted the findings. Future studies could specifically
35.28 ms; range = 1756–1819 ms). This suggests that assess individuals to determine the level of attention
on average the three PWA in the current study were available on a traditional attention measure. This could
slower, although more accurate overall than the partici- help ensure attention deficits robust enough to require
pants in Marshall and Basilakos’ study. The current change. Also, the lack of observed effects could be due
participants may have sacrificed speed of processing to the limited number of participants, as well as to the
for accuracy on tasks. Further, it appeared that some measures administered for the study. The very nature
individuals (JJ, MW) allocated more attention to tone of aphasia affords certain modifications to linguisti-
identification, resulting in lower performance in card cally based materials (i.e., Relaxation Inventory). As a
sorting. Nonetheless, all individuals who received MM result, sensitivity and established reliability and validity
demonstrated an increase in the number of cards sorted standards are sacrificed. Due in part to assessment
and a slight decrease in RT by the last session of Phase modifications during this study, firm conclusions cannot
A2. be drawn. Future studies utilizing a different measure of
Regarding SOE, the present study was unable to attention as well as a larger number of participants could
replicate the finding that PWA present with deficits in be beneficial. Furthermore, the attention task involved
the evaluation of task demand (Clark and Robin 1995, both card sorting and tone identification, which has
Murray et al. 1997a, Tseng et al. 1993). That is, the implications for the executive function of dual-task
current participants’ ratings of task difficulty tended processing. As a result, it would be difficult to determine
to correspond to their task performance. While the if the performance was simply a change in attention, or
cause for these differing findings can only be speculated, if it could potentially be attributed to a deficit with
future research should examine the relationship between executive function.
evaluation of task demand (i.e., SOE) and the allocation All three participants reported that MM was easy
of attentional resources. Because it appears that some to learn and carry out on a daily basis, and reported
participants sacrificed accuracy for speed, it is possible feeling more ‘relaxed’ and ‘peaceful’ after MM training
that participants’ ratings reflect the portions of the task than before. With the knowledge that PWA can learn
they performed better (e.g., tone identification or card meditative practices, and with such successful findings
sorting), rather than the task as a whole. in neurologically intact individuals, it is important to
Further, the results of this study revealed no signifi- continue evaluating the benefits of MM in PWA. While
cant improvements in language performance as a result MM did not appear to alter attention or language in this
of training in MM. Perhaps this finding is testament particular study, it is possible that MM may be beneficial
to the reduced ability for change in chronic aphasia. to PWA in other realms that were not measured in
Additionally, the language tasks administered in this this study, such as mood or quality of life (Bédard
study were not resource demanding. Therefore, if a et al. 2003). Moreover, previous evidence suggests that
more resource-demanding language task were included, complementary treatments may be beneficial in post-
differences might be observed. Future studies should stroke language rehabilitation (Murray and Ray 2001)
evaluate the effectiveness of treatment for attention and and future study regarding MM or other meditation
language in individuals with chronic aphasia versus practices for PWA should continue.
a more acute onset as well as using more resource-
demanding language tasks.
In conclusion, this study explored a way to treat Note
deficits in divided attention for three PWA. The study 1. The divided attention methods of this study are modelled after
is in response to the call for complementary and Erickson et al.’s (1996). See the References for the complete
alternative medicine techniques in the field of speech– citation.
language pathology (Laures and Shisler 2004). The
findings of the current study provide further informa-
tion regarding attention deficits in PWA, as well as References
preliminary evidence regarding MM as a therapeutic ALEXANDER, M. P., 2006, Impairments of procedures for implement-
strategy for this population. To the authors’ knowledge ing complex language are due to disruption of frontal
684 Ellen Orenstein et al.
attention processes. Journal of the International Neuropsycho- MCNEIL, M. R., ODELL, K. and TSENG, C., 1991, Toward the
logical Society, 12, 235–247. integration of resource allocation into a general theory of
BÉDARD, M., FELTEAU, M., MAZMANIAN, D., FEDYK, K., KLEIN, R., aphasia. Clinical Aphasiology, 20, 21–39.
RICHARDSON, J., PARKINSON, W. and MINTHORN-BIGGS, M., MOORE, A. and MALINOWSKI, P., 2009, Meditation, mindfulness
2003, Pilot evaluation of a mindfulness-based intervention and cognitive flexibility. Consciousness and Cognition, 18(1),
to improve quality of life among individuals who sustained 176–186.
traumatic brain injuries. Disability and Rehabilitation, 25(13), MURRAY, L. L, 1999, Attention and aphasia: Theory, research and
722–731. clinical implications. Aphasiology, 13, 91–111.
CHIESA, A. and SERRETTI, A., 2010, A systematic review of neurobi- MURRAY, L. L., 2000, Effects of varying attentional demands on the
ological and clinical features of mindfulness meditations. word retrieval skills of adults with aphasia, right hemisphere
Psychological Medicine, 40, 1239–1251. brain damage, or no brain damage. Brain and Language,
CLARK, H. M. and ROBIN, D. A., 1995, SOE during a lexical decision 72(1), 40–72.
task: Resource allocation deficits following brain damage. MURRAY, L. L., 2002, Attention deficits in aphasia: presence, nature,
American Journal of Speech–Language Pathology, 4, 143– assessment, and treatment. Seminars in Speech and Language,
147. 23(2), 107–116.
ERICKSON, R. J., GOLDINGER, S. D. and LAPOINTE, L. L., MURRAY, L. L., HOLLAND, A. L. and BEESON, P. M., 1997a, Accuracy
1996, Auditory vigilance in aphasic individuals: detecting monitoring and task demand evaluation in aphasia. Aphasiol-
nonlinguistic stimuli with full or divided attention. Brain ogy, 11(4–5), 401–414.
and Cognition, 30(2), 244–253. MURRAY, L. L., HOLLAND, A. L. and BEESON, P. M., 1997b,
GOODGLASS, H., KAPLAN, N. and BARRESI, B., 2001, Boston Diagnos- Grammaticality judgements of mildly aphasic individuals
tic Aphasia Examination, 3rd edn (Baltimore: Lippincott, under dual-task conditions. Aphasiology, 11(10), 993–1016.
Williamson & Wilkins). MURRAY, L. L., HOLLAND, A. L. and BEESON, P. M., 1998, Spoken
HELM-ESTABROOKS, N., 1990, Aphasia Diagnostic Profile (Austin, language of individuals with mild fluent aphasia under
TX: PRO-ED). focused and divided-attention conditions. Journal of Speech,
HELM-ESTABROOKS, N., 2002, Cognition and aphasia: a discussion Language, and Hearing Research, 41(1), 213–227.
and a study. Journal of Communication Disorders, 52(17), MURRAY, L. L. and RAY, A. H., 2001, A comparison of relaxation
1–16. training and syntax stimulation for chronic nonfluent aphasia.
HONEY, G. D., BULLMORE, E. T. and SHARMA, T., 2000, Prolonged Journal of Communication Disorders, 34(1), 87–113.
reaction time to a verbal working memory task predicts NICHOLAS, L. E. and BROOKSHIRE, R. H., 1993, A system
increased power of posterior parietal cortical activation. for quantifying the informativeness and efficiency of the
NeuroImage, 12(5), 495–503. connected speech of adults with aphasia. Journal of Speech
JHA, A. P., KROMPINGER, J. and BAIME, M. J., 2007, Mindfulness and Hearing Research, 36(2), 338–350.
training modifies subsystems of attention. Cognitive, Affective PEACH, R. K., RUBIN, S. S. and NEWHOFF, M., 1994, A topograph-
and Behavioral Neuroscience, 7(2), 109–119. ical event-related potential analysis of the attention deficit
KABAT-ZINN, J., 1982, An outpatient program in behavioral for auditory processing in aphasia. Clinical Aphasiology, 22,
medicine for chronic pain patients based on the practice 81–96.
of Mindfulness Meditation: theoretical considerations and SLANSKY, B. L. and MCNEIL, M. R., 1997, Resource allocation
preliminary results. General Hospital Psychiatry, 4, 33–47. in auditory processing of emphatically stressed stimuli in
KABAT-ZINN, J., 1994, Wherever You Go, There You Are: Mindfulness aphasia. Aphasiology, 11(4–5), 461–472.
Meditation in Everyday Life (New York, NY: Hyperion). TANG, Y.-Y., MA, Y., WANG, J., FAN, Y., FENG, S., LU, Q., YU,
KAZDIN, A., 1982, Single-Case Research Designs: Methods for Clinical Q., SUI, D., ROTHBART, M. K., FAN, M. and POSNER, M. I.,
and Applied Settings (Oxford: Oxford University Press). 2007, Short-term meditation training improves attention and
LAURES, J. S. and SHISLER, R. J., 2004, Complementary and self-regulation. Proceedings of the National Academy of Sciences,
alternative medical approaches to treating adult neurogenic USA, 104(43), 7152–7156.
communication disorders: a review. Disability and Rehabili- TEASDALE, J. D., SEGAL, Z. and WILLIAMS, J. M. G., 1995, How does
tation, 26(6), 315–325. cognitive therapy prevent depressive relapse and why should
LAZAR, S. W., BUSH, G., GOLLUB, R. L., FRICCHIONE, G. L., KHALSA, attentional control (mindfulness) training help? Behaviour
G. and BENSON, H., 2000, Functional brain mapping of Research and Therapy, 33(1), 25–39.
the relaxation response and meditation. Neuroreport, 11(7), TSENG, C. H., MCNEIL, M. R. and MILENKOVIC, P., 1993, An
1581–1585. investigation of attention allocation deficits in aphasia. Brain
LEVY, B. R., JENNINGS, P. and LANGER, E. J., 2001, Improving and Language, 45(2), 276–296.
attention in old age. Journal of Adult Development, 8, 189– VALENTINE, E. R. and SWEET, P. L. G., 1999, Meditation and
192. attention: a comparison of the effects of concentrative
MARSHALL, R. J. S. and BASILAKOS, A. A., 2010, More Difficult Than and Mindfulness Meditation on sustained attention. Mental
They Think: Perceived Sense of Effort in Aphasia. Poster Health, Religion and Culture, 2(1), 57–90.
presented at the Annual Meeting of the American Speech– WIENER, D. A., CONNOR, L. T. and OBLER, L. K., 2004, Inhibition
Language–Hearing Association Convention, Philadelphia, and auditory comprehension in Wernicke’s aphasia. Aphasiol-
PA, USA. ogy, 18, 599–609.
MARSHALL, S. C., GRINNELL, D., HEISEL, B., NEWALL, A. and HUNT, ZYLOWSKA, L., SMALLEY, S. L. and SCHWARTZ, J. M., 2009,
L., 1997, Attentional deficits in stroke patients: a visual dual Mindful awareness and ADHD. In F. Didonna (ed.), Clinical
task experiment. Archives of Physical Medicine and Rehabilita- Handbook of Mindfulness (New York, NY: Springer Science
tion, 78(1), 7–12. & Business Media), pp. 319–338.