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Mindfulness-Based Resilience Training to Reduce Health Risk, Stress Reactivity, and Aggression among Law Enforcement Officers: A Feasibility and Preliminary Efficacy Trial



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Mindfulness-Based Resilience Training to Reduce Health Risk,
Stress Reactivity, and Aggression among Law Enforcement
Officers: A Feasibility and Preliminary Efficacy Trial
Michael S. Christopher, PhDa,*, Matthew Hunsinger, PhDa, Lt. Richard J. Goerling, MBAa,b,
Sarah Bowen, PhDa, Brant S. Rogers, MSa,c, Cynthia R. Gross, PhDd, Eli Dapolonia, MAa,
and Jens C. Pruessner, PhDe
aSchool of Graduate Psychology, Pacific University, Hillsboro, OR, USA
bMindful Badge Initiative, Hillsboro, OR, USA
cStress Reduction Clinic, Hillsboro, OR, USA
dCollege of Pharmacy and School of Nursing, University of Minnesota Twin Cities, Minneapolis,
eDepartments of Psychology, Psychiatry, Neurology and Neurosurgery Douglas Institute, McGill
University, Montreal, Quebec, Canada
The primary objective of this study was to assess feasibility and gather preliminary outcome data
on Mindfulness-Based Resilience Training (MBRT) for law enforcement officers. Participants (
61) were randomized to either an 8-week MBRT course or a no intervention control group. Self-
report and physiological data were collected at baseline, post-training, and three months following
intervention completion. Attendance, adherence, post-training participant feedback, and
interventionist fidelity to protocol all demonstrated feasibility of MBRT for law enforcement
officers. Compared to no intervention controls, MBRT participants experienced greater reductions
in salivary cortisol, self-reported aggression, organizational stress, burnout, sleep disturbance, and
reported increases in psychological flexibility and non-reactivity at post-training; however, group
differences were not maintained at three-month follow-up. This initial randomized trial suggests
MBRT is a feasible intervention. Outcome data suggest MBRT targets key physiological,
psychological, and health risk factors in law enforcement officers, consistent with the potential to
improve officer health and public safety. However, follow-up training or “booster” sessions may be
needed to maintain training gains. A fully powered longitudinal randomized trial is warranted.
*Corresponding Author: Michael Christopher, PhD, School of Graduate Psychology, Pacific University, 190 SE 8th Ave, Suite 260,
Hillsboro, OR, 97123;; tel: 503-352-2498.
Declaration of Interest
Drs. Christopher, Hunsinger, and Bowen received funding from the National Institutes of Health during the conduct of the study. Dr.
Preussner received funding from the Canadian Institutes of Health Research and the Natural Sciences and Engineering Research
Council of Canada during the conduct of the study. Mr. Goerling, Mr. Rogers, Dr. Gross, and Mr. Dapolonia have no funding to
HHS Public Access
Author manuscript
Psychiatry Res
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Published in final edited form as:
Psychiatry Res
. 2018 June ; 264: 104–115. doi:10.1016/j.psychres.2018.03.059.
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mindfulness; resilience; stress; police; aggression; cortisol
1. Introduction
Policing is one of the most highly stressful occupations (Violanti et al., 2006; Violanti et al.,
2011). Unpredictable exposures to critical incidents, violence, chronic stress, job
dissatisfaction, and societal expectations for optimal performance can create a toxic work
environment and lead to significant negative mental health, professional, and behavioral
outcomes for law enforcement officers (LEOs) (Avdija, 2014; McCrathy and Atkinson,
2012; O’Hara et al., 2013).
Consistent exposure to acute and chronic stress is a risk factor for adverse mental health in
LEOs, including anxiety (Gershon et al., 2009; Violanti et al., 2014), sleep problems (Bond
et al., 2013; Neylan, 2013), depression (Garbarino et al., 2013; Wang et al., 2010) and
suicidal ideation (He et al., 2002; McCafferty et al., 1992; Wang et al., 2010). LEO suicide
rates are up to three times higher than those in the general public (Clark et al., 2012;
Violanti, 2010); as a consequence, LEOs are more likely to die from suicide than in the line
of duty (Violanti, 2004), with an estimated LEO suicide occurring every 17 hours (Larned,
Effects of LEO stress are also evident in elevated rates of burnout and addictive behaviors.
LEOs report higher rates of job dissatisfaction and burnout than most other occupations
(Backteman-Erlanson et al., 2013; De la Fuente Solana et al., 2013; Schaible and Six, 2016),
and they may rely on negative and avoidant coping strategies in response to stress and
burnout, including alcohol use and other avoidance-based behaviors (Gershon et al., 2009;
Ménard and Arter, 2013; Pasillas et al., 2006; Smith et al., 2005; Willman, 2012). Relative to
the general public, LEOs have elevated rates of alcohol consumption (Ballenger et al., 2011)
and binge drinking (Weir et al., 2012).
Appropriate use of force is a necessary component of successful policing; however,
psychologically impaired LEOs are more likely to use excessive force (Kop et al., 1999;
Kurtz et al., 2015; Nieuwenhuys et al., 2012b), be aggressive toward suspects (Can and
Hendy, 2014; Gershon et al., 2009; Griffin and Bernard, 2003; Kurtz et al., 2015;
Rajaratnam et al., 2011), and exhibit poor decision-making (Nieuwenhuys et al., 2012a;
Rajaratnam et al., 2011; Violanti et al., 2014). Bureau of Justice Statistics (https:// estimates that among 59.4 million U.S. residents age 16 or older who had
face-to-face contacts with police, 2.3 million experienced LEO threat or use of force, and
nearly 75% of those who reported force described it as excessive (Berzofsky, 2017).
Several key factors are associated with LEO excessive and inappropriate use of force,
including burnout (Kop et al., 1999; Kop and Euwema, 2001; Queirós et al., 2013; Sack III,
2009), abnormal stress reactivity (Groer et al., 2010; Strahler and Ziegert, 2015; Yao et al.,
2016), and poor psychological health (Ménard and Arter, 2013; Nieuwenhuys et al., 2012b).
Physiological indices may also reflect effects of stress on LEO behavior. Studies on human
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responses to stressful events demonstrate neuroendocrine factors play an important role in
stress reactivity (Bibbey et al., 2013; Nater et al., 2013). Abnormal secretion of the
glucocorticoid cortisol as the final product of the hypothalamic-pituitary-adrenocortical
(HPA) axis is considered a crucial factor in the link between chronic psychosocial stress and
the adverse effects on health (Chrousos, 2009). Changes to the circadian regulation of
cortisol secretion are also considered important to stress reactivity (Menet and Rosbash,
2011; Nader et al., 2010). The cortisol awakening response (CAR), frequently used as a
biomarker of HPA axis status or functioning, combines features of a reactivity index
(awakening) with circadian regulation (Stadler et al., 2016). Findings on the relationship
between CAR and occupational stress are mixed. Several studies among LEO samples have
yielded significant positive relationships between cortisol and occupational stress (Austin-
Ketch et al., 2012; Groer et al., 2010; Walvekar et al., 2015), and greater CAR has been
found to be prospectively predictive of increased acute stress disorder (Inslicht et al., 2011);
however, another recent study (Violanti et al., 2017) found a significant negative association
between the most stressful occupational events and slope of the CAR pattern among LEOs.
Despite the many risks to LEO health, and the consequential risks to public safety, effective
LEO trainings and interventions to mitigate these harms are still lacking. Studies have
reported improvements in LEO stress and mental health risk factors following an
intervention (e.g., Arnetz et al., 2013; Arnetz et al., 2009; McCrathy and Atkinson, 2012);
however, a recent meta-analysis examining effectiveness of stress reduction programs among
LEOs found small effect sizes, concluding that, “insufficient evidence exists to demonstrate
the effectiveness of stress management interventions for reducing negative physiological,
psychological or behavioral outcomes among police officers and recruits.” (Patterson et al.,
2014, p. 508).
Interventions suited to the unique context, vulnerabilities, and strengths of this population
are needed to improve LEO stress reactivity and psychological health, and reduce aggression
and violence. Preliminary evidence suggests mindfulness training (MT) may be a promising
approach. MT has garnered significant empirical support in lab, clinical, and community-
based research, evincing outcomes such as reduced aggression (Fix and Fix, 2013; Kelley
and Lambert, 2012; Zoogman et al., 2014) and anger (Peters et al., 2015; Singh et al., 2014).
MT has also been shown to reduce stress reactivity, including reductions in pre- to post-
training CAR levels (Brand et al., 2012; Lengacher et al., 2012; Marcus et al., 2003);
however, others (Black et al., 2017; Matousek et al., 2011) have found prolonged increase in
CAR after awakening at the post-training assessment. MT may therefore exert its effect by
helping to normalize CAR, increasing it in samples with dampened stress reactivity and
reducing it in those with heightened stress reactivity. A sample of military veterans
experienced reduced CAR pre- to post-MT (Bergen-Cico et al., 2014), and improvement in
mental health was related to reduced CAR in an LEO sample who received MT (Christopher
et al., 2016). Despite mixed findings, given the outcomes in the military and LEO MT
studies, along with the majority of studies identifying a positive association between cortisol
and stress among LEOs, our expectation in the current study was that MT would reduce
CAR levels. Additionally, a recent study concluded that salutary effects of MT may be most
likely in high-stress populations, in which stress is known to affect onset or aggravation of
poor mental and physical health outcomes. MT may reduce stress reactivity, and
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subsequently impact stress-related disease-specific biological processes (Creswell and
Lindsay, 2014).
Recent meta-analyses suggest MT reduces negative psychological health and risk factors
common among LEOs, including stress levels (Khoury et al., 2013; Khoury et al., 2015),
depression and suicidal ideation (Hofmann et al., 2010; Khoury et al., 2013), alcohol misuse
(Chiesa and Serretti, 2014; Goyal et al., 2014), sleep difficulties (Gong et al., 2016; Yu et al.,
2017), anxiety (Hofmann et al., 2010; Zhang et al., 2015), and burnout (Luken and
Sammons, 2016; Regehr et al., 2014), and increases psychological resilience (Kallapiran et
al., 2015; Zenner et al., 2014), mindfulness (Gu et al., 2015; Visted et al., 2015),
psychological flexibility (Cavanagh et al., 2014) and self-compassion (Chiesa and Serretti,
2009). MT has been shown to be feasible and lead to improved health outcomes among
several high-stress cohorts, including military personnel (Johnson et al., 2014; Stanley et al.,
2011), physicians (Epstein and Krasner, 2013; Schroeder et al., 2016), and inner-city
teachers (Meiklejohn et al., 2012).
Despite evidence of MT’s effects on outcomes relevant to risk factors amongst LEOs, its
feasibility and preliminary efficacy in this population has not yet been systematically
evaluated. In the current randomized controlled trial (RCT), we hypothesized that
Mindfulness-Based Resilience Training (MBRT; Christopher et al., 2016), a program
adapting MT for LEOs, would be feasible to implement and acceptable to the target
population. We additionally hypothesized that, relative to a no intervention control (NIC)
group, at post-training and three-month follow-up, MBRT participants would evidence: 1)
improved psychological health and risk outcomes (i.e., decreased sleep disturbance, alcohol
use, anxiety, depression, suicidal ideation, stress, and burnout, and increased resilience,
mindfulness, psychological flexibility, and self-compassion); 2) reduced aggression and
anger; and 3) improved regulation of stress reactivity (i.e., reduced post-training CAR
2. Method
2.1 Participants
LEOs were recruited from law enforcement agencies in a large urban area and surrounding
metro region in the Pacific Northwestern United States through emails, fliers, and in-person
presentations (See Table 1 for participant demographics).
2.2 Measures
2.2.1 Feasibility and Acceptability.—Feasibility benchmarks included study
enrollment (targeted goal of 60 participants), acceptance of randomization to MBRT or NIC
(≥ 90% acceptance), MBRT class attendance (≥ 75% of weekly sessions for MBRT
participants who maintained study enrollment throughout the 8-week intervention), and
overall study attrition (≤ 20%). Acceptability was assessed using three Likert-type scale (0
to 6) items: likelihood of recommending the course to a fellow officer, likelihood of
attending the course again in the future, and reasonableness of assigned home practice
(minimum benchmark score of four out of six on all acceptability items, indicating “likely”
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or “reasonable”). Adherence to meditation practice assigned to MBRT participants as
homework was assessed using iMINDr (Wahbeh et al., 2011), a software application on an
iPod Touch (Apple, Inc.) provided to MBRT participants during the first class, which tracked
time, date, and length of listening for each guided meditation.
2.2.2 Treatment Expectancy and Credibility.—Expectancy and credibility were
measured by the Expectancy/Credibility Questionnaire (E/CQ; Devilly and Borkovec, 2000;
Hicks et al., 2016) to determine whether expectancy was associated with any differential
improvements observed in the MBRT condition. Participants were asked to evaluate the
expected effectiveness of the program, both by how much they
it would improve
their symptoms and how much they
it would improve their symptoms.
2.2.3 Psychological Health and Risk—PROMIS® (v1.0) short form versions were
used to assess sleep disturbance (6 items), alcohol use (7 items), anxiety (6 items), and
depression (6 items). Scores are reported on the
score metric (
= 50;
= 10), centered
on the general U. S. population mean in terms of age, gender and race/ethnicity. PROMIS
measures have variable ranges (sleep disturbance [32–76], alcohol use [39–77], anxiety [39–
83], and depression [38–80]), with higher scores indicating a higher rate of the measured
outcome. These short forms have demonstrated acceptable internal consistency and
correlations with expected legacy measures (Cella et al., 2010). In the present sample,
alcohol use (αPre = .94; αPost = .94; αFollow-up = .90), anxiety (αPre = .90; αPost = .91;
αFollow-up = .92), depression (αPre = .90; αPost = .84; αFollow-up = .93), and sleep disturbance
(αPre = .87; αPost = .88; αFollow-up = .93) demonstrated good to excellent internal
consistency. Minimally important difference (MID) provides an estimate of the amount of
change or difference people consider meaningful (Wyrwich et al., 2005). MIDs are
important reference values used to evaluate the effectiveness of interventions in clinical
research using PROMIS symptom measures (Thissen et al., 2016). Among adult clinical
samples (Lee et al., 2017; Purvis et al., 2017; Yost et al., 2011), PROMIS short form MID
estimates range from 2.5–5.5
-score points for anxiety, depression, and sleep disturbance.
Suicidal ideation was assessed using the 7-item Concise Health Risk Tracking scale (CHRT;
Trivedi et al., 2011). The CHRT ranges from 7–35, with higher scores indicating greater
suicidal ideation. In a normative sample of depressed outpatient treatment seekers, the
authors found
= 16.1 and
= 5.0 (Trivedi et al., 2011). The CHRT has demonstrated
good internal consistency and is correlated with depression and hopelessness (Celano et al.,
2016). The CHRT demonstrated adequate internal consistency in the present study (αPre = .
79; αPost = .75; αFollow-up = .69).
The Police Stress Questionnaire (PSQ; McCreary and Thompson, 2006) is a 40-item
questionnaire consisting of two subscales measuring operational stressors (20 items) and
organizational stressors (20 items). Each subscale ranges from 1–7, with higher scores
indicating greater perceived stress. In a normative LEO sample, the authors found
= 3.26,
= 1.22 and organizational
= 3.53,
= 1.57 (McCreary et al.,
2017). The subscales have demonstrated excellent internal consistency, factorial validity, and
convergent validity (Shane, 2010). Similarly, in our sample, both operational (αPre = .93;
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αPost = .93; αFollow-up = .94) and organizational (αPre = .93; αPost = .93; αFollow-up = .94)
factors demonstrated excellent internal consistency.
The Oldenburg Burnout Inventory (OLBI; Demerouti et al., 2003; Halbesleben and
Demerouti, 2005) is a 16-item measure of burnout that assesses exhaustion and
disengagement from work. The OLBI has acceptable internal consistency, factorial validity,
and expected correlations with other constructs (Demerouti et al., 2010). The OLBI ranges
from 1–4, with higher scores indicating greater burnout. In a normative sample of
employees, the authors found
= 2.07,
= .44 (Demerouti et al., 2010). In the present
sample, the OLBI demonstrated adequate internal consistency (αPre = .73; αPost = .76;
αFollow-up = .73).
The Five Facet Mindfulness Questionnaire-Short Form (FFMQ-SF; Bohlmeijer et al., 2011),
a 24-item version of the FFMQ (Baer et al., 2006), assessed dispositional tendency to be
mindful in daily life. The observe and describe facets of the scale have demonstrated weaker
psychometric properties and issues with novice and non-meditating samples (de Bruin et al.,
2012; Lilja et al., 2013). Thus, the current study used three of the five facets—acting with
awareness, nonjudging of experience, and nonreactivity to inner experience. Each facet has
five items, resulting in a 15-item scale. Each facet ranges from 5–25, with higher scores
indicating greater mindfulness. In a normative non-meditating sample, the authors found
acting with awareness
= 13.19,
= 3.32, nonjudging
= 14.09,
= 3.63, and
= 13.47,
= 3.07 (Bohlmeijer et al., 2011). In the present sample, internal
consistency for the acting with awareness (αPre = .81; αPost = .81; αFollow-up = .86),
nonjudging (αPre = .86; αPost = .70; αFollow-up = .81); and nonreactivity (αPre = .74; αPost
= .80; αFollow-up = .85) facets were acceptable to good.
The Acceptance and Action Questionnaire-II (AAQ-II; Bond et al., 2011) is a seven-item
measure that assesses psychological flexibility, defined as a willingness to experience
unwanted private experiences, such as bodily sensations, emotions, thoughts, and memories,
in the pursuit of one’s values and goals. The AAQ-II ranges from 7–49, with lower scores
indicating greater psychological flexibility. In a normative sample of people who were
seeking outpatient psychological treatment for substance misuse, the authors found
28.34 and
= 9.92 (Bond et al., 2011). The AAQ-II has good internal consistency,
factorial validity, and expected correlations with other constructs (Fledderus et al., 2012).
The internal consistency in the present sample was good to excellent (αPre = .89; αPost = .89;
αFollow-up = .93).
The Self-Compassion Scale-Short Form (SCS-SF; Raes et al., 2011) is a 12-item version of
the 26-item SCS (Neff, 2003). It assesses kindness and understanding toward oneself in
instances of pain or failure, perception of one’s experiences as part of the larger human
experience, and ability to hold painful thoughts and feelings in mindful awareness. The
SCS-SF ranges from 12–60, with higher scores indicating greater self-compassion. In a
normative university student sample, the authors found
= 36.00 and
= 7.33 (Raes et
al., 2011). The SCS-SF demonstrated good internal consistency, factorial validity, and
expected correlations with other constructs (Raes et al., 2011). The SCS-SF demonstrated
good internal consistency in the present sample (αPre = .84; αPost = .80; αFollow-up = .85).
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The Connor-Davidson Resilience Scale (CD-RISC; Connor and Davidson, 2003) contains
25 items designed to measure resilience, defined as characteristics that allow individuals to
cope with adversity. The CD-RISC ranges from 0–100, with higher scores indicating greater
resilience. In a large LEO sample, the authors found
= 77.28 and
= 10.40 (Devilly and
Varker, 2013). The CD-RISC has demonstrated excellent internal consistency, factorial
validity, and expected correlations with other constructs across various populations,
including LEOs (McCanlies et al., 2014). The CD-RISC demonstrated good to excellent
internal consistency in the present sample (αPre = .90; αPost = .89; αFollow-up = .91).
2.2.4 Aggression and Anger—The Buss-Perry Aggression Questionnaire-Short Form
(BPAQ-SF; Bryant and Smith, 2001) is a 12-item scale of aggression derived from the 29-
item BPAQ (Buss and Perry, 1992). The BPAQ-SF was developed to assess four
dispositional sub-traits of aggression: physical aggression, verbal aggression, anger, and
hostility. The BPAQ-SF ranges from 1–5, with higher scores indicating greater aggression.
In a validation sample of newly incarcerated federal offenders, the authors found
= 2.12
= 1.05 (Diamond and Magaletta, 2006). The BPAQ-SF has demonstrated good
internal consistency and strong convergent and discriminant validity (Diamond and
Magaletta, 2006). The BPAQ-SF demonstrated good internal consistency in the present
sample (αPre = .83; αPost = .83; αFollow-up = .81).
The PROMIS® (v1.0) short form version of anger (5 items) was used, and has shown
acceptable internal consistency and correlations with expected legacy measures (Cella et al.,
2010). PROMIS anger demonstrated good internal consistency in the present sample (αPre
= .89; αPost = .87; αFollow-up = .86).
2.2.5 Cortisol Awakening Response—Using the passive drool method, participants
collected 2–3 ml of saliva at home at 0, 30, and 45 minutes after awakening (spontaneous or
by alarm clock) on three consecutive days in the week pre-training, and three consecutive
days in the week post-training, with waitlist collection times yoked to MBRT. Participants
were asked to refrain from eating, drinking any liquids except for water, smoking, brushing
teeth, taking medications, and exercising before completing sample collections. Participants
returned completed samples to the research team by mail, using prepaid insulated boxes.
Samples were stored in a minus 80°C freezer until thawed for assay. Saliva was processed
and assayed for cortisol with an FDA-approved direct (non-extracted) salivary EIA cortisol
kit (Pantex; Santa Monica, CA) at ZRT Laboratory (Beaverton, OR). Cortisol was measured
in 25 microliter saliva samples with slight modifications of a previously described method
(Du et al., 2013). Inter-assay coefficient of variation for cortisol is 8% at 1 ng/ml, 7.1% at 4
ng/ml, and 7.6% at 12.9 ng/ml. The detectable limit is 0.1 to 30ng/ml. All cortisol values
were converted from ng/ml to nmol/L.
2.3 Procedures
Beginning in April 2016, two MBRT groups were conducted, and NIC participants were
offered the training at no charge after the final follow-up assessment (October 2016). This
allowed LEOs who may have been interested in MBRT, but were assigned to the NIC
condition, to access the training. The Pacific University IRB approved all study procedures.
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Potential participants were recruited using several methods. Recruitment emails with study
information and attached informational flyers were sent to police department chiefs in the
urban area and surrounding metro region where the study was conducted. We asked police
chiefs to distribute the email to their officers and to post the informational flyers. Research
team members also delivered 10–15 minute in-person informational and recruitment
sessions to groups of LEOs at a number of police departments. To be eligible for study
participation, interested individuals had to be a full-time sworn LEO with no exposure to
MBRT or a similar mindfulness course. Those meeting criteria were scheduled for an initial
pre-training assessment appointment, during which they provided written informed consent
and completed all measures via computer. LEOs were subsequently randomly assigned
using permuted-block randomization (1:1 ratio) with stratification (gender and age) to
MBRT or NIC. Participants completed a similar computer-administered battery of measures
post-training and at three-month follow-up. Participants were given kits at pre- and post-
training to collect awakening saliva samples and mail back to the research lab.
2.3.1 Mindfulness Training.—MBRT was designed to enhance resilience for LEOs in
the context of acute and chronic stressors inherent to policing. Based on a Mindfulness-
Based Stress Reduction (Kabat-Zinn, 1990) framework, MBRT was delivered in eight
weekly 2-hour sessions with an extended 6-hour class in the seventh week. Sessions
contained experiential and didactic exercises, including body scan, sitting and walking
meditations, mindful movement, and group discussion. Content and language were adapted
for an LEO population; the primary focus of the curriculum was learning strategies to
manage stressors inherent to police work, including critical incidents, job dissatisfaction, and
public scrutiny, as well as interpersonal, affective and behavioral challenges common to
LEOs’ lives. The adaptation process was overseen by a co-developer of MBRT (co-author
R.G.), who is a police lieutenant and certified mindfulness trainer. Several LEOs in the
training division in their respective departments were additionally consulted on program
content and delivery. An initial version of MBRT was pilot tested and qualitative feedback
solicited from LEO participants, leading to further adaptations. To supplement in-session
content and support practice between sessions, MBRT participants were each given an iPod
Touch programmed with guided practices and monitoring software (iMINDr; (Wahbeh et al.,
2.3.2 Fidelity.—All MBRT sessions were audio-recorded for instructor fidelity rating.
Three of the eight sessions from each cohort were randomly selected using a web-based
randomizer, for a total of six coded sessions. The rating team was comprised of two doctoral
students and one clinical psychologist (co-author S.B.), none of who were involved in the
study intervention or assessment. Two raters independently rated each of the six selected
sessions. Raters assessed MBRT content, themes and instructor skill for each of the selected
sessions. Protocol-specified session content was assessed using a 4-point scale (0 =
not at all
, 1 =
somewhat present
, 2 =
), presence of session themes were assessed
using a 4-point scale (0 =
, 1 =
minimally present
, 2 =
, 3 =
), and
global ratings of MBRT-specific skill used a 4-point scale (0 =
, 1 =
, 2 =
, 3 =
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2.4 Data Analytic Approach
We examined change from pre- to post-training for each self-report outcome using a multi-
level modeling (MLM) approach with restricted maximum likelihood estimation, which is
appropriate for smaller sample sizes (Maas and Hox, 2005; Snijders and Bosker, 1993).
Each MLM model included participant as a random effect; group, time, and the group-by-
time interaction were included as fixed effects. Expectancies at pre-training (due to pre-
training differences between the MBRT and NIC conditions) and years on the police force
(due to pre-training correlations between years on the police force and multiple outcomes)
were included as covariates. Intent-to-treat (ITT) analyses, without imputed missing data,
assessed pre-training between-group differences for all outcomes, demographic variables,
and expectancy data. For variables with no significant pre-training differences, we examined
post-training between-group differences. When pre-training differences existed, we
conducted an analysis of covariance (ANCOVA) to examine post-training differences with
pre-training responses as an additional covariate. Group-by-time interactions were tested for
all outcomes, but a significant interaction effect was not required for further analysis of post-
training differences. This strategy is consistent with the feasibility design and avoids
inflating Type II errors. All findings are reported with exact
-values, and interpretation of
magnitudes of confidence intervals and effect sizes are intended to guide further research.
We conducted the same analyses with an ITT sample with imputed data using maximum
likelihood estimation in order to investigate the robustness of our results. Conclusions with
imputed data differed for four outcomes (see Table 3). However, given that the means in the
imputed dataset were in the same direction as the non-imputed data set, and that data were
likely missing completely at random (based on data we were able to collect from
participants who dropped out of the study after randomization and the results of Little’s
Missing-ness test,
> .10), we report results of analyses without imputed data. To examine
MBRT group maintenance of improvements three months after the training, we conducted
MLM analyses examining change from pre-training to three-month follow-up for all
Three analyses were used to assess stress reactivity. First, cortisol data from the three days
of post-training sampling were combined with the three days of pre-training cortisol data to
assess cortisol change over time using a four-factor mixed design ANOVA (group [MBRT,
NIC] by time [pre-, post-training] by day [1, 2, 3] by minute [0, 30, 45]). Second, we
computed the area under the curve with respect to increase (AUCI) for each day to assess
overall change in CAR from pre- to post-training by group. Demographic (gender and age),
mental health (traumatic experiences and depression) variables, and other potential
confounds (time between waking and first saliva collection and shift worked) were entered
as covariates in the first two sets of analyses. Third, we regressed each variable post-training
on the same variable at pre-training and saved the standardized residuals (e.g., we regressed
responses on the PROMIS measures at post-MBRT on PROMIS responses at pre-training);
creating a residualized change score variable for each measure. Pearson’s zero-order
correlations using the residualized change scores were used to investigate whether changes
in AUCI from pre- to post-training correlated with changes in self-report measures across the
same assessment points in the MBRT group.
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3. Results
3.1 Feasibility and Acceptability
Results suggest MBRT was feasible to implement among LEOs, as evidenced by number of
participants enrolled, acceptance of randomization, session attendance, and overall attrition
rate. Sixty-eight potential participants were screened, 61 of who were enrolled in the study;
97% (
= 59) of participants accepted the condition (MBRT or NIC) to which they were
randomly assigned. Overall, 20% of participants withdrew from the study prior to
completing 3-month follow-up measures (
= 12) (see Figure 1 for CONSORT flow diagram
for details). Of MBRT participants who remained enrolled throughout the 8-week
intervention period, session attendance was 79% (range = 0–3 absences).
Results suggest MBRT was generally acceptable to participants (all items range from 0–6),
as evidenced by the likelihood of recommending the class to a fellow officer (
= 5.08,
= 1.79) and attending the same course or a similar training in the future (
= 4.45,
2.02). Mean participant report of amount of time required to complete homework outside of
class indicated it was somewhat reasonable (
= 3.56,
= 1.59). Regarding adherence to
assigned practice, MBRT participants engaged in an average of 322.35 minutes of out-of-
class meditation practice (
= 357.49; range = 1–1340) over the 8-week training, on an
average of 13.85 (
= 12.63; range = 1–44) out of a possible 56 days, with an average of
10.62 minutes per day (
= 9.52; range = 1–77).
Regarding instructor fidelity, one-way random-effects models showed inter-rater consistency
was excellent for mean ratings of coverage of session content, ICC = .85, with mean rating
of content indicating somewhat present to thorough (
= 1.49;
= .25). For presence of
main themes, inter-rater consistency was excellent, ICC = .83, with mean rating indicating
present (
= 1.99;
= .50). For global ratings of instructor skill, inter-rater consistency
was good, ICC = .71, and mean value indicated skill was rated between adequate and
mastery (
= 2.65;
= .28).
3.2 Preliminary Outcome Data
Given the nature of this feasibility RCT trial, the primary focus was on indices of feasibility,
and on pre- to post-training between-group differences. Secondarily, we assessed whether
pre- to post-training changes were maintained at the three-month follow up.
There were no statistically significant differences between NIC and MBRT groups at pre-
training on demographic variables (see Table 1), motivation to start and complete MBRT,
and E/CQ treatment credibility items. The majority of E/CQ treatment expectancy items and
main outcomes did not evince significant differences (
s > .10); however, relative to NIC,
MBRT participants endorsed a lower composite E/CQ score of responses assessing the
degree to which they felt the intervention would improve job stress, job performance, and
resilience (
= .04). MBRT participants also endorsed higher self-compassion (
= .05) and
trend-level higher resilience (
= .06) compared to NIC participants. Therefore, pre-training
composite E/CQ feelings were included as covariates in all outcome analyses; when
examining post-training between-group differences for self-compassion and resilience,
scores at pre-training were included as covariates.
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3.3 Psychological Health and Risk
Analyses revealed a significant group-by-time interaction for burnout (
= .01),
organizational stress (
= .05), alcohol use (
= .01), FFMQ non-reactivity
= .04), and
psychological flexibility (
= .01) (see Table 2 for outcome means/SDs, and Table 3 for
interaction analyses and effect sizes). At post-training, planned follow-up analyses revealed
MBRT participants endorsed a significant improvement in burnout (
= .006;
= .73),
organizational stress (
= .05;
= .52), FFMQ non-reactivity (
= .04;
= .60), and
psychological flexibility (
= .006;
= .73) and trend-level improvement in sleep
disturbance (
= .08;
= .60). Although there was a significant group-by-time interaction,
planned follow-up analyses indicated a non-significant pre- to post-MBRT effect on alcohol
use relative to NIC (
= .12,
= .37) Analyses also revealed no significant main or
interaction effects for anxiety, depression, suicidal ideation, operational stress, psychological
resilience, FFMQ nonjudging or acting with awareness, and self-compassion.
3.4 Aggression and Anger
Analyses revealed a significant group-by-time interaction for aggression (
= .05); at post-
training, planned follow-up analyses revealed MBRT participants endorsed significantly less
aggression than NIC participants (
= .03;
= .55). There were no significant interaction
effect or main effects for anger,
> .10.
3.5 Cortisol Awakening Response
Analyses revealed a significant group-by-time by day-by-minute interaction (
= 2.88,
= .
02). Follow-up analyses revealed that on post-training sampling day three, MBRT
participants had higher waking (0 minute) salivary cortisol than NIC participants (
= 6.70;
= 11.46,
= 5.12;
= .05;
= .59), whereas MBRT
participants had trend-level lower 45 minute salivary cortisol (
= 14.79,
= 18.02,
= 9.10;
= .08;
= −.42). Additionally, there was a significant
group-by-time interaction for day three AUCI (
= 3.88,
= .03). Although there was no
group difference in day three AUCI levels at pre-training; MBRT participants had
significantly lower AUCI levels on day three post-training (
= 45.16;
= 199.80) than
NIC participants (
= 187.67;
= 206.75;
= .02;
= −.70). Analyses revealed no
significant group-by-time interaction for overall AUCI (
= 1.44,
= .24); however, gender
was a significant covariate (
= .05). A post-hoc test in only men in the sample (
= 41)
revealed a group-by-time interaction for overall AUCI (
= 2.94,
= .04), and follow-up
within group analyses revealed MBRT participants experienced a significant reduction in
overall AUCI (ΔAUCI = −61.11,
= 1.97,
= .05,
= .58), whereas as NIC experienced no
significant change (ΔAUCI = 35.07,
= −.74,
= .47,
= .13).
Analyses revealed a significant correlation between residualized change scores for AUCI and
depression (
= −.42;
= .04) in the MBRT group. There were no other significant
correlations between residualized change scores for AUCI and self-report variables.
Analyses assessing whether MBRT participants maintained changes in outcomes relative to
NIC participants at three-month follow-up revealed no significant main or interaction
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effects; however, no significant between-group outcome differences evident at post-training
were present at three-month follow-up (
s > .05).
4. Discussion
The primary goals of this randomized controlled trial were to assess feasibility and
acceptability, and to gather preliminary outcome data for MBRT. Results suggest MBRT is
feasible and acceptable to LEOs, evidenced by meeting benchmarks for participant
enrollment (
= 61), acceptance of randomization (97%), class attendance (79%), and
overall attrition rate (20%). The 20% attrition rate is consistent with several recent
mindfulness-based intervention (MBI) meta-analyses, in which average attrition rates were
approximately 16% (Khoury et al., 2013) and 29% (Nam and Toneatto, 2016). Given the
demanding, frequently changing nature of LEO work schedules evidenced in our open trial
(Christopher et al., 2016), we established a 20% attrition rate as our benchmark. Indeed,
45% withdrew due to a change in work schedule preventing them from attending MBRT
sessions. The enrollment and attrition rates are consistent with previous MT research among
high-stress cohorts, including military personnel (Johnson et al., 2014; Stanley et al., 2011),
healthcare professionals (Gauthier et al., 2015; Klatt et al., 2015), and inner-city teachers
(Kuyken et al., 2013; Meiklejohn et al., 2012). The current trial used weekly reminders and
follow-up text/phone calls after a missed session to enhance retention, as participant contact
has been shown to help enhance retention in clinical trials (e.g., Brueton et al., 2011),
including MT (Crane and Williams, 2010). Supporting acceptability, a majority of
participants reported “high-likelihood” of attending MBRT in the future and recommending
the course to a fellow LEO, which mirrors MBRT group quantitative improvements in
psychological health, aggression, and CAR. Fidelity results, including coverage of content,
presence of main themes, and instructor skill, provide further support for the feasibility and
acceptability of MBRT, supporting it as a replicable protocol. High levels of interrater
consistency suggests instructor fidelity can be reliably coded in future studies.
Preliminary outcome data support several psychological health and risk hypotheses. Relative
to NIC, MBRT participants endorsed improvements in psychological health outcomes
(burnout, organizational stress, and sleep disturbance [trend-level significance]) and
potential mechanisms (psychological flexibility and non-reactivity). This replicates previous
MT meta-analyses of RCTs across various healthy and clinical populations (e.g., Cavanagh
et al., 2014; Gong et al., 2016; Goyal et al., 2014; Luken and Sammons, 2016) including
military personnel (Kearney et al., 2013; Omidi et al., 2013). We are only aware of one other
published study on the impact of MT on LEO psychological health outcomes – a single-arm
study in which participants also endorsed post-training reduction in burnout, organizational
stress, and sleep disturbance, and increases in mindfulness (Christopher et al., 2016).
Relative to NIC, MBRT participants endorsed improvement in burnout, which was assessed
using a measure that includes both affective and behavioral aspects of this construct (i.e.,
exhaustion and disengagement). However, despite this and significant improvements in
several domains of psychological health, no significant immediate effects emerged on
anxiety, depression, or suicidal ideation. This could indicate that while many affective
experiences themselves may not change, their effects on behaviors, such as sleep
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disturbance, reactivity or avoidance, may shift. This shift in reaction to emotion or stress,
while the emotion or stress itself may not change, is aligned with mindfulness-based
practices, and has been seen in other MBI trials (Bowen and Marlatt, 2009; Elwafi et al.,
2013; Garland et al., 2014; Witkiewitz and Bowen, 2010; Witkiewitz et al., 2011).
The lack of significant improvement in resilience and self-compassion was surprising, given
that these can also be understood as ways of relating to experiences. High rates of stress and
trauma in LEOs’ routine work are not dissimilar to those seen in military personnel, and
previous MT research with military cohorts has found increases in cognitive (Jha et al.,
2015), physiological (Johnson et al., 2014), and psychological (Meredith et al., 2011)
resilience, as well as self-compassion (Mantzios and Wilson, 2015). A recent study suggests
engaging in MT practice protects against attentional lapses over high-demand intervals
among military cohorts, and is an important method by which to build cognitive resilience
(Jha et al., 2017). The non-significant improvement in psychological resilience (and other
health and risk outcomes) may also be related to a small sample size and reduced power.
MBRT had a medium-to-large effect size (
= .64) on psychological resilience, suggesting
that it may indeed be a key outcome. Similarly, as noted above, although there was no
statistically significant improvement in anxiety and only trend-level improvement in sleep
disturbance, participants in the MBRT group endorsed a pre- to post-training assessment
mean reduction of 3.42 and 4.74
-score points for anxiety and sleep disturbance
respectively, which is within the range of a minimally important difference in symptoms.
To our knowledge, this is the first RCT to demonstrate a reduction in aggression in an LEO
sample. Given the link between aggressive tendencies and excessive use of force among
LEOs (Griffin and Bernard, 2003; Koepfler et al., 2012; Sellbom et al., 2007), this is an
important outcome. A recent systematic review (Fix and Fix, 2013) and meta-analysis
(Zoogman et al., 2014) provide support for MT as a method to reduce aggression, including
in high-stress contexts such as correctional settings (Milani et al., 2013; Murphy, 1994;
Shonin et al., 2013). MBRT, and MBIs in general, focus on shifting the relationship to an
experience (self-judgment or denial) versus the experience itself (e.g., an emotion). Current
study results showing significant reductions in aggression, but not in anger, may reflect this;
while a participant may still feel anger in response to an event, the habitual aggressive
reaction may change, wherein the individual is able notice the emotion, then pause, observe,
and choose a skillful response.
While exposure to trauma and stressors is an inherent part of a first responder’s job,
programs enhancing the ability to relate to stressors more skillfully may reduce harmful
effects of stress on health and behavior. Cortisol results suggest that MBRT may lead to
reduced cortisol increase after awakening, while at the same time increasing the level at
awakening. More specifically, we observed reduced waking cortisol levels increases post-
training for male participants, and on day three post-training for both male and female
participants. This outcome may indicate recovery of an impaired cortisol regulation where
individual days start looking more robust and healthy again, in an otherwise chronically
stressed sample. However, these data should be interpreted with caution, because the other
two days did not show the same pattern of change. Several studies have examined the impact
of MT on CAR and have found mixed results. One way to interpret these mixed findings is
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to consider that CAR levels might be too low or high, and as such, normalization would
consist of bringing levels either up, or down. Along those lines, among samples of military
veterans with PTSD (Bergen-Cico et al., 2014), substance use disorders patients (Marcus et
al., 2003), cancer patients and their caregivers (Lengacher et al., 2012), and healthy adults
(Brand et al., 2012), participants experienced significant reductions in CAR levels from pre-
to post-training. Alternatively, among samples of patients currently receiving chemotherapy
for colorectal cancer (Black et al., 2017) and who completed treatment for breast cancer
(Matousek et al., 2011), CAR showed a prolonged increase after awakening at the post-
training assessment. In these studies, authors suggest that given the prolonged traumatic
nature of cancer and its treatment, it may have resulted in participants exhibiting a blunted
CAR at pre-training, and therefore MT would be expected to increase, and not decrease,
CAR. Additionally, residualized change in AUCI and depression were significantly inversely
correlated in the MBRT group. This may indicate that the recovery of cortisol regulation is
associated with reduction in depression, which indirectly supports the interpretation of day
three cortisol change.
Sex hormones have also been implicated in differences in CAR profiles between men and
women (Juster et al., 2016), and different facets of mindfulness are also linked to sex
variation in cortisol reactivity (Laurent et al., 2013). The sex differences on immediate post-
training cortisol levels certainly merit further study. In a recent meta-analysis of MT RCTs
among healthy female and male adults (Sanada et al., 2016), despite a scarce number of
studies (
= 5) and variability in MT’s and data collection protocols, results suggest MBIs
appear to have beneficial effects on cortisol secretion on healthy adults.
The current study also assessed outcomes three months following completion of the
intervention, and found no significant between-group differences. One possible explanation
is low adherence to ongoing mindfulness practice after completion of the 8-week training.
Only 2 out of 24 MBRT participants endorsed any mindfulness practice from post-training
to three-month follow-up. Poor adherence to ongoing mindfulness practice is common in
MT RCTs, particularly once the active intervention has ceased (Virgili, 2015). Qualitative
studies of MBIs have identified several key barriers to practice, including difficulty finding
time without the structure of the class, difficulty with long meditations, and self-critical
thinking (Banerjee et al., 2017; Martinez et al., 2015; Morgan et al., 2015). Future MT
research with high-stress populations must also identify barriers specific to this population,
and address them during training and ongoing to assess their impact on practice. This is
important because a number of RCT studies found a relationship between mindfulness
practice and positive outcomes (e.g., (Carmody and Baer, 2008; Crane et al., 2014; Morgan
et al., 2014), although others found that amount of mindfulness practice is unrelated to
outcomes (e.g., Quach et al., 2017).
Alongside evidence of feasibility and preliminary support for primary psychological,
behavioral and physiological outcomes, there are several limitations to consider, suggesting
caution in interpretation of results. First, given our aim to assess feasibility and acceptability
of MBRT among LEOs, we purposefully concentrated on a small sample at first. Although
recent guidelines suggest preliminary efficacy testing not be included in pilot studies (Leon
et al., 2011), given the dearth of effective interventions among LEOs (Patterson et al., 2014),
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we deemed it important to include these promising outcome data. However, the small sample
size may have resulted in Type II errors as evidenced by medium effect sizes for several
outcomes that were not statistically significant (e.g., alcohol use [
= .37], resilience [
= .
64], self-compassion [
= .57]). Future research should plan to examine the efficacy of
MBRT in a fully powered multisite RCT. Second, similar to military samples, police
samples may be prone to underreport mental health symptoms due to stigma and concerns
regarding confidentiality (Fox et al., 2012), therefore the mean endorsed values for several
outcomes, such as suicidal ideation and alcohol use, may be lower than actually experienced
in this sample. Third, although the attrition rate met our 20% benchmark, future research
with LEOs and other groups of first responders should explore various MT delivery
schedules, including a briefer protocol, intense immersion models, and integrating the
training into the workplace. Fourth, although we included a number of covariates in the
salivary cortisol analyses, we did not assess for menstrual phase among female participants,
which may have contributed to the observed sex differences in AUCI. Fifth, although we
assessed police stressors, we did not assess other factors such as non-work-related stress and
level of social support, which may have impacted outcomes. Finally, the sample was
gathered from a single metropolitan area, which limits the generalizability of the findings.
Despite these limitations, the current study is the first RCT of an MT tailored to the unique
stressors inherent to policing, laying a foundation for future trials assessing outcomes and
mechanisms of a mindfulness-based approach to mitigating effects of stressors and stress on
law enforcement and other first responder populations. In addition to demonstrating
feasibility and acceptability, preliminary outcome data suggest MBRT may lead to short-
term improvement in aspects of LEO psychological health and risk, aggression, and stress
reactivity. Future trials should focus on supporting enactment of regular mindfulness
practice following course completion, address barriers to practice, and perhaps provide
“booster” sessions to support training gains. While exposure to trauma and stressors is an
inherent part of a first responder’s job, programs that teach these individuals to relate to
these experiences more skillfully may help reduce the harmful effects of stress on their own
health as well as their behaviors with citizens they serve.
The authors express their sincere gratitude to the law enforcement officers who participated in the study. The
authors also thank Aaron Bergman, Dharmakaya Colgan, and Joshua Kapan for their assistance in teaching the
study courses, and Letícia Ribeiro, Ashley Eddy, Candice Hoke, Rebecca Vestal, Tenille Woodward, William Stahl,
and Amy LeRoy for their assistance with data collection.
Research reported in this publication was supported by the National Center for Complementary & Integrative
Health of the National Institutes of Health under Award Number R21AT008854. The content is solely the
responsibility of the authors and does not necessarily represent the official views of the National Institutes of
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Figure 1.
Participant Flow
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Figure 2.
Pre- to post-training changes in cortisol awakening response by group.
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Table 1
Participant Demographics at Pre-Training
or Mean %
or Mean %
2 /
31 -- 30 --
Age (
) 44.73 (6.63) -- 43.22 (5.43) --
= 0.98 .17
2 = 0.20 .65
Female 3 10% 4 10%
Male 28 90% 26 90%
2 = 5.06 .54
White 27 88% 25 84%
Black 1 3% 0 0%
Native 3 3
Native American/
Alaskan 0 0% 1 3%
Asian 1 3% 1 3%
Multi-racial 1 3% 0 0%
Other 0 0% 2 7%
2 = 2.07 .15
Hispanic/Latino 1 3% 4 13%
Not Hispanic/Latino 30 97% 26 87%
Years of education (
) 15.89 (2.37) -- 14.75 (2.35) --
= 1.59 .14
Years on the job (
) 18.50 (6.98) -- 17.97 (6.69) --
= 0.30 .38
Relationship status
2 = 7.74 .17
Married 23 74% 25 83%
Divorced 4 13% 2 7%
Widowed 1 3% 0 0%
Cohabitating 0 0% 1 3%
Single 3 10% 0 0%
Other 0 0% 2 7%
2 = 11.90 .16
Officer 9 29% 4 13%
Deputy 3 10% 5 17%
Criminalist 0 0% 1 3%
Detective 3 10% 6 20%
Sergeant 6 19% 10 33%
Lieutenant 3 10% 5 17%
Commander 1 3% 1 3%
Captain 4 13% 0 0%
Other 2 6% 0 0%
MBRT = Mindfulness-Based Resilience Training; NIC = no intervention control
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Table 2
Descriptive Statistics for Outcomes at all Time Points
Pre-Training Post-Training Three-Month Follow-Up
NIC (n = 30) M (SD) NIC (n = 26) M (SD) NIC (n = 25) M (SD)
MBRT (n = 31) M (SD) MBRT (n = 24) M (SD) MBRT (n = 24) M (SD)
Alcohol Use 46.38 (7.83) 46.89 (8.69) 46.59 (7.98)
46.44 (7.99) 44.04 (6.29) 45.70 (6.60)
Anxiety 52.25 (5.43) 48.70 (8.26) 49.28 (7.72)
51.91 (9.62) 48.83 (8.69) 50.66 (8.79)
Depression 48.36 (6.90) 47.32 (6.34) 46.27 (7.37)
47.49 (8.58) 46.69 (6.69) 48.15 (8.50)
Sleep Difficulties 52.14 (7.63) 51.25) (5.83) 51.59 (8.74)
50.69 (8.37) 47.40 (6.93) 49.62 (8.67)
Suicidal Ideation 8.30 (2.16) 7.69 (1.86) 7.80 (1.38)
8.54 (3.15) 8.29 (2.40) 8.45 (1.88)
Organizational Stress 3.11 (1.13) 3.25 (1.14) 2.95 (1.27)
2.99 (1.32) 2.65 (1.13) 2.76 (1.20)
Operational Stress 2.82 (.98) 2.76 (1.02) 2.79 (1.19)
2.92 (1.30) 2.66 (1.17) 2.73 (1.14)
Cortisol AUCI26.38 (59.16) 45.42 (64.26) --
39.25 (51.48) 24.77 (44.78) --
Burnout 2.43 (.31) 2.44 (.36) 2.37 (.34)
2.36 (.35) 2.20 (.29) 2.25 (.29)
Resilience 76.10 (9.34) 77.07 (9.50) 77.48 (10.19)
81.48 (12.36) 83.66 (10.73) 83.20 (11.38)
Anger 52.89 (8.24) 50.69 (7.71) 49.90 (7.32)
51.34 (8.55) 50.05 (6.89) 51.02 (8.16)
Aggression 1.86 (.61) 1.74 (.57) 1.63 (.53)
1.87 (.63) 1.47 (.43) 1.60 (.51)
Nonreactivity 16.93 (3.16) 17.30 (4.04) 18.28 (3.83)
17.35 (3.35) 19.54 (2.96) 18.41 (3.97)
Nonjudging 18.13 (3.13) 20.03 (3.09) 19.12 (3.41)
17.12 (4.79) 19.37 (3.22) 18.04 (4.04)
Acting with Awareness 18.10 (3.29) 18.26 (3.67) 19.20 (3.52)
18.16 (3.42) 18.29 (3.09) 18.70 (2.86)
Psychological Flexibility 14.56 (6.64) 13.88 (5.46) 10.76 (5.50)
14.45 (6.69) 11.70 (6.52) 12.75 (6.88)
Self-Compassion 36.33 (6.89) 37.61 (6.20) 38.64 (6.58)
39.93 (6.59) 40.95 (5.70) 41.62 (7.12)
. MBRT = Mindfulness-Based Resilience Training; NIC = no intervention control; AUCI = area under the curve(increase)
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Table 3
Time by Group Interactions and Effect Sizes for Outcomes
Pre- to Post-
Time × Group F-
Value, p-Value
Pre- to Post-Training
Time × Group F-
Value, p-Value
(Imputed Dataset)
to Three-
Month Follow-
Time × Group
F-Value, p-
Pre- to Post-
Cohen’s d
Effect Size
Psychological Health/Risk
Alcohol use 5.29, .02 5.29, .02 .46, .49 .37
Anxiety .04, .83 .13, .71 .09, .75 .01
Depression .03, .95 .01, .89 .12, .72 .09
Sleep difficulties .75, .39 1.28, .26 .04, .83 .60
Suicidal ideation .07, .78 .00, .98 .35, .55 .16
Organizational stress 3.77, .05 2.45, .08
3.69, .06 .52
Operational stress 2.26, .13 .77, .38 1.44, .23 .09
Burnout 6.37, .01 5.79, .01 .58, .45 .73
Resilience 2.38, .13 .82, .36 .84, .36 .64
Nonreactivity 4.22, .04 .86, .35
.03, .86 .60
Nonjudging .50, .48 .44, .50 3.37, .07 .20
Acting with awareness .62, .43 .06, .80 .56, .45 .00
Psychological flexibility 6.51, .01 2.82, .09
.23, .62 .73
Self-compassion 1.88, .17 1.64, .20 1.02, .32 .57
Anger .26, .60 .11, .74 .50, .48 .08
Aggression 4.09, .05 2.65, .10
.03, .84 .53
Cortisol Awakening
AUCI1.24, .24 -- -- .37
Results differ between imputed and non-imputed data sets. AUCI = area under the curve(increase)
Psychiatry Res
. Author manuscript; available in PMC 2019 June 01.
... 25 Likewise, there is evidence on the effectiveness of mindfulness-based training in enhancing resilience 26 and life satisfaction 26 and reducing depression, 12 27 anxiety, 12 27 PTSD, 10 perceived stress, 27 28 sleep problems, 10 27 28 aggression 28 and burn-out. 27 28 However, there were null results for similar outcome measures such as resilience, 28 perceived stress, 10 depression 28 and anxiety. 28 Though an earlier meta-analysis of stress interventions for police officers did not find significant effects on psychological outcomes, 29 this study and another systematic review cautioned against drawing conclusions and pointed out the need for more large-scale, well-designed and rigorous evaluation studies. ...
... 27 28 However, there were null results for similar outcome measures such as resilience, 28 perceived stress, 10 depression 28 and anxiety. 28 Though an earlier meta-analysis of stress interventions for police officers did not find significant effects on psychological outcomes, 29 this study and another systematic review cautioned against drawing conclusions and pointed out the need for more large-scale, well-designed and rigorous evaluation studies. 29 30 As there has been increasing attention given to promoting police officers' mental health through training programmes in recent years, a synthesis of empirical evidence on existing training programmes is necessary to better understand whether these practices are evidence-based and whether police agencies should invest in these preventive approaches universally. ...
... The maximum total score of the modified checklist was 28. The level of methodological quality was then grouped into four categories: excellent (26)(27)(28), good (20)(21)(22)(23)(24)(25), fair (15)(16)(17)(18)(19) and poor (14 or less). Studies rated as 'poor' for the methodological quality assessment were excluded from the meta-analysis. ...
There has been an increasing interest in primary prevention programmes developed to improve police officers’ mental health. This meta-analysis synthesised the existing findings on psychological skills training for police personnel including resilience training and mindfulness-based training. Particularly, this study systematically assessed the effectiveness of training programmes on mental health outcomes including resilience, depression, anxiety and perceived stress. A comprehensive search of EBSCO, ProQuest and Web of Science was conducted for studies written in English from 1999 to 2022. Two independent researchers screened 5604 studies. Eligible studies are intervention studies with controlled trials that involved training programmes to improve participants’ mental health and reported at least one of the following outcomes: resilience, depression, anxiety and perceived stress. The meta-analysis estimated standardised mean differences (SMDs) for each of the four outcomes. A total of 12 studies, involving 2298 police personnel from 8 countries, met the criteria for inclusion and quality assessment. The training programmes of the eligible studies varied in training approaches, duration, total sessions and follow-up periods. The results suggest that training programmes have a statistically significant moderate effect on depression (SMD=−0.47, 95% CI=−0.73 to −0.22) and anxiety (SMD=−0.40, 95% CI=−0.73 to −0.06), while the effects on resilience (SMD=1.03, 95% CI=−0.36 to 2.41) and perceived stress (SMD=−1.03, 95% CI=−2.15 to 0.08) are not statistically significant. This study highlights the role of primary prevention approaches in supporting officers’ mental health by showing that training programmes are effective in mitigating the risk of depression and anxiety.
... Later, Christopher et al. (2018) conducted a randomized control trial of MBRT and reported reduced stress, aggression, burnout, and sleep disturbance among police officers. In this study, improved psychological flexibility and mindful non-reactivity were specifically identified as potential mindfulness mechanism for these outcomes. ...
... One possibility is that the correct decision to use force among more mindful participants confronted with armed subjects is a function of the greater ability for attention and awareness of internal and external stimuli that is inherent to mindfulness (Baer 2015). Another possible explanation is that mindful reactivity is associated with less stress and improved parasympathetic response (Andersen et al. 2018;Christopher et al. 2018;Christopher et al. 2016), which in turn may improve sensory perception and attention (Shackman et al. 2011) and reduce automaticity and reliance on implicit processing (Brown et al. 2017;Lueke and Gibson 2015) in deadly force scenarios. Further, neurological mechanisms of mindfulness such as attention regulation, body awareness, and emotion regulation (Germer 2013) may also explain the connection between greater mindful reactivity and the use of force; however, future studies are needed to explore the role of such factors as they were not measured in the current study. ...
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The aim of this study was to explore the impact of mindfulness, race, and the decision to use deadly force in a law enforcement shooting simulation. A sample of 41 college students completed a mindfulness measure and then assumed the role of a police officer in a deadly force–related training scenario. Participants armed with a simulated firearm were directed to assess and respond as a law enforcement official to a male suspect (Black or White) holding an object (cell phone or weapon) within a short time frame. There was no significant difference in the number of unarmed Black and White targets that were shot; however, armed Black targets were shot significantly more than armed White targets. Notably, all participants fired on the armed Black targets. Mindfulness was associated with reduced likelihood of shooting unarmed targets. Participants who shot the unarmed Black target displayed significantly lower mindfulness than those who shot the unarmed White target or those that did not shoot at all. Mindfulness did not vary across groups when the target was armed. Mindfulness was associated with improved decision making in simulated deadly force-related scenarios.
... Prominent researchers such as Kabat-Zinn (2003, 2005 and Brown and Ryan (2003) have provided empirical evidence of the effectiveness of mindfulness practices in education. Significantly, the impact of mindfulness extends beyond academia to a variety of fields including health care (Lomas et al., 2018) and law (Christopher et al., 2018). To be more specific, not only can mindfulness be used in education, but it also has positive effects that go beyond traditional boundaries. ...
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Introduction Mindfulness at Higher Education Institutions (HEIs) may enhance personal development, learning, and entrepreneurial thinking. Thus, this scoping review investigates the effects of mindfulness on HEI entrepreneurship education, focusing on teaching, learning, and entrepreneurial intention. Method To identify relevant articles for inclusion, the study used a predetermined set of keywords and a descriptive search algorithm in six electronic databases. The process of study selection adhered to the principles outlined in the Preferred Reporting of Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and resulted in the inclusion of eleven (11) studies. Said studies spanned several nations and employed various research methods, with an emphasis on quantitative approaches. Results Results indicated that mindfulness did not have a direct impact on lecturers’ commitment to teaching entrepreneurship. Nevertheless, mindfulness appeared to indirectly impact teaching outcomes by influencing other variables, such as readiness for change. From an educational processes and outcomes perspective, mindfulness was found to improve the entrepreneurship learning environment and enhance students’ entrepreneurial orientation. The latter included students’ intentions to develop or participate in environmental and socially responsible entrepreneurial ventures. Discussion The present study advances our understanding of the relationship between mindfulness, entrepreneurship teaching and students’ entrepreneurial orientation in higher education settings. Nevertheless, it also demonstrates a lack of comprehension of the exact mechanisms at play, and therefore highlights the need for further research in this scientific area. By gaining a broader awareness of the impact of mindfulness on entrepreneurship education, education professionals and decision-makers can improve the design of programmes to cultivate the entrepreneurial orientation and skills necessary for students’ success in a rapidly changing business environment. Systematic Review Registration The review process has been duly registered with the Open Science Framework (OSF) and given the identifier DOI 10.17605/OSF.IO/YJTA3 .
... In instances when the mean age was not available in a study paper, the mean age was calculated from the age range information (e.g., Christopher et al., 2018;MacLean et al., 1997;Tsiouli et al., 2014). For some studies, overall mean age was calculated through taking the average of the intervention and control groups (Bottaccioli et al., 2020;Danucalov et al., 2013;Feicht et al., 2013;MacDonald and Minahan, 2018). ...
... The efficacy of MBIs to positively impact Canadian police officer wellbeing is becoming well established in research (Stevenson, 2022). Acting on the evidence, which includes reducing aggression, alcohol use, and working memory degradation while improving psychological flexibility, resilience, sleep quality, emotional regulation, and distress tolerance, is long overdue (Christopher et al., 2016;Christopher et al., 2018;Christopher et al., 2020;Fitzhugh et al., 2019;Fleischmann et al., 2021;Grupe et al., 2021;Jha et al., 2020;Kaplan et al., 2020;Sylven, 2023). Further, MBIs are shown to both increase grey matter plasticity in executive function brain regions and strengthen connectivity in the DMN (Kral et al., 2022;Tang et al., 2020;Sezer et al., 2022). ...
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The setting of policing exposes its officers to a host of negative health outcomes physiologically, psychologically, and spiritually. Policing mindsets around accessing mental health are far from fixing the epidemic of its mental health crisis or being able to sustain a healthy workforce. Policing is losing the battle with a misguided and a scientifically misinformed war on drugs. Canadian legislators are shifting mindsets from decriminalizing substance use towards applying a public health lens to the mycelium underlying its root causes. So too should its peace officers—not just to restore peace in society—but also in their own minds and in their dysregulated nervous systems by synergizing psilocybin’s neural benefits with mindfulness-based psychotherapy. Western science’s exploration into the healing magic of mushrooms and mindfulness is in its infancy compared with the centuries of wisdom from both Indigenous science and eastern contemplative traditions. Not only does their fusion amplify hope for those suffering but perhaps it offers a scientific key to the neurogenesis of resilience. This is a pracademic trip driven by a retired and now reformed agent from Canada’s War on Drugs.
... For all FRs, resilience was a significant buffer against suicidality. Prior studies have shown that mindfulness-based resilience training may be efficacious among LEOs to address key physiological, psychological, and health risk factors (Christopher et al., 2018). Additionally, there are internet-delivered resilience training programs that are currently offered for EMTs, a platform that was created to increase access to this resource (Wild et al., 2018). ...
First responders are routinely exposed to traumatic events that can affect their mental health to the extent of suicidal ideation and suicide completion. The purpose of our study is to inform the comparability of predictors of suicidality across first responder types to elucidate the most efficacious targets for intervention and clinical intercession. Clients ( N = 224) sought counseling services between 2015 and 2020 at a not-for-profit organization. We conducted a matched study with cases defined as those with suicidality at baseline and those without suicidality at baseline (controls). First responder types were law enforcement officers (LEOs), firefighters, and emergency medical technicians. Clients were mostly LEOs (41.5%), followed by firefighters (29.9%) and emergency medical technicians (28.6%). Logistic regression models tested the relationship between mental health measures and suicidality. All measures of mental health constructs varied significantly across those with or without suicidality and differed across first responder subtype. Depression and posttraumatic stress disorder were significant predictors of suicidality for both LEOs and firefighters. Alcohol/substance misuse was only a significant predictor among LEOs. Resilience was a protective factor for both LEOs and emergency medical technicians. Specific differences in predictors of suicidality across first responder subtypes may enable occupation-specific targets for mental healthcare.
... Aemala-Or et al. [64] Barrett et al. [104][105][106][107][108][109][110] Barrett et al. [111][112][113][114][115][116] Christopher et al. [117][118][119] Errazuriz et al. [120] Galante et al. [39,[121][122][123] Huang et al. [124] Hwang et al. [125] Kral et al. [65,[126][127][128] MacKinnon et al. [66,129] Schellekens et al. [30,130,131] Siebelink et al. [67,132] van Dijk et al. [71,133] Overall Analysis ...
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Introduction Mindfulness-based programmes (MBPs) are widely used to prevent mental ill-health that is becoming the leading global cause of morbidity. Evidence suggests beneficial average effects but wide variability. We aimed to confirm the effect of MBPs on psychological distress, and to understand whether and how baseline distress, gender, age, education, and dispositional mindfulness modify the effect of MBPs on distress among adults in non-clinical settings. Methods We conducted a pre-registered systematic review and individual participant data (IPD) meta-analysis (PROSPERO CRD42020200117). Thirteen databases were searched in December 2020 for randomised controlled trials satisfying a quality threshold and comparing in-person, expert-defined MBPs in non-clinical settings with passive control groups. Two researchers independently selected, extracted, and appraised trials using the revised Cochrane Risk-of-Bias Tool (RoB2). Anonymised IPD of eligible trials were sought from collaborating authors. The primary outcome was psychological distress (unpleasant mental or emotional experiences including anxiety and depression) at 1 to 6 months after programme completion. Data were checked and imputed if missing. Pairwise, random-effects, two-stage IPD meta-analyses were conducted. Effect modification analyses followed a within-studies approach. Public and professional stakeholders were involved in the planning, conduct and dissemination of this study. Results Fifteen trials were eligible, 13 trialists shared IPD (2,371 participants representing 8 countries, median age 34 years-old, 71% women, moderately distressed on average, 20% missing outcome data). In comparison with passive control groups, MBPs reduced average distress between one- and six-months post-intervention with a small to moderate effect size (standardised mean difference (SMD) -0.32; 95% confidence interval (CI) -0.41 to -0.24; p-value < 0.001; 95% prediction interval (PI) -0.41 to -0.24 (no heterogeneity)). Results were robust to sensitivity analyses, and similar for the other psychological distress time point ranges. Confidence in the primary outcome result is high. We found no clear indication that this effect is modified by baseline psychological distress, gender, age, education level, or dispositional mindfulness. Conclusions Group-based teacher-led MBPs generally reduce psychological distress among community adults who volunteer to receive this type of intervention. More research is needed to identify sources of variability in outcomes at an individual level.
Racially minoritized adults lack equal representation in research and experience disparities in healthcare. Little is known about which trait-level factors may help mitigate negative and promote positive psychological health among adults from these communities. The aim of this study was to assess the differential impact of dispositional mindfulness, self-compassion, and resilience in predicting depression, anxiety, stress, and life satisfaction in a sample of racially minoritized adults. This study is a cross-sectional analysis of 169 participants (37.3% female and 62.7% male) between the ages of 18 and 64 ( M = 37.05; SD = 11.94). Separate hierarchical multiple regression models examined the relative influence of mindfulness facets (acting with awareness (AA); nonjudging of inner experience (NJ), and nonreactivity of inner experience (NR)), self-compassion, and resilience in predicting depression, anxiety, stress, and life satisfaction. Self-compassion, resilience, AA, and NR predicted depression; self-compassion, resilience, and NR predicted anxiety; self-compassion, resilience, and NR predicted stress; and self-compassion predicted satisfaction with life. Self-compassion, resilience, AA, NJ, and NR differentially predicted depression, anxiety, stress, and life satisfaction; however, only self-compassion consistently predicted all outcomes. Future research may incorporate an intersectional methodology and account for differences among different racially minoritized groups.
Resilience is an important personal characteristic that influences health and recovery. Previous studies of chronic pain suggest that highly resilient people may be more effective at modulating their pain. Since brain gray matter in the antinociceptive pathway has also been shown to be abnormal in people with chronic pain, we examined whether resilience is related to gray matter in regions of interest (ROIs) of the antinociceptive pathway (rostral and subgenual anterior cingulate cortex (rACC, sgACC), anterior insula (aINS), dorsolateral prefrontal cortex (dlPFC)) normally and in people who are experiencing chronic pain. We extracted gray matter volume (GMV) and cortical thickness (CT) from 3T MRIs of 88 people with chronic pain (half males/females) and 86 healthy controls (HCs), who completed The Resilience Scale and Brief Pain Inventory. We found that resilience scores were significantly lower in people with chronic pain compared to HCs, whereas ROI GMV and CT were not different between groups. Resilience negatively correlated with average pain scores and positively correlated with GMV in the bilateral rACC, sgACC, and left dlPFC of people with chronic pain. Mediation analyses revealed that GMV in the right rACC and left sgACC partially co-mediated the relationship between resilience and average pain in people with chronic pain. The resilience-pain and some resilience-GMV relationships were sex-dependent. These findings suggest that the antinociceptive pathway may play a role in the impact of resilience on one's ability to modulate chronic pain. A better understanding of the brain-resilience relationship may help advance evidence-based approaches to pain management.
In the line of duty, law enforcement officers are exposed to various stressors. Therefore, they are vulnerable to the onset of mental health disorders. Unfortunately, many officers in need may not readily seek out mental health assistance because of the stigma associated with mental illness that persists within the culture of law enforcement. Psychoeducation and a judgment-free environment can reduce the stigma surrounding mental health treatment. Though both mental health professional (MHP)-led programs and peer-led support programs for law enforcement do help, we argue that neither one on its own is enough to combat stigma and increase treatment access and adherence. Therefore, we argue that a model that incorporates both peer-led initiatives and the expertise of mental health professionals may help dispel stigma, increase trust, and increase service use among law enforcement officers. Following a discussion of the theoretical basis for a hybrid model, we describe the Texas Post-Critical Incident Seminar (PCIS) program as a real-world application of a hybrid model.
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In order to increase the cost-efficiency, availability and ease of accessing and delivering mindfulness-based interventions (MBIs), clinical and research interest in mindfulness-based self-help (MBSH) interventions has increased in recent years. Several studies have shown promising results of effectiveness of MBSH. However, like all self-help interventions, dropout rates and disengagement from MBSH are high. The current study explored the facilitators and barriers of engaging in a MBSH intervention. Semi-structured interviews with members of healthcare staff who took part in an MBSH intervention (n = 16) were conducted. A thematic analysis approach was used to derive central themes around engagement from the interviews. Analyses resulted in four overarching themes characterising facilitation and hindrance to engagement in MBSH. These are “attitude towards engagement”, “intervention characteristics”, “process of change” and “perceived consequences”. Long practices, emerging negative thoughts and becoming self-critical were identified as the key hindrances, whilst need for stress reduction techniques, shorter practices and increased sense of agency over thoughts were identified as the key facilitators. Clinical and research implications are discussed.
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Introduction Mindfulness-based intervention is proposed and practiced as an alternative treatment, however, current evidence supporting the treatment effect of mindfulness-based interventions remains unclear. The study proposed to evaluate the effectiveness of mindfulness-based interventions for insomnia. Methods Eight databases (including PubMed, Medline and PsycInfo) were searched and the reference list of relevant records were screened for identifying eligible studies. Randomized controlled trials examining any forms of mindfulness-based intervention which containing meditation will be included for optimizing the search. Clinical trials with very small sample were excluded. Statistical analyses were performed using Review Manager version 5.3 using random effect model. The quality of included studies were assessed according to the Cochrane Collaboration tool for assessing risk of bias. Results An initial search result of 7462 records was then reduced to a final sample of fourteen selected trials for meta-analyses. A sampling of 1295 participant with sleep complaint was recruited, aged 57.5 in average and varied in health conditions. Subgroup analyses were conducted for the substantial heterogeneity among studies noted. Significant improvements were found in subjective insomnia severity when compared with no treatment/usual care in both healthy sample (SMD -0.78, 95% CI -0.99 to -0.57, p<0.001, 388 subjects) and cancer sample (SMD -0.25, 95% CI -0.40 to -0.10, p=0.001, 678 subjects). Inconsistent results were found in the specific sleep parameters measured by sleep diary and actigraph. However, insufficient data were available for comparing the efficacy of mindfulness-based intervention with other comparators, such as sleep hygiene education, psychotherapy and western medication. Conclusion Despite the mindfulness-based interventions demonstrate clinical benefit for improving the subjective sleep quality, the validity of evidence was limited for the diversity of treatment contents, heterogeneity of sample, the small sample size of included trials and cultural influence. Support (If Any) N/A.
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Background: The objective of this randomized clinical experiment was to test the influence of a mindfulness meditation practice, when delivered during 1 session of active chemotherapy administration, on the acute salivary cortisol response as a marker of neuroendocrine system activity in cancer patients. Methods: A mindfulness, attention-control, or resting exposure was assigned to 57 English- or Spanish-speaking colorectal cancer patients at 1 county oncology clinic and 1 university oncology clinic at the start of chemotherapy. Saliva samples were collected at the start of chemotherapy and at subsequent 20-minute intervals during the first 60 minutes of chemotherapy (4 samples in all). Self-reporting on biobehavioral assessments after chemotherapy included distress, fatigue, and mindfulness. Results: An area-under-the-curve analysis (AUC) showed a relative increase in cortisol reactivity in the mindfulness group after adjustments for biological and clinical measures (β = 123.21; P = .03). More than twice as many patients in the mindfulness group versus the controls displayed a cortisol rise from the baseline to 20 minutes (69% vs 34%; P = .02). AUC values were uncorrelated with biobehavioral measure scores, although mindfulness scores were inversely correlated with fatigue (r = -0.46; P < .01) and distress scores (r = -0.54; P < .01). Conclusions: Findings suggest that mindfulness practice during chemotherapy can reduce the blunting of neuroendocrine profiles typically observed in cancer patients. Implications include support for the use of mindfulness practice in integrative oncology. Cancer 2017. © 2017 American Cancer Society.
The Operational and Organizational Police Stress Questionnaires (PSQ-Op and PSQ-Org) are useful tools for understanding individual differences in the perception of policing-specific stress. However, two of the limitations of the PSQ-Op and PSQ-Org are their lack of normative values that provide organizations with a baseline with which to judge the effectiveness of stress-reduction interventions or new resilience-based training initiatives and cut-offs that can identify the percentage of employees who might be experiencing high, moderate, and low levels of policing-specific stress. Specifically, they do not allow individual departments or policing organizations to assess the relative degree of work-related stress their members are experiencing, or to determine whether that level of stress is excessive. To address this gap in knowledge, we developed gender-based norms and cut-off values for the two PSQ measures. These norms are provided for both overall scale scores and individual items, and implications for addressing officer stress are discussed.
Study design: Prospective cohort study. Objective: To determine validity and responsiveness of Patient-Reported Outcomes Measurement Information System (PROMIS) health domains. Summary of background data: PROMIS health domains (anxiety, depression, fatigue, pain, physical function, satisfaction with participation in social roles, sleep disturbance) may measure quality of care and determine minimal important differences (MIDs) after spine surgery. We examined concurrent validity of PROMIS domains before and PROMIS domain MIDs after anterior cervical spine surgery. Methods: We included 148 adults undergoing cervical spine surgery from February 2015 through June 2016. We determined concurrent validity by correlations of preoperative PROMIS domains with legacy measures and responsiveness of PROMIS domains using distribution-based and anchor-based criteria (preoperative to postoperative change, within 6 months) anchored to treatment expectations (assessed using North American Spine Society Patient Satisfaction Index criteria). Statistical significance was accepted as p < 0.05. Results: All PROMIS domains showed moderate to strong correlations with Neck Disability Index, Short-Form Health Survey, version 2 (SF-12v2), and Brief Pain Inventory pain interference and weak correlations with intensity of arm/neck pain (except between PROMIS pain and neck pain [r = 0.45, p < 0.001] and PROMIS physical function and SF-12v2 physical [r = -0.14, p = 0.138] and mental [r = 0.39, p < 0.001] components). PROMIS domains were well correlated with Generalized Anxiety Disorder-7 and Patient Health Questionnaire-8 except PROMIS physical function (r = -0.29, p = 0.002). Distribution-based PROMIS MID estimates ranged from 2.3-3.9 points. Incorporating cross-sectional and longitudinal anchor-based criteria, final PROMIS MID estimates were as follows: anxiety, -5.7; depression, -4.6, fatigue, -5.8; pain, -5.2; physical function, 4.5; satisfaction with participation in social roles, 4.4; and sleep disturbance, -7.4. Conclusions: PROMIS domains are a valid assessment of health in this population and were responsive to postoperative improvements in symptoms and quality of life. Level of evidence: 2.
As U.S. service members deploy for extended periods on a repeated basis, their ability to cope with the stress of deployment may be challenged. A growing number of programs and strategies provided by the military and civilian sectors are available to encourage and support psychological resilience to stress for service members and families. Though previous research from the field of psychology delineating the factors that foster psychological resilience is available, there has been no assessment of whether and how well the current military resilience programs are addressing these factors in their activities. Further, little is known about the effectiveness of these programs on developing resilience. To assist the Department of Defense in understanding methodologies that could be useful in promoting resilience among service members and their families, the research team conducted a focused literature review to identify evidence-informed factors for promoting psychological resilience. The team also reviewed a subset of military resilience programs to determine the extent to which they included those evidence-informed factors. This article describes the context, approach, and findings from these research activities.
Trial registration: NCT01258985. Registered 10 December 2010 PERSPECTIVE: This study examined whether PROMIS short form instruments (Physical Function, Pain Interference, Depression, and Anxiety) were able to detect change over time among adults with knee osteoarthritis, and provided minimally important change estimates for each measure. This standard of reference can help apply or interpret these instruments in the future.
Background Positive psychological constructs have been associated with reduced suicidal ideation, and interventions to cultivate positive feelings have the potential to reduce suicide risk. This study compares the efficacy of a 6-week, telephone-based positive psychology (PP) intervention against a cognition-focused (CF) control intervention among patients recently hospitalized for depression and suicidal ideation or behavior. Method A total of 65 adults with a current major depressive episode reporting suicidal ideation or a recent suicide attempt were enrolled from participating in-patient psychiatric units. Prior to discharge, participants were randomized to the PP ( n = 32) or CF ( n = 33) intervention. In both interventions, participants received a treatment manual, performed weekly PP (e.g. gratitude letter) or CF (e.g. recalling daily events) exercises, and completed weekly one-on-one telephone sessions over 6 weeks. Between-group differences in hopelessness (primary outcome), depression, suicidality and positive psychological constructs at 6 and 12 weeks were tested using mixed-effects models accounting for intensity of post-hospitalization psychiatric treatment. Results Compared with PP, the CF intervention was associated with significantly greater improvements in hopelessness at 6 weeks ( β = −3.15, 95% confidence interval −6.18 to −0.12, effect size = −0.84, p = 0.04), but not 12 weeks. Similarly, the CF intervention led to greater improvements in depression, suicidal ideation, optimism and gratitude at 6 and 12 weeks. Conclusions Contrary to our hypothesis, the CF intervention was superior to PP in improving hopelessness, other suicide risk factors and positive psychological constructs during a key post-discharge period among suicidal patients with depression. Further study of this CF intervention is warranted in populations at high suicide risk.
Police officers encounter unpredictable, evolving, and escalating stressful demands in their work. Utilizing the Spielberger Police Stress Survey (60-item instrument for assessing specific conditions or events considered to be stressors in police work), the present study examined the association of the top five highly rated and bottom five least rated work stressors among police officers with their awakening cortisol pattern. Participants were police officers enrolled in the Buffalo Cardio-Metabolic Occupational Police Stress (BCOPS) study (n = 338). For each group, the total stress index (product of rating and frequency of the stressor) was calculated. Participants collected saliva by means of Salivettes at four time points: on awakening, 15, 30 and 45 min after waking to examine the cortisol awakening response (CAR). Saliva samples were analyzed for free cortisol concentrations. A slope reflecting the awakening pattern of cortisol over time was estimated by fitting a linear regression model relating cortisol in log-scale to time of collection. The slope served as the outcome variable. Analysis of covariance, regression, and repeated measures models were used to determine if there was an association of the stress index with the waking cortisol pattern. There was a significant negative linear association between total stress index of the five highest stressful events and slope of the awakening cortisol regression line (trend p-value = 0.0024). As the stress index increased, the pattern of the awakening cortisol regression line tended to flatten. Officers with a zero stress index showed a steep and steady increase in cortisol from baseline (which is often observed) while officers with a moderate or high stress index showed a dampened or flatter response over time. Conversely, the total stress index of the five least rated events was not significantly associated with the awakening cortisol pattern. The study suggests that police events or conditions considered highly stressful by the officers may be associated with disturbances of the typical awakening cortisol pattern. The results are consistent with previous research where chronic exposure to stressors is associated with a diminished awakening cortisol response pattern.