Introduction
Feeling tensed, restless, rushed, or overwhelmed as a result of daily stress is very common in western society. The lifestyle in the contemporary 24-h economy is characterized by speed, time pressure, competition, job insecurity, being constantly available due to modern telecommunication, an overload of stimuli, and multi-tasking in different roles that we fulfill (Stansfeld and Candy
2006). Work-related pressure is indicated as the main source of stress in the USA (Aikens et al.
2014). According to the American Institute of Stress, 75 to 90 % of the GP visits in the USA are related to stress (Rosch
2001). The International Labor Organization estimated that 30 % of all work-related disorders are due to stress (Mino et al.
2006). In line, 22 % of the working population in the European Union experience work-related stress in a way that it has a large negative impact on their well-being (European Agency for Safety and Health at Work
2014). These numbers are expected to only go up in the future (Shanafelt et al.
2015).
Stress is a real health hazard. On the short term, stress can lead to complaints such as headaches, flu-like symptoms, muscle tension and strains, increased heart rate and blood pressure (Gura
2002; Schneiderman et al.
2005), sleep problems (Sadeh et al.
2004), or being mentally unstable and irritable (Hassmén et al.
2000). On the long term, stress can lead to severe fatigue and burnout (Leone et al.
2011; Wessely et al.
1998), anxiety and depression (Hammen
2004; Netterstrøm et al.
2008), problems with cognitive and executive functioning (Mcewen and Sapolsky
1995), relationships and family problems (Coyl et al.
2002), somatic complaints like a weakened immune system (Cohen et al.
1991), cardiovascular disorders, digestive problems (Schneiderman et al.
2005), and chronic illnesses (Wolever et al.
2012). Consequences of stress at the workplace can be a loss of productivity, absenteeism, accidents, poorer judgments, errors, interpersonal problems and conflicts, chronic somatic diseases, abuse of alcohol and drugs, and mental diseases (European Agency for Safety and Health at Work
2014; Kalia
2002). The costs of stress are enormous on both a personal and a societal level. Total annual costs of disorders that were caused by stress were estimated to be $660 billion in the USA and €920 billion in Europe (Mino et al.
2006).
Due to the severe consequences and very high costs of work-related stress, as well as its high occurrence, there is an urgent need for effective solutions. Treatment as usual for work-related stress complaints are either person-directed (cognitive behavioral therapy, psychotherapy, counselling, skill training, communication training, social support, and relaxation exercises), organization-directed (work process restructuring, work performance appraisals, work shift readjustments, and job evaluation), or a combination of both (Awa et al.
2010). A meta-analysis by Richardson and Rothstein (
2008) on work-related stress management interventions, which included 63 experimental studies, showed that the most popular interventions were the ones with relaxation and meditation techniques (average duration of interventions was 6.5 weeks, with weekly 1–2-h sessions, with a mean effect size of 0.50), though cognitive behavioral interventions appeared to be the most effective (average duration of interventions was 7.5 weeks, with weekly 1–2-h sessions, with an average effect size of 1.16). The popularity of relaxation and meditation techniques is probably because they are easily accessible, easy to implement, and least expensive (Richardson and Rothstein
2008). This is in line with Henriques et al. (
2011) who state that interventions that are easily applicable, inexpensive, can be used by a large number of people, and have minimal side effects are preferable. Methods that meet these criteria and have been proven to be effective in reducing stress and its related symptoms (e.g., depression, stress, anxiety, and somatic complaints) are mindfulness, yoga, and physical exercise.
Mindfulness is an intervention that rapidly gained popularity in the last decades in the USA and Europe. Mindfulness has its origin in the 2500-year-old Buddhist tradition. The definition of mindfulness is ‘awareness that arises through deliberately paying attention in the present moment, non-judgmentally’ (Kabat-Zinn
2003). All human beings have the capacity to be fully aware, though the periods that we are fully present are mostly short and sustaining awareness is a special skill (Siegel et al.
2009). Mindful awareness involves a non-judgmental attitude. We tend to judge experiences immediately: we find things pleasant or unpleasant, good or bad. This judging or labeling colors our experience, and as a result, we do not see clearly how things really are. This awareness and attitude are cultivated by formal practices (for instance, sitting meditation, body scan) and informal practices that integrate these practices in daily life (for instance, doing a routine activity mindfully or eating a meal with awareness). During these practices, attention is trained (monitoring, directing, and sustaining) and self-investigation takes place. Due to observing the content of the mind and our inner reactions, we can relate differently to internal events (Fjorback et al.
2011). We do not have much control over our life events and inner turmoil, but we do have control over how we relate to it. Mindfulness will not eliminate life’s pressures, but it can help us respond to them in a more deliberate and calm manner that benefits our mind and body, as well as our relationship with others.
Mindfulness has shown to be effective in the treatment of stress and rumination (Chiesa and Serretti
2009; Delgado et al.
2010), anxiety and depression (Brown and Ryan
2003; Chiesa and Serretti
2011; Hofmann et al.
2010), chronic pain (Kabat-Zinn et al.
1985), enhances immune functioning (Davidson et al.
2003), cognitive functioning (Zeidan et al.
2010), and improves self-compassion (Chiesa and Serretti
2009) and overall mental well-being (Carmody and Baer
2008).
Yoga has its roots in India and is practiced since thousands of years, but it is only since this century that yoga has become very popular in the USA and Europe (Li and Goldsmith
2012). The word yoga (Sanskrit) means ‘unity’ or ‘to unite,’ which refers to the combination of physical postures (Asanas) and breathing techniques that are being executed with full attention. Multiple studies showed that yoga helps to decrease the effects of stress by reducing the level of the stress hormone cortisol (Granath et al.
2006; West et al.
2004), promoting relaxation and sleep (Khalsa
2004), diminishing muscle tension and counteract musculoskeletal disorders (such as repetitive strain injury [RSI]/complaints arm neck shoulder [CANS]) (Gura
2002), boosts immune functioning (Ross and Thomas
2010), controls blood pressure, heart and metabolic rate, improves strength and physical flexibility, and eases somatic complaints (Raub
2002).
Physical exercise has also been shown to effectively reduce stress and its related symptoms. Regular physical exercise decreases symptoms of anxiety and depression (Conn
2010a; Conn
2010b; McDonald and Hodgdon
1991), as well as psychological stress and anger (Hassmén et al.
2000); counters an over reactive stress-response system; and reduces rumination (Mothes et al.
2014). Physical exercise gives energy and at the same time promotes relaxation and better sleep (DiLorenzo et al.
1999; Youngstedt et al.
1997), boosts the immune system (LaPerriere et al.
1990), and enhances cognitive and executive functioning as well as positive affect (Reed and Buck
2009). Regular exercise further enhances cardiovascular and muscular strength (Pober et al.
2004). A meta-analysis by Conn et al. (
2009) showed that physical exercise is an effective tool in preventing and reducing work-related stress, as well as reducing the duration of absenteeism from work (Van den Heuvel et al.
2003).
Knowing that stress-related complaints express themselves mentally and physically, an intervention that targets stress on both levels would be expected to be effective. The aim of the current proof of concept study is to examine the effects of a newly developed 6-week training program in which physical exercise, yoga, and mindfulness meditations are combined. Effects on workability as the primary outcome measure are assessed, as well as effects on secondary outcomes of anxiety, depression, stress, sleep, and positive and negative affect in a sample of employees with (work-related) burnout complaints. Workability is defined as (work-related) stress symptoms such as fatigue, lack of concentration, inactivity, lack of motivation, mental as well as physical workability, and the return to work index. Correlations between intensity of home practice, number of attended sessions, and changes in primary outcome measures are also assessed. In addition to these quantitative measures, feasibility (intervention participation) and acceptability (intervention satisfaction) of the Mindful2Work training are examined.
Discussion
This proof of concept study assessed feasibility and acceptability of the newly developed Mindful2Work training, as well as preliminary effects on workability, anxiety, depression, stress, sleep, and affect in employees suffering from (work-related) stress. In addition, we investigated whether the amount of home practice and number of attended sessions was related to outcome.
We considered attendance and the subjective evaluations to be indicators of feasibility and acceptability. Nearly 90 % of all participants followed five or all six sessions, and dropout rate was zero. It is known from participation in psychological treatment in general that nearly 47 % of clients drop out before the treatment or training is completed (Wierzbicki and Pekarik
1993). We therefore conclude that the Mindful2Work training has a very high feasibility in this sample of participants with burnout related symptoms. Perhaps this high attendance rate was indicative of the level of suffering. Participants were characterized by a high level of burnout related symptoms when they started the Mindful2Work training and were seeking to relieve their suffering. In addition, high conscientiousness and perfection is often seen in people at risk for burnout, which might further explain their consistent participation. Moreover, in most cases, the employer paid for the training costs, which may also have motivated the employees to attend all sessions. Employees were partly on sick leave from work, therefore they perhaps felt the space to attend all sessions, which were mostly held during work time, and for most participants, travel distance was within a range of only 5 km.
The participants gave the Mindful2Work training an average grade of 8.1 out of ten and were highly positive about all three elements of the training and the combination of the three. Participants further clarified many changes that happened in their lives since the Mindful2Work training (i.e., sleep better, more optimistic, more aware of physical tension and therefore better able to let go of it, more insight and understanding of themselves during depression/burnout, better able to cope in stressful situations, more positive attention towards themselves). Most of these changes were still present 6 months after the start of the training. We feel that we can therefore safely conclude that the Mindful2Work training has a very high acceptability.
Since employees that were (self-) referred to this training suffered from complaints that affected their ability to function well at work, the primary outcome measure of this study was workability. Overall, the Mindful2Work training had a very large positive effect on the workability. The risk for long-term dropout from work decreased by nearly 60 %, the mental and physical workability increased, as well as the hours participants returned back to work. Large effects were found immediately after training and lasted, and in most cases, grew even stronger in the long term. Particularly the increase in working hours has obvious financial advantages, since societal costs for people that are absent from work are very high (i.e., Rosch
2001). Inspecting the overall mental and physical workability grade, which went from a low of 4.88 and 6.08, respectively, to a high of 7.04 and 7.65, respectively, also indicated substantial improvements after training.
Treatment as usual for burnout is either person-directed, organization-directed, or a combination of both. Awa et al. (
2010) conducted a meta-analysis of all three intervention types and found that 80 % of the included studies led to positive effects on burnout. Duration of interventions ranged from 2 days to 10 months, and effect sizes (only stated in three studies) ranged from small to large. The positive effects of person-directed interventions were maintained in the short term (6 months or less), while a combination with organization-directed interventions had longer lasting effects (12 months and more). The duration of the selected interventions was typically 6 months or less. Interventions that had booster courses (to refresh) had longer lasting effects. However, effects diminished over time in all cases. In comparison to treatment as usual, the effect sizes of the Mindful2Work training were larger and the positive effects of the training were not only maintained but also seemed to extend further in the long term. Furthermore, the duration of the Mindful2Work training was relatively short, compared to treatment as usual, which is favorable not only for regarding cost-effectiveness, but also for accelerating return to work. To compare, a regular MBSR training covers usually around 27 h of training sessions, whereas the Mindful2Work program consisted of 14 h of training sessions.
There are more similar interventions (e.g., the mindful at work programs from Wolever et al.
2012) that also contain physical exercise, yoga, or mindfulness, but comparison to the current study is difficult because the components are usually not combined but studied separately. However, previous positive effects of physical exercise on workability have been shown. For instance, Pohjonen and Ranta (
2001) showed that regular physical exercise (9-month training program of twice a week) kept the level of workability index of employees constant after 1 year, while the workability of the control group who did not exercise decreased. During a 5-year period, these changes were maintained for the intervention group, while the workability index of the control group declined three times faster. Furthermore, it was shown that physical activity predicts lower levels of future job burnout, depression, and other mental disorders (Sanchez-Villegas et al.
2008). In line, mindfulness trainings have shown positive effects on workability. Mindfulness decreases the effects of stress in employees (Chaskalson
2011) improves mental well-being (i.e., Brown and Ryan
2003; Carmody and Baer
2008; Chiesa and Serretti
2009), cognitive functioning (Zeidan et al.
2010), and physical health (Davidson et al.
2003; Delgado et al.
2010), which all contribute to mental and physical workability. Research shows that yoga also contributes to this, on a mental (Smith et al.
2007; Wolever et al.
2012) and a physical level (Vera et al.
2009).
Since all three different elements of the training have shown to be effective before, but effect sizes of this combined training appear much higher and longer lasting than what has been reported in the literature with respect to the three separate interventions, one could speculate that this may be due to the synergetic effect of three effective elements. Due to the different elements in the training, stress is targeted on multiple levels. On a physical level, tension is decreased and relaxation and regeneration are promoted. Furthermore, the physical activities are conducted with mindful awareness, and the emphasis lies on a shift from thinking (willpower; “What do I want?”), to feeling (“How am I really doing?”; “What do I need right now?”). The body is a great source of information. By feeling, the connection with the body is restored and the wisdom of the body can be used. Bodily sensations are signals that tell us how we are doing, and also exactly what we need and what our limitations are. Listening to the body and taking care of oneself decreases the tendency to cross or ignore our limits. Besides working with the body, working with the mind is the other level where stress is targeted in the Mindful2Work training. By enhancing attention and less mind wandering to the past or future, more peace of mind and equanimity is established. This was also reflected in participant’s answers to the open evaluation questions. Furthermore, the self-investigation during meditations and exercises provides important insights. Participants learn to take a distance from internal (thoughts, feelings, and physical sensations) and external events and regain freedom in having a choice in how they relate to them. In line, this was emphasized in the evaluations by the participants. Given the fact that body and mind are intertwined and non-stop information exchange takes place, it is likely that working on both levels leads to synergy: the total sum is bigger than the separate parts. This synergy is likely to explain the large effects of this training. This hypothetical synergy is further underlined by the fact that 95 % of the participants considered the three elements a good combination and 60 % wanted to continue with all three of them after the training. Possibly, the mindful exposure to nature during the sport part of the training (boot camp in the park) provides a positive effect in itself which in turn has a continuing positive effect on the physical exercise, yoga, and meditation that follow. Meta-studies of nature-assisted therapies (NAT) confirm these positive effects of exposure to nature for a variety of symptoms and disorders, including stress-related symptoms (Annerstedt and Währborg
2011; Währborg et al.
2014).
In addition to the effects on workability, large immediate, middle long-term, and long-term effects were also found for secondary outcome measures anxiety, depression, stress, sleep problems, and affect. In line with primary outcomes, not only did most effects last up to 6 months after the start of the training, but effects also seemed to ‘grow.’ Participants felt much less anxious, stressed and depressed, suffered from less somatic stress complaints such as shoulder, neck and back aches, slept better, and felt more positive and energetic. Although in the follow-up period after the training and the months after the follow-up session no training sessions were offered, the effects of the training seemed to extend further. It seemed like the seeds of the training were planted and the fruits blossomed even more later on in time. It seems that although the intervention stopped, the tools that were learned in the training were still used and mastery enhanced.
Overall, effects were not related to the amount of home practice or number of sessions attended. In the mindfulness literature, this finding is not uncommon. Although positive associations have been found between intensity of formal home practice (‘prescribed’ home work exercises each week) in MBSR and MBCT courses and outcomes such as rumination and relapse to depression, no relationships were found with amount of informal home practice (any other mindfulness practices, outside of the prescribed home work, i.e., mindful walking the dog, mindful washing the dishes) (Crane et al.
2014; Hawley et al.
2014). The lack of associations in the current study might be explained by the difficulties in measuring home practice. We asked participants to report retrospectively how much they exercised, practiced yoga, and meditation over the past period (instead of keeping a daily diary) and did not differentiate between formal and informal meditation practice. Participants might not have accurately remembered this retrospective time period, and also the term ‘home practice’ might have been somewhat ambiguous. Some participants might have interpreted this as formal meditations only, whereas others might interpret this as covering both formal and informal meditations or not being aware of a difference between the two. In line, it is unclear whether participants distinguished between mindful physical exercise (like in the Mindful2Work training) and general sports. And last, it might be somewhat limited to only look at the practice quantity, whereas brief practices of very high quality (which is difficult to define objectively) might be just as effective, or this might differ per person. Taking all this into account, we feel caution applies when interpreting the lack of correlations between home practice, attended sessions, and changes in outcome measures. A disadvantage of this type of correlational research is that even when amount of practice is related to outcome, due to the inherent bidirectionality of correlational research, it is unclear whether practice leads to good outcome or whether good outcome motivates practice.
Although long-lasting and transformational effects of mindfulness training (Kabat-Zinn;
2003; Singh et al.
2008), yoga (Smith et al.
2007; Vera et al.
2009) and physical exercises (Pohjonen and Ranta
2001) have been shown before, we cannot attribute the long lasting effects solely to the Mindful2work training since around one third of the participants took part in other forms of training after the M2W training. For future studies, these additional treatments should be monitored in greater detail. Also part of the training took place outside; contact with nature and the direct physical sensations of warm and cold, wet and dry, etc. could have perhaps enhanced present moment awareness in itself, and in turn, relieved stress and improved well-being (Annerstedt and Währborg
2011). We also need to be cautious since no control group or wait-list measurement was included, mainly self-reports were used, and the sample size was only small. Although no control group was included, 92 % of the participants reported on the evaluation questionnaire that they attributed the positive effects to the Mindful2Work training, of which 32 % attributed the positive effects to the Mindful2Work training plus another element (i.e., working less, another complementary training). Naturally, some social desirability in participants’ answers should be taken into consideration. From attribution theory, it is known that the locus of causality (whether you attribute success to yourself or to an external agent) significantly influences the outcome (Harvey et al.
2014). Perhaps the low dropout and large effects of the Mindful2Work training can be explained by elements of the attribution theory. Although participants stated that they attributed the success to the training, perhaps this indirectly means they attributed the success to themselves. After all, they were the ones who adhered to all the training sessions and home practices and therefore had legitimate reasons to attribute the success to themselves. This is for instance where mindfulness-based interventions differ from medication treatment. Also important to realize is the severity of symptoms of participants of the current sample. At the start of the Mindful2Work training, 92 % met the criteria for risk for dropout from work, and although this risk was highly reduced 6 months after the training, still around one third of the participants was at risk for dropout. This severity of suffering was further illustrated by the fact that although effects were overall very large, after training, still nearly 40 % scored above the clinical cutoff point for anxiety disorder. These still relatively high rates are also likely to be related to the additional therapies some participants sought after training. For future (more preventative) studies, it would be interesting to see what the effects on stress-related symptoms are in a less severe group, employees that are still fully at work but suffer from stress nevertheless.
For future studies, the inclusion of a (wait-list) control group, a randomized design, and more objective assessments would be of interest. Also, a higher focus on measures of positive aspects would be recommended, such as work satisfaction and work performance. In addition, focus on effects of participants’ own goals is also recommended (i.e., the goal attainment scale) to shed more light on the particular goals the Mindful2Work training is effective for. Lastly, since this proof of concept study was merely a first step, a logical next step besides including a control group could be to examine the mechanisms of change (mediators) of the Mindful2Work training. What are the mechanisms that contributed or mediated these very large effects? A recent systematic review for instance showed that treatment outcome effects of mindfulness training (in that case MBCT) were associated with, predicted by, or mediated by constructs such as mindful awareness, rumination, worry, self-compassion, and affect (Van der Velden et al.
2015).