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Psychology, Health & Medicine


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Enhancing relaxation states and


positive emotions in physicians through
a mindfulness training program: A one-
year study
a a a
Alberto Amutio , Cristina Martínez-Taboada , Daniel Hermosilla &
b
Luis Carlos Delgado
a
Faculty of Psychology, Department of Social Psychology and
Methodology of the Behavioral Sciences, University of the Basque
Country (UPV/EHU), Donostia-San Sebastian, Spain
b
Department of Psychology and Sociology, University of Zaragoza-
Click for updates Unizar, Zaragoza, Spain
Published online: 08 Dec 2014.

To cite this article: Alberto Amutio, Cristina Martínez-Taboada, Daniel Hermosilla & Luis
Carlos Delgado (2014): Enhancing relaxation states and positive emotions in physicians through
a mindfulness training program: A one-year study, Psychology, Health & Medicine, DOI:
10.1080/13548506.2014.986143

To link to this article: http://dx.doi.org/10.1080/13548506.2014.986143

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Psychology, Health & Medicine, 2014
http://dx.doi.org/10.1080/13548506.2014.986143

Enhancing relaxation states and positive emotions in physicians


through a mindfulness training program: A one-year study
Alberto Amutioa*, Cristina Martínez-Taboadaa, Daniel Hermosillaa and
Luis Carlos Delgadob
a
Faculty of Psychology, Department of Social Psychology and Methodology of the Behavioral
Sciences, University of the Basque Country (UPV/EHU), Donostia-San Sebastian, Spain;
b
Department of Psychology and Sociology, University of Zaragoza-Unizar, Zaragoza, Spain
Downloaded by [University of Bristol] at 03:04 27 March 2015

(Received 24 June 2014; accepted 4 November 2014)

Previous research on mindfulness has focused mainly on stress-related negative


symptoms and short-term effects. In contrast, the present article focuses on the
impact of a mindfulness-based stress reduction (MBSR) program on improving well-
being (i.e. relaxation states and related positive emotions) in a longitudinal study for
a period of one year. A randomized controlled trial in a sample of 42 physicians was
used. The intervention group participated in an 8-week MBSR program, with an
additional 10-month maintenance period and completed measures of mindfulness and
relaxation at pre-intervention, post-intervention and after 10 months. Heart rate mea-
sures were also obtained. Significant improvements in favor of the experimental
group compared with the control group on the levels of mindfulness and relaxation
(including positive emotional states, such as at ease/peace, renewal, energy, opti-
mism, happiness, acceptance, and even transcendence) were obtained after eight -
weeks. Remarkably, change magnitudes (effect size) significantly increased at the
end of the maintenance period after a year, especially for mindfulness and positive
energy. Additionally, heart rate significantly decreased for the intervention group and
maintained a year after the beginning of the treatment. Results are relevant in terms
of practical consequences for improving health and well-being in this population and
also in terms of cost-efficiency.
Keywords: physicians; mindfulness; relaxation states; positive emotions; heart rate

Introduction
Chronic stress arousal can contribute to a wide range of physical disorders as well as
psychological distress (Smith, 2007a; Vrijkotte, van Doormen, & De Geus, 2000). Phy-
sicians are at high risk of developing stress-related symptoms and burnout. In line with
this fact, in a study conducted by Amutio, Ayestaran, and Smith (2009) in a sample of
1275 medical professionals, only 6.8% of this sample reported high levels of positive
emotions and well-being at work. However, the prevalence of emotional exhaustion, a
key component of the burnout syndrome, was 32.8% among physicians. Additionally,
the sample presented a series of negative consequences at several levels, including pro-
fessional, physical, and psychological.
A substantial amount of literature has reported the negative consequences of distress
and burnout on physician′s health and productivity levels, including an increased risk

*Corresponding author. Email: alberto.amutio@ehu.es

© 2014 Taylor & Francis


2 A. Amutio et al.

for errors and impoverished patient care (Moreno, Gálvez, Rodríguez, & Sanz, 2012;
Wallace, Lemaire, & Ghali, 2009). Similarly, behavioral medicine has provided evidence
for the negative contribution of work stress in the development of coronary heart dis-
ease (Davidson, Mostofsky, & Whang, 2010; Devi, 2011).
Positive emotions and health have been the focus of many studies, most of them
within the field of “positive psychology” (Fredrickson, 2000, 2003; Gander, Proyer,
Ruch, & Wyss, 2013). One of the mind-body interventions with proven efficacy for
increasing positive emotions and improving health is mindfulness meditation (Brown &
Ryan, 2003; Choi, Karremans, & Barendregt, 2012; Prazak et al., 2012). Mindfulness is
described as calm awareness of the present moment with acceptance (Bishop et al.,
2004). In this sense, the goal of mindfulness is the cultivation of calm and focus aware-
ness and action in the world as it is, undistracted by personal concerns and biases.
A new approach to mindfulness is based on relaxation and psychological states of
mind. Psychological relaxation theory (Smith, 2007a, 2007b, 2012), emphasizes the sub-
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jective experience of a wide range of relaxation states. According to this view, during
or after the practice of relaxation, different psychological states are reported by thou-
sands of practitioners around the world (Gillani & Smith, 2001; Smith, 2007a; Smith,
Amutio, Anderson, & Aria, 1996). Briefly, these relaxation states (R-States) seem to fall
into four categories: basic relaxation (sleepy, physically relaxed, disengaged, mentally
relaxed, rested/refreshed), positive energy (energized, happy, thankful/loving, optimistic),
core mindfulness (quiet mind, aware, acceptance, flow), and transcendence (awe and
wonder, prayerful, reverent, mystery, timeless …). These positive states are associated
with one’s perception of well-being at work and increased job performance
(Fredrickson, 2003). Unfortunately, the narrow focus on arousal reduction, and lately, in
neurophysiology, has limited the investigation of important positive psychological medi-
ating variables involved in relaxation (Smith, 2007b, 2012).
Traditionally, relaxation techniques, such as progressive muscle relaxation, breathing,
or yoga stretching, have been used in stress management and healing (Kaspereen, 2012;
Manzoni, Pagnini, Castelnuovo, & Molinari, 2008). Both are negative goals, in that they
involve reducing or getting rid of something one does not want (e.g. stress, anxiety,
depressed mood). However, the positive effects of relaxation involve getting what one
wants as, for example, enhancing health and well-being, or even transcendent goals,
involving going beyond ones desires, (de Bloom, Geurts, & Kompier, 2013; Smith,
2012).
Lately, a program known as mindfulness-based stress reduction (MBSR) has been
successfully applied to health care professionals (Davies, 2008; Ludwig & Kabat-Zinn,
2008; Martín & García-Banda, 2010), professors, students, and even to the general pop-
ulation (Chiesa & Serreti, 2009; Franco, Mañas, Gangas, Moreno, & Gallego, 2010) for
treating a wide array of psychological and psychosomatic disorders. Likewise, various
types of psychosocial interventions in occupational stress have been developed (Ewers,
Bradshaw, McGovern, & Ewers, 2002; Krasner et al., 2009). Despite all this, official
programs providing ongoing professional training in health do not explicitly include
stress reduction techniques, such as relaxation or mindfulness (Smith, 2007a; Wallace
et al., 2009) and few workplaces include programs that foster psychological well-being
(Page & Vella-Brodrick, 2013). Self-care is typically presented as an individual respon-
sibility (Irwing, Dobkin, & Park, 2009).
Given the scarcity of longitudinal studies on mindfulness in relation to well-being
and health in physicians, the low prevalence of positive emotions at work in this popu-
lation, and the negative consequences for patients care (Brown & Gunderman, 2006;
Psychology, Health & Medicine 3

Smith, 2001; Wallace et al., 2009), we designed a study with the main goal of verifying
the effectiveness of a mindfulness-based program (MBSR) on physicians’ positive emo-
tions (i.e. relaxation states) and to explore whether the results were sustained over time.
We hypothesized that the MBSR program would be effective for enhancing a wide
range of positive emotional states associated to relaxation.

Methods
Participants
The total sample was comprised of 42 physicians with an average age of 47.31
(SD = 9.42), of which 57.1% were women and 42.9% men. All participants were
actively employed in public (42.9%) or private (52.4%) practice. As for number of years
worked, 66.7% of the sample had a work experience of at least 10 years. The inclusion
criteria were willing to complete the questionnaires and commitment to adhering to the
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program’s attendance and homework requirements. The exclusion criterion included


being in psychiatric or psychological treatment, or not being actively employed at the
time of the study.

Instruments
Five Facets of Mindfulness Questionnaire (FFMQ – Spanish version of Cebolla et al.,
2012). It measures a trait-like general tendency to be mindful in daily life. Each item of
the questionnaire was evaluated on a five-point Likert-type scale ranging from 1 (never
or very rarely) to 5 (very frequently or always). The five scales of this 39-item question-
naire are: non-reactivity, observing, acting with awareness, describing, and non-judging
(Cronbach’s α from .75 to .91). The current study demonstrated satisfying internal con-
sistencies ranging from .73 to .90.
Smith Relaxation States Inventory (SRSI-3 – Smith, 2007c). It consists of a 38-item
inventory designed to measure 19 relaxation-related states using a six-point Likert scale
ranging from 1 (not at all) to 6 (maximum). It evaluates immediate relaxation states “at
the present moment” and it is appropriate for use after relaxation training to measure
session effects. The inventory measures the four categories or dimensions: basic relaxa-
tion, positive energy, mindfulness, and transcendence (Cronbach’s α, .65–.90). These
factors explain around 72.8% of the total variance. Cronbach’s alpha values for each of
the relaxation states in the current sample ranged from .63 to .89.
Heart rate – HR– (in beats per minute – bpm) measures were taken and recorded
before and after each of the sessions by means of a digital monitor (Model M3, Omron).

Procedure
Participants were recruited among health care professionals through the Official Medical
College of Biscay, in the Basque Country (Spain) by means of a training course directed
to improve the relationships with their patients and reduce their own stress. Those inter-
ested were invited to an introductory meeting, where the general contents of the course
were presented. Individuals who met the inclusion requirements were accepted. Two
subjects were excluded for not meeting the criteria. At this time, all participants read
and signed the official statement of informed consent by the University of the Basque
Country and were given the pre-test questionnaires.
4 A. Amutio et al.

Participants in the experimental group (n = 21) were randomly selected by the statis-
tical program SPSS 20.0. The remaining subjects were included in the control group
(n = 21). Each participant in the experimental group committed to attending the ses-
sions, doing the exercises assigned as homework, and answering the evaluation ques-
tions at the end of each of the phases of the study. No economical or professional
compensation was given for participating in the course. The waitlist control group was
told that a similar course would be offered again.
The intervention followed the MBSR program (Kabat-Zinn, 2003) and was based on
the psycho-educational model of Krasner et al. (2009). The format was of an intensive
group training course divided into two phases: the first one was 28 h long (eight weekly
sessions of 2.5 h each during two months plus one additional eight-hour retreat session).
The second phase (maintenance) developed along the next 10 months following the end
of the first phase, with one session of 2.5 h per month (25 h).
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First phase (8 weeks)


The first phase of the program was taught by an MBSR instructor who was trained by
Kabat-Zinn at the Stress Reduction Clinic in the University of Massachusetts, following
the standardized protocol (Kabat-Zinn, 2003).
Participants were asked to practice mindfulness exercises every day for a period of
45 min by means of a set of CDs distributed to them and containing the same exercises
as the ones practiced in the class sessions (i.e. body-scan, yoga postures, and mindful-
ness exercises). Each of the participants had to register the number of days practiced
per week and the length of each of the sessions by means of a record sheet specially
designed for that purpose.
Once the first phase of the intervention was completed, a post-test was given for
both of the groups in order to verify the effect of the program over the studied psycho-
logical variables.

Second phase (maintenance – 10 months)


Four weeks after the end of the first phase of the intervention, a second phase started
for the experimental group (n = 21), in order to verify if the results obtained in the pre-
vious phase improved or were, at least, maintained over time. A different instructor
taught this maintenance phase. The structure of the intervention program sessions was
the same as in the previous phase. Again, heart rate measures were taken and recorded
for the experimental group at the beginning and end of each of the sessions. Also, par-
ticipants had to register the number of days and time practiced each month at home. At
the end of this second phase, a second post-test was given to the experimental group
pertaining to the psychological measures. A quasi-experimental design was used.
Control measures were not taken at this phase due to logistical reasons.

Statistical analyses
ANOVAs conducted to check for initial differences between the experimental and con-
trol groups revealed no significant differences between them for any of the studied vari-
ables (p > .05). Chi square (χ²) values for sociodemographic and professional
characteristics between both groups were also non-significant (p > .05).
Next, a series of between-group ANOVAs were performed in order to test whether
there were statistically significant differences between the average scores of the
Psychology, Health & Medicine 5

experimental and control groups after the first eight-week phase of our training program.
Additionally, and in order to evaluate the magnitude of change (effect size) exhibited by
the experimental group through the entire MBSR intervention program, a series of
Cohen’s d (Cohen, 1988) were calculated.

Results
After eight weeks of MBSR training, significant positive changes were found in the
experimental group in mindfulness and all the relaxation dimensions, as compared to
the control group, where no significant changes were obtained (Table 1, Figures 1a
and 1b).
Additionally, as shown in Table 2, significant decreases of heart rate (p < .01) were
also obtained. No significant variations in average change from pre-test to post-test were
found in the control group, except for the relaxation dimension of transcendence, which
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was significantly lower after the eight weeks of treatment (F = 2.39, p < .05).
Correlation analyses of average change scores from pre-test to post-test in the exper-
imental group after the first eight-week treatment phase showed an important number of
significant correlations:

 Increments in mindfulness, as measured with the FFMQ, were strongly correlated


with improvements in SRSI-3 measures (p < .05): basic relaxation (r = .59), posi-
tive energy (r = .59), core mindfulness (r = .70), and transcendence (r = .67).
 Heart rate changes were significantly associated to the mean change in most of
our relaxation dimensions, as measured by the SRSI-3 (p ≤ .02): basic relaxation
(r = .62), positive energy (r = .60), and core mindfulness (r = .57). All these cor-
relations were even stronger at the end of the maintenance phase at 12 months.

Within-group ANOVAs were also used to test for significant differences in the
experimental group between average change scores during the study’s two different

Table 1. Mean values and ANOVAs for repeated measures between the experimental and control
groups.
Control Experimental
Pre-test Post-test Pre-test Post-test var var*group
M SD M SD M SD M SD F sig F sig
FFMQ 3.51 .25 3.34 .33 3.34 .44 3.71 .51 7.06 .01 13.14 .00
Observing 3.02 .88 2.83 .98 3.33 .60 3.98 .64 5.00 .03 18.53 .00
Describing 3.88 .53 3.82 .58 3.58 .72 3.83 .62 2.39 .13 4.97 .03
Acting aware 3.93 .70 3.91 .61 3.16 .87 3.48 .65 1.25 .27 2.05 .16
Non-judging 4.19 .52 4.16 .52 3.42 .64 3.78 .66 4.98 .03 6.41 .01
Non-reacting 3.23 .57 3.26 .67 3.17 .51 3.46 .63 3.79 .05 2.75 .05
SRSI-3
Basic relaxation 2.52 .50 2.60 .51 2.54 .53 3.08 .61 17.34 .00 9.41 .00
Positive energy 3.01 .62 3.01 .60 3.09 .64 3.80 .82 16.17 .00 17.02 .00
Core-mindfulness 4.29 .92 4.24 .95 3.74 .89 4.45 .71 9.21 .00 11.82 .00
Transcendence 2.64 .93 2.40 .92 2.67 .82 3.27 1.02 2.55 .12 13.22 .00
6 A. Amutio et al.

Figure 1a. Between-group mean values for mindfulness (FFMQ) at pre-test and post-test (end of
the first 8-week treatment phase).
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Figure 1b. Between-group mean values for relaxation dimensions at pre-test and post-test (end
of the first eight-week treatment phase).

phases. At the end of the maintenance phase, even bigger significant differences in all
the studied variables are obtained. As we can see in Table 2, main effects (Cohen’s d)
are very important and bigger than in the first phase of treatment for mindfulness and
relaxation (specially the dimensions of positive energy and transcendence).
To summarize, we were able to confirm that mindfulness and relaxation levels
increased significantly for the experimental group after eight weeks of MBSR training,
as compared to the control group. As for the experimental group, these results signifi-
cantly improved over the 10-month maintenance phase. Relaxation levels increased
around 30% from the beginning of the treatment. At the same time, heart rate levels
diminished significantly within this group (Figures 2a and 2b).
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Table 2. Mean values for the experimental group and within-group ANOVAs at pre-test, 8 weeks and 12 months of treatment.
Pre-test Post-test Follow-up
M SD M SD F Sig. d. M SD F Sig. d.

FFMQ 3.34 .44 3.71 .51 9.95 .01 .78 3.85 .49 14.38 .00 1.10
Observing 3.33 .60 3.98 .64 13.07 .00 1.05 4.09 .62 14.58 .00 1.25
Describing 3.58 .72 3.83 .62 6.12 .02 .37 4.01 .58 5.62 .03 .66
Acting aware 3.16 .87 3.48 .65 1.87 .19 .42 3.55 .69 7.67 .01 .50
Non-judging 3.42 .64 3.78 .66 6.35 .02 .55 3.96 .66 8.45 .01 .83
Non-reacting 3.17 .51 3.46 .63 4.68 .04 .51 3.58 .55 17.05 .00 .77
SRSI-3
Basic relaxation 2.54 .53 3.08 .61 17.08 .00 .94 3.16 .78 21.29 .00 .95
Positive energy 3.09 .64 3.80 .82 16.82 .00 .98 3.99 .81 20.09 .00 1.24
Core-mindfulness 3.74 .89 4.45 .71 17.74 .00 .89 4.60 1.01 18.84 .00 .92
Transcendence 2.67 .82 3.27 1.02 7.42 .01 .65 3.65 1.36 8.49 .01 .90
Heart rate 75.40 11.94 69.00 9.01 10.45 .00 −.60 69.57 7.25 11.86 .00 −.59
Note: d = Cohen’s d (magnitude of change or effect size).
Psychology, Health & Medicine
7
8 A. Amutio et al.
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Figure 2a. Mean values for the relaxation dimensions (SRSI-3) from pre-treatment to 12 months
in the experimental group.

Figure 2b. Mean values for heart-rate from pre-treatment to 12 months in the experimental
group.

Discussion
Our primary goal of confirming the effectiveness of the mindfulness-based program at
enhancing physicians’ emotional states was met. More specifically, after completing the
intervention and having analyzed all the obtained data, we verify that the MBSR pro-
gram was a useful tool to enhance physicians’ levels of relaxation (including reduced
heart rate) and associated positive emotions. The results support our initial hypothesis.
Some additional results concerning the effectiveness of the program merit explicit
discussion. First, our results maintain and even improve 10 months after the end of the
intensive treatment phase, especially for mindfulness, and relaxation states of positive
energy and transcendence. Continued practice is a critical key for the effectiveness of
this kind of program if we take into account some studies indicating the strong relation-
ship between practiced time and well-being levels (Carmody & Baer, 2008; Semple,
Psychology, Health & Medicine 9

2010). This finding supports the definition of mindfulness as a skill that can be devel-
oped over time (Bishop et al., 2004; Shapiro et al., 2008).
Second, significant reductions in heart rate were found only after eight weeks of
treatment and maintained until the end of the treatment ten months later. This is an
important finding, since, normally, decreases in heart rate are found among long-term
practitioners only (Ditto, Eclache, & Goldman, 2006; Hussain & Bhushan, 2010).
Third, we found a significant direct relationship between improvements in relaxation
states and heart rate reductions after eight weeks of treatment. This is in line with
Fredrickson (2003) notion that positive emotions have a clear and consistent effect of
undoing the cardiovascular repercussions of negative emotions and also with Davidson,
Mostofsky, and Whang (2010), who found a clinically relevant relationship between cor-
onary heart disease and positive affect (22% relative risk reduction for each one-point
increment in positive affect on a five-point scale), concluding that positive emotions are
protective factors for cardiovascular disease and a key element of preventive treatments.
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With respect to the clinical significance of our findings, we would like to emphasize
that the obtained changes in heart rate and relaxation levels provide support for the
usefulness of mindfulness as an efficient tool for emotion regulation and have potential
implications for the treatment of some distress-related disorders, such as depressed
mood or cardiovascular disease. In addition to increasing basic relaxation levels, our
sample of physicians obtained significant increases in positive energy (e.g. “strength-
ened” “confident,” “optimism”), a dimension of perceived personal competence and
well-being at work (Brown & Gunderman, 2006; Wallace et al., 2009). Finally, the fact
that they reported significant improvements of their understanding and communication
with patients adds to the external validity of this study.
The obtained outcomes are relevant in terms of its positive impact on physician’s
well-being and health, and the important benefits for the relationship between medical
doctors and their patients. There is a substantial amount of literature establishing posi-
tive and significant links among physicians’ well-being and good communication skills
with patient satisfaction, better clinical outcomes, and improved quality of life
(Anagnostopoulos et al., 2012; Del Canale et al., 2012). These results are confirmatory
of previous studies carried out with health professionals in different countries (Krasner
et al., 2009; Martín & García-Banda, 2010; Prazak et al., 2012; Shapiro, Oman,
Thoresen, Plante, & Flinders, 2008), and suggest that mindfulness training can serve as
a viable tool for the promotion of self-care and well-being.
Regarding the merits of this investigation, we want to emphasize the fact that it is a
controlled study extended over a period of a year. There are few lengthwise studies in
the mindfulness area. In this sense, there is little evidence to suggest that significant
improvements after the eight-week program could be maintained in the long term
(Chiesa & Serreti, 2009; Geary & Rosenthal, 2011). Likewise, this study has the addi-
tional merit of obtaining significant differences between groups and important size
effects with a small non-clinical sample. Finally, this investigation includes a broader
catalog of positive emotions than any other in the field of positive psychology and
mindfulness.
As for the limitations, sample size did not allow for more robust statistics. Also,
heart rate measures were not registered in the control group due to logistical reasons
and practical constraints. Nonetheless, it seems reasonable to conclude that the changes
found in HR were due to treatment effects, given the significant correlations found
among the obtained declines in this variable and relaxation states. Future research would
10 A. Amutio et al.

benefit from more sophisticated measures, such as heart rate variability. A final limita-
tion is the lack of control group during the second phase of our study.

Conclusion
Bearing in mind these limitations, we conclude that this study shows sufficient evidence
to suggest that the mindfulness-based training program was an efficient intervention to
enhance relaxation states. These R-States are profoundly adaptive and contribute to
improve one’s perception of well-being and health. Training programs should be aimed
at experiencing these positive psychological states as an important goal for achieving
deeper effects.
One of the main advantages of this program is that it can be taught in a group for-
mat. It also implies the optimization of the economic and social resources invested in
health and the quality of patient care. Future studies will be able to replicate these find-
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ings with clinical samples and active control groups.

Funding
Research granted by the University of the Basque Country (UPV/EHU-10/23) in cooperation with
the Official Medical College of Biscay in Spain. ].

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