CLINICAL TRIAL

published: 26 February 2021

doi: 10.3389/fpsyt.2021.624876

Mindfulness Training Improves

Quality of Life and Reduces
Depression and Anxiety Symptoms
Among Police Officers: Results From
the POLICE Study—A Multicenter
Randomized Controlled Trial
Marcelo Trombka 1,2,3,4,5,6*, Marcelo Demarzo 7 , Daniel Campos 8,9 , Sonia B. Antonio 7 ,
Karen Cicuto 7 , Ana L. Walcher 1,2,3,4 , Javier García-Campayo 9 , Zev Schuman-Olivier 5,6 and
Neusa S. Rocha 1,2,3,4
1
Postgraduate Program in Psychiatry and Behavioral Sciences, Federal University of Rio Grande do Sul (UFRGS),
Porto Alegre, Brazil, 2 Department of Psychiatry, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil, 3 Innovations and
Interventions for Quality of Life Research Group, Porto Alegre, Brazil, 4 Clinical Research Center, Hospital de Clínicas de Porto
Alegre, Porto Alegre, Brazil, 5 Department of Psychiatry, Harvard Medical School, Boston, MA, United States, 6 Cambridge
Edited by:
Health Alliance, Center for Mindfulness and Compassion, Cambridge, MA, United States, 7 Mente Aberta, Brazilian Center for
Angela Fang,
Mindfulness and Health Promotion, Department of Preventive Medicine, Federal University of São Paulo (UNIFESP),
University of Washington,
São Paulo, Brazil, 8 Department of Psychology and Sociology, University of Zaragoza, Huesca, Spain, 9 Grupo de
United States
Investigación en Salud Mental en Atención Primaria, Miguel Servet University Hospital, Zaragoza, Spain
Reviewed by:
Sverre Urnes Johnson,
University of Oslo, Norway Background: Police officers’ high-stress levels and its deleterious consequences are
Bassam Khoury,
raising awareness to an epidemic of mental health problems and quality of life (QoL)
Harvard University, United States
impairment. There is a growing evidence that mindfulness-based interventions are
*Correspondence:
Marcelo Trombka efficacious to promote mental health and well-being among high-stress occupations.
[email protected]
Methods: The POLICE study is a multicenter randomized controlled trial (RCT) with three
Specialty section: assessment points (baseline, post-intervention, and 6-month follow-up) where police
This article was submitted to officers were randomized to mindfulness-based health promotion (MBHP) (n = 88) or
Psychological Therapies,
a waiting list (n = 82). This article focuses on QoL, depression and anxiety symptoms,
a section of the journal
Frontiers in Psychiatry and religiosity outcomes. Mechanisms of change and MBHP feasibility were evaluated.
Received: 01 November 2020 Results: Significant group × time interaction was found for QoL, depression and
Accepted: 21 January 2021
Published: 26 February 2021
anxiety symptoms, and non-organizational religiosity. Between-group analysis showed
Citation:
that MBHP group exhibited greater improvements in QoL, and depression and anxiety
Trombka M, Demarzo M, Campos D, symptoms at both post-intervention (QoL d = 0.69 to 1.01; depression d = 0.97; anxiety
Antonio SB, Cicuto K, Walcher AL,
d = 0.73) and 6-month follow-up (QoL d = 0.41 to 0.74; depression d = 0.60; anxiety
García-Campayo J, Schuman-Olivier Z
and Rocha NS (2021) Mindfulness d = 0.51), in addition to increasing non-organizational religiosity at post-intervention
Training Improves Quality of Life and (d = 0.31). Changes on self-compassion mediated the relationship between group and
Reduces Depression and Anxiety
Symptoms Among Police Officers:
pre-to-post changes for all QoL domains and facets. Group effect on QoL overall health
Results From the POLICE Study—A facet at post-intervention was moderated by mindfulness trait and spirituality changes.
Multicenter Randomized Controlled
Trial. Front. Psychiatry 12:624876. Conclusion: MBHP is feasible and efficacious to improve QoL, and depression and
doi: 10.3389/fpsyt.2021.624876 anxiety symptoms among Brazilian officers. Results were maintained after 6 months.

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Trombka et al. Mindful Policing: Mental Health/Well-Being

MBHP increased non-organizational religiosity, although the effect was not sustained
6 months later. To our knowledge, this is the first mindfulness-based intervention
RCT to empirically demonstrate these effects among police officers. Self-compassion,
mindfulness trait, and spirituality mechanisms of change are examined.
Clinical Trial Registration: www.ClinicalTrials.gov. identifier: NCT03114605.

Keywords: mindfulness, police officer, quality of life, depression, anxiety, religiosity, well-being, self-compassion

INTRODUCTION marital troubles are another facet of the pernicious consequences

of stress (37, 38). QoL is a broad-ranging concept, affected in
Policing is a high-stress occupation (1, 2), ranking as one of the a complex way by the person’s physical health, psychological
most psychologically dangerous professions worldwide (3, 4). state, level of independence, social relationships, and their
Different from other vulnerable occupations, officers repeatedly relationships to salient features of their environment (39).
face dangerous, unpredictable, and potentially traumatic Perceived stress levels are negatively associated with QoL and
situations (e.g., exposure to human misery and death, shooting, explain up to 34% of its variability (40). Two studies evidenced
critical incidents, and life-changing errors with emotional significant associations between Brazilian police stress and
cost). Dealing with verbal and physical aggression, having to QoL deficits in the social, affective, professional, and health
use force to restrain, giving evidence in court, and high-speed areas (6, 23). Extensive literature associate religiosity and its
driving are examples of operational stressors (4). Organizational dimensions (i.e., organizational, non-organizational, intrinsic)
stressors often include hierarchical and bureaucratic structures with psychological health and QoL (41–43). It is negatively
which can perpetuate discrimination, sexism, and racism; poor related to stress among officers and can be an effective coping
communication; long and irregular shifts; new recruit hazing tool for occupational stress (44, 45).
and cultural assimilation; hostile public image; and inadequate The last two decades have seen a dramatic increase in
resources (4–6). Exposure to acute and chronic stressors are the scientific research and popular interest about mindfulness.
associated with a myriad of negative consequence for officers’ Mindfulness can be defined as an innate meta-awareness
mental health, physical health, and quality of life (QoL). capacity to attend to present-moment experience while avoiding
When compared to the general population, officers exhibit entanglement in cognitive biases with an orientation of curiosity,
higher rates of depression (7), anxiety (8), burnout (9), alcohol openness, and acceptance (46). It can be enhanced by simple
abuse (10), post-traumatic stress disorder (PTSD) (11), and meditative attentional practices, as well as through structured
suicide (12). Police perceived work stress predicts depression training programs such as mindfulness-based interventions
and anxiety symptoms (7, 13). For instance, the prevalence of (MBIs). MBIs are group-based weekly classes composed of
depression among officers is nearly twice as high as the general meditation practices, such as the body scan, mindful movement,
population (14). Half of all completed suicides are related to and sitting and walking meditation; experiential inquiry-
depressive and other mood disorders (15). Anxiety disorders based learning process; and exercises to develop insight (47).
more than double the risk of suicide attempts, and a combination MBIs implicitly teach self-compassion, which is composed of
of depression and anxiety greatly increases the risk by 17 (16, three interacting components: self-kindness (i.e., being kind
17). Recent data show that in the USA, more officers die from and understanding toward oneself in instances of perceived
suicide than in the line of duty (18). Poor mental health can be inadequacy or suffering vs. self-judgment), a sense of common
deleterious to physical health. Indeed, officers have elevated risks humanity (i.e., perceiving one’s experiences as part of the larger
for diabetes, obesity, cardiovascular disease, and sudden cardiac human experience vs. isolation), and mindfulness itself (i.e.,
death (19–21). Brazilian Police mental health scenario is also holding one’s painful thoughts and feelings in balanced awareness
alarming, with a high prevalence of stress, depression, anxiety, vs. over identification with suffering or avoidance/disconnection)
and PTSD (6, 22–24). Crime rate in Brazil is high and exposure (48). Mindfulness training (MT) may regulate how the individual
to violence is associated with occupational stress, burnout, and appraises stress and increase secondary appraisals of approach-
suicide (23, 25–28). The 2019 Brazilian Public Annual Report oriented coping resources, thus reducing stress reactivity. A
evidenced the same pattern as the USA: more officers died from process of enhanced self-regulation is established by synergistic
suicide than at work (29). systems of attention/cognitive control, emotional regulation, and
Work-related stress, accompanied by a culture where display self-related processes (49, 50).
of emotion is often viewed as a sign of weakness (30), pays a Meta-analyses indicate that MBIs decrease stress (51),
toll on multiple work and life dimensions. Officers experiencing depression and suicidal ideation (52, 53), anxiety and burnout
high levels of stress and fatigue are less efficient and prone (53, 54), and increases QoL (55) and spirituality (56). MBIs
to absenteeism, uncontrolled anger toward suspects, impaired have been shown to be feasible and to lead to improved
judgment and decision-making (31, 32); increased implicit racial health outcomes in non-clinical populations at the workplace
bias (33), including the decision to shoot (34); and to use (57), including several high-stress occupations, such as the
excessive force (35, 36). Disruptive family relationships and military (58–62), healthcare providers (63), firefighters (64), and

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Trombka et al. Mindful Policing: Mental Health/Well-Being

inner-city teachers (65). Published in 2016, a single-arm pilot Participants and Settings
study pioneered the field of MT within law enforcement officers Police officers working at two major Brazilian cities were
(LEOs), suggesting positive effects following mindfulness-based recruited from 2016 to 2018.
resilience training (MBRT)—an 8-week mindfulness-based stress (1) Civil Police. The study center in Porto Alegre was located
reduction (MBSR) adaptation designed to enhance resilience at the Police Hall of the State of Rio Grande do Sul. Civil
for LEOs in the context of stressors inherent to policing— Police main duties are to oversee public order and security,
on outcomes such as perceived stress, burnout, emotional adopt measures necessary to avoid danger or injury to persons
intelligence, and mental and physical health (66). Since and public or private property, and ensure the administration
then, three other trials have replicated and extended those of criminal offenses, including execution of arrest warrants and
benefits (67–69). requisitions requested by the judicial branch.
With the development of positive psychiatry, specialty scope (2) Civil Guard. The study center in São Paulo was
incorporates—along with the treatment of mental illness— located at the headquarters of Unifesp Santo Amaro. Civil
psychosocial interventions targeting those at high risk of Guard fundamental duties include the protection of goods,
developing mental or physical illness, and goals encompass services, and municipal facilities, as well as patrolling areas and
increased well-being and positive psychosocial characteristics preventive policing.
(e.g., resilience, spirituality, religiosity) (70). Two reviews Participants meeting the following inclusion criteria were
concluded that randomized controlled trials (RCTs) are needed enrolled: (1) active police officers; (2) 21–65 years old; (3)
to clarify the role of psychosocial interventions for stress availability to attend eight sessions; (4) willingness to participate
management and mental health/well-being promotion among voluntarily. Exclusion criteria included (1) previous involvement
police officers (71, 72). In light of these findings, the in any MBI or regular mindfulness practice over the last 3
burden of high-stress levels and mental health problems months, or one of the following diagnosis, assessed by the
epidemic in the police, plus aforementioned MBIs’ salutary Mini International Neuropsychiatric Interview (MINI): (2) major
effects, further empirical evaluation of MBIs’ impact on that depressive episode (current); (3) manic or hypomanic episode
vulnerable population is needed. The POLICE (imPact Of a (current); (4) psychotic syndrome (current or past); (5) substance
mindfuLness-based Intervention on burnout and quality of use disorder (past 12 months, except tobacco); (6) risk of suicide.
life in poliCE officers) study is a multicenter RCT evaluating
the efficacy of mindfulness-based health promotion (MBHP)
to promote police officers’ QoL and mental health at post- Procedures
intervention and after 6 months. As designated at the The POLICE study was advertised within the two Police
research protocol manuscript (73), our hypothesis is that Institutions using the internet, social media, and posters. Officers
officers allocated to MBHP, compared with a waiting list who showed interest contacted the research team by phone or
(WL), will show enhancement on QoL and reduction on email and were initially screened. Potential participants had
burnout symptoms (primary outcomes), besides improvement a face-to-face interview scheduled where they were provided
on several mental health measures (secondary outcomes). We detailed information about the study and inclusion/exclusion
also investigated primary outcomes of potential mechanisms of criteria were assessed. Eligible volunteers filled the informed
change through mediation and moderation analysis. Mediators consent form and were randomly assigned to MBHP or
clarify how/why intervention works, while moderators identify WL by an independent researcher who were unaware of the
whom or under what conditions interventions have effects characteristics of the study and was not involved in the trial
(74). The POLICE study design overcomes previous studies’ or had access to study data. Randomization was implemented
limitations such as absence of control group/follow-up or small using sealed envelopes. Officers allocated to the WL group
sample sizes. did not receive any intervention for 6 months. After the
6-month assessment, MBHP was offered for all participants
randomized to the WL group. Officers received authorization
MATERIALS AND METHODS from the Police Institutions to attend the program which
happened during working hours. Due to the nature of the
A detailed description of POLICE study Materials and Methods intervention, the POLICE study was single-blind—the outcomes
is available at the research protocol manuscript (73). assessment was blind, albeit participants were aware of their
group assignment. While we initially planned to randomize
Design 160 participants (allowing for up to 20% loss to follow-
The POLICE study was a multicentric, parallel, two-armed up) to detect a moderate effect size (Cohen’s d = 0.05)
RCT with three assessment points: baseline, post-intervention, with a power of 0.80 and an alpha of 0.05, from the 194
and 6-month follow-up (73). Participants were randomized participants screened, 170 officers met enrollment criteria and
to MBHP—an 8-week MBI—or a WL control group. The were randomized. We defined participants as external police
clinical trial protocol was prepared in accordance with SPIRIT officers if during the study they were exerting operational
2013 statement (75) and was approved by the centers’ ethical activities and as internal police officers if their contact with
committees. Figure 1 shows the CONSORT flow diagram civilians was done inside police agencies or they were assigned
through the study. to administrative roles.

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Trombka et al. Mindful Policing: Mental Health/Well-Being

FIGURE 1 | Consort diagram.

Intervention space; “primary and secondary suffering;” “hello-thanks-goodbye

MBHP (76) is an 8-week MBI based on the MBSR model (77). It thought”) (81, 82). Compassion training techniques are also
was adapted to suit the context and needs of primary healthcare included (equanimity in the condition of human suffering,
and national and local health systems, developing a framework receiving affection and showing affection to oneself). This
that supports the learning process to individuals from distinctive rigorous training follows the British and Brazilian guidelines for
cultural and educational backgrounds. MBHP was designed to good practices of mindfulness (83, 84). MBHP groups started
address human universal vulnerabilities, not focusing on any with an average of 21 officers. One interventionist led the MBHP
specific health condition. It has been applied since 2009 by groups in Porto Alegre and one led the MBHP groups in São
Mente Aberta—Brazilian Center for Mindfulness and Health Paulo. MBHP core curriculum content is described in Table 1.
Promotion, and by the University of Zaragoza in Spain. There
is a strong emphasis on informal mindfulness practices, such Assessments and Outcomes
as walking, eating, exercising, talking, and doing housework. The POLICE study had three assessment points, which occurred
Concepts of radical acceptance (78), values clarification (79), and during the 2 weeks before the intervention, the 2 weeks
positive psychology (80) are heavily emphasized. Session six is following the intervention, and 6 months after the intervention.
conducted in silence for the purpose of deepening the practice. Participants allocated to the WL filled the surveys on the same
Besides MBSR core practices, psychoeducational activities and timeline. Surveys were answered on the Survey Monkey Software
practices from mindfulness-based cognitive therapy (MBCT) and (http://surveymonkey.com). When computers or tablets were not
Breathworks curriculum are introduced (i.e., 3-min breathing available, participants answered using pen and paper and the

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Trombka et al. Mindful Policing: Mental Health/Well-Being

TABLE 1 | Mindfulness-based health promotion (MBHP) core curriculum content.

Session Didactive teaching Practices Homework

1. Mindfulness: Presentation and aims Eating a raisin Body scan

leaving the Stress and dispersion Simple mindfulness exercises (listening to sounds, Attention for routine activity
automatic pilot What is and what is not mindfulness areas of contact with your body, sensations of your Eating one meal mindfully
Characteristics, attitudes, and motivation feet touching the floor) Mindfulness diary
Introduction to practice diaries Body scan
9-dots exercise
2. Mindfulness in What to do with the body Mindfulness in breathing Body scan
the body What to do with the mind Body scan Mindfulness in breathing
Breathing Primary and secondary suffering Awareness of pleasant events (diary)
Information on posture Attention for routine activity
Preconceptions/fears/challenges Habit changing
in meditation
3. Mindfulness in Importance of the body Mindful walking Body scan
movement How mindfulness works Mindfulness in breathing Mindfulness in breathing
Cognitive defusion Hello-thanks-goodbye thought Mindful walking
Awareness of unpleasant events (diary)
Attention for routine walking
4. Expanding Doing mode/being mode Mindful movements Body scan
mindfulness Reinforcing daily practice Mindfulness in breathing, sensations, sounds, and Mindfulness in breathing
Obstacles to the practice thoughts Mindful walking
Self-compassion 3-min breathing space 3-min breathing space
Mindful walking Awareness of communication difficulties (diary)
5. Dealing with Importance of acceptance Mindful movements Practice of choice
difficulties with Values and committed action Mindfulness of thoughts 3-min breathing space during stress
acceptance Meaning of life 3-min breathing space in doubles
Hedonic and eudaimonic well-being
6. Mindfulness in All practices in silence Mindful movements Practice of choice
silence Body scan Mindfulness conversation
Sitting meditation
Mindful walking
7. Mindfulness What is and what is not compassion Loving kindness (for oneself and others) Practice of choice
and compassion Biological basis Sitting meditation Loving kindness (for oneself and others)
Ways of training compassion Mindful movements Attention for self-compassion in routine activity
Fear of compassion in western society
8. Mindfulness Mindfulness in daily life Connecting with personal values and life purposes Daily life mindfulness incorporation
for life Recommendations for long-term practice Loving kindness (for oneself and
(personal value-based practice) others)
Mindfulness poetry

data were transcribed via single entry to the password-protected relationships, and environment, besides overall QoL and general
software. Primary and secondary outcomes were previously health facets. WHOQOL-BREF Portuguese version exhibits
reported (73). This article will specifically report the findings strong psychometric properties (85). Cronbach’s α in the present
related to QoL, anxiety and depression symptoms, and religiosity. sample was physical health, α = 0.79; psychological, α = 0.84;
We will also address MBHP feasibility and the possible role of social relationships, α = 0.79; and environment, α = 0.76.
mediators (i.e., mindfulness trait, decentering, self-compassion,
and spirituality) and moderators (i.e., sex, age, number of Secondary Outcomes
sessions, mindfulness trait, decentering, self-compassion, and Hospital Anxiety and Depression Scale (HADS)
spirituality) to post-intervention QoL improvement as formerly Fourteen-item scale that quantifies the severity of anxiety
proposed (73). Because the Connor-Davidson-25 Scale of (HADS-A) and depressive symptoms (HADS-D) in community
Resilience (CD-RISC-25) was not applied to all participants, we and hospital settings. HADS Portuguese version shows good
excluded resilience from our mediation and moderation analysis. psychometric properties (86). Cronbach’s α in the present sample
was 0.81 for HADS-A and 0.78 for HADS-D.
Primary Outcome
World Health Organization Quality of Duke University Religion Index (DUREL)
Life-BREF (WHOQOL-BREF) Five-item instrument capturing three dimensions of religiosity:
Twenty-six-item instrument that produces scores for four organizational religiosity (OR), non-organizational religiosity
domains related to QoL: physical health, psychological, social (NOR), and intrinsic religiosity (IR). The NOR subscale measures

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Trombka et al. Mindful Policing: Mental Health/Well-Being

private religious activities (e.g., prayer, meditation, Scripture and the 95% CI were calculated for within- and between-group
study), while the OR subscale involves public religious activities. comparisons, based on Botella and Sanchez-Meca, and Cumming
IR subscale assesses the degree of personal religious commitment and Calin-Jageman recommendations (100, 101). Mediation
or motivation, pursuing religion as an ultimate end in itself (43). hypothesis was tested by bootstrap regression analysis using
DUREL Portuguese version presents high internal consistency the Preacher and Hayes approach (PROCESS) (Model 4) (102).
and discriminant validity (87). Cronbach’s α in the present study The pre-to-post changes in mindfulness (MAAS), decentering
was 0.88. (EQ), self-compassion (SCS), and spirituality (WHOQOL-SRPB-
BREF) were included as proposed mediators between group and
Mechanisms of Change QoL outcome. Separate moderation analyses were conducted for
Mindful Attention Awareness Scale (MAAS) WHOQOL-BREF using the Bootstrapping PROCESS (model 1).
Fifteen-item scale designed to assess a core characteristic Independent moderation models were tested for each proposed
of dispositional mindfulness. MAAS Portuguese version has mediator: sex, age, number of sessions, and pre-to-post changes
adequate reliability and validity (88). Cronbach’s α in the present on mindfulness (MAAS), decentering (EQ), self-compassion
study was 0.96. (SCS), and spirituality (WHOQOL-SRPB-BREF). Significant
moderation was followed up by significant interaction between
Self-Compassion Scale (SCS) the independent variable (X) (group: WL vs. MBHP) and the
Twenty-six-item instrument measuring six components of self- dependent variable (Y) (pre-to-post changes in WHOQOL-
compassion. Portuguese SCS version exhibits good psychometric BREF). Statistical analyses were performed using the IBM SPSS
properties (89). Cronbach’s α in the present study was 0.81. version 23 for Windows.

WHOQOL-SRPB-BREF
Thirty-four-item scale evaluating QoL domains of spirituality, RESULTS
religiosity, and personal beliefs. WHOQOL-SRPB-BREF Baseline Data and Participant
Portuguese version shows strong psychometric properties (90).
Characteristics
Cronbach’s α in the present study was 0.88.
Descriptive statistics and sociodemographic characteristics of
participants are shown in Table 2. No statistically significant
Data Analysis differences between groups were found on any sociodemographic
Group differences at baseline on demographic data and outcome data, or on primary and secondary outcomes at baseline.
variables were evaluated using χ 2 -tests for categorical variables
and Student’s t-test for continuous data. Intention-to-treat
Feasibility
(ITT) mixed-models analyses without any ad hoc imputation
We randomized 87.6% (n = 170 out of 194) of officers assessed
were used to account for missing data with the restricted
for eligibility. Due to reported lack of time, four individuals did
maximum likelihood estimation (REML) (91), rather than
not start the intervention. Participants who were randomized to
repeated measures ANOVA described in the original protocol
the MBHP arm and started the intervention (n = 84) attended a
based on the authors’ recommendation and due to the amount
mean of 6.44 (SD 2.14) of eight weekly sessions, 82.1% (n = 69)
of missing data. The mixed-model approach is appropriate
attended at least four sessions, and 69% (n = 58) at least
for RCTs with multiple time points and pre-only to post-
six sessions. Eight-week assessment was completed by 75.3%
only designs, it does not assume that the last measurement is
(n = 128) and 6-month follow-up was answered by 71.2% (n =
stable, it does not involve any substitution of missing values
121) of the enrolled sample.
with supposed or estimated values, it is conducted using all
available observations (92, 93), and it is robust to violations
of distributional assumptions (94). A linear mixed model for
Change in Primary and Secondary
each primary and secondary outcome measure was implemented Outcomes From Pre- to Post-intervention
with time (pre, post, and follow-up) as within-group factor and 6-Month Follow-Up
and group (WL and MBHP) as between-group factor using Primary Outcome: Quality of Life (WHOQOL-BREF)
the MIXED procedure with a random intercept for subject. Results for the WHOQOL-BREF showed a significant group
An identity covariance structure was specified to model the × time interaction effect in all QoL domains—physical health
covariance structure of the intercept. Wald statistic (or Z-test) [F (2,252.59) = 13.83; p < 0.001], psychological [F (2,245.89) = 20.36;
was conducted to test the residual error variance estimation p < 0.001], social relationships [F (2,248.25) = 9.02; p < 0.001],
and the null hypothesis of homogeneity of residuals (95, 96). and environment [F (2,250.096) = 15.20; p < 0.001], the overall
Significant effects were followed up with pairwise contrasts QoL facet [F (2,251.98) = 7.51; p < 0.01), and general health
adjusted by Bonferroni correction. These statistical tests have facet [F (2,254.216) = 5.10; p < 0.05]. Within-group comparisons
shown their robustness regardless of violations of the required revealed a significant pre-to-post and pre-to 6-month follow-
assumptions when group sizes are equal (97). Results are reported up changes in MBHP group for physical health [F (2,251.67) =
in line with conventional ANOVA, as mixed-model repeated 18.65; p < 0.001], psychological [F (2,244.84) = 19.12; p < 0.001],
measures, according to studies that used this approach for social relationship [F (2,247.02) = 12.72; p < 0.001], environment
repeated measures designs (98, 99). Effect sizes (Cohen’s d) [F (2,248.77) = 18.67; p < 0.001], overall QoL [F (2,249.20) = 9.13;

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TABLE 2 | Sociodemographic data.

Variable Total sample WL MBHP Statistics

(n = 170) (n = 82) (n = 88) (WL vs. MBHP)

Age 42.26 (7.71) 42.46 (7.95) 42.07 (7.53) t(168) = 0.33

(range = 24–60) (range = 24–60) (range = 24–59) p = 0.74
Sex χ²(1) = 0.937
Male 43 (25.3%) 18 (22%) 25 (28.4%) p = 0.33
Female 127 (74.7%) 64 (78%) 63 (71.6%)
Educational status χ²(1) = 2.238
High school 15 (8.8%) 10 (12.2%) 5 (5.7%) p = 0.135
University 155 (91.2%) 72 (87.8%) 83 (94.3%)
Type of work χ²(1) = 0.377
Internal 85 (50%) 43 (52.4%) 42 (47.7%) p = 0.539
External 85 (50%) 39 (47.6%) 46 (52.3%)
Stable partner χ²(1) = 0.005
Yes 121 (71.2%) 57 (69.5%) 64 (72.7%) p = 0.94
No 44 (25.9%) 21 (25.6%) 23 (26.1%)
Missing data 5 (2.9) 4 (4.9) 1 (1.1%)

Means and SDs are represented for age (years). WL, waiting list control group; MBHP, mindfulness-based health promotion.

p < 0.001], and general health [F (2,252.38) = 15.16; p < 0.001]. group (Table 4). Type of work (i.e., internal vs. external) was not
No significant changes were found in WL group except for a significant covariate for DUREL measure (F-values from 0.023
pre-to-post reductions on the psychological domain (Table 3). to 0.867; all ps > 0.05).
Between-group comparisons showed significant differences
between groups, indicating higher scores in the MBHP group
at post and 6-month follow-up compared with the WL control
Mediators for WHOQOL-BREF Increase
group across all domains and facets (Table 4). After MBHP (Pre-to-post Intervention)
Additional mixed-model analyses showed that the type of Mediation results showed a significant indirect effect of MBHP
work (i.e., internal vs. external) was not a significant covariate on the change of QoL outcome through the change of
for WHOQOL-BREF domains and facets (F-values from 0.019 to self-compassion scores (SCSs) from pre-to-post intervention
1.563; all ps > 0.05). (Figure 2). Specifically, the total score of the SCS remained as
the only significant mediator for pre-to-post changes on physical
health [b = 0.94 (0.33), Ba CI 95% [0.34, 1.70]; R2 = 0.25],
Secondary Outcomes: Depression and Anxiety psychological [b = 1.33 (0.32), Ba CI 95% [0.78, 2.03]; R2 = 0.47],
(HADS), Religiosity (DUREL) social relationships [b = 1.31 (0.37), Ba CI 95% [0.67, 2.16];
A significant group × time interaction effect was found for both R2 = 0.26], environment [b = 0.75 (0.26), Ba CI 95% [0.29, 1.32];
HADS subscales, Depression [F (2,247.44) = 12.52; p < 0.001] R2 = 0.26], overall QoL [b = 1.27 (0.40), Ba CI95% [0.54, 2.18];
and Anxiety [F (2,167.70) = 12.76; p < 0.001], and statistically R2 = 0.22], and general health [b = 1.15 (0.38), Ba CI 95% [0.45,
significant differences between groups were found at post and 1.89]; R2 = 0.18].
6-month follow-up, showing lower scores in the MBHP group
compared with the WL group for both depression and anxiety
subscales (Table 4). At pre-intervention, 32 (18.9%) and 52 Moderators for WHOQOL-BREF Increase
(30.8%) participants scored above HADS-D and HADS-A cut-off After MBHP
(≥8), whereas at post-intervention, 20 (16.2%) and 27 (22.3%) Moderation was demonstrated by a significant interaction effect
officers scored above the cut-off, respectively. When considering for general health facet, indicating that the relationship between
the MBHP group, 16 (18.2%) and 29 (32.9%) valid responses were the group and the pre-to-post change on the general health
above HADS-D and HADS-A cut-off scores at pre-intervention, score was independently moderated by the pre-to-post change
and 3 (4.7%) and 8 (12.7%) at post-intervention, respectively. in MAAS [b = 1.28 (0.61), 95% CI [0.67, 2.49], t = 2.09, p <
Type of work was not a significant covariate for depression 0.05] and spirituality scores (WHOQOL-SRPB-BREF) [b = 0.098
[F (1,163.46) = 0.13; p > 0.05] and anxiety [F (1,162.30) = 0.05; p > (0.04), 95% CI [0.012, 0.18], t = 2.25, p < 0.05]. Specifically,
0.05] subscales. increases on MAAS [b = 3.64 (1.02), 95% CI [1.63, 5.66], t = 3.59,
For DUREL, results showed only a significant p < 0.01] and spirituality (WHOQOL-SRPB-BREF) [b = 0.3.26
interaction effect on non-organizational religiosity subscale (0.86), 95% CI [1.55, 4.96], t = 3.78, p < 0.01] at post significantly
[F (2,241.62) = 3.51; p < 0.05]. Specifically, between-group moderated the group effect for general health. Sex, age, number of
comparison revealed statistically significant differences at post sessions, and changes in self-compassion and decentering scores
where the MBHP reported higher scores compared with the WL were not yielded as significant moderators.

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Trombka et al.
TABLE 3 | Means, SDs, and within-group effect sizes for primary and secondary outcomes at pre-, post-intervention, and 6-month follow-up.

Waiting list Mindfulness-based health promotion

Outcome Pre Post FU Pre vs. post Pre vs. FU Pre Post FU Pre vs. post Pre vs. FU
(N = 82) (N = 62) (N = 60) Mean dif.; d (95% CI) Mean dif.; d (95% CI) (N = 88) (N = 66) (N = 61) Mean dif.; d (95% CI) Mean dif.; d (95% CI)

WHOQOL-BREF
Physical health 14.49 (2.51) 14.00 (3.12) 14.32 (2.83) 0.40 0.24 14.70 (2.44) 16.26 (2.20) 16.12 (2.19) 1.52*** 1.28***
d = −0.19 (−0.41, 0.02) d = −0.07 (−0.30, 0.07) d = 0.63 (0.37, 0.89) d = 0.57 (0.33, 0.82)
Psychological 14.60 (2.49) 13.87 (3.18) 14.42 (2.53) 0.80** 0.25 14.83 (2.40) 16.47 (1.79) 16.16 (2.24) 1.42*** 1.09***
d = −0.13 (−0.34, 0.08) d = −0.03 (−0.21, 0.15) d = 0.66 (0.42, 0.91) d = 0.54 (0.29, 0.78)
Social relationships 13.89 (3.20) 13.43 (3.77) 13.84 (2.92) 0.38 0.19 14.12 (3.14) 15.79 (2.26) 15.50 (2.89) 1.58*** 1.25**
d = −0.14 (−0.37, 0.08) d = −0.03 (−0.30, 0.23) d = 0.53 (0.28, 0.77) d = 0.43 (0.20, 0.67)
Environment 13.50 (2.44) 13.14 (2.75) 13.78 (2.34) 0.38 0.35 13.31 (2.10) 14.72 (1.69) 14.68 (1.96) 1.26*** 1.23***
d = −0.15 (−0.36, 0.07) d = 0.11 (−0.12, 0.35) d = 0.66 (0.40, 0.93) d = 0.61 (0.39, 0.90)
Overall quality of life 14.86 (3.42) 14.41 (3.66) 14.40 (4.04) 0.38 0.53 14.95 (3.12) 16.49 (1.80) 16.72 (1.80) 1.40** 1.60**
d = −0.13 (−0.34, 0.09) d = −0.13 (−0.43, 0.16) d = 0.49 (0.16, 0.81) d = 0.56 (0.23, 0.89)
General health 12.74 (3.80) 12.97 (4.51) 13.67 (3.83) 0.11 0.77 13.50 (3.70) 15.69 (3.11) 15.74 (2.72) 2.04*** 1.93***
d = 0.06 (−0.17, 0.29) d = 0.24 (−0.03, 0.52) d = 0.58 (0.34, 0.83) d = 0.60 (0.33, 0.86)
HADS
Anxiety 7.06 (3.43) 7.55 (3.62) 7.68 (3.91) 0.49 0.77 6.80 (3.75) 5.10 (3.01) 5.82 (3.31) 1.63*** 1.61***
d = 0.14 (−0.09, 0.37) d = 0.18 (−0.09, 0.44) d = −0.44 (−0.69, −0.21) d = −0.26 (−0.52, 0.00)
Depression 5.68 (3.48) 6.78 (3.98) 7.14 (3.74) 1.04* 1.52** 5.45 (3.22) 3.56 (2.52) 4.74 (4.14) 1.74* 0.59
8

d = 0.31 (0.09, 0.54) d = 0.41 (0.16, 0.67) d = −0.58 (−0.87, −0.29) d = −0.21 (−0.52, 0.08)
DUREL
Organizational 3.25 (1.51) 3.20 (1.68) 3.26 (1.47) 0.11 0.01 3.40 (1.43) 3.32 (1.37) 3.46 (1.47) 0.09 0.07
religiosity d = −0.03 (−0.18, 0.12) d = 0.01 (−0.19, 0.20) d = −0.06 (−0.19, 0.08) d = 0.04 (−0.15, 0.23)
Non-organizational 3.70 (1.64) 3.50 (1.76) 3.52 (1.63) 0.28 0.17 3.67 (1.63) 4.03 (1.60) 3.75 (1.54) 0.31 0.02
religiosity d = −0.12 (−0.32, 0.08) d = −0.11 (−0.33, 0.11) d = 0.21 (0.04, 0.39) d = 0.05 (−0.17, 0.23)
Intrinsic religiosity 11.16 (3.44) 11.63 (3.50) 11.48 (3.17) 0.24 0.23 11.49 (3.15) 11.88 (3.34) 12.13 (3.29) 0.44 0.39
d = 0.13 (−0.01, 0.28) d = 0.09 (−0.10, 0.27) d = 0.12 (−0.01, 0.23) d = 0.20 (0.05, 0.36)
Overall DUREL 18.11 (5.85) 18.32 (6.15) 18.26 (5.65) 0.19 0.05 18.55 (5.40) 19.23 (5.38) 19.34 (5.35) 0.65 0.24
d = 0.04 (−0.09, 0.16) d = 0.03 (−0.13, 0.18) d = 0.12 (0.01, 0.24) d = 0.14 (0.00, 0.29)

Means and SDs are represented for primary and secondary outcomes. Pre, pre-treatment; Post, post-intervention; FU, 6-month follow-up; d, Cohen’s d; WHOQOL-BREF, World Health Organization Quality of Life–BREF; HADS, Hospital
February 2021 | Volume 12 | Article 624876

Anxiety and Depression Scale; DUREL, Duke University Religion Index. *p < 0.05, **p < 0.01, ***p < 0.001. Means differences are described with absolute values and were calculated using estimated marginal means adjusted by

Mindful Policing: Mental Health/Well-Being

Bonferroni for multiple comparisons. P-values of the Wald test were <0.05 for primary and secondary outcomes.
Trombka et al. Mindful Policing: Mental Health/Well-Being

TABLE 4 | Between-group comparisons at post and 6-month follow-up.

Outcome Pre (MBHP vs. WL) Post (MBHP vs. WL) FU (MBHP vs. WL)

F-values F-values d (95% CI) F-values d (95% CI)

WHOQOL-BREF
Physical health F (1, 262) = 0.20 F (1, 320) = 23.62*** 0.84 (0.48, 1.20) F (1, 330) = 14.86*** 0.71 (0.34, 1.07)
Psychological F (1, 241) = 0.28 F (1, 298) = 33.72*** 1.01 (0.64, 1.38) F (1, 309) = 13.38*** 0.72 (0.36, 1.09)
Social relationships F (1, 262 ) = 0.25 F (1, 324) = 17.53*** 0.76 (0.40, 1.12) F (1, 334) = 9.81** 0.57 (0.20, 0.93)
Environment F (1, 257) = 0.54 F (1, 317) = 13.95*** 0.69 (0.34, 1.05) F (1, 328) = 12.52*** 0.41 (0.05, 0.77)
Overall quality of life F (1, 312) = 0.05 F (1, 365) = 11.28** 0.72 (0.37, 1.08) F (1, 373) = 15.16*** 0.74 (0.37, 1.11)
General health F (1, 281) = 0.21 F (1, 341) = 17.45*** 0.70 (0.34, 1.06) F (1, 351) = 8.41** 0.62 (0.26, 0.98)
HADS
Anxiety F (1, 253) = 0.21 F (1, 315) = 15.33*** −0.73 (−1.09, −0.38) F (1, 339) = 17.19*** −0.51 (−0.87, −0.15)
Depression F (1, 277) = 0.15 F (1, 336) = 24.46*** −0.97 (−1.33, −0.60) F (1, 356) = 13.43*** −0.60 (−0.97, −0.24)
DUREL
Organizational religiosity F (1, 215) = 0.55 F (1, 263) = 0.58 0.08 (−0.27, 0.42) F (1, 270) = 0.11 0.14 (−0.22, 0.49)
Non-organizational religiosity F (1, 230) = 0.005 F (1, 289) = 4.29* 0.31 (0.04, 0.66) F (1, 297) = 0.26 0.14 (−0.21, 0.50)
Intrinsic religiosity F (1, 199) = 0.40 F (1, 236) = 0.96 0.07 (−0.27, 0.42) F (1, 241) = 0.72 0.14 (−0.04, 0.66)
Overall DUREL F (1, 192) = 0.30 F (1, 223) = 2.06 0.16 (−0.19, 0.50) F (1, 227) = 0.53 0.20 (−0.16, 0.55)

Post, post-intervention; FU, 6-month follow-up; d, Cohen’s d; WHOQOL-BREF, World Health Organization Quality of Life–BREF; HADS, Hospital Anxiety and Depression Scale; DUREL,
Duke University Religion Index. *p < 0.05, **p < 0.01, ***p < 0.001.

FIGURE 2 | Mediation analyses for pre-to-post changes on quality of life (WHOQOL-BREF). SCS, Self-Compassion Scale. All coefficients represent unstandardized
beta coefficients (standard errors in parentheses). Mediators and dependent variables are pre-to-post changes. *p < 0.05; **p < 0.01; ***p < 0.001.

DISCUSSION self-compassion as an important mechanism of action which

mediates the improvement in all QoL domains and facets, and
To the extent of our knowledge, we demonstrated the first (7) is feasible in the Brazilian police environment.
empirical evidence grounded on a RCT that among police
officers, an 8-week MBI (1) enhances all QoL domains and Primary and Secondary Outcomes
facets, (2) reduces depression symptoms, (3) decreases anxiety Participants randomized to receive MBHP demonstrated greater
symptoms, (4) maintains QoL and mental health benefits after levels of self-reported QoL at post-intervention than the WL
6 months, (5) increases non-organizational religiosity, (6) has group across its multiple domains and facets with medium to

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Trombka et al. Mindful Policing: Mental Health/Well-Being

large effect sizes. Notably, at 6-month follow-up, the difference inadequate training, lack of equipment, corruption, hostile
between groups across all QoL domains and facets remained public image, bureaucracy, and rigid hierarchy, in addition to
significant indicating medium effect sizes. As expected, the hazing, discrimination, sexism, and racism within departments,
psychological domain was the one that showed the largest effect may represent Brazilian police work-related stressors that
size magnitude between groups both at post-intervention and possibly explain these findings (6, 23, 118, 119). Inasmuch as
at 6-month follow-up. These findings are consistent with Grupe organizational conditions affect the Police Institution as a whole,
et al.’s (68) single-arm study with 30 LEOs who exhibited it explains why the covariate analysis showed that internal and
increased psychological well-being after 8 weeks of MT and with external police officers equivalently benefit from the intervention.
Christopher et al.’s (66) pioneering single-arm pilot (n = 43) that Brazilian police scientific literature de facto demonstrates that
reported increased LEO global mental health following MBRT. stress levels are similar between officers exerting operational or
Noteworthy, a study by the UK College of Policing suggests that administrative roles (120, 121), in line with international data
online mindfulness resources improve officers’ well-being (103). pointing that organizational stressors may be more challenging
Our results are in accordance with the literature that indicates than operational experiences (122).
MT’s positive impact in QoL and well-being across different The significant interaction effect and difference between
populations (55, 81, 104), including military and war veterans groups on non-organizational (private) religiosity at post-
(58, 62, 105, 106). intervention can be attributed to the possibility that many
MBHP presented efficacy to decrease depression symptoms at participants considered mindfulness meditation a private
post-intervention and at 6-month follow-up, displaying large and religious activity and/or MT led participants to increase private
medium effect sizes, respectively. These results are in line with religious activities such as other types of meditation, prayer,
Grupe et al. (68) pre–post pilot findings that exhibited a trend etc. MBHP, such as MBSR, is a secular behavioral medicine
level decrease on depression symptoms with medium effect size intervention that teaches skills addressed to reduce universal
after MT. Individuals allocated to receive MBHP also showed human suffering where spiritual themes are not explicitly
reduced levels of anxiety when compared with the control explored. That being said, MBIs can enhance transcendence
group both at post-intervention and at 6-month follow-up with and awareness of interconnectedness in which oneself is not
medium effect sizes. While Christopher et al.’s (67) rigorous RCT seen as separate from everyday activities, other people, or the
that enrolled 61 LEOs did not find a significant reduction on world (123); thus, studies consistently have been suggesting
anxiety symptoms, the authors stated that the small sample size that it might lead to increments in spirituality/religiosity
and type II error could explain the findings given that the trial (56, 124–126). MBHP components of values clarification and
main aim was to explore MBRT feasibility and acceptability. Our compassion/loving-kindness practices for oneself and others
results resonate with the aforementioned Grupe et al. pilot (68) potentially contributed to this finding. It is also important to
that showed a salient reduction in anxiety symptoms after MT mention that Brazil is a highly religious country (predominantly
which persisted after 5 months. Furthermore, a growing body of catholic) where 90% of the population identify with a spiritual
evidence denotes MT’s declining effects on depression symptoms or religious group (127), and in our sample, that proportion
among military personnel (107–110). was ∼80%.
Whereas, the scientific literature is still not clear about
how long MBI effects last, its psychological benefits tend to
decrease over time (111, 112). Previous studies with MBIs and Mediation and Moderation
police personnel mental health follow-up have mixed results The hypothesis that self-compassion could mediate QoL
(67, 68). Persistent salutary effects of MHBP after 6 months improvement was confirmed for all QoL domain and facets.
should be highlighted; however, the study design does not Self-compassion has empirically shown to mediate MBI’s
illuminate its longstanding impact as prolonged follow-up was effects on mental health and well-being (128–133). It is
not performed. The WL within-group significant reductions in associated with a wide variety of positive outcomes related
QoL psychological domain after 8 weeks and the increment in to psychological well-being and QoL (e.g., life satisfaction,
depression symptoms after 8 weeks and at 6-month follow-up positive affect, social connectedness, flourishing) (48, 134–137)
(Table 3) could be explained as a consequence of dealing with and inversely associated with psychopathology (i.e., depression,
new stressors intrinsic to the police activity without mindfulness anxiety, stress, suppression of unwanted thoughts, self-criticism,
skills or due to the nocebo effect and frustration, disappointment, shame, anger) (137–141). Emotional regulation deficits and
and anger about not being offered MBHP immediately (113). experiential avoidance are linked to depression, anxiety, and a
Police officers’ QoL and mental health impairment lower QoL (142, 143). Denial, suppression, and avoidance of
represented in the baseline assessment lower scores when negative emotions are emotional regulation strategies commonly
compared with populational national and international samples used by officers and those who are able to identify their
might have contributed to the intervention impact (85, 114–116). feelings and be present to moment-to-moment experience show
For instance, the poor mental health of our non-clinical sample better mental health (144–146). The police toughness culture
is expressed by the average score of 7.06 on HADS-Anxiety combined with exposure to uncontrollable situations, violence,
(Table 3), close to the ≥8 cut-off score that presents sensitivity and potentially traumatic situations results in high levels of
and specificity for anxiety disorders of ∼0.8 (117). Exposure shame, guilt, isolation, self-critical thinking, anger, and trauma-
to extensive criminality, low wages, long and irregular shifts, related disorders (2, 11, 146–148); therefore, self-compassion

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Trombka et al. Mindful Policing: Mental Health/Well-Being

emerges as a crucial skill to be learned and cultivated. First- the relevance and potential societal impact of applying MBIs
generation MBIs (i.e., MBSR, MBCT) did not explicitly teach self- within the police environment and its design—a multicenter
compassion skills, but they are interwoven into the mindfulness RCT with follow-up assessment. RCTs are the “gold standard”
instructions (e.g., “whenever you notice that the mind has in evidence-based medicine and the only type of study able
wandered off, bring it back with gentleness and kindness”) to establish causation. Other key strengths are the sample
(149, 150). In addition to implicit teaching, MBHP curriculum size that allowed us to detect differences between groups and
(73, 76) includes didactive teaching on compassion (e.g., fears of the focus on mental health/quality of life promotion and
compassion), formal practices of compassion/loving kindness for prevention of psychological suffering. Given mental illness’
oneself and informal practices (i.e., attention for self-compassion emotional, physical, economic, and social cost, a balanced
in routine activity), providing explicit opportunities for inner approach between early intervention strategies and treatment
compassion cultivation. is needed, consonant with preventive medicine and positive
Mindfulness trait and spirituality group effect moderation psychiatry (70, 164).
for WHOQOL-BREF general health facet pre–post changes are
consistent with the literature that associates both characteristics
with self-regulated behavior (151–153) and better health (154– CONCLUSION AND FUTURE DIRECTIONS
157) in a variety of settings, including policing (69, 146, 158).
Alsubaie et al.’s systematic review of MBCT and MBSR (159) The POLICE study makes an important contribution to the
concluded that global change in mindfulness are linked to emerging field of MT for police mental health and QoL.
better health outcomes. Historically, it should be remembered Although on its infancy, results from the first trials are
that MBSR—the first MBI—was developed in 1979 for people promising. Qualitative studies are needed to understand
with chronic health conditions with the intention to create a officers’ attitudes, feelings, and behaviors toward MT in
vehicle for the effective training of medical patients in relatively greater depth (e.g., language attunement; potential obstacles
intensive mindfulness meditation and its immediate applications and resistances related to police norms and customs; impact
to stress, pain, and illness (77). The fact that the number on family life). Occupational health literature suggests that
of sessions attended did not moderate the effect on QoL is physical exercise, MBIs, cognitive-behavioral therapy, and
aligned with Carmody and Baer’s review (160) demonstrating change in organizational practices promote mental health
no significant correlation between number of in-class MBSR and well-being with no particular superiority, although
hours and mean effect size. Moreover, our research group had more rigorous evaluations are needed (165). Future police
previously suggested that an abbreviated MBI (four sessions) may RCTs should use active control interventions. Long-term
have a similar efficacy to a standard MBI (eight sessions) in a follow-up, cost-effectiveness data, cross-cultural research, and
non-clinical population (161). replication on male samples will play a pivotal role for the
field expansion. Complementary neurobiological, cognitive,
Feasibility behavioral, and psychometric measures addressing mechanisms
The findings indicate that MBHP is feasible among Brazilian (e.g., attentional/cognitive control, emotional regulation,
police officers. Randomization process was successful interoceptive awareness, rumination) and a wide scope of
considering that baseline characteristics were similar in both outcomes, encompassing health and well-being; workplace (e.g.,
groups. Initial dropout rate was low, and most of the participants interpersonal relationships, absenteeism, safety, leadership,
accepted the randomization and completed the assessments. return on investment); societal (e.g., mental capital, ethics,
MBI’s “completion” has been defined as attending four or more impact on civilians); and effective policing (e.g., impulse control,
sessions (112). In view of these criteria, our completion rate was working memory, task performance) perspectives should be on
high and comparable with previous MBI studies (162), including the research agenda. Importantly, if mindfulness and loving-
within the police (67, 68). kindness meditation could reduce implicit racial bias (166, 167),
its impact in decreasing officers’ stereotype-biased judgments
Strengths and Limitations and behaviors would warrant further investigation. “Stepped-
The empirical results reported herein should be considered care” and “low intensity–high volume” approaches (168) can
in the light of some limitations. Our sample was composed increase accessibility and facilitate the nurturing of “Mindful
predominantly of female officers (Table 2) working at two of Police Departments.” Evidence-based programs designed for
the most violent cities in the world (119). We used a waitlist cultivation and embodiment of self-compassion skills such
control design rather than an active control intervention. While as mindful self-compassion (169) and compassion cultivation
there are ethical advantages to a waitlist design because it training (170) or the interweaving of self-compassion practices
allows for the provision of care to research participants who in MT are auspicious. Rigorous research will inform and guide
are seeking help while permitting a non-intervention evaluation, procedures, public policy decision-making, and systematic real-
such design may overestimate intervention effects (163). Finally, world implementation of MT for Police Institutions around the
single data entry may be associated with errors within the globe, nourishing the conditions for officers’ physical, emotional,
registry and a MIXED procedure with a random intercept and mental fitness, and contributing to the judicious and mindful
for subject was conducted but test for random slope was not use of police power and authority, which could benefit society as
considered. The POLICE study has several strengths including a whole.

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Trombka et al. Mindful Policing: Mental Health/Well-Being

DATA AVAILABILITY STATEMENT writing. MD, SA, and KC coordinated the study at São Paulo
center. SA was particularly involved in the implementation and
The raw data supporting the conclusions of this article will be conduction of the project at this site. MT and NR coordinated
made available by the authors, without undue reservation. the study implementation and conduction at Porto Alegre center.
KC and AW were responsible for data curation. JG-C and
ETHICS STATEMENT ZS-O commented and critically reviewed the manuscript for
important intellectual content. All authors read and approved the
The study was approved by HCPA and UNIFESP Research final manuscript.
Ethics Committees under number 60406416.9.1001.5327. The
patients/participants provided their written informed consent to FUNDING
participate in this study.
This work was supported by CAPES Brasil - Coordenação
AUTHOR CONTRIBUTIONS de Aperfeiçoamento de Pessoal de Nível Superior under
Grant 88882.346691 – Finance Code 001; by Hospital de
MT, MD, and NR were responsible for manuscript writing, Clínicas de Porto Alegre Research Incentive Fund and
co-conceptualized, designed the study, and obtained funding. by Mente Aberta - Brazilian Center for Mindfulness and
DC were responsible for statistical analysis and manuscript Health Promotion.

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Mechanisms of action in mindfulness-based cognitive therapy (MBCT) and
mindfulness-based stress reduction (MBSR) in people with physical and/or Conflict of Interest: The authors declare that the research was conducted in the
psychological conditions: a systematic review. Clin Psychol Rev. (2017) absence of any commercial or financial relationships that could be construed as a
55:74–91. doi: 10.1016/j.cpr.2017.04.008 potential conflict of interest.
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effect sizes for psychological distress. J Clin Psychol. (2009) 65:627–38. Campayo, Schuman-Olivier and Rocha. This is an open-access article distributed
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161. Demarzo M, Montero-Marin J, Puebla-Guedea M, Navarro-Gil M, Herrera- distribution or reproduction in other forums is permitted, provided the original
Mercadal P, Moreno-González S, et al. Efficacy of 8- and 4-session author(s) and the copyright owner(s) are credited and that the original publication
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