The Italian population has recently experienced the first nationwide lockdown of the 21st century due to the Covid-19 infectious disease. After the Covid-19 outbreak in China in December 2019, the epidemic moved to the European region and was declared a pandemic by the WHO on 11 March 2020 [1
], when Italy was the worst affected country outside China and was soon becoming the new center of the virus spread. City and regional lockdowns in Italy had already started in February, but the nationwide lockdown started on 9 March 2020, with an estimated 56 million people ordered to remain at home: bars, restaurants, schools and churches were closed and only essential services were permitted (e.g., vital health-care, food stores, electricity/gas/water/fuel suppliers, garbage collection). At the release of the toughest lockdown measures, on 4 May 2020, Italy had officially experienced 210,717 Covid-19 cases and had suffered 28,884 deaths due to this disease [2
Besides the casualties and the economic loss (with a −9.1% estimated drop in GDP for 2020 [3
]) associated with the Covid-19 pandemic, the fear of the virus and the 2-month lockdown had a serious psychological impact on a large part of the Italian population. Early reports emerging in the literature have shown that between 40% and 50% of adults have experienced psychological distress following the Covid-19 outbreak [4
], and that 30% of adults and children are at high risk for post-traumatic stress symptoms [6
]. These results are in line with those previously collected from Chinese samples [7
], and extend our previous knowledge of the psychological burden of quarantines coming from past (shorter and smaller scale) experiences of isolation due to public health emergencies and relative confinement measures [11
Previous experiences with global health emergencies have shown that the effective use of lockdown as a public health approach requires minimizing the harmful effects associated with it: the fundamental steps to this purpose seem to be the ensuring of sufficient primary supplies during the lockdown, and a clear communication, by the authorities, of the reasons for the restrictions and of the protocols to be followed [11
], as well as cash transfers and job retention acts [12
]. Moreover, other institutional and individual interventions have been proposed to protect mental heath in vulnerable groups, in particular during emergency situations such as the Covid-19 outbreak. These include stigma mitigation [13
], psychological/psychiatric assistance [14
], psychoeducation [16
] and teaching self-help methods [15
Teaching evidence-based self-help methods often represents a viable option to address the urgent need of psychological support for large numbers of people, when in-person services are suspended [18
]. A recent review of the meta-analyses of self-guided interventions to alleviate anxiety, depression and stress concluded that such interventions significantly improve well-being in comparison to control groups, albeit with effect sizes smaller than those associated with traditional guided individual or group therapies [20
]. The interventions that proved to be the most effective included self-guided cognitive-behavioral therapy, acceptance and commitment therapy, and Mindfulness-Based Interventions (MBIs).
Mindfulness-Based Interventions are generally based on meditation practices taken from the Buddhist tradition and adapted into contemporary, psychologically-oriented programs [21
]. These programs are usually delivered over 8 consecutive weeks, with eight group meetings led by a mindfulness instructor and daily individual practice at home [22
]. Several studies have highlighted the benefits of MBIs mainly in terms of self-reported reductions in anxiety, depression and stress levels [23
]. Other improvements due to MBIs have been reported for job burnout [26
], interoceptive awareness [27
], empathy [29
], character traits [31
] and psychological well-being [33
]. It is important to underline that, after the completion of the program, participants can maintain and enhance the benefits gained during the training program by continuing with the meditation on their own. Two decades since the introduction of MBIs, research has showed that they could be effective in promoting well-being also when delivered through a single introductory group meeting, during which the meditation practices are taught and participants carry on the program individually [35
], or when delivered via the internet [37
]. MBIs are therefore tools potentially suitable for dealing with stressors arising during lockdown periods, because they can help manage psychological suffering and they can be delivered even in situations where face-to-face meetings are suspended and a large number of people need psychological support.
In the present study, an 8-week Mindfulness-Oriented Meditation course (MOM, which is a standardized MBI) was delivered, through two face-to-face meetings (before these meetings were prohibited by the government due to the spread of the Covid-19 pandemic) and six video-lessons, to a sample of female teachers (Figure 1
). Although the MOM course was not originally aimed at mitigating the psychological distress resulting from the Covid-19 pandemic, as this event was unpredictable, it ended up being addressed to a class of the general population most vulnerable to the consequences of this event: many studies have indeed frequently shown that being a woman is one of the risk factors for poor mental health outcomes during the Covid-19 pandemic [5
Moreover, it is well known that, when a population faces the same stressful situation, such as in the case of the Covid-19 pandemic, not everyone suffers the same way. Individual adaptive or non-adaptive responses to adverse events depend on a variety of biological, cultural, social and psychological components, which can be encompassed in the concept of psychological resilience [43
]. Past research found that resilience is directly related, on the one hand, to secure attachment [44
], mental health [46
], psychological well-being [48
], empathy [49
], mindfulness [50
] and interoceptive awareness [51
], and, on the other hand, inversely related to childhood trauma [45
], anxiety, depression [52
] and burnout [53
]. Many studies have shown the link between measures of resilience and personality traits, such as harm avoidance, self-directedness, persistence and neuroticism [45
]. The sample of teachers who received the MBI were studied here in terms of their resilience profile, generated on the basis of temperamental (i.e., mainly innate) and characterological (i.e., mainly due to personal experiences and education) measures taken at baseline with the Temperament and Character Inventory [58
In our study, we therefore analyzed, within the full sample of female teachers receiving the MOM course, the data of a group of teachers with a high-resilience (HR) profile, and the data of a group of teachers with a low-resilience (LR) profile. These teachers were assessed with validated self-report instruments one month before (when the Covid-19 outbreak in China did not seem to threaten the Italian population) and one month after the imposition of the national lockdown in Italy (when the population was shocked by the unprecedented measures taken by the Italian government to deal with the spread of the Covid-19 infectious disease). In this period, the teachers received an 8-week mindfulness meditation course—partly (25%) delivered in person and partly (75%) via the internet. They were assessed in terms of their mindfulness skills, empathy, personality profile, interoceptive awareness, psychological well-being, emotional distress and burnout level.
Three main objectives were pursued in our study. Objective 1
: to establish whether the two groups of teachers, who had two opposite profiles of resilience at baseline (obtained from teachers’ personality profiles before the MOM course), were different at baseline in the other measures employed in our study as well. Based on previous research on resilience [44
], we hypothesized that the low-resilience group, compared to the high-resilience group, had worse baseline levels of psychological well-being, mindfulness skills, interoceptive awareness, emotional distress, empathy and burnout (H1).
: to examine the changes in the two groups that occurred from before to after the MOM course; this also allows observation of the between-group differences after the intervention. Based on the previous literature on the effects of MBIs [23
], which referred to periods free from global health emergencies like that related to the Covid-19 pandemic, we hypothesized that both groups of teachers experienced similar improvements in mindfulness skills, empathy, character traits and interoceptive awareness (H2). As the psychological impact of compulsory isolation in the context of a world-wide pandemic has not previously been examined in relation to mindfulness meditation courses, the analyses of changes in the measures of psychological well-being, burnout and emotional distress (anxiety and depression) were exploratory.
: to evaluate the teachers’ satisfaction with the MOM course and their perception of the course’s impact on their lives in the context of the Covid-19 outbreak. Based on our many years of experience in conducting MOM courses (see Methods), we hypothesized a moderate to high course satisfaction (H3a). Based on the perceived effectiveness of mindfulness meditation as a self-help method [20
], we also hypothesized that participants could perceive mindfulness meditation as a useful practice in living through the Covid-19 lockdown period (H3b).
An 8-week Mindfulness-Oriented Meditation (MOM) training program was organized by the University of Udine on behalf of the Prevention Department and financed by the Friuli Venezia-Giulia region, in the northeast of Italy in a preventive medicine project. This project was originally designed to support teachers’ mental health (i.e., to prevent professional burnout and improve well-being [60
]). After participant recruitment, two parallel MOM courses were scheduled and two schools were chosen as the locations for the courses. Participants enrolled in one of the two courses based on the location of the course (the locations of the courses were about 60 km away). The MOM courses were held by two of the authors (A.M., a professional socio-health educator, and A.P., a psychologist), who have more than five years of experience in practicing and teaching mindfulness meditation.
In the original design of the study, data collected from participants in the MOM training should have been compared with data from control participants obtained after the end of the MOM course (in two sessions, eight weeks apart—the same time that elapsed between the pre- and post-MOM course assessments). However, due to the Covid-19 outbreak in Italy in the first weeks of the MOM course, the control group of participants was not assessed; data from teachers attending the MOM course who were assessed one month before and one month after the national lockdown could not have been fairly compared to the data from teachers who were in a condition with fewer restrictions thanks to the loosening of the lockdown.
The MOM training program started on Tuesday 11 February 2020. At the end of the second week of the course, on Sunday 23 February, the regional government of Friuli Venezia-Giulia ordered the closure of all schools and universities. The following six teachings were therefore delivered through 30-minute video lessons sent via the internet, and participants were asked to continue their MOM practice on their own (see Figure 1
). They could communicate with their MOM instructor through emails, telephone messages and phone calls in case they wanted to share their meditation experiences or to pose questions about the contents of the video lessons.
Participants were assessed in the days before the training program (Time T0, between 6 February 2020 and 11 February 2020) and after the end of the program (Time T1, between 2 April 2020 and 15 April 2020). Data was obtained using paper-and-pencil questionnaires at T0 and using internet-based questionnaires at T1. For T1, the teachers agreed to complete the survey entirely in one session (as done at T0), paying close attention.
In total, 67 school teachers (1M, 66F; all Caucasian) were recruited through official communications sent to primary and secondary State schools and preschools in the province of Udine, Friuli Venezia-Giulia. The sample size was determined by the maximum number of participants eligible for the two MOM courses. In the two MOM courses, there was an equal proportion of teachers from different school levels (21 teachers from primary schools, 4 from secondary and 2 from preschools in the first course; 22 from primary, 5 from secondary and 4 from preschools in the second course).
This study concerned the 66 female teachers (age: 51.5 ± 7.9 years) participating in the MOM training program. The sample considered is representative of the Italian teachers, which are on average older than in most other developed countries (average age of teachers in Italy—48.6 years; average for countries of the Organization for Economic Cooperation and Development—44.1 years) [61
Written informed consent was obtained from all participants during the first assessment session. This study was approved by the Ethics Committee of the University of Udine and all procedures performed in the study were in accordance with the ethical standards of the 1964 Helsinki declaration and its later amendments (ethical code: CGPER-2019-12-09-01). All data was processed anonymously and data confidentiality was ensured.
2.3. Mindfulness Oriented Meditation (MOM) Course
The MOM course is an 8-week training program, with a 2 h group meeting per week and 30 min daily meditation practice at home [31
]. In its structure it is similar to an MBSR course (Mindfulness-Based Stress Reduction), the most common mindfulness meditation program developed by Kabat-Zinn [65
]. Each MOM meeting is divided into three parts: a 15/30 min teaching on topics related to meditative practice, a 30 min guided MOM practice and a final phase during which participants can share their experiences and ask questions to the instructor. These are the topics covered in the teachings [64
]: historical introduction to mindfulness meditation, what is mindfulness meditation and how to practice it, facing pain with a mindful attitude, attention and awareness, being in the here and now, disidentification, deautomatization, and letting go. The MOM practice, which is the same throughout the course, entails a 10 min session of paying attention to one’s breathing (anapanasati meditation), 10 min dedicated to heeding one’s bodily sensations (body scan meditation) and 10 min dedicated to being aware of one’s emotional and mental phenomena (vipassana meditation). The main reference for these practices within the Buddhist context, from which mindfulness meditation was adapted, is the Satipatthāna discourse [66
], although the instructions given to participants during the meditations do not refer to Buddhism. The same three practices are part of other contemporary, secular and psychologically-oriented mindfulness meditation courses, such as MBSR. After the first meeting, participants are provided with a 30 min audio recording containing a guided MOM practice (http://www.medita-mom.it/materiale
), as an aid for home meditation practice. Participants are provided with articles and book suggestions on the topics covered in the course based on personal requests.
The theoretical or practical parts of the MOM course delivered in this study were not tailored for the specific group of teachers participating in the study during the Covid-19 outbreak: the teachings remained adherent to the original version of the MOM course [64
] and the meditation—guided by instructors in the first two meetings and to be performed at home by the participants throughout the course—remained the same during the 8 weeks of the course. Discussions between participants and instructors, which normally take place in the final part of each MOM meeting, were replaced by personal communications via mail, phone messages or calls in the last 6 MOM weeks (see Figure 1
), after the government prohibited face-to-face meetings due to the Covid-19 outbreak.
Demographic characteristics were obtained at T0. Participants reported their age, gender, level of education, body height and body weight, previous experiences in meditation and if they were diagnosed with any medical disease or psychiatric disorder.
Home practice was assessed through diaries collected every two weeks. Teachers were asked to record their daily practice of mindfulness meditation in the diaries.
Mindfulness skills were assessed with the Italian version of the Five-Facet Mindfulness Questionnaire (FFMQ [67
]). This 39-item instrument measures five mindfulness scales: observing (OBS), describing (DES), acting with awareness (AWA), non-judging of inner experience (NJU), and non-reactivity to inner experience (NRE). Respondents are asked to rate each statement using a 5-level Likert scale (1 = never or very rarely true, 5 = very often or always true; item example: “I watch my feelings without getting lost in them”). Higher scores in each scale reflect a greater level of mindfulness. FFMQ has a high internal consistency for the total score (Cronbach’s α = 0.86) and acceptable values for its five scales (α ≥ 0.74) [68
] (see below the Results section for present sample Cronbach’s α).
Empathy was assessed with the Italian translation of the Questionnaire of Affective and Cognitive Empathy (QCAE [69
]). Using a 4-level Likert scale response format (1 = strongly disagree, 4 = strongly agree), this 31-item instrument assesses the two main components of empathy, namely affective empathy (AE, a person’s emotional resonance to other people’s experiences; item example—“It worries me when others are worrying and panicky”) and cognitive empathy (CE, the ability to understand how other people feel; item example—“I always try to consider the other fellow’s feelings before I do something”). QCAE has acceptable internal consistency for the AE and CE components, and the total score (α ≥ 0.77) [70
The personality profile was assessed with the Italian adaptation of the 125-item Temperament and Character Inventory (TCI; [58
]). This tool assesses the temperament and character dimensions of personality using a dichotomous true-false response format (item example: “I’m often so determined that I continue working long after other people give up”). Temperament scales include novelty-seeking (NS, the propensity towards impulsivity, exploratory excitability and eccentricity), harm avoidance (HA, the propensity to respond strongly to aversive stimuli), reward dependence (RD, the propensity to respond intensely to signs of social gratification) and persistence (P, the tendency to pursue goals despite fatigue and frustration). Character scales include self-directedness (SD, the ability to recognize the self as autonomous, and the feeling of self-confidence, honor and hope), cooperativeness (C, the ability to recognize the self as an organic part of society) and self-transcendence (ST, the ability to recognize the self as an organic part of nature and its source). TCI in its 125-item version has acceptable internal consistency for all scales (α ≥ 0.71) [71
Interoceptive awareness was assessed with the Italian version of the Multidimensional Assessment of Interoceptive Awareness scale (MAIA [72
]). This 32-item instrument uses a 6-level Likert scale response format (0 = never, 5 = always; item example—“I notice when I am uncomfortable in my body”). MAIA measures interoceptive awareness through eight subscales: noticing (NOT, the awareness of neutral, comfortable and uncomfortable body sensations), not-distracting (NDI, the propensity not to distract oneself from sensations of discomfort or pain), not-worrying (NWO, the propensity not to worry when sensations of discomfort or pain are experienced), attention regulation (ARE, the ability to focus and sustain attention to body sensations), emotional awareness (EAW, the ability to connect body sensations to underlying emotional states), self-regulation (SRE, the ability to manage distress by listening to body sensations), body listening (BLI, the propensity to actively listen to the body for information) and trusting (TRU, the tendency to trust your body). The Cronbach’s α values for internal consistency varied between 0.53 and 0.80 in the eight MAIA scales [73
Psychological well-being was assessed with the Italian version of the 18-item Psychological Well-being Scales (PWB [74
]). This tool uses a 4-level Likert scale response format (1 = strongly disagree, 4 = strongly agree; item example—“I like most parts of my personality”) and the six scales included are self-acceptance (SA), autonomy (AU), environmental mastery (EM), personal growth (PG), positive relations with others (PR) and purpose in life (PL). Higher scores on any scale indicate greater indices of happiness and psychological well-being. PWB Scales showed Cronbach’s α values ranging from 0.60 to 0.70 [76
], which appears to be a sufficient level of internal consistency based on the fact that each subscale comprised only three items.
Emotional distress was assessed using the Italian version of the Hospital Anxiety and Depression Scale (HADS [77
]). This 14-item instrument uses a 4-level Likert scale response format, with levels that differ depending on the question. Although originally developed to measure anxiety (item example: “Worrying thoughts go through my mind”) and depression (item example: “I look forward with enjoyment to things”) in non-psychiatric clinical settings, the HADS has been extensively employed as an effective tool even in non-clinical populations [79
]. It provides separate scores for anxiety, depression and global emotional distress. In a review of the literature, HADS showed a high internal consistency across studies for both anxiety (mean Cronbach’s α = 0.83) and depression measures (mean Cronbach’s α = 0.82) [80
Teacher burnout was assessed with the Italian translation of the Maslach Burnout Inventory Educators Survey (MBI-ES [81
]). Using a 7-level Likert scale response format (0 = never, 6 = always; item example—“I feel frustrated by my job”), this 22-item instrument measures three components of burnout in relation to teacher–student interaction: feelings of overwhelming emotional exhaustion (EE), depersonalization and detachment from the job (DP), and a lack of personal or professional accomplishment (PA). Burnout is indicated by high scores for EE and DP, and a low score for PA. MBI-ES has acceptable internal consistency for each of its components (α ≥ 0.76) [82
The evaluation of the MOM course, also in relation to the Covid-19 outbreak, was obtained at T1. This included six general questions prepared by the authors of the study about the MOM course, and four questions related to the Covid-19 emergency (see Table 1
). Each question was rated on a 5-point Likert-type scale (for Q1–Q8, 1 = not at all, 5 = very much; for Q9–Q10, 1 = much worse, 5 = much better).
2.5. Statistical Analyses
Before all analyses, missing values in participants’ responses were imputed using the mean score of the whole sample for the corresponding item, since the total percentage of missing values was very low (0.10%).
Analyses of baseline data and pre- to post-course changes included a between-subject Group factor. As past research has shown that the most influential TCI scales on self-reported resilience were harm avoidance (HA, negatively correlated to resilience) and self-directedness (SD, positively correlated to resilience) [54
], participants were classified as having a low-resilience (LR) or high-resilience (HR) profile on the basis of their HA and SD scores obtained at baseline. Participants in the LR group therefore had higher HA and lower SD scores than participants in the HR group. The clustering procedure, which assigned each participant to one of the two groups, was performed on the participants’ standardized HA and SD scores (see Figure 2
) with the k-means algorithm [83
Between-group differences at baseline were analyzed using independent-sample t tests. Pre- to post-course changes in all the tests were submitted to separate analyses of variance (ANOVAs). All the scales of QCAE, MAIA, PWB, HADS, MBI-ES and the temperament scales of TCI were analyzed, using ANOVAs with Time (Time T0, Time T1) as within-subject and Group (LR, HR) as between-subject factors. While the four temperament scales of TCI are assumed to measure relatively independent aspects of the temperament, the three character scales of TCI are considered to globally measure three aspects of the maturity and development of the self [31
], and were therefore analyzed using a single ANOVA with Time (Time T0, Time T1) and Scale (SD, C, ST) as within-subject factors and Group (LR, HR) as the between-subject factor. The same analysis was conducted for FFMQ, where the Scale levels were the five facets of mindfulness (i.e., OBS, DES, AWA, NJU and NRE), as these facets can be considered parts of the unique construct of mindfulness [63
For these ANOVAs, sensitivity power analyses were carried out as a function of available sample size (with α = 0.05, β = 0.02). These analyses showed that, except for the small main effect of Group in the RD dimension of TCI, the significant effects of interest in this study were greater than the Minimum Detectable Effect’s size (for the main effects of Group, all ηP2 > 0.109, average MDE ηP2 = 0.104; for the main effects of Time, all ηP2 > 0.108, average MDE ηP2 = 0.025; for interaction effects between Time and Group, all ηP2 > 0.081, average MDE ηP2 = 0.014).
The analyses were performed with the free software environment R, version 3.6.3 (R Foundation for Statistical Computing, Vienna, Austria). The assumptions of normality and homogeneity of variance were checked for each group of data (using a significance threshold of 0.01 to avoid alpha-inflation). Data transformation or robust tests were used in the case of violations of the normality assumption. In the case of violations of the sphericity assumption, the degrees of freedom in the ANOVA were corrected by applying the Greenhouse–Geisser procedure (indicated by [GG] in the results). All post-hoc pairwise contrasts were performed using the Holm–Bonferroni procedure. As a measure of effect size, the Partial Eta-Squared (ηP2) was used. All effects are reported as significant at p < 0.05.