Reduced Trauma Symptoms and Perceived Stress in Male Prison Inmates through the Transcendental Meditation Program: A Randomized Controlled Trial

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1 Reduced Trum Symptoms nd Perceived Stress in Mle Prison Inmtes through the Trnscendentl Medittion Progrm: A Rndomized Controlled Tril Snford Nidich, EdD; Tom O Connor, PhD; Thoms Rutledge, PhD; Jeff Duncn; Blze Compton, MA; Angel Seng; Rndi Nidich, EdD E-pub: 10/07/2016 ABSTRACT Context: Trum events re four times more prevlent in inmtes thn in the generl public nd re ssocited with incresed recidivism nd other mentl nd physicl helth issues. Objective: To evlute the effects of Trnscendentl Medittion (TM) on trum symptoms in mle inmtes. Design: One hundred eighty-one inmtes with moderte- to high-risk criminl profile were rndomly ssigned to either the TM progrm or to usul cre control group. Min Outcome Mesures: The nd the Perceived Stress Scle were dministered t bseline nd four-month posttest. Results: Significnt reductions in totl trum symptoms, nxiety, depression, dissocition, nd sleep disturbnce subscles, nd perceived stress in the TM group were found compred with controls (ll p vlues < 0.001). The high-trum subgroup nlysis further showed higher mgnitude of effects in the TM group compred with controls on ll outcomes, with Cohen effect sizes rnging from 0.67 to Conclusion: Results re consistent with those of prior studies of the TM progrm in other popultions nd its effects on trum symptoms nd perceived stress. INTRODUCTION Trum events re four times more prevlent in inmtes thn in the generl public. 1 Elevted trum symptoms re ssocited with poor lifestyle decision mking nd higher rtes of recidivism. 1 Experience of trum exposure lso is ssocited with dverse mentl nd physicl helth conditions, including crdiovsculr disese, metbolic disese, utoimmune disorders, nd cncer. 2,3 Recent reserch suggests n evolving role for medittion therpies in popultions with severe medicl nd psychitric symptoms. 4,5 Systemtic reviews of clinicl trils investigting medittion therpies such s the Trnscendentl Medittion (TM) technique reported evidence of benefits on outcomes rnging from nxiety nd depression to hypertension. 4-7 Correctionl fcility residents represent one lrge-scle popultion exposed to heightened stress tht my benefit from prcticing medittion. Prison inmtes report high levels of premorbid stress nd incresed exposure to trum nd violence before incrcertion reltive to the generl popultion. 8,9 Poor stress mngement skills my further contribute to behviorl problems mong inmtes during incrcertion tht could ffect their bility to benefit from rehbilittion opportunities. In review of medittion prctices in inmte popultions, the TM progrm hd the lrgest body of support, including reserch showing sttisticlly significnt reductions of psychologicl distress fctors mong inmtes receiving TM instruction. 10 On the bsis of these initil findings, rndomized controlled Perm J 2016 Fll;20(4): tril of prison inmtes ws designed to evlute the impct of this stress reduction progrm on trum symptoms nd trum-ssocited fctors. The current rticle describes the results of rndomized controlled study investigting the effects of the TM progrm on totl trum symptoms: nxiety, depression, dissocition, sleep disturbnce subscles, nd perceived stress in popultion of inmtes with moderte- to high-risk criminl profile. Although reserch hs been conducted on this intervention s ppliction to specific types of trum in other popultions, 11,12 this is the first known published study to evlute the effects of the TM progrm on trum symptoms in prison inmtes. METHODS Subjects One hundred eighty-one mle inmtes in the Oregon stte correctionl system were rndomly ssigned to either the TM progrm (n = 90) or no-tretment control group (n = 91). Two prisons took prt in this tril: Oregon Stte Correctionl Institution nd Oregon Stte Penitentiry. Both prisons re run by the Oregon Deprtment of Corrections nd re locted in Slem, OR. Oregon Stte Correctionl Institution is medium-security prison housing pproximtely 900 men. Oregon Stte Penitentiry is mximum-security prison housing bout 2400 men. To be eligible for the study, the men hd to hve t lest four months of their prison Snford Nidich, EdD, is Professor nd the Director of the Center for Socil nd Emotionl Helth t Mhrishi University of Mngement in Firfield, IA. E-mil: snidich@mum.edu. Tom O Connor, PhD, is n Assistnt Professor of Criminl Justice t Western Oregon University in Monmouth. E-mil: oconnortom@ol.com. Thoms Rutledge, PhD, is Stff Psychologist t Veterns Administrtion Sn Diego Helthcre System in L Joll, CA. E-mil: thoms.rutledge@v.gov. Jeff Duncn is Reserch Anlyst for the Oregon Deprtment of Corrections in Slem. E-mil: jeff.b.duncn@doc.stte.or.us. Blze Compton, MA, is n Affilited Reserch Associte t the Center for Socil nd Emotionl Helth t Mhrishi University of Mngement in Firfield, IA. E-mil: blzecompton@gmil.com. Angel Seng is n Affilited Reserch Associte t the Center for Socil nd Emotionl Helth t Mhrishi University of Mngement in Firfield, IA. E-mil: seng.ngelk@gmil.com. Rndi Nidich, EdD, is Senior Resercher t the Center for Socil nd Emotionl Helth t Mhrishi University of Mngement in Firfield, IA. E-mil: rnidich@mum.edu. The Permnente Journl/Perm J 2016 Fll;20(4):

2 Reduced Trum Symptoms nd Perceived Stress in Mle Prison Inmtes through the Trnscendentl Medittion Progrm: A Rndomized Controlled Tril sentence left to serve nd hve t lest moderte-risk level on the Automted Criminl Risk Score. This score is generted from n lgorithm tht uses seven risk fctors: ge, erned time, sentence length, revoction, number of prior incrcertions, prior theft convictions, nd type of crime (person, property, or sttutory). Procedures Trnscendentl Medittion Progrm The tretment group ws tught the TM technique in stndrd 7-step course (during 5 sessions lsting pproximtely 1 hour per session). They were then encourged to prctice this stress reduction technique for 20 minutes twice dy, once in the morning nd once in the lte fternoon. Two certified TM techers who hd more thn 10 yers of teching experience were the instructors for this study. The sme stndrdized TM course sequence ws used for ll study prticipnts; this sequence is described fully in the literture. 13 The TM technique is simple, nturl, effortless technique tht llows the mind to experience finer levels of the thinking process until the mind trnscends nd experiences the lest excited stte of humn wreness. 13 Overll, TM produces profound stte of restful lertness. 14 Prticipnts in the TM group lso hd the option to ttend group follow-up trining nd medittion sessions severl times week during the four-month intervention. No-Tretment Controls Subjects in the control group continued with their dily schedule nd did not prticipte in the TM progrm. All subjects in both groups continued to receive their usul cre. Outcome Mesures The following mesures were dministered t bseline nd four-month posttesting. Written informed consent ws received from ll subjects before testing. The (TSC) ssesses trum-relted problems in severl ctegories, 15 with the source of the trum being psychologicl nd/or physicl. A modified TSC inventory ws used in this study, which included 30 of the originl Tble 1. Bckground nd demogrphic chrcteristics by group for entire smple Vrible Trnscendentl Medittion (n = 90) Control (n = 91) p vlue Age, yers ± ± 8.22 NS Rce/ethnicity, no. (%) White 47 (52) 48 (53) NS Hispnic 8 (9) 4 (4) Africn Americn 17 (19) 12 (13) Ntive Americn 14 (16) 14 (15) Other 4 (4) 13 (14) ACRS 0.33 ± ± 0.16 Perceived Stress Scle ± ± 6.96 Totl trum ± ± Anxiety subscle 2.99 ± ± Dissocition subscle 3.39 ± ± Depression subscle 6.07 ± ± Sleep disturbnce subscle 7.72 ± ± 4.62 NS Dt re presented s bseline men ± stndrd devition unless indicted otherwise. ACRS = utomted criminl risk score; NS = not significnt. Tble 2. Four-month djusted posttest scores for trum-ssocited symptoms Vrible Trnscendentl Medittion (n = 73) Control (n = 71) p vlue d Perceived Stress Scle ± ± 0.76 < Totl trum ± ± 1.75 < Anxiety subscle 2.08 ± ± 0.42 < Dissocition subscle 1.80 ± ±.0.29 < Depression subscle 3.25 ± ±.0.32 < Sleep disturbnce subscle 3.62 ± ±.51 < Dt re presented s djusted posttest men ± stndrd error. d = effect size bsed on Cohen s d. Tble 3. Bckground nd demogrphic chrcteristics for the high-trum symptoms subgroup (bseline totl trum score 26) Vrible Trnscendentl Medittion (n = 41) Control (n = 53) p vlue Age, yers ± ± 8.29 NS ACRS 0.36 ± ± 0.16 NS Perceived Stress Scle ± ± 5.74 NS Totl trum ± ± Anxiety subscle 6.56 ± ± Dissocition subscle 5.00 ± ± 2.40 NS Depression subscle 8.90 ± ± 3.12 NS Sleep disturbnce subscle ± ± 3.70 NS Dt re presented s bseline men ± stndrd devition. ACRS = utomted criminl risk score; NS = not significnt. test items to give totl score nd scores on the following subscles: dissocition, depression, nxiety, nd sleep problems. 15 Ech symptom item ws rted ccording to its frequency of occurrence, using 4-point scle rnging from 0 = never to 3 = often. The TSC ddresses brod trum-relted symptoms nd hs strong 44 The Permnente Journl/Perm J 2016 Fll;20(4):16-007

3 Reduced Trum Symptoms nd Perceived Stress in Mle Prison Inmtes through the Trnscendentl Medittion Progrm: A Rndomized Controlled Tril Tble 4. Four-month djusted posttest scores for trum-ssocited symptoms in the high-trum subgroup (bseline totl trum score 26) Vrible psychometric properties. 16 The TSC hs been found to relibly index trum sequele. 17 The modified TSC used in this study produced Cronbch α = Perceived Stress Scle The Perceived Stress Scle is 10-item inventory with totl score designed to ssess the self-perception of stress. 18 No-tretment control group Allocted to intervention (n = 91) Received llocted tretment (n = 91) Did not receive llocted intervention (n = 0) Lost to follow-up (n = 20) Declined to complete posttesting (n = 20) Anlyzed (n = 71) Excluded from nlysis becuse of posttesting noncomplince (n = 20) Trnscendentl Medittion (n = 32), men + SE Figure 1. CONSORT flow digrm. CONSORT = Consolidted Stndrds of Reporting Trils. Assessed for eligibility (N = 302) Excluded (n = 121) Not meeting inclusion criteri (n = 36) Declined to prticipte (n = 85) Rndomized (n = 181) Control (n = 41), men + SE p vlue d Perceived Stress Scle ± ± 1.02 < Totl trum ± ± 2.47 < Dissocition subscle 2.15 ± ± 0.40 < Depression subscle 3.86 ± ± 0.69 < Anxiety subscle 2.57 ± ± 0.61 < Sleep problems subscle 4.53 ± ± 0.71 < d = effect size bsed on Cohen s d; SE = stndrd error. Responses re bsed on the previous 4 weeks, using 5-item response set, rnging from Never to Very often. The level of perceived stress mesured by the Perceived Stress Scle hs been found to be sensitive to medittion intervention. 19 Cronbch α for the Perceived Stress Scle is reported to be Trnscendentl Medittion group Allocted to intervention (n = 90) Received llocted intervention (n = 90) Did not receive llocted intervention (n = 0) Lost to follow-up (n = 17) Declined to complete posttesting (n = 12) Trnsferred to nother prison (n = 3) Erly relese (n = 2) Anlyzed (n = 73) Excluded from nlysis becuse of posttesting noncomplince (n = 17) Sttisticl Anlysis Anlysis of covrince, djusting for bseline dependent scores, ws used for ll nlyses. Effect sizes, bsed on Cohen s d, were clculted using men chnge score group differences/posttest pooled stndrd devition. In ddition, subgroup nlyses were conducted using high-trum subjects (equl to or greter thn the men bseline totl trum score for the combined groups). Completer nlysis ws conducted for ll subjects who were posttested, regrdless of level of tretment complince. Alph ws set t 0.05, two-tiled. RESULTS Tble 1 shows the subjects demogrphic nd bckground chrcteristics by group for the entire smple. The men ge of the men prticipting in the study ws 29 yers. Approximtely 52% were white, 16% were Africn Americn, nd 15% were Ntive Americn. Figure 1 shows the CONSORT flow digrm for ll subjects. A totl of 144 subjects (TM: n = 73; Control: n = 71) completed both bseline nd 4-month posttesting. Tble 2 shows men chnges on the totl trum scle, trum subscles, nd Perceived Stress Scle. Significnt reductions in totl trum (F[1, 141] = 19.73, p < 0.001), s well s the dissocition (F[1, 141] = 18.21, p < 0.001), depression (F[1, 141] = 13.32, p < 0.001), nxiety (F[1, 141] = 14.23, p < 0.001), nd sleep disturbnce subscles (F[1, 141] = 21.61, p < 0.001) on the TSC, nd perceived stress (F(1, 140) = 27.09, p < 0.001) were observed in the TM group compred with controls. Effect sizes were mostly in the moderte to lrge rnge, with depression nd nxiety subscles = 0.50 nd the Perceived Stress Scle = Seventy-nine of the 90 men (88%) rndomly ssigned to the TM group completed the initil TM course. During the course of the study, 80% of the men (72) were complint with TM prctice (defined s t lest once dy), with 68% (62) prcticing twice dy on verge. Tble 3 shows the demogrphic nd bseline dt for the high-trum symptoms subgroup (TM: n = 32; control: n = 41). Tble 4 shows chnges on the totl trum scle, trum subscles, nd The Permnente Journl/Perm J 2016 Fll;20(4):

4 Reduced Trum Symptoms nd Perceived Stress in Mle Prison Inmtes through the Trnscendentl Medittion Progrm: A Rndomized Controlled Tril the Perceived Stress Scle for the hightrum symptoms subgroup. Significnt reductions in totl trum score (F[1, 70] = 14.20, p < 0.001); the dissocition (F[1, 70] = 17.60, p < 0.001), depression (F[1, 70] = 14.29, p < 0.001), nxiety (F[1, 70] = 11.97, p = 0.003), nd sleep disturbnce subscles (F[1, 70] = 13.09, p = 0.001); nd the Perceived Stress Scle (F[1, 69] = 18.60, p < 0.001) were observed in the TM group compred with controls. Effect sizes were reltively lrge, rnging from 0.67 to DISCUSSION In this clinicl tril, the TM technique showed significnt reductions in TSC totl trum symptoms; nxiety, depression, the dissocition, nd sleep disturbnce subscles of the TSC; nd in the Perceived Stress Scle reltive to usul-cre control group. Results for the high-trum symptoms subgroup indicted tht the TM progrm might be prticulrly efficcious for those with higher levels of trum symptoms. Trum ws the focus of the current intervention effort for three resons. First, correctionl fcility residents re known to report high rtes of trum bckgrounds compred with noncorrectionl fcility popultions. Second, lthough previous TM reserch in correctionl settings hs shown improvement in other psychosocil stress fctors, no known reserch to dte hs specificlly focused on trum s min study outcome. Lst, lthough growing body of TM reserch suggests tht this technique my be prticulrly beneficil for reducing trum symptoms, 11,12 there is need for lrger rndomized controlled trils to ssess the impct of the TM progrm on trum symptoms nd ssocited fctors. To our knowledge, this is the lrgest rndomized controlled tril to dte of the effects of the TM progrm on trum symptoms, nd the first of its kind conducted in correctionl setting. Prior studies hve been conducted on veterns nd interntionl refugees in communitybsed settings nd hve found similr results in reductions in trum symptoms becuse of TM prctice. 11,12 The current findings therefore build on prior gps in the literture, extend the rnge of mentl helth benefits previously documented on the TM progrm, nd provide further evidence for the clinicl vlue of providing TM in correctionl fcilities nd other institutionl settings. Prior reserch indictes tht regulr TM prctice decreses hyperrousl of the sympthetic nervous system nd hypothlmic-pituitry-drenl xis, 20,21 providing possible mechnism for how TM prctice my reduce trum symptoms. 22 This sme mechnism hs been proposed for the effects of the TM progrm on crdiovsculr disese. 23 Evidence linking trum exposure nd crdiovsculr disese hs been found cross different popultions nd stressor events. 2 This tril offered severl methodologic strengths, including rndomized controlled design, high tretment-complince rtes, nd high-trum symptoms subgroup. Limittions included the use of notretment control condition in the study rther thn more ctive control condition. There is, therefore, the possibility tht t lest some of the benefits ssocited with the TM intervention re not specific to TM. Future reserch with more ctive control group should be used to determine the degree of unique benefits ssocited with TM. The long-term stbility nd further improvement in trum symptoms cnnot be determined becuse of the bsence of follow-up mesurement beyond the four-month posttest ssessment dte. Finlly, reserch on the TM progrm should be conducted on femle popultion of inmtes to determine the generlizbility of effects cross genders. Future studies of trum symptoms in prison popultions should focus specificlly on inmtes with documented posttrumtic stress disorder nd should tke into ccount other psychitric disorders tht my be present, s well s stndrd psychotherpy nd drug tretments being dministered. Future reserch lso should ssess the reltionship of trum symptoms to functionl impirment nd other qulity of life issues. CONCLUSION These findings extend prior reserch on TM nd trum symptoms. A recent review of posttrumtic stress disorder reserch indictes need for novel, evidence-bsed tretments to supplement first-line therpies. 24 The current study findings, long with those of prior reserch on TM nd posttrumtic stress, 11,12 suggest tht the TM progrm holds promise for the tretment of trum nd stressrelted disorders. v Trnscendentl Medittion nd TM re service mrks registered in the US Ptent nd Trdemrk Office, licensed to Mhrishi Foundtion, nd used under sublicense. Disclosure Sttement Blze Compton, MA, is prt-time consultnt to Mhrishi Foundtion USA Inc, Firfield, IA. The other uthors hve no conflicts of interest to disclose. Acknowledgments The reserch ws supported by the Dvid Lynch Foundtion, New York, NY. We wish to thnk Mtt Dixon for his prticiption in the project. Kthleen Louden, ELS, of Louden Helth Communictions provided editoril ssistnce. Authors Contributions Snford Nidich, EdD, nd Rndi Nidich, EdD, prticipted in the study design, nlysis of dt, nd drfting nd criticl review of the finl mnuscript. Tom O Connor, PhD, prticipted in the study design, collection of dt, nd drfting nd criticl review of the finl mnuscript. Angel Seng prticipted in the sttisticl nlysis nd drfting of the mnuscript. Blze Compton, MA, prticipted in the delivery of Trnscendentl Medittion tretment. Thoms Rutledge, PhD, prticipted in drfting of the mnuscript nd criticl review. Jeff Duncn prticipted in dt cquisition nd criticl review of the mnuscript. All uthors hve given finl pprovl to the mnuscript. How to Cite this Article Nidich S, O Connor T, Rutledge T, et l. Reduced trum sypmtoms nd perceived stress in mle prison inmtes through the Trnscendentl Medittion progrm: A rndomized controlled tril. Perm J 2016 Fll;20(4): DOI: org/ /tpp/ References 1. Ardino V, Milni L, Di Blsio P. 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