A synergistic mindsets intervention protects adolescents from stress.

Social-evaluative stressors-experiences in which people feel they could be judged negatively-pose a major threat to adolescent mental health1-3 and can cause young people to disengage from stressful pursuits, resulting in missed opportunities to acquire valuable skills. Here we show that replicable benefits for the stress responses of adolescents can be achieved with a short (around 30-min), scalable 'synergistic mindsets' intervention. This intervention, which is a self-administered online training module, synergistically targets both growth mindsets4 (the idea that intelligence can be developed) and stress-can-be-enhancing mindsets5 (the idea that one's physiological stress response can fuel optimal performance). In six double-blind, randomized, controlled experiments that were conducted with secondary and post-secondary students in the United States, the synergistic mindsets intervention improved stress-related cognitions (study 1, n = 2,717; study 2, n = 755), cardiovascular reactivity (study 3, n = 160; study 4, n = 200), daily cortisol levels (study 5, n = 118 students, n = 1,213 observations), psychological well-being (studies 4 and 5), academic success (study 5) and anxiety symptoms during the 2020 COVID-19 lockdowns (study 6, n = 341). Heterogeneity analyses (studies 3, 5 and 6) and a four-cell experiment (study 4) showed that the benefits of the intervention depended on addressing both mindsets-growth and stress-synergistically. Confidence in these conclusions comes from a conservative, Bayesian machine-learning statistical method for detecting heterogeneous effects6. Thus, our research has identified a treatment for adolescent stress that could, in principle, be scaled nationally at low cost.

Neural control of affiliative touch in prosocial interaction.

The ability to help and care for others fosters social cohesiveness and is vital to the physical and emotional well-being of social species, including humans1-3. Affiliative social touch, such as allogrooming (grooming behaviour directed towards another individual), is a major type of prosocial behaviour that provides comfort to others1-6. Affiliative touch serves to establish and strengthen social bonds between animals and can help to console distressed conspecifics. However, the neural circuits that promote prosocial affiliative touch have remained unclear. Here we show that mice exhibit affiliative allogrooming behaviour towards distressed partners, providing a consoling effect. The increase in allogrooming occurs in response to different types of stressors and can be elicited by olfactory cues from distressed individuals. Using microendoscopic calcium imaging, we find that neural activity in the medial amygdala (MeA) responds differentially to naive and distressed conspecifics and encodes allogrooming behaviour. Through intersectional functional manipulations, we establish a direct causal role of the MeA in controlling affiliative allogrooming and identify a select, tachykinin-expressing subpopulation of MeA GABAergic (γ-aminobutyric-acid-expressing) neurons that promote this behaviour through their projections to the medial preoptic area. Together, our study demonstrates that mice display prosocial comforting behaviour and reveals a neural circuit mechanism that underlies the encoding and control of affiliative touch during prosocial interactions.

Society of Critical Care Medicine and American Society of Health-System Pharmacists Guideline for the Prevention of Stress-Related Gastrointestinal Bleeding in Critically Ill Adults.

RATIONALE: Critically ill adults can develop stress-related mucosal damage from gastrointestinal hypoperfusion and reperfusion injury, predisposing them to clinically important stress-related upper gastrointestinal bleeding (UGIB). OBJECTIVES: The objective of this guideline was to develop evidence-based recommendations for the prevention of UGIB in adults in the ICU. DESIGN: A multiprofessional panel of 18 international experts from dietetics, critical care medicine, nursing, and pharmacy, and two methodologists developed evidence-based recommendations in alignment with the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. Conflict-of-interest policies were strictly followed during all phases of guideline development including task force selection and voting. METHODS: The panel members identified and formulated 13 Population, Intervention, Comparison, and Outcome questions. We conducted a systematic review for each question to identify the best available evidence, statistically analyzed the evidence, and then assessed the certainty of the evidence using the GRADE approach. We used the evidence-to-decision framework to formulate the recommendations. Good practice statements were included to provide additional guidance. RESULTS: The panel generated nine conditional recommendations and made four good practice statements. Factors that likely increase the risk for clinically important stress-related UGIB in critically ill adults include coagulopathy, shock, and chronic liver disease. There is no firm evidence for mechanical ventilation alone being a risk factor. Enteral nutrition probably reduces UGIB risk. All critically ill adults with factors that likely increase the risk for stress-related UGIB should receive either proton pump inhibitors or histamine-2 receptor antagonists, at low dosage regimens, to prevent UGIB. Prophylaxis should be discontinued when critical illness is no longer evident or the risk factor(s) is no longer present despite ongoing critical illness. Discontinuation of stress ulcer prophylaxis before transfer out of the ICU is necessary to prevent inappropriate prescribing. CONCLUSIONS: The guideline panel achieved consensus regarding the recommendations for the prevention of stress-related UGIB. These recommendations are intended for consideration along with the patient's existing clinical status.

The Stress Phenotyping Framework: A multidisciplinary biobehavioral approach for assessing and therapeutically targeting maladaptive stress physiology.

Although dysregulated stress biology is becoming increasingly recognized as a key driver of lifelong disparities in chronic disease, we presently have no validated biomarkers of toxic stress physiology; no biological, behavioral, or cognitive treatments specifically focused on normalizing toxic stress processes; and no agreed-upon guidelines for treating stress in the clinic or evaluating the efficacy of interventions that seek to reduce toxic stress and improve human functioning. We address these critical issues by (a) systematically describing key systems and mechanisms that are dysregulated by stress; (b) summarizing indicators, biomarkers, and instruments for assessing stress response systems; and (c) highlighting therapeutic approaches that can be used to normalize stress-related biopsychosocial functioning. We also present a novel multidisciplinary Stress Phenotyping Framework that can bring stress researchers and clinicians one step closer to realizing the goal of using precision medicine-based approaches to prevent and treat stress-associated health problems.

Indicated Stress Prevention Addressing Adolescents with High Stress Levels Based on Principles of Acceptance and Commitment Therapy: A Randomized Controlled Trial.

INTRODUCTION: Stress affects many adolescents and is associated with physical and mental health symptoms that can have a negative impact on normative development. However, there are very few evidence-based, specific treatment approaches. The aim of the study was to investigate an eight-session group intervention using components of Acceptance and Commitment Therapy (ACT) enriched with elements of CBT (psychoeducation, problem solving) and art therapy, compared to a waitlist control (WLC) group, regarding its efficacy in reducing stress and associated symptoms. METHODS: We conducted a randomized controlled trial in eight cohorts. Eligible participants were 13-18 years old with elevated stress levels. Via block-randomization (n = 70), participants were allocated to receive ACT (n = 38) or WLC (n = 32) and subsequent ACT. We used a multimodal assessment (self-reports, interviews, ecological momentary assessment, physiological markers) before treatment (T1), after the training of the ACT group (T2) and after subsequent training in the WLC group (T3). Primary outcome was perceived stress at T2 assessed with the Perceived Stress Scale. The trial was preregistered at the German Clinical Trials Register (ID: DRKS00012778). RESULTS: Results showed significantly lower levels of perceived stress in the ACT group at T2, illustrating superiority of ACT compared to WLC with a medium to large effect size (d = 0.77). Furthermore, the training was effective in the reduction of symptoms of school burnout and physical symptoms associated with stress. CONCLUSION: Indicated prevention, especially when based on the principles of ACT and CBT, seems efficient in significantly decreasing stress in adolescents with increased stress.

The effectiveness of digital psychosocial interventions on psychological distress, depression, anxiety, and health-related quality of life in patients with gynaecological cancer: a systematic review and meta-analysis.

PURPOSE: Patients with gynaecological cancer often experience psychological issues due to multiple stressors. Psychological disturbances have debilitating effects on patients with gynaecological cancer. In recent decades, digital psychosocial interventions have rapidly advanced and been incorporated into mental health interventions. Digital psychosocial interventions could provide patients with several benefits over traditional in-person interventions, including convenience, anonymity, flexible scheduling, and geographic mobility. The aim of this systematic review was to synthesize the effectiveness of digital psychosocial intervention in reducing psychological distress, depression, and anxiety and improving health-related quality of life in patients with gynaecological cancer. METHODS: Three-step extensive search was performed on 22 December 2022 from nine bibliographic databases, trial registries and grey literature. Experimental studies involving patients with gynaecological cancer utilizing digital psychosocial interventions for the improvement of mental health outcomes were included. Meta-analysis was conducted using RevMan 5.4 software. Heterogeneity was analysed by Cochran's Q test and I2. Subgroup analyses were attempted to evaluate relative effect sizes of subgroup features. RESULTS: Meta-analysis of nine studies revealed small effect size in reduction of depression post-intervention (d = 0.24, 95% CI - 0.46 to - 0.02) and medium effect size in reduction of psychological distress post-intervention (d = 0.51, 95% CI - 0.81 to - 0.21) and follow-up (d = 0.65, 95% CI - 1.25 to - 0.05) compared to the control group. The effects of digital psychosocial interventions on anxiety and health-related quality of life were not statistically significant. CONCLUSIONS: Digital psychosocial interventions probably reduced psychological distress and slightly reduced depression amongst patients with gynaecological cancer compared to the control group, which can be integrated into clinical practice. Additional trials with rigorous methodology and bigger sample sizes are needed to validate findings. TRIAL REGISTRATION: PROSPERO (CRD42023389502).

Mental health app boost my mood (BMM) as preventive early intervention for adolescents with (sub)clinical depressive symptoms.

BACKGROUND: Depression is a common mental disorder. Detecting (sub)clinical depressive symptoms in adolescents at an early stage and offering a low-threshold early intervention can minimize the risk of serious and/or long-term depression. As such, a digital intervention can be a low-threshold preventive and early intervention. This study aims to examine whether the Boost My Mood (BMM)-app is a suitable preventive early intervention for adolescents with (sub)clinical depressive symptoms. METHODS: This naturalistic single-arm evaluation study (N = 50) was conducted in adolescents aged 16-21 with (sub)clinical depressive symptoms. Furthermore, the BMM-app was studied in relation to anxiety, worrying, stress, and sleeping problems. An exploratory objective was to determine whether positive expectations and social support are related to app use. RESULTS: The study showed a significant decrease in not only depressive symptoms, but also anxiety, worrying and stress while using the BMM-app. Sleeping problems did not significantly decrease over time while using the BMM-app. The degree of use of the BMM-app and telling significant others about using the BMM-app were both not related to a decrease in depressive symptoms. The BMM-app was used significantly more when the adolescent had told relatives about their depressive symptoms. CONCLUSIONS: A digital intervention, such as the BMM-app, can be a low-threshold preventive and early intervention for adolescents with (sub)clinical depressive symptoms. Beneficial effects of the BMM-app were reported on depressive symptoms as well as other aspects of quality of life, such as anxiety, worrying, and stress. Whereas several factors may have played a role in the current findings on depressive symptoms, there are reasons to assume that part of the reduction in symptoms could be attributed to the BMM-app. Although no causality can be assumed, this study is a first step in the implementation of preventive apps in mental health care.

Midwife-led psycho-education intervention to reduce childbirth fear: a quasi-experimental study.

This quasi-experimental study aimed to assess the impact of a midwife-led psycho-education intervention on reducing fear of childbirth (FOC) and perceived stress (PS) in pregnant women. The present study involved 96 pregnant women. The intervention group received three 30-45 min telephone sessions using 'BELIEF' (Birth Emotion-Looking to Improve Expectant Fear) psycho-education approach. The outcomes were assessed using questionnaires on childbirth attitudes and PS. Data analysis was performed using Stata version 17. In the intervention group, the mean score for FOC decreased from 39.41 ± 7.02 to 29.91 ± 5.60 (9.5; 24.1%). The mean difference (MD) of 28.22% was statistically significant (adjusted MD: -10.51, 95% CI: -11.60, -9.41, P < 0.001). In the intervention group, mean scores for PS decreased from 22.77 ± 6.94 to 18.23 ± 5.69 (4.54; 19.93%). In the control group, scores increased from 22.68 ± 6.76 to 24.82 ± 6.58 (2.14; 9.43%). The 29.36% MD was statistically significant (aMD: -6.95, 95% CI: -8.73, -5.18, P < 0.001). The findings of this study indicate that the midwife-led psycho-education intervention, utilizing the 'BELIEF' protocol over the telephone, has a significant effect on reducing FOC and PS, as well as increasing the preference for vaginal birth.

Feasibility and acceptability of a theory-based online tool for reducing stress-induced eating.

Stress-induced eating is associated with various health risks like obesity and cardiovascular disease, exacerbated by the overconsumption of unhealthy foods. This study sought to investigate replacement coping strategies for stress-induced eating that participants can seek to implement using behaviour change techniques like implementation intentions. The study adopted a feasibility and acceptability design, with 258 participants (88.37% female) aged 17-75 years old who self-reported stress-induced eating. Participants were asked to identify cues for their stress-induced eating and evaluate the acceptability of eight potential replacement coping strategies. After selecting their preferred strategy, participants formed implementation intentions, linking the strategy with their previously identified cues. There were six themes of cues for stress-induced eating as identified by participants, including a range of external and internal stressors. Themes regarding the acceptability of the replacement coping strategies were organised based on constructs from integrated social cognition theories. Participant responses reflected cognitive and affective attitudes, and control and normative beliefs behind engagement in coping behaviour; further, automatic and volitional processes were described by participants as playing a role in whether a coping strategy was deemed as useful. Plans formulated by participants commonly detailed specific situations and strategies to utilise, though few described start times or durations of their plan. Action planning was found to significantly increase following formation of implementation intentions, and participants' descriptions supported the feasibility and acceptability of utilising implementation intentions to adopt alternative coping strategies to stress-induced eating. Future research should conduct a randomised controlled trial to assess the efficacy of the implementation intentions intervention in promoting uptake of replacement coping strategies to reduce stress-induced eating.

Applying the Family Stress Model to responsive feeding and early obesity prevention.

Rapid weight gain during infancy and obesity during early childhood may lead to adverse health outcomes during later childhood and into adulthood, especially in families experiencing economic hardship. Families experiencing economic hardship may also experience food insecurity, which can impact child development and responsive feeding, an important target for obesity prevention in early life. The Family Stress Model suggests that stress, particularly economic hardship, can negatively impact parents' mental health, parenting, and quality of family relationships. This review proposes a conceptual model that expands upon the original Family Stress Model by including parent-child dyadic interactions during feeding (i.e., responsive feeding) as well as the coparenting relationship around feeding. Our conceptual model integrates responsive feeding into the Family Stress Model and includes the impact of food insecurity on feeding and child health outcomes. Such models that consider multiple influences on child development have implications for the design of effective interventions to promote healthy growth for entire families. Future directions in this research will empirically test the model and explore early intervention strategies that aim to promote responsive feeding, nutrition security, and health within families. Continuing interdisciplinary research between the fields of nutrition and family development will be key to addressing the complex interplay of family stressors, parent responsiveness, and childhood obesity.

A model for improving the learning environment in high-stress and emotion-bound clinical settings.

INTRODUCTION: In clinical settings, it is necessary to create a clinical learning environment that provides the ground for the learners to acquire competencies especially in high-stress and emotion-bound clinical settings. METHODS: In the present study, a model for improving the learning environment in high-stress and emotion-bound clinical settings was designed by conducting a multi-method study in the form of three sub-studies. RESULTS: This model was designed with 3 pivotal concepts; organizing learning opportunities around safe care, fair participation in learning opportunities and creating a positive emotional climate and 6 peripheral concepts; designing physical space and appropriate equipment for education and care, preparing learners to attend the clinical setting, preparing learners to participate in learning opportunities, balancing the learner role and the care provided by the learners, the presence of a competent educator and providing education to all learners, and acquiring the ability to manage emotions by learners, faculty and staff. CONCLUSIONS: The implementation of the model obtained from this study provides the basis for solving the challenges of clinical learning environments, especially in high-stress and emotion-bound clinical settings, and improves clinical education and the realization of educational and care outcomes.

A Qualitative Analysis of the Impact of Preoperative Mindfulness-Based Stress Reduction on Total Knee Arthroplasty Surgical Experiences.

We qualitatively explored the impact of preoperative mindfulness-based stress reduction (MBSR) on total knee arthroplasty (TKA) experiences. Participants (n = 10) who received MBSR prior to TKA participated in semi-structured interviews concerning their experiences with MBSR and its perceived impact on surgery. We analyzed interviews according to reflexive thematic analysis, and coded data into three main themes: 1) Impact of MBSR on surgery experiences; 2) Contributors to change; and 3) Motivations for participation. Participants noted they were able to relax, feel more confident, and cope more effectively during the preoperative period, and that others in their lives noticed positive changes following their participation in MBSR. Participants' openness to mindfulness and health-related beliefs and may have contributed to the positive impacts they experienced from MBSR. Participants described being motivated to participate in MBSR to help them prepare for their surgery and to learn new coping strategies. Participants described a strong level of commitment to the intervention. With further research, integration of MBSR into prehabilitation for TKA may be appropriate.

The effect of peer mentoring program on clinical academic progress and psychological characteristics of operating room students: a parallel randomized controlled trial.

BACKGROUND: One of the new educational systems is the mentorship method. This study aimed to investigate the effect of peer mentoring program on clinical academic progress and psychological characteristics of operating room students. METHODS: This research was a randomized controlled trial that was conducted on undergraduate students in the operating room department of Khomein Faculty of Medical Sciences, Markazi Province in Iran. The number of operating room students were 70 that were divided into intervention and control groups by random allocation using Permuted Block Randomization. Inclusion criteria included all operating room students who were in internship, and exclusion criteria included failure to complete the questionnaires. The data collection tools were the demographic questionnaire, Depression Anxiety Stress Scale, Rosenberg Self-Esteem Scale and Situational Motivational Scale. In the control group, clinical training was done in the traditional way. In the intervention group, training was done by peer mentoring method. The obtained data were analyzed using descriptive statistics, independent t-test, paired t-test, chi-square test, ANCOVA, univariable and multivariable linear regression. RESULTS: The study revealed significant differences between the intervention and control groups. Post-intervention, the intervention group demonstrated substantial increases in self-confidence (mean difference = 5.97, p < 0.001) and significant reductions in stress levels (mean difference = -3.22, p < 0.001). Conversely, minimal changes were noted in the control group for both self-confidence (mean difference = 0.057, p = 0.934) and stress levels (mean difference = 0.142, p = 0.656). Although both groups experienced decreases in anxiety and depression levels, these changes were not statistically significant (p > 0.05). Furthermore, the intervention significantly enhanced academic progress in the intervention group compared to the control group (mean difference = 20.31, p < 0.001). CONCLUSION: The results showed that the implementation of the peer mentoring program was effective in improving academic progress, self-confidence, and reducing the stress of operating room students. Therefore, this educational method can be used in addition to the usual methods to improve the education of operating room students.

The effect of facilitated tucking and white noise on stress and sleep of newborns receiving nasal continuous positive airway pressure.

OBJECTIVE: To investigate the effects of facilitated tucking and white noise on stress and sleep in neonates receiving nasal continuous positive airway pressure (CPAP). METHOD: This study was conducted as a randomised controlled experimental study of neonates receiving nasal CPAP in neonatal intensive care units. The study sample consisted of 108 newborns (facilitated tucking (n = 36), white noise (n = 36) and control (n = 36)) receiving nasal CPAP support in the NICU. The neonates' sleep parameters were recorded by actigraphy for 24 h. Data were collected using the Neonatal Descriptive Information Form, the Sleep Tracking Form and the Neonatal Stress Scale. Percentage, mean, chi-squared and one-way ANOVA were used for data analysis. RESULTS: It was found that 50.9% of the newborns were female, their mean gestational age was 33.54 ± 3.38, their mean height was 43.56 ± 5.12, and their mean weight was 2139.23 ± 827.82. The total sleep time of the neonates in the facilitated tucking and white noise group increased by 3 h, their sleep efficiency increased by 20% and their mean stress scores decreased (p < 0.05). CONCLUSION: Facilitated tucking and white noise each showed a similar improvement in sleep duration and sleep efficiency and a reduction in stress scores in neonates receiving nasal CPAP. Close monitoring of sleep in this population and supportive care practices are recommended. PRACTICE IMPLICATIONS: The findings of this study may help to reduce sleep problems and stress levels in the clinical care of neonates in the NICU through developmental nursing practices.

The effect of trans-theoretical model interventions and motivational interviewing on stress, hope and psychological toughness in mothers of children with cancer.

PURPOSE: The present study aimed to determine the effect of trans-theoretical model (TTM) interventions and motivational interviews on stress, hope, and psychological toughness in mothers of children with cancer. DESIGN AND METHODS: In this interventional study, 70 mothers of children with cancer were randomly divided into control and intervention groups. In the intervention group, the mothers completed the questionnaires. Next, TTM-based intervention was implemented three times, once a week, each session lasting 20 min. Trained nurses performed face-to-face motivational interviewing on each mother three times, each session lasting 20 min. The parenting stress, hope, and toughness questionnaires were completed a month later for the intervention group. For the control group, questionnaires were completed at the beginning of the study and two months later. Data were analyzed using SPSS-23 software, Chi-square, Kruskal-Wallis, Fisher's exact test, and t-test. RESULTS: The average stress score in the intervention group decreased by 30.62 points, while it increased by 4.45 points in the control group. The average score for hope in the intervention group increased by 4.45 points, but it increased by 2.54 points in the control group. Finally, the average toughness score of the intervention group increased by 24.68 points, while it decreased by 3.80 points in the control group. CONCLUSION: TTM-based intervention and motivational interviewing reduced parental stress and increased hope and perseverance among mothers in the intervention group, which may contribute to improved quality of care for children with cancer. PRACTICE IMPLICATIONS: According to this study, nurses and other treatment staff can use these interventions as effective methods to reduce stress and increase the hope and psychological toughness of mothers with children with cancer.

The Effects of Mindfulness Meditation on Nursing Students' Stress and Anxiety Levels.

AIM: The aim of this study was to evaluate the effects of a virtual mindfulness meditation intervention on stress and anxiety levels of 145 nursing students. BACKGROUND: Because of the twin demands of classroom and clinical workloads, nursing students experience greater amounts of stress and anxiety than the average college student. Mindfulness meditation is a promising method to alleviate stress and anxiety. METHOD: A pretest-posttest randomized controlled design was used. Participants received either weekly mindfulness meditation recordings or recordings on nursing information. Participants completed the Perceived Stress Scale and the Generalized Anxiety Disorder-7 Scale. RESULTS: A two-way mixed analysis of variance and follow-up simple main effects tests revealed that participants in the experimental group, who received meditation recordings, experienced significantly lower levels of stress and anxiety on posttest surveys than the control group. CONCLUSION: Mindfulness meditation can reduce stress and anxiety levels in nursing students. This can improve students' overall mental and physical well-being.

Mental health intervention development for indigenous youth: Essential elements and guiding principles.

There is a need for intervention studies to address mental health issues with Indigenous youth. The purpose of this work is to: 1) consider calming approaches introduced by Native-American adolescents who described in writing how they manage day-to-day stress; and 2) identify culturally relevant constructs (elements and principles) for development of mental health promotion interventions for use with Indigenous youth. Central ideas shared by Native-American adolescents were merged with existing literature to identify essential elements and guiding principles for intervention development. Three essential elements (talking circles; mindfulness practice; tailored educational content) with associated guiding principles are recommended for intervention development.

Effects of mindfulness-based stress reduction programs on Nurses' perceived stress levels.

INTRODUCTION: Poor quality of care and patient safety, adverse patient outcomes, high rates of burnout and turnover, and increased job dissatisfaction are all linked to uncontrolled stress among nurses. Unmanaged nurse stress can lead to disorganized thinking, decreased ability to focus and concentrate, and can put patients at risk. The purpose of the integrative review was to determine the effects of a mindfulness-based stress reduction (MBSR) program to reduce the perceived stress levels of nurses. RESEARCH METHODOLOGY: Included was a search of databases using key search terms and inclusion and exclusion criteria. Relevant peer-reviewed articles within the last five years were appraised to identify similarities and differences. This paper discusses the implications of unresolved stress on nurses and patients they care for including quality and safety of patient care, cost of nurse turnover rates related to stress, and poor work efficiency. RESULTS AND DISCUSSION: Literature results suggest that implementation of a mindfulness-based stress reduction (MBSR) program leads to a reduction in perceived stress levels among nurses resulting in improved patient outcomes, increased job satisfaction, and reduction of organizational costs associated with the hiring and onboarding process. CONCLUSIONS AND FURTHER RECOMMENDATIONS: It is the conclusion of this integrative review that implementation of a MBSR program leads to improvements in stress reduction and indirectly positively impacts patient outcomes. It is recommended that organizations implement a formal eight-week mindfulness-based stress reduction program. MBSR IMPLEMENTATION RESOURCES: There are no conflicts of interest or financial gains for the recommendations for MBSR implementation resources. These resources are solely provided for additional learning and implementation purposes. There are both free resources and for purchase resources available that guides implementation and operationalization of the MBSR program.