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First responders report elevated rates of mental disorders, including posttraumatic stress disorder (PTSD), yet many are reluctant to seek care. Preventative resilience training programs attempt to proactively address this issue, and there is evidence showing promise for programs targeting cognitive processes. However, these programs rarely address the physical health conditions associated with PTSD. There is emerging evidence of mind-body exercise training improving PTSD symptoms as well as its associated physical health symptoms. However, the feasibility and acceptability of delivering a web-based mind-body resilience training among first responders are not yet known.
This study aimed to evaluate the feasibility, usability, and acceptability of a web-based mind-body tactical resilience training program designed for first responders. In addition, we explored the preliminary effectiveness of the training program on mental health outcomes, adaptive cognitive strategies, and work productivity.
A total of 42 first responders based in the United States enrolled in the web-based training program. Participants were administered web-based surveys before enrolling in the 6-week web-based program and at the end of the program. The primary outcomes of feasibility were measured using the number of training hours, program adherence rates, and self-reported data on frequency of practice. Acceptability and usability were measured using self-reported data. Secondary outcomes were symptoms of PTSD, psychological distress, emotion regulation, stress mindset, psychological preparedness, and work performance.
Overall, the training program was feasible based on the median number of training hours spent on the web-based program (7.57 hours out of an expected total of 6 to 9 hours), and 55% (23/42) of the enrolled participants completed more than half of the program. Although acceptability, usability, and frequency of practice were rated as high, this was based on only 29% (12/42) of the respondents who provided follow-up data. Secondary outcomes showed a significant improvement in the adaptive cognitive strategy of the stress mindset, with a mean difference of –5.42 (SD 4.81; 95% CI −8.475 to −2.358;
These findings suggest that a mind-body tactical resilience training program delivered in a web-based format is feasible and acceptable among first responders; however, further refinements may be required to improve adherence rates. Further research using a larger, more rigorous trial design is warranted to examine the effectiveness of this type of training as a possible prevention or treatment strategy for this population.
First responders are regularly exposed to trauma and report elevated rates of mental health morbidities, including depression, suicidal thoughts and behavior, heavy alcohol use, and posttraumatic stress disorder (PTSD) [
A type of training rising in popularity in many first responder organizations is resilience training. This training seeks to prevent the development of psychiatric illnesses by equipping individuals with adaptive coping skills that would enable them to maintain psychological health despite exposure to adversity [
To date, promising evidence has been found for preventative resilience training targeting cognitive processes in military settings, another high-risk occupation group. A randomized controlled trial (RCT) on Israeli infantry soldiers examining the impact of a preventative attention bias modification training found that participants who received 4 sessions of attention bias modification training delivered before combat deployment had a significantly lower PTSD rate following combat exposure compared with those who did not receive the training. Another RCT on military cadet officers compared the effect of 2 other types of resilience training, one involving the use of a single session on coping skills using arousal training and adaptive thinking styles and the other involving multiple sessions of guided self-reflection that targeted maladaptive cognitions by reframing the experience of stress using more adaptive cognitive strategies such as growth and stress-is-enhancing mindsets [
A type of physical activity intervention that uniquely integrates both psychological and physical health strategies is yoga training, a type of mind-body exercise that combines breathing techniques, controlled physical movement, and mindfulness practices simultaneously [
Indicative evidence has also been found for programs that include mind-body approaches using a web-based format [
A novel web-based mind-body tactical resilience training program was developed specifically for first responders to address these research gaps. The primary aim of this study was to ascertain the feasibility, acceptability, and usability of a web-based mind-body tactical resilience training program that is culturally informed and job-specific to first responders. In addition, the study explored the secondary outcomes of the preliminary effectiveness of the web-based training program in (1) reducing symptoms of PTSD and psychological distress; (2) modifying mindsets about stress, emotion regulation, and perceived psychological preparedness; and (3) improving work productivity.
The Online 6-Week Tactical Resilience Training program (
Screenshot of the Online 6-Week Tactical Resilience Training program landing page.
Screenshot of the Online 6-Week Tactical Resilience Training program dashboard.
Screenshot of an article.
Screenshot of a homework video.
As part of the modeling phase, first responders based in the United States were previously surveyed on the relevance of techniques and sections as well as web-based content preferences to determine the feasibility, acceptability, and usability. This consultation phase was not part of the research study and was conducted by the YFFR program developers before the development of the web-based program. To consult with first responders, YFFR placed an advertisement in their regular web-based newsletter to their local first responder network asking for feedback on the development of a web-based training program. Interested first responders were directed to a web-based survey as part of the advertisement. A total of 78 first responders answered this anonymous web-based survey, half of whom (39/78, 50%) had attended a previous YFFR training. Questions were asked on general interest in a web-based mind-body resilience training program; current yoga and meditation practices (if any), including frequency and place of practice; preferences for a web-based program, including time commitment and preferred time of day; helpful reminder cues; learning tools; use of technology; preferences for live classes; and strategies to encourage training participation. Examples of the questions include the following:
The web-based program was based on the YFFR in-person training protocol, which was designed to provide proactive resilience training specifically for first responders. It is primarily based on the principles of traditional Hatha yoga, which involves regulation of breathing using synchronized movements and postures, as well as trauma-sensitive yoga, a trauma-informed approach designed with trauma survivors in mind to cultivate a safe environment [
Although the web-based training program was intended to be self-paced, participants were expected to complete the course within a 6-week period, with automated weekly reminders sent to prompt program adherence. The 6-week time frame was based on the expected time commitment of 1 week per module; however, participants were given an additional 2 weeks to catch up on any materials missed. The program was mobile-responsive, which made access easy using a desktop, laptop, tablet, or mobile phone.
Course outline of the 6-Week Tactical Resilience Training program.
Module number | Module name | Description | Homework video or audio |
1 | Introduction: using this course | Introduction and habit creation |
20-minute yoga sequence |
2 | Foundations of Yoga For First Responders | What is yoga, mindfulness, the missing skillset, and Yoga For First Responders |
20-minute basic yoga practice 15-minute mindfulness |
3 | Processing stress | Processing stress, interoception and proprioception, and removing the armor—functional mobility training |
15-minute AMRAPa sequence for building heat 30-minute removing the armor |
4 | Building resilience | Resilience, neural pathways, perception, and recovery |
16-minute sleep recovery 10-minute breathwork and mental reframing technique 1 10-minute breathwork and mental reframing technique 2 |
5 | Enhancing performance | Flow, job- or life-specific application, and handling challenges |
13-minute yoga sequence 13-minute yoga warm-up for SWATb operators |
6 | Conclusion: continuing your training | Additional web-based resources, community networks, final quiz, and certificate of completion |
20-minute daily yoga practice 5-minute before-shift practice 5-minute after-shift practice |
aAMRAP: as many rounds as possible.
bSWAT: special weapons and tactics.
This study aimed to examine the feasibility, acceptability, and usability of the 6-Week Tactical Resilience Training program and explore the preliminary effectiveness of a web-based mind-body tactical resilience training program specifically designed for the needs of active-duty first responders. The study was conducted with a small group of first responders where all participants were allocated to receive the intervention. Participants comprised first responders located throughout the United States with no previous training or relationship with YogaShield YFFR.
Participants were recruited through email advertisements that were circulated to YogaShield’s first responder networks located across metropolitan and regional areas throughout the United States. Using snowball sampling methods, these networks then distributed the email advertisements to their social and professional networks. First responders with no previous YFFR training were invited to participate in the study. Participants met the inclusion criteria if they were current active-duty frontline first responders, specifically firefighters, police, and paramedics, and dispatchers who were either in paid employment or in a volunteer capacity. Participants also had to currently reside in the United States, be aged ≥18 years, and speak English. The recruitment advertisement described the purpose of the study and what would be involved and contained a link to the study website as well as the participant information sheet and consent form. The advertisement also emphasized that participation in the study was voluntary and not a requirement of their job. Study recruitment occurred in February 2021 for approximately 3 weeks.
Each participant completed their own informed consent form by indicating their agreement with a declaration statement. By agreeing to take part in the study, participants declared that they had read and understood the participant information sheet, could ask any questions they may have, understood the risks and benefits, and knew that they were free to withdraw at any point throughout the duration of the study without penalty or consequences. Agreement was expressed by checking a box and providing their name and email address. Participants were also informed that the study data would be deidentified before analysis. Compensation was not provided for participation. Ethics approval was obtained from the Human Research Ethics Committee and the University of New South Wales before the commencement of the study (HC200707).
Eligible participants who consented to the study were directed to complete the baseline assessment on the web. Upon completion, participants were provided with a hyperlink to register for the web-based training program by entering their name and preferred email address. Log-in credentials were automatically sent to participants’ designated email address. The web-based training program was made available at the end of the recruitment period on February 22, 2021, after which all the registered participants were able to commence the course. The web-based program was designed to be completed within a 6-week period, with an additional 2-week “catch-up” period. Although participants were encouraged to complete the program within 8 weeks, the program was still available for those who were unable to complete the web-based course within that time frame. Automatic email reminders were sent before the start of the web-based program, as were weekly reminders to continue working through the program. Web-based follow-up surveys were distributed upon completion of the web-based training program or at the end of the 8-week study period for those who had not yet completed the program within that time frame.
The baseline and postintervention surveys were collected electronically via the REDCap (Research Electronic Data Capture; Vanderbilt University) platform [
Demographic information, including age, gender, occupation type, employment status, length of service, previous yoga or resilience training, and help seeking, was collected at the start of the baseline survey. Participants were also asked to indicate the approximate number of critical incidents that they had attended since becoming a first responder. The first 2 items on serious injuries and fatalities were based on a previous study on the impact of cumulative exposure on first responder mental health [
The feasibility of the web-based program was based on the number of hours spent on the program as well as program adherence data obtained from the hosting platform. On the basis of a previous feasibility study for web-based delivery of a similar mindfulness-based training with active-duty first responders, we established at least 50% of participants completing more than half of the program as the cutoff benchmark for feasibility [
The web-based follow-up assessment also contained measures of usability and acceptability, which were adapted from a previous study on a web-based mental health training program for first responders and construction workers [
The preliminary effectiveness of the secondary outcomes was assessed at baseline and at the 8-week follow-up time point. Symptoms of PTSD were measured using the PTSD-8 [
Psychological distress was measured using the 6-item Kessler Psychological Distress Scale (K6) [
Emotion regulation was assessed using the Emotion Regulation Questionnaire, a 10-item scale designed to measure respondents’ tendency to regulate their emotions through cognitive reappraisal or expressive suppression [
Mindsets on stress were measured using the Stress Mindset Measure [
Psychological preparedness was measured using a modified version of a previously validated subscale of psychological preparedness for natural disasters [
Work performance was assessed using a single item from the Health and Work Performance Questionnaire and 2 additional items pertaining to past-month sickness absence [
Descriptive statistics were used to demonstrate participants’ responses to the feasibility, acceptability, and usability of the Online Tactical Resilience Training program. Differences in the mean scores for each of the outcomes between baseline and the 8-week follow-up point were assessed using paired-sample 2-tailed
A total of 57 participants consented to the study, of whom 52 (91%) completed the baseline survey. All 52 participants were invited to register for the web-based training program, of whom 42 (81%) registered and enrolled.
The Online 6-Week Tactical Resilience Training program feasibility study procedure flow.
Sample demographic characteristics (N=42).
Characteristics | Values | |
Age (years), mean (SD) | 42.98 (7.61) | |
|
||
|
Law enforcement | 17 (40) |
|
Firefighter or rescue worker | 17 (40) |
|
Paramedic or emergency medical technician | 13 (31) |
|
Dispatcher | 3 (7) |
|
||
|
Full time | 41 (98) |
|
Part time | 1 (2) |
|
Casual or seasonal or reserve | 0 (0) |
|
Volunteer | 0 (0) |
|
||
|
Man | 25 (60) |
|
Woman | 17 (40) |
|
||
|
1 to 5 | 3 (7) |
|
>5 to 10 | 4 (10) |
|
>10 to 15 | 4 (10) |
|
>15 to 20 | 14 (33) |
|
>20 | 17 (40) |
|
||
|
No | 28 (67) |
|
Yes | 14 (33) |
|
||
|
1 to 5 | 1 (2) |
|
6 to 10 | 3 (7) |
|
11 to 20 | 4 (10) |
|
>20 | 28 (67) |
|
||
|
1 to 5 | 3 (7) |
|
6 to 10 | 5 (12) |
|
11 to 20 | 6 (14) |
|
>20 | 28 (67) |
|
||
|
0 | 9 (21) |
|
1 to 5 | 15 (36) |
|
6 to 10 | 7 (17) |
|
11 to 20 | 3 (7) |
|
>20 | 8 (19) |
|
||
|
0 | 4 (10) |
|
1 to 5 | 29 (69) |
|
6 to 10 | 8 (19) |
|
11 to 20 | 0 (0) |
|
>20 | 1 (2) |
|
||
|
0, n (%) | 8 (19) |
|
1, n (%) | 4 (10) |
|
2, n (%) | 3 (7) |
|
3, n (%) | 4 (10) |
|
4, n (%) | 2 (5) |
|
5, n (%) | 3 (7) |
|
6, n (%) | 18 (43) |
|
Value, mean (SD) | 3.64 (2.47) |
aOccupation groups are not mutually exclusive.
Analysis examining baseline predictors of program completion found no evidence that age (
Most respondents (10/12, 83%) agreed that it was easy to find the information they needed and that the main modules of the course were useful. Although most also rated the lecture videos (10/12, 83%), interactive exercises (11/12, 92%), and yoga videos (12/12, 100%) as useful or very useful, some respondents did not find the discussion forums (3/12, 25%) or live Zoom classes (if attended; 1/6, 17%) useful.
Acceptability was high among those who responded to the follow-up survey, with most respondents (11/12, 92%) agreeing that the course was engaging and interesting and met their expectations and that they would recommend the program to their coworkers. All respondents (12/12, 100%) rated the overall course as useful and believed that it helped improve their overall well-being.
The qualitative feedback received on what participants learned from the training was primarily positive. Some examples of comments included the following: “It felt good to do them, I learned something new,” “I felt so much better and the days I didn’t do my yoga I felt not so focused,” and “I learned that it is okay to put myself first, and that I can control my mindset.” The only major negative feedback regarding the course was the length of time required to complete it, as described by a participant: “Course material was more than expected and took more time, this not allowing time for homework.”
Following their use of the web-based Tactical Resilience Training program, participants reported significantly higher stress-is-enhancing mindsets compared with the baseline, with a mean difference of –5.42 (SD 4.81; 95% CI −8.475 to −2.358;
Baseline and posttraining score mean and SD for secondary outcome variables (N=12).
Measure | Baseline score, mean (SD) | Posttraining score, mean (SD) | |
PTSD-8a | 21.67 (5.23) | 20.08 (6.19) | .05 |
K6b | 7.33 (5.53) | 6.17 (6.19) | .53 |
SMMc | 15.33 (5.30) | 20.75 (7.38) | .002 |
ERQd (cognitive reappraisal) | 30.42 (5.87) | 34.42 (4.66) | .11 |
ERQ (expressive suppression) | 15.08 (5.09) | 15.33 (5.91) | .86 |
Psychological preparedness | 22.18 (4.12) | 23.91 (3.11) | .19 |
Performance | 7.45 (0.93) | 7.73 (1.27) | .34 |
Sickness absence | 3.00 (1.41) | 1.50 (0.71) | .21 |
aPTSD-8: 8-item abbreviation of the Harvard Trauma Questionnaire.
bK6: 6-item Kessler Psychological Distress Scale.
cSMM: Stress Mindset Measure.
dERQ: Emotion Regulation Questionnaire.
The primary aim of this study was to examine the feasibility, acceptability, and usability of a web-based mind-body tactical resilience training program that was culturally informed and specific to first responders. Results from the number of hours spent and program adherence rates suggest that the web-based mind-body resilience training program is feasible among active-duty first responders. Although acceptability, usability, and frequency of practice were rated as high, this was based on only 29% (12/42) of the respondents who provided follow-up data. Analyses of secondary outcomes showed a significant improvement in mindsets on stress, whereas no other significant changes were found for any of the other secondary outcomes. However, the findings on secondary outcomes were exploratory only, and our study was underpowered to assess effectiveness. To the best of our knowledge, this is the first time that a web-based mind-body tactical resilience training program designed specifically for first responders has been developed and tested.
The total number of training hours provided an indication of feasibility; however, this varied considerably between participants, with a median of 7.57 hours for the overall web-based program. A median of 5.45 hours was spent on the web-based modules, whereas a median of 1.35 hours was spent on the homework yoga videos. However, homework videos were only tracked via access through the web-based program. Access via the separate app was not tracked as part of this study as this was only intended to supplement participants’ learning and homework videos could only be accessed upon completion of the accompanying module. It is possible that the actual use of the homework videos was higher as a result. Program adherence for the web-based delivery of the mind-body resilience training surpassed the benchmark based on a previous mindfulness-based feasibility study on first responders [
Second, the web-based self-guided format for this type of program may not have met the needs of some first responders who may have preferred the presence of an instructor. Previous reviews have demonstrated the superiority of guided web-based interventions to unguided web-based interventions in improving completion rates and symptom reduction, likely because of the provision of human support, feedback, and encouragement in completing the intervention and applying newly learned skills in practice [
Our study also experienced low retention rates in the follow-up assessment. Although it is not known why this high loss occurred, this may have been due to several factors. First, it is possible that the follow-up assessment, which comprised multiple questionnaires, was too lengthy. The lack of incentives to complete the assessments may have also contributed to this high loss. Furthermore, as the research team was based overseas, there was little opportunity to communicate the benefits of the research program other than via email. Improving follow-up procedures and expanding methods of contact such as the use of social media and better recruitment procedures through first responder agencies may help improve retention rates in future studies. Finally, it is also possible that retention rates for the follow-up assessment and program completion were affected by the COVID-19 pandemic, an unprecedented time in history and a particularly demanding one for first responders because of the nature of their roles. The study trial occurred in the middle of the COVID-19 pandemic, and although it is not known if retention was directly affected by the uniqueness of the time, it is possible and understandable that adherence to the follow-up assessment and web-based program was not a priority for many first responders during this disruptive time of ongoing uncertainty.
Although our study was underpowered to detect measures of effectiveness, our significant finding on the stress mindset shows that it may be possible for this type of program to modify important perceptions of stress. Evidence is emerging on the influence of stress mindsets on perceived stress, physiological health, and mental health outcomes. Specifically, adopting a stress-is-enhancing mindset has been found to mitigate the development of depression and anxiety symptoms among college students with high levels of stress [
Our work adds to the limited studies on high-risk occupations [
Our study has a number of important limitations, most notably the small sample size and high study attrition rate, where only 29% (12/42) of the enrolled participants completed the follow-up assessment. Although high dropout rates for program completion are common for many web-based interventions [
Preliminary findings from this study suggest that this tailored web-based mind-body tactical resilience training program appeared to be feasible and acceptable among active-duty first responders. The use of mind-body exercises to integrate both psychological and physical strategies in a web-based format appears to be well received; however, further refinements to the existing program, implementation, and follow-up study procedures may be required to improve program adherence and follow-up assessment response rates. More research is required on the optimal duration and frequency of this type of program to better inform feasibility, as well as on the inclusion of social support via guided and group-based formats and social media. Given the low rates of help seeking among this population [
6-item Kessler Psychological Distress Scale
posttraumatic stress disorder
randomized controlled trial
Research Electronic Data Capture
Yoga For First Responders
LT is supported by the Australian Government Research Training Program Scholarship. RAB is supported by a National Health and Medical Research Council investigator grant (1173921). SBH is also supported by a National Health and Medical Research Council investigator grant (1178666). This study was funded by the Australian Government Research Training Program Scholarship. The funders had no access to the data and no input on the analysis and production of the manuscript.
LT, MD, RAB, and SBH declare support from the Australian Government for the submitted work. MD and SBH are employed by the Black Dog Institute, a not-for-profit research institute that provides mental health training to a range of organizations. LT is a trained instructor of Yoga For First Responders. OM is the founder and chief executive officer of YogaShield Yoga For First Responders. RMF, EMB, and JRY are employed by YogaShield Yoga For First Responders. OM, RMF, EMB, and JRY contributed to the development of the Online 6-Week Tactical Resilience Training program only and had no access to the data or input on the analysis.