Adapting Mindfulness Training for Military Service Members With Chronic Pain

Abstract

Introduction

Rates of chronic pain in military personnel are disproportionately high. Chronic pain is often associated with mental health and substance use disorders as comorbid conditions, making treatment of chronic pain complex. Mindfulness-based interventions (MBIs) are a promising behavioral approach to managing chronic pain and psychosocial sequelae. The unique nature of the military context may require adaptations to original MBIs for successful delivery in active-duty military populations. This study adapted the mindfulness-based stress reduction (MBSR) program to create a mindfulness training program that was relevant to active-duty Army personnel experiencing chronic pain. This article delineates the adaptation process employed to modify the MBSR program to the military context and discusses the resulting training program.

Materials and Methods

The adaptation process consisted of three iterative stages: 1) Drafting the preliminary intervention protocol with recommendations from stakeholders, including military healthcare providers; 2) Refining the preliminary protocol after pretesting the sessions with research team members and a military Veteran advisory committee; and 3) Delivering the preliminary protocol to one cohort of active-duty Soldiers with chronic pain, collecting feedback, and further refining the intervention protocol.

Results

Military-related adaptations to MBSR addressed three areas: military culture, language and terminology, and practical and logistical factors relevant to implementation in the military setting. This adaptation process resulted in a live, online program with six, weekly, sessions. Feedback from a military Veteran advisory committee resulted in modifications, including increasing military-relevant examples; preliminary testing with the target population resulted in additional modifications, including shortening the sessions to 75 min and structuring discussions more efficiently.

Conclusions

The adaptation process was successful in generating an engaging mindfulness training program that was highly relevant to the military context. Obtaining input from stakeholders, such as military healthcare providers and active-duty soldiers, and iterative feedback and modification, were key to the process. Moreover, the program was designed to maintain the integrity and core elements of MBIs while adapting to military culture. A future randomized controlled trial design will be used to evaluate the effectiveness of the intervention in improving chronic pain in military personnel. This program is responsive to the military’s call for nonpharmacologic treatments for chronic pain that are easily accessible. If effective, the mindfulness program has the potential for widespread dissemination to complement standard care for Service Members experiencing chronic pain.

INTRODUCTION

Managing chronic pain in U.S. military personnel is of significant concern.¹ Chronic pain is prevalent in over 40% of U.S. soldiers deployed during Operation Enduring Freedom and Operation Iraqi Freedom (OEF/IEF)² and in over 50% of U.S. military Veterans.^3–5 Chronic pain in the military imposes significant societal burden: It is the leading cause of medical discharge, and disability payments are a significant cost to the Department of Defense.⁶ Individuals with chronic pain experience high rates of functional disability, decreased quality of life, and emotional distress.⁷ Furthermore, chronic pain is frequently associated with posttraumatic stress disorder, depression, substance use disorders, and traumatic brain injury as comorbid conditions,^8,9 making treatment multi-faceted and challenging. Considering the risks^10–13 and limited effectiveness^10,14,15 of long-term opioid use, in addition to the high rates of prescribed opioid medications in Soldiers returning from combat deployment,² there is a critical need for effective non-pharmacological methods of pain management to fully address the complex problem of chronic pain.

In 2009, the U.S. Army Surgeon General chartered the Army Pain Management Task Force. The Task Force was charged with recommending a comprehensive pain management strategy to optimize the quality of life for active-duty Service Members. The final report recommended a holistic, multidisciplinary, and multimodal approach to pain management.¹ In particular, the report strongly recommended integrating complementary approaches to augment conventional pain management; among the most highly recommended were mindfulness-based interventions (MBIs), which have strong evidence for efficacy, safety, and acceptability for chronic pain management,¹ particularly among civilian populations.

Mindfulness has its origin in Eastern traditions, including Buddhist psychology and meditation practices.¹⁶ Mindfulness is now widely taught throughout the United States as a secular mind-body practice. Mindfulness skills involve the self-regulation of attention to present-moment experience¹⁷ and the development of non-judgmental awareness of moment-by-moment experience, including thoughts, emotions, or sensations that arise, even if unpleasant or unwanted.^17,18 The most extensively researched MBI is the Mindfulness-based Stress Reduction (MBSR) program. MBSR involves systematic, intensive training in mindfulness meditation and gentle yoga stretches.^19,20,21 It is delivered as a group intervention consisting of eight weekly, 2.5-h sessions and a full-day silent retreat between weeks six and seven.^19,21

MBIs, such as MBSR, are effective at improving mental and physical health outcomes in conditions including depression, anxiety,^22,23 chronic pain,^23,24 and substance use disorders.²³ They include formal practices to increase mindful awareness such as sitting and walking meditation, which can be guided or self-directed. Attention is focused on an aspect of present experience (eg, breathing and body sensations) with an open attitude, allowing thoughts, emotions, and distractions to come and go naturally without judging them. In addition, MBIs include informal practices aimed at bringing mindfulness to daily activities.¹⁷ Thus, through mindfulness training, individuals with chronic pain cultivate an attitude of detached observation toward body sensations.²⁰ This attitude can result in reduced stress response and decreased negative emotional reactivity to pain, leading to more adaptive behaviors and better mental and physical health.^25,26

Although MBIs have been found to be an efficacious behavioral approach for chronic pain,^27–29 there is a limited study of their incorporation into military settings. MBSR has been adapted to promote psychological stress resilience in active-duty pre-deployment military populations, resulting in the Mindfulness-based Mind Fitness Training (MMFT) program.³⁰ However, to our knowledge, MBI’s have not been adapted to active-duty contexts specifically for chronic pain treatment.

Given the unique military context with its own language, belief system, and set of norms, courtesies, and customs,^31–34 MBIs as implemented in civilian populations may not be socially acceptable³⁵ in a military setting.³⁰ Adaptations that consider military culture are needed to ensure that an MBI is perceived as relevant and helpful in active-duty military populations. One such aspect is the authoritarian structure of the military, consisting of rigidity, regimentation, and conformity among Service Members, with unit cohesion valued over individual autonomy.^31,32 There is a clear hierarchy and strict rules that leave little room for questioning authority figures.³¹ Even civilian professionals, such as psychologists working with Service Members, may be viewed as officer-equivalent authorities who should be shown deference.³¹ In contrast, the typical MBI encourages participants to adopt a healthy skepticism toward what the instructor says and to ask many questions during the program.^36,37

In addition, some of the traditional terminology used in MBIs is unaligned with the military context. To illustrate, the concepts of slowing down and ‘being’ rather than ‘doing’ may be seen as counterproductive, given the military’s mission-oriented setting that values action and personal sacrifice.^31,33,34 Moreover, the military has its own widely used acronyms and specialized terminology.^33,34 Healthcare providers working with military personnel and not well-versed in this language may be perceived as lacking credibility in a group that places high confidence in the knowledge of authority figures.^33,34

Practical and logistical factors could also interfere with implementing an MBI requiring lengthy, weekly in-person class time. The mobile nature of the military, the ability to be deployed or have a change of station with little notice,^31,33 and the fact that Service Members could be called to duty any time of day, renders the typical MBI format impractical. Thus, several characteristics unique to military settings indicate a need to adapt and evaluate MBIs in military populations before implementation on a large scale.

The purpose of this study was to adapt the traditional MBSR program to a distance-based, online format more suitable for active-duty Soldiers experiencing chronic pain. This article delineates the process employed to adapt mindfulness training to the military context and describes features of the resulting mindfulness training program. Although modifications to MBSR included those relevant to both military and chronic pain populations, this article focuses on military-relevant adaptations.

Mindfulness Training Program Adaptation Process

The MBSR program was adapted and developed as a distance-based, group intervention for active-duty soldiers being treated for chronic pain. The researchers utilized a formative, iterative process of drafting, revising, pretesting, and refining the adapted mindfulness intervention protocol. The intervention protocol included materials delivered via a live, interactive videoconferencing platform and a supporting mobile application (app). The RTI International Institutional Review Board (IRB) approved the study.

The adaptation process included three stages:

Stage 1: Drafting the Preliminary Mindfulness Intervention Protocol

The research team, which included investigators with experience conducting research with active-duty populations, including an OEF/IEF Veteran, first drafted a mindfulness intervention protocol based on the MBSR curriculum (see Table I for an outline of the standard MBSR program).¹⁹ Consistent with best practice of engaging stakeholders in the adaptation process,³⁷ military and pain management experts and collaborators at Womack Army Medical Center (WAMC), including physicians and psychologists, provided consultation and feedback on the draft protocol. Based on stakeholder input, the original draft was modified, resulting in a preliminary intervention protocol.

TABLE I.

Summary of the Standardized Mindfulness-based Stress Reduction (MBSR) Program

Program Format
Course duration	8 weeks
Session length and frequency	Weekly, 2 ½ h sessions and a 7-h Saturday retreat
Instructor qualifications	Daily personal mindfulness meditation practice and training in delivering the MBSR curriculum (certification available but not required)
Group size	Typically ranges from 10 to 40 participants
Typical session elements	Mindfulness skills practice; discussion of home and in-class practice experience; educational content; contemplative poem or story
Home practice	Recommended 45 min of daily practice
Course Curriculum
Formal Meditation Practices	Description
Sitting meditation	Observation of breath and other perceptions (eg, sounds, thoughts, emotions, body sensations)
Body scan	Sequentially directed attention from toes to head with the objective observation of bodily sensations and cognitive/emotional responses
Walking meditation	Observation of physical sensations of walking and any cognitive or emotional responses
Mindful movement	Gentle yoga stretches and postures with an observation of bodily sensations (can be lying down, standing, or sitting in a chair)
Loving-kindness meditation	Silent wishes of goodwill (eg, health, safety, ease, and happiness) toward oneself and others to cultivate kindness and compassion
Informal Mindfulness Practices	Description
Breathing space	Brief (1–3 minutes) mindful check-in of thoughts, emotions, sensations, and breath
Mindful eating	Observation of senses (smell, touch, and taste) and any cognitive or emotional reactions while eating
Mindfulness in daily life	Moment-to-moment awareness of experience while engaging in routine, daily activities (eg, showering and brushing teeth)
Example Educational Topics
Defining mindfulness vs. being on autopilot
Stress: The fight-or-flight response; health impacts of chronic stress
Recognizing habitual, automatic reactions (cognitive, emotional, and physical)
Mindful communication

Stage 2: Refining the Preliminary Mindfulness Intervention Protocol

A trained MBSR instructor who is a clinical psychologist working at WAMC and experienced in working with the target population delivered the first three sessions of the preliminary intervention protocol via videoconferencing, first with research team members and second with an advisory committee of U.S. Army Veterans no longer in the Service. Conducting the three draft sessions allowed the research team to evaluate the timing, flow, and delivery of the intervention using the online platform and resolve any technical problems that arose. Additionally, the advisory committee of military Veterans participated in a focus group to provide feedback with regards to acceptability and the military context, contributing to refining the preliminary protocol.

As the structure and content for the mindfulness intervention protocol was refined, the development of the accompanying mobile app ensued. The Mindfulness Training for Pain app was based on Personal Health Intervention Toolkit (PHIT) for Duty, a mobile app framework for personalized health intervention studies.³⁸ Study investigators established an app design to augment the online mindfulness program with personal delivery of didactic materials, narrated meditations, mindfulness and chronic pain resources, and contact information for professional support.

Stage 3: Pretesting With the Target Population and Further Refining the Preliminary Protocol

During this stage of the adaptation process, the same instructor delivered the refined preliminary intervention protocol via the online platform to a cohort of four active-duty soldiers being treated for chronic pain at WAMC. Although eight Soldiers originally consented to participate, one soldier was assigned to temporary duty with no access to wireless internet prior to the first session, and three soldiers were excluded for working in the same footprint as the mindfulness instructor who was also a clinical psychologist at WAMC, to prevent the possibility of a dual relationship between the instructor and a group participant. Study personnel observed sessions to assess the fidelity of intervention implementation, the timing and pacing of sessions, and participant engagement. Within a week following the six-session intervention, participants completed semi-structured phone interviews with study personnel, in which they were asked questions regarding usability, comprehension, and utility of the online mindfulness program as well as usability and utility of the mobile app feature. They were also asked to give suggestions for improving the intervention. The research team then further refined the mindfulness intervention protocol based on implementation and interview data. Once refinements to meditation narrations, learning content, and other materials were completed, they were incorporated into the Mindfulness Training for Pain app. Results of pilot feasibility testing conducted after the program development phase are not reported here.

Description of the Adapted Mindfulness Training Program

Military-related adaptations to the MBSR curriculum addressed three related areas (1) military culture; (2) language and terminology; and (3) practical and logistical factors relevant to the military.

Military Culture

To maintain the chain of command, the instructor presented the course material in a directive manner. This demeanor was important to ensure the instructor was viewed as credible and trustworthy and to increase participants’ buy-in to adhering to home practice assignments. The sessions were structured such that the instructor provided didactic information and a rationale for learning mindfulness skills for pain management and military performance before guiding participants through experiential exercises. Each session included a relevant video clip by a public figure or scientist to increase participant buy-in and engagement. Most videos referred to the utility of mindfulness in military populations or included an interview with a military Veteran or Service Member. In addition, Soldiers from different parts of the chain of command (eg, enlisted and officers) were not enrolled in the same group, so as to not detract from participants’ engagement in the sessions and to help reduce the fear of repercussions. Utilizing polling and whiteboard features that allowed participants to share information anonymously during discussions helped further address privacy and stigma.

The military’s mission orientation was addressed by presenting clear objectives for each session. Mindfulness exercises were described as skills that are useful for job readiness and optimizing performance. It was emphasized that mindfulness could help participants increase focus on the job at hand without being carried away by cognitive and emotional reactions to painful sensations caused by chronic pain. Furthermore, the training program was interspersed with military-relevant examples to help define mindfulness and demonstrate its utility within the military. Examples included how mindfulness training could be useful during physical fitness training or on a night watch. As the program was refined, the Veteran advisory committee suggested adding more military-relevant examples (eg, situational awareness to explain mindfulness; the relevance of using mindfulness during work tasks, such as rucking). See Table II for a non-exhaustive list.

Table II.

Military-Specific Examples Included in the Mindfulness Training Program

Topic	Example or Question for Participants
Mindful vs. a mindless activity	If the mind is wandering while qualifying on the shooting range, it will reduce the accuracy
The relevance of mindfulness to military performance	If you are doing a task, such as a guard duty or battle drills, and you lose focus, how does that impact performance? Let us say you are daydreaming on guard duty—what might be an outcome?
The relevance of mindfulness to military performance	Presented a research study by Jha et al.40—Minds At Attention: Mindfulness training curbs attentional lapses in military cohorts
Understanding the definition of mindfulness	Mindfulness has similarity to situational awareness—with mindfulness, we practice not only awareness of the external environment, but also inward on what is happening in our minds and bodies
Mindfulness vs. autopilot	What about being on autopilot can be problematic? (Example: Keeping head on a swivel to detect problems while maintaining contact with other vehicles during convoy operations)
Managing stress	Mindfulness training can be useful even in the military where there is high OPTEMPO (operating tempo; fast pace), as it offers a tool to better manage stress
Using mindfulness in daily life	Mindfulness skills can be useful throughout our day and at work. Examples: Being highly focused during physical fitness training or the night infiltration course, when the mind is not wandering to unrelated thoughts
Mindful eating exercise	This exercise trains the brain to notice our senses, such as touch and taste. Example: during Military Operations in Urban Terrain Training, operations team members communicate when to move by touch (ie, squeeze and tap)

Addressing the military’s emphasis on regimentation, sessions were highly structured and didactic materials presented briefly and efficiently. The program utilized online platform features to maintain a sense of structure and efficiency. For example, PowerPoint slides were shown onscreen during sessions. Participants used a hand-raise or chat feature during discussions, reducing inefficiency from participants talking over each other or dominating the conversation. Compared with the traditional MBSR curriculum, the length of group discussions was reduced and discussions were not open-ended; rather, discussion questions were shown on a PowerPoint slide and focused on skills development. Based on feedback from the Veteran advisory committee and later Soldier participants who desired even more efficiency and less redundancy during discussions, the manual was refined so that each discussion included no more than three distinct questions. Moreover, to maximize the time spent during discussions, the manual and PowerPoint slides prompted participants to use only the hand-raise tool (or polling/whiteboard where specifically requested), rather than the chat tool, which participants found too time-consuming. Sessions included briefer practice periods, consistent with the military’s emphasis on brevity and task orientation. To try to reduce boredom or lethargy in a population with high rates of sleep deprivation and fatigue,³⁹ session components rotated between didactics, video clips, experiential practice, and group discussion, so that long, uninterrupted periods of time were not spent on any one activity.

Language and Terminology

This component was addressed in three ways. First, the researchers purposefully selected a mindfulness instructor who was familiar with the Army environment, procedures, and vernacular. The instructor, who works at WAMC, was comfortable using terms and acronyms frequently used among military personnel (eg, physical fitness training [PT], military operation specialty [MOS]), and used them during didactics and discussions. Second, key phrases were repeated to promote retention of concepts, such as describing mindfulness exercises as brain training and as skills to add to one’s mindfulness toolkit. Third, a language that could be perceived as unaligned with military culture was minimized. For example, the concept of slowing down during mindfulnessexercises was not emphasized as in MBSR. Rather, it was acknowledged that even though the high operating tempo (OPTEMPO; fast pace) of the military setting was not going to change, mindfulness skills could still be incorporated and provide benefit.

Practical and Logistical Factors

Participants joined the live, group sessions on the videoconferencing platform in the evenings from a personal device in their homes or another location. This format was developed to optimize enrollment and attendance in military personnel who often work long hours, were experiencing physical pain, and maybe deployed or traveling, by reducing the need for an in-person meeting. Moreover, by conducting sessions on weeknights during off-duty hours, participants could join the class from the comfort of their homes in civilian clothing. Participants could log in to the mindfulness training app to access guided audio recordings to assist with home practice, review PowerPoint slide material, and watch archived session recordings. If participants missed a live session, watching the recorded video was a way to stay up-to-date before the next session and counted toward participation in terms of attendance tracking.

WAMC pain management specialists initially raised concerns regarding the feasibility of implementing the program at its standard length (eight, weekly, 2.5-h sessions plus a day-long retreat). Thus, the program was shortened to consist of six weekly sessions lasting 75–90 min each. The number of mindfulness skills was reduced to accommodate the shorter duration and focus on the most relevant skills. Loving-kindness meditation was excluded, as WAMC consultants said it was less relevant to the military setting. Yoga was excluded based on IRB disapproval, because of online course implementation without direct physical supervision of participants experiencing chronic pain. Subsequently, based on observational and interview data indicating that some sessions lasted the full 90 min and participants preferred shorter sessions, any redundant videos, examples, and prompts were removed, thus decreasing the length of sessions to 65–75 min. See TABLE III for the final adapted mindfulness program sequence.

TABLE III.

Final Mindfulness Training Program Sequence

Session No. and Title	Session Focus	In-session Mindfulness Exercises	Home Practice Assignments
1. Using Mindfulness to Manage      Chronic Pain: An Introduction	The relevance of mindfulness training to chronic pain and to the military	Sitting meditation (breath focused)	Sitting meditation: ≥5–10 min daily
	Mindfulness vs. autopilot
2. Stress and Chronic Pain	Stress, fight-or-flight, and how mindfulness can help	Review: Sitting meditation (breath)	Sitting meditation: ≥5–10 min daily
	Pain cycle and relationship to stress; aprimary and secondary pain	New: Mindful walking; body scan	Alternating days: Mindful walking and body scan
3. Managing Stress and Pain      Mindfully in Everyday Life	Mindfulness in everyday life and how to break the cycle of stress and pain	Review: Mindful walking; body scan	Alternating sitting meditation, mindful walking, and body scan as choose: ≥10 min daily
		New: Mindful eating (raisin or fruit); breathing space	Informal: Breathing space ≥ once per day; one routine activity mindfully per day
4. Mindful Acceptance Part I and      Letting Go	Interactive: Top 10 Tunes (ie, habitual negative thought patterns)	Review: Breathing space; mindful walking	Sitting meditation: ≥15 min daily
	Introduce mindful acceptance of pain and other experiences	New: Sitting meditation (emphasis on letting go of thoughts); mindful acceptance practice	Alternating mindful walking/body scan
			Informal: Noticing and letting thoughts go; routine activity
5. Mindful Acceptance Part II and      Expanding Awareness	Review and expand on mindful Acceptance of pain	Review: Sitting meditation (breath); Mindful walking	Alternate between sitting meditation, mindful walking, body scan: ≥15 min daily
	Expanding mindfulness outwards to sounds	New: deepening mindful acceptance practice; mindfulness of sounds	Informal: Breathing space; moments of mindfulness in daily life (eg, sounds and taste)
6. Moving Forward	Training takeaways	Review: Sitting meditation; body scan; mindful walking; breathing space	Continue practice from entire mindfulness toolkit
	Taking our skills into the rest of our lives

^aMindfulness was described as a skill that can help one differentiate primary pain (sensory experience) from secondary pain (cognitive and emotional reactions and resistance).⁴¹

Mindfulness Training for Pain app

The Mindfulness program supporting mobile app was designed to mirror the online intervention protocol, providing six corresponding training sessions (Fig. 1A). Each session (Fig. 1B) provided content refreshers via narrated meditations and self-guided slides (Fig. 1C) and viewing of a recorded webcast of the recent online session. This allowed for personal review of materials, while also supporting participants who might have missed an online session to maintain a level of participation in the group. Furthermore, each session menu provided access to associated video testimonials from public figures (Fig. 1D and 1E). Participants were encouraged to log each personal practice session (Fig. 1A) whether done in concert with the app or on their own.

FIGURE 1.

Example screens from the Mindfulness Training for Pain mobile application (app). (A) Mobile app home-page, including links to each of the six training sessions. (B) Links to session content refreshers. (C) Example PowerPoint slide from the training. (D) Links to videos shown and additional resources. (E) Image from a video shown in the course.

DISCUSSION

The purpose of this study was to adapt the evidence-based MBSR program to create a live, online mindfulness training program that was relevant for active-duty Soldiers experiencing chronic pain. Only two studies have examined the use of the MBSR program without adaptation to treat chronic pain in active-duty military personnel.^42,43 One study examined the feasibility of MBSR in nine military Service-women with chronic pelvic pain.⁴² The authors noted that participants reported benefits from the program, but attendance rates were low and participants reported that the time commitment was significant. In addition, several participants preferred an online format. The authors concluded that other delivery formats may increase engagement.⁴² Another study examining MBSR for active-duty military with traumatic brain injury headache experienced similar challenges with attendance and retention,⁴³ underscoring a need to adapt MBIs for active-duty personnel treated for chronic pain conditions.

The well-studied MMFT program,³⁰ also adapted from MBSR, differs from our program in several ways. Because MMFT was developed to promote psychological stress resilience in pre-deployment personnel, it is offered in-person to whole military units across the chain of command, with an additional goal of enhancing unit cohesion and teambuilding. Additionally, it is a similar length as the standard MBSR program.³⁰ However, both MMFT and this adapted program similarly emphasize the military’s mission orientation and a top–down, directive approach to instruction.

The adapted mindfulness program was consistent with Crane and colleagues’³⁶ framework to adapt MBIs to different populations and contexts. Aligned with this framework, the program maintained the essential elements of an MBI by incorporating instruction and repetitive practice in formal and informal mindfulness meditation techniques that target the development of skills such as present-moment focus; observing thoughts as mental experiences, not as facts; and an approach orientation to experiences, as opposed to avoidance of one’s internal experiences. Exercises included sitting and walking meditation, body scan, openness toward painful sensations, letting go of negative pain-related thoughts, and mindfulness of daily activities.

Also consistent with the Crane et al framework,³⁶ the flexible aspects of the mindfulness program included the integration of adapted curriculum elements and variations in the program structure, length, and delivery that were tailored to the specific population and context. Our adaptations incorporated military-relevant terminology and examples (eg, performance optimization, mindfulness as it relates to situational awareness) and removed traditional MBI terminology that is not aligned with the military context. For example, in MBSR, the instructor often “invites” group members to participate in an exercise, rather than being directive, emphasizes “being” rather than “doing,” and teaches an exercise known as “loving-kindness.” Thus, traditional MBI culture may be viewed as too soft in a masculine-dominated warrior culture valuing strength and toughness.⁴⁴

We also reorganized the structure and delivery of sessions (eg, internet-based, fewer and shorter length, more focused discussions, and use of directive language to maintain hierarchical structure). By utilizing the online platform’s engaging features such as polls and the whiteboard, participants could anonymously respond to more sensitive discussion questions, useful in an environment where there is both a high fear of health-related stigma³⁴ and a strong culture of masculinity.⁴⁴ Moreover, our instructor was not only a trained mindfulness instructor, but also a psychologist with experience working with military personnel, and thus was well-versed in military culture and terminology.

Less specific to MBIs, models exist to help guide the cultural adaptation of evidence-based interventions, such as HIV/AIDS prevention^45,46 and substance-abuse prevention programs.⁴⁷ These models involve information gathering, preliminary adaptation development and testing, adaptation refinement, and retesting.^45,48,49 A key component is the involvement of stakeholders, members of the target population and intervention participants throughout the adaptation process.^45,46,49,50 Following such guidelines, we received feedback from stakeholders and study participants at multiple stages of curriculum development, allowing us to refine the program as feedback was received and prior to testing in a larger sample. Most critically, we obtained input and consultation from individuals with military background or experience. These individuals included our research partner at the Interdisciplinary Pain Management Center, a military pain psychologist, and team members with experience conducting military research—including a military Veteran no longer in the Service. In particular, an advisory committee of military Veterans participated in a test-run of half of the online sessions and a focus group. We believe this input enhanced the program’s credibility.

The study has several limitations. Because of the small sample size of four Service Members in the preliminary cohort, feedback from pilot testing could uncover additional areas for refining the mindfulness program. We did not test the effectiveness of the program, as the adaptation process was part of a feasibility study. Analyses from the final aim of the study, in which we tested the adapted intervention in sequential cohorts, are currently underway to gain a more in-depth understanding of the program’s feasibility and acceptability. Future studies are needed to evaluate the effectiveness of the intervention in comparison to usual care or an active treatment condition. In addition, it is unknown whether the program would be useful for chronic pain patients in branches of the military outside of the Army. We speculate that the program would be relevant, assuming that efforts were undertaken to revise examples and scenarios for other military branches.

Conclusion

We utilized a systematic adaptation process to develop a six-session, weekly, abbreviated, live, and online mindfulness program to address the high level of chronic pain experienced by active-duty soldiers. The intervention was relevant and sensitive to the military context in a topic area that, at face value, is contradictory to many aspects of military culture. It is also responsive to the recommendations of Pain Management Task Force to use complementary and nonpharmacologic treatments for chronic pain. Complementary approaches are also part of the military’s ongoing efforts to address opioid use disorders and reduce unsafe opioid prescribing for pain conditions.^1,51 Given the online format, Soldiers from multiple bases or deployed settings could participate at the same time via the online platform, which could maximize its large-scale use. If effective, the training has the potential for widespread dissemination as a complement to usual medical care for chronic pain in military personnel.

Preliminary work for this article presented at the Womack Army Medical Center Research Symposium, Fort Bragg, NC, May 2017

Clinicaltrials.gov registration: NCT03104465; PIs: Shari Miller, PhD and Susan Gaylord, PhD; Registered on April 7, 2017

FUNDING/COI

This project was supported by the National Institutes of Health (NIH) Award R34AT008423. Author CEB’s work on this project and manuscript was supported by the NIH Ruth L. Kirschstein National Research Service Award T32AT003378. The authors have no conflicts of interest to declare.