Nurturing compassion in schools: A randomized controlled trial of the effectiveness of a Compassionate Mind Training program for teachers

RESEARCH ARTICLE Nu u ing compassion in schools: A andomized con olled ial o he e ec i eness o a Compassiona e Mind T aining p og am o eache s Ma cela Ma osID 1 *, Isabel Albuque que 1 , Ana Galha do 1,2 , Ma ina Cunha 1,2 , Ma ga ida Ped oso LimaID 1 , La a Palmei a 1,3 , Nicola Pe occhi 4 , Ki s en McEwan 5 , F ances A. Ma a os 5 , Paul Gilbe 5 1Uni e si y o Coimb a, Facul y o Psychology and Educa ional Sciences, Cen e o Resea ch in Neu opsychology and Cogni i e and Beha iou al In e en ion (CINEICC), Coimb a, Po ugal, 2Ins i u o Supe io Miguel To ga, Coimb a, Po ugal, 3Uni e sidade Po ucalense, In an e D. Hen ique, Po o, Po ugal, 4John Cabo Uni e si y, Rome, I aly, 5Uni e si y o De by, College o Heal h, Psychology & Social Ca e, De by, Uni ed Kingdom *ma cela.ma os@ pce.uc.p Abs ac Objec i es Schools a e expe iencing an unp eceden ed men al heal h c isis, wi h eache s epo ing high le els o s ess and bu nou , which has ad e se consequences o hei men al and physical heal h. Add essing men al and physical heal h p oblems and p omo ing wellbeing in educa ional se ings is hus a global p io i y. This s udy in es iga ed he easibili y and e ec i eness o an 8-week Compassiona e Mind T aining p og am o Teache s (CMT-T) on indica o s o psychological and physiological wellbeing. Me hods A p agma ic andomized con olled s udy wi h a s epped-wedge design was conduc ed in a sample o 155 public school eache s, who we e andomized o CMT-T (n= 80) o a wai lis con ol g oup (WLC; n= 75). Pa icipan s comple ed sel - epo measu es o psychological dis ess, bu nou , o e all and p o essional wellbeing, compassion and sel -c i icism a base- line, pos -in e en ion, and 3-mon hs ollow-up. In a sub-sample (CMT-T, n= 51; WLC n= 36) es ing hea - a e a iabili y (HRV) was measu ed a baseline and pos -in e en ion. Resul s CMT-T was easible and e ec i e. Compa ed o he WLC, he CMT-T g oup showed imp o emen s in sel -compassion, compassion o o he s, posi i e a ec , and HRV as well as educ ions in ea s o compassion, anxie y and dep ession. WLC pa icipan s who ecei ed CMT-T e ealed addi ional imp o emen s in compassion o o he s and om o h- e s, and sa is ac ion wi h p o essional li e, along wi h dec eases in bu nou and s ess. Teache s sco ing highe in sel -c i icism a baseline e ealed g ea e imp o emen s pos CMT-T. A 3-mon h ollow-up imp o emen s we e e ained. PLOS ONE PLOS ONE | h ps://doi.o g/10.1371/jou nal.pone.0263480 Ma ch 1, 2022 1 / 36 a1111111111 a1111111111 a1111111111 a1111111111 a1111111111 OPEN ACCESS Ci a ion: Ma os M, Albuque que I, Galha do A, Cunha M, Ped oso Lima M, Palmei a L, e al. (2022) Nu u ing compassion in schools: A andomized con olled ial o he e ec i eness o a Compassiona e Mind T aining p og am o eache s. PLoS ONE 17(3): e0263480. h ps://doi. o g/10.1371/jou nal.pone.0263480 Edi o : Walid Kamal Abdelbasse , P ince Sa am Bin Abdulaziz Uni e si y, College o Applied Medical Sciences, SAUDI ARABIA Recei ed: No embe 3, 2021 Accep ed: Decembe 30, 2021 Published: Ma ch 1, 2022 Copy igh : ©2022 Ma os e al. This is an open access a icle dis ibu ed unde he e ms o he C ea i e Commons A ibu ion License, which pe mi s un es ic ed use, dis ibu ion, and ep oduc ion in any medium, p o ided he o iginal au ho and sou ce a e c edi ed. Da a A ailabili y S a emen : Da a canno be sha ed publicly because o he sensi i e na u e o some o he da a collec ed. The da a ha suppo he indings o his s udy will be made a ailable upon easonable eques om he Uni e si y o Coimb a Ins i u ional Da a Access (con ac ia [email p o ec ed]) o esea che s who mee he c i e ia o access o con iden ial da a. Conclusions CMT-T shows p omise as a compassion- ocused in e en ion o enhancing compassion, wellbeing and educing psychophysiological dis ess in eache s, con ibu ing o nu u ing compassiona e, p osocial and esilien educa ional en i onmen s. Gi en i s a ou able and sus ainable e ec s on wellbeing and psychophysiological dis ess, and low cos o deli e , b oade implemen a ion and dissemina ion o CMT-T is encou aged. In oduc ion The p omo ion o men al wellbeing cons i u es a public heal h p io i y, wi h men al heal h di - icul ies being leading causes o disabili y and ep esen ing a long-las ing and majo economic, social and heal h bu den [1]. The Uni ed Na ions 2030 Agenda o Sus ainable De elopmen [2] highligh s he impo ance o p omo ing heal h and wellbeing o all ages and accen ua es he need o os e compassion and empa hy o ackle global inequali y and cul i a e peace ul and esilien socie ies. Schools a e wi hs anding an unp eceden ed men al heal h c isis and ha e become inc eas- ingly s ess ul en i onmen s o he whole educa ional communi y [3]. Facing he mul iple challenges o wo king in schools (e.g., excessi e wo kload, ime p essu es, bu eauc acy, pupil dis up i e beha iou s), eache s epo high le els o s ess and bu nou wi hin all educa ion sec o s and ac oss coun ies [4]. In Po ugal, he la es educa ion sec o esea ch e ealed ha 75% o eache s p esen high le els o bu nou , wi h 25% epo ing ex eme bu nou and 84% in ending o lea e he p o ession due o s ess and compe i i e p essu es [5]. Along wi h his e en ion c isis in he eaching p o ession, long- e m eache s ess is associa ed wi h a ange o poo wellbeing and p o essional ou comes, which ca y signi ican socioeconomic cos s. Fo example, absen eeism and s a u no e , educed sel -e icacy [6,7], poo wellbeing and bu n- ou [8–10], wi h ad e se consequences o men al [6,11] and physical heal h [5,12,13]. The p olonged ac i a ion o s ess- esponsi e physiological sys ems (e.g., hypo halamic-pi ui a y- ad enal axis; sympa he ic ne ous sys em) no only impai s psychological wellbeing [14] bu also nega i ely a ec s neu oendoc ine (e.g., co isol), au onomic (e.g., hea a e a iabili y, HRV) and immune-in lamma o y esponses [14,15], wi h long-las ing changes in s ess- ela ed gene exp ession [16,17], which ha e a de imen al impac on men al and physical heal h. In addi ion, eache ’s s ess nega i ely impac s pupils’ social adjus men , academic pe o - mance [18] and men al wellbeing [19–21]. Fo example, Obe le and Schone -Reichl [22] e ealed ha s uden ’s co isol le els we e much highe in class ooms led by a eache who epo ed eeling o e whelmed. Longi udinal s udies ha e u he e ealed ha eache s epo - ing highe bu nou ea ly in he yea ha e class ooms p esen ing mo e beha iou al p oblems ac oss he yea [23]. When eache s epo lowe le els o wo k- ela ed s ess, s uden s ind hose eache s mo e in e es ed and en husias ic in eaching [24], which in luences pupils’ mo i a ion and a ec [25,26]. In addi ion, eache s’ wellbeing is linked o an a ay o posi i e ou comes, such as posi i e class oom p ocesses (e.g., eache s’ ac i e suppo owa ds s uden s, class oom social clima e), as well as s uden s’ sel -e icacy, subjec i e wellbeing, achie emen , and mo i a ion and a i ude owa ds lea ning [27,28]. One sou ce o eache s ess is he compe i i e dynamic o mode n neolibe al socie ies ha ha e come o ex u e lea ning en i onmen and schools [29,30]. This compe i i eness is a majo sou ce o s ess, which is pa icula ly e iden in schools. This compe i i eness is a majo PLOS ONE Compassiona e Mind T aining o Teache s PLOS ONE | h ps://doi.o g/10.1371/jou nal.pone.0263480 Ma ch 1, 2022 2 / 36 Funding: This wo k has been unded by he Reed Founda ion (UK) and suppo ed by he Compassiona e Mind Founda ion (UK). Compe ing in e es s: The au ho s ha e decla ed ha no compe ing in e es s exis . sou ce o s ess, a ec ing bo h eache s (e.g., hea ie wo kloads, achie emen ocus, pe o - mance e alua ion) and pupils (e.g., ocus on academic achie emen , sel -in e es ). In ac , sel - and o he - ocused compe i i e p essu es ha e been highligh ed as a key sou ce o eache s and pupil men al heal h p oblems [31–34], and unde lie ea s o ailu e, eelings o shame and nega i e social compa isons, sel -c i icism and esis ances o compassion [35–37]. Schools a e c ucial social a enas ha can p omo e compe i i eness and sel -in e es o cul i- a e p osociali y and compassion, and whe e hese wo dis inc mo i a ional sys ems: compe i- i eness s compassion, wi h hei social in o ma ion lows and biological pa e ns, become cho eog aphed and played ou [36,38]. Con a y o compe i i e mo i es, when indi iduals a e ca ing and sha ing, pa icula physiological sys ems linked o a ilia ion and social connec ed- ness a e s imula ed [e.g., pa asympa he ic ne ous sys em, oxy ocine gic sys em), which con- ibu e o wellbeing, s ess managemen and emo ion egula ion, 39,40]. In ac , s udies show ha social ela ionships and ad e si y impac one’s physiology e en a he epigene ic le el [e.g., di e en ial me hyla ion in oxy ocin ecep o gene_OXTR, 17]. Compassion, commonly de ined as a sensi i i y o su e ing in sel and o he s wi h a com- mi men o y o alle ia e and p e en i [41,42], is an inna e p osocial mo i a ion ha e ol ed wi h he mammalian ca ing sys em. Compassion has bene i s o men al heal h, emo- ion egula ion and social ela ionships [e.g., 43–47]. Fu he mo e, compassion posi i ely impac s physiological heal h, including in luences in gene ic exp ession [e.g., lowe le els o CTRA- ela ed gene exp ession, 48; epigene ic p o iles o he OXTR, 49]. Expe imen al s udies ha e also documen ed ha cul i a ing compassion impac s physiological sys ems, educing a ousal and inc easing pa asympa he ic ac i a ion [e.g., hea - a e a iabili y, HRV, 50–53], dec easing sensi i i y o h ea [49], and ac i a ing speci ic neu al ci cui s dis inc om empa- hy and mind ulness aining [54]. Gi en he bu geoning e idence o he nume ous bene i s o compassion o e he pas decade, se e al in e en ions ha e been de eloped ha speci ically aim o cul i a e compassion [51]. A g owing body o empi ical e idence has es i ied hei posi i e impac on men al and physical wellbeing and p osocial beha iou [55–57]. One o hese app oaches is an e olu ion- a y and biopsychosocial e idence-based app oach called Compassiona e Mind T aining [CMT; 42,58,59]. CMT was de eloped as an in e en ion o he gene al public and comp ises psychoeduca ion and a se o co e compassion and mind ulness p ac ices aken om Compas- sion Focused The apy [CFT; 58,60,61]. CFT, based upon e olu iona y psychology, a ach- men heo y, psychological science, and an unde s anding o mo i a ional sys ems, is a ansdiagnos ic he apy o indi iduals dealing wi h shame and sel -c i icism, and cu en ly deli e ed o pa ien s wi h a wide ange o men al and physical heal h di icul ies. CFT has been shown o be an e ec i e app oach in a mul i ude o clinical condi ions and symp oms [62,63]. CMT is designed o ac i a e and de elop e ol ed, a ilia i e ca e- ocused mo i a ional sys- ems and emo ions in o de o down- egula e compe i i e and h ea - ocused sys ems and s imula e psychological and neu ophysiological p ocesses (p ima ily associa ed wi h he pa a- sympa he ic sys em) conduc i e o be e emo ion egula ion, wellbeing, heal h and social ela- ionships [58,60,61]. CMT uses a ange o e idence-based p ac ises such as b ea hing echniques, isualisa ions and beha iou al p ac ises o s imula e he agus ne e, balance he au onomic ne ous sys em [64] and ec ui a ious neu o ci cui s associa ed wi h compassion [53,54]. CMT s i es o cul i a e a compassiona e mind which includes he h ee in e ac i e lows o compassion: he abili y o be compassiona e owa d he sel , and o he s, as well as o ecei e compassion om o he s. Each o hese make a con ibu ion o well-being and p osocial beha iou , bu each can also ha e ea s, blocks, and esis ances ha need o be ackled [58,61, 65]. CMT also add esses key issues linked o compe i i e h ea s such as sel -c i icism and ea s o compassion [58,60,65]. PLOS ONE Compassiona e Mind T aining o Teache s PLOS ONE | h ps://doi.o g/10.1371/jou nal.pone.0263480 Ma ch 1, 2022 3 / 36 CMT seeks o de elop men al compe encies and physiological s a es ha p omo e wo un- damen al in e ela ed p ocesses o compassion. The i s is he abili y o be sensi i e and u n owa ds su e ing in sel and o he s, o ole a e and engage wi h his su e ing, a he han a oid i o dissocia e, which is ela ed o many a ibu es, such as he mo i a ion o ca e and he capaci y o eeling sympa hy and empa hy. The second is he commi men o alle ia e and p e en su e ing and equi es a pa icula se o a ilia i e skills in he sphe e o a en ion, emo ion, cogni ion and beha iou conduci e o he de elopmen o a compassiona e mind [58,61]. Impo an ly, his means ha indi iduals need o de elop he cou age o mo e owa ds su e ing and po en ially pain ul si ua ions o men al s a es, bu also he wisdom o knowing wha o do. Hence CMT is cen ed a ound he de elopmen o compe encies needed o cou a- geously u n owa ds and engage wi h di icul ies in sel and o he s, and a a ie y o skills linked o easoning, men alizing and emo ional egula ion, which enable compassion mo i es o be ansla ed in o compassiona e ac ions [42,61,65]. CMT has been ailo ed o use wi h di e en o ma s (e.g., leng h, p ac ices) in nonclinical popula ions, namely he gene al public [66,67], heal h ca e educa o s and p o ide s [68], men- al heal h p o essionals [69], nu ses [70,71], i e igh e s [72] and psycho he apy s uden s [73]. The e is a moun ing e idence base o CMT e ec i eness in imp o ing men al and physiologi- cal heal h and p osocial beha iou [56,59,62,63]. A pilo andomised con olled s udy in a communi y sample [67,74] ound ha a b ie CMT in e en ion p omo ed bene icial psycho- logical changes associa ed wi h wellbeing and imp o emen s in HRV. Highe HRV is indica- i e o highe pa asympa he ic ne ous sys em ou low ia he agus ne e ac i i y and is associa ed wi h sel -compassion, eelings o pe cei ed sa eness and wa m h and g ea e abili y o sel -soo he when s essed [e.g., 64,75–78]. A ecen uncon olled s udy demons a ed he p omising e ec s o an 8-week CMT g oup in e en ion o he gene al public, in inc easing le els o compassion, posi i e emo ions and wellbeing, and educing sel -c i icism and psycho- logical dis ess, and alida ed he main enance o hese changes a 3-mon h ollow-up [66]. In addi ion, a andomised con olled ial o CFT in e en ion as guided sel -help in an adul communi y sample epo ed posi i e e ec s on wellbeing and psychopa hological indica o s up o 12 mon hs a e baseline [79]. This knowledge ha p omo ing compassion ( o sel and o he s) has a ange o psychologi- cal and physiological bene i s o men al and physical wellbeing and p osocial beha iou [55] needs o be p io i ised and inco po a ed in o eache educa ion and in o schools [36,80] and is aligned wi h in e na ional guidelines o he p omo ion o heal h and wellbeing [2,27]. Like- wise, in Po ugal, go e nmen ecommenda ions o Educa ion emphasise he impo ance o ad ancing heal h li e acy and social-emo ional compe encies in educa ional se ings o p o- mo e heal h and psychological wellbeing [81,82]. Recognising he g owing p oblems o s ess in schools and he c isis wi hin he eaching p o ession, he e a e now a numbe o p ojec s o imp o e wellbeing and esilience in eache s, wi h hose s emming om compassion and mind ulness-based in e en ions demons a ing o be pa icula ly e ec i e [83–86]. One o hese is he Compassiona e Schools Resea ch Ini ia- i e, which implemen ed and e alua ed a 6-module Compassion Mind T aining o Teache s (CMT-T), building upon p e ious CFT and CMT p og ams [67], in schools in Po ugal and he UK. In he UK, an ea lie e sion o he CMT-T, applied in 70 eache s and suppo s a , was easible and well- ecei ed, wi h pa icipan s (N= 34) posi i ely e alua ing he cu iculum and he p ac ices and i s help ulness o dealing wi h emo ional di icul ies [32]. A subsample o 20 eache s comple ed p e- and pos -sel - epo assessmen s and showed signi ican dec eases in sel -c i icism and inc eases in sel -compassion a pos -in e en ion; howe e , bu nou and psychopa hology did no signi ican ly change [32]. PLOS ONE Compassiona e Mind T aining o Teache s PLOS ONE | h ps://doi.o g/10.1371/jou nal.pone.0263480 Ma ch 1, 2022 4 / 36 In Po ugal, an uncon olled pilo s udy wi h 31 eache s showed ha CMT-T was easible and well- ecei ed, inc eased eache s’ compassion o o he s, sel -compassion and compassion o o he s mo i a ions and ac ions, and educed dep ession, s ess and ea s o compassion o o he s [87]. Impo an ly, when sel -c i icism was con olled o , a dec ease in bu nou and an inc ease in sel -compassion and in sa is ac ion wi h p o essional li e we e addi ionally ound. In line wi h p e ious s udies [88–90], his inding emphasises he impo ance o a ge ing sel - c i icism ac oss he in e en ion, gi en i s key ole in how CMT-T ope a es in p omo ing eache s’ abili ies o be compassiona e owa ds hemsel es and hus os e ing hei wellbeing and diminishing psychological dis ess. Fu he mo e, his s udy ound ha ea s o compas- sion o o he s media ed he impac o CMT-T on eache s’ bu nou and ha sel -compassion media ed he in e en ion e ec on psychological wellbeing. Thus, hese indings emphasise he impo ance o a ge ing bo h he ea s, blocks and esis ances o compassion alongside cul- i a ing sel -compassion abili ies in eache s o dec ease dis ess and p omo e psychological wellbeing. Finally, he quali a i e expe ience o he CMT-T o bo h pa icipan s and acili a- o s sugges ed ha u u e i e a ions o he p og am migh bene i om ex ending he du a ion o sessions and leng h o he p og am [87]. Ano he s udy explo ed he in e na ional u ili y o he CMT-T and concluded his is a easible, use ul and e ec i e in e en ion in c oss-cul u al educa ional se ings, no only in e ms o in oducing and p omo ing a compassion-based school e hos bu also on cul i a ing he psychological wellbeing o hose wo king in educa ion [91]. The e o e, CMT-T may p o ide a sui able app oach o coun e ac he cu en challenges in educa ional se ings and inspi e a shi om compe i i eness/ h ea -based o compassiona e/ a ilia i e mo i a ional sys ems, o imp o e educa o s’ s ess egula ion, p osocial quali ies, beha iou and wellbeing. S ill, a u he e alua ion o he p agma ic e ec i eness o a e ined e sion o CMT-T on eache s’ wellbeing and men al heal h, using a la ge sample size and a andomized con olled design, is needed. Mo eo e , he impac o he CMT-T on a ilia i e- and s ess- ela ed biophysiological ma ke s, pa icula ly on he pa asympa he ic ac i i y as measu ed h ough HRV [40,56], wa an s empi ical suppo . Addi ionally, as an al e na i e o adi ional pa allel designs, he use o a s epped wedge design would allow exposing bo h he in e en ion and con ol g oups o he CMT-T, while also es ablishing a wi hin-subjec s psy- chological and physiological baseline in he con ol g oup and con olling o he con ounding e ec o ime [92]. Gi en he g owing esea ch on he mul idimensional bene i s o compassion cul i a ion, and pilo s udies on CMT-T, he cu en s udy sough o u he explo e he easibili y and e ec i eness o he CMT-T on eache s’ psychological dis ess, wellbeing and compassion o sel and o he s, by e alua ing a e ined 8-week e sion o he CMT-T and using a andomised con olled and s epped wedge design. CMT-T speci ically aimed a p omo ing posi i e a ec and sa is ac ion wi h p o essional li e and educing symp oms o dep ession, anxie y, s ess, and bu nou (p ima y ou come a iables), by inc easing he lows o compassion ( o sel , o o he s and om o he s), sel -compassion and compassion o o he s mo i a ions and ac ions, and by diminishing ea s o compassion ( o sel , o o he s and om o he s) and sel -c i icism (seconda y/p ocess ou come a iables). Fu he mo e, he p esen s udy aimed o explo e he impac o he CMT-T on hea a e a iabili y (HRV), an indica o o agal egula o y ac i i y and a physiological ma ke o a pe son’s abili y o lexibly espond o en i onmen al challenges and egula e emo ional esponses [56,75], which has been p oposed as a p ima y measu e o assess and ain compassion [56]. I was hypo hesised ha CMT-T p oduces signi ican inc eases in HRV. In addi ion, he p esen s udy aimed a examining he impac o he CMT-T on eache s who ecei ed he in e en ion a e a pe iod o baseline obse a ions whe e hey ac ed as con ols. I was hypo hesised ha hese pa icipan s would e eal no signi ican PLOS ONE Compassiona e Mind T aining o Teache s PLOS ONE | h ps://doi.o g/10.1371/jou nal.pone.0263480 Ma ch 1, 2022 5 / 36 changes om baseline o p e-in e en ion bu would e eal signi ican changes in bo h ou - come and p ocess a iables a e ecei ing he CMT-T in e en ion. In ligh o p e ious esea ch poin ing o he ole o indi idual di e ences in sel -c i icism on how indi iduals espond o compassion-based in e en ions in gene al [88–90], and on he impac o CMT-T in pa icula [87], we also explo ed how sel -c i icism migh in luence he e ec s o he CMT-T in e en ion. Baseline sel -c i icism was hypo hesized o impac he CMT-T e ec s on he p ocess and ou come a iables. Fu he mo e, we examined whe he changes om p e- o-pos CMT-T we e di e en when compa ing high and low sel -c i ics, as well as whe he he e we e di e ences be ween hese wo g oups in he magni ude o change. In addi ion, he cu en s udy aimed o examine whe he he e ec s o a ending he CMT-T we e sus ained a 3-mon h pos -in e en ion. Finally, gi en ha he in e - ela ionship be ween he h ee lows o compassion (i.e., com- passion o o he s, being open o compassion om o he s, and sel -compassion) is a key aspec o he CFT/CMT app oach [61,93], we explo ed whe he he associa ions be ween he lows o compassion would change om be o e o a e he CMT-T, pa icula ly whe he hese we e s eng hened a e aining. Me hods S udy design The cu en s udy was a p agma ic wo-a m andomized con olled ial (RCT), wi h one in e en ion g oup (CMT-T) and one wai lis con ol g oup (WLC), and a s epped-wedge design whe e all g oups and pa icipan s in g oups we e o e ed he in e en ion. This s udy was app o ed by he E hics Commi ee o he Facul y o Psychology and Educa ional Sciences o he Uni e si y o Coimb a (CEDI22.03.2018), and egis e ed a ClinicalT ials.go (Iden i- ie : NCT05107323; Compassiona e Schools: Feasibili y and E ec i eness S udy o a Compas- siona e Mind T aining P og am o P omo e Teache s Wellbeing). The indings o his RCT a e epo ed con o m he Consolida ed S anda ds o Repo ing T ials (CONSORT) guidelines [94; see S1 File] and he Jou nal A icle Repo ing S anda ds (JARS) o esea ch in psychology [95]. Gi en he s epped wedge design, he e we e ou assessmen momen s in he s udy: 1) Time 1 (T1)—baseline/p e-in e en ion assessmen , was comple ed by he CMT-T g oup and he WLC g oup du ing he week p e ious o he s a o he CMT-T in e en ion; 2) Time 2 (T2) —pos -in e en ion assessmen one was comple ed by CMT-T g oup and WLC g oup du ing he i s -week pos -in e en ion; 3) Time 3 (T3)—pos -in e en ion assessmen wo, was com- ple ed by WLC g oup pa icipan s one week a e hey had also ecei ed he CMT-T in e en- ion; 4) 3-mon hs Follow-up assessmen , his was conduc ed h ee mon hs a e he CMT-T conclusion ( o all pa icipan s who comple ed he in e en ion). In T1, T2, and T3 all pa ici- pan s comple ed a se o sel - epo ques ionnai es assessing p ima y and seconda y ou comes. A subsample o pa icipan s (n= 55 in he expe imen al g oup, and n= 40 in he WLC g oup) unde wen he HRV measu emen a T1, T2, and T3. In he 3-mon h ollow-up assessmen , only sel - epo da a we e collec ed. The s udy was implemen ed be ween Oc obe 2018 and Augus 2019, ac oss he ollowing phases: 1) Oc obe /No embe 2018 (T1 o CMT-T G oups 1&2 and o WLC G oups 1&2); 2) Decembe 2018/Janua y 2019 (T2 o CMT-T G oups 1&2 and o WLC G oup 1&2; WLC G oup 1&2 s a ed he in e en ion; T1 o WLC G oup 3); 3) Ma ch 2019 (T3 o WLC G oup 1&2 a e ecei ing he in e en ion; T2 o WLC G oup 3, be o e s a ing he in e en- ion; T1 o CMT-T G oup 3); 4) May 2019 (T2 o CMT-T 3 G oup; T3 o WLC G oup 3, a e ecei ing he in e en ion); 5) Follow-up assessmen was conduc ed be ween Ma ch- PLOS ONE Compassiona e Mind T aining o Teache s PLOS ONE | h ps://doi.o g/10.1371/jou nal.pone.0263480 Ma ch 1, 2022 6 / 36 Augus 2019 by all pa icipan s who ecei ed he in e en ion 3-mon hs a e hei espec i e g oup inished he CMT-T. Pa icipan s and ec ui men In May/June 2018, pa icipan s we e ec ui ed amongs eaching s a in public schools (p e o high school g ades) in he cen e egion o Po ugal (Viseu and Coimb a dis ic s). Schools’ boa ds we e in i ed o pa icipa e in he s udy. Fou schools en olled in he p ojec , p o ided u he e hical app o al and in i ed all eaching s a o a end an in o ma i e 2-h session abou he s udy. This ec ui men session was led by he esea ch eam in each school and included a b ie desc ip ion o he s udy aims, p ocedu es, condi ions o pa icipa ion and e hical conside a ions. Addi ionally, a lea le con aining his in o ma ion was dis ibu ed among s a by he schools’ Boa d. Teache s in e es ed in pa icipa ing in he s udy con ac ed he esea ch eam ia email. They we e hen con ac ed ia email and assessed o inclusion c i- e ia and equi ed o p o ide in o med consen . In o med consen cla i ied he olun a y, con- iden ial and anonymous na u e o he s udy and da a p o ec ion igh s. Each pa icipan c ea ed a unique and nume ical code o gua an ee con iden iali y ha was used in all assess- men asks. The assessmen momen s and in e en ion we e conduc ed a he schools. Pa icipan s we e eligible o pa icipa ion i hey: (a) we e eache s in he en olled schools; and (b) p o ided in o med consen . Fig 1 displays he low o pa icipan s. O e all, 164 each- e s showed in e es o ake pa in he s udy and me he eligibili y c i e ia. Nine eache s ailed o a end he baseline assessmen . A e baseline assessmen , 155 pa icipan s we e andomly assigned wi hin each school o ei he he CMT-T in e en ion (CMT-T g oup) o he wai lis con ol (WLC) g oup. Each WLC g oup s a ed he CMT-T a e hei pa allel CMT-T g oup comple ed he in e en ion, i.e., a e app oxima ely wo mon hs. In o al, six g oups ecei ed he CMT-T (npe g oup M= 18), which was deli e ed in he school se ing. F om he ini ial 80 pa icipan s alloca ed o he CMT-T g oup, i e ailed o a end any session. Mo eo e , nine pa icipan s d opped-ou (11.25%) because o wo k schedule incompa ibili y, and we e excluded om u he analysis. F om he ini ial 75 pa icipan s alloca ed o he WLC g oup, 29 did no a end he second assessmen and we e also excluded om he analysis. The emaining 46 pa icipan s om he WLC g oup we e alloca ed o he in e en ion a Time 2. F om hose, 37 ecei ed he in e en ion, and nine op ed no o ecei e he in e en ion. The e we e no d opou s om he in e en ion a Time 2. Sociodemog aphic cha ac e is ics o pa icipan s a e p esen ed om Table 1. The s udy sam- ple was composed o 155 eache s wo king in public schools om Po ugal’s cen e egion. Pa - icipan s’ age anged om 25 o 63 yea s old, wi h a mean age o 51.35 (SD = 7.24). The majo i y o he pa icipan s was emale (92.9) and held a g adua e/hono s deg ee (67.1%) o had comple ed a mas e ’s deg ee (23.9%). Mos pa icipan s we e ma ied (65.8%), 16.8% we e di o ced, and 13.5% we e single. In e ms o eaching- ela ed cha ac e is ics, pa icipan s had been wo king as eache s o 10 mon hs o 41 yea s (M= 27.01, SD = 8.29), and augh in se e al g ade le els: 12.3% we e p eschool eache s, 16.1% augh in elemen a y school, 15.4% in middle school, 36.1% in high school, and 14.8% in special educa ion. The pa icipan s quali ied as mid- dle o high school g ade le el eache s augh in he ollowing con en a eas: 25.5% languages, 6.5% social and human sciences, 13.5% ma hema ics and expe imen al sciences, 2.6% a is ic exp ession, 0.4% physical educa ion, and 3.9% in o ma ion echnologies. Eigh eache s did no p o ide in o ma ion abou hese aspec s. Rega ding school se ing, eache s we e ec ui ed in wo la ge middle/high schools om an u ban a ea, in one clus e o schools ha included la ge schools om a semi-u ban a ea and small schools om u al a eas, and in one clus e o schools om an u ban a ea including a la ge school and small schools om u ban as well u al a eas. PLOS ONE Compassiona e Mind T aining o Teache s PLOS ONE | h ps://doi.o g/10.1371/jou nal.pone.0263480 Ma ch 1, 2022 7 / 36 Independen samples es s and chi-squa ed es s indica ed ha he in e en ion g oup and he wai lis con ol g oup we e simila in age, sex, ma i al s a us, yea s o eaching and eaching subjec a eas, indica ing a success ul andomiza ion. Signi ican di e ences we e ound be ween he wo g oups in educa ion le el and eaching g ade le el. Fig 1. Flowcha o s udy pa icipan s. h ps://doi.o g/10.1371/jou nal.pone.0263480.g001 PLOS ONE Compassiona e Mind T aining o Teache s PLOS ONE | h ps://doi.o g/10.1371/jou nal.pone.0263480 Ma ch 1, 2022 8 / 36 In e en ion The Compassiona e Mind T aining P og am o Teache s (CMT-T). The Compassion- a e Mind T aining p og am o Teache s (CMT-T) is a compassion mind aining in e en ion ailo ed o eaching s a and deli e ed in a g oup o ma ac oss eigh sessions o app oxi- ma ely 2.5 hou s each. The 8-week CMT-T is a e ined e sion o he 6-week CMT-T cu icu- lum [87], which was de eloped based on an ea lie e sion o he p og am o school s a designed and es ed by Ma a os e al. [32] and on a b ie CMT p og am o he gene al public [67]. The easibili y and p elimina y e ec i eness o he pilo e sion o he CMT-T showed Table 1. Baseline cha ac e is ics o he pa icipan s (N= 155). Cha ac e is ic To al (N= 155) CMT-T (n= 80) WLC (n= 75) Tes s a is ic (p- alue) Age, yea s (153) = .32 (p= .747) Mean (SD) 51.35 (7.24) 51.54 (8.21) 51.16 (6.09) Range 25–63 25–63 28–62 Sex n(%) χ 2 = .04 (p= .840) Male 11 (7.1) 6 (7.5) 5 (6.7) Female 144 (92.9) 74 (92.5) 70 (93.3) Ma i al s a us n(%) χ 2 = 2.28 (p= .684) Single 21 (13.5) 13 (16.3) 8 (10.7) Ma ied/Regis e ed pa ne ship 102 (65.8) 52 (65) 50 (66.6) Di o ced 26 (16.8) 12 (15) 14 (18.7) Widowed 6 (3.9) 3 (3.8) 3 (4) Educa ion le el n(%) χ 2 = 12.70 (p= .005) Bachelo 3 (1.9) - 3 (4) G adua e/Hono s 104 (67.1) 60 (75) 44 (58.7) Pos g adua e specialisa ion 11 (7.1) 1 (1.3) 10 (13.3) Mas e s 37 (23.9) 19 (23.8) 18 (24) Yea s o eaching expe ience, yea s (153) = .07 (p= .946) Mean (SD) 27.01 (8.29) 27.05 (9.56) 26.96 (6.73) Range 0.83–41 0.83–41 2–38 Teaching g ade le el n(%) χ 2 = 18.54 (p= .001) P eschool 19 (12.3) 8 (10.0) 11 (14.7) Elemen a y school 25 (16.1) 18 (22.5) 7 (9.3) Middle school 24 (15.5) 4 (5.2) 20 (26.7) High school 56 (36.1) 34 (42.2) 22 (29.3) Special educa ion (All le els) 23 (14.8) 11 (13.8) 12 (16.0) Missings 8 (5.2) 5 (6.3) 3 (4.0) Teaching subjec a eas n(%) χ 2 = 11.26 (p= .128) Se e al a eas (P e and Elemen a y School) 44 (28.4) 26 (32.5) 18 (24.0) Languages 38 (24.5) 13 (16.3) 25 (33.3) Social and human sciences 10 (6.5) 8 (10.0) 2 (2.7) Ma hema ics and expe imen al sciences 21 (13.5) 12 (15.0) 9 (12) A is ic exp ession 4 (2.6) 1 (1.2) 3 (4.0) Physical educa ion 1(0.6) 1 (1.2) 0 (0.0) In o ma ion echnologies 6 (3.9) 3 (3.7) 3 (4.0) Special Educa ion (All a eas) 23 (14.8) 11 (13.8) 12 (16.0) Missings 8 (5.2) 5 (6,3) 3 (4.0) No e. CMT-T = Compassiona e Mind T aining o Teache s; WLC = Wai lis con ol g oup. h ps://doi.o g/10.1371/jou nal.pone.0263480. 001 PLOS ONE Compassiona e Mind T aining o Teache s PLOS ONE | h ps://doi.o g/10.1371/jou nal.pone.0263480 Ma ch 1, 2022 9 / 36 bu nou , dep ession, anxie y and s ess, and sa e, elaxed and ac i a ed posi i e a ec . Medium- o-la ge e ec s sizes we e ound, excep o bu nou and s ess, whe e e ec sizes we e small. A signi ican di ec main e ec o ime o HRV (RMSSD) wi h a medium e ec size was ound. Signi ican di ec g oup e ec s we e ound o compassion o sel , compassion o o he s mo i a ion and ac ion, ea s o compassion o sel , sel -c i icism, in ape sonal mind ulness, sa e and ac i a ed posi i e a ec , dep ession and s ess, wi h e ec sizes anging om small o medium. Table 3. Means, s anda d de ia ions be o e (T1) and a e (T2) he CMT-T, ime main e ec , g oup main e ec and ime g oup in e ac ion e ec . CMT-T G oup (N= 66) WLC G oup (N= 46) Time G oup Time X G oup Measu es Time M SD M SD F p η 2 pF p η 2 pF p η 2 p Compassion o Sel (CEAS) T1 63.05 14.93 60.37 17.44 2.52 .115 .023 4.92 .029 .044 7.65 .007 .066 T2 68.52 14.99 58.89 16.12 Compassion o O he s (CEAS) T1 76.63 13.04 75.72 13.08 0.208 .649 .002 2.59 .110 .023 5.47 .021 .048 T2 78.73 12.26 72.59 12.40 Compassion om O he s (CEAS) T1 64.05 18.16 61.64 18.28 0.24 .625 .002 1.66 .201 .015 1.14 .287 .010 T2 64.83 16.32 59.53 14.36 Sel -Compassion Mo i a ion & Ac ion (CMAS) T1 89.71 14.31 87.21 10.93 51.39 <.001 .318 26.40 .000 .194 40.06 <.001 .267 T2 107.18 12.57 88.30 12.31 Compassion o o he s Mo i a ion & Ac ion (CMAS) T1 58.42 10.41 56.63 9.08 47.28 <.001 .303 12.39 .001 .101 16.10 <.001 .128 T2 69.24 9.80 59.50 10.40 Fea s o Compassion o Sel T1 7.47 7.51 9.13 7.69 1.66 .201 .015 7.42 .008 .063 5.83 .017 .050 T2 4.76 7.11 9.96 8.22 Fea s o Compassion o O he s T1 13.89 7.04 12.35 6.52 18.86 <.001 .146 1.15 .287 .010 20.41 <.001 .157 T2 8.39 7.23 12.46 6.67 Fea s o Compassion F om O he s T1 10.14 7.59 11.18 8.28 0.94 .334 .009 2.95 .089 .26 4.51 .036 .040 T2 8.28 7.88 11.93 8.84 Sel -c i icism T1 15.68 7.19 18.80 8.94 0.11 .743 .001 8.27 .005 .071 2.95 .089 .027 T2 14.40 7.34 19.67 9.77 Sa e PA T1 2.38 .70 2.29 .66 13.61 <.001 .111 6.16 .015 .053 11.10 .001 .092 T2 2.81 .69 2.31 .71 Relaxed PA T1 2.18 .75 2.13 .83 12.80 .001 .105 3.17 .078 .028 9.17 .003 .078 T2 2.62 .80 2.17 .81 Ac i a ed PA T1 2.64 .69 2.50 .74 9.95 .002 .084 4.77 .031 .042 6.62 .011 .057 T2 2.94 .55 2.53 .75 Sa is ac ion wi h P o essional Li e T1 14.62 4.88 12.57 4.47 1.63 .205 .015 1.33 .251 .012 7.316 .008 .063 T2 14.06 5.23 14.11 5.02 Bu nou T1 48.26 16.32 54.47 15.17 4.72 .032 .041 3.38 .069 .030 0.95 .333 .009 T2 46.89 14.11 50.89 16.56 Dep ession T1 2.94 3.13 4.72 4.49 13.44 <.001 .109 11.02 .001 .091 0.06 .803 .001 T2 1.82 1.68 3.74 3,83 Anxie y T1 2.97 3.54 4.24 3.65 10.78 .001 .089 3.99 .048 .035 0.22 .643 .002 T2 2.13 2.63 3.13 3.56 S ess T1 6.45 3.84 8.02 4.28 4.56 .035 .040 6.52 .012 .056 0.03 .867 .000 T2 5.71 2.97 7.15 3.53 HRV (RMSSD in ms 2 ) CMT-T (n= 51); WLC (n= 36) T1 31.48 21.94 32.49 18.98 5.29 .024 .059 0.18 .892 <.001 0.76 .386 .009 T2 37.62 31.85 35.26 20.08 No e: CMAS = Compassion Mo i a ion and Ac ion Scale; CEAS = Compassion Engagemen and Ac ion Scales; PA = Posi i e a ec . h ps://doi.o g/10.1371/jou nal.pone.0263480. 003 PLOS ONE Compassiona e Mind T aining o Teache s PLOS ONE | h ps://doi.o g/10.1371/jou nal.pone.0263480 Ma ch 1, 2022 16 / 36 The e was a signi ican medium- o-la ge e ec o he in e en ion (i.e., ime x g oup in e - ac ion e ec s) on compassion o sel , sel -compassion and compassion o o he s mo i a ion and ac ion, ea s o compassion o o he s, sa e, elaxed and ac i a ed posi i e a ec , and sa is- ac ion wi h p o essional li e. Signi ican ime x g oup in e ac ion e ec s wi h small e ec sizes we e ound o compassion o o he s and ea s o compassion o sel and om o he s. Di e ences wi hin g oups in changes om p e-in e en ion o pos - in e en ion Mean di e ences om p e- o pos -in e en ion in he s udy a iables we e hen examined wi hin each g oup h ough epea ed measu ed ANOVAs. Acco ding o Table 4, when compa - ing mean sco es in he CMT-T g oup be o e (T1) and a e he p og am comple ion (T2), ega ding hose a iables wi h signi ican ime x g oup e ec s, signi ican inc eases we e ound in compassion o sel , sel -compassion mo i a ion and ac ion, compassion o o he s mo i a- ion and ac ion, and in sa e, elaxed and ac i a ed posi i e a ec . Fu he mo e, he e we e sig- ni ican dec eases in ea s o compassion o sel , o o he s and om o he s. Resul s ega ding hose a iables whe e no signi ican ime x g oup e ec s we e ound, e ealed ha in he CMT-T g oup, he e was also a signi ican dec ease in dep ession and anxie y symp oms. The same analysis was conduc ed in he WLC g oup, a signi ican dec ease was ound o compas- sion o o he s, along wi h an inc ease in sa is ac ion wi h p o essional li e, om T1 o T2. Sig- ni ican dec eases we e also ound o bu nou and anxie y symp oms. We did no ind a signi ican ime x g oup in e ac ion e ec on HRV. Howe e , gi en he educed numbe o pa icipan s unde aking HRV measu emen s which migh ha e impac ed Table 4. Mean compa isons a T1 and T2 in he CMT-T and he in WLC g oup. CMT-T G oup _T1 (N= 66) CMT-T G oup_T2 (N= 66) WLC G oup_T1 (N= 46) WLC G oup_T2 (N= 46) M SD M SD F (65) pη 2 pM SD M SD F (45) pη 2 p Compassion o Sel (CEAS) 63.05 14.93 68.52 14.99 9.71 .003 .134 60.37 17.44 58.89 16.12 .78 .382 .017 Compassion o O he s (CEAS) 76.63 13.04 78.73 12.26 1.80 .184 .028 75.72 13.08 72.59 12.40 4.46 .040 .090 Compassion om O he s (CEAS) 64.05 18.16 64.83 16.32 0.20 .655 .003 61.64 18.28 59.53 14.36 1.06 .309 .024 Sel -Compassion Mo i a ion & Ac ion (CMAS) 89.71 14.31 107.18 12.57 83.96 <.001 .564 87.21 10.93 88.30 12.31 0.56 .459 .012 Compassion o o he s Mo i a ion & Ac ion (CMAS) 58.42 10.41 69.24 9.80 74.47 <.001 .534 56.63 9.08 59.50 10.40 3.43 .070 .071 Fea s o Compassion o Sel 7.47 7.51 4.76 7.11 8.18 .006 .112 9.13 7.69 9.96 8.22 0.56 .460 .012 Fea s o Compassion o O he s 13.89 7.04 8.39 7.23 44.96 <.001 .409 12.35 6.52 12.46 6.67 0.01 .905 .000 Fea s o Compassion F om O he s 10.14 7.59 8.28 7.88 5.51 .022 .078 11.18 8.28 11.93 8.84 0.62 .434 .014 Sel -c i icism 15.68 7.19 14.40 7.34 2.22 .141 .034 18.80 8.94 19.67 9.77 1.04 .313 .023 Sa e PA 2.38 .70 2.81 .69 28.65 <.001 .309 2.29 .66 2.31 .71 0.06 .811 .001 Relaxed PA 2.18 .75 2.62 .80 25.47 <.001 .285 2.13 .83 2.17 .81 0.14 .715 .003 Ac i a ed PA 2.64 .69 2.94 .55 24.87 <.001 .280 2.50 .74 2.53 .75 0.11 .739 .002 Sa is ac ion wi h P o essional Li e 14.62 4.88 14.06 5.23 1.34 .252 .020 12.57 4.47 14.11 5.02 6.08 .018 .119 Bu nou 48.26 16.32 46.89 14.11 0.83 .367 .013 54.47 15.17 50.89 16.56 4.66 .036 .096 Dep ession 2.94 3.13 1.82 1.68 11.21 .001 .147 4.72 4.49 3.74 3.83 3.99 .053 .081 Anxie y 2.97 3.54 2.13 2.63 4.99 .029 .071 4.24 3.65 3.13 3.56 5.70 .021 .112 S ess 6.45 3.84 5.71 2.97 2.19 .144 .033 8.02 4.28 7.15 3.53 2.53 .118 .053 HRV (RMSSD in ms 2 ) CMT-T (n= 51); WLC (n= 36) 31.48 21.94 37.62 31.85 5.96 .018 .107 32.49 18.98 35.26 20.08 .894 .351 .025 No e: CMAS = Compassion Mo i a ion and Ac ion Scale; CEAS = Compassion Engagemen and Ac ion Scales; PA = Posi i e a ec . h ps://doi.o g/10.1371/jou nal.pone.0263480. 004 PLOS ONE Compassiona e Mind T aining o Teache s PLOS ONE | h ps://doi.o g/10.1371/jou nal.pone.0263480 Ma ch 1, 2022 17 / 36 on he signi icance o he ime x g oup in e ac ion, he medium e ec size ound o he di ec main e ec s o ime, and a clea end eme ging by he isual inspec ion o he plo (Fig 2), we explo a i ely inspec ed mean di e ences a HRV (RMSSD) be o e (T1) and a e he CMT-T (T2) in he wo g oups, sepa a ely. Repea ed measu ed ANOVA showed a signi ican inc ease in HRV om T1 o T2, wi h a la ge e ec size, only in he expe imen al g oup. In e es ingly, he WLC showed a non-signi ican inc ease in HRV om T1 o T2 (see Table 4). The ole o sel -c i icism When con olling o baseline sel -c i icism, a signi ican ime x sel -c i icism in e ac ion e ec was ound (F= 1.90, p= .020, η 2 p = .368). In addi ion, signi ican e ec s o he in e en ion (i.e., ime x g oup e ec s) we e ound o : compassion o sel (F= 10.24, p= .002, η 2 p = .095), compassion o o he s (F= 4.33, p= .040, η 2 p = .043), sel -compassion mo i a ion and ac ion (F= 47.22, p<.001, η 2 p = .327), compassion o o he s mo i a ion and ac ion (F= 14.37, p< .001, η 2 p = .129), ea s o compassion o sel (F= 5.41, p= .022, η 2 p = .053) and o o he s (F= 15.36, p<.001, η 2 p = .137), as well as sa e (F= 9.23, p= .003, η 2 p = .087), elaxed (F= 8.48, p= .004, η 2 p = .080) and ac i a ed (F= 5.73, p= .019, η 2 p = .056) posi i e a ec , and sa is ac ion wi h p o essional li e (F= 5.35, p= .023, η 2 p = .052). Pai ed-samples T- es s compa ing high and low sel -c i ics in he CMT-T g oup be ween baseline (T1) and pos -in e en ion (T2) we e hen pe o med (Table 5). The high sel -c i ics showed a signi ican inc ease in compassion o sel , sel -compassion mo i a ion and ac ion, Fig 2. Time ×g oup in e ac ion o HRV (RMSSD; ms2). h ps://doi.o g/10.1371/jou nal.pone.0263480.g002 PLOS ONE Compassiona e Mind T aining o Teache s PLOS ONE | h ps://doi.o g/10.1371/jou nal.pone.0263480 Ma ch 1, 2022 18 / 36 compassion o o he s mo i a ion and ac ion, and in sa e, elaxed and ac i a ed posi i e a ec . These pa icipan s also e ealed a signi ican dec ease in ea s o compassion o sel and o o he s, in sel -c i icism and in dep ession and anxie y symp oms. As o he low sel -c i ics, hey showed a signi ican inc ease in sel -compassion and compassion o o he s mo i a ions and ac ions, and in sa e, elaxed and ac i a ed posi i e a ec , as well as signi ican dec eases in ea s o compassion o o he s. All e ec sizes anged om medium o la ge. To examine po en ial di e ences in he magni ude o change om p e- o-pos in e en ion be ween high and low sel -c i ics, change sco es (T2 –T1) we e compu ed, and independen samples - es ’s calcula ed. Resul s e ealed no signi ican di e ences be ween high and low sel -c i ics in he magni ude o change in all s udy a iables, wi h he excep ion o anxie y [ (47) = -2.10, p= .041] and sel -c i icism [ (46) = -3.57, p= .001], whe e he change was g ea e in he high sel -c i icism g oup. S epped wedge analysis: Di e ences in changes om baseline, p e- in e en ion o pos -in e en ion wi hin he WLC g oup’ pa icipan s who comple ed he CMT-T Repea ed Measu es ANOVAs we e pe o med o es di e ences in all s udy’s a iables om baseline o p e-in e en ion and pos -in e en ion (Table 6) in he WLC g oup pa icipan s who comple ed he CMT-T be ween T2 and T3. A pos -in e en ion, pa icipan s p esen ed inc eased le els o he h ee lows o compassion ( o sel , o o he s and om o he s), sel - compassion and compassion o o he s mo i a ions and ac ions, posi i e a ec (sa e, elaxed, ac i a ed) and sa is ac ion wi h p o essional li e, as well as dec eased ea s o compassion ( o sel , o o he s and om o he s), bu nou , dep ession, anxie y and s ess symp oms. All di e - ences e lec ed la ge e ec sizes. Table 5. Mean compa isons a T1 and T2 o he high sel -c i icism g oup (N= 31) and he low sel -c i icism g oup (N= 18) wi hin he CMT-T g oup. High Sel - c i icism _T1 High Sel - c i icism _T2 Low Sel - c i icism _T1 Low Sel - c i icism _T2 M SD M SD p d M SD M SD p d Compassion o Sel (CEAS) 60.80 16.75 67.27 14.80 -2.17 .038 .40 67.59 12.88 69.94 15.25 -0.70 .495 .17 Compassion o O he s (CEAS) 76.24 14.24 79.04 13.54 -1.17 .253 .22 79.67 13.23 77.00 13.80 0.82 .426 .19 Compassion om O he s (CEAS) 61.60 18.08 60.80 16.96 0.32 .750 .06 72.50 15.62 68.56 15.19 1.32 .204 .25 Sel -Compassion Mo i a ion & Ac ion (CMAS) 87.32 15.43 108.58 12.03 -7.07 <.001 1.27 91.39 11.29 104.39 14.39 -3.52 .003 .83 Compassion o O he s Mo i a ion & Ac ion (CMAS) 59.16 11.37 70.45 9.15 .6.11 <.001 1.10 55.72 9.70 66.22 11.99 -3.79 .001 .93 Fea s o Compassion o Sel 10.45 8.69 6.16 9.36 2.27 .031 .41 3.89 4.52 2.33 2.89 2.04 .058 .48 Fea s o Compassion o O he s 15.39 6.13 10.06 7.81 4.95 <.001 .89 11.28 7.78 7.50 6.37 2.92 .010 .69 Fea s o Compassion om O he s 12.90 8.22 10.29 9.72 1.66 .108 .30 6.17 5.93 5.22 4.67 0.91 .375 .22 Sel -C i icism 21.83 4.80 17.80 6.89 3.17 .004 .58 7.28 2.52 9.89 5.95 -2.34 .032 .55 Sa e PA 2.14 .68 2.63 .65 -3.90 .001 .72 2.72 .78 3.06 .70 -3.06 .007 .74 Relaxed PA 2.05 .91 2.66 .77 -4.86 <.001 .88 2.34 .62 2.68 .86 -2.39 .029 .56 Ac i a ed PA 2.45 .77 2.86 .56 -4.74 <.001 .86 2.82 .65 3.08 .55 -2.39 .029 .56 Sa is ac ion wi h P o essional Li e 13.77 5.12 13.77 5.59 0.00 1.00 .00 15.88 5.28 15.53 5.77 .536 .599 .13 Bu nou 54.65 14.80 53.23 13.33 .631 .533 .11 43.67 17.43 40.78 13.99 0.97 .348 .23 Dep ession 4.03 3.54 2.23 1.54 3.15 .004 .56 2.00 2.77 1.17 1.29 1.59 .131 .39 Anxie y 4.35 4.23 2.74 3.31 2.62 .014 .47 1.50 1.69 1.78 1.73 -0.55 .593 .13 S ess 7.29 4.25 6.48 3.20 1.02 .320 .18 6.28 3.34 5.06 2.64 1.41 .178 .33 No e: CMAS = Compassion Mo i a ion and Ac ion Scale; CEAS = Compassion Engagemen and Ac ion Scales; PA = Posi i e a ec . h ps://doi.o g/10.1371/jou nal.pone.0263480. 005 PLOS ONE Compassiona e Mind T aining o Teache s PLOS ONE | h ps://doi.o g/10.1371/jou nal.pone.0263480 Ma ch 1, 2022 19 / 36 Fu he mo e, pos -hoc pai wise compa isons e ealed no signi ican changes om baseline o p e-in e en ion in any o he s udy a iables excep o symp oms o dep ession and anxi- e y, which dec eased be ween T1 and T2. Be ween baseline and pos -in e en ion, pa icipan s showed signi ican imp o emen s in sel -compassion and compassion om o he s, sel -com- passion and compassion o o he s mo i a ions and ac ions, posi i e a ec (sa e, elaxed, ac i- a ed) and sa is ac ion wi h p o essional li e, along wi h signi ican educ ions in ea s o compassion ( o sel , o o he s and om o he s), bu nou , and dep ession, anxie y and s ess symp oms. In addi ion, be ween p e-in e en ion and pos -in e en ion, pa icipan s e ealed signi ican inc eases in he h ee lows o compassion ( o sel , o o he s and om o he s), in sel -compassion and compassion o o he s mo i a ions and ac ions and in posi i e a ec (sa e, elaxed, ac i a ed). They also e ealed signi ican dec eases in ea s o compassion ( o sel , o Table 6. Means and SDs o he ou come measu es a baseline (T1), p e-in e en ion (T2) and pos -in e en ion (T3) and epea ed measu es analysis o a iance (N= 37) and pai wise compa isons, o he WLC g oup pa icipan s who comple ed he CMT-T in e en ion be ween T2 and T3. Baseline (T1) P e-in e en ion (T2) Pos -In e en ion (T3) F p η 2 p Pai wise Compa isons Ou come measu es M (SD) M (SD) M (SD) T1-T2 p T1-T3 p T2-T3 p Compassion o Sel (CEAS) a 59.66 (16.51) 59.22 (15.79) 68.38 (16.12) 9.84 .001 .241 .438 (1.79) .809 -8.72 (2.83) .004 -9.16 (2.25) <.001 Compassion o O he s (CEAS) 74.66 (14.52) 73.06 (13.19) 77.75 (12.66) 3.68 .031 .106 1.59 (1.76) .372 -3.09 (1.82) .100 -4.69 (1.69) .009 Compassion om O he s (CEAS) a 60.06 (18.55) 58.63 (15.02) 68.50 (16.61) 7.10 .004 .186 1.44 (2.43) .559 -8.44 (3.46) .021 -9.88 (2.49) <.001 Fea s o Compassion o Sel 9.84 (8.72) 10.66 (8.48) 5.28 (6.99) 9.31 <.001 .231 -.813 (1.35) .551 4.56 (1.40) .003 5.38 (1.28) <.001 Fea s o Compassion o O he s 13.28 (6.91) 12.66 (7.20) 6.31 (5.41) 24.45 <.001 .441 .625 (.997) .527 6.97 (1.20) <.001 6.34 (1.12) <.001 Fea s o Compassion F om O he s 12.66 (8.94) 12.47 (9.40) 8.50 (7.79) 6.84 .002 .181 .188 (1.19) .876 4.16 (1.31) .003 3.97 (1.30) .005 Sel -Compassion Mo i a ion & Ac ion (CMAS) 87.13 (11.39) 88.25 (11.64) 108.06 (13.39) 70.09 <.001 .693 -1.13 (1.79) .535 -20.94 (2.01) <.001 -19.81 (2.15) <.001 Compassion o o he s Mo i a ion & Ac ion (CMAS) 55.84 (9.16) 59.25 (9.63) 71.16 (9.01) 46.02 <.001 .598 -3.31 (1.82) .071 -15.31 (1.61) <.001 -11.91 (1.58) <.001 Sel -c i icism a 17.75 (8.53) 18.72 (9.16) 18.08 (10.82) .310 .664 .010 -.97 (.94) .311 -.34 (1.58) .829 .63 (1.14) .587 Bu nou a 53.75 (14.99) 50.28 (17.39) 43.22 (15.56) 9.53 .001 .235 3.47 (1.75) .056 10.53 (2.71) .001 7.06 (2.78) .016 Dep ession a 4.97 (4.76) 3.28 (3.43) 2.38 (2.59) 8.59 .001 .217 1.69 (.57) .006 2.59 (.78) .002 .91 (.52) .092 Anxie y 4.16 (3.73) 2.53 (3.03) 2.09 (2.25) 8.73 .001 .220 1.63 (.53) .004 2.06 (.55) .001 .44 (.48) .370 S ess 8.28 (4.22) 7.13 (3.77) 6.50 (2.65) 3.32 .043 .097 1.16 (.64) .081 1.78 (.79) .031 .63 (.66) .354 Sa e PA 2.33 (.74) 2.40 (.71) 2.78 (.76) 9.55 <.001 .235 -.07 (.11) .517 -.45 (.12) .001 -.38 (.10) .001 Relaxed PA 2.10 (.76) 2.18 (.80) 2.70 (.83) 13.08 <.001 .297 -.08 (.11) .492 -.60 (.12) <.001 -.52 (.15) .002 Ac i a ed PA 2.53 (.84) 2.59 (.83) 2.79 (.79) 3.95 .024 .113 -.06 (.09) .531 -.26 (.10) .017 -.20 (.09) .045 Sa is ac ion wi h P o essional Li e 13.41 (4.43) 14.94 (5.04) 15.78 (4.50) 6.13 .004 .165 -1.53 (.79) .063 -2.36 (.60) <.001 -.84 (.65) .204 Th ea Emo ions - 6.25 (2.89) 5.72 (2.80) 3.61 .065 .094 - - - - .53 (.28) .065 Soo hing Emo ions - 13.31 (2.75) 14.06 (2.46) 3.97 .050 .102 - - - - -.75 (.38) .050 D i e Emo ions - 11.92 (3.31) 13.33 (3.22) 13.69 .001 .281 - - - - -1.42 (.38) .001 HRV (RMSSD in ms 2 ; n = 36) 32.49 (18.98) 35.25 (20.08) 35.04 (17.85) .46 .631 .010 -2.76 (17.55) .351 .21 (21.07) .952 -2.55 (18.73) .419 No e: a = G eenhouse-Geisse co ec ion; CMAS = Compassion Mo i a ion and Ac ion Scale; CEAS = Compassion Engagemen and Ac ion Scales; PA = Posi i e a ec . h ps://doi.o g/10.1371/jou nal.pone.0263480. 006 PLOS ONE Compassiona e Mind T aining o Teache s PLOS ONE | h ps://doi.o g/10.1371/jou nal.pone.0263480 Ma ch 1, 2022 20 / 36 o he s and om o he s) and bu nou . The emo ional clima e a wo k was also assessed in hese pa icipan s a T2 and T3, and signi ican inc eases in soo hing/sa eness and d i e/ i ali y emo ions a wo k we e ound om p e- o-pos -in e en ion. A dec ease in h ea emo ions a wo k was also obse ed, bu did no each he signi icance h eshold. Th ee-mon h ollow-up compa ison wi h pos -in e en ion Repea ed measu es ANOVAs esul s conside ing pos -CMT-T (T2) and he 3-mon hs ollow- up (T3) a e p esen ed in Table 7. No signi ican di e ences we e ound o all he conside ed a iables poin ing o he main enance o he CMT-T he apeu ic gains, excep o sel -compas- sion mo i a ions and ac ions and compassion ( o o he s) mo i a ions and ac ions. Pai wise compa isons showed a signi ican dec ease om T2 o T3 in he sel -compassion mo i a ions and ac ions (p<.001) and in he compassion o o he s mo i a ions and ac ions (p= .020). How a e he lows o compassion ela ed p e- and pos -in e en ion? We explo ed whe he he associa ion be ween he lows o compassion changed om p e- o-pos in e en ion in all pa icipan s who comple ed he CMT-T. P io o he CMT-T, co ela ions be ween he h ee lows we e mode a e: Sel -compassion—Compassion o O he s = .54, p<.001; Sel -compassion—Compassion F om O he s = .40, p<.001; Compassion o O he s—Compassion F om O he s = .39, p<.001. A e he in e en ion, co ela ions be ween he lows inc eased in magni ude ac oss all he lows: Sel -compassion—Compassion o O he s = .60, p<.001; Sel -compassion—Compassion F om O he s = .54, p<.001; Compassion o O he s—Compassion F om O he s = .52, p<.001. Table 7. Mean compa isons a pos -CMT-T (T3) and 3-mon hs ollow-up (T4), e ec size and obse ed powe (N= 48). T3 T4 Ou come measu es M SD M SD F (1, 46) pη 2 p Obse . powe Compassion o Sel (CEAS) 69.35 13.92 66.89 13.10 2.93 .094 .06 .389 Compassion o O he s (CEAS) 78.33 12.26 77.16 12.51 0.84 .366 .02 .145 Compassion om O he s (CEAS) 63.22 16.41 60.57 14.04 2.02 .162 .04 .285 Sel -Compassion Mo i a ion & Ac ion (CMAS) 109.72 10.10 102.72 13.05 14.52 <.001 .24 .961 Compassion o o he s Mo i a ion & Ac ion (CMAS) 71.49 9.75 67.37 11.12 5.82 .020 .12 .654 Fea s o Compassion o Sel 6.28 8.70 8.19 12.28 2.03 .161 .04 .286 Fea s o Compassion o O he s 8.74 7.79 10.02 9.45 2.24 .141 .05 .311 Fea s o Compassion F om O he s 9.32 8.73 10.11 10.98 0.40 .532 .01 .095 Sel -c i icism 16.88 9.50 15.84 9.90 0.64 .427 .02 .123 Sa e PA 2.76 0.75 2.70 0.67 0.32 .572 .01 .086 Relaxed PA 2.78 0.63 2.76 0.69 0.02 .884 .00 .052 Ac i a ed PA 2.82 0.63 2.87 0.64 0.46 .499 .01 .102 Sa is ac ion wi h P o essional Li e 15.33 4.44 15.59 4.45 0.26 .614 .01 .079 Bu nou 43.59 12.35 45.02 16.49 0.52 .476 .01 .108 Dep ession 2.30 2.26 2.93 3.83 1.33 .255 .03 .204 Anxie y 2.45 2.64 2.43 3.18 0.00 .957 .00 .050 S ess 6.29 2.69 5.47 3.63 3.18 .081 .07 .415 Th ea Emo ions 5.48 2.65 5.08 2.66 1.02 .322 .04 .163 Soo hing Emo ions 13.94 2.30 13.88 1.93 0.05 .835 .00 .055 D i e Emo ions 13.25 2.69 13.21 2.32 0.01 .929 .00 .051 No e: CMAS = Compassion Mo i a ion and Ac ion Scale; CEAS = Compassion Engagemen and Ac ion Scales; PA = Posi i e a ec . h ps://doi.o g/10.1371/jou nal.pone.0263480. 007 PLOS ONE Compassiona e Mind T aining o Teache s PLOS ONE | h ps://doi.o g/10.1371/jou nal.pone.0263480 Ma ch 1, 2022 21 / 36 Discussion Schools a e acing an unpa alleled men al heal h c isis. Teache s wi hin all educa ion sec o s and ac oss coun ies inc easingly e eal ele a ed s ess and bu nou and in end o lea e he p o ession [3,4]. This scena io is pa icula ly conce ning in Po ugal, whe e eache s’ s ess and bu nou a e p e alen and associa ed wi h he compe i i e p essu es and g owing e en- ion c isis in he eaching p o ession [5]. Impo an ly, eache s’ s ess has ad e se conse- quences o hei men al and physical heal h and nega i ely in luences pupils [e.g., 5,8]. Fu he mo e, his aises se ious economic, heal hca e and socie al challenges. The e o e, i is c ucial o p omo e adap i e cogni i e and emo ional egula ion ha suppo s eache s in cop- ing wi h he challenges o he school con ex and p omo es hei men al wellbeing. G owing empi ical suppo has highligh ed he bene icial impac o compassiona e-based in e en ions on imp o ing emo ional egula ion skills cen al o s ess egula ion [63]. In educa ional se ings, he Compassiona e Schools Resea ch Ini ia i e de eloped and examined he impac o a Compassion Mind T aining in e en ion o Teache s (CMT-T), in schools in Po ugal and he UK, and ound empi ical suppo o i s in e na ional u ili y, easibili y and p elimina y e ec i eness on a ange o men al heal h indica o s [32,87,91]. The cu en s udy in ended o expand his p elimina y e idence and es he easibili y and e ec i eness o a e ined e sion o he CMT-T on eache s’ psychological dis ess, wellbeing, compassion o sel and o he s, and hea a e a iabili y (HRV), using a andomised con olled and s epped wedge design in a la ge sample. The CMT-T had a high a endance a e, and eache s conside ed he in e en ion e y impo an and help ul. They we e highly mo i a ed o a end he sessions and would ecom- mend i o colleagues. These indings sugges ha he e ised 8-week CMT-T was highly a ed in e ms o accep abili y and e ealed adequa e p ac icali y and adap a ion, p o iding e idence ha he CMT-T is a easible in e en ion o eache s. These easibili y esul s a e in suppo o p e ious pilo s udies using an ea lie e sion o he CMT-T in Po ugal and he UK [32,87, 91], ein o cing he accep abili y o CMT-T modules and p ac ices. In pa icula , eache s ound he modules’ Building a compassiona e mind/sel ’, ’Unde s anding and wo king wi h sel -c i icism’, and ’Unde s anding he unc ions o ou emo ions’ o be he mos help ul. In gene al, his is simila o he esul s epo ed in he Po uguese pilo s udy [87]. In bo h s udies, he wo modules add essing he soo hing sys em’s cul i a ion and he de elopmen o he com- passiona e mind/sel and, mul iple sel es, we e chosen by eache s as he mos use ul. In e es - ingly in his e ined CMT-T, whe e sel -c i icism was a ge ed h oughou he in e en ion, he module ocused on he unc ional analysis o sel -c i icism and using he compassiona e sel o deal wi h i was also iden i ied as a e y ele an one. In line wi h Ma os e al. [87], he p ac ices assessed as he mos help ul by he eache s we e he Soo hing Rhy hm B ea hing, Compassion o he sel , Building he compassiona e sel , ollowed by Mind ulness and Sa e Place Image y. These accep abili y esul s ex end cu en knowledge on he e alua ion o CMT in e en ions wi h communi y samples [e.g., 66,67,74] and should in o m he de elopmen , implemen a ion and e alua ion o CMT in e en ions in u u e esea ch. The p esen andomised con olled s udy e ealed signi ican ime x g oup in e ac ion e ec s o he CMT-T on compassion o sel , sel -compassion and compassion o o he s mo i a ion and ac ion, ea s o compassion o o he s, sa e, elaxed and ac i a ed posi i e a ec , and sa is ac ion wi h p o essional li e, wi h medium o la ge e ec sizes. Mo eo e , signi ican ime x g oup in e ac ion e ec s wi h small e ec sizes we e also ound o com- passion o o he s and ea s o compassion o sel and om o he s. These indings pa ially suppo ou hypo heses and a e discussed in de ail below conce ning he p ocess and ou - come a iables. PLOS ONE Compassiona e Mind T aining o Teache s PLOS ONE | h ps://doi.o g/10.1371/jou nal.pone.0263480 Ma ch 1, 2022 22 / 36 The esul s highligh ed se e al di e ences be ween g oups. Rega ding he e ec s o he CMT-T on sel -compassion, compa ed wi h he WLC g oup, eache s in he CMT-T g oup e ealed a signi ican inc ease in compassion o sel and sel -compassion mo i a ion and ac ion and a signi ican educ ion in ea s o compassion o sel . These changes ep esen ed medium o la ge e ec sizes. S epped wedge analyses u he co obo a ed hese indings e ealing ha eache s who ecei ed he in e en ion a e ac ing as con ols also showed sig- ni ican imp o emen s in compassion o sel and sel -compassion mo i a ion and ac ion, and signi ican dec eases in ea s o compassion o sel a e comple ing he CMT-T. These esul s co obo a e ou hypo heses, indica ing ha a e he CMT-T, eache s imp o ed hei sensi i - i y and engagemen wi h hei own su e ing, along wi h an enhanced mo i a ion o engage wi h li e’s di icul ies and su e ing wi h a ca ing and accep ing a i ude owa ds onesel , ins ead o wi hd awing, a oiding o denying hose di icul ies. They also e ealed an inc eased abili y o ole a e dis ess conce ning onesel , o be kind and suppo i e when acing ha dships, and showed a g ea e capaci y o ac compassiona ely owa ds hemsel es. Simul aneously, he CMT-T p oduced a decline in ea s, blocks and esis ances o be sel -compassiona e. These esul s ex end hose epo ed by Ma os e al. [87], documen ing signi ican inc eases in each- e s’ sel -compassion mo i a ion and ac ion (as assessed by he CMAS) a e he CMT-T, bu whe e changes in sel -compassion a ibu es and compe encies (as measu ed by he CEAS), and ea s o compassion o sel , did no each s a is ical signi icance. In he p esen s udy, sig- ni ican imp o emen s in compassion engagemen and ac ion owa ds onesel (as measu ed by he CEAS) we e addi ionally ound in eache s a pos -in e en ion, which is in line wi h p e ious s udies showing simila esul s using CMT in communi y samples [66,67]. This ind- ing sugges s ha his e ined longe e sion o CMT-T no only p omo es an inc ease in one’s mo i a ion o be accep ing and ca ing, o ole a e dis ess, and o commi o beha ing compas- siona ely owa ds onesel (as assessed by he CMAS), bu also diminishes he inhibi o s o be sel -compassiona e, and os e s he sensi i i y o and engagemen wi h one’s su e ing includ- ing compe encies o sensi i i y, sympa hy, empa hy, dis ess ole ance, non-judgmen and ca e o wellbeing (i.e., sel -compassiona e engagemen ) and commi ed ac ions o y o alle ia e and p e en one’s su e ing (i.e., sel -compassiona e ac ion). Ou esul s go beyond hose o an ea lie e sion o he CMT-T whe e imp o emen s in sel -compassion [as measu ed by he Sel -Compassion Scale, SCS; 122] we e only signi ican wi h inc eased p ac ice o he ech- niques in oduced [and no jus session a endance), as suppo ed by he quali a i e analyses [32]. Fu he mo e, hese indings a e also in suppo o s udies using CMT in o he p o essions ha ound signi ican inc eases in sel -compassion (as measu ed by he SCS) in heal h ca e educa o s and p o ide s [68], men al heal h p o essionals [69], psycho he apy s uden s [73], and i e igh e s [72]. The CMT-T also a ge s he cul i a ion o compassion o o he s [58,61], and pa icipan s in he CMT-T g oup e ealed signi ican inc eases in compassion o o he s mo i a ion and ac ion (as measu ed by he CMAS) and a signi ican educ ion in ea s o compassion o o h- e s, om p e o pos -in e en ion, wi h medium o la ge e ec sizes. These indings pa ially suppo ou hypo heses and indica e ha he CMT-T seems o educe eache s’ ea s, blocks and esis ances o being compassiona e o o he s while also p omo ing hei mo i a ion, dis- ess ole ance, and commi men o ac in compassiona e ways owa ds o he s. E en hough he e was a end owa ds posi i e change in compassion o o he s engagemen and ac ion (as measu ed by he CEAS), his inc ease did no each he h eshold o signi icance, con a ily o wha was ound in he CMT-T pilo s udy [87]. This inding migh be a ibu able o a ceiling e ec , which has been epo ed in p e ious s udies wi h his measu e [93] and using CMT in communi y samples [66,67] as pa icipan s’ baseline sco es we e highe in compassion o o he s, in compa ison o he o he wo lows o compassion, which migh be ela ed o a social PLOS ONE Compassiona e Mind T aining o Teache s PLOS ONE | h ps://doi.o g/10.1371/jou nal.pone.0263480 Ma ch 1, 2022 23 / 36 desi abili y bias. In ac , esul s om he s epped wedge analyses suppo his hypo hesis and show ha , a e ecei ing he CMT-T in e en ion, WLC pa icipan s also exhibi ed signi ican inc eases in compassion o o he s (as measu ed by he CEAS) as well as in compassion o o h- e s mo i a ion and ac ion and signi ican dec eases in ea s o compassion o o he s. A mo e in-dep h obse a ion o hese indings e ealed ha e en hough he pos -in e en ion sco es o he CMT-T and he WLC pa icipan s who ecei ed he in e en ion be ween T2 and T3 we e simila , he o me p esen ed baseline le els highe han he p e-in e en ion sco es o he la e . In ac , in g oup compa isons analyses, he WLC g oup showed a signi ican dec ease in compassion o o he s be ween baseline and p e-in e en ion (wi h a medium e ec size). This was an unexpec ed inding, which migh be ela ed o he ele a ed baseline sco es in his measu e and o he pa allel inc ease in bu nou le els in hese WLC pa icipan s. As a whole, he p esen esul s add o p io CMT s udies wi h eache s whe e his low o com- passion was no speci ically e alua ed using a ecognised quan i a i e measu e [32] and wi h o he p o essions [e.g., heal hca e educa o s and p o essionals, 68,69; i e se ice pe sonnel, 72]. In ega d o changes in compassion om o he s, eache s in he CMT-T g oup signi ican ly dec eased hei ea s o ecei ing compassion om o he s (wi h a medium e ec size), al hough no signi ican di e ences we e ound in compassion ecei ed om o he s as mea- su ed by he CEAS, which assesses how one pe cei es o he people’s mo i a ion and abili y o engage wi h one’s su e ing and o ake ac ion o alle ia e one’s dis ess. S epped wedge analy- ses u he add o hese esul s, e ealing signi ican inc eases in he pe cep ion o compassion ecei ed om o he s (as measu ed by he CEAS) and educ ions in ea s o compassion om o he s. These indings ex end he ones desc ibed in he CMT-T pilo s udy [87], whe e nei he compassion om o he s no ea s o ecei ing compassion om o he s signi ican ly changed om p e- o pos -in e en ion. In he cu en s udy, and as expec ed, he CMT-T p oduced a educ ion in eache s’ inhibi o s and esis ances o being he ecipien o compassion om o he s which is ela ed o an imp o emen in one’s abili y o be open and willing o ecei e compassion om o he s. Mixed esul s ega ding CMT-T induced inc eases in he pe cep ion o o he s being mo e compassiona e owa ds he sel in his s udy wa an u he explo a ion. O e all, ou esul s a e aligned wi h p e ious s udies using CMT in communi y samples [66, 67] and add o p eceding esea ch implemen ing CMT wi h eache s [32,91] and o he p o es- sionals [68–70,72,73] ha did no assess his low o compassion. An impo an aspec o he CFT/CMT app oach is he conside a ion o he in e - ela ionship be ween he h ee lows o compassion (CEAS: compassion o o he s, being open o compas- sion om o he s, and sel -compassion). In line wi h ou hypo hesis, esul s showed ha he associa ion be ween he h ee lows o compassion was s eng hened a e he CMT-T imple- men a ion. These da a highligh ha CMT-T seems o enhance he gene al le el o se e al com- ponen s o he h ee lows o compassion and ein o ce engende men o a compassiona e mind in which highe sco es in one low o compassion end o be accompanied by highe sco es in ano he low. These esul s a e analogous o p e ious esea ch explo ing CMT in he gene al popula ion [e.g., 66,67] and p o ide u he suppo o he assump ion ha CMT s imula es he ca ing mo i a ional sys em, which acili a es one’s openness and mo i a ion [58,66,116]. Taken oge he hese esul s and he speci ici y o he a ge popula ion, his s udy p o ides e idence o he e ec i eness o he CMT-T in educing eache s’ ea s, blocks and esis ances o compassion ( o sel , o o he s and om o he s) while also acili a ing hei mo i a ion, dis- ess ole ance and commi men o be compassiona e owa ds hemsel es and o he s, along wi h de eloping he a ibu es and p ac icing he compe encies o sel -compassion and com- passion o o he s. The e o e, he CMT-T may con ibu e o a enua ing he ba ie s o com- passion and s eng hening eache s’ compassiona e mind and abili ies, including g ea e sel - PLOS ONE Compassiona e Mind T aining o Teache s PLOS ONE | h ps://doi.o g/10.1371/jou nal.pone.0263480 Ma ch 1, 2022 24 / 36 compassion, openness o ecei ing compassion and suppo om o he s, and mo i a ion and compe encies o es ablish mo e compassiona e ela ionships, pa icula ly in he school en i- onmen (e.g., colleagues, s a , pupils). One o he cen al aims o CMT-T is o p omo e bo h o e all and p o essional wellbeing, which in he cu en s udy we e assessed h ough ypes o posi i e a ec , linked o eelings o elaxa ion and calmness, eelings o sa eness and con en men , and ene gised posi i e emo- ions (e.g., exci ed, ene gised, en husias ic), and h ough eache s’ sa is ac ion wi h hei p o- essional li e. G oup compa isons e ealed ha he CMT-T g oup signi ican ly inc eased sa e, elaxed and ac i a ed posi i e a ec om p e- o pos -in e en ion, wi h la ge e ec sizes. S epped wedge analyses u he subs an ia ed hese indings and e ealed ha , a pos -in e - en ion, WLC pa icipan s who comple ed he CMT-T p esen ed inc emen ed le els o eel- ings o sa eness and elaxa ion (wi h la ge e ec sizes) and o i ali y/ac i a ion (medium e ec sizes). These esul s a e in line wi h ou hypo heses and wi h p eceding esea ch ha epo ed inc eases in posi i e a ec , pa icula ly in eelings o sa eness, con en men , and elaxa ion, a e a CMT in e en ion in communi y samples [66,67]. Con e sely o hese p e ious s udies whe e no changes we e ound in ac i a ed posi i e a ec , in e es ingly, he CMT-T p oduced enhanced ene gizing posi i e emo ions (e.g., exci emen , i ali y and en husiasm) hypo he- sized o be ela ed o he d i e sys em, in addi ion o heigh ened posi i e emo ions o sa eness, con en men , calmness and elaxa ion, hypo hesized o be ela ed o he soo hing sys em [58, 116]. These indings suppo he CFT amewo k ega ding he bene icial impac o os e ing compassion and educing i s inhibi o s on cul i a ing ypes o posi i e a ec linked o he a ilia i e and ca e-gi ing men ali ies [58,116]. Mo eo e , i may be ha he speci ici y o he se ing whe e CMT-T was implemen ed acili a es he p omo ion o a di e en ype o ac i e posi i e emo ions ela ed o he d i e esou ce-seeking sys em [58,116]. This may be ela ed o he ac ha eache s end o su e om bu nou and exhaus ion [4], which may be e lec ed in a dampening o his ene gizing posi i e a ec p io o he in e en ion. Hence, he ac ha CMT-T is applied o hei p o essional li es and wi hin he school con ex may encou age an adap i e s imula ion o he d i e esou ce-seeking sys em and os e his ype o posi i e ene - gizing emo ions which, balanced by he p omo ion o eelings o sa eness and elaxa ion, may be c ucial o p o essional pe o mance and wellbeing. In ac , his hypo hesis seems o be u - he suppo ed by he esul s using a new measu e assessing emo ional clima e a wo k (i.e., he ac i a ion o he sa eness, d i e and h ea a ec sys ems) in a subsample o eache s. These pa icipan s exhibi ed signi ican inc eases in posi i e emo ions linked o soo hing/sa eness and d i e/ i ali y a wo k om p e- o-pos CMT-T, ep esen ing medium o la ge e ec sizes. Rega ding eache s’ sa is ac ion wi h p o essional li e, no signi ican changes we e ound in he CMT-T g oup. Howe e , s epped wedge analyses e ealed signi ican inc eases be ween base- line (T1) and pos -in e en ion (T3) in he WLC pa icipan s who ecei ed he CMT-T (medium e ec size). O no e, in he g oup compa ison analyses, he WLC g oup p esen ed a signi ican inc ease in sa is ac ion wi h p o essional li e om T1 o T2. Howe e , a baseline, hese pa icipan s had lowe sco es in sa is ac ion wi h p o essional li e han he CMT-T g oup, and his inc ease pu bo h g oups a a simila le el a T2. As a whole, hese esul s con- ce ning he aluable e ec s o CMT-T on o e all and p o essional wellbeing ex end p e ious s udies using ea lie e sions o CMT-T ha did no assess hese indica o s [32,87] and ind- ings om esea ch using CFT as guided sel -help in he gene al popula ion ha demons a ed imp o emen s in wellbeing a pos -in e en ion [79]. Alongside he cul i a ion o posi i e emo ions and wellbeing, he CMT-T also aims o a ge and educe su e ing and psychological dis ess. 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