This study tested a 4-week, internet-based Mindfulness-Based Cognitive Therapy (MBCT)program designed to help people experiencing adjustment disorder during the COVID-19pandemic. Adjustment disorder is a stress-related condition that can cause anxiety,depression, and difficulty coping after major life changes.We compared the online MBCT program to two other groups: an internet-based relaxationtraining program and a wait-list group. A total of 301 adults from Poland took part. Wemeasured symptoms of adjustment disorder, depression, and anxiety before the program,right after, and one month later.Results showed that the online MBCT program led to greater improvements in depression andanxiety than the other two groups. People in MBCT also developed more self-compassion andwere better able to distance themselves from unhelpful thoughts, which helped reducetheir symptoms. Benefits lasted at least one month after the program ended.These findings suggest that a brief, self-guided, online mindfulness program can be aneffective, accessible way to support mental health during stressful times such as apandemic.
Background and Rationale Adjustment disorder (AjD) is a stress-related mental health
condition characterized by maladaptive emotional and behavioral responses to an
identifiable stressor. Core symptoms include persistent preoccupation with the stressor
and difficulty adapting, often accompanied by anxiety, depressed mood, and avoidance
behaviors. According to ICD-11 criteria, AjD symptoms emerge within three months of a
stressor and typically resolve within six months after the stressor ends, although in
many cases they can persist longer and contribute to chronic distress.
Epidemiological studies indicate that AjD is highly prevalent, affecting up to 30% of
clinical populations and a substantial proportion of the general public during times of
widespread stress. Despite this, AjD remains understudied compared to mood and anxiety
disorders. Few empirically validated psychological interventions are available, and
existing treatment recommendations are often extrapolated from evidence on depression and
anxiety.
The COVID-19 pandemic presented a unique context in which AjD rates surged globally. Fear
of infection, prolonged social isolation, economic uncertainty, and disruption of daily
life contributed to high levels of stress-related distress. Surveys during the pandemic
indicated that 18-43% of adults in Europe reported symptom patterns consistent with AjD,
underscoring the urgent need for scalable interventions that could be delivered remotely
and at low cost.
Mindfulness-Based Cognitive Therapy (MBCT) MBCT is an eight-week, group-based
psychological program originally developed to prevent relapse in recurrent depression. It
combines mindfulness meditation practices with cognitive-behavioral therapy strategies,
fostering non-judgmental awareness of present-moment experience, greater cognitive
flexibility, and reduced reactivity to negative thoughts and emotions.
Mechanistic research suggests that MBCT works by:
Increasing cognitive defusion - the ability to step back from and observe thoughts
without automatically believing or reacting to them.
Reducing experiential avoidance - the tendency to suppress or avoid difficult emotions
and sensations.
Enhancing self-compassion - a kinder, more understanding stance toward oneself in times
of suffering.
These processes are relevant to AjD, where stressor-related rumination and self-critical
coping often maintain distress. Although MBCT's efficacy for depression and anxiety is
well-established, little is known about its effects in AjD or its feasibility in brief,
fully online, self-guided formats.
Internet-Delivered MBCT (iMBCT) Internet-delivered psychological interventions (IPIs)
have the potential to greatly expand access to evidence-based care. Online MBCT (iMBCT)
can be delivered synchronously (live sessions with a facilitator) or asynchronously
(self-paced, unguided), with evidence supporting effectiveness in reducing distress and
improving resilience. Unguided iMBCT programs are especially promising for public health
implementation due to their low delivery cost and scalability, but high-quality trials in
specific clinical groups remain rare.
Study Objectives
The primary aim of this study was to evaluate the efficacy of a four-week, unguided,
internet-delivered MBCT program for adults meeting ICD-11 criteria for AjD during the
COVID-19 pandemic. We compared iMBCT with:
An active control - a four-week, unguided internet-delivered Progressive Muscle
Relaxation (iPMR) program.
A passive control - a wait-list control (WLC).
Secondary aims were to examine whether changes in key psychological processes (cognitive
fusion, experiential avoidance, self-compassion) mediated symptom improvement, providing
insight into the mechanisms through which iMBCT exerts its effects.
Methods Overview This was a three-arm, parallel-group randomized controlled trial. A
total of 301 adults from Poland who met ICD-11 AjD criteria (based on the Adjustment
Disorder New Module - 20) were randomized to iMBCT, iPMR, or WLC. Interventions lasted
four weeks, with assessments at baseline, post-intervention, and one-month follow-up (for
intervention groups).
Interventions
iMBCT: A self-guided adaptation of MBCT condensed to six modules over 30 days. Modules
included audio-guided mindfulness meditations (body scan, sitting meditation, mindful
movement), reflective journaling, and psychoeducational materials. Content was delivered
through a secure online platform with automated email reminders.
iPMR: A self-guided Progressive Muscle Relaxation program based on the Bernstein and
Borkovec protocol, progressing from tensing and releasing 16 muscle groups to relaxation
through mental recall. Audio instructions and written materials were provided.
WLC: No intervention during the 4-week study period. Participants were offered a choice
of iMBCT or iPMR afterward.
Outcomes and Process Measures
Primary outcomes:
AjD symptoms (ADNM-20)
Depressive symptoms (PHQ-9)
Anxiety symptoms (GAD-7)
Process measures:
Cognitive Fusion (CFQ)
Experiential Avoidance (AAQ-II)
Self-Compassion (SCS-SF)
Key Findings
All groups showed significant symptom reductions over time, but iMBCT participants had
greater improvements in depression and anxiety than both iPMR and WLC.
AjD remission rates were highest in the iMBCT group.
Cognitive defusion fully mediated the effect of iMBCT on depression and anxiety,
suggesting it is a key mechanism of change.
Increases in self-compassion were observed only in the iMBCT group compared to WLC.
Benefits in the intervention groups were maintained at one-month follow-up.
Significance and Implications This trial provides the first randomized evidence that a
brief, unguided iMBCT program can effectively reduce symptoms of AjD, depression, and
anxiety, and improve transdiagnostic processes associated with resilience. Its low cost,
scalability, and sustained benefits make it a promising tool for addressing
stress-related disorders in situations where traditional face-to-face therapy is
unavailable or impractical, such as during large-scale public health crises.
The findings also add to the mechanistic literature on MBCT, highlighting cognitive
defusion as a central pathway to symptom improvement in AjD. This may inform refinements
in mindfulness-based interventions and encourage further research on tailoring MBCT to
specific stressor-related conditions.
Future research should test longer-term outcomes, evaluate implementation in diverse
cultural contexts, and explore the integration of brief guidance or peer support to
reduce attrition.
Behavioral: Mindfulness-Based Cognitive Therapy (Internet-delivered)
A 4-week (30 days), unguided online adaptation of the Mindfulness-Based Cognitive Therapy
(MBCT) program. The intervention consisted of six sequential modules delivered through a
secure web platform, including guided mindfulness meditations, body scan, mindful
movement, and cognitive-behavioral exercises. Participants received audio recordings,
written materials, and reflective tasks, along with automated reminder emails. No
therapist guidance was provided.
Other Name: iMBCT
Behavioral: Progressive Muscle Relaxation (Internet-delivered)
A 4-week, unguided online progressive muscle relaxation (PMR) program adapted from
Bernstein and Borkovec's protocol. The program included six sequential modules teaching
systematic tensing and relaxing of major muscle groups, gradually reducing the number of
groups until relaxation could be achieved through recall alone. Materials included audio
recordings, written instructions, and automated reminder emails. No therapist guidance
was provided.
Other Name: iPMR
Behavioral: No Intervention - Waitlist Control
Participants in this arm received no active intervention during the 4-week waitlist
period but completed all study assessments on the same schedule as intervention arms.
After the waiting period, participants were offered the choice to take part in either the
online MBCT or PMR program.
Inclusion Criteria:
Participants are required to be (a) at least 18 years old, (b) have access to the
Internet, (c) currently experiencing some form of psychological distress related to
COVID-19 pandemic, such as stress, anxiety, and/or low mood, and d) have the willingness
to commit to a free online intervention program with two pre and post measurements
online, within four weeks.
Exclusion Criteria:
(a) participating simultaneously in any pharmaceutical or psychosocial therapy, (b) if
they were suffering from a current or lifetime psychotic disorder, bipolar disorder, or
substance abuse problem; (c) if they reported current suicidal tendencies, (d) if they
did not meet criteria for Adjustment Disorder (less than 47,5 points in ADNM-20
questionnaire), (e) participated in the past or currently in any of 8 weeks mindfulness
programs (e.g., MBSR, MBCT).
Faculty of Psychology, University of Warsaw
Warsaw 756135, Poland
Not Provided