Supplementary Intervention description
The program “Open and Calm” (OC; anonymized, 2013), was inspired by the Relaxation Responsebased Resiliency Program (R3P) developed by Herbert Benson and colleagues at Massachusetts
General Hospital through four decades (Park et al., 2013), and was therefore formally entitled
“Relaxation-Response-Based Mental Health Promotion (RR-MHP). It was designed as a
standardized course for public mental health promotion and stress reduction.
The RR tradition and theoretical consensus in the meditation literature (Sedlmeijer et al., 2012) hold
that the core of most meditative techniques comprises (a) the continuous returning of attention to a
meaningful focus, i.e., focused attention training; and (b) the non-reactive witnessing or monitoring
of ongoing experience. The OC meditation practice therefore focused on these two aspects and
termed them “Open” (defined as “relaxed and receptive” experience of a chosen focus) and “Calm”
(defined as “non-intervening”) conscious processing of internal and external experience. The course
structure followed the well-established body-psycho-social view upon stress, stress resiliency, and
overall health factors, focusing each week on working with either they body, the mind, or social
relationships, respectively, in a cyclic fashion (See the week-by-week course description below).
While meditation was trained every week, OC therefore also involved bodily, cognitive, and social
practices. Importantly, all practices trained the OC principles (e.g., Open attention toward the
breath, an emotion, or another person) and were integrated by an OC framework model, as
described below.
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Formats
The standardized OC program was offered in two formats: The group format (OC-G) involved
weekly 2.5-hr sessions and one-two 1.5-hr personal sessions. The individual format (OC-I) involved
personal, weekly 1.5-hr sessions. Formats used identical course materials involving a course book
(anonymized, 2013), online materials, 1—2 daily meditations of 10—20 min following audio files,
frequent “mini-meditations” of 1-2 min, and bodily, cognitive, and social practices. Group courses
were held a fixed times mostly at weekday evenings from 7pm-9.30 pm, so employed participants
could maintain a normal working week during the course. Individual sessions were offered in
expanded working hours (weekdays, 8am-6pm). Naturally, the group format involved much less
personal contact with the instructor (CGJ) than the individual format. As a consequence, the
individual format involved a deeper level of personal, therapeutic conversations and the meditative
practices were sometimes “tailored” to the individual patients’ needs each particular week. For
example, if an individual participant experiences a specific bodily pain, this could be the subject of
a whole, individualized, meditative session, while this was not possible in the group-based format,
although meditations were adapted to the group’s collective experiences. Oppositely, interparticipant social support, normalization, motivation etc. were of course only present in the groupbased format. This was especially encouraged in weeks 5-7, where the instructor asked participants
to reflect upon the weekly themes, book chapters, and their previous experience with these themes
in the first thematic cycle (week 2-4), while the instructor would sit outside the participant circle,
take notes, and only provide brief ideas or comments to their common reflection. The instructor
always conducted the meditative, bodily, cognitive, and social practices.
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A focus on states rather than techniques
As an important point inspired by the RR-tradition, OC focused on promoting beneficial states
rather than specific techniques. Being “Open” and being “Calm” was described as two ways of
receiving and relating to ongoing (bodily, mental, and social) stimuli and experiences – and not as
two exclusive (e.g., meditative) techniques. To the contrary, it was often discussed how many
techniques, events, or situations may promote open (relaxed and receptive) attention and a calm
(initially non-intervening, i.e., not-automatically reacting) relationship with experiences. For
example, verbal psychotherapy may also increase one’s motivation and ability to elicit these states.
Prioritizing sleep, nutritious food, or good exercise generally also increases one’s ability to remain
Calm in stressful situations. Benson’s group wrote about the commonalities of psychotherapy and
meditation already 30 years ago (Kutz et al., 1985) that meditation may contribute to therapeutic
progress because it promotes the emergence of previously subconscious or preconscious material
into conscious experience, intensifying the material to be worked with in the therapeutic setting. In
other words, meditation renders the mind more “Open” (relaxed and receptive), to information –
which in turn provides the opportunity to reflect on this material and thereby gain a more adaptive
relationship with it – which will often be a more “Calm” relationship, when “Calm” is defined as a
relationship characterized by a stronger, conscious ability to react as and when intended, rather than
a relationship characterized by automatized behaviors or self-regulation. Thus, meditation may
intensify processes, which are also active in many other types of therapeutic settings.
All in all, rather than portraying “Open” and “Calm” as something unique only trained
within meditation, the OC program therefore explicated how these two central processes may be
intensively trained in meditation, but that they may be common processes or states, which may also
be promoted by bodily, cognitive or social factors. This strategy was assumed to relate the
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stress-reduction program in Denmark. Supplementary intervention description. Page 3 / 13
meditative practice with several everyday contexts and promote creativity and curiosity on behalf
on the OC participants in discovering ways of promoting the beneficial states, rather than creating a
focus on e.g., “learning how to meditate” to be able to benefit from the course. In addition, the
consistent modeling of meditative, bodily, cognitive, and social practices onto the same, underlying
framework model (described below) was assumed to facilitate quicker learning of the basic theory
and method, promote cognitive associations between e.g., meditative and bodily OC techniques,
and create a synergy that would improve the mental health effects, both on the short and long term.
Contrasting “Open” and “Calm” with “Flight” and “Fight”
The OC states were also presented as oppositions to the “Fight and Flight” responses, to explain
how they might counter stress and promote stress resiliency. “Open” (being relaxed and receptive)
was contrasted with “Flight” (being nervous/strained and avoidant). “Calm” (being non-intervening
or non-regulating towards the content of conscious experience) was contrasted with “Fight” (being
change-oriented or regulation-oriented due to the threat perception underlying the stress response).
The choice of defining “Calm” as non-intervening was in this way based on the typical action- or
regulation orientation or that arises with the stress-response. Terms such as “Acceptance” or “Nonjudgment”, which are central in current mindfulness studies (e.g., Baer et al., 2006) was not a focus
in OC. Although the concepts of acceptance, non-judgment and non-interference overlap, it was
hypothesized to be an easier “first step” to focus on stopping the urge to change or cope with
situational stressors, rather than starting with a focus on accepting or not evaluating experiences
during a stressful situation. In addition, acceptance, non-judgment, “beginner’s mind”, and other
central principles in mindfulness (Kabat-Zinn, 2014) are, in our experience, quite difficult to define
and separate from one another. The ability to refrain from seeking to change one’s experience
seemed the most central antidote to the “fight” response, and easier to define and explain clearly.
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Thus, when training the ability to be “Calm”, OC encouraged participants to start training the idea
that “I don’t have to do anything about this”. OC did not focus on training the ability to contain
stimuli in a non-judgmental or acceptant, mental atmosphere. Rather, OC would reinforce, that the
atmosphere could be whatever it turned out to be – hateful or loving – but that participants were
simply to train the ability to stop the fight (and-flight, using the Open state) reactions to stressful
experiences, e.g., reactions such as trying to repress mental stress, or working harder to get a job
done. It was often humorously stated that OC trained two types of doing-nothing: (a) doing nothing
but relaxing and receiving input from your focus of choice; and (b) letting the information occur in
conscious registration without changing it, or “doing nothing about it”. Importantly, however, the
Calm-training did not aim for passivity, but only for an ability to be non-intervening initially, to
stop automatic reactions to stressors and promote conscious contemplation of optimal coping, after
which the framework OC model clearly recommended “Participation”, as described next. In the
context of the stress response, “Participation” was contrasted with the “freeze” response, since
active participation in regulating internal or external environments is in opposition to freezing or
not being able to participate.
The framework Open and Calm model
A core model of consciously influenced, personal development was used every week to explain, in
simple terms, the essence of meditation and of optimal ways of coping with stress and strengthening
stress resiliency. A detailed and theoretical account of this model will be published elsewhere. This
OC model basically portrayed a circular relationship between “Experience”, “Processing”,
“Participation”, and “Consequences”. Briefly, “Experience” referred to the sensory content of any
conscious experience, e.g., to the sensation of a quickened pulse in a stress reaction. The optimal
state for improving “Experience” was “Open”. As always, “Open” was defined as “relaxed and
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receptive”. The basic argument presented for viewing Open states as optimal for Experience was
that being relaxed and receptive (in contrast to strained and avoidant/repressive) in the direction of
one’s consciously chosen focus generally always improves the information available for conscious
registration of sensory content. The optimal state for improving “Processing” was “Calm”, which
was always defined as “non-intervening”. The principal argument was that the more Calm (as
opposed regulation-oriented) a person could be while processing virtually any type of stimuli, the
easier it would be to stop the automatic, stress-induced self-regulations or series of actions. Again,
the goal of the “Calm” training was not to “feel better about it” (e.g., to feel more acceptant), but
simply to stop the automatized stress-induced behavioral or internal patterns of stress-adaptation.
The third element of the core OC model was termed “Participation”, which referred to mental and
behavioral (physical) self-regulation of all types, i.e., including both the repressing (or, conversely,
attentive exploring) of an emotion, as well as physical movements and social behaviors. In this way,
“Processing” is in principle also a type of “Participation” (since one is non-intervening by choice),
but this was not discussed and was never commented on by the participants. But in principle, Calm
Processing is indeed one specific type of Participation: namely being non-intervening by choice.
The specific term “Participation” was deliberately chosen as an alternative to terms such as
“behavior” or “actions”, which are classical core terms of cognitive therapy, to emphasize the
situated nature of all self-regulatory processes and underline, that subjects can always only take part
of the responsibility for the totality of a situation and their possible ways of staging themselves and
engaging with this situation (Nissen, 2005, 2012). It was discussed, for example, which part of a
physiological stress-response or a social interaction, one might have the biggest, conscious
influence on, recognizing that one can never achieve full control of neither body, mind, nor social
interactions. Main purposes of using Participation as a term were e.g., to make participants
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consciously consider which coping strategies to take part in (for example, the social theme
highlighted three types of social support that have empirically proven effective, being emotional
support, informative support, and support with daily practicalities) and to reduce guilt and shame of
not having participated in ways that effectively reduced stress until now by highlighting that all
phenomena are biopsychosocially situated and influenced.
The final element of the core OC model was termed “Consequences”. It was included
primarily as a didactical tool to promote awareness of the fact that any type of Participation will
have some Consequences, and some Consequences, but not all, will affect conscious Experience.
For example, drinking coffee will have physiological Consequences, which may (or may not) affect
Experience. Thus, in essence, the OC model as a whole portrayed consciously influenced, personal
development as a four-aspect phenomenon: (a) “Experience”: Subparts of processed information is
advanced (consciously or not) to become the content of conscious registration, which may occur in
may forms, one of which is a relaxed and receptive state (Open Experience); (b) “Processing”: The
information that is thus consciously registered may be consciously processed in many different
ways, one of which may be a non-intervening witnessing (Calm Processing); (c) Participation:
Having registered and consciously processed the information, one may, or may not, decide to take
part in internal or external regulatory processes; (d) Consequences: Participating through bodily,
mental or social strategies will always have some (bodily, mental, or social) consequences, some of
which will affect the content of conscious registration (Experience).
Importantly, the OC course focused consistently on training Open Experience and
Calm processing. Thus, the full model was not the focus of the course. Rather, a major point of
using the OC model repeatedly was to bring awareness to the fact that the core of the whole
program was to train elements of consciously influenced development that (arguably) lay before
any type of Participation. Thus, intervention participants were repeatedly exposed to the idea, that
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the immediate goal of the OC program was to change their behavior, but their ways of attending to
information (relaxed and receptive, or “Open” attentiveness was the ideal) and in their ways of
“handling” or Processing information (an initially non-intervening or “Calm” processing was the
ideal) before any type of consciously chosen adaptation or self-regulation (Participation). Naturally,
many participants did find it very important to change their ways of participating in life (e.g., in
their occupational and social activities), and it was often emphasized that Participation of course
was no less important for mental health, stress reduction, quality of life etc. – than Experience and
Processing. However, it was hypothesized that having a clear, interventional focus on two definable
states would be important for participants’ abilities to quickly get a sense of the goals of the
program and then adapt and experiment individually with ways of integrating these two qualities of
mind into their concrete, daily Participation within different practices and contexts.
Controversially, as part of having a consistent, overall “message”, the OC program did
not emphasize daily compliance. Compliance with e.g., daily meditation practices and cognitive
practices was of course recommended, but not emphasized. To the contrary, it was revealed at the
first session that research in similar meditation-based stress reduction programs has not been able to
demonstrate a significant association between weekly or total number of meditation sessions and
improvement on mental-health related outcomes (Carmody & Baer, 2009; Jensen et al., 2012;
Virgili, 2013). This is of course a controversial strategy. For example, in MBSR, Jon Kabat-Zinn
and colleagues are known to emphasize that “you don’t have to like it [the meditative practice], you
just have to do it” (Kabat-Zinn, 2014). The OC message was, to the contrary “You don’t have to do
it, unless you feel like it”. This recommendation was carefully presented. It was presented as part of
(a) the focus on the cultivation of states, rather than techniques. Here, it was stated that for a 9-week
course, it might be just as important that to arrive at e.g., a motivating, cognitive-emotional insight
into the value of prioritizing non-meditative activities eliciting OC states (these states may also be
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stress-reduction program in Denmark. Supplementary intervention description. Page 8 / 13
elicited by e.g., exercise, healthy sleep patterns, or pleasant interactions with family or friends) as
the number of minutes spent meditating each week. In addition, the controversial compliance
strategy was (b) explicitly presented to reinforce the overall OC principles. Thus, participants were
recommended to select a specific place and specific time for their daily meditation practice and to
meditate each day, but to always investigate whether they felt motivated to meditate and to keep the
“Calm”-principle in mind, that they did not have to do it. This overall consistent emphasis on states,
rather than specific techniques was applied to invoke creativity and attention to the many possible
ways in which participants might promote relaxed and receptive awareness and an allowing or nonintervening processing. Finally the compliance strategy was used to (c) communicate clearly that
compliance with the OC practices was mainly the responsibility of the participants themselves.
Thus, the instructor would never ask, for example, “How many times did you meditate this week?”,
but always “Did you meditate as often as you think was appropriate for you, this week?”.
Experience
Consequences
Processing
Participation
Figure 1. The Open and Calm core didactic model. The core OC model was used every week
in line with the intervention’s cyclically changing bodily-psycho-social focus (see the weekby-week course description).
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Meditation practice
The OC program involves three basic meditations inspired by the Relaxation Response (RR)
tradition (Park et al., 2013) and by mindfulness meditation (Wallace, 2010). Meditations are
described in more detail in the week-by-week course description. In addition, versions of the
meditations in different lengths and versions with fewer or no instructions (e.g., 15 or 20 minutes of
silence) were available to participants. All meditations trained the ability to maintain a sensory
focus (to be “Open” towards a vehicle of attention, e.g., the movement of the breath, or the thought
of one’s workplace) and the ability to refrain from interfering with the changing content of ones
experience (to be “Calm” and allow sensations to come and go, and only react on them if this was
consciously willed). OC meditation was thus partly based on concentrative meditation (e.g.,
Buddhist Samatha [breath] and Ananda Marga [mantra]) which entail focusing on a specific
perception over time; and partly on mindfulness traditions (e.g., Zen and Vipassana), involving
detached, non-judgmental witnessing of experience. OC meditation is therefore applying two
central techniques found in several meditative traditions (Sedlmeier et al., 2012), in line with the
RR tradition, emphasizing the same two components and underlining similarities of physiological
effects across variations of meditative techniques (Benson & Proctor, 2010).
Week-by-week course description
The thematic course progression follows a body-psycho-social model of mental health promotion
and neurocognitive and clinical evidence on the importance of repetition and personal integration of
interventional methods for learning and long-term effects.
Week 1. Themes: ‘The OC Model’ and ‘Relaxation Response Meditation’. The simple, cognitive
OC model and a basic RR-meditation was taught. ). In the first week, OC trained the core RR
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meditation technique developed by Herbert Benson and colleagues through extensive scientific
studies across different meditative practices (Park et al., 2013). This technique involves the
repetition of a meaningful mantra, which is coupled with attentiveness to the movements of the
breath. In the RR tradition, participants freely select their mantra, and this was also mentioned as an
option in OC. However, in the first week, OC recommended the use of “Open” (inbreath) and
“Calm” (outbreath) to cognitively reinforce the attentiveness to these central concepts and states
throughout the program.
In weeks 2 and 5 (weeks focusing on the body) the meditation involved awareness of the breath
without the mantra, although participants were encouraged to use the mantra, should they so prefer,
or as a tool to re-focus or limit attentiveness to distracting thoughts. The main goals were to
establish a regular meditation practice, and to understand the central model and thereby the
rationale behind the course methods (bodily, cognitive, meditative, and social).
Week 2. Theme: “The Body”. Psycho-education on the RR and bodily health. Physical grounding
and relaxation exercises. Meditation focused on sensing and allowing the movements of the breath.
The RR-inspired “New and Nice” practice was introduced. This involved daily notes on one new
bodily sensation (training Open body awareness) and one pleasant relationship with an experience
(e.g., relating to a bodily stressor in a Calm way). Using the OC framework model to discover ways
of increasing OC states in relation with body.
Week 3. Theme: “The Mind”. Emotions and thoughts. Psycho-education on typical mental reactions
to stress, e.g., unconscious repression of bodily signals, automatic fight-and-flight impulses, and
critique of self and others. Cognitive practice on discovering one’s awareness of pleasant and
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unpleasant emotions, and one’s relationship with each of them. The meditation started by focusing
on the breath (5 min), and then directed attention towards feelings (5 min) and thoughts (5 min).
Daily noticing of ‘New and Nice’, but focusing on emotions or thoughts. Using the OC framework
model to discover ways of increasing OC states in relation with thoughts and emotions.
Week 4. Theme: “Social Relations”. Psycho-education on social support. Participants were
encouraged to invite a friend or a colleague to the course to spark positive interest and support for
their OC course in their network. Meditation focused on experiencing and relating calmly to the
stressed as well as relaxed, social contexts. The meditation started by focusing on the breath (6
min), and then directed attention towards focusing on whatever arose to consciousness of bodily or
mental experiences when first thinking about a stressful situation or context (6 min) and then a
pleasant situation (6 min). Daily noticing of ‘New and Nice’ aspects of social interactions. Using
the OC framework model to discover ways of increasing OC states in a social context of choice.
Weeks 5—7. Repetition of the course material, themes, and practices of weeks 2—4. Week 5 also
included a mid-way evaluation and reflection. Questions-and-answer sessions as well as repetition
of the psycho-educative material was encouraged among participants themselves to increase social
learning, social support, and group cohesion.
Weeks 8—9. Theme: “The focus you wish for”. A stronger focus on personal growth and personal
ownership of the OC method. Participants chose a daily or weekly bodily, mental, or social focus
based on personal relevance. Week 9 included cognitive practices on the total course experiences
and the potential personal long-term effects of OC practices. Using the model to improve future,
personal integration of OC.
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References
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