The Experience of Shared Meditation Involving People With Cancer,Health Professionals and Third Persons: A Qualitative Focus-Group Study

Abstract

In recent years, mindfulness-based interventions have gained in popularity as a non-pharmacological intervention for improving well-being in oncology. Our project aims to address the benefit of shared meditation involving patients, medical staff ant third parties (neither patients, nor carers). The intervention programme was based on 12 weekly 2h sessions (including 2 half-day retreats), followed by 3 monthly follow-up sessions in remote format. Focus groups were conducted at the end of our programme for each category of the 42 participants who experienced shared meditation based on 5 preselected open-ended questions. Responses were transcribed and analysed using NVivo software. Four salient themes were identified attesting that shared meditation: (1) was a positive experience, with physical and psychological benefits, even though requiring much commitment, (2) provided an experience enabling them to see themselves as people rather than just patients, (3) allowed them to rethink their lives by reconsidering their relationship with themselves and their disease, and (4) improved their relationships, not only with carers in the therapeutic setting but also outside it, with third parties. Their feelings of stigmatisation linked to the disease were attenuated. Improvement of psychosocial skills was reported as a major benefit of shared meditation. Beyond the positive effects on well-being, shared meditation could enable patients and others to develop a sense of social connectedness and to nurture a sense of common humanity. Our qualitative data provide valuable insights into how shared meditation can be implemented, not only within the care setting but also within the community at large.

Trial Registration: ClinicalTrials.gov NCT06041607 registered: 09/18/2023

Introduction

People with cancer often experience high levels of distress, from the point of diagnosis through treatment and recovery, with rates higher than 45% reported worldwide. ¹ Distress is defined by the National Comprehensive Cancer Network (NCCN) as a complex, unpleasant emotional experience that leads to impairments in mental, emotional, and physical well-being, and hinders coping with symptoms and treatment. ² Because of the substantial cognitive, emotional, and administrative demands of delivering highly complex care, healthcare professionals in oncology are also particularly exposed to stress, with a prevalence of burnout reaching a global rate of 40% among physicians and nurses. ³ The well-being of oncology providers is essential to their professional fulfilment, positive patient outcomes, ⁴ and quality of communication with their patients. ⁵

Well-being should be considered as an institutional priority and as a means of reinforcing mutual trust between the person being cared for (who wishes to play an active role in her/his disease) and the health professional (who sometimes needs care). ⁶ Understanding that suffering is part of shared human experience and cultivating together our sense of common humanity, ⁷ whatever one’s status (patient, health professional and neither patient or carer), could contribute to alleviating suffering and enhancing well-being. In this sense, the sharing of experiences by patients and oncology providers could contribute to building bridges that help them to feel less isolated from others.

In this respect, among the recognised mind-body tools for alleviating distress in integrative oncology, mindfulness-based interventions are demonstrating increasing evidence of their beneficial effects. Integrative oncology is a patient-centred, evidence-informed field of cancer care that, by fostering an open and informed dialogue between patients and their healthcare providers, aims to optimise health, quality of life, and clinical outcomes and to empower patients to become active participants in the management of their disease. ⁸ Promoting effective coping strategies is therefore essential to fostering adaptation to the stress caused by cancer and to improve patients’ well-being. ⁹

Mindfulness is a secular practice of meditation founded in the traditions of Buddhism.

Kabat-Zinn defines it as a state that involves the ‘purposeful attention to the present moment, including thoughts, emotions, and bodily sensations, as it arises, without judgment’. ¹⁰ Mindfulness emphasises the importance of accepting all thoughts and experiences as they are, without trying to alter or change them, and thereby developing a greater sense of well-being. In addition to the physical and emotional aspects of well-being, mindfulness could indeed provide patients with autonomy and empower them to be in control of their care. ⁴ In a clinical context, mindfulness was shown to improve an individual’s ability to cope with stressful life events such as disease or treatment as demonstrated in recent systematic reviews.^11-13 In the last decade, mindfulness-based interventions have increasingly been adapted from the well-known mindfulness-based stress reduction (MBSR, ¹⁴ ) programme as an intervention for people with cancer. Recent meta-analyses and reviews published in oncology in the last 2 years provide substantial evidence of their effectiveness in alleviating stress,^12,15-19 anxiety and depression^17-21 as well as enhancing quality of life.^12,15,18,19 They also demonstrate benefits in improving coping abilities,^11,12 mindfulness skills, ²² self-compassion, ²² and enhancing perceived efficacy in coping with cancer. ¹¹ According to the American Society of Clinical Oncology (ASCO) and the Society for Integrative Oncology, mindfulness-based interventions are highly recommended for people with anxiety and depression during and after treatment.^23,24 Recent meta-analyses of the experience of healthcare professionals have shown that mindfulness reduces work distress ²⁵ and improves caregiver well-being.^26,27 Mindfulness-based interventions are also effective in improving mindfulness, empathy, and self-compassion levels.^26,27 In response to the need for healthcare organisations to reduce burnout in oncology, the European Society for Medical Oncology (ESMO) Resilience Task Force (RTF) recently provided recommendations in which mindfulness is considered relevant for the optimised management of well-being at personal and institutional levels. ²⁸

In this context, we developed a multi-step project to offer mindfulness meditation as part of joint workshops with cancer patients, our target population, and health professionals. We suggested that third parties (‘non-patients’ and ‘non-care-giving’ subjects) should also be involved, in order to break out of the context of the hospital and the illness. Since suffering is a shared experience regardless of whether one is a patient, a health professional, or a third person, one may assume that professionals, patients and others could act collaboratively to improve the wellness in and around them, leading to the emergence of collaborative and interactive health care. The research hypothesis is that beyond the individual benefit meditating together may bring to participants, particularly in the daily management of stress, it may provide additional benefit in terms of well-being and strengthened links between patients, health professionals and third persons, which could constitute an added value, particularly for patients, our target population. As this hypothesis has never been assessed, we first developed a mindfulness-based programme and conducted a pilot study which demonstrated the feasibility, acceptability, and relevance of shared meditation.^6,29 Perceptions of participants were explored through a focus-group study which demonstrated that shared meditation was appreciated, particularly by patients, who found it motivating and a way to relieve their feelings of loneliness in the face of illness. ³⁰ Since all participants reported better stress management, their opinion was taken into account in building a randomised trial. ³¹ The trial aimed to evaluate the potential added value of shared meditation involving people with cancer, health professionals and third persons (experimental arm) compared to meditation conducted with patients only (control arm). The study protocol provided from the outset for the integration of a qualitative approach through focus groups conducted in the experimental arm at the end of the shared meditation programme, in order to finetune the quantitative data from the self-questionnaires. The characteristics of the qualitative analysis were described in the study protocol publication as secondary objectives. ³¹ This complementary approach is particularly crucial in a context where there is still no validated questionnaire specifically allowing our hypothesis of the added value of shared meditation to be explored.

We herein present the analysis of the qualitative data obtained in the focus groups at the end of the programme for each category of participants. This qualitative study aimed to capture and explore participants’ experiences and perceptions in order to clarify (1) the added value provided by shared meditation, (2) ways of improving the programme and modalities for its future implementation and dissemination.

Methods

Study Design and Participants

IMPLIC-2 was a 2-arm single-centre randomised controlled trial targeting people with cancer (https://classic.clinicaltrials.gov/ct2/show/NCT06041607). The IMPLIC-2 protocol was drafted in accordance with standard protocol items according to recommendations for interventional trials (SPIRIT). ³¹ We chose to associate a qualitative approach with the randomised trial. While the individual benefits of meditation in relieving psychological distress that have increasingly been demonstrated in people with cancer in recent years,^15,16,19,21 less qualitative research has focused on how meditation, its levers and determinants help patients to cope with illness, an issue that is poorly reflected by quantitative data. We believe that the mixed method is pertinent, as quantitative and qualitative data can complement each other when seeking to understand and clarify the effect of an intervention. ³¹

Participants’ experiences (patients, healthcare professionals, and third parties) regarding shared meditation are not objective facts but rather subjective and contextual constructions. Indeed, shared meditation creates a collective reality in which participants co-construct meanings. Thus, focus groups, through participant interactions, make it possible to capture this intersubjective dimension and highlight dynamics that would not emerge through other methods.

This qualitative study was reported in line with the COnsolidated Criteria for REporting Qualitative research (COREQ). ³² The same meditation programme was delivered in 2 modes: (1) for the experimental arm, in the form of joint group workshops involving health professionals, patients, and third persons (neither patients nor health professionals); (2) for the control arm, in the form of workshops for patients only. Only patients were randomised in experimental or control arm. All participants provided written informed consent before any study procedure.

Eligibility criteria concerning the recruitment of participants in this study as well as the detailed methodology are fully described elsewhere. ³¹ The main parameter for inclusion was curiosity about meditation and motivation to be part of a study on it. Those recruited had to have no current or previous experience of regular or intensive meditation or comparable practice. ³³ The health status of people with cancer had to allow them to attend the sessions. Concerning the medical staff, any medical and/or paramedical staff involved in the management of patients were eligible. As for third persons, any person belonging to the general public and not belonging to the above-mentioned categories was eligible, including non-medical staff at our institution, and people from outside the centre who were relatives or not of the patients.

The eligibility of subjects presenting significant vulnerability such as a very advanced cancer stage with life-threatening consequences, alcohol or drug dependence, severe depression, severe social anxiety, recent bereavement, etc. was assessed on a case-by-case basis. In this regard, the participant’s degree of commitment to the project was a determining criterion.

The whole study was conducted on 96 participants in 6 groups of 16 participants. The control patient meditation arm comprising 2 groups of 16 patients was conducted at our institution (Comprehensive Cancer Centre François Baclesse). The experimental shared meditation arm composed of 4 mixed groups of 16 participants each (involving 8 patients, 4 health professionals, and 4 third persons) followed the programme outside the hospital (Pôle des Formations et de Recherche en Santé of Caen University, France). Focus groups were proposed 1 week after the end of the intervention to participants who experienced shared meditation and completed the programme that is, 64 subjects of the experimental arm. Only volunteers willing to participate attended the focus group session. Written informed consent for study participation included the guarantee of medical confidentiality and treatment of de-identified data, the participant’s agreement to the recording of the interviews and their de-identified transcription onto a written medium, and the guarantee that all recordings would be destroyed after analysis of the data for reasons of confidentiality.

To ensure the rigour and trustworthiness of the focus group results, several strategies were implemented. First, data triangulation was achieved by combining verbatim transcripts, observer notes, and post-session debriefings between the moderator and the observer. Second, the analysis was conducted by an external qualitative expert (Coordinator of the Regional Ethics Space Normandy, Associate Professor of Philosophy and Ethics), independent of the research team, to minimise bias. Third, NVivo 12 software was used for systematic coding, ensuring transparency and reproducibility of the thematic analysis. Fourth, standardised open-ended questions guided the focus groups, allowing for consistency across sessions while capturing diverse perspectives from patients, healthcare professionals, and third parties. Finally, participant quotations were used to illustrate key themes, enhancing the credibility of the findings by grounding them in participants’ own words.

Mindfulness Intervention

An expert in meditation designed the programme on ‘meditating together’ and created and organised the workshops. It should be noted here that although reference is made to ‘shared meditation’ or ‘meditating together’, the type of meditation on which our programme is based is mindfulness. The instructor has over 20 years of experience in meditation (practice and teaching). She completed a University Diploma in Medicine, Meditation and Neuroscience and a training as MBSR instructor. Within this study, she developed a programme based on mindfulness and compassion (without audio-guided meditation) which was optimised following our pilot study. ⁶ Compared to the MBSR programme (8 weeks of approximately 2.5 hours and a retreat day), it has a different format, with more sessions over a longer period of time, in line with the fatigue levels of our target population. It alternates between practice and theory and specifically addresses the themes of kindness and self-compassion in response to our research hypothesis.

The programme for all participants was based on 12 weekly sessions of 2 hours. ³¹ Three monthly follow-up sessions of 2 hours in remote format were added to the initial programme to promote sustainable follow-up. Two half-day retreats in silence took place, one between the ninth and the 10th weekly sessions and a final one at the end of the programme (after the last remote monthly session). Finally, a focus group session was organised in the experimental arm in the days following the last retreat.

The themes addressed during the weekly meditation sessions focused on mindfulness, and especially explored breathing, sensations, sounds, body scan, impermanence, and compassion. The 2 half-day silent retreats aimed to allow participants to explore meditation in more depth over a longer period, and were also an opportunity to meditate on taste at mealtimes, to meditate while walking outdoors, and to conduct a debrief at the end.

As part of the programme, participants were required to complete daily practice exercises and meditate at home. To guide them, written materials specially designed for this purpose by the teacher were also provided. Finally, in order to resolve any problems raised during the sessions that could not be managed within the group, individual follow-up was offered, if necessary, by phone, video call or face-to-face discussion.

Focus Group Procedures

Participants’ opinions on the offer to meditate together was gathered using the focus group method conducted in the experimental arm, among those who volunteered to take part. ³⁴ Four focus group sessions were planned, with up to 16 participants from each category per session (ie, up to 2 groups of patients, 1 group of health professionals, and 1 group of third persons) in order to guarantee the homogeneity of each group and to ensure fruitful and equitable discussion. Focus group sessions were based on a preselected set of 5 open-ended questions aiming to clarify the personal added value provided by the shared meditation programme. Sessions were conducted by an external moderator (specialist in ethical issues) who launched the questions to be discussed, and a neutral observer (taking notes during the session). The questions discussed were as follows:

• - What fears or hesitations did you have before starting shared meditation (involving patients, health professionals, and third persons)?

• - How did you personally experience being in a meditation group involving patients, health professionals and third persons?

• - What do you see as the advantages or benefits of this kind of meditation?

• - What difficulties and obstacles have you personally encountered in this context of shared meditation?

• - Debate and discuss ways of promoting and sustaining the sessions and the programme.

For the first 4 questions (dealing with shared meditation), each group considered them sequentially with respect to the other 2 groups. For example, for the patients, the difficulties and possible benefits related to the presence of third persons was discussed, then those related to the presence of health professionals. The focus group was planned to last approximately 2 hours for each group, in order to obtain complete answers to the questions and therefore generate sufficient information for data saturation. While data saturation was not quantitatively measured, the repetition of themes across groups was assessed and used as an indicator suggesting sufficient depth of exploration.

Data Analysis

Our thematic analysis draws on the reflexive approach proposed by Braun and Clarke, ³⁵ which emphasises active interpretation of data and researcher subjectivity. Unlike a positivist approach focused on purely descriptive coding, we adopted an interpretative and contextual approach, where themes emerge from a dialogue between the data, theory and our own position as researchers.

The data analysis was therefore carried out independently by a specialist in qualitative analysis. The data analyses were based on verbatim transcripts of the recorded discussions, the observer’s notes and debriefings between the moderator and the observer. In the context of this focus-group study, this modality of analysis falls under one of the types of triangulation in qualitative research. ³⁶ The focus group recordings were transcribed by the researcher responsible for data analysis, then actively and repeatedly reread, and notes were taken on initial ideas, recurring themes, and salient points from the verbatim transcripts. All the data were then entered into NVivo© 12 software, which enabled initial coding using descriptive codes (eg, ‘apprehension’) or interpretive codes (eg, ‘improvement in the caregiver-patient relationship’).

A thematic analysis method was employed, combining deductive (theory-driven) and inductive (data-driven) theme identification. Some codes were grouped into salient themes (eg, ‘fear’ and ‘constraint’ merged into ’apprehension’). To ensure theme consistency, these were rediscussed with focus group facilitators during validation meetings, where each interpretation was systematically challenged (eg, ’Does this interpretation truly reflect the data, or is it influenced by our theoretical expectations?’). Excerpts associated with each theme were reread to verify their relevance to the research question, and the essence of each theme was clarified to derive a meaningful title. Thus, the results are presented by key content emerging from the responses to each open-ended question and illustrated by verbatim quotations (specified in italics).

As an ethics professional and public health researcher, the analyst’s position influenced this research on several levels. Her experience and involvement in other multidisciplinary research projects involving caregivers and patients, shaped her understanding of the issues raised by the participating caregivers, patients and third parties. Moreover, her previous work on shared meditation made her aware of the experiential dimensions of the narratives, which particularly drew her attention to themes related to the dimension of sharing between participants. To limit bias and enhance rigour, the following strategies were implemented. Regular team meetings were held throughout the analysis phase with sociologist and physician colleagues to challenge interpretations, validate reactions to the data, and question analytical decisions. For example, during one debriefing, the team asked: ’Does our interpretation of the ‘shared humanity’ theme that emerged from a dialogue between participants reflect the data, or does it stem more from our desire for social cohesion’? These meetings allowed for the analyst’s interpretations to be challenged, her reactions to the data to be validated, and interpretative decisions to be made, all informed by this critical and shared reflexive approach. ³⁷ The focus group analysis concentrated on how meanings were socially constructed through interactions. Transcripts were coded not only for individual responses, but also for sequences of exchanges (agreements, disagreements, or moments of collective awareness). We selected participant quotes to illustrate and help describe each theme. The observer’s notes captured non-verbal dynamics (nods, silences) that revealed group-level processes, such as the negotiation of shared norms (‘Here, we are all equal’).

Results

Characteristics of Participants in the Shared Meditation Programme

The total population (n = 64) in the shared meditation programme was predominantly female (82%), with a mean age of 56, mostly living in couples (67%), in urban settings for 51% of them, and 58% of participants had finished at least high-school education.

The third parties were found to have no connection with the patients or health professionals. Of the 64 participants who completed the programme, 42 participated in the 4 focus group sessions (23 patients in 2 groups: 22 women, 1 man; 1 group of 10 health professionals: 9 women, 1 man; 1 group of 9 third persons: 4 women, 5 men). Complete answers to the questions were obtained within 2 hours, with sufficient information ensuring data saturation. The pre-selected semi-structured questions were identical for each group. After 2 hours, the themes, opinions and experiences shared became redundant from one group to another, with no new perspectives emerging. Indeed, upon analysis, the researchers noted the repetition of ideas and the absence of new categories in the verbatim transcripts. This is probably due to a certain homogeneity in the profiles around the common experience of cancer, which generates a relatively closed context even if there is diversity in participant types.

State of Mind and Apprehensions Before Starting Shared Meditation

Generally speaking and irrespective of their group, the participants expressed their confidence and motivation regarding the offer of shared meditation. As this was a university hospital research project, they felt this guaranteed the competence of those involved: ‘The fact that it was in the context of a research study reassured me. I told myself that I was going to be dealing with someone very competent’ [Patient 9, group 1].

While the patient, third party and carer groups did not express any concerns about the nature of the activity, many did express personal fears about the form it would take. In other words, the commitment and regularity required (6 months, every week, 2 hours, etc.) as well as the fact that they were unaware of the status of the other participants, raised some concerns.

Inclusion in the study was considered by many of the participants as a constraint to be honoured and an investment in oneself, the study and the others. Several patients spoke of their initial refusal to undergo any obligation because they no longer had any others (retirement or no activity due to their illness), or they mentioned their difficulties in attending regularly owing to their professional activities: ‘It was an investment, telling myself that there would be no room for absences: When you commit yourself, you commit yourself!’ [Patient 8, group 1]. This duty to be present was also expressed by the carers, but more in terms of their professional work schedule and the fear that it might hamper it. However, these constraints and obligations were ultimately felt to be positive by all the groups. Making a commitment to the programme was considered necessary for ‘keeping at it’, given the daily issues of fatigue, watching the clock, commuting and work schedules: ‘In fact, the constraint helped me to see the process through to the end’ [Patient 10, group 1]. The fact that the sessions took place outside hospital, their organisation (appointments, clocking in and out, regular frequency, etc.) and the active involvement of the study organisers ultimately kindled their motivation to attend. Indeed, without it, some said that they would not have attended throughout the programme.

Some participants were initially apprehensive about who they would share meditation with. For the 2 patient groups, their apprehension concerned contact only with other patients, which they did not want: ’I didn’t want to come back with patients. I wanted to get out of that circle’ [Patient 5, group 2]. Like the third parties, a group made up mainly of patients was perceived as a support group focused on the subject of living with the disease. This sometimes led to concerns about the context of the group in general and to communication issues: ’I too was apprehensive about the group phenomenon. (. . .) I’m not someone who opens up naturally’ [Patient 11, group 1]. For the carers, their apprehension related more to meeting patients being cared for in the course of their professional activity, whom they did not necessarily wish to meet in any other context. However, the heterogeneity of the groups was mentioned by most of the participants in all the groups as an additional factor of motivation. Some immediately expressed a desire to take part in the study in a group with a variety of participants, while others said they were motivated precisely by this specificity: ’If it had been just between patients, I wouldn’t have come’ [Patient 10, group 1]. In the end, shared meditation proved to be a singular, essential and positive asset for participation in the experiment.

Experience of Shared Meditation

The comments on ‘sharing meditation’ were all very positive, and the feedback highlighted not only one-off benefits but also lasting benefits for most of the participants, all groups included, as illustrated in Figure 1.

Figure 1.

Participants’ views on the benefits specifically related to the shared meditation and personal benefits. Significant themes in participants’ experiences of the 2 types of benefits were identified through the analysis.

A Shared Experience

Sharing meditation improved everyone’s cognitive, emotional and social well-being. First, because it revealed a community with similar expectations: ’I think we’re all looking for the same thing in the end’ [Patient 6, group 2], but also because ’In the end, it puts the human being back in the centre. Whether you’re a patient, a health professional or someone else, we all have anxieties, even if the causes are different’ [Caregiver 1]. Sharing meditation revived the ability to communicate satisfactorily and also nurtured the ability to develop relationships, because everyone was involved personally outside their own social category of health professional or patient: ’It was me as a person who came to this group, not the carer’ [Caregiver 5]. In this activity, where everyone took a moment for themselves and shared it with others, ‘we completely forget each other’s status. Whether it’s a doctor or an oncologist, you realise that they’re normal people with their own concerns and limitations. And it’s not so important that we’re all mixed up. It’s even a plus that people are mixed and that the groups are mixed. It takes away the idea that you’re always among sick people. Personally, I think it’s great when it’s open and you’re with people from all walks of life’ [Patient 14, group 2].

While patients greatly appreciated the involvement of health professionals, they also emphasised the benefits of including third parties. Their presence strengthened the cohesion of the groups and, in the general opinion, the mix contributed to the feeling of normalisation to allow real sharing between individuals. ’There, we were in real life. Even if it’s good to talk about the disease in hospital, it always brings us back to the same place’ [Patient 11, group1]. Shared meditation seemed to encourage the re-establishment of a relational symmetry between participants, which is usually difficult to establish in a hospital setting that assigns a specific role to each person. ‘The third parties were really important. I found they were the link between caregivers and patients’ [Patient 10, group 1]. ‘Whatever our group, we were all participants in a study, in an experiment; very quickly the masks came off, we were peers’ [Third party 4].

Beyond a shared experience, the theme ‘shared humanity’ emerged from a dialogue where a patient’s vulnerability (‘I felt judged by caregivers. . .’ [Patient 7, group 1] elicited an empathetic response from another patient (‘Me too, I sometimes fear making mistakes’ [Patient 10, group 1], followed by similar disclosures from others.

Breaking Out of the Isolation of Illness

The patients were in favour of this mixed approach as a way of breaking out of the confines of their illness, and they appreciated the fact that meditation enabled them to be seen as people and not just as patients: ‘For me, meditation means being part of normal life’ [Patient 10, group 1]. ‘It’s good to talk to each other; it feels good. I didn’t just want to talk about my illness’ [Patient 2, group 1]. The mixed groups also helped to dampen the feeling of stigmatisation: ‘The mix of people prevented the disease from isolating us from each othe’, [Patient 9, group 2]. Patients said that taking part in groups made up exclusively of patients would have placed them in a different, more reductive group dynamic, which would have been less satisfying for them because the discussions about the disease would have been too dominant. In the end, ‘Whether you’re a patient or a carer, you’re always dealing with life and death, and I think that’s what connects us. That’s why I really appreciated this mix’ [Patient 10, group 1].

Improving the Relationship Between Health Professionals and Patients

For one participant in the patient group, the process of sharing enabled her to emotionally review her fear of the medical profession, which she described as a ‘phobia’. This singular testimonial is emblematic of many others that point to the benefits of shared meditation between carers and patients in terms of the carer-patient relationship.

The carers spoke of an improvement in their relationship through the practice of meditation. Firstly, because it enabled them to better manage their emotions and stress by giving them the means to ‘settle down’. Secondly, they noticed a marked improvement in the way their patients positioned themselves in their care. In their experience of caring for patients, they observed that they progress in a balanced relationship: ‘It created a bond that was not at all a patient/carer bond. At Baclesse, I was in my position as a carer and they, as patients. Yet there was none of the usual distance’ [Caregiver 8]. For the health professionals, meditation was seen as a way of improving relations with patients: ‘It removes barriers. As you said, there’s the human aspect. Mixed meditation helps patients to talk freely with the doctor and the nurse’ [Caregiver 9].

Moreover, in recognising the stress of caring as much as the stress of being ill, the patients considered that there was an opportunity to share and exchange ideas outside institutional or social categorisations, that is, something beneficial for everyone. This prompted some of them to request the presence of oncologists or doctors in this type of experience.

In the end, shared meditation had a calming effect on both parties. The patients were more relaxed and the health professionals more open to listening to each other. ‘And I found that the practice really benefited me. I wasn’t expecting that at the start of the study. I thought it was good for the carers, good for the patients. But now, having a patient to support, I could see that it optimised the work. So I found it very interesting’ [Third party 6].

Advantages and Benefits of Shared Meditation

Relationship With Illness

Shared meditation improved the physical and psychological well-being of patients, enabling them to rethink their lives in the face of illness. In terms of well-being, several patients testified to the physical and psychological benefits of meditation at the start of treatment, on the long duration of the disease, and even on remission. Some carers made the same remark about their patients. Generally speaking, everyone experienced a greater sense of self-control and a reduction in stress, anxiety and ruminations. Meditation helped individuals to focus on the present and to stop dwelling on the past or speculating about the future, which is often perceived as highly uncertain. It improved emotional management and sleep, and also helped people to cope better with the side-effects of treatment and clinical examinations.

For patients undergoing treatment, meditation was seen as a way of helping them to cope with this difficult period more effectively. It allowed them to set aside time for themselves in a soothing activity and in a protective context: ‘to improve support, for relaxation and everything else that goes with it. Because life doesn’t stop. You’ve got the disease, but you’ve still got your day-to-day life’ [Patient 1, group 1]. Meditation could also help them avoid falling into the trap of isolation. For patients who were not undergoing treatment, meditation provided a way of calming them down and giving them the tools they need to cope better with the lasting or permanent changes brought about by the disease: ‘They told me it’s all over, you’re cured, you can go back to your normal life, but there’s no normal life after that. I think meditation helps you to accept a different life after the illness, you enter a new world’ [Patient 6, group 1].

Relationship With Oneself

While the patients reported the benefits of meditation in coping with the disease or treatments, the participants in the other groups also declared that it helped them in their own context. Caregivers and third parties alike said that meditation enabled them to ‘take a step back’, ‘take care of themselves’, set aside ‘time for themselves’ and ‘refocus’ to ‘better live in the present’. It allowed them to control their emotions and rethink their stress levels, whether due to daily or professional activities. Generally speaking, meditation developed a shared sense of purpose that strengthened the cohesion of the experience: ‘I felt that for many people, including myself, there was a search for a way to understand life: to have the keys to be able to manage everything that happens in life. And that goes for the health professionals as well as for others’ [Patient 5, group 1]. This explains why the benefits felt were unanimously reported as lasting, or rather ‘to be sustained’ through regular long-term practice.

Difficulties and Obstacles Encountered During Shared Meditation

Organisational difficulties were collectively mentioned, such as time slots that were more or less suitable or locations that were considered more or less appropriate, but it was videoconferencing that was most often mentioned as being deleterious. In fact, for many people in all the groups, videoconferencing was considered unsuitable and less satisfactory than face-to-face: ‘videoconferencing weakens the group and the group’s commitment’ [Caregiver 5]. The participants mentioned their difficulty in expressing themselves in this context, the lack of non-verbal communication, and the fact that it meant the end of the experience. For many participants across all groups, the question of continuity arose. The end of the face-to-face sessions and the appointments often led to a break with regular practice. Life took over again, and the rigour of regular practice gave way to daily constraints. Even if informal practice and the occasional use of the techniques learned were often mentioned, the break in continuity was regretted by many participants.

Scope for Sustainability and Improvement of Shared Meditation

The areas for improvement are to be seen in the light of the difficulties encountered and the expectations expressed. They mainly concern 2 needs: (1) the offer of a long-term activity that participants would like to take part in, or that they would like others to know about and share, (2) the need for meditation to be systematically available from the start of care, so that the benefits can be shared with other patients.

Discussion

The present study aimed to explore whether shared meditation involving people with cancer, health professionals and third parties can offer added value in alleviating distress, particularly in patients. We conducted focus groups to qualitatively examine participants’ experiences and perceptions towards shared meditation. Four salient themes were identified. Participants reported that the mixed nature of the groups: (1) was a positive experience, with physical and psychological benefits, even though it required a great deal of commitment, (2) offered an additional unique advantage (compared with groups of patients only) that enabled them to feel that they were people rather than just patients, (3) allowed them to re-think their lives by reconsidering their relationship with themselves and their illness, and (4) improved their relationships with others in the therapeutic setting but also beyond, thanks to the presence of third parties, thereby attenuating their feelings of stigmatisation linked to the disease.

Improved Psychosocial Skills, a Frequently Reported Benefit in the Shared Meditation Experience

The improvement of psychosocial skills was inferred from 3 types of qualitative indicators in the participants’ narratives. These primarily concerned temporal comparisons, as participants spontaneously and explicitly described a change. Secondly, positive life stories described situations where participants attributed a positive outcome to a category of psychosocial skill. Finally, metaphors or expressions of transformation that appeared in statements such as ‘I have gained confidence in myself’ [Patient 8, group 1] or ‘I feel better equipped’ [Patient 10, group 2] were interpreted as signs of subjective improvement. Our findings are in line with former qualitative studies that identified the promotion of coping and self-efficacy as important challenges for people with cancer.^38-40 Defined as a person’s ability to cope with the demands and challenges of everyday life, psychosocial skills can be emotional, cognitive or social in nature.^41-43 Shared meditation was recognised by all participants as beneficial for the first 2 of these factors, but the sharing of meditation seems to be particularly useful for promoting social skills. In terms of cognitive skills, shared meditation helped participants to better recognise the difficulties encountered and to take a step back from their personal situation. For patients, this re-centring process could have contributed to regulation of the self and reframing of the perception of cancer. Most participants reported a shift in mindset and perspective that enabled better psychological adaptation and a way to reconsider their life. Shared meditation was also shown to improve emotional regulation in participants. For patients, it led to improvement of resilience, and for health professionals, it increased their availability and receptiveness. Focusing on the present moment enabled them to improve their self-control and relieve their stress, negative thoughts and feelings.

Meditation may not only impact the way people cope with cancer but also their confidence in their ability to cope with stressors, that is, their perceived self-efficacy. As shown by others, self-efficacy is positively associated with cancer patients’ quality of life and negatively associated with distress. ⁴⁴ Self-compassion, measured with the Neff scale, ⁴⁵ was also significantly improved. A change in self-compassion was shown to explain the gain in most other outcomes, ⁴⁶ which leads Neff to consider self-compassion as a productive way of approaching distressing thoughts and emotions, thereby generating individual mental and physical well-being. ⁷ Moreover, self-compassion benefits others within interpersonal relationships and is associated with enhanced feelings of greater interconnectedness. ⁴⁷ Our participants clearly expressed this greater sense of interpersonal connection. Understanding and identifying emotions and stress, self-awareness and self-control improved communication with others, both at a personal and professional level, particularly the quality of the relationship between patients and healthcare professionals. Patients reported that the programme had improved the relationship with their health professionals. By cultivating unconditional positive regard and empathetic understanding, mindfulness can enhance the therapeutic relationship.^5,48,49 Our participants reported that the group experience and feeling connected to other participants, whatever their status, was an important aspect of the shared meditation. Meditating together created an atmosphere that fostered the social support that they experienced, allowing them to learn from each other, as observed by Schellekens et al when evaluating the benefits of peer support in their participation in a meditation programme for cancer patients. ⁵⁰

The interdependent health-related effects between patients and their partners have also been reviewed, ⁵¹ and mindfulness-based interventions are likely to promote more efficient connections between caregivers and patients and efficacy in caregiving, as improved well-being in caregivers is associated with higher quality care in patients. ⁵² Realising that unpleasant emotions are not unique and personal but also experienced by others can develop a sense of common humanity, that ‘we’re all in this together’ and that vulnerability is inherent to life. ⁵³

Recent reviews, which gave pride of place to psychosocial criteria such as feelings of self-compassion ²² or coping and feelings of self-efficacy, ¹¹ showed that mindfulness has a positive influence on these indicators in programmes conducted with patients only. In our study, participants often reported feeling a greater sense of interpersonal connection. The patients’ observations clearly indicated that the shared nature of meditation enabled them to experience direct contact with otherness, whether with professionals or third parties, showing how the heterogeneity of the group facilitates interconnection, induces an atmosphere that promotes social support in participants, and benefits the process of coping with cancer.

Limitations

This study is not without limitations. First, this ‘self-selected’ population based on voluntary participation comprised mainly women from a privileged socio-professional background, which may omit key perspectives on shared meditation. Men may be less receptive and responsive to mindfulness than women because of their different coping mechanisms. ⁵⁴ Therefore, further investigation of how gender affects the efficacy of mindfulness is warranted. Second, although the hospital management allowed the staff to participate during their working hours, some members of staff were unable to attend or had to be absent frequently for organisational reasons, underlining the need to optimise the hospital’s workflow to enable all staff who so wish to follow this kind of programme. Third, the participants completed the interview shortly after the intervention. It is possible that other longer-term effects would have emerged if they had been recruited into the focus groups several months after the mindfulness intervention. Fourth, the interpretation inherent in the coding is directly rooted in the previous study. ³⁰ It was important that the same researcher conducted both qualitative analyses using the same protocol (not present during the focus groups) to ensure interpretative consistency between the 2 studies, but this may also have introduced a bias. For data analysis, the triangulation was based on the combination of verbatim transcripts, field notes and debriefings involving researchers: in the context of this focus-group study, this analysis corresponds to one of the types of triangulation in qualitative research. ³⁶ However, no face-to-face interviews were realised in our study, so that no multiple methods of data collection were available to perform a ‘method triangulation’, although recent literature advocated for an upheld qualitative approach integrating thorough reflexivity, replicability, and rigour. ⁵⁵ Finally, although the focus groups allowed us to better characterise the benefit of shared meditation, the design of the study, that is, interviews conducted only in mixed participants, did not allow us to definitively establish the added value of this type of meditation. Indeed, this does not allow for comparison with the benefits of meditation observed in the context of meditation conducted only with patients.

An Optimised Meditation Programme

Participants’ experiences and perceptions were key to the findings of this study, and their feedback identified important areas for improving our programme. Concerning the programme and its components, the content will remain largely the same while its organisation will be improved. The 12 weekly sessions will last 2 hours including a break, and a 3-hour retreat, a format appreciated by all the participants. Following our pilot study where the main shortcomings identified were the shortness of our preliminary programme (3 months) and difficulty to sustain the activity when it stopped, ⁶ we added 3 monthly 2-hour follow-up sessions after the 12 face-to-face sessions to allow participants to integrate meditation into their daily practice. These organisational adjustments with remote sessions did not seem to suit the participants and we are considering organising a booster or follow-up sessions in order to maintain the long-term benefits, possibly in the form of a monthly face-to-face meeting. ²¹ Finally, the programme will primarily include patients, our target population, with the participation of healthcare professionals and third parties (maximum around 20% without imposing any ratio). This will ensure that the groups are mixed, a fundamental source of satisfaction for the patients.

Towards the Active Implementation of Our Meditation Programme

Our aim is to transfer the results of this research to clinical practice through an active implementation phase, ⁵⁶ including the detailed description of the programme and analysis of the processes required to implement it, with a view to dispensing and disseminating it. The shared meditation programme will be conducted in the presence of a neuropsychologist in order to gather detailed information about its constituent elements (verbatims) and the methods used to deliver it. Exploratory analysis of the data obtained will make the following possible: (1) a detailed description of the programme specifying the critical elements and the delivery methods in the form of a practical meditation guide allowing its replication; (2) an analysis of the processes required to roll the programme out in a wider setting. The conditions for its dissemination (implementation, audience, etc.) will be established and the experience of 2 participants in the previous IMPLIC studies will be integrated; (3) establishment of a training programme for instructors, who can then pass on the programme and its methodology (based on the manual) with a view to wider distribution to other care centres (Cancer Centres and/or others). A meditation training course recognised by the Centre François Baclesse would give it full legitimacy, not only for patients (as observed in this study) but also for health professionals and institutions, and would make it easier to incorporate into the care trajectory.

Conclusions

The present study provides further insights into the benefits of shared meditation for patients coping with cancer. These qualitative results suggest that it can enhance well-being in cancer patients by teaching a way of being and coping that can be used in their daily lives. Beyond that, our approach could enable patients and others to develop a sense of social connectedness and to cultivate together our sense of common humanity.

Supplemental Material

sj-pdf-1-ict-10.1177_15347354261439128 – Supplemental material for The Experience of Shared Meditation Involving People With Cancer, Health Professionals and Third Persons: A Qualitative Focus-Group Study

Supplemental material, sj-pdf-1-ict-10.1177_15347354261439128 for The Experience of Shared Meditation Involving People With Cancer, Health Professionals and Third Persons: A Qualitative Focus-Group Study by Virginie Prevost, Titi Tran, Bénédicte Clarisse, Alexandra Leconte, Marie Fernette, Guillaume Grandazzi and Mylène Gouriot in Integrative Cancer Therapies