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Yoga consisted of dynamic movement in and out of certain poses, with continuous awareness of bodily sensations. Moreover, the weekly meetings consisted of group dialogues about both on-going practice and topics related to stress biology and stress reduction. Diary based methodologies can be particularly suitable when the research question is focused on exploring change over time [ 33 ]. Participants received a diary, developed by the research group, with extensive experience in the interdisciplinary research field of behavioural cardiology.

The research group contained cardiologist, cardiac nurse, mindfulness instructor as well as experts in clinical psychology and qualitative methodology. If words did not seem to flow easily, they were encouraged to reflect over one or some of the following questions: How did you feel during practice? Did any particular thoughts or stories appear? Did any particular emotions or moods occur? Was it pleasant or unpleasant to practice? How did you handle the pleasant or unpleasant experience? What are your feelings here and now after the practice session?

Which thoughts appear now when you reflect over your practice session? The development of these questions was inspired by the goals expressed in the MBSR manual, but since the analytical method was conventional and inductive we aimed at keeping the questions open and not linked to any theoretical framework.

This non-directive focus on the immediate experiences of feelings, thoughts, moods and ways to handle the experiences, could reveal meaningful benefits from, and barriers to, the practice of meditation and yoga. Twelve participants, of the 16 who completed the course, filled out their diaries according to instructions, and all entries were included in the analysis. Among the four completers whose diaries were not included in the analysis, two was empty of written content, and two did not hand in their diaries at the end of the MBSR intervention.

Systematic reviews of MBI:s have shown that these interventions have very few inherent dangers or potential side effect [ 18 ]. We were aware of the fact that participation without completion could be experienced as a failure, and perhaps worsen a sense of hopelessness. However, all patients had the opportunity to specifically address these issues with their assigned cardiac rehabilitation nurse.

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Participants were informed that the diaries would be collected at the end of the intervention and handled as a confidential document. We anticipated that some participants might feel strong aversion against the writing assignment and we therefore added to the written instructions a statement that clarified that it was acceptable with very short reflections or sometimes nothing written at all to prevent a sense of pressure. A qualitative method was applied to the analysis of the linguistic content in the diaries [ 34 , 35 ]. The content analysis approach can be either conventional or directed, also described as inductive or deductive category development.

In conventional content analysis, coding categories are derived directly from the text data. With a directed approach, according to Hsieh and Shannon, analysis starts with a theory or relevant research findings as guidance for initial codes [ 36 ]. As there was not enough previous research about the phenomenon, a qualitative, conventional approach was applied. The first author OL had long personal, as well as teaching, experiences of mindfulness meditation.

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During the analysis, this pre-understanding was put aside to the largest extent as possible in order not to let it influence the interpretation of data. In the first step of analysis diary entries were transcribed into a word file with a total of 46 double-spaced pages of data and excerpts were tagged with a coded number as a way to prevent identification. The word file was then read and re-read multiple times to achieve immersion and obtain a sense of the whole.

Mostly, the diary entries were longer and more detailed in the first half of the course and shorter in the second half. In the second step quotations that appeared to capture key thoughts or concepts were highlighted in their exact words. A total number of quotations were derived from the data. During this phase all relevant quotations were coded into more condensed sentences, and the codes were also tagged with a week-number which one of the 8 weeks of MBSR according to the date it was originally written.

The majority of the participants wrote free reflections while a few pondered the suggested questions.

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Then, in the third step, first impressions about the content in the codes were annotated as initial analysis, and codes were then grouped into emergent subcategories based on how the different codes were related and linked. These emergent subcategories were used to organize and group codes into meaningful clusters. In the fourth step, some overlapping was found and finally six subcategories were condensed into two categories. Lastly, in the fifth step, the categories were condensed into one more interpretative main category, to capture the time frame of the entries.

The analysis suggested that saturation of content variety was reached within our data after 10 diaries, since the last two diaries did not provide any new codes. The analysis was validated by checking for the representativeness of the data as a whole by thoroughly discussing the coding scheme, clusters and the preliminary categorisation with the co-authors who had extended experience in study design and clinical research PG, MK, LJ and qualitative content analysis IT.

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Disagreements were discussed until consensus was reached. Finally, each category was strengthened by quotations. The quotations were translated from Swedish into English by the first author OL , edited by a professional translator and then again read and compared with the original language by the co-authors. Trustworthiness, defined as credibility, transferability, dependability and confirmability must be considered when evaluating qualitative data [ 37 ].

Credibility was established through ensuring the richness of the data by including participants, with rich experience of participating in an 8-week MBSR program, that were able and willing to share their immediate reflections in a diary. This method also allowed persistent observations over time. All participants that had filled out the diary were included in the analysis, which further increased credibility. To facilitate transferability, a clear description of the context, selection and characteristics of participants, data collection and process of analysis were presented.

The procedure of data analysis was described in detail and a critical examination of the structure of the categories by all the authors were further steps to ensure dependability. Confirmability was furthermore established with some of our findings converging with the existing literature. Four women and eight men provided diary entries for the analysis.

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The proportions of diary entries written at the beginning week 1—2 , middle week 3—6 and the end week 7—8 of the course have been visualized in bars. Taking on the challenge of daily mindfulness practice, the participants were describing a journey with obstacles and struggles, as well as rewarding experiences. This journey appears to reflect a progressive development culminating in the harvesting of the fruits of practice. The participants experienced both struggles and rewards continuously over time.

Descriptions of various challenging facets of mindfulness practice, both physical and psychological, commonly occurred during the whole 8-week course, although distressing experiences were more predominant during the first half. The diary entries showed a wide variety of ways of dealing with these struggles, including both constructive and less constructive strategies of facing difficult experiences.

As the weeks passed, the participants more frequently described an enhanced ability to concentrate, relax and deal with various distractions. They also put into words a heightened ability to observe the content of their mind and reported a number of ways the practice was starting to yield rewards in the form of positive feelings and a sense of mastery and well-being.

Facing the challenges of daily practice refers to how the participants struggled with obstacles to daily practice, with a distracted and distressed mind, as well as with bodily sensations. Especially during the first weeks of the course, the participants described various doubts and obstacles to daily practice. Two participants had difficulties understanding the meaning of the practice and two participants expressed doubt about their personal suitability for mindfulness. There were also notes from two participants about difficulties understanding the instructions and one patient expressed doubts about the right level of effort when practicing.

A year-old man reflected during the first week of practice:. Many participants also felt stressed about finding the time to practice and two participants described the journaling as challenging. One participant also realized that it was hard to change ingrained behaviours and habits and three participants found it difficult to prioritize themselves.

Journey Into Chaos

Eleven out of 12 participants described some kind of struggle with distractions and distressing feelings during practice session. They frequently reported becoming disturbed by sounds from the environment and also from uninvited mental content and impulses. A year-old woman noticed during the second week:.


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I was expected to be present here and now, but suddenly my thoughts were engaged in how to rearrange the curtains. Eight participants described feeling impatient, stressed, worried and unable to relax.


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Some noticed how they continuously judged their performance and subsequently felt a longing for signs of progress. A year-old man wrote during the second week of the course:. I would love to feel that I take the next step while doing this practice. All 12 participants described various physical symptoms and unpleasant sensations in the body during practice and two reported becoming aware of pain and tension that they had not noticed before. A year-old woman wrote the following passage in her diary during the third week of training:.

When I think about it, I realize that I have aches in my body, all the time more or less. Another related and frequently reported challenge was mental fatigue, drowsiness and a tendency to fall asleep, which were reported by seven participants. Two participants also described a sense of heaviness that emerged during practice. During the first couple of weeks three participants also noticed muscle soreness as a result of the yoga practice. Harvesting the fruits of daily practice refers to how the participants became more open to the flow of mental content and begun to sense positive effects as well as benefits of practice in everyday life.

Five participants described an increased ability to observe the flow of thoughts and sensations during practice. These patients became more aware of the continuously changing stream of experiences and five participants noticed an altered sense of time. During the end of the second week, a year-old woman wrote in her diary:. I am doing the sitting meditation, focusing on my breathing, my nose, my chest, my belly.