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The number of patients living with cancer is growing, and a substantial number of patients suffer from psychological distress. Mindfulness-based interventions (MBIs) seem effective in alleviating psychological distress. Unfortunately, several cancer patients find it difficult, if not impossible, to attend a group-based course. Internet-based MBIs (eMBIs) such as Internet-based mindfulness-based cognitive therapy (eMBCT) may offer solutions. However, it is yet to be studied what facilitators and barriers cancer patients experience during eMBCT.
This study aimed to explore facilitators and barriers of individual asynchronous therapist-assisted eMBCT as experienced by both patients and therapists.
Patients with heterogeneous cancer diagnoses suffering from psychological distress were offered eMBCT. This 9-week intervention mirrored the group-based MBCT protocol and included weekly asynchronous written therapist feedback. Patients were granted access to a website that contained the eMBCT protocol and a secured inbox, and they were asked to practice and fill out diaries on which the therapist provided feedback. In total, 31 patients participated in an individual posttreatment interview on experienced facilitators and barriers during eMBCT. Moreover, eight therapists were interviewed. The data were analyzed with qualitative content analysis to identify barriers and facilitators in eMBCT.
Both patients and therapists mentioned four overarching themes as facilitators and barriers: treatment setting (the individual and Internet-based nature of the treatment), treatment format (how the treatment and its guidance were organized and delivered), role of the therapist, and individual patient characteristics.
The eMBCT provided flexibility in when, where, and how patients and therapists engage in MBCT. Future studies should assess how different eMBCT designs could further improve barriers that were found.
Cancer poses a major psychological challenge for individuals. A meta-analysis of psychiatric disorder in oncological and hematological settings yielded a prevalence of psychiatric disorder of 30% to 40% [
Mindfulness-based interventions (MBIs) such as mindfulness-based stress reduction (MBSR) [
Evidence for the effectiveness of MBIs for cancer patients has rapidly expanded. In 2015, an overview including six systematic reviews in heterogeneous cancer patients demonstrated significant small to moderate effects on various psychosocial outcomes in cancer patients [
Moreover, a previous review suggests that eMBIs may be helpful in alleviating symptom burden of patients with physical health conditions, particularly when the eMBI is tailored to specific symptoms [
However, how to optimally deliver eMBIs remains unknown [
Previously, a qualitative study has provided important perspectives for examining the user experience in an MBI. In a qualitative study of an eMBI for recurrent depression, patients identified aspects such as flexibility and reduced cost, as well as the need for support in time management [
The patients of this study took part in a 3-armed trial on the (cost-) effectiveness of MBCT for distressed cancer patients (Clinicaltrials.gov no. NCT02138513) [
Both patients randomized to eMBCT and their therapists were invited by the researcher to talk about the following questions:
How did you experience the eMBCT?
What facilitated and what impeded your participation in eMBCT?
How did you experience the relationship with the therapist or patient?
How would you improve the eMBCT?
The abovementioned questions were followed by specific probes
Patients were interviewed via telephone or in person within 3 months after eMBCT treatment completion or dropout. Patients were purposefully sampled to gather an even distribution of completers versus noncompleters and breast cancer versus other tumor types. Patient interviews were conducted by FC and EJ. FC is a PhD student with an MSc degree in behavioral science with no prior experience in qualitative research. He was the trial coordinator for the larger RCT [
Therapists were invited for a focus group interview during the last plenary therapist supervision session approximately 3 months after completing the last MBCT. Both the patient interviews and therapist focus group started by explaining confidentiality and the explorative nature of the interview. AS and ML conducted the focus group interviews. AS is a professor of psychiatry in the role of principle investigator of the larger RCT [
We used conventional qualitative content analysis to analyze the data in which coding categories are derived directly from the text data [
The eMBCT was based on the MBCT protocol for recurrent depression published by Segal et al [
The eMBCT was mainly text-based and included asynchronous interaction with a therapist similar to the study of Bruggeman-Everts et al [
We defined adherence as having attended ≥4 sessions. Therapists without prior eMBCT experience were provided with guidelines and were supervised by more experienced eMBCT therapists. See
The eMBCT dashboard containing the programme overview.
A fellow (fictional) participants' diary entry.
Example of an online eMBCT diary form accompanying one of the homework assignments.
Written therapist feedback via the secured messaging inbox.
Demographical characteristics of Internet-based mindfulness-based cognitive therapy therapists.
Variable (N=8) | Mean (SD) | n (%) |
Age, years | 55.50 (7.2) | |
Gender, female | 6 (75) | |
Years of experience in teaching MBCTa | 8.75 (2.7) | |
Prior experience with eMBCTb | 4 (50) |
aMBCT: mindfulness-based cognitive therapy.
ceMBCT: Internet-based mindfulness-based cognitive therapy.
Out of the 125 patients randomized to eMBCT, 45 were invited for a posttreatment interview. In total, 12 patients declined and 2 recordings failed. As a result, 31 interviews were used in the qualitative analysis. Interviews lasted from 5 to 25 min. Out of the patients interviewed, 14 had participated in 4 or more sessions of eMBCT, 10 had attended less than 4 sessions of eMBCT, and 7 had not started at all. See
A total of 11 out of 12 eMBCT therapists were invited for a focus group interview after completion of all eMBCTs. Out of these 12 therapists, 7 therapists agreed to participate and 1 therapist agreed to provide an individual interview with FC for scheduling reasons. Therapists declined either because of having provided too few individual online treatments to share experiences (n=1) or because of scheduling reasons (n=2). The focus group interview lasted for 90 min. The single individual therapist interview lasted for 25 min. The final sample of therapists included both therapists who had experience with online mindfulness before this project (n=4) and therapists who had no prior experience with online mindfulness before this project (n=4). See
All patient facilitators (
Treatment setting concerned subthemes on the external conditions of the eMBCT: flexibility of timing, the individual nature, and the home practice environment of the training.
It was considered convenient to be able to manage your own time schedule, which increased treatment receptivity. One patient stated the following:
Because you can start when you are ready and have the peace of mind for it, you can absorb it much better, because you actually want to at that moment.
A patient indicated that the individual setting facilitated a sense of autonomy that helped in taking care of himself:
I didn’t feel like doing the movement exercises. In a group setting I would have had to explain myself, so you are more inclined to go along with the group. But now, being on my own, I carried full responsibility for my own actions. Getting this space felt comfortable, because there were moments at which the therapy really asked a lot of me. At those times I could allow myself to take a time out and decide when I wanted to continue again.
Furthermore, it was considered to be facilitating not to be confronted with other patients’ cancer stories. One patient stated the following:
This only was about me and I didn’t have to spend energy on someone else’s story.
Being able to complete the sessions and exercises in your own home environment and not having to travel was appreciated. One patient stated:
For me, it was ideal because I knew that the group-based MBCT would take place at [the mental health institute] and it was impossible to reach by public transport.
Demographic and clinical characteristics of Internet-based mindfulness-based cognitive therapy patients.
Variable (N=31) | Mean (SD) | n (%) | ||
Age, years | 53.0 (12.3) | |||
Gender, male | 6 (19) | |||
Secondary | 14 (45) | |||
Vocational or university | 17 (55) | |||
Time since diagnosis | 3.2 (2.7) | |||
Breast | 16 (52) | |||
Other | 15 (48) | |||
Curative | 24 (77) | |||
Yes | 11 (35) | |||
Psychological distress, HADSa | 16.2 (7.1) | |||
Completer | 14 (45) | |||
10 (32) | ||||
Other priorities | 4 (40) | |||
Too difficult | 3 (30) | |||
Too intensive | 1 (10) | |||
Illness | 1 (10) | |||
Missed peers | 1 (10) | |||
7 (23) | ||||
Wanted MBCT | 3 (43) | |||
Illness | 1 (14) | |||
Other priorities | 1 (14) | |||
Could not log in | 1 (14) | |||
Needed mental health services | 1 (14) |
aHADS: Hospital Anxiety and Depression Scale.
bMBCT: mindfulness-based cognitive therapy.
Theme 1: treatment setting
Time management
Program at own time improves receptivity
Individual setting
Sense of autonomy
Not having to cope with other patients’ stories
Home setting
Not having to travel
Theme 2: treatment format
Website
Clear and easy to navigate
Privacy precautions
Diaries
Rereading own notes
Stimulated reflection
Theme 3: role of the therapist
Practical guidance
Clarifying practical matters
Mindfulness
Deepened understanding
Embodiment stimulated practice
Theme 4: patient characteristics
Writing fluency
Written expression in describing experiences
Curiosity
Curiosity stimulated perseverance
Theme 1: treatment setting
Time management
Responsibility for time management
Individual setting
No learning from peer group
Home setting
Lack of privacy in own home
Illness barriers
Cancer-related reading impairments
Lack of information
Lack of information before start
Theme 2: treatment format
Website
Complicated
Diaries
Complicated to fill out
Obligatory nature was burdensome
Describing experiences was confrontational
Theme 3: role of the therapist
Asynchronicity
No dialogue emerging
Frequency
Wished more frequent feedback
Theme 4: patient characteristics
Writing fluency
Lack of verbal fluency made diaries difficult
Responsibility for your own time management was mentioned as a barrier because it required a lot of self-discipline. One patient stated:
What I like about it is that I can manage my own time which went very well the first couple of weeks. After a while some chores interrupted me and then at the end of the day I realized: I still have to practice. Sometimes I did not do it anymore and sometimes I did. So you have to be very disciplined to stick to the schedule.
Patients described the lack of a group setting as a drawback of the intervention. They missed the peer support and the ability to learn together in the eMBCT. One patient stated:
I am a rational being. In a group there are always others who help me to unravel my emotions. This helps me. And I know, when I sit behind my computer my autopilot turns on and the treatment becomes a rational, experimental exercise.
Other patients mentioned that they felt less comfortable having to do exercises at home, not having the privacy they needed. One patient stated:
I practiced in my home office, but that room is connected to my living room. I found it uncomfortable to practice with my husband around, and even though he would never be eavesdropping, I felt restricted in doing certain exercises.
One patient indicated that her cancer type caused her to have trouble reading. As the eMBCT was mainly text-based, this was a problem to her. She stated the following:
It was mainly physical, I didn’t have the energy and my vision is in such a bad state. Even with medication, my vision is bad. And my eyes itch and burn and hurt.
Moreover, patients indicated that they would have wished more information on the way the platform and course were organized before the start of the training. One patient stated:
Expectation management would have helped a lot, I had a very brief instruction. And I have to choose where to put my energy into. What is expected of me, can I handle it, does it fit in my planning?
The treatment format theme included codes on the facilitators and barriers of the means by which the eMBCT was internally organized and delivered.
The website was accessible and navigating throughout the website was easy. One patient stated:
Opening the exercises and the way [the website] guided you through the structure was easy.
Moreover, patients valued the privacy precautions and indicated that the website felt safe. One patient stated:
I thought it was neat that I could see who visited my profile. In my case it was only my therapist according to the system, so I presume that the system is right, but it felt well taken care of.
The diaries proved to be of value for patients because it enabled them to read back and learn from their own experiences. One patient stated:
In my own [diaries] I looked back to see what my experiences were yesterday, or how did I handle this last time?
Patients also indicated that having to write stimulated reflection upon experiences. One patient stated:
Writing about my feelings was different from when I would have talked about it. It was more reflective, less spontaneous. I noticed that when I mailed I checked it again and again and added a few things. This really was an advantage. It really made me think about what I felt and experienced. Because of the writing itself this really hit me.
The website was complicated to some patients. One patient stated:
The website and its explanation was not really user friendly. There were many steps you had to take before you could do what you actually had to do.
A patient mentioned that the diaries were complicated to fill out:
I got the message that some fields still needed to be filled out. In general, I couldn’t find where to fill out what in the diaries and it made me quit.
Patients thought it was burdensome that the diaries were obligatory. One patient stated:
It was so much. Filling out the diaries every day [...]. I subscribed for a mindfulness course because I didn’t feel well and all of a sudden, you have this huge obligation.
The diaries were also considered quite confronting at times. One patient stated:
When you had a negative experience, filling out the diary made me revive the negative moment.
This theme included codes on the role of the therapist and the way the therapist facilitated or hindered participating in eMBCT.
Patients indicated that the therapist was often able to clarify practical aspects that were unclear. One patient stated:
I always want to do things right, and I wasn’t sure about how I did the meditation exercises in the beginning. Is this the way I am supposed to do this? So after a while I just mailed my therapist asking questions about the how and what of exercises, and I got a prompt reply most of the times.
The ways in which therapists provided feedback enriched patients’ understanding of underlying mindfulness values, such as the mild and nonjudgmental attitude. One patient stated:
(My therapist) was very patient and gave me all the space I needed [...]. She was like this all the time, in everything she did, not forcing, but stimulating me. “Do it for yourself when you do the exercises. If you do them, you could benefit a lot.” This made me feel more connected.
The embodiment of mindfulness values, such as the nonjudgmental attitude, supported and motivated patients to practice with the right intentions. One patient stated:
My therapist struck me as very mild. “Don’t force yourself, be gentle,” that certainly stood out. I don’t know how she would have been if I hadn’t practiced as much, but she was gentle with me.
The asynchronous nature of the feedback proved to be a barrier. According to the patient, the written feedback of therapist did not seem to encourage a dialogue but rather seemed limited to giving responses to questions. One patient stated:
Suppose I tell you I found the exercise uncomfortable. I then send you a message saying “I found it uncomfortable.” Only after 3 days I then get a reply “What was uncomfortable? Can you specify what you mean?” I then specify what I mean in another message. You keep sending messages back and forth over a period of time. If you have a conversation with someone, you have direct interaction. It is a totally different mode of communication. In a business context I think messaging is fine. In this context it was unhelpful.
As the therapist provided feedback on past weeks’ diaries, sometimes questions were left unanswered for a whole week. Some patients would have liked to have more frequent feedback. One patient stated:
Just two three times a week a brief moment of contact saying “how are you”?
Individual characteristics seemed to influence the fit between patient and eMBCT.
The ability to express themselves in writing was very helpful for some to give words to their subjective experiences and to ask for clarification to the therapist if it was necessary. One patient stated:
I am an easy writer, which perhaps set my experience apart from others. I can imagine that if you have a hard time expressing what you do and feel it would be different.
Curiosity sparked some to look beyond initial difficulties and to persevere in times of lack of motivation. One patient stated:
I think I was curious about the coming exercises. Maybe those will be more pleasant to do. This made me continue for a few more weeks.
The heavy reliance on writing skills was a barrier to some patients. One patient stated:
I liked doing the exercises, but having to write down my experiences on a daily basis [...], to sit down and write it all down, it put me off. For whom am I doing this?
Facilitators and barriers experienced by therapists are depicted in
Theme 1: treatment setting
Timing
Flexibility
Individual setting
Tailoring to patient
Better suited to some patients
Theme 2: treatment format
Asynchronicity
More time for reflection
Schedule
Maintaining a schedule prevents dropout
Writing
Stimulated reflection
Becomes more goal oriented
Anonymity
Stimulates openness
Theme 3: role of the therapist
Feedback
Providing group context
Provides reassurance
Personalizing training
Theme 4: patient characteristics
Self-discipline
Supporting self-sufficiency
Theme 1: treatment setting
Timing
Larger time investment
More flexibility warranted
Individual setting
No modeling by peers
Elaboration on personal themes
Theme 2: treatment format
Asynchronicity
No present moment experiences
Difficulty to maintain continuity
Technical issues
Technical issues cause delay
Writing
No nonverbal communication
Limited in therapeutical repertoire
Lack of understanding not readily apparent
Theme 3: role of the therapist
Feedback
Empty diaries impair feedback
More explicit checking and self-disclosure necessary
Mindfulness
Embodying behind computer
Theme 4: patient characteristics
Self-efficacy
Lack of self-efficacy
Writing fluency
Lack of ability in written expression
Therapists welcomed the fact in that they were able to choose at what time to provide feedback, which made them adaptive to circumstances. One therapist stated:
You can provide feedback in between other chores. Sometimes you plan to give feedback from 9 to 10 and then someone enters your office. There goes your planning. I then tell myself [...] “I’ll have time at another moment.” This is an advantage, you can do it in your own time.
The individual nature of eMBCT allowed for tailoring to the patients’ specific circumstances and giving feedback on individual real-life examples, which increases the relevance of the feedback. One therapist stated:
In the group you only have limited amount of time during which you must touch upon the most important themes. Online I have much more choice where to provide feedback on, what it means for a specific patient to react on autopilot, and which personal themes emerge.
Another important advantage of the individual nature of eMBCT is that it can be provided to patients who may otherwise be unsuitable for the group. Another therapist stated:
Some patients can be so disruptive in a group. They don’t get the point and only tell their own story. Sometimes you actually wished to provide someone in a group with an individual online training so you can address the individual themes.
Therapists indicated that providing feedback costs a considerable amount of time, which made it difficult for them to stick to a fixed time window. One therapist stated:
Especially in the beginning, it took me much longer. Because of asking questions, or clarifying issues. Or referring back to earlier diary entries.
Furthermore, therapists indicated that working online required much more flexibility and resulted in fragmentation of the times spent on eMBCT. One therapist stated:
When a patient indicates that the programme does not work, I start looking for help immediately. Even though I receive this mail outside of my regular time window for feedback.
Learning from fellow peer experiences in a group setting can be very helpful, and therapists felt limited in bringing in peer experiences themselves. One therapist stated:
In one-on-one contact, you can bring in experiences from other patients but to really experience them first hand provides another perspective.
Moreover, it was often difficult to find the balance between elaboration on personal themes and the eMBCT theme. One therapist stated:
A tension emerged between someone’s personal themes and combining those with this week’s mindfulness theme. Sometimes I thought, “this patient is occupied by something entirely different.”
Therapists and patients interacted asynchronically. This meant that according to the therapists, patients had time for reflection. One therapist stated:
Because there is some time between practice and feedback some experiences get the time to settle in. Patients can think about it, read it again, check with themselves what they experienced and how they reacted to it. This time in between could perhaps engage patients.
Moreover, the asynchronous contact was beneficial to therapists. One therapist stated:
Sometimes my irritation causes me to cut patients off. Behind the computer I can tell myself “let’s put this to a rest for now.”
Maintaining a fixed interaction schedule between therapist and patient was very helpful in preventing treatment dropout. One therapist stated:
When patients are able to put in work on a weekly basis and we stick to this rhythm, a kind of synchronicity emerges and assignments and my feedback to these assignments flow naturally.
Writing feedback stimulated contemplation in therapists themselves. One therapist stated:
By taking a step back I recognized, hey, it annoys me what patients write down. Or I thought by myself, “come on, start practicing.” Then I thought, “stop.” You can read back your own feedback and then think by yourself “I should not do this.”
Due to increasing experience, they got more efficient in their feedback over time. One therapist stated:
I became a lot more economical in my feedback over time. I tend to scan more for abnormalities or diary entries which I don’t recognize, or diary entries of which I think “this could influence dropout.” I tend to reply less, but what I say is then more relevant.
The fact that patients were able to write about their experiences rather anonymously was helpful in opening up to experiences, which meant that in general, they shared their experiences in rather great detail. Moreover, it rendered the therapist to use patients’ own quotes. One therapist stated:
Patients think I don’t see them and they don’t see me. They tend to confide more to a diary. Sometimes they told me “I don’t know whether I should write everything down in such an uncensored manner.” And I encouraged them to do so. I sometimes used quotes from their own diaries and they asked me “Wow, did I write this down?” They sometimes used impressive words.
Therapists were unable to comment on present moment experiences. This made it difficult to communicate what mindfulness is about. One therapist stated:
The experience-driven nature, the contact when a patient says something or shows emotion with which you can work instantly, which everyone immediately feels, that is direct. And it has a lot of impact. This is why things are so slowed down in the online. You have no direct experience to work with.
The asynchronicity made it more difficult to maintain continuity and to prevent dropout from the eMBCT. One therapist stated:
Whenever a life event took place or I fell ill myself [...] the schedule started to get awry fairly quickly. Patients hand in their diaries too late [...] and you start hopping from miscommunication to miscommunication. In the worst case, the training gets bogged down and the output is zero.
Therapists indicated that technical issues also proved to be a barrier to treatment continuity. One therapist stated:
The technical background might have been a possible reason for dropout. I thought it was difficult myself. The whole logistics of where to find what, how the site was built up, where I had to click. I didn’t think it was intuitive. It took me some time.
Therapists indicated that a major drawback of the communication in writing is the complete lack of nonverbal communication. One therapist stated:
I prefer to see someone’s nonverbal emotions. And to show that I open up. I had to think about this, how do I do this in writing? Is that even possible?
Moreover, they sometimes felt as if their therapeutical repertoire was limited by writing. One therapist stated:
I noticed that my feedback sometimes, as it was in writing only, did not contain everything I wanted to say. My repertoire is bigger and I was not always able to use all my skills.
Sometimes, because of emphasis on reading and writing, it only became clear at a later stage that the patient did not fully understand everything. One therapist stated:
Sometimes patients come up with issues that have been taken care of already. Maybe because the training relies so heavily on reading and writing, patients absorb the training differently.
Therapists indicated that it was facilitating for patients that they were able to provide a group context. One therapist stated:
You can provide examples from other patients or a funny example from a group situation.
In their feedback, they considered it motivating to provide reassurance very explicitly. One therapist stated:
In the online training I am much more complimentary for doing the exercises despite being so tired, and in the group I am much less inclined to do so.
Therapists were also involved in making the training more personal. One therapist stated:
I make it very clear from the start that “I write this feedback to you. This is not standardized feedback,” so the patient knows he or she is dealing with an actual person. Someone actually replied “Good to know that there is a person at the other side.”
Feedback
A lack of diary entries was a turnoff for therapists in providing stimulating feedback. One therapist stated:
I noticed that it was not very stimulating when patients filled out very little. I think my own feedback will have been much shorter as well, and I much easier reverted to saying “good luck next week.”
Therapists indicated that they experienced it as a barrier that more explicit disclosure and checking with the patient is necessary. One therapist stated:
I tell more about myself, “I recognize this when doing the body scan myself,” far more often than I used to do in a group setting, and you have to be very explicit, check and check again how things come across.
Therapists also stated that it was hard for them to embody mindfulness values behind the computer. One therapist stated:
When patients start to get doubtful, or skeptical about the training, the power of your presence can be really important. Not in the sense of being able to convince people but with a visible nonverbal way of saying, “everything is OK,” and showing this by being embodied. You can’t do this via the PC.
Therapists indicated that for some patients, the eMBCT was partly a training in self-discipline, which supported patients’ self-sufficiency after the training. One therapist stated:
Some patients train in self-discipline. They have to, which maybe renders them more likely to continue practicing. Yes, dropout is higher, but those who do finish the training are very disciplined in doing so and did it more on their own, without the group context. More self-reliant, which is in line with mindfulness.
In the eMBCT, patients need to be resolute and determined. This was mentioned as a barrier to complete eMBCT. One therapist stated:
When a patient was not able to login, the webmaster provided a link. The patient then neglected this link. If someone helps you, as a patient you must go for it and say “OK thank you, I will try again, and if it doesn’t work, I will mail you again.”
Therapists indicated that a lack of writing skills made it difficult to understand patients’ messages. One therapist stated:
Sometimes it was difficult to read past the spelling mistakes and to actually see what someone meant, and not to write down constantly “what do you mean?”
The aim of this study was to gain qualitative understanding of the facilitators and barriers of eMBCT in a sample of heterogeneous cancer patients. Both eMBCT completers and dropouts participated in posttreatment interviews. Moreover, we conducted a focus group interview with eMBCT therapists. In all, this study adds to the existing quantitative evidence for eMBIs in cancer [
Patients and therapists reported similar advantages and disadvantages of the timing, the individual nature, the asynchronous nature (for patients, this was detrimental to the relevance of therapist feedback, and for therapists, this was a threat to treatment continuity), the diaries, and the importance of self-discipline. The fact that so many aspects of the eMBCT were mentioned both as facilitator and barrier emphasizes the importance of offering flexibility in eMBIs [
There were also differences between patients and therapists. As known from a previous qualitative study on eMBCT [
Although studies to date do not suggest that differences between how therapists handle the contact with their clients explain much variance in treatment outcome [
The current eMBCT was individual, asynchronous, and therapist-assisted. One important adaptation may be to offer a peer support group [
Another consideration may be to employ a synchronous videoconferencing format [
Eventually, one could employ a blended format, combining the advantages of Web and group-based therapy [
Previous studies have provided encouraging quantitative evidence, for example, eMBIs in cancer patients [
This is the first study to qualitatively explore facilitators and barriers of eMBCT for cancer patients. The relatively large sample size enabled us to reach data saturation and report a broad view of experiences. Moreover, we interviewed both completers and dropouts. Furthermore, we had the opportunity to gather data in the therapists. Nevertheless, our results should be interpreted within the limitations of our findings. We did not perform member checks to ensure validity of the verbatim transcripts. Moreover, the sample of the larger RCT consisted of cancer patients who self-selected themselves for a trial on an MBI. This implies that our findings cannot be extrapolated to cancer patients in general. In addition, some patients or therapists who participated in the training and were invited for focus groups or individual interviews declined participation, which may further limit the generalizability of our findings to all participating patients.
We aimed to gain understanding of the facilitators and barriers of individual, asynchronous, and therapist-assisted eMBCT for cancer patients. Patients and therapists reported similar advantages and disadvantages of the timing, the individual nature, the asynchronous nature, the diaries, and the importance of self-discipline. Future studies should assess how different eMBCT delivery formats could further improve treatment accessibility, program adherence, and treatment outcome.
Internet-based mindfulness-based cancer recovery
Internet-based mindfulness-based cognitive therapy
Internet-based mindfulness-based intervention
mindfulness-based intervention
mindfulness-based cognitive therapy
mindfulness-based stress reduction
randomized controlled trial
The authors would like to thank all patients and therapists who participated in this study, and Heidi Willemse, Eva Witteveen, and David Huijts for their help in gathering data.
None declared.