For many years practitioners have known that groups have substantial therapeutic potential. As explained by Kivlighan, Miles and Paquin (2010), Yalom and colleagues were among the first to assess therapeutic factors in the context of the group. Yalom, Tinklenberg and Gilula (1968, as cited in Kivlighan et al., 2010) produced a framework of 12 components thought to capture fundamental change processes in group therapy across treatment settings, populations, problems, and therapeutic styles. These 12 components are described in Kivlighan et al. (2010) and include the giving and receiving of support, feeling connected to others, and being instilled with hope.
As we might expect, experiences of peer relationships appear commonly espoused in qualitative studies investigating MBIs. As described in the Introduction, peers are
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noted to influence engagement, how participants feel during interventions, and how individuals feel about themselves - their ‘self-relationships’ (e.g. Poppe et al., 2013; Malpass et al., 2011). Irving et al. (2014) explained that many of their participants spoke about the group structure facilitating their persistence with mindfulness. Individuals spoke about being in the MBI room as almost forcing one to practice. This phenomenon appeared present in the current study too. Richard talked about his sense of comradeship and obligation to his group encouraging him to engage with practice. Caroline spoke similarly. She explained that although she found her facilitator’s guidance poor, she believed there was worth in attending the group because she felt encouraged to practice whilst there. Like participants in the current study, individuals in Irving et al. (2014) described being forced into practice as a positive experience. Peer relationships therefore appear therapeutic for some, due to their influence on engagement and perseverance with mindfulness practice.
Irving et al. (2014) spoke about how feeling supported and experiencing a sense of mutuality with course peers seemed central to the facilitative nature of participants’ MBI group. In particular, attending the MBI was perceived by individuals as an opportunity to learn that others struggled and suffered with the same things. Similar findings were reported in Malpass et al. (2011) who conducted a meta-synthesis of qualitative papers. They reported that participants across many studies spoke about shared experience, in particular learning that others have similar problems. It was reported that this led to a sense of being normal and less isolated and was important for accepting one’s illness or difficulty. Such experiences appear reflected in the present study too. For Harriet, perceiving others as similar to her and understanding her led to a sense of relief. She also described acts of being supported by her group and it seemed she felt heard and considered by them as a result. Irv reported feeling understood by his peers and said this cultivated a sense of being under less pressure. He also recounted experiencing a reduction in guilt
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when he realised others felt guilty because of their illnesses too. Caroline spoke about learning that others experienced the same issues as her, which led to a reduction in her feelings of isolation and a sense of belonging. Again, Nadia said that finding commonality between her and other group members led to a sense of being normal.
I wonder whether perceiving oneself as similar to others and gaining support from group members were so important to the current participants due to the wider discourses around ME/CFS. It has been noted that ME/CFS is an illness frequently stigmatised against. As postulated earlier, such stigma may create an anxiety around being judged or misunderstood by others. Perhaps feeling accepted, supported, and similar to others was so important because it gave participants a sense of safety in an unsafe world.
An interesting reading of the data emerges if we consider findings from Brooks et al. (2014). In their IPA study, Brooks et al. (2014) reported that significant others such as partners (and in one case the proprietor of a health shop) played an important role in individuals’ experiences. This was in the context of healthcare professionals being unable to provide a definitive diagnosis or curative treatment. Finding themselves in a situation where they were unable to obtain answers from the sources they would usually access, individuals sought information and support from those close to them (Brooks et al., 2014). Similarly, participants in Edwards et al. (2007) reported gaining information by speaking to other individuals with the condition, through reading, and via the internet. As in Brooks et al. (2014), the seeking of such information was talked about in the context of dissatisfactory healthcare input. Participants in the current study espoused similar views. For example, Caroline referred to a process of giving and receiving information, “somebody has a problem and you think, ‘Well I tried it this way, try that’, and then they say the same to you, so you’re constantly sharing” (698-701). Caroline
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explained that this sharing was “beneficial” because peers were “helping each other” (line 697 / 696-697). Therefore, as well as finding a relief from stigma and a sense of belonging, the group also appears potentially important for the giving and receiving of healthcare information. Perhaps, as espoused in Caroline’s account and the participants in Edwards et al. (2007), this can give a sense of gaining new information and of understanding one’s situation better.
I would argue that learning about the importance of peer relationships has particular implications for practitioners intending to conduct group-based MBIs with individuals living with ME/CFS. It could be suggested that the group may be just as therapeutic as the mindfulness skills themselves. Indeed, participants in other studies have noted as much. Two participants in Smith, Fergal, Jones, Holttum and Griffiths (2014) did not report much change from the MBI sessions, but did talk about valuing the group process, one saying it was “nice to know that somebody else was suffering just like you” (p. 4). In the current study, Caroline very specifically stated that the group process was more valuable to her than the sessions. She said “I got more out of the group as we were talking at break erm than I did with the session” (703-706). A similar essence shone through Irv’s account. He reported finding the group very therapeutic, but only finding worth in the techniques a few months after the sessions had finished. Irv said about his first session, “What I actually got from it was the fact that I’d met some people [] I’m talking to people who understand and they’re listening and I’m listening to them” (786-792). Irv spoke about this interaction meaning he took something away that was “more readily available” (789-790). Interestingly this sense of accessibility (or non-accessibility) appeared echoed in Smith et al. (2014). Here, the aforementioned participant described the mindfulness practices as very difficult to engage with and complete.
Therefore, perhaps practitioners need to provide a space where peer relationships can prosper. The wider literature supports this assertion and authors such as Yalom
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and Leszcz (2005) have provided guidelines to this end. Richard gave insight in his interview into how he believed his facilitators helped build successful group dynamics. This appears consistent with the advice given in the aforementioned guidelines as he explained that his facilitators had methods of being warm and respectful to participants, yet ensuring conversation was moving so that certain individuals did not dominate the interaction.
Yalom and Leszcz’s (2005) guidelines also consider the selection of clients and the composition of therapy groups. They suggest that diagnosis is less important in predicting group behaviour than are attachment and personality. Despite this, since feeling that one is not alone or unique in their problems and suffering is thought so important for therapeutic change (e.g. Yalom et al., 1968, as cited in Kivlighan et al., 2010), perhaps it would be helpful to bring together groups of individuals likely to be able to resonate with each other. This might mean others with ME/CFS, or those experiencing conditions characterised by similar symptoms such as fibromyalgia or chronic pain. Perhaps it may also be helpful to dedicate an amount of session time to group communication, during which individuals could speak to one another and discuss their experiences. For example, participants in the current study spoke about spending breaks catching up with peers. I wonder whether splitting the larger cohort into smaller groups for certain activities might also achieve the same goal. Here participants may have more opportunity to communicate. They could also feel more comfortable talking without the gaze of the facilitator, who may well be perceived as wanting individuals to stay focussed on the task in hand.