Introduction

According to the cancer treatment and survivorship report of 2016–2017 (American Cancer Society 2019), the number of US cancer survivors will rise from the current 15.5 million to nearly 20.3 million by January of 2026, affecting almost 10 million males and 10.3 million females. The National Cancer Institute reports through the Surveillance, Epidemiology, and End Results (SEER) program that in 2018, approximately 38.4% of men and women will be diagnosed with cancer at some point during their lifetime and about 66.9% people will survive 5 years or more after being diagnosed with cancer (National Cancer Institute 2018). Due to this epidemic-like situation, the National Cancer Institute and cancer care organizations are focusing their continuum of care toward longevity and improving the quality of life (QOL) in cancer survivors. The link between spirituality and its profound effect on the quality of life in those living with cancer has been well researched in the last few decades (Bai and Lazenby 2015).

Successful cancer coping has been shown to have a link with one’s spiritual/religious beliefs and practices in several qualitative research studies (Ashing-Giwa et al. 2004; Levine et al. 2007; Maliski et al. 2012; Schulz et al. 2008). These studies have demonstrated that spirituality brings closeness to one’s self and strengthens their relationship with a Higher Power along with increasing their hope and resilience. This greatly helps cancer survivors deal with the life-threatening illness. Several proposed spiritual models have been found to be very effective coping strategies in cancer survivors. Among them is Schultz’s three-dimensional model, which describes the vertical connection to a Higher Power, the horizontal connection to self, others, and the world as well as a temporal element with connections to the past, present, and future in addition to an individual’s place in history/culture (Schulz et al. 2008; Tsang and McCullough 2003). Further, the 12-dimensional Hierarchical Model of Spirituality (Schulz et al. 2008; Tsang and McCullough 2003), based on Tsang’s and McCullough’s hierarchical model, has been found to be a very effective coping strategy in cancer survivors. This multidimensional model of spirituality has been used to assess the Posttraumatic Spiritual Growth (PTSG) in a phenomenological study of cancer survivors (Denney et al. 2011). This spiritual model is an extension of the Hierarchical Model of Spirituality proposed by Tsang and McCullough (2003), which was comprised of a dispositional level (Level 1) and operational level (Level 2) of organization.

Studies have shown that cancer survivors often have questions related to spirituality and that they want their spiritual needs to be met by their oncology providers (Astrow et al. 2007; Surbone and Baider 2010). However, most physicians do not engage patients on spiritual matters (Astrow et al. 2007; Surbone and Baider 2010). Therefore, this framework should be reconsidered with the introduction of integrative care such as mind–body healing practices in oncology. In recent years, studies have shown that life-threatening illnesses have caused positive psychological changes in cancer survivors (Hefferon et al. 2009). These changes have been reported in 60–90% of cancer survivors and have been named as Posttraumatic Growth (PTG) (Stanton et al. 2006). PTG has been shown to have a strong spiritual component in those with history of cancer (Denney et al. 2011; Fallah et al. 2012; Heidarzadeh et al. 2014, 2018). The spiritual struggle faced by patients might be addressed by providing them with a meditation tool that specifically focuses on enhancing the spiritual well-being of individuals. Spiritually focused meditation has been found to be effective in enhancing physical and psychological well-being in terminally ill cancer patients (Cole 2005; Cole et al. 2012).

Brahma Kumaris Raja Yoga Meditation (BK-RYM) is a form of spiritually focused meditation with the aim of achieving self-mastery over the mind by connecting the practitioner with the positive, nurturing, and loving part of the self (Jayanti 2010). This form of meditation has been shown to increase self-satisfaction and happiness in life by enhancing positive thinking in both short-term and long-term meditators (Ramesh et al. 2013). Further, changes in the autonomic nervous system of regular practitioners positively impact physiological as well as psychological functions of the body (Gupta et al. 2011; Kiran et al. 2014; Vyas et al. 2008; Maini et al. 2011; Sukhsohale et al. 2012). As BK-RYM has a strong spiritual foundation, the experiences of cancer survivors who have been practicing this form of meditation can provide healthcare providers with an insight into the potential of spiritual practice to ease the emotional and physical health challenges that accompany this life-threatening illness.

Although qualitative research on cancer survivors suggests the need for spiritual care and the benefit of spiritual well-being in coping with cancer-related health issues (Ashing-Giwa et al. 2004; Holt et al. 2012), there is limited research about the lived experience of cancer survivors who have practiced a spiritually based meditation practice, such as BK-RYM, for an extended period of time before their cancer diagnosis. This particular meditation practice was chosen as the researcher herself was a long-term BK-RYM practitioner and had seen a tremendous change in her life over the course of almost 20 years. Furthermore, BK-RYM not only brings about relaxation of the body and the mind, but aims to bring about a change in consciousness in order to gain self-mastery, (O’Donnell 2016) which is in contrast to cognitively based practices that are more frequently researched, such as Mindfulness-Based Stress Reduction (MBSR) programs (Ledesma and Kumano 2009). Hence, this qualitative study was undertaken using interpretative phenomenological analysis (IPA) to get an in-depth and subjective understanding of the role of a spiritually based mediation practice (e.g., BK-RYM) in the experience of individuals diagnosed with cancer. The research question that guided this study was, “What is the lived spiritual experience of long-term Raja Yoga meditation practitioners diagnosed with cancer?”

Methods

This study utilized Interpretative Phenomenological Analysis (IPA) to investigate and describe the experiences of three cancer survivors. IPA is a phenomenological research method that is idiographic in nature and employs a double-hermeneutic approach to garner an in-depth understanding of the meaning of a lived experience. In double-hermeneutic analysis, the participants first make meaning of their own experiences, and this narrative is then interpreted by the researcher (Smith et al. 2009), who maintains an attitude of self-awareness and self-conscious reflection (Smith and Osborn 2008) throughout the data collection and analysis process.

Study Design

A purposive sampling method was used to select participants in order to obtain a rich and detailed insight of participants’ experiences. As IPA typically targets a small sample due to its idiographic approach, three participants were recruited for this pilot study (Smith et al. 2009). Inclusion criteria for selecting these participants were: English speaking, regular BK-RYM practice (defined as a commitment to practice this form of meditation daily for at least one hour; and attending online or in person daily spiritual lectures lasting 45 min to one hour at the Brahma Kumaris meditation center), and being between 18 to 80 years old with at least 10 years of regular meditation practice at the time of the cancer diagnosis. Exclusion criteria were: Cancer survivors who were non-English speaking, cognitively impaired, or still receiving active medical treatment in the form of chemotherapy or radiotherapy.

Recruitment

After securing permission from the Director of the Brahma Kumaris Spiritual Organization in the USA, a recruitment letter was sent to all the Brahma Kumaris centers across the country via email. The coordinator of each center then passed this information on to regular meditation students. Interested candidates were instructed to contact the researcher via email. Prospective candidates were then asked five pre-interview screening questions via phone (Table 1) to check for their eligibility to be included in the study according to the predetermined criterion.

Table 1 Interviews
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Data Collection

Between January and March 2016, semi-structured, one-on-one interviews were conducted over the phone or Skype to elicit in-depth information about each participant’s experiences (Smith and Osborn 2008). The in-depth interview lasted for 60–90 min for each participant. A short 15–30 min follow-up interview was conducted in order to verify the findings obtained from the in-depth interview. The in-depth interview was guided by seven open-ended questions, designed by the researcher, to initiate the interview process that encouraged the participants to describe their spiritual experiences throughout their cancer journey (Table 1).

The researcher actively listened to participants’ words in response to each interview question with the aim of understanding the meaning of the experience for the participant. The researcher bracketed her own spiritual experiences including her long-time experience with BK-RYM, as well as her memories and experience with her sister who died of cancer. After each interview session, the researcher documented her own reflections about the participant’s insights and perceptions of the phenomenon.

Data Analysis

Data analysis was conducted using the steps described by Smith, Flowers, and Larkin (Smith et al. 2009). Recorded data from the semi-structured interviews were transcribed by the researcher. The participant’s transcript was read and reread at least three times by the researcher to gain access to the participant’s inner world. Three types of comments—descriptive, linguistic, and conceptual were noted for each participant, after which emergent themes and super-ordinate themes were created.

Ethics

After participants agreed to enroll in the study, the details of the study were explained to them, and informed consent was obtained. Throughout the research process from the participant selection to the data analysis phase of the study, the researcher ensured that the ethical principles of a qualitative research study were well addressed (Sanjari et al. 2014). The participant’s confidentiality and anonymity were given prime importance in this study. Pseudonyms were used in transcripts in order to protect their identities.

Results

The demographics of the participants are displayed in Table 2. Although participant selection was not restricted by any specific type of cancer, all participants who contacted the researcher were breast cancer survivors in different stages of the illness. All participants were BK-RYM meditation practitioners at the time of the cancer diagnosis with a history of regular meditation practice ranging from 20 to 32 years.

Table 2 Participant demographics
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To maintain the confidentiality of the participants, pseudonyms were given. Their first name was determined according to the most predominant quality that was observed by the researcher in them at the time of interview. The three participants were named Love, Happy, and Peace. All of them had a deep desire to serve mankind and therefore, the last name given for each was “Angel.”

After reflecting upon participants’ experiences in this study, emergent themes were identified, which were grouped together and arranged within five primary, super-ordinate themes along with 20 sub-themes (Table 3). These five super-ordinate themes were:

  1. 1.

    Positive state of mind (happy no matter what)

  2. 2.

    Self-awareness (identification with soul not body)

  3. 3.

    God’s healing power (openness to divine healing)

  4. 4.

    Spiritual support (experience of support from God and spiritual community)

  5. 5.

    Spiritual growth (increased wisdom and insight)

Table 3 Master table with super-ordinate themes and sub-themes
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Discussion

The findings from this study corroborate the three-dimensional spiritual model developed by Schulz et al. (2008) in that all three participants shared that they each felt a strong connection with their spiritual self, God, and others. In addition to aligning with Schulz’s model, many of the themes and sub-themes that emerged from this study are congruent with Hill’s expanded version of Tsang and McCullough’s (2003) Hierarchical Model of Spirituality, which comprised of the two levels—dispositional and operational. Hill (2005) incorporated the 12 domains of religiousness and spirituality into these two levels. The dispositional level assesses broad differences in religious tendencies or traits and describes the personal characteristics of individuals more likely to be religious. This level includes the domains of general religiousness or spirituality, religious or spiritual commitment, religious or spiritual development, and religious or spiritual history. The operational level describes how spirituality can be experienced, expressed, and applied in real life situations. Domains conceptualized under this level comprise of religious or spiritual social participation, religious or spiritual private practices, religious or spiritual support, religious or spiritual coping, religious or spiritual beliefs and values, religion or spirituality as motivating forces, religious or spiritual techniques for regulating and reconciling relationships, and religious or spiritual experiences.

The stable, positive, and happy state of mind with easy acceptance of the diagnosis without any fear that was observed in all the participants was in contrast to the negative feelings of sadness, fear, anger and depression, which are the usual emotions in those diagnosed with cancer (Ashing-Giwa and Lim 2011). All three participants attributed their profound positive state of mind to their regular spiritual practice of BK-RYM meditation. A link between spiritual practice and optimism and euphoria has been demonstrated in the literature (Chan et al. 2006). The inner stability observed in these participants represented a high degree of “general spirituality” and reflects “spiritual development”, which are two of the components of the dispositional domain in Hill’s Hierarchical Model of Spirituality (Hill 2005). Their positive feelings in the form of fearlessness and happiness along with their positive attitude toward cancer also demonstrate the positive emotional impact that long-term spiritual practice (or “spiritual history” as identified in the dispositional domain of Hill’s model) can have on practitioners (Hill 2005).

All participants perceived their identity to be something more than what others would think and feel about them. The identification of the self as a spiritual being rather than with the physical body was a powerful spiritual tool that all participants practiced for self-healing. This spiritual awareness seemed to assist them in embodying positive qualities such as love, peace, happiness, power, purity, wisdom, and bliss. In BK-RYM, detachment from the physical body and staying in soul consciousness, which refers to identifying the self as a soul, a point of light rather than a body is the basic step that an individual learns to practice (Whaling 2012). The themes of soul consciousness as well as awareness of eternity stood out as the most profound “spiritual beliefs” (a component of Hill’s operational domain) (Hill 2005) that enabled the participants to face their health challenges with ease.

According to all three participants, their spiritual relationship with God allowed them to experience His healing presence in the form of love, peace, compassion, and courage, which empowered them to manage their cancer-related health issues with hope and equanimity. As the practice of BK-RYM involves forging a strong relationship with the Divine (Panjabi 2008), these cancer survivors used their meditation practice to consciously cultivate an even stronger connection during the course of their illness. Connection with a Higher Power has been included as one of the components of Schultz’s spiritual model (Schulz et al. 2008). Simon, Crowther, and Higgerson’s qualitative study on African-American Christian woman diagnosed with breast cancer also found that the cancer survivors felt a close relationship with God (Simon et al. 2007), which was similar to the experience shared by the participants in this study.

All participants in the study felt a strong spiritual support primarily from God and also from being a member of a spiritual community. Research studies on cancer have shown that cancer survivors often seek and experience spiritual support (Astrow et al. 2007; Surbone and Baider 2010). A number of qualitative inquiries on cancer survivors have also reported God as a major spiritual support during cancer treatment (Schulz et al. 2008; Simon et al. 2007). The spiritual support from God, support from spiritual knowledge, and support from a spiritual family provided these three participants with a motivating force (Hill’s operational domain) (Hill 2005) to deal with their health challenges. The sub-theme of support from daily spiritual knowledge reflects their “spiritual commitment” (a component of Hill’s dispositional domain) (Hill 2005) to study every single day irrespective of the condition of their body.

The participants in this study shared that they received ample spiritual support from God, spiritual family as well as their daily spiritual study; perhaps, this could have facilitated the spiritual growth they all experienced. Studies of cancer survivors have shown increased growth in the spiritual dimension of health following the diagnosis of cancer, known as Posttraumatic Spiritual Growth (Denney et al. 2011; Fallah et al. 2012; Heidarzadeh et al. 2014). However, none of the participants in this study perceived the cancer diagnosis as “trauma”; instead, they received it as a blessing from God. Therefore, spiritual growth identified in this study is more clearly described as “post-cancer spiritual growth.” This finding of spiritual growth was consistent with a study by Denney et al., where cancer survivors attributed their spiritual growth to the spiritual support they had received during the cancer treatment (Denney et al. 2011).

Another unique aspect common to all participants was the creation of a positive and light atmosphere, which they perceived made others who came close to them feel uplifted and inspired. Because of their spiritual meditation practice, they were able to take great care of themselves by being stable, peaceful, loving, kind, humble, and patient throughout the course of their illness. The theme of becoming an inspirational model, identified in this study, can very well be compared to Hill’s operational domain of increased “spiritual social participation” (Hill 2005), where cancer survivors served as a source of inspiration to others.

All themes generated in this study represent the rich “spiritual experiences” (Hill’s operational domain) (Hill 2005) that participants attributed to their long-term spiritual practice with cancer being a triggering agent. Their spiritually focused meditation practiced by the participants enabled them to approach this health challenge with unusual ease and equanimity.

The current study provides increased understanding of how spirituality, specifically in the form of BK-RYM, can play an integral role in coping with the challenge of cancer. Themes demonstrating transcendent awareness and reflecting positive coping skills not identified in previous spiritual models related to cancer were soul consciousness, awareness of eternity, lack of fear, being happy no matter what and becoming an inspirational model.

Limitations

The rich spiritual experiences gathered from this study may not be representative of the entire population. IPA researchers do not expect findings to be replicated exactly by others; yet, the insights gained from a study in some specific context could be beneficial in other, similar contexts (Yardley 2008). Therefore, generalizability in qualitative research is considered to be “potentially wide-ranging and flexible” (Yardley 2008). Additionally, as this study focused on the experiences of cancer patients who have been long-term practitioners of a specific type of meditation practice, the findings of this study may not be comparable to findings based on other meditative practices. Recall bias is another possible limitation of this study as the participants may not have been able to recall every experience during the interview session. Another limitation of this study is related to participants’ self-reflective reports concerning how they made others feel uplifted due to their own positive attitude and behavior. The lack of cross-checking these recollections with those to whom the participants referred might be a limitation. Furthermore, the researcher holds similar spiritual beliefs and practices the same form of meditation as the participants in this study, which might have introduced potential bias related to the interpretation of the study results.

Although research studies have been conducted seeking to better understand the lived experiences of breast cancer survivors, there have been no published studies that examined the spiritual experiences of long-term meditators who were diagnosed with cancer following several years of meditation practice. This study may serve as a guiding resource for healthcare professionals, especially oncology personnel, to consider the profound role spirituality can play in the well-being of cancer patients and survivors. Although the participants in this study had a history of long-term meditation practice pre-diagnosis and were spiritually mature at the time of diagnosis, spiritually focused meditation practices, if started post-diagnosis might also have the potential to benefit this population. Therefore, such spiritual practices if started early at the time of diagnosis as part of the treatment plan might reduce cancer-related stress and suffering, which in turn may improve overall health outcomes.

Conclusions

The spiritual experiences of the cancer survivors in this study unveiled the spiritual beliefs, values, and spiritual identity of these practitioners of BK-RYM and assisted them in maintaining a positive state of mind. The practitioners’ spiritual connection with their spiritual self, God, and others enabled them to live through the challenges of cancer with relative ease and equanimity. The experience of cancer provided the survivors an opportunity to grow spiritually and to act as an inspirational role model for others to lead a more virtuous life.

More studies are needed to explore how a prior meditation practice and spiritual lifestyle such as BK-RYM can impact one’s ability to withstand health challenges that almost everyone has to face at some point of time. As this study included only breast cancer survivors, similar studies involving participants with other types of cancer, as well as male participants, should be conducted in the future to understand and explore more deeply the lived spiritual experiences of long-term meditators.

Although many studies have reported a link between meditation and well-being of cancer survivors, the role of spiritually focused meditation would benefit from additional research. With the emergence of new themes in this study, further research is needed to unravel the mystery of the relationship between soul consciousness and awareness of eternity in maintaining a positive state of mind when faced with health-related adversity. Due to the rich spiritual experiences of the cancer survivors in this study, future research could target replicating this study by focusing on the impact of spiritually focused meditation techniques such as BK-RYM, spiritual transformation meditation (Cole et al. 2012) and transcendental meditation (Wachholtz and Pargament 2005) to name a few, on other chronic diseases as well other types of cancer.