Keywords

Introduction

Physical, psychological, and spiritual domains of end-of-life care have been identified as priorities by both medical professional organizations and cancer patients themselves. Two milestone Institute of Medicine (IOM) reports , “Approaching death: Improving care at the end of life” (1997) and “Improving palliative care for cancer” (2001), as well as the National Consensus Project for Quality of Palliative Care Clinical Practice Guidelines (2004) and the National Quality Forum (2006) recommendations for preferred practices for palliative and hospice care identified spiritual well-being (psychological, psychiatric, spiritual, and existential domains of care) as core domains of quality end-of-life care.

Facing a diagnosis of advanced cancer is challenging for even the most resilient individuals. Distress associated with this diagnosis can manifest in many ways including physical symptoms, psychological symptoms, and spiritual/existential symptoms.

Existential concerns are a major issue among the advanced cancer population as feelings regarding one’s mortality are brought to the forefront. A consensus conference on improving the quality of spiritual care as a dimension of palliative care was recently held (Puchalski et al., 2009). This conference was formed under the central premise that spiritual care is a fundamental component of end-of-life support . Importantly, the consensus panel explicitly recommended psychotherapy approaches that focus on meaning to address spiritual/existential issues for end-of-life care.

Theoretical Background of Meaning-Centered Psychotherapy

Nearly 15 years ago, our research group at Memorial Sloan Kettering Cancer Center began to understand that a meaning-centered approach to psychosocial care was imperative to alleviate distress among advanced cancer patients. For those patients who are in fact facing death, meaning and the preservation of meaning are not only clinically and spiritually/existentially important but are central concepts to therapeutic intervention. Meaning-centered psychotherapy (MCP) was conceived at the intersection of a baffling clinical problem and inspiration. Clinically, we witnessed despair and hopelessness take hold of our advanced cancer patients and, consequently, the emergence of the desire for hastened death. What we found most surprising was that although 45 % expressing a desire for hastened death were struggling with a clinical depression (Breitbart et al., 2000), a significant percentage were not clinically depressed, but rather facing an existential crisis encompassing a loss of meaning, value, purpose, and hope.

When our research group as well as others demonstrated the central role that meaning plays in diminishing psychosocial distress and despair at the end of life, we were inspired to develop a meaning-centered intervention. This effort led us to the work of Viktor Frankl, his concepts of logotherapy (Frankl, 1955, 1959, 1969, 1975), and pioneers in existential philosophy and psychiatry. We found Frankl’s concepts of meaning and spirituality to be powerful tools that could be utilized in our psychotherapeutic work with advanced cancer patients facing existential issues at the end of life. Frankl’s main contributions have been increased awareness of the spiritual component of human experience and the central importance of meaning (or the will to meaning) as a motivating force in human psychology. Frankl’s basic concepts include:

  1. 1.

    Meaning of life—life has meaning and never ceases to have meaning even up to the last moment of life, and while meaning may change in this context, it never ceases to exist.

  2. 2.

    Will to meaning—the desire to find meaning in human existence is a primary instinct and basic motivation for human behavior.

  3. 3.

    Freedom of will—we have the freedom to find meaning in existence and to choose our attitude toward suffering.

  4. 4.

    The three main sources of meaning in life are derived from creativity (work and deeds), experience (art, nature, humor, love, relationships, roles), and attitude (the attitude one takes toward suffering and existential problems).

  5. 5.

    Meaning exists in a historical context; thus legacy (past, present, and future) is a critical element in sustaining or enhancing meaning.

Meaning-Centered Psychotherapy (MCP)

Model of MCP

Based on Viktor Frankl’s logotherapy and the principles above, we developed the “meaning-centered psychotherapy” to help patients with advanced cancer sustain or enhance a sense of meaning, peace, and purpose in their lives even as they approach the end of life (Breitbart, 2002; Breitbart, Gibson, Poppito, & Berg, 2004; Greenstein & Breitbart, 2000). This intervention is based on a theoretical model in which the enhancement of meaning results in improved quality of life and reduced distress, despair , and suffering. The figure below depicts the model underlying our MCP intervention, in which enhanced meaning is conceptualized as the catalyst for improved psychosocial outcomes.

Figure 1 depicts the model underlying the MCP intervention, much of which has been supported by published research. Specifically, meaning is viewed as both an intermediary outcome and a mediator of changes in these important psychosocial outcomes. Religious faith is not expected to directly impact psychosocial outcomes, but may moderate the intermediary outcome of meaning (see, e.g., Nelson, Rosenfeld, Breitbart, & Galietta, 2002, indicating that religious faith does not provide unique contribution to enhanced psychosocial outcomes after controlling for spirituality). This model also presumes that other factors will impact response to a meaning-based intervention, including prognostic awareness, psychosocial treatment preference, and therapeutic alliance. We recognize that the directionality of many of the variables included in this model could potentially be bidirectional; however, we present the model we believe underlies the intervention.

Fig. 1
figure 1

Study model—mediators and moderators of treatment outcome

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In order to target the despair and hopelessness driving the desire for hastened death, a number of existential concepts were called upon that do not directly involve meaning, but serve as a critical framework for conducting the therapeutic work of MCP. Although the MCP intervention is literally centered on meaning and sources of meaning, the richness of the therapeutic content is due to the integration of meaning and the theories of existential philosophy and psychotherapy. The therapeutic value of MCP would be limited without the contribution of existential concepts such as death anxiety, freedom, responsibility, choice, creativity, identity, authenticity, existential guilt, transcendence, transformation, mortality, and existential isolation. These concepts inform the intervention and are utilized to reinforce the goals of MCP related to the search , connection, and creation of meaning.

Appropriate Participants for MCP

While the majority of advanced cancer patients could benefit from participation in MCP, the intervention is best suited for individuals with moderate to extreme distress, as indicated by a score of 4 or higher on the distress thermometer (NCCN Clinical Practice Guidelines in Oncology). The distress thermometer is a brief screening tool that assesses the patient’s level of current distress by asking, “Please note your current distress on a scale from 0 to 10,” where 0 is “no distress” and 10 is “extreme distress.” When the source of the patient’s distress is emotional or spiritual/religious in nature, MCP may be a particularly efficacious intervention. Furthermore, MCP is currently delivered in the outpatient setting, and therefore, patients with physical limitations sufficient to preclude participation in the outpatient setting are not suited for this intervention. The patient’s physical limitations are assessed using the Karnofsky Performance Rating Scale (KPRS) . KPRS scores range from 0, “dead,” to 100, “normal, no complaints: no evidence of disease.” Scores below 60—“requires considerable assistance and frequent medical care”—deem a participant inappropriate for study participation in the outpatient setting.

Meaning-Centered Group Psychotherapy (MCGP )

Since its inception, MCP has been tested and demonstrated to be an effective intervention in a group format. Meaning-centered group psychotherapy (MCGP) was tested in a randomized clinical trial with advanced cancer patients. The format of MCGP includes eight 1 ½ hour weekly sessions; each session includes didactic teaching, discussions, and an experiential exercise component. Didactic teaching introduces group members to the themes presented in each session, while group experiential exercises allow for enhanced learning and homework practice outside of sessions. Elements of support and expression of emotion that characterize most psychotherapeutic groups are inevitably present in each session but are limited by the psycho-educational focus of MCGP. Each session is focused on a specific theme related to meaning and advanced cancer (Table 1). Our research team received several National Cancer Institute grants to rigorously test the efficacy of MCGP in advanced cancer patients (refer to Breitbart et al., 2010, 2015, for comprehensive results). In summary, stronger treatment effects were observed for MCGP compared with supportive group psychotherapy for quality of life, spiritual well-being, depression, hopelessness, desire for hastened death, and physical symptom distress (Breitbart et al., 2010, 2015). MCGP proved to be a highly effective intervention, increasing a sense of meaning, spiritual well-being, and hope, while decreasing end-of-life despair (Breitbart et al., 2010, 2015). For information regarding session content, refer to the Meaning-Centered Group Psychotherapy Treatment Manual (Breitbart & Poppito, 2014a).

Table 1 Individual meaning-centered psychotherapy session topics and themes
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Challenges of MCGP

While the group format of MCGP has been effective for advanced patients with a wide range of cancers, it is not without its challenges. Due to the structure of the MCGP sessions, in which each subsequent session builds upon the last, attendance at each session is crucial in order to fully benefit from the intervention. The rigid schedule necessary to conduct outpatient group sessions of MCGP, coupled with the physical limitation inherent in this population, resulted in high rates of missed sessions and high levels of attrition. In order to solve the problems presented by offering MCP in a group format, Individual Meaning-Centered Psychotherapy (IMCP) was developed. IMCP has the potential to address the unmet need for one-on-one flexible interventions critical to advanced cancer populations. It represents an opportunity to provide an effective intervention for existential and spiritual suffering that can be practically delivered.

Individual Meaning-Centered Psychotherapy (IMCP )

IMCP is a seven-session individual intervention, which utilizes didactics, discussions, and experiential exercises that focus on specific themes related to both meaning and advanced cancer. IMCP serves three major purposes : (1) to promote a supportive environment for cancer patients to explore personal issues and feelings surrounding their illness on a one-to-one therapeutic basis, (2) to facilitate a greater understanding of possible sources of meaning both before and after a diagnosis of cancer, and (3) to aid patients in their discovery and maintenance of a sense of meaning in life during illness. The ultimate goal of this intervention is to optimize coping through the pursuit of an enhanced sense of meaning and purpose. As Frankl points out, the possibility of creating or experiencing meaning exists until the last moment of life.

In the pilot study of IMCP for patients with advanced cancer, 120 patients with stage III or IV cancer were randomly assigned to seven sessions of either IMCP or therapeutic massage (Breitbart et al., 2012). Participants were assessed for spiritual well-being and quality of life, as well as anxiety, depression, hopelessness, and symptom burden. Posttreatment, cancer patients in the IMCP group reported significantly greater improvement in the primary study outcomes, spiritual well-being, and quality of life (Breitbart et al., 2012). Furthermore, IMCP patients demonstrated greater improvements in symptom burden and symptom-related distress than patients in the therapeutic massage group.

The intervention is intended to help broaden the scope of possible sources of meaning through the combination of (1) didactic teaching of the philosophy of meaning on which the intervention is based, (2) session exercises and homework for each participant to complete, and (3) open-ended discussion, which may include the therapist’s interpretive insights and comments. However, it is important for clinicians to understand that meaning making is an individualized process, and therefore, it is the individual member’s responsibility to use these sessions to actively explore and discover the sources of meaning in their own right. In this format, patients are not passive recipients of the intervention, but are active participants in the process itself, bringing to the table their own experiences, beliefs, and hopes that shape their journey to enhanced meaning and purpose. Although session topics remain the same within both individual and group formats, IMCP includes seven sessions, while MCGP is an eight-session intervention. The third topic, Historical Sources of Meaning and Legacy, is covered over two sessions in the group format to ensure ample time for each group member to participate in the often lengthy discussion of one’s legacy. A list of session topics for the individual format of MCP (seven-session format) can be found in Table 1.

In the following section, an overview of each session is provided. For a comprehensive guide to session content, refer to the Individual Meaning-Centered Psychotherapy Treatment Manual (Breitbart & Poppito, 2014b).

Session 1: Concepts and Sources of Meaning

The initial session of IMCP includes a series of introductions. During this session, introductions between the patient and therapist occur in addition to introductions between the patient and the intervention. IMCP is a therapeutic program drastically different from traditional forms of psychotherapy; therefore, it is imperative that the therapist spend time in the first session orienting the patient to the structure, logistics, and goals of the intervention. Following introductions, the therapist welcomes the patient to share his/her cancer story, beginning at the time of diagnosis and continuing to the present day. The therapist should encourage the patient to describe how he/she has been affected physically, emotionally, and socially. The remainder of the session focuses on the concept of meaning. Patients are asked to provide their own definition of meaning to help the therapist better understand how the patient connects to and defines meaning in his/her own life. Following this exercise, the therapist offers a definition developed by our research team to offer the patient additional ways to think about the concept of meaning. Furthermore, the patient’s meaningful moments in his/her life are explored, and rapport begins to build between the therapist and patient in this first session.

Session 2: Cancer and Meaning

In session 2, the main goal is to explore the topic of “Cancer and Meaning” in light of the guiding theme: Identity—before and after diagnosis. In order to reflect upon the origins of meaning in each person’s life, it is important to start with their own understanding of who they are. This session will help to reveal the patient’s authentic sense of identity, and what made his/her personal experiences meaningful. The experiential exercise for session 2 explores what makes this individual who they are and how cancer has impacted their identity (Breitbart & Poppito, 2014b). What the patient is most likely to discover through this exercise is that the core aspects of his/her identity after cancer are strikingly similar to their identity prior to cancer. Furthermore, it is the role of the clinician to attend to these themes and highlight them as characteristics that have persevered despite a life-altering diagnosis of advanced illness (Breitbart & Poppito, 2014b). The following IMCP excerpt from session 2 exemplifies the type of interaction that can occur:

  • Patient: I am someone who loves her family and friends. I am an optimistic person. I am someone who was comfortable in their own skin. I am someone who loves to explore New York City.

  • Interventionist: Tell me a little more about being optimistic and how that characterizes who you are.

  • Patient: I think I’m always a hopeful person in general, like glass half full, and I guess when I was reading this, I noticed personality characteristics, so I knew also that I had to compare it, and so that’s where I wrote that down because I feel like the cancer is kind of eating away at that optimistic thing because of the worry and the fear. I try to stay strong to my true self, but this other angle creeps in. But on the positive side, cancer has really intensified my relationships with people and has also made me aware and reminded me to be a more generous person. It is just mind blowing the amount of people who want to bring us meals and ask me how I’m doing and ask my husband how he is doing, and people have given us monetary donations. And I keep telling people don’t worry I’m fine; I don’t need a meal; I’m functioning; feed your own family, but they all insist and want to do something . So it’s always in my head that I need to pay it forward, and it really is a wonderful thing.

  • Interventionist: Absolutely.

  • Patient: It’s something wonderful to come out of a really shitty thing.

  • Interventionist: Yes it is, and recognizing that and taking that approach is attitude.

  • Patient: Yes, yes, it is.

  • Interventionist: Out of something so negative, but out of it, something so beautiful that the things that are most important to you have become more intense and more meaningful, and it has given you the opportunity, the illness has, to see the world as a more wonderful place than you thought it was before your illness.

  • Patient: I think I took it for granted, and I don’t take it for granted anymore.

  • Interventionist: And that is a great thing that has come out of this, this after cancer identity. What strikes me is that you said you were kind of surprised when you look at this after cancer part and thought, wow, three out of these four things aren’t affected by cancer or at least aren’t affected by cancer in a bad way. It goes to show that from such a profound challenge that can challenge you physically and psychologically, the core of who you are and the things that make you, you, haven’t changed. And in fact you are now someone who argues less and loves more, who sees the world and people as being caring and generous, and wants to give back to the world. I think that is incredible.

  • Patient: Yes, I agree. It is nice to be reminded of that, these, almost the positives that have come out of cancer.

Session 3: Historical Sources of Meaning —“Life as a Living Legacy”

The main goal for session 3 is to introduce and explore the topic of Historical Sources of Meaning and the guiding theme: Life as a living legacy. Following the discussion of identity in the previous session, session 3 serves as an opportunity to explore the context in which identity developed through the exploration of legacy. In IMCP, we present the idea of legacy through three temporal parts: (1) the legacy that has been given from the past, (2) the legacy that one lives in the present, and finally (3) the legacy that one will give in the future (Breitbart & Poppito, 2014b). The experiential exercise for session 3 allows the patient to have the opportunity to explore and express meaningful past experiences in order to uncover the historical context of his/her living legacy.

For some patients, discussion of the “legacy given” will be a nice trip down memory lane, while for others it may include difficult experiences related to unmet needs, losses, or disappointments. Whether memories are awesome or dreadful, it is undeniable that this legacy is a part of who our patients are. Our role as therapists is to bear witness to the patient’s story; the experience of telling the story may be comforting and transformative for a patient who is struggling physically and emotionally (Breitbart & Poppito, 2014b).

Furthermore, this session explores the present and future components of legacy. Through this process, the patient can begin to witness his/her living legacy as a cohesive whole by integrating past memories with present accomplishments toward future contributions (Breitbart & Poppito, 2014b). The therapist should help the patient find the thread that weaves through his/her past, present, and future legacy while listening for themes of hardship, loss, and adversity that can be reflected upon in the next session discussing life’s limitations.

Session 4: Attitudinal Sources of Meaning —“Encountering Life’s Limitations”

The main goal for session 4 is to explore the topic of Attitudinal Sources of Meaning and the guiding theme: Encountering Life’s Limitations. Session 4 is centered on Viktor Frankl’s core theoretical belief that our last vestige of human freedom is our capacity to choose our attitude toward suffering and life’s limitations in any given situation. Furthermore, the session focuses on Frankl’s belief that meaning and suffering are not mutually exclusive, but that one has the potential to find meaning in life through suffering. The attitudinal source of meaning is offered to patients as a way in which they can take control of their life in a meaningful way during a time in which the illness has likely stripped from them their sense of peace and control. The experiential exercise for this session allows the patient to reflect on times when he/she has faced obstacles and limitations in the past. It is the role of the therapist to point out how the patient has chosen his/her attitude in the past and how he/she can continue to use this source of meaning to face the challenges presented by illness (Breitbart & Poppito, 2014b). The review of how the patient has turned tragedies into triumphs in the past bolsters strength and self-efficacy regarding the patient’s ability to combat the obstacles and limitations that lie ahead.

The following IMCP excerpt exemplifies the type of interaction that occurs during the session 4 experiential exercise:

  • Patient: I think the tragic loss of both my parents shortly after I graduated from college. My father passed away when I was 19 ½ and my mom 1 year later. I had two brothers who were a great support to me, and 1 year before my mom passed, I met my dear husband, who I married 1 month after her death. I gathered the strength to bear the loss of my parents drawing on the values and love passed onto me by my dear mom and dad. They left a whole lifetime of values with me, and that is what helped me get through this. That and my husband coming into my life just a year previous, so I was very lucky in that respect. I don’t know what would have happened if I hadn’t met him at that point; life would have went a very different way maybe, but I was able to gather a lot of strength then and I got through it. It was really balanced by a wonderful time in my life, during a tragic situation.

  • Interventionist: It sounds like you fell in love in the wake of grief.

  • Patient: Exactly, when I think back, I think it is an amazing thing that happened. He never met my father, but met my mother when she was not herself. I fell in love with my husband the second he opened the door for a blind date; that was a gift from God. I have had a lot of gifts from God.

  • Interventionist: So meeting him and the love that you experienced with him certainly gave you strength, and it sounds like your brothers were also pillars of strength for you during that time. It really seems that the way you have always been able to cope with losses and limitations in the past is through the support of your family. When I came in today, I saw your children all around your chemo suite, and I think it is such a touching and beautiful example of how you continue to utilize the strength found in your family to face the current limitations presented by your illness.

  • Patient: I couldn’t get through this without them; they are so amazing.

The homework assigned in session 4 is a long-term homework assignment intended to build upon the work done thus far and further explore the concept of “Life as a Legacy.” Additional information on this long-term homework assignment can be found in the Individual Meaning-Centered Psychotherapy Treatment Manual (Breitbart & Poppito, 2014b).

Session 5: Creative Sources of Meaning —“Actively Engaging in Life via Creativity and Responsibility”

The main goal for session 5 is to introduce and explore the topic of Creative Sources of Meaning and the guiding theme: “Actively engaging in life via creativity and responsibility.”

It is the role of the clinician in this session to provide psycho-education regarding the relationship between creativity, courage, and responsibility. As humans, our existence calls us to create, and our ability to respond to this creative calling forms the basis for taking responsibility for our lives. Creativity and responsibility, therefore, are inextricably linked. While creativity requires action, the beauty of this source of meaning is that it continually gives us second chances to start over, make amends, forge new paths, traverse uncharted territories, and transcend our given bounds.

The challenge of creativity is that it takes a good deal of courage, tenacity, and inner fortitude to continually risk putting oneself out there in the face of uncertainty and doubt. It takes a great deal of courage to confront an advanced stage cancer diagnosis and find the energy and inner resolve to move ahead in spite of an uncertain future. Patients may feel existential guilt when they ignore this creative calling and fail to respond to life. It is imperative to normalize the guilt that patients may experience as well as to foster strength by helping patients to acknowledge their day-to-day ability to create as courageous. By the end of session 5, the patient should have a solid understanding of the significance of “creativity and responsibility” as important sources of meaning in life (Breitbart & Poppito, 2014b).

Session 6: Experiential Sources of Meaning —“Connecting with Life”

The main goal for session 6 is to introduce and explore the topic of Experiential Sources of Meaning by way of the guiding theme: Connecting with Life. Thus far, the sources of meaning introduced have required active involvement in life; experiential sources embody more passive engagement with life. Creative and attitudinal sources ask us to give to life, while experiential sources call us to give ourselves over to the lightness of being alive (Breitbart & Poppito, 2014b). There are three major ways in which we connect to life—through love, beauty, and humor. During the experiential exercise for session 6, patients are invited to provide examples of ways they connect to these sources of meaning. Following engagement in this exercise, it is the role of the therapist to reflect on the fact that experiential sources of meaning remain accessible despite limited physical capabilities or emotional hardship (Breitbart & Poppito, 2014b). As the illness progresses, patients may find comfort in these sources of meaning that require little activity to access. By the end of session 6, the patient should have a solid understanding of the significance of connecting with life through experiential sources of meaning.

Session 7: Transitions and Hopes for the Future

The final seventh session allows for time to reflect upon the experience of engaging in this intervention over the previous six sessions. The patient’s thoughts and feelings surrounding the finality of this therapeutic experience in light of facing important transitions and endings in their own life should be explored (Breitbart & Poppito, 2014b). Furthermore, these themes can be explored through the sharing of the meaningful experiences within the treatment process. The exercise for session 7 facilitates discussion of transitions and the future.

The following IMCP excerpt exemplifies the type of interaction that occurs during the final session:

  • Patient: I never thought that I was a strong person, but I think you made me realize that I am.

  • Interventionist: You have overcome so much. Not only have you overcome obstacles but you have gone the extra mile to create the life that you want despite the limitations you have faced. You have showed me that when life wasn’t really giving you what you wanted and what you needed, you went out and found it; you went out and created it. That is attitude.

  • Patient: Did I tell you that my boss and dear friend had adopted a baby from China?

  • Interventionist: Yes, and you were asked to be her godmother?

  • Patient: Yes. I was there yesterday, and this baby that we brought over together is now 17 years old. I forgot the joy the child brought me, and she came trotting down the lobby and started hugging and kissing me, and I thought I am so lucky. Even if I don’t see her that often, I am so lucky. She brought great joy to my life.

  • Interventionist: That is wonderful, and I am so struck by that because in our last session, we talked about these experiential sources of meaning and of love.

  • Patient: And I didn’t put that down! I needed to realize how much I love that child.

  • Interventionist: So in thinking about some of the themes we have discussed such as love, in general, what was this experience going through meaning-centered psychotherapy like for you?

  • Patient: You know what is interesting, I never really talked about my husband until these sessions, but at my last memoir class, the prompt was about looking at a painting and looking through the painting. The bottom line is that I have a picture of the shore near where we met, and for the first time in my life, I wrote about him. My class and instructor were so struck that I had never mentioned him, and I think that I did that because I was able to open up with you.

  • Interventionist: So what did it feel like to write about him and to have the story of you and him witnessed by others?

  • Patient: It felt so good that they loved it. Professionally, I love having the ability to write and be appreciated for it, but emotionally, I loved writing that story.

  • Interventionist: It is so wonderful that you were able to open up to others and connect that way.

  • Patient: It was so rewarding. I think overall, over these seven sessions, I have opened up.

  • Interventionist: I have certainly noticed. Which is why I think we have made some progress, and I encourage you to explore how opening up and connecting to others can provide you with freedom and take you on a unique journey through the rest of your life.

Future Directions of MCP

MCP for Caregivers (MCP-C )

In recent years, there has been growing recognition of the unmet needs of the informal caregivers of our patients. The literature shows that structured, goal-oriented, integrative, and time-limited interventions are best suited for informal caregivers of cancer patients (Applebaum & Breitbart, 2013). Currently, we are developing Meaning-Centered Psychotherapy for Cancer Caregivers (MCP-C). The goal of MCP-C is to explore critical sources of meaning in the caregiver’s life in an attempt to alleviate existential distress experienced by caregivers who are providing practical and emotional support to patients while coping with their own feelings related to the illness (Applebaum, Kulikowski, & Breitbart, 2015). Previous studies have called for the development of interventions delivered in alternative modalities to increase the number of informal caregivers that can access services (Applebaum & Breitbart, 2013). Therefore, clinical trials are currently underway to evaluate the efficacy of MCP-C delivered over the Internet.

MCGP for Breast Cancer Survivors (MCGP-BCS )

In partnership with the American Cancer Society, members of our team are testing an innovative application of the meaning-centered group (MCG) approach in a new but critically important and large population: breast cancer survivors. This adaptation of MCP consists of eight sessions, which address existential issues that cancer survivors commonly face. It focuses on the future, and life survivors would like to create, using some behavioral strategies to assist survivors with getting “unstuck.” We are currently evaluating the delivery of MCG for breast cancer survivors (MCG-BCS) through a virtual group format that involves the use of telephones and computers to connect potentially geographically diverse posttreatment group members who are, thus, not able to return to their cancer treatment center frequently. MCG-BCS has the potential to address the challenges in finding meaning that many breast cancer survivors face.

MCP for Bereaved Parents

The loss of a child is arguably the most devastating type of bereavement, leaving parents of the child in turmoil and suffering intense grief. Due to the existential distress commonly experienced by bereaved parents, a meaning-centered approach is fitting (Lichtenthal & Breitbart, 2015). We are currently evaluating the efficacy of meaning-centered grief therapy for parents bereaved by cancer to address the challenges in finding meaning in their lives and loss that parents frequently face. This intervention involves 16 one-on-one sessions, building upon the principles of MCP and adding content specific to coping with grief. It is designed to assist parents with recognizing their ability to choose their attitude in the face of their grief and suffering, to connect with important sources of meaning in their lives from which they may have become disconnected, and to help them continue their connection to their deceased child (Lichtenthal & Breitbart, 2015).

MCP for Adolescents and Young Adults with Cancer

Adolescents and young adults facing cancer make up a unique and specialized population of cancer patients. Adolescence and young adulthood are critical periods of development in the search for meaning, purpose, and identity. As adolescents and young adults battle cancer, they may face developmental challenges and barriers to finding meaning and a coherent sense of identity due to life disruption from their diagnosis and course of treatment. The adaptation of MCP for the adolescent and young adult population accounts for these unique developmental tasks and may provide relief to the existential distress experienced by these patients. Content derived from qualitative semi-structured interviews with adolescents and young adults focusing on identity, meaning, and purpose is being used to adapt MCP for the adolescent and young adult population.

MCGP in Cancer Survivors (MCGP-CS )

Research has shown that meaning-focused coping may be a helpful tool in effectively adjusting to cancer; patients who experience their lives as meaningful report better adjustment to the cancer experience, better quality of life, and better overall psychological functioning (Park, Edomondson, Fenster, & Blank, 2008; Tomich & Helgeson, 2002). Based on our research in advanced cancer, a research group in the Netherlands worked to adapt meaning-centered group psychotherapy to address the needs of individuals struggling to adjust to life after cancer (Van der Spek et al., 2014). Results from the most recent feasibility study indicate that MCGP-CS is feasible, patients were highly compliant, and patients reported satisfaction following the intervention (Van der Spek et al., 2014). Further evaluation is underway to establish the effectiveness of MCGP-CS in a larger randomized controlled clinical trial.

Key Takeaways

  • Meaning-centered psychotherapy was developed when meaning was first identified by our research group and others as a central tool in diminishing psychosocial distress and despair at the end of life.

  • MCP is based on Viktor Frankl’s logotherapy and was developed to help patients with advanced cancer to sustain or enhance a sense of meaning, peace, and purpose in their lives even as they approach the end of life (Breitbart, 2002; Breitbart et al., 2004; Greenstein & Breitbart, 2000).

  • MCP is based on a theoretical model in which the enhancement of meaning results in improved quality of life and reduced distress, despair , and suffering.

  • MCP has shown to be a highly effective intervention for existential distress among cancer patients, specifically improving quality of life and spiritual well-being, while diminishing depression, hopelessness, and the desire for hastened death (Breitbart et al., 2010, 2015).

  • The core principles that have contributed to its success in treating advanced cancer patients have been utilized and built upon to generate solutions for a wider population, including cancer survivors, young adults, caregivers, and bereaved parents.