Finding Meaning in the Face of Suffering

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SPECIAL REPORT: PSYCHO-ONCOLOGY, PART II

Meaning-Centered Psychotherapy and Cancer

Cancer can lead to suffering in many forms: physical, emotional, spiritual, and existential. It limits patients’ ability to plan for the future and, too often, their lives. How can we help patients cope with their suffering and existential distress in the face of such challenges? Meaning-Centered Psychotherapy (MCP) may have something to offer. MCP is a brief, structured, manualized intervention that organizes and distills existential concepts so that they are more accessible and relevant to patients’ lives. Born out of research demonstrating that meaning can serve as a buffer against the depression and hopelessness that many patients with metastatic disease report, Breitbart and colleagues developed MCP to help enhance patients’ sense of meaning and purpose in the face of advanced cancer.^1-7

Theoretical framework underlying MCP

Inspired by the work of Viktor Frankl, MD, PhD,⁸ on logotherapy and the work of Irvin Yalom, MD,⁹ specific concepts highlighted in MCP include:

Meaning of life: There is always the possibility of creating or experiencing meaning, even in the last moments of life. The feeling that “life is meaningless” therefore reflects a disconnection from what gives our lives meaning.

Will to find meaning: The desire to find meaning in our existence is a primary motivating force in human behavior that drives us to search for and create meaning throughout our lives.

Freedom of will: We have the freedom to choose how to think about and respond to what comes our way, including limitations, challenges, losses, and uncertainty. This is a core concept in MCP, as the ability to choose our attitude toward suffering is something we always have control over, even in the worst of circumstances.

Sources of meaning: A sense of meaning can be derived from connecting to sources of meaning, including those described in MCP as historical, attitudinal, creative, and experiential (see Table for details).

Table. Meaning-Centered Psychotherapy Sessions

Guided by structured questions in each session, MCP helps patients systematically reflect on what matters most to them and how sources of meaning can be accessed during challenging times. If a given source of meaning is not accessible, because of physical limitations or concerns about contracting COVID-19, for example, MCP therapists brainstorm with patients about how to tap into the meaningful aspects of these activities or experiences in adapted forms. Therapists repeatedly highlight sources of meaning in the patient’s life that can be used as resources to buoy the patient during difficult moments.

This is the sentiment behind Nietzsche’s quote, “He who has a Why to live for can bear almost any How” that Frankl often referenced. In essence, MCP helps patients connect to their “Whys”—that is, their reasons for living—despite the suffering they endure. Frankl viewed suffering as a potential springboard for seeking and finding meaning. Patients’ drive to make sense of the challenges they face may lead to growth and identification of positive sequelae that can emerge as a byproduct of their adversity.

However, therapists should be clear that MCP is not a prescription for turning lemons into lemonade; instead it provides an opportunity to reflect on patients’ free will, highlighting adaptive perspectives as a choice in attitude. Therapists guide the development of a coherent narrative about how meaning and values influenced past choices, which can help address regrets. The enhanced sense of meaning resulting from such processes can improve patients’ quality of life and reduce distress.

Research demonstrating the efficacy of MCP

MCP has demonstrated efficacy in enhancing meaning in the lives of patients with advanced cancer in several large-scale trials and has been designated a National Cancer Institute Research-Tested Intervention Program. In 2 randomized controlled trials (RCTs) with patients who had advanced cancer, Meaning-Centered Group Psychotherapy (MCGP; an 8-session version of MCP) demonstrated efficacy over supportive group psychotherapy in improving spiritual well-being, quality of life, and sense of meaning, as well as decreasing anxiety, hopelessness, and desire for hastened death.^6,7

While MCGP showed efficacy, challenges with attrition in groups prompted development of an individual format that would allow for more flexible scheduling for patients.¹⁰ Thus, the 7-session format of Individual Meaning-Centered Psychotherapy (IMCP) was developed.^5,11 In a pilot RCT comparing IMCP to therapeutic massage, participants receiving IMCP experienced significantly greater improvement in spiritual well-being, symptom burden, and distress.5 There was also less attrition compared with MCGP trials. A larger- scale RCT of IMCP demonstrated its superior efficacy in improving quality of life and sense of meaning compared with Supportive Psychotherapy and Enhanced Usual Care (see Figure).¹¹ IMCP also resulted in greater reductions in anxiety and desire for hastened death than Enhanced Usual Care. These studies provide strong support for the efficacy of both MCGP and IMCP in treating psychological and existential distress among patients with advanced cancer.

Figure. Changes in Sense of Meaning in Life Over Time

Clinical applications

MCP should be delivered in the context of a supportive therapeutic relationship; an exploration of how to find meaning in suffering can only work effectively when the therapist acknowledges, supports, and validates the patient’s suffering. The structured nature of MCP, which includes a combination of didactics, experiential exercises, and guided discussion, enables the deep exploration of powerful concepts in a short period of time (Table; MCP treatment manuals^4,12,13). MCP capitalizes on its time-limited format to propel patients to engage with emotionally provocative topics and take steps toward addressing unfinished business. MCP concludes with a Legacy Project to encourage patients to connect to sources of meaning and actively engage in something they have wanted to do but have not yet done.

Each MCP session introduces key existential concepts followed by an experiential exercise to help patients apply these concepts to their lives. Patients are encouraged to reflect on the exercise before the session, in writing if possible. Ultimately, the goal is for the sources of meaning identified to serve as coping resources that patients can continue to draw upon after therapy has concluded. Patients’ ability to shift from one source of meaning to another is emphasized, as some sources may become less available due to disease progression. Therapists support the concept of moving from ways of doing to ways of being to assist patients to recognize that meaning can also be derived more passively.

Additional existential concepts, including responsibility, transformation, authenticity, and existential guilt are also woven throughout the treatment. Therapists assist to detoxify death by speaking openly about it as the ultimate limitation in life, which is directly discussed in the session on attitudinal sources of meaning. They may challenge a patient’s resistance to exploring difficult existential realities, such as death or existential guilt, by using a gentle “existential nudge” to encourage reflection. In addition to facilitating the exploration of sources of meaning and existential concepts, the therapist plays a powerful role in enhancing the impact of MCP by witnessing the patient’s suffering, unique legacy, identity, and sense of meaning. Thus, the therapist becomes another figure through which patients can experience meaningful connection and share their “living legacy.” Therapists are encouraged to offer genuine reflections throughout MCP about patients’ meaningful impact on them, which can be particularly powerful for socially isolated patients.

Because MCP focuses on the universal struggles with existential distress in illness, it is not linked to a specific psychiatric diagnosis. MCP is not designed to treat acute psychiatric symptoms (eg, severe depression); therapists should refer patients to first-line stabilizing treatment (eg, medication) prior to attempting MCP. Patients with sufficient physical or cognitive limitations (eg, advanced dementia) to preclude participation in psychotherapy are not suited for this intervention. In research, MCP has demonstrated particular efficacy in improving outcomes in patients with moderate to severe distress (scoring 4 or higher on the Distress Thermometer).¹⁴

The individual and group formats of MCP are nearly identical in content but differ in length. MCGP has 8 sessions, providing additional time to focus on the historical sources of meaning, which involves patients sharing about their past, present, and future legacy. In MCGP, group members each share responses to the experiential exercises and commonalities are emphasized. Group facilitators acknowledge the “co-creation of meaning” between themselves and group members; everyone present becomes witnesses, or repositories of meaning, for each other, and thus are part of a meaningful legacy created within the group.

In facilitating MCGP groups, the basic tenets of group processes remain important.¹⁵ Facilitators should intentionally honor each member’s unique values. IMCP is structured similarly yet affords more flexibility and the opportunity to deepen the meaning-centered work with fewer time constraints. Ideally patients should attend all sessions to get the maximum benefit, as there is a logical progression of content. However, in-person attendance is not necessary as MCP has been successfully delivered via telehealth.^16,17

Case Vignette

“Dr Smith” was a 40-year-old, married physician with one child who began MCP shortly after he received a diagnosis of advanced pancreatic cancer. Although skeptical of how meaning could help him, Dr Smith was hoping for relief from the overwhelming distress he was experiencing about his diagnosis. He was particularly upset by changes in his ability to work as a physician and fulfill responsibilities to his wife, children, and aging parents.

During Session 2, Identity Before and After Cancer, it became clear that being suddenly thrust into the patient role threatened Dr Smith’s sense of identity as someone who provides care for others and strives for perfection. While Dr Smith acknowledged gaining a greater understanding of the existential nature of his distress through discussion, he expressed frustration that there was no way to “fix” this suffering.

In Session 3, Historical Sources of Meaning, the concept of legacy proved to be the key to shifting the meaning Dr Smith made of his current struggles. He realized the distress around perceived changes to his identity were connected to the legacy he was given, as he had been encouraged by his family to be perfect and “fix things.” He realized he could choose to respond differently to the legacy he was given, leading to changes in how he parented and allowing things to be imperfect and messy more often.

As sessions progressed, ways that Dr Smith creatively responded to the physical challenges he faced were identified, reinforcing the concepts of choice and courage in how he faced his predicament. This included the choice to engage in MCP despite his skepticism and to accept help from others, which became a meaningful lesson he wanted to model for his child. In his final session, Dr Smith expressed feeling more connected to the people who mattered most to him, recognizing new ways he could continue to share his legacy of responsibility and caregiving with those whose lives he touched personally and professionally.

Conclusions and future directions

Given its demonstrated efficacy, efforts are underway to disseminate MCP by training clinicians who work with cancer patients through a National Cancer Institute-funded training program. Additionally, many replication and adaptation studies are ongoing, including efforts to adapt MCP for cancer survivors, parents bereaved by cancer, cancer caregivers, and patients in hospice.^16-19 Cultural and linguistic adaptations have also been conducted.⁴

MCP may be especially helpful in working with patients struggling with adversity and situations that feel beyond their control. This may be more relevant than ever in context of the COVID-19 pandemic, which, in threatening lives and imposing limitations on access to sources of meaning, has increased existential distress for patients, caregivers, and health care providers. Patients living through the pandemic are facing isolation, restrictions on their freedom, personal losses, and even greater threats to their and their loved ones’ mortality than they have previously experienced.

MCP empowers patients to focus on the choices they have in the face of limitations, helping them to connect to what matters most. It reaffirms the idea that meaning is always possible. When we are feeling disconnected, MCP facilitates reconnection. Therapists from a variety of theoretical orientations may find it helpful to draw on MCP concepts to support individuals through these uncontrollable and extraordinary circumstances. In turn, we derive meaning from the uniquely reciprocal nature of MCP, in that, as we accompany patients in their exploration of meaning, we co-create meaningful connection and our own personal legacies.

Dr Lichtenthal is Assistant Attending Psychologist, Department of Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center, and Assistant Professor of Psychology, Department of Psychiatry, Weill Cornell Medicine; Dr Roberts is Postdoctoral Research Fellow, Department of Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center; Dr Pessin is Research Project Manager, Department of Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center; Dr Applebaum Assistant Attending Psychologist, Department of Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center, and Assistant Professor of Psychology, Department of Psychiatry, Weill Cornell Medicine; and Dr Breitbart is Chair, Department of Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center, and Professor of Clinical Psychiatry, Department of Psychiatry, Weill Cornell Medicine. The authors report no conflicts of interest concerning the subject matter of this article.

Acknowledgement—Research on MCP has been supported by the National Cancer Institute (R01 CA128187, R01 CA128134, R25 CA190169, T32 CA009461, P30 CA008748), the National Institute of Nursing Research (R21 AT01031), The Fetzer Institute, and the Kohlberg Foundation.

References

1. Breitbart W, Rosenfeld B, Pessin H, et al. Depression, hopelessness, and desire for hastened death in terminally ill patients with cancer. JAMA. 2000;284:2907-2911.

2. Nelson CJ, Rosenfeld B, Breitbart W, Galietta M. Spirituality, religion, and depression in the terminally ill. Psychosomatics. 2002;43:213-220.

3. Breitbart W, Gibson C, Poppito SR, Berg A. Psychotherapeutic interventions at the end of life: a focus on meaning and spirituality. Can J Psychiatry. 2004;49:366-372.

4. Breitbart W. Meaning-Centered Psychotherapy in the Cancer Setting: Finding Meaning and Hope in the Face of Suffering. New York, NY: Oxford University Press; 2017.

5. Breitbart W, Poppito S, Rosenfeld B, et al. Pilot randomized controlled trial of individual meaning-centered psychotherapy for patients with advanced cancer. J Clin Oncol. 2012;30:1304-1309.

6. Breitbart W, Rosenfeld B, Gibson C, et al. Meaning-centered group psychotherapy for patients with advanced cancer: a pilot randomized controlled trial. Psycho-Oncol. 2010;19:21-28.

7. Breitbart W, Rosenfeld B, Pessin H, et al. Meaning-centered group psychotherapy: an effective intervention for improving psychological well-being in patients with advanced cancer. J Clin Oncol. 2015;33:749-754.

8. Frankl VE. Man’s Search for Meaning. Revised ed. New York: Washington Square Press; 1959/1984.

9. Yalom ID. Existential Psychotherapy. New York, NY; Basic Books; 1980.

10. Applebaum AJ, Lichtenthal WG, Pessin HA, et al. Factors associated with attrition from a randomized controlled trial of meaning-centered group psychotherapy for patients with advanced cancer. Psycho-Oncol. 2012;21:1195-1204.

11. Breitbart W, Pessin H, Rosenfeld B, et al. Individual meaning-centered psychotherapy for the treatment of psychological and existential distress: a randomized controlled trial in patients with advanced cancer. Cancer. 2018;124:3231-3239.

12. Breitbart W, Poppito SR. Individual Meaning-Centered Psychotherapy for Patients With Advanced Cancer: A Treatment Manual. Oxford: Oxford University Press; 2014.

13. Breitbart W, Poppito SR. Meaning-Centered Group Psychotherapy for Patients With Advanced Cancer: A Treatment Manual. Oxford: Oxford University Press; 2014.

14. NCCN. Distress management: Clinical practice guidelines. J Natl Compr Canc Netw. 2003;1:344-374.

15. Yalom ID. The Theory and Practice of Group Psychotherapy. 4th ed. New York: Basic Books; 1995.

16. Lichtenthal W, Roberts K, Jankauskaite G, et al. Meaning-centered group psychotherapy for breast cancer survivors. Breitbart W, Ed. Meaning-Centered Psychotherapy in the Cancer Setting. New York, NY: Oxford University Press; 2017: 54-66.

17. Lichtenthal WG, Catarozoli C, Masterson M, et al. An open trial of Meaning-Centered Grief therapy: rationale and preliminary evaluation. Palliat Support Care. 2019;17:2-12.

18. Applebaum AJ, Kulikowski JR, Breitbart W. Meaning-centered psychotherapy for cancer caregivers (MCP-C): rationale and overview. Palliat Support Care. 2015;13:1631-1641.

19. Rosenfeld B, Saracino R, Tobias K, et al. Adapting Meaning-Centered Psychotherapy for the palliative care setting: results of a pilot study. Palliat Med. 2017;31:140-146.