Wendy G. Lichtenthal, PhD, FT
A large body of research has shed light on how the cancer experience and related losses often leave patients and their families struggling to find a sense of meaning in their lives.1-7 The COVID-19 pandemic has amplified these difficulties, as meaningful activities and experiences have been compromised by social distancing, travel restrictions, business closures, and financial hardship. Such challenges to one’s sense of meaning in life have been associated with negative psychosocial outcomes in a variety of populations.3,8-11 It follows that addressing meaning-related challenges may help individuals adjust to the distressing circumstances they face.
Breitbart et al12-17 set out to do just this, developing meaning-centered psychotherapy to enhance meaning and purpose in patients with advanced cancer.18-20 Meaning-centered psychotherapy is a brief, manualized intervention that uses a combination of didactics, experiential exercises, and guided discussion in each session, capitalizing on its time-limited format to inspire change. A seven-session individual format and an eight-session group format have demonstrated efficacy in improving patients’ sense of meaning and quality of life.12-17
Meaning-centered psychotherapy draws from the work of Frankl21 and Yalom22 and is founded on several core concepts: (1) Meaning in life can always be created or experienced; (2) Individuals have a natural will to search for and create meaning; (3) -Individuals have free will to choose their response-to-challenges attitude in the face of suffering; and (4) A sense of meaning in life can be derived from connecting to sources of meaning (eg, those activities, experiences, choices, and connections that are most important to an individual).12-17 Connecting to sources of meaning is especially valuable during times of suffering. Frankl21 referenced this Friedrich Nietzsche’s quote: “He who has a Why to live for can bear almost any How.” One goal of meaning-centered psychotherapy is to connect individuals to their “Whys”—their sources of meaning—despite the suffering they endure. It also explores the choices individuals make in the face of the limitations they experience, highlighting how, even in the most out-of-control circumstances, one faces one’s challenges is within one’s control.
Given the applicability of such concepts in many stressful life circumstances, we have adapted meaning-centered psychotherapy for other populations impacted by cancer, including cancer survivors23 and bereaved family members.24 These adaptations similarly help individuals recognize their ability to choose their attitude in the face of suffering, their ability to connect to sources of meaning in their lives, and their ability to choose how they construct meaning about different life events (including illness and loss).24 They can be considered cognitive-behavioral-existential interventions, using cognitive techniques to facilitate adaptive meaning-making, behavioral approaches to reduce avoidance, and existential concepts such as free will and choice to enact change.24
Examples of Meaning-Centered Psychotherapy Adaptations
Meaning-Centered Group Psychotherapy for Cancer Survivors (MCGP-CS): Patients who have completed active treatment of their disease often experience a heightened desire to live meaningfully and authentically, yet may feel “stuck,” struggling to make sense of their illness, reconcile changes to their sense of identity, and connect to meaningful aspects of their lives.5,7 MCGP-CS helps cancer survivors consider how they authentically want to live their lives moving forward, despite any fears and treatment-related side effects with which they may be living.23,25 It uses an eight-session group format to reduce the sense of isolation and loneliness that survivors often report.15
In a pilot study we conducted in collaboration with the American Cancer Society, we found that breast cancer survivors with higher levels of distress who participated in MCGP-CS reported a greater sense of meaning compared with those in a standardized support group.23 A Dutch version of MCGP-CS has also shown great promise, resulting in increases in meaning, adjustment to cancer, and psychological well-being when compared with a support group and standard care in an efficacy trial.23,26,27
Integrative Oncology is guest edited by Jun J. Mao, MD, MSCE, Laurance S. Rockefeller Chair in Integrative Medicine and Chief of Integrative Medicine Service at Memorial Sloan Kettering Cancer Center, New York.
Guest Editor’s Note: Many patients with cancer and survivors face psychological distress associated with treatment-related side effects, loss of control over one’s life, and fear of cancer recurrence. Despite the desire to live meaningfully, many struggle to reconcile with the illness and changes to their sense of identity. In this article, Dr. Lichtenthal describes the benefits of meaning-centered psychotherapy to reinforce meaning and purpose in the lives of patients with cancer and cancer survivors. Meaning-centered therapy can also help this population cope with the fear, loss, and isolation caused by the COVID-19 pandemic.
Meaning-Centered Grief Therapy: Meaning-centered grief therapy was initially developed for parents bereaved by cancer who commonly face profound difficulty finding meaning in their lives and in the untimely loss of their child.28-30 Such challenges have been associated with prolonged grief, depression, and anxiety.28,29,31-36
Meaning-centered grief therapy offers a palatable, nonpathologizing approach, systemically exploring different facets of meaning that have been associated with negative outcomes in bereavement, over 16 one-on-one sessions.24,30,37 It facilitates adaptive sense-making of the loss, helping individuals author their and the deceased’s stories while addressing regrets and anger by highlighting individuals’ ability to self-compassionately choose helpful perspectives and narratives. It helps parents connect to sources of meaning in their lives, such as valued experiences, activities, and relationships (including their precious connection to their child)38-40 to help them coexist with their grief. Pilot studies of meaning-centered grief therapy for parents bereaved by cancer have suggested it improves their sense of meaning in life, prolonged grief, depression, and anxiety.24
Applying Meaning-Centered Concepts During Challenging Times
A meaning-centered approach may be helpful for patients struggling with many types of adversity and situations that feel beyond their control. The COVID-19 pandemic has presented such circumstances, limiting individuals’ access to sources of meaning that could otherwise help them cope with their fear, loss, and isolation. Meaning-centered psychotherapy empowers patients to focus on the choices they have in the face of such limitations and to brainstorm about how to creatively adopt meaningful activities and experiences to sustain their well-being.41
Meaning-centered psychotherapy has been designated an National Cancer Institute (NCI) Research-Tested Intervention Program, and efforts to establish an evidence base for its adaptations, some of which have been delivered via telehealth,24,25 are underway.12 These efforts include attempts to adapt meaning-centered psychotherapy for cancer caregivers,42 patients in hospice,43 and different cultural groups.12
Oncology clinicians may consider referring patients and their family members to meaning-centered psychotherapy and its adaptations when they appear to struggle to find meaning in their lives, their illness, and the experience of loss.12 Efforts to train clinicians in meaning-centered psychotherapy are being made through an NCI-funded training program. Future research may consider examining the integration of meaning-centered interventions with other evidence-based approaches such as mindfulness meditation44 to help reduce the suffering of patients and their families, from diagnosis through bereavement.
This research has been supported by the National Cancer Institute (R01 CA128187, R01 CA128134, R25 CA190169, R03 CA139944, K07 CA172216, T32 CA009461, P30 CA008748); National Institute of Nursing Research (R21 AT01031); The Fetzer Institute; the Kohlberg Foundation; the American Cancer Society; and the Isabel, Harold, and Gerry Feld Fund for Bereavement.
DISCLOSURE: Dr. Lichtenthal reported no conflicts of interest.
1. Kaiser K: The meaning of the survivor identity for women with breast cancer. Soc Sci Med 67:79-87, 2008.
2. Degner LF, Hack T, O’Neil J, et al: A new approach to eliciting meaning in the context of breast cancer. Cancer Nurs 26:169-178, 2003.
3. Park CL, Edmondson D, Fenster JR, et al: Meaning making and psychological adjustment following cancer: The mediating roles of growth, life meaning, and restored just-world beliefs. J Consult Clin Psychol 76:863-875, 2008.
4. Rosedale M: Survivor loneliness of women following breast cancer. Oncol Nurs Forum 36:175-183, 2009.
5. Park CL, Zlateva I, Blank TO: Self-identity after cancer: ‘Survivor,’ ‘victim,’ ‘patient,’ and ‘person with cancer.’ J Gen Intern Med 24(suppl 2):S430-S435, 2009.
6. Hodgkinson K, Butow P, Hunt GE, et al: Breast cancer survivors’ supportive care needs 2-10 years after diagnosis. Support Care Cancer 15:515-523, 2007.
7. Carpenter JS, Brockopp DY, Andrykowski MA: Self-transformation as a factor in the self-esteem and well-being of breast cancer survivors. J Adv Nurs 29:1402-1411, 1999.
8. Simonelli LE, Fowler J, Maxwell GL, et al: Physical sequelae and depressive symptoms in gynecologic cancer survivors: Meaning in life as a mediator. Ann Behav Med 35:275-284, 2008.
9. Salsman JM, Yost KJ, West DW, et al: Spiritual well-being and health-related quality of life in colorectal cancer: A multi-site examination of the role of personal meaning. Support Care Cancer 19:757-764, 2011.
10. Carver CS, Antoni MH: Finding benefit in breast cancer during the year after diagnosis predicts better adjustment 5 to 8 years after diagnosis. Health Psychol 23:595-598, 2004.
11. Tomich PL, Helgeson VS: Five years later: A cross-sectional comparison of breast cancer survivors with healthy women. Psychooncology 11:154-169, 2002.
12. Breitbart W: Meaning-Centered Psychotherapy in the Cancer Setting: Finding Meaning and Hope in the Face of Suffering. New York; Oxford University Press; 2017.
13. 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 30:1304-1309, 2012.
14. Breitbart W, Rosenfeld B, Gibson C, et al: Meaning-centered group psychotherapy for patients with advanced cancer: A pilot randomized controlled trial. Psychooncology 19:21-28, 2010.
15. 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 33:749-754, 2015.
16. Breitbart W, Poppito SR: Individual Meaning-Centered Psychotherapy for Patients with Advanced Cancer: A Treatment Manual. New York; Oxford University Press; 2014.
17. Breitbart W, Poppito SR: Meaning-Centered Group Psychotherapy for Patients With Advanced Cancer: ATreatment Manual. New York; Oxford University Press; 2014.
18. Breitbart W, Rosenfeld B, Pessin H, et al: Depression, hopelessness, and desire for hastened death in terminally ill patients with cancer. JAMA 284:2907-2911, 2000.
19. Nelson CJ, Rosenfeld B, Breitbart W, et al: Spirituality, religion, and depression in the terminally ill. Psychosomatics 43:213-220, 2002.
20. Breitbart W, Gibson C, Poppito SR, et al: Psychotherapeutic interventions at the end of life: A focus on meaning and spirituality. Can J Psychiatry 49:366-372, 2004.
21. Frankl VE: Man’s Search for Meaning (ed Revised). New York; Washington Square Press; 1984.
22. Yalom ID: Existential Psychotherapy. New York; Basic Books; 1980.
23. van der Spek N, Lichtenthal WG, Holtmaat K, et al: Meaning-centered group psychotherapy for cancer survivors, in Holland J, Breitbart W, Butow P, et al (eds): Psycho-Oncology. New York; Oxford University Press; in press.
24. Lichtenthal WG, Catarozoli C, Masterson M, et al: An open trial of meaning-centered grief therapy: Rationale and preliminary evaluation. Palliat Support Care 17:2-12, 2019.
25. Lichtenthal W, Roberts K, Jankauskaite G, et al: Meaning-centered group psychotherapy for breast cancer survivors, in Breitbart W (ed): Meaning-Centered Psychotherapy in the Cancer Setting, pp 54-66. New York; Oxford University Press; 2017.
26. van der Spek N, van Uden-Kraan CF, Vos J, et al: Meaning-centered group psychotherapy in cancer survivors: A feasibility study. Psychooncology 23:827-831, 2014.
27. van der Spek N, Vos J, van Uden-Kraan CF, et al: Efficacy of meaning-centered group psychotherapy for cancer survivors: A randomized controlled trial. Psychol Med 47:1990-2001, 2017.
28. Lichtenthal WG, Currier JM, Neimeyer RA, et al: Sense and significance: A mixed methods examination of meaning making after the loss of one’s child. J Clin Psychol 66:791-812, 2010.
29. Wheeler I: Parental bereavement: The crisis of meaning. Death Stud 25:51-66, 2001.
30. Lichtenthal WG, Breitbart W: The central role of meaning in adjustment to the loss of a child to cancer: Implications for the development of meaning-centered grief therapy. Curr Opin Support Palliat Care 9:46-51, 2015.
31. Davis CG, Wortman CB, Lehman DR, et al: Searching for meaning in loss: Are clinical assumptions correct. Death Stud 24:497-540, 2000.
32. MacKinnon CJ, Smith NG, Henry M, et al: Meaning-based group counseling for bereavement: Bridging theory with emerging trends in intervention research. Death Stud 38:137-144, 2014.
33. Barrera M, D’Agostino NM, Schneiderman G, et al: Patterns of parental bereavement following the loss of a child and related factors. Omega (Westport) 55:145-167, 2007.
34. O’Connor K, Barrera M: Changes in parental self-identity following the death of a child to cancer. Death Stud 38:404-411, 2014.
35. Park CL: Making sense of the meaning literature: An integrative review of meaning making and its effects on adjustment to stressful life events. Psychol Bull 136:257-301, 2010.
36. Papa A, Lancaster NG, Kahler J: Commonalities in grief responding across bereavement and non-bereavement losses. J Affect Disord 161:136-143, 2014.
37. Lichtenthal WG, Lacey S, Roberts K, et al: Meaning-centered grief therapy, in Breitbart WS (ed): Meaning-Centered Psychotherapy in the Cancer Setting, pp 88-99. New York; Oxford University Press; 2017.
38. Scholtes D, Browne M: Internalized and externalized continuing bonds in bereaved parents: Their relationship with grief intensity and personal growth. Death Stud 39:75-83, 2015.
39. Ronen R, Packman W, Field N, et al: The relationship between grief adjustment and continuing bonds for parents who have lost a child. Omega: J Death Dying 60:1-31, 2010.
40. Field NP, Filanosky C: Continuing bonds, risk factors for complicated grief, and adjustment to bereavement. Death Stud 34:1-29, 2010.
41. Lichtenthal WG, Roberts KE, Pessin H, et al: Meaning-centered psychotherapy and cancer: Finding meaning in the face of suffering. Psychiatric Times 37:23-25, 2020.
42. Applebaum AJ, Kulikowski JR, Breitbart W: Meaning-centered psychotherapy for cancer caregivers: Rationale and overview. Palliat Support Care 13:1631-1641, 2015.
43. Rosenfeld B, Saracino R, Tobias K, et al: Adapting meaning-centered psychotherapy for the palliative care setting: Results of a pilot study. Palliat Med 31:140-146, 2017.
44. Duncan M, Moschopoulou E, Herrington E, et al: Review of systematic reviews of non-pharmacological interventions to improve quality of life in cancer survivors. BMJ Open 7:e015860, 2017.
Dr. Lichtenthal is Associate Attending in the Department of -Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York.