The recent publication of the results of our National Cancer Institute (NCI) RO1-funded randomized controlled trial of meaning-centered group psychotherapy for advanced cancer patients in the Journal of Clinical Oncology,¹ and the accompanying summary published in this issue of The ASCO Post, represent the culmination of many years of effort.

This clinical research effort was born out of clinical experience with thousands of patients with advanced cancer, who taught us the importance of sustaining meaning to maintain the courage and will to live life, even in the face of death. These patients taught us that experiencing meaningful moments could be accompanied by the emotion of joy, which made it possible to better tolerate suffering and uncertainty. This recent trial of meaning-centered group psychotherapy in fact demonstrates the power of sustaining meaning in the amelioration of suffering and despair.

Importance of Meaning in End-of-Life Care

Our research group at Memorial Sloan Kettering Cancer Center has conducted a series of studies examining the importance of meaning and spiritual well-being in end-of-life care.^2-4 We demonstrated a central role for spiritual well-being, and, in particular, meaning, as a buffering agent, protecting against depression, hopelessness, and desire for hastened death among terminally ill cancer patients.

We also found that spiritual well-being was significantly associated with end-of-life despair (as defined by hopelessness, desire for hastened death, and suicidal ideation), even after controlling for the influence of depression. Moreover, when spiritual well-being was divided into two components—one measuring a sense of meaning and another measuring spirituality linked to religious faith—the inability to maintain a sense of meaning was much more strongly associated with end-of-life despair than was the faith component of spiritual well-being. That is, the ability to sustain a sense of meaning was associated with lower levels of hopelessness, desire for hastened death, and suicidal ideation.

These findings are significant in the face of what we have come to learn about the consequences of depression and hopelessness in cancer patients. Depression and hopelessness are associated with dramatically higher rates of suicide, suicidal ideation, and desire for hastened death and interest in physician-assisted suicide.^2,5 Our findings² demonstrate that hopelessness is an independent and synergistic predictor of desire for death that is as powerful an influence on desire for death as (and independent of) depression.

Meaning-Centered Psychotherapy for Advanced Cancer Patients

The importance of spiritual well-being and the role of “meaning” in particular in moderating depression, hopelessness, and desire for death in terminally ill cancer and AIDS patients demonstrated by our research group led us to look beyond the role of antidepressant treatment for depression in this population. We chose to focus new efforts on developing nonpharmacologic (psychotherapeutic) interventions that can address such issues as hopelessness, loss of meaning, and spiritual well-being in patients with advanced cancer at the end of life.

This effort led to an exploration and analysis of the work of Viktor Frankl and his concepts of “logotherapy” or meaning-based psychotherapy.^6,7 While Dr. Frankl’s logotherapy was not designed for the treatment of cancer patients or those with life-threatening illness, his concepts of meaning and spirituality clearly, in our view, had applications in psychotherapeutic work with advanced cancer patients.

Dr. Frankl’s main contributions to human psychology have been to raise awareness of the spiritual component of human experience and the central importance of meaning (or the will to meaning) as a driving force or instinct in human psychology. His basic concepts include the following ideas:

• Life has meaning and never ceases to have meaning even up to the last moment of life; meaning may change in this context, but it never ceases to exist.
• The desire to find meaning in human existence is a primary instinct and basic motivation for human behavior.
• We have the freedom to find meaning in existence and to choose the attitude toward suffering.
• The three main sources of meaning in life are creativity (work, deeds, dedication to causes), experience (art, nature, humor, love, relationships, roles), and attitude (the attitude one takes toward suffering and existential problems).
• Meaning exists in a historical context—thus, legacy (past, present, and future) is a critical element in sustaining or enhancing meaning.

The novel intervention we developed and call “meaning-centered psychotherapy” is based on the concepts described above and the principles of Dr. Frankl’s logotherapy. It is designed 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.^8-10

We initially conducted a pilot randomized trial of an 8-week (1½-hour weekly sessions) meaning-centered group psychotherapy intervention, based on the concepts of meaning as elucidated by Viktor Frankl, which utilized a highly developed treatment manual incorporating a mixture of didactics, discussion, and experiential exercises that focus on particular themes related to meaning and advanced cancer. Our findings^1,12 demonstrate that meaning-centered group psychotherapy is a highly effective intervention, increasing a sense of meaning, spiritual well-being, and hope, while decreasing end-of-life despair.

That said, during the course of the meaning-centered group psychotherapy clinical trial, it became quite obvious to us that the group format for psychotherapy interventions in patients with advanced cancer near the end of life posed limitations. We therefore developed and tested, in a pilot randomized controlled trial, an individual format of meaning-centered psychotherapy, which proved highly effective.¹³

Goals of Psychotherapy in Palliative Care

The nature and scope of the clinical goals of psychotherapeutic or counseling interventions in the palliative care setting have been evolving. Most psychotherapists and counselors would agree that, until recently, there were two basic constructs that were universally accepted as the basis of the counseling intervention with a dying patient: support and nonabandonment.

In essence, supportive counseling allies with a patient’s defenses and coping strategies, supporting or reinforcing them. For example, the patient who is dying and is using denial in the face of the proximity of death would be supported by the therapist in this way of coping. We all find ourselves allying with hopes, even unrealistic ones, expressed by patients and families in the dying process. However, experienced clinicians also create possibilities for patients to discuss death and dying by gentle questioning.

Nonabandonment or presence is a second basic principle of counseling the terminally ill. The therapist makes a commitment to escort or accompany the patient through the course of treatment and the dying process. There is power in the presence of the therapist in accompanying the patient on this too-often lonely path. The question many of us have asked in recent years is “Can we accomplish something more ambitious in psychotherapy with the terminally ill?”

The “more ambitious” goal of psychotherapy with the terminally ill is to help patients come to a sense of acceptance of a life lived and, ultimately, an acceptance of death (ie, being able to face death with a sense of peace and equanimity). Many suggest such a goal of care is not achievable by all and perhaps inappropriate for many. I would suggest that tasks of life completion are achievable and essential at this phase of life. Acknowledging or facing death (ie, the finiteness of life) is the impetus for transformation. Facing death forces us to turn around and face life—the life one has lived.

When one examines the life one has lived and struggles to accept that lived life, one is faced with a number of challenges and tasks of dying. Facing death can enhance the process of pursuing a sense of coherence, meaning, and completion of one’s life. It allows for realization that the last chapter of one’s life is the last opportunity to live to one’s full potential, to leave behind an authentic legacy, to connect with the beyond, and to transcend life as we know it.

The goal is to preserve the idea that there is still life to be lived—still time to become—so that one can die with a sense of peace, equanimity, and acceptance of the life one lived. The paradox of the end-of-life dynamic is that through acceptance of the life one has lived comes acceptance of death. The lessons of the dying can inform the living of the value of life. Perhaps we die so that we can appreciate the importance of living. ■

Disclosure: Dr. Breitbart reported no potential conflicts of interest.

References

1. Breitbart W, Rosenfeld B, Pessin H, et al: Meaning-centered group psychotherapy: An effective intervention for reducing despair in patients with advanced cancer. J Clin Oncol 33:749-754, 2015.

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

3. Nelson C, Rosenfeld B, Breitbart W, et al: Spirituality, depression and religion in the terminally ill. Psychosomatics 43:213-220, 2002.

4. McClain C, Rosenfeld B, Breitbart W: The influence of spirituality on end-of-life despair among terminally ill cancer patients. Lancet 361:1603-1607, 2003.

5. Breitbart W, Rosenfeld B: Physician-assisted suicide: The influence of psychosocial issues. Cancer Control 6:146-161, 1999.

6. Frankl VF: Man’s Search for Meaning, 4th ed. New York, Simon &
Schuster, 1959.

7. Frankl VF: The Will to Meaning, 2nd ed. New York, Penguin Books, 1969.

8. Greenstein M, Breitbart W: Cancer and the experience of meaning: A group psychotherapy program for people with cancer. Am J Psychother 54:486-500, 2000.

9. Breitbart W: Spirituality and meaning in supportive care: Spirituality- and meaning-centered group psychotherapy interventions in advanced cancer. Support Care Cancer 10:272-280, 2002.

10. 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.

11. 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.

12. 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.