Meaning-Centered Group Psychotherapy for Patients with Advanced Cancer

It is estimated that cancer claims the lives of nearly 600,000 men and women each year in the United States. In the time prior to death, patients experience end-of-life challenges such as physical and psychological distress, spiritual issues, concerns about carrying out everyday tasks, and grief over leaving family and other loved ones behind. Patients may think of themselves as spiritual and/or religious and may depend on spiritual and/or religious beliefs to help them cope with their distress. Spiritual and religious beliefs and practices vary based on the patient and his or her individual needs. Interventions are needed to help patients with advanced cancer find meaning in their lives, improve their spiritual well-being, and reduce emotional and physical distress. 

Meaning-Centered Group Psychotherapy (MCGP) aims to help terminally ill patients with advanced cancer enhance meaning in their lives. MCGP was developed to assist terminally ill cancer patients who are experiencing hopelessness, despair, and a desire for hastened death due to their prognosis. MCGP is influenced by the work of psychiatrist Viktor Frankl and logotherapy, which posits that human beings are motivated by searching for meaning in their lives. The intervention integrates Frankl's concepts of meaning with fundamental existential concepts and a focus on connecting and finding meaning in human existence. The concepts of meaning developed by Frankl and adapted for MCGP include meaning of life (i.e., life always has meaning, even when we are disconnected from it), will to meaning (i.e., we innately seek and create meaning in our lives), freedom of will (i.e., we have the freedom and responsibility to discover meaning, direction, and identity), and sources of meaning (i.e., we derive meaning from four main sources―creativity, experience, attitude, and legacy).

The manualized intervention is delivered to a group of 8-10 participants by 2 clinicians. The themes covered in the sessions include concepts and sources of meaning; cancer meaning; sources of meaning focused on the past; sources of meaning focused on the present and future; encountering life's limitations; creativity and responsibility; experiential sources of meaning in nature, art, and humor; and intervention termination (goodbyes and hopes for the future). Each of eight weekly 90-minute sessions includes a participant check-in, an introduction to the session topic, an exercise that engages patients in active group discussions, and a wrap-up exercise reflecting on the session theme. Participants are given homework assignments in preparation for subsequent sessions.  

Clinicians must be master's-level psychologists or social workers with a background in psycho-oncology and participate in the training workshops from the MCGP team at the Memorial Sloan-Kettering Cancer Center. Each trainee conducts a session while a trainer completes a treatment adherence form to measure the clinician's ability to facilitate the intervention with fidelity.

-- 90 minutes for each of eight weekly sessions

-- 3-4 hours for clinician training, which includes reviewing the treatment manual, listening to cases, and role-playing cases

-- 90 minutes for the trainee to conduct a session and the trainer to complete the treatment adherence coding sheet

-- 60 minutes for weekly ongoing supervision

The intervention targets adults with advanced cancer.

The intervention is implemented in clinical settings.

Required resources to implement the program include the following:
-- Meaning-Centered Group Psychotherapy (MCGP) for Patients With Advanced Cancer Treatment Manual
-- MCGP Independent Rater-Treatment Integrity Coding Form
-- Treatment Adherence Coding Manual for MCGP

For costs associated with this program, please contact the developer, William Breitbart. (See products page on the EBCCP website for developer contact information.)

MCGP was evaluated in a randomized controlled trial at the Memorial Sloan-Kettering Cancer Center between August 2007 and May 2012 with patients who had advanced cancer. Study participants were recruited through flyers posted in waiting areas throughout the Cancer Center, a review of medical records, and referrals from doctors. Patient eligibility requirements included being diagnosed with stage IV cancer (or stage III cancer if diagnosed with a poor-prognosis disease), able to speak English, aged age 18 and over, and ambulatory. Exclusion criteria were significant cognitive impairment or psychotic symptoms based on clinician assessment or physical limitations that would limit participation in an outpatient group-based intervention.

Patients were randomized to MCGP or to Supportive Group Psychotherapy (SGP). Like MCGP, SGP is a manualized intervention delivered in eight weekly sessions to patients with advanced cancer. It helps patients cope by encouraging them to share concerns related to their diagnosis and treatment, describe experiences and emotions related to cancer, identify challenges they face, and offer support and advice to one another. Clustered randomization was used to assign 253 patients to either MCGP (n=132) or SGP (n=121). Groups of 8-10 participants were formed and then randomly assigned to either MCGP or SGP, with each set of 8 groups containing 4 MCGP and 4 SGP groups.

MCGP sessions were led by a psychiatrist, clinical psychologist, or social worker with experience treating patients with advanced cancer and co-facilitated by either a second clinician or clinical psychology doctoral student. SGP sessions were facilitated by a clinical psychologist or social worker along with a co-therapist. Clinicians leading both MCGP and SGP groups were trained in the respective approaches and received weekly supervision. In addition, sessions were audio-recorded and coded by two independent reviewers to measure adherence to the manualized format.

Females represented 69.6% of study participants, and males represented 30.4%. The sample ranged in age from 27 to 91 years with a mean age of 58.2 years. The sample was White (69.0%), African American (13.9%), Hispanic (10.3%), and other (6.7%).

The primary outcomes were spiritual well-being and quality of life, and the secondary outcomes were depression, desire for hastened death, hopelessness, physical symptoms of distress, and anxiety. Participants completed self-report questionnaires to measure primary and secondary outcomes before participating in the group intervention, after the last group session, and 2 months after completion of treatment. Outcomes were measured using the following instruments:

-- Spiritual well-being: Functional Assessment of Chronic Illness Therapy Spiritual Well-Being Scale
-- Quality of life: McGill Quality of Life Questionnaire
-- Depression: Beck Depression Inventory
-- Desire for hastened death: Schedule of Attitudes Toward Hastened Death
-- Hopelessness: Hopelessness Assessment in Illness Questionnaire
-- Physical symptoms of distress: Memorial Symptom Assessment Scale Global Distress Index
-- Anxiety: Anxiety subscale of the Hospital Anxiety and Depression Scale

Treatment effects were evaluated across all three time points for participants who attended at least three group sessions (either MCGP or SGP).

• Among study participants attending three or more sessions, those receiving MCGP showed significantly greater increases in spiritual well-being compared with those receiving SGP (p<.05).

• Among study participants attending three or more sessions, those receiving MCGP showed significantly greater increases in quality of life compared with those receiving SGP (p<.05)

• Among study participants attending three or more sessions, those receiving MCGP showed significantly greater decreases in depression compared with those receiving SGP (p<.05).

• Among study participants attending three or more sessions, those receiving MCGP showed significant decreases in desire for hastened death compared with those receiving SGP (p<.05).

• Among study participants attending three or more sessions, those receiving MCGP showed significant decreases in hopelessness compared with those receiving SGP (p<.05).

• Among study participants attending three or more sessions, those receiving MCGP showed significantly greater decreases in physical symptoms of distress compared with those receiving SGP (p<.05).