2nd Sapporo Conference for
Palliative and Supportive in Cancer

Meaning-Centered Psychotherapyfor Cancer Patients
William Breitbart, M.D., Chairman
Jimmie C Holland, Chair in Psychiatric Oncology
Department of Psychiatry and Behavioral Sciences
Memorial Sloan-Kettering Cancer Center
New York, New York, USA
www.MSKCC.org

“Hope is the creation of an uncertain futurewith meaning.” – William Breitbart

The Concept of Despair at the End of Life

• Desire for hastened death• Suicidal ideation• Loss of meaning/spiritual well-being• Hopelessness• Loss of Dignity• Demoralization• Depression/Anxiety/Panic

The Unique Nature of Human Existence• Human Beings are Uniquely Aware of our Existence(awe-dread paradox, finiteness, responsibility, guilt , culture)• Meaning – Making is the Defining Characteristic of
Human Beings as a Species• Connection / Connectedness is Essential to HumanSurvival , and the Essence of the Human Experience(to each other, past ,present, future, something greater)• The Capacity for Transformation is Unique to HumanBeings (growth, benefit finding, attitude towards suffering)Cancer and Meaning

Enhance
MeaningCancer

Suffering
Limitations
Identity
DeathGuilt

Maintain
Meaning

Loss ofMeaning

The Importance of Meaning andSpiritual Needs in Cancer
In a sample of 248 cancer patients the following rates ofendorsement were found for questions regarding needs:• Overcoming fears - 51%• Finding hope - 42%• Finding meaning in life - 40%• Finding peace of mind - 43%• Finding spiritual resources - 39%
Higher rate of spiritual/existential needs in ethnic
minorities, unmarried patients, more recent diagnosis

Moadel A et al. Psychooncology 1999, 8:378-385

The Universality of Existential Suffering
In a sample of 162 Japanese cancer inpatients, existential
distress was related to:• Dependency - 39 %• Meaninglessness - 37 %• Hopelessness - 37 %• Burden to others - 34 %• Loss of social role - 29 %• Feeling irrelevant - 28 %Morita T, et al, psycho-oncology, 9:164-168, 2000.

Spirituality and QOL in Cancer
Percent of Subjects Enjoying Life "Very Much" by
Meaning/Peace and Symptoms Level% who enjoy life "verymuch"

80

78.6

76.6

70

66.2

60
50

47.6

40
30
20
100

Lo
Meaning/Peace26.8

25
9.3

High
Meaning/Peace10.7

No Pain High PainNo Fatigue

HighFatigue
Pain Level and Fatigue Level

Brady MJ, et al, Psychooncology, 1999, 8:417-428p=.001

Spirituality in QOL in Cancer% who ejnoy
life "verymuch"

Percent of Subjects Enjoying Life "Very Much" byFaith and Symptom Levels
8074.26960
403741.5
Lo Faith
Hi Faith200
No Pain Hi Pain

NoHi
Fatigue Fatigue

Pain Level and Fatigue Level

Brady MJ et al, Psychooncology, 1999, 8: 417-428p=.001

Spirituality and Depression in Cancer
Severity of Depressive Symptoms (HDRS score)
2015FACIT
Spiritual10
Well-Being
Scale
50Low

ModerateHigh

Level of Spirituality
Nelson, Rosenfeld, Breitbart. Psychosomatics, 2002

p=.001

Spirituality and Depression inCancer Patients
Correlation Between Spirituality/religion
And Depression
Depression (HDRS)

p-.40.001

Meaning/peace Subscale

-.51

.001

Faith Subscale

-.13

n.s.

Religiosity Index

.04

n.s.

Facit Total Score

Nelson, Rosenfeld, Breitbart . Psychosomatics 2002

Spirituality & Desire for Hastened Death:
A Group of 160 Terminally Ill Cancer
Patients

Schedule ofAttitudes
Toward aHastened
Death Score

9876543210Low

ModerateHigh

Spiritual Well-Being Score
p <.001

Spirituality & Hopelessness in Cancer:
A Group of 160 Terminally Ill Cancer
Patients
1210Beck8Hopelessness
Scale Score 6420Low

ModerateHigh

Spiritual Well-Being Total Score
p <.001

Spiritual Well Being and Suicidal
Ideation: N=30 in Group of 160
Terminally Ill Cancer Patients
50%
40%

SuicidalIdeation

30%
20%10%0%

High

ModerateLow

Spiritual Well-Being Score
p <.001

Spiritual Well-Being in Relation to End
of Life Despair Among Cancer Patients
Regression models predicting end-of-life despairfrom Meaning, Faith and Depression

FACIT Meaning subscale
FACIT Faith subscale
Depression (HDRS)(Correlations in bold are significant, p <.05)

BHS SAHD SI-.44 -.44 -.84-.18 -.06 -.21.26 .23 .11

A Meta-Analysis of Meaning and it’s
Relation to Distress in Cancer Patients
In a meta-analysis of 62 studies examining therelationship between “Meaning in Life” ( usuallymeasured by the FACIT-SWB) and distress incancer patients:

Meaning in life demonstrated significant
negative associations with cancer distress(r= -0.41, 95% CI= -0.47 to -0.35, k=44)

Winger JG et al, Psycho-oncology, E pub ahead of print 2015.

Viktor E. Frankl, M.D. (1905-1997)

Meaning Centered Psychotherapy
Basic Concepts
Meaning:
1. Meaning of Life - Life has meaning and never ceases tohave meaning. The possibility of creating or experiencing
meaning exists until the last moments of life
2. Will to Meaning - The desire to find meaning in humanexistence is a third primary and basic motivation forhuman behavior; (i.e. libido, will to power, will tomeaning).
3. Freedom of Will - Freedom to find meaning in existence
and to choose one’s attitude towards suffering; to choose
how we respond to uncertainty

Meaning Centered Psychotherapy BasicConcepts
The Sources of Meaning: Achieving Transcendence
1. Creativity - work, deeds, causes
2. Experience - nature, art, relationships
3. Attitude - the attitude one takes towards
suffering and existential problems; limitations,uncertain future
4. Historical - individual, family, community history;
Legacy: past, present, futureMeaning-Centered Psychotherapy
Session Topics & Themes• Session #1: Concepts & Sources of Meaning– Introductions to Intervention & Meaning• Session #2: Cancer & Meaning– Identity – Before & After Cancer Diagnosis• Session #3: Historical Sources of Meaning– Life as a Living Legacy (past-present-future)• Session #4: Attitudinal Sources of Meaning– Encountering Life’s Limitations• Session #5: Creative Sources of Meaning–

Actively Engaging in Life (via: creativity & responsibility)• Session #6: Experiential Sources of Meaning– Connecting with Life (via: love, beauty & humor)• Session #7: Transitions– Reflections & hopes for futureSession #1Concepts and Sources of Meaning:Experiential Exercises• List one or two experiences or moments
when life has felt particularly meaningful toyou- whether it sounds powerful or mundane.
For example, it could be something that
helped you through a difficult day, or a time
when you felt most alive.

Session # 2
Cancer and Meaning: ExperientialExercises• Write down 4 answers to the question, “Whoam I?” These can be positive or negative, andinclude personality characteristics, body
image, beliefs, things you do, people you
know, etc….For example, answers mightstart with, “I am someone who___ ,” or “I ama __ .”• How has cancer affected your answers?

Sessions # 3
Meaning & the Historical Context of Life:
Experiential Exercises• Tell us the story of your name.
• Tell us about your life and the history of yourfamily.
• What are your most important
accomplishments, and what do you feelmost proud of?
• What have you learned about life that you
would want to pass on to others?

Session # 4- Meaning & AttitudinalValues: Limitations, Finiteness of Life• Are you still able to find meaning in yourdaily life despite the finiteness of life?
• Since your diagnosis, have you felt a sense ofa loss of meaning in life? That life is not
worth living?
• Thoughts about what is a “good” or“meaningful” death.
• Thoughts about what happens after death?

Session # 5- Meaning Derived from
Creative Values & Responsibility
Courage, Commitment and Care

• What are your responsibilities?
• What are the tasks you have for your life?
• Who are you responsible to and for?
• What is your unfinished business?
• What tasks have you always wanted to do,but have yet to undertake?

Session # 6- Meaning & Experiential
Values: Love, Nature, Art, Beauty, Humor:• List and discuss 3 things that strike you as
beautiful and still make you feel alive.
• List 3 things that still make you laugh.

Session # 7- Transitions• Process Termination• Review of memoirs, legacy project• Review sources of meaning• Hopes for future- List 3 hopes for the future• Saying good-byeMeaning Centered Psychotherapyin Advanced Cancer• Meaning-Centered Psychotherapy, in Groupand Individual Formats, has been
demonstrated in multiple Randomized
Controlled Trials to:– Enhance Spiritual Well Being, Meaning, Faith,– Enhance Quality of Life– Decrease Hopelessness, Desire for Hastened
Death, Symptom Distress, Depression,Anxiety
Funding: R21 AT/CA 0103; RO1 CA 128134; R01 CA 128187; Fetzer Institute; Kohlberg Foundation

Breitbart et al, Psycho-oncology 2010, Breitbart, et al 2002,2004,2006
Breitbart et al, JCO 30: 1304-1309, 2012, Breitbart et al JCO 33: 749-54 2015

Research-tested Intervention Programs (RTIPs)
RTIPs - Moving Science into Programs for People
http://rtips.cancer.gov/rtips/

Meaning-Centered Group Psychotherapy for Patients
Advanced Cancer

Setting
Origination

Meaning-Centered Group Psychotherapy
for Patients with Advanced Cancer
Designed to enhance the quality of life forcancer survivors. (2015)
Psychosocial - Anxiety, Psychosocial Coping, Psychosocial - Depression andPsychosocial - Stress/distress (posttraumatic stress)
Cancer patients
Survivorship/Supportive Care
Adults (40-65 years), Older Adults (65+years), Young Adults (19-39 years)
Female, Male
Asian, Black, not of Hispanic or Latino
origin, Hispanic or Latino, White, not of
Hispanic or Latino origin
ClinicalUnited States

Funded byNCI (Grant number(s): CA 128187)

Program Title
PurposeProgram Focus
Population Focus
TopicAge
GenderRace/Ethnicity

This program has been
evaluated on criteria fromthe RE-AIM framework,
which helps translate
research into action.
Reach
80.0%
Effectiveness100.0%
Adoption
16.7%
Implementation
71.4%

From Oxford University Press

Meaning-Centered Group Psychotherapy for Patients with Advanced Individual Meaning-Centered Psychotherapy for Patients with Advanced
Cancer:Cancer: A Treatment Manual
A Treatment Manual
August 2014 │ Paperback
ISBN: 9780199837243
112 pp. │ LIST PRICE: $29.95

August 2014 │ Paperback
ISBN: 9780199837250
128 pp. │ LIST PRICE: $29.95

Meaning-Centered Psychotherapy (MCP) for advanced cancer patients is a highly effective intervention for advanced cancer patients, developedand tested in randomized controlled trials by Dr. Breitbart and colleagues at Memorial Sloan-Kettering Cancer Center. These treatment
manuals for group therapy and individual therapy provide clinicians in the oncology and palliative care settings with a highly effective, brief,
structured intervention shown to be effective in helping patients sustain meaning, hope and quality of life.

ABOUT THE AUTHORSWILLIAM S. BREITBART, MD, Chair, Department of Psychiatry and Behavioral Sciences; Chief, Psychiatry Service, Memorial Sloan Kettering Cancer
CenterSHANNON R. POPPITO, PhD, Clinical Psychologist / Behavioral Health Consultant, Behavioral Health Optimization Program, Los Angeles Air ForceBase
To order your copy, visit oup.com/us

Novel Adaptations of MCP for New
Populations and Purposes in Cancer• W. Lichtenthal ~ USA: Meaning- Centered Grief Therapy(MCGT) NCI RO3, NCI K-award• W. Lichtenthal ~ USA: Meaning- Centered Group Psychotherapy for BreastCancer Survivors (MCGP-BCS) ACS• A. Applebaum ~ USA: Meaning -Centered Psychotherapy for
Caregivers (MCP-C) NCI-RO3, ACS• I. Verdonck ~ The Netherlands: MCGP for General Cancer
Survivors (MCGP-CS) DCS• J.Keraney ~ USA : Meaning-Centered Psychotherapy for AYA with Cancer
Silverberg Foundation• L. Fillion~ Canada: MCP for Hospice Nurses NCIHR• Replication Studies in: Italy, the Netherlands, Spain, Israel, Taiwan

Meaning-Centered Psychotherapy in the Cancer Setting
FINDING MEANING AND HOPE IN THE FACE OF SUFFERING

Meaning-Centered-Psychotherapy in theCancer Setting provides a theoreticalcontext for Meaning-CenteredPsychotherapy (MCP), a nonpharmacologic intervention which has
been shown to enhance meaning andspiritual well-being, increase hope,
improve quality of life, and significantly
decrease depression, anxiety, desire for
hastened death, and symptom burden
distress in the cancer setting.

order online at oup.com/us and enterpromo code ampromd9 at check out tosave 30%Also Available on Amazon.com and Kindle

MEANING-CENTERED PSYCHOTHERAPY R25 TRAINING PROGRAM
Learn principles, techniques, and applications of Meaning-Centered Psychotherapy
Our comprehensive two-day training will feature lectures, manual review,
simulated patient role plays
Funded by NCI, Grant #1 R25 CA190169, William Breitbart (PI) MEMORIAL SLOAN KETTERING CANCER CENTER

For more information

Email: psytrainMCP@mskcc.org
breitbaw@mskcc.org
www.mskcc.org/psycho-oncology