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International Meaning Conference
July, 2016, Toronto
Meaning-Centered Psychotherapy
for 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
Palliative Care: Beyond Symptom
Control
• Concepts of adequate palliative care
must be expanded in their focus
beyond pain and physical symptom
control to include psychiatric,
psychosocial, existential and spiritual
domains of care.
Handbook of Psychiatry
in Palliative Medicine
Second Edition
Edited by Harvey Max Chochinov &
William Breitbart
William Breitbart M.D.
Email: [email protected]
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Contact Information for
Dr. William Breitbart. M.D
Chairman
Jimmie C Holland Chair in Psychiatric Oncology
Department of Psychiatry & Behavioral Sciences
Memorial Sloan Kettering Cancer Center
Email: [email protected]
William Breitbart, M.D.
Editor-in-Chief
Memorial Sloan Kettering
Cancer Center
New York, NY
Email: [email protected]
To Submit Articles:
Cambridge University Press
http ://mc.manuscriptcentral.com/pax
For Information: email:
[email protected]
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 Human
Survival , and the Essence of the Human Experience
(to each other, past ,present, future, something greater)
• The Capacity for Transformation is Unique to Human
Beings (growth, benefit finding, attitude towards suffering)
Cancer and Meaning
Enhance
Meaning
Cancer
Suffering
Limitations
Identity
Death
Guilt
Maintain
Meaning
Loss of
Meaning
Spirituality
• A construct involving concepts of:
–FAITH
–MEANING
Faith
• A belief in a higher transcendent power,
not necessarily identified as God and not
necessarily through participation in the
rituals or beliefs of a specific organized
religion
• Faith in a transcendent power may identify
this power as being external to the human
psyche or internalized
Meaning
• Having a sense that one’s life has meaning
involves the conviction that one is fulfilling
a unique role and purpose in a life that is a
gift. A life that comes with a responsibility
to live to one’s full potential as a human
being. In so doing, being able to achieve a
sense of peace, contentment or even
transcendence through connectedness
with something greater than one’s self
Meaning
• Meaning is the experience of feeling fully alive, of being in love
with Being
• Meaning is the experience of Being, Becoming, & Having Been
• The experience of Connection and Transcendence( Care; Time;
Attitude):
Connectedness, Love, Care & Indebtedness, to one’s life,
one’s self , one’s loved ones, to the past present and future.
Connection to the authentic self ( the “who” not the” what”
I am), to others, to the transcendent, to meaningful moments
• The experience of Love, Beauty, Joy, and Life in all its duality
• Meaning is the experience of Freedom- being free to be our true
selves
The Importance of Meaning and
Spiritual Needs in Cancer Patients
In a sample of 248 cancer patients the following rates of
endorsement 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
% who enjoy life
"very much"
Percent of Subjects Enjoying Life "Very Much" by
Meaning/Peace and Symptoms Level
80
70
60
50
40
30
20
10
0
78.6
76.6
66.2
47.6
Lo
Meaning/Peace
26.8
25
9.3
High
Meaning/Peace
10.7
No Pain High Pain
No
High
Fatigue Fatigue
Pain Level and Fatigue Level
Brady MJ, et al, Psychooncology, 1999, 8:417-428
p=.001
Spirituality in QOL in Cancer
Percent of Subjects Enjoying Life "Very Much" by
Faith and Symptom Levels
% who ejnoy
life "very
much"
80
74.2
69
60
40
37
41.5
Lo Faith
Hi Faith
20
0
No Pain Hi Pain
No
Hi
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)
20
15
FACIT
Spiritual
10
Well-Being
Scale
5
0
Low
Moderate
High
Level of Spirituality
Nelson, Rosenfeld, Breitbart. Psychosomatics, 2002
p=.001
Spirituality and Depression in
Cancer 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 of
Attitudes
Toward a
Hastened
Death Score
9
8
7
6
5
4
3
2
1
0
Low
Moderate
High
Spiritual Well-Being Score
p <.001
Spirituality & Hopelessness in Cancer:
A Group of 160 Terminally Ill Cancer
Patients
12
10
Beck
8
Hopelessness
Scale Score 6
4
2
0
Low
Moderate
High
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%
Suicidal
Ideation
30%
20%
10%
0%
High
Moderate
Low
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 despair
from Meaning, Faith and Depression
FACIT Meaning subscale
FACIT Faith subscale
Depression (HDRS)
(Correlations in bold are significant, p <.05)
BHS
-.44
-.18
.26
SAHD SI
-.44 -.84
-.06 -.21
.23 .11
A Meta-Analysis of Meaning and it’s
Relation to Distress in Cancer Patients
In a meta-analysis of 62 studies examining the
relationship between “Meaning in Life” ( usually
measured by the FACIT-SWB) and distress in
cancer 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 to
have 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 human
existence is a third primary and basic motivation for
human behavior; (i.e. libido, will to power, will to
meaning).
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 Basic
Concepts
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 Group 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: Historical Sources of Meaning
– Life as a Living Legacy (past-present-future)
• Session #5: Attitudinal Sources of Meaning
– Encountering Life’s Limitations
• Session #6: Creative Sources of Meaning
–
Actively Engaging in Life (via: creativity & responsibility)
• Session #7: Experiential Sources of Meaning
– Connecting with Life (via: love, beauty & humor)
• Session #8: Transitions
– Reflections & hopes for future
Session #1
Concepts and Sources of Meaning:
Experiential Exercises
• List one or two experiences or moments
when life has felt particularly meaningful to
you- 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: Experiential
Exercises
• Write down 4 answers to the question, “Who
am I?” These can be positive or negative, and
include personality characteristics, body
image, beliefs, things you do, people you
know, etc….For example, answers might
start with, “I am someone who___ ,” or “I am
a __ .”
• How has cancer affected your answers?
Sessions # 3 & 4
Meaning & the Historical Context of Life:
Experiential Exercises
• Tell us the story of your name.
• Tell us about your life and the history of your
family.
• What are your most important
accomplishments, and what do you feel
most proud of?
• What have you learned about life that you
would want to pass on to others?
Session # 5- Meaning & Attitudinal
Values: Limitations, Finiteness of Life
• Are you still able to find meaning in your
daily life despite the finiteness of life?
• Since your diagnosis, have you felt a sense of
a 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 # 6- Meaning Derived from
Creative Values & Responsibility
• 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 # 7- 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 # 8- 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 Psychotherapy
in Advanced Cancer
• Meaning-Centered Psychotherapy, in Group
and 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
Meaning-Centered Group Psychotherapy for
Advanced Cancer Patients:
A Randomized Controlled Trial to Enhance
Spiritual Well-Being at the End of Life
NCI Grant # R01 CA128187
William Breitbart, M.D. (Principal Investigator)
Hayley Pessin, Ph.D.
Wendy Lichtenthal, Ph.D.
Allison Applebaum, Ph.D.
Memorial Sloan Kettering Cancer Center
Barry Rosenfeld, Ph.D. (Co-Investigator)
Fordham University
Breitbart et al. (in press). Journal of Clinical Oncology.
Methods
• Patients with stage III or IV cancer (solid tumors or NonHodgkins Lymphomas) were recruited for participation in
the study.
• Eligible patients with these diagnoses included those
receiving ambulatory care at Memorial Sloan Kettering
Cancer Center in New York City non-Memorial patients.
• Patients were randomized to receive either MeaningCentered Group Psychotherapy or Supportive Group
Psychotherapy weekly for 8 weeks. Both therapies were
manualized.
• Patients were evaluated with a battery of self-report and
clinician-rated measures pre-intervention, postintervention, and at a 2-month follow-up.
MCGP Trial – Study Measures
• Spiritual Well-Being (Meaning; Faith)
– FACIT Spiritual Well-Being Scale (FACIT-SWB)
• Quality of Life
– MQOL: McGill Quality of Life Questionnaire
• Depression
– Beck Depression Inventory (BDI)
• Anxiety
– Hospital Anxiety & Depression Scale-Anxiety Subscale (HADS-A)
• Hopelessness
– Hopelessness Assessment in Illness (HAI)
• Desire for Hastened Death
– Schedule of Attitudes Toward Hastened Death (SAHD)
• Physical Symptom Distress
– Memorial Symptom Assessment Scale (MSAS)
MCGP Sample Characteristics (n = 253)
• Mean Age:
58.2 years (SD = 11.0, range = 27 to 91)
• Gender:
Males
=
30%
Females
=
70%
• Race:
White
Other
=
=
76%
10%
Black
Hispanic
=
=
14%
12%
• Cancer Site:
Breast
Lung
=
=
30%
16%
Pancreas =
Colorectal =
18%
15%
• Cancer Stage:
IV
=
86%
III
14%
• Mean KPRS:
82.6 (SD = 9.4, range = 50 to 100)
=
Accrual and Retention (2008-2013)
Randomized (n = 253)
Withdrew
(n = 43*)
* = 23 due to
illness
Withdrew
(n = 12*)
* = 8 due to
illness
MCGP
(n = 132)
SGP
(n = 121)
Completed
treatment
(n = 89)
Completed
treatment
(n = 78)
Withdrew
(n = 43*)
Completed
follow-up
(n = 77)
Completed
Follow-up
(n = 65)
Withdrew
(n = 13*)
* = 27 due to
illness
* = 9 due to
illness
MCGP vs SGP RCT Results
Changes in Psychological Functioning for Patients Receiving MCGP
Measure
FACIT-SWB
Baseline
Post-tx
Follow-up
(n=120)
(n=89)
(n=77)
Mean (SD)
Mean (SD)
Mean (SD)
29.64 (11.55) 34.03 (10.45) 33.83 (11.61)
Time x Tx
Arm B
0.18
Baseline vs.
Post-Tx
d
0.54
MQOL
6.37 (1.86)
7.12 (1.81)
7.03 (1.71)
0.28
0.40
BDI
16.43 (8.81)
11.36 (8.06)
11.49 (7.31)
-0.28
-0.67
HADS-A
8.29 (4.49)
6.43 (3.44)
7.07 (1.71)
-0.16
-0.52
HAI
4.87 (3.11)
3.57 (2.95)
4.07 (3.30)
-0.30
-0.53
SAHD
2.70 (3.44)
2.01 (2.35)
2.30 (3.34)
-0.22
-0.31
MSAS
1.53 (0.67)
1.26 (0.75)
1.18 (0.72)
-0.23
-0.35
MCGP patients experienced statistically significant improvements in spiritual well-being, quality of life,
depression, anxiety, hopelessness, desire for hastened death, and physical symptom distress both immediately
after the intervention and at 2-month follow-up.
In hierarchical linear models the interaction between study arm assignment and time was a significant predictor of
all of these variables except anxiety, indicating that patients receiving MCGP were experiencing greater
improvements in these areas over time than patients receiving SGP.
(Blue= p < .05, Red = p < .01)
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, developed
and 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 AUTHORS
WILLIAM S. BREITBART, MD, Chair, Department of Psychiatry and Behavioral Sciences; Chief, Psychiatry Service, Memorial Sloan Kettering Cancer
Center
SHANNON R. POPPITO, PhD, Clinical Psychologist / Behavioral Health Consultant, Behavioral Health Optimization Program, Los Angeles Air Force
Base
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 Breast
Cancer 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 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: [email protected]
[email protected]
www.mskcc.org/psycho-oncology
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 for
cancer survivors. (2015)
Psychosocial - Anxiety, Psychosocial Coping, Psychosocial - Depression and
Psychosocial - 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
Clinical
United States
Funded by
NCI (Grant number(s): CA 128187)
Program Title
Purpose
Program Focus
Population Focus
Topic
Age
Gender
Race/Ethnicity
This program has been
evaluated on criteria from
the RE-AIM framework,
which helps translate
research into action.
Reach
80.0%
Effectiveness
100.0%
Adoption
16.7%
Implementation
71.4%