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Section 26
Meaning-Centered Therapy: Pilot Group

Question 26 | Test | Table of Contents

Introduction
As described in another paper in this issue, Dr. William Breitbart and I have been developing the Meaning-Centered Group Psychotherapy intervention with the hope of helping people find a sense of meaning while struggling with cancer illness and treatment. During the course of our first pilot group, completed in May, 2000, one of the participants seemed to allude to this struggle while describing his father's work as a former Philadelphia firefighter. "The fireman," Mr. D. proudly explained to us, "is the one running into the building that everybody else is running out of. No matter what," he continued, "you gotta overcome your fear of the house that's on fire if you're gonna do your job." This seemed an apt metaphor for what many cancer patients go through as they try to overcome their fear of the fire in their own house, and live their lives fully despite knowing how limited their time might turn out to be.

Group Composition
Group leaders were the author and Dr. William Breitbart, the developers of the intervention. Two of the group members were patients of one of the leaders, and the others were recruited via a letter in the hospital's outpatient psychiatric clinic. There were no restrictions based on primary cancer dx, but it was felt that some homogeneity in stage of illness was appropriate, and all group members had relatively advanced disease. They were also informed that this was part of a new group therapy program and that we would be eliciting feedback from them later. This may have lent the group an additional mission--not only to help themselves, but also to help the group leaders and future group members through their input. We had strongly recommended that they read Viktor Frankl's Man's Search for Meaning before the first session.

The group comprised four men, an unusual gender composition in the literature. There initially had been a fifth member, the only woman. However, Ms. S. left after the first session, when she began a very aggressive treatment protocol, though there may have been some other contributing factors as well. The four participants had seven cancer diagnoses between them. Psychiatric diagnoses tended to be adjustment disorder, and depression or anxiety disorder, with no psychosis or current substance abuse. All group members were in continuing individual treatment at the counseling center. We met for eight weekly ninety-minute sessions, for which participants were not charged. Given this small number of members, we were fortunate that only once during the whole course of the group, one member was absent, due to medical condition.

Member Profiles
Mr. D. is a thirty-nine-year-old single white man with a history of skin cancer, now with recurrent esophageal cancer. A metastasis was diagnosed during the course of our meetings. Mr. D. grew up in Philadelphia, the middle of three children, and is a former police officer. In addition, he is an amateur photojournalist who shoots footage of fires and other disasters. (It was he who inspired the title of this article.) He feels his long acquaintanceship with other people's tragedies helped normalize the experience when it was his turn, though, in fact, he always had been attracted to these kinds of scenes since childhood.

Mr. R. is a seventy-five-year-old divorced white male originally from Minnesota. He is a retired trade magazine editor and a veteran of World War II, currently presenting with rectal cancer. In addition, he has a significant history of alcoholism. Though his problem was once severe enough to force him to live on the streets, he presently is an active AA member and recently celebrated his thirty-fifth year of sobriety. Mr. R. has two grown children and two grandchildren, about whom he cares deeply. Since the onset of his cancer, he began to realize his dream of writing a historical novel, which was close to completion at the group's end.

Mr. L. is a sixty-seven-year-old married corporate attorney with a history of leukemia, in remission for a decade, and current lymphoma that began progressing recently. He is a father of three and grandfather of four. Mr. L. is bitter about his internist's failure to diagnose the disease earlier. Since his retirement from his job, Mr. L., until recently, had been involved with pro bono business projects in poor communities. He was to run a project in South Carolina when progressing illness preempted his trip. Mr. L. loves gardening but had not been tending to it very much since the progression of his illness. He was the group member who was most obsessed with details of his illness and treatment possibilities, sometimes to a point that could be somewhat wearing for other group members, and, to be honest, at times the group leaders as well.

Mr. E. is a sixty-nine-year-old white widower and grandfather who was born and raised in the Midwest. He has been diagnosed with advanced colon cancer and locally advanced prostate cancer. Before his retirement, he had had a successful school supply business. Mr. E. lost his wife five years ago during his initial cancer treatment. Deeply concerned with her husband's treatment, Mrs. E. apparently ignored her own health and died a few months after being diagnosed with late-stage melanoma. Mr. E. was the class comic, so to speak, cutting into painful discussions with jokes from time to time.

Ms. S., whose tenure in the group was very brief, is a forty-two-year-old single white female who is self-employed as a consultant in the publishing industry despite her diagnosis of Stage IV melanoma. She began salvage treatment soon after the first session and left the group.

Structure of the Group
As discussed in the previous paper, a substantial portion of many of the sessions was to be devoted to structured discussion of Frankl's principles, including didactic sections and group exercises. Not too surprisingly, this structure underwent a quiet transformation over the course of the eight sessions. While the focus on tasks seemed necessary at the beginning, this structure soon gave way to the group members' enjoyment of simply talking and listening to each other, responding supportively and sometimes interpretively. Over time, group leaders also tended to become less proactive, coming to rely less on structured exercises, and instead being more responsive to spontaneous discussions. On one occasion, group members began discussing the issues that would have been the focus of the exercises planned for that session anyway. Perhaps, we were all getting more comfortable with each other as well as the subject matter, as we developed a working alliance. On more than one occasion, group members reported that they never talked this openly with other people, sometimes not even with their spouses.

At the very beginning of the group, we asked members to describe one or two meaningful events in their lives, keeping in mind Frankl's suggestion that there were three basic sources: 1. creative work and causes; 2. relationships, art, and beauty; and 3. the attitude one takes towards unavoidable suffering. Examples are reported in Table I. The balance in the group's responses was striking: out of the eight events they reported, all involved relationships with important others (though one also involved pride in one's work), putting love at the top of the list of sources of meaning. This finding recalls previous findings in the empirical literature. As Mr. R., the former editor and recent novelist, said, "You're not going to find yourself on your deathbed saying, 'Oh shit, what about that meeting I missed.' No, you're going to think of all the times you missed being with the people you love." Thus, Mr. R. described the way in which regret can be the flip side of meaning--serving as a cue for what was important for him to focus on before he died. The importance of connectedness to others, not only family members, was to become a constant motif throughout our meetings.

Finiteness and Denial: The Daisy Chain
The first theme to manifest itself, however, was the issue of denial, which arose as early as the introductions. Ms. S. was the only group member to openly discuss the probability of death in the near future. The rest of the group, literally to a man, responded strongly that she could not know that, and that her statement implied giving up. Ms. S. responded evenly, stating that she understood what they meant but felt she was only being realistic, though she also agreed that it was difficult for her to keep from becoming hopeless when she knew what was in store. I commented that hope could have many facets, as one could hope for longer life as well as for a life filled with joyful and meaningful moments regardless of how much longer it was. While the atmosphere seemed comfortable, and Ms. S did not seem to be intimidated, it is also true that she did not return to the group after this session. She reported that, while she felt very comfortable in the group, her new treatment precluded her ability to attend further. She continued her individual psychotherapy, usually via telephone.

In a later session, group members described the discomfort they had felt during this particular discussion, and all stated that they never thought about death. The only exception for all of them was a brief period right after the diagnosis of their first cancer. Instead, participants said they focused on day-to-day tasks. Mr. R. went on to describe his experience in World War II, relating the ways in which everyone had only each other on whom to depend in order to survive. Ms. S., he said, had broken the daisy chain and let death into the room.

In later sessions, the theme of death was occasionally introduced, by either the group leaders or the members themselves. On one occasion, participants spontaneously brought up death from two different perspectives-the practical question of cemetery plots and the more esoteric question of an afterlife. Three of the four members believed in an afterlife. Mr. L., the attorney, even recounted his college experience with a professor who incorrectly claimed that Jews do not have a concept of an afterlife. A tenacious Mr. L. had his rabbi fax him documentation to the contrary. Mr. R. was somewhat doubtful about an afterlife but stated he believed in God, and that God will help if you ask. A common theme in these discussions involved reunion fantasies, as all loved ones would come together once again. Mr. L. described his own religiousness in more generally spiritual terms, as a way of feeling like part of the grand scheme of things. Mr. E. disavowed the possibility of skepticism. "If I'm wrong," he said, "I don't want to know."

The cemetery discussion was notable for its open acknowledgment of death coupled with what also appeared to be a further disavowal of it, as the men described their cemetery plots almost as if from the standpoint of how it would feel lying on top of them, rather than interred inside them. For example, Mr. E. talked about his father's choice of a corner plot in order to get better ventilation from the empty side, while Mr. L., the gardener, described his mother's plot with a beautiful view of the mountains, and how he longed to be in that nature-filled environment rather than in New Jersey with his wife's family. He was going to stay in New Jersey, though, since his wife mattered more. The discussion was very poignant and funny as well, especially as Mr. E. began telling jokes when the discussion was too painful for him. The participants seemed to let death in at this point, though in very measured doses.

The daisy chain was broken much more directly in later sessions, as the end of group loomed and as Mr. D., the former policeman, learned of his metastasis. He talked about his conflicted feelings about his nephew, how he wanted to continue to be close to him but was afraid of the boy's getting very attached to him and then having to grieve. Group members responded very supportively. Mr. E. talked about his grandchildren's reaction to his wife's death, how much their memories of her mean to them now and how much they would have lost had they been deprived of those moments. Mr. R. chimed in that memories often feel better than the original event, as you can sit back and savor the moments more. It appeared to me that Mr. D.'s concern was twofold, however, as he may not have been prepared himself to commit to his nephew knowing he would have to break that connection. His belief in reunion after death did give him some comfort, however.

As expected, the finiteness of the group brought up strong feelings. Ever perseverant, Mr. L. tried unsuccessfully to negotiate more sessions. The topic was processed a number of times, as group leaders suggested that the finiteness of the group mirrored the finiteness of our lives. The knowledge that the group would end lent it an urgency, forcing us to use our time wisely. The group members made plans to continue meeting themselves, with the detail-oriented Mr. L. slated to do the scheduling, and with Mr. E., an epicure, to pick the restaurants. There was also talk of taking educational trips to a magazine publisher, a police station, etc., as each participant would reexperience himself by sharing more of his life with the others. Though the group was ending, it seemed that it might also have an afterlife.

The finiteness of the group was not only a symbol of ending in general; it also forced the group members to take responsibility themselves for continuing the work started in the group. One of the issues we explored at length was, in fact, those tasks for which members felt responsible. Mr. D., who was single, for instance, felt responsible to help his parents and siblings deal with his illness and, in a more conflicted manner, to his only nephew, to be the kind of uncle in which he feels he can confide. Mr. R. fears one of his sons may be alcoholic and wants to help him get on a healthier track before he dies. He also feels an obligation to himself, to further develop as a writer and finish projects, something he had not done nearly enough when healthy.

Mr. L. wants to be more of a friend to his children and to do a better job of tending to his seedlings and vegetables. Mr. E. wants to build his relationship with his grandchildren despite the fact that he has a difficult relationship with his son-in-law. All the members also seem to feel a responsibility to each other, to keep their spirits up and to have fun.

Cognitive Reframing
The previous paper explored the need for cognitive reframing, as elaborated by Frankl and Folkman. In the group, we found group members often relied on this defense spontaneously. For example, we asked in an early session about the changes that had been caused by participants' cancers. Of the fifteen responses, five were negative and ten were positive [see Tables II and III]. Negative responses referred to physical and occupational limitations, as well as increased depression and anxiety. Positive changes tended to refer more to what Frankl described as experiential and attitudinal values, including intensification of love and support, more social openness and compassion, and a general sense of personal growth. For instance, Mr. D. gave as an example of a negative change, the fact that "Cancer prevents me from doing the things that make me me." When I asked whether there were now new things that made him him, he responded, "Yes. I'm very proud that I didn't turn to mush when the doctors gave me the diagnosis," recalling Lazarus' and Folkman's finding regarding coping with trauma. The issue of denial should be kept in mind, however, as cognitive reframing refers not only to making the best of a bad situation, but to the honest recognition that the situation may still be bad. More research will be necessary to better tease these apart in order to assess clinical outcome of group participation in the future.

Humor and Beauty
Frankl invoked the importance of both humor and beauty as avenues for transcendence, the former by gaining distance from one's situation and the latter by experiencing oneself as part of something bigger, such as is the case in love or the experience of art or nature. Both humor and beauty had important places in our sessions, and one session was devoted to these themes alone. Though Mr. E. often used humor defensively, so did others occasionally, as they described its importance in maintaining their mood. Group members knew they were going to be asked to discuss humorous and beautiful moments that occurred during the course of the week. Interestingly, the group member who tended toward obsessiveness, Mr. L., could not complete his humor homework assignment. He simply could not think of anything funny. In response to this, his wife photocopied comic materials for him and the group, including a listing of Borscht-belt one-liners and other kinds of printed humor. Group members enjoyed many of the jokes that were read out loud, but even more, they noted the sweetness of Mrs. L.'s gesture in finding them for the rest of the group. During the course of the discussion, Mr. L. began to recall an absurd running joke he had with his grandson and could not help but laugh as he recounted its silliness.

Mr. D. remembered an incident from his adolescence that had been embarrassing at the time but now amused him when recalled from the perspective of adulthood. Thus, the ability to enjoy a laugh was not only a needed respite from the seriousness of the topic, but it also indicated the ability to see negative events from a different perspective.

Most examples of beauty involved the experience of nature. Mr. D. remembered a beautiful spring day he once spent with an eighty-four-year-old man. "When you're eighty four," he remembered the older man saying, "everyday is a beautiful spring day." Mr. D. hoped he would be able to have a similar perspective as his illness progressed, though he recognized that this would be difficult. Other examples included beautiful sunrises experienced while with friends or on a honeymoon, a road blanketed by a fresh, heavy snow. Mr. D. remembered with joy the time he helped a woman give birth to her son during an emergency. Mr. L. seemed particularly moved by the discussion, and it was not until this session that the intensity of his love for his wife became dear. Both he and the widowed Mr. E. cited their wives as primary examples of beauty in the world. Mr. E. went so far as to bring a picture of his wife and described her as an example of how love and beauty could transcend death.

Termination
As the group neared its end, we began discussing hopes and plans for the future. Mr. D., falling back on his background as an amateur photojournalist, was thinking of putting together a video for other esophageal cancer patients to try to share some of what he had learned in dealing with his treatment.

Mr. R., who was finishing his novel during the course of the group, also began and finished a short story, which he plans to send out to various literary magazines. As he put it, "life is one thing, but art is something special." "Ars longa, vita brevis," I thought as he spoke. He will also begin working on audiotaped memoirs for his children
Mr. L. is striving to work more on his garden, especially his vegetables, and has learned that he will be able to run the project in South Carolina after all, albeit from home. He also is trying to get his family together more often.
Mr. E. loves to cook, and is also involved with giving advice to others in the school supply business. He continues to enjoy his relationship with his daughter and grandchildren, while maintaining an uneasy truce with his son-in-law.

Table I. Meaningful Events

Table II. Negative Changes in Self due to Cancer

Table III. Positive Changes in Self due to Cancer

Personal Reflection Exercise #12
The preceding section contained information regarding cancer and psychotherapy. Write three case study examples regarding how you might use the content of this section in your practice.
Reviewed 2023

Update
The Benefits of Concurrent
Engagement in Meaning-Centered
Psychotherapy and Meaning-Centered
Psychotherapy for Cancer Caregivers:
A Case Study

Roberts, K. E., & Applebaum, A. J. (2022). The benefits of concurrent engagement in meaning-centered psychotherapy and meaning-centered psychotherapy for cancer caregivers: A case study. Palliative & supportive care, 20(5), 754–756.

Peer-Reviewed Journal Article References:
Desautels, C., Savard, J., Ivers, H., Savard, M.-H., & Caplette-Gingras, A. (2018). Treatment of depressive symptoms in patients with breast cancer: A randomized controlled trial comparing cognitive therapy and bright light therapy. Health Psychology, 37(1), 1–13. 

Fung, H. H., Lu, M., & Isaacowitz, D. M. (2019). Aging and attention: Meaningfulness may be more important than valence. Psychology and Aging, 34(1), 85–90.

Regenwetter, M., Hsu, Y.-F., & Kuklinski, J. H. (2019). Towards meaningful inferences from attitudinal thermometer ratings. Decision, 6(4), 381–399.

Wong, P. T. P. (2017). Meaning-centered approach to research and therapy, second wave positive psychology, and the future of humanistic psychology. The Humanistic Psychologist, 45(3), 207–216.

QUESTION 26
How are humor and beauty avenues for transcendence? To select and enter your answer go to Test.

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