William S. Breitbart, Shannon Poppito-Individual Meaning-Centered Psychotherapy For Patients With Advanced Cancer - A Treatment Manual-Oxford University Press (2014)
William S. Breitbart, Shannon Poppito-Individual Meaning-Centered Psychotherapy For Patients With Advanced Cancer - A Treatment Manual-Oxford University Press (2014)
William S. Breitbart, Shannon Poppito-Individual Meaning-Centered Psychotherapy For Patients With Advanced Cancer - A Treatment Manual-Oxford University Press (2014)
Meaning-Centered
Psychotherapyfor
Patients with
AdvancedCancer
Individual
Meaning-Centered
Psychotherapy
for Patients with
Advanced Cancer
ATreatment Manual
W I L L I A M S . B R E I T B A R T, M D
Interim Chairman
Chief, Psychiatry Service, Department of Psychiatry and Behavioral Sciences
Attending Psychiatrist, Pain & Palliative Care Service, Department of Neurology
Memorial Sloan-Kettering Cancer Center
Professor of Clinical Psychiatry, Department of Psychiatry
Weill Medical College of Cornell University
NewYork, NewYork
1
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Contents
Acknowledgments ix
Preface xi
Introduction:Treatment Overview xxiii
Session 1.
Session 2.
Session 3.
Session 4.
Session 5.
Session 6.
Session 7.
References 57
Handouts 59
Homework/Experiential Exercises 65
Index 77
vii
Acknowledgments
We are indebted to our families for their love and support, and we
remember those precious to us, both family and patients, who have died
during the period of time we conducted the work reflected in this text.
We are indebted to our colleagues at Memorial Sloan-Kettering who
played central roles in the development and conduct of trials of both
MCP formats. Special thanks to Mindy Greenstein, Hayley Pessin,
Barry Rosenfeld, Wendy Lichtenthal, Allison Applebaum, and our many
research collaborators, research assistants, interventionists, predoctoral
and postdoctoral fellows and research managers and coordinators.
Our thanks to the National Institutes of Health, the National Cancer
Institute, the National Center for Complementary and Alternative
Medicine, the Fetzer Institute, and the Kohlberg Foundation, who provided funding for MCP clinical trials research.
Finally, our gratitude to the hundreds of patients who participated
in the clinical trials of MCP and their devoted families and caregivers. While most of the patients who participated in the clinical trials of
MCP are no longer with us, their legacies are alive and affect the course
and meaning of our lives in profound ways.
ix
Preface
xi
patients is an approach to care that promotes the belief that the possibility of creating or experiencing meaning exists until the last moment of life.
It has been a decade since our research group at Memorial Sloan-Kettering
found its way to understanding the clinical and spiritual/existential
importance of meaning and the preservation of meaning as a concept
central to a psychotherapeutic intervention for patients with advanced
cancer who, in fact, are facing death. We came to call this intervention
Meaning-Centered Psychotherapy (MCP). We first developed a group
format of MCP we called Meaning-Centered Group Psychotherapy
(MCGP). It was designed to help advanced cancer patients understand
the importance and relevance of sustaining, reconnecting with, creating, and experiencing meaning in their lives through common and reliable sources of meaning that may serve as resources of meaning to help
diminish despair near the end of life.
In a randomized controlled trial of MCGP (Breitbart et al., 2010),
we demonstrated the efficacy of this intervention in improving spiritual well-being and a sense of meaning, as well as in decreasing anxiety, hopelessness, and desire for death. (The reader is referred to The
Treatment Manual for Meaning-Centered Group Psychotherapy for Patients
with Advanced Cancer, also from Oxford University Press). Our experience with the group format of MCP taught us that a more flexible, individual format of MCP, Individual Meaning-Centered Psychotherapy
(IMCP). IMCP has proved to be as equally effective as MCGP, but it
allows for more flexibility in time and place (e.g., office, bedside, or
chemo suite) for scheduling sessions, resulting in reduced attrition and
enhanced rates of intervention completers (Breitbart etal., 2012).
In this preface of Individual Meaning-Centered Psychotherapy for Patients
with Advanced Cancer: A Treatment Manual, we hope to present the
scientific rationale for IMCP as an effective intervention for patients
with advanced cancer. The manual itself is detailed, and we trust it
will serve as a step-by-step guide for clinicians and researchers to use
in applying the intervention in clinical settings, conducting replication
studies, or developing adaptations of the intervention for local cultures
and languages. It is recommended that the reader refer to the forthcoming Oxford University Press publication Textbook of Meaning-Centered
Psychotherapy for Cancer, for detailed descriptions of therapeutic techniques utilizing transcripts of examples of therapeutic encounters.
xii
xiii
This research highlights the role of meaning as a buffer against depression, hopelessness, suicidal ideation, and desire for hastened death, and
it is significant in the face of what we know about the consequences of
depression and hopelessness in cancer patients. Depression, hopelessness, and loss of meaning are associated with poorer survival (Watson
etal., 1999)and higher rates of suicide, suicidal ideation, hopelessness,
and desire for hastened death (Breitbart etal., 2000; Chochinov etal.,
1995; Kissane etal., 1997). Additionally, hopelessness and loss of meaning have been shown to be independent of depression as predictors of
desire for death, and they are as influential on desire for death as depression (Breitbart etal., 2000). Therefore, there was a critical need for the
development of a psychosocial intervention for advanced cancer patients
that addressed loss of meaning as a method for improving psychosocial
outcomes (e.g., quality of life, depression, anxiety, hopelessness, desire
for death, and end-of-life despair).
Also important to the theoretical conceptual model of MCP is Park
and Folkmans (1997) concept of a form of meaning-focused coping. They describe meaning in terms of reevaluating an event and the
extent to which one has made sense of or found meaning in an
event (Andrykowski, Brady, & Hunt, 1993; Folkman, 1997; Park &
Folkmanm 1997; Taylor, 1983, 1993). Unlike Park and Folkmans conceptualization of meaning as global or situational, Frankl viewed meaning as a state, created moment by moment; individuals can move from
feeling demoralized, as though their lives hold no value (see Kissane
etal., 1997), to recognizing their personal sense of meaning and purpose, which allows them to value even more intensely the time remaining. Experiencing meaning, or having the sense that one has led a
meaningful life, according to Frankl, suggests that meaning is both
experienced and created moment by moment throughout life, as well as
in a more ontological fashion as one reflects on a life lived (Frankl, 1955,
1959, 1969, 1975).
Conceptualizing meaning as a state or sense subject to change suggests
its potential responsiveness to intervention. Frankl also viewed suffering
as a potential springboard, both for having a need for meaning and for
finding it (Frankl, 1955, 1959, 1969, 1975). Hence, the diagnosis of a
terminal illness may be seen as an experience of distress or despair that
may offer an opportunity for growth and meaning. Either one has a loss
xv
xvi
xviii
Future Directions
IMCP has been demonstrated to be an effective intervention for patients
with advanced cancer. In addition to having developed and tested the efficacy of MCGP, we are currently adapting and testing MCP for other cancer
populations, (e.g., breast cancer survivors, bereaved parents, informal cancer
caregivers), as well as for oncology care providers (Fillion etal., 2009). We are
adapting MCP for other cultures and in other languages in order to provide
the intervention to immigrant minority cancer populations (e.g. Spanish,
Chinese). Colleagues in Spain, Israel, Italy, the Netherlands, Taiwan, and
other countries are adapting MCGP and IMCP for their countries.
Summary
IMCP represents the individual format of meaning-centered psychotherapy, developed by Breitbart and colleagues in the Department of
Psychiatry and Behavioral Sciences, Memorial Sloan-Kettering Cancer
Center. It is a novel and unique intervention demonstrated to be effective in enhancing meaning and diminishing despair in advanced cancer
patients. IMCP has great promise as an intervention that can be utilized
in the palliative care setting, as well as in the acute cancer treatment setting for advanced cancer patients.
References
Andrykowski, M.A., Brady, M.J., & Hunt, J.W. (1993). Positive psychosocial
adjustment in potential bone marrow transplant recipients:Cancer as a psychosocial transition. Psycho-Oncology, 2, 261276.
Brady, M. J., Peterman, A. H., Fitchett, G., Mo, M., & Cella, D. (1999).
A case of including spirituality in quality of life measurement in oncology.
Psycho-Oncology, 8, 417428.
Breitbart, W., Rosenfeld, B., Pessin, H., Kaim, M., Funesti-Esch, J., Galietta,
M.,...Brescia, R. (2000). Depression, hopelessness, and desire for hastened
death in terminally ill patients with cancer. Journal of the American Medical
Association, 284, 29072811.
Breitbart, W., Rosenfeld, B., Gibson, C., Kramer, M., Li, Y., Tomarken,
A.,...Schuster, M. (2010). Impact of treatment for depression on desire
xix
xx
Kissane, D. W., Bloch, S., Smith, G. C., Miach, P., Clarke, D. M., Ikin,
J.,...McKenzie, D. (2003). Cognitive existential group psychotherapy
for women with primary breast cancer: A randomised controlled trial.
Psycho-Oncology, 12, 532546.
Lee, V., Cohen, S. R., Edgar, L., Laizner, A. M., & Gagnon, A. J. (2006).
Meaning-making and psychological adjustment to cancer:Development of
an intervention and pilot results. Oncology Nursing Forum, 33, 291302.
McClain, C., Rosenfeld, B., & Breitbart, W. (2003). The influence of spirituality on end-of-life despair among terminally ill cancer patients. Lancet, 361,
16031607.
Meier, D.E., Emmons, C.A., Wallerstein, S., Quill, T., Morrison, R.S., &
Cassel, C.K. (1998). A national survey of physician-assisted suicide and
euthanasia in the United States. New England Journal of Medicine, 338,
11931201.
Moadel, A., Morgan, C., Fatone, A., Grennan, J., Carter, J., Laruffa,
G.,...Dutcher, J. (1999). Seeking meaning and hope:Self-reported spiritual and existential needs among an ethnically diverse cancer patient population. Psycho-Oncology, 8, 14281431.
Morita, T., Tsunoda, J., Inoue, S., & Chihara, S. (2000). An exploratory factor
analysis of existential suffering in Japanese terminally ill cancer patients.
Psycho-Oncology, 9, 164168.
Nietzsche, F. (1986). Human, all too human:Abook for free spirits. Cambridge,
UK:Cambridge University Press.
Nelson, C., Rosenfeld, B., Breitbart, W., & Galietta, M. (2002). Spirituality,
depression and religion in the terminally ill. Psychosomatics, 43, 213220.
Park, C., & Folkman, S. (1997). Meaning in the context of stress and coping.
Review of General Psychology, 1, 115144.
Sartre, J.P. (1984). Being and nothingness. NewYork, NY:Citadel Press.
Seneca, L. A. (1932). On the shortness of life (J. W. Basore, Trans.). London,
UK:Loeb Classical Library.
Singer, P. A., Martinm, D. K., & Kelner, M. (1999). Quality end-of-life
care:Patients perspective. Journal of the American Medical Association, 281,
163168.
Spiegel, D., & Yalom, I. (1978). A support group for dying patients. International
Journal of Group Psychotherapy, 28, 233245.
Spiegel, D., Bloom, J., & Yalom, I.D. (1981). Group support for patients with
metastatic breast cancer. Archives of General Psychiatry, 38, 527533.
Taylor, S.E. (1983). Adjustment to threatening events:Atheory of cognitive
adaptation. American Psychologist, 38, 11611173.
Taylor, E.J. (1993). Factors associated with meaning in life among people with
recurrent cancer. Oncology Nursing Forum, 20, 13991405.
xxi
Watson, M., Haviland, J. J., Greer, S., Davidson, J., & Bliss, J. M. (1999).
Influence of psychological response on survival in breast cancer
population-based cohort study. Lancet, 354, 13311336.
Yalom, I., & Greaves, C. (1977). Group therapy with the terminally ill.
American Journal of Psychiatry, 134, 396400.
Yalom, I.D. (1980). Existential psychotherapy. NewYork, NY:Basic Books.
Yanez, B., Edmondson, D., Stanton, A.L., Park, C.L., Kwan, L., Ganz, P.A., &
Blank, T.O. (2009). Facets of spirituality as predictors of adjustment to
cancer:Relative contributions of having faith and finding meaning. Journal
of Consulting and Clinical Psychology, 77, 730741.
xxii
Introduction:Treatment Overview
xxiii
Patient Selection
Individual meaning-centered psychotherapy (IMCP) was developed as
an existential intervention to help sustain and/or enhance meaning and
spiritual well-being in advanced cancer patients with relatively limited
prognosis (approximately 6 months to a year). The intervention was
not developed to treat a specific DSM psychiatric disorder (e.g., major
depressive disorder), but rather metadiagnostic constructs such as loss of
meaning, loss of spiritual well-being, despair, and demoralization,
which are often manifest in reports of poor quality of life, hopelessness,
desire for hastened death, depressive and anxious symptoms, symptom
distress, and loss of meaning. The randomized controlled trials of IMCP
included patients with stage III or IV solid cancers, who had limited
xxiv
xxv
Intervention Overview
The ultimate goal of this intervention is to optimize coping through an
enhanced sense of meaning and purpose, and to make the most of the
xxvi
time the participants have left, regardless of how long or how limited
that time is. It is important to keep in mind that it is the participants
responsibility to use the sessions to discover the sources of meaning in
their lives; they are perceived not as passive recipients of the therapists
wisdom, but instead as active participants in the process. The intervention is intended to help broaden the scope of possible sources of meaning through the combination of the following:
1. Didactic teaching of the importance of meaning in human existence
and the need for meaning-making as a defining human characteristic
2. Experiential exercises and homework to enhance learning and the
incorporation of the importance of meaning into patients lives
3. Open-ended discussion, which includes interpretive comments by the
therapist to promote emotional expression and to facilitate patients
adoption of a meaning-focused perspective on coping
xxvii
themselves in finding what is meaningful in their lives. This responsibility also includes finding worthwhile definitions of what constitutes
meaningfulness in the first place, as will be explored in Session 1 and
will lay the basis for much of what follows.
Each session in this manual includes the following:(1)a title page; (2)a
session overview, which gives a brief summary of the components of
each session and the tasks that need to be completed; (3)a discussion of
the session goals and content; (4)a description of the didactic portion
of each session; (5)a discussion of the experiential exercise/homework
review that is completed in each session, and (6)a Therapist Adherence
Checklist and Process note. The Therapist Adherence Checklist is the
measure we utilized during our randomized controlled trials comparing individual meaning-centered psychotherapy (IMCP) with supportive psychotherapy. This checklist can therefore be utilized in similar
research studies undertaken by users of this manual who are engaging
in replication studies or other comparative intervention studies. The
Therapist Adherence Checklist identifies the key components of each
IMCP session and so clinicians can also use these as a brief guide for the
content to be covered in each session.
xxviii
xxix
family. Other examples include being a role model in terms of how one
copes with his or her suffering, or experiencing suffering as a catalyst for
changing some aspect of one's life. In other words, sometimes people
reframe their suffering, assuming they dont have the control to remove
the source of that suffering, and explore what purposes it might serve at
this point in their lives. This highlights Frankls central premise that we
have the ability to turn tragedy into triumph, by the way we choose to
find meaning in suffering.
Suffering is not inherently necessary for finding meaning, but it is one
possible avenue for it. Meaningfulness, in this view, is not something
that can be taken for granted but is instead something to create or
achieve. It is through such achievements that one can feel a sense of
fulfillment or transcendence (as in the feeling of being a part of something greater than oneself ). What we strive for in life is not necessarily
happiness, which can be elusive, but a sense of meaning, fulfillment, and
contentment through which happiness may eventually arise.
xxx
end-stage cancer who was very concerned that she not be a burden on
her family. When she described having cared for loved ones during their
illnesses in the past, the psychiatrist asked how it had felt for her to care
for them. She responded that it had been very meaningful for her to be
there for those loved ones, and that she was grateful for the opportunity
to make them more comfortable in their final days. When she was asked
whether she thought her family might feel similarly about caring for her,
she responded that she had never thought to look at it that way.
Care must be taken, however, not to let such instances fall into a patronizing game whereby the therapist simply imposes a more positive spin
on a patients attitude but, rather, to explore from the individuals perspective the possibility of meaning. In the earlier example, the notion of
burden was reframed as a gift in which the patient was giving someone
else the opportunity to take care of her, but this reframing occurred
within the context of exploring her own experience.
xxxi
SESSION 1
Life holds meaning for each and every individual, and even more, it retains
this meaning literally to his last breath. And the [therapist] can show his
patient that life never ceases to have a meaning. To be sure, he cannot show
his patient what the meaning is, but he may well show him that there is a
meaning, and that life retains it:that it remains meaningful, under any
conditions...Even the tragic and negative aspects of life, such as unavoidable
suffering, can be turned into a human achievement by the attitude which a
man adopts toward his predicament...transforming despair into triumph.
Viktor Frankl, The Will to Meaning (1969, p.ix)
Session 1 Overview
1. IntroductionsWelcome and Overview
General Introduction and Overview
Therapist/patient introductions
Intervention overview (e.g., treatment goals, logistics)
Introduction to Session1
Goal 1:Learn patients cancer story
Goal 2:Introduce concepts and sources of meaning
2. Patients Cancer Story
3. Patients Definitions of Meaning
4. Studys Definitions of Meaning
5. Experiential Exercise
6. Session Wrap-up
Brief summation of session
Brief overview of next weeks session:Cancer and Meaning
Homework:read first chapter of Frankls Mans Search for Meaning
Homework:prepare answers to Session 2 experiential exercise
Reminder of following session (day/time)
1
Session Preparation
The therapist should prepare for this first session by fully reviewing
pertinent manualized session information. During this preparatory
period, the therapist should reflect upon the session topic and goals.
Therapists should prepare copies of the Session 1 handouts, exercises,
and homework.
Session Goals
There are five main goals for this first session: (1) conduct initial introductions between therapist and patient; (2) introduce the patient to a
general overview of the intervention (e.g., treatment goals, structured
weekly topics, and logistics); (3) become familiar with the patients cancer story; (4) introduce the patient to an overview of this first session
(e.g., Viktor Frankls work and foundations of meaning); and (5) discuss
definitions of meaning and conduct the experiential exercise of meaningful moments (Experiential Exercise 1.1).
Introduction to Intervention
Example 1.1 is a sample script of what the therapist may say to welcome the participant and familiarize him or her with this individual
meaning-centered intervention. Therapists are expected to have a prior
understanding of this scripted format and be able to present information in their own words.
EXAMPLE1.1
Welcome to your first session of individual meaning-centered psychotherapy (IMCP). This individualized treatment was adapted from a
meaning-centered therapy model based on the work of Viktor Frankl, the
author of Mans Search for Meaning and a number of other books on the
subject of finding a sense of meaning in life. Well be meeting for seven weekly
sessions, in which well be discussing the concept of meaningfulness and how
people find a sense of meaning and purpose both in general and also specifically in relation to having a diagnosis of cancer. Terms like meaning and
purpose can be rather vague, which is why we will include some specific
exercises as well as a lot of discussion of the concepts that come up and how
they relate to peoples actual experiences.
Introductions
The therapist should briefly introduce himself or herself (e.g., name,
credentials, staff position). The therapist should then encourage the
patient to briefly introduce himself or herself by sharing the following
information:(1)name; (2)where he or she is from; (3)marital status;
and (4)number of children. Refer to Example1.2 for a sample script.
Introductions should not exceed 5 minutes.
EXAMPLE1.2
Today well start with introductions to each other and the therapy in general,
as well as a brief introduction to concepts and sources of meaning. In general,
well start each session with a check-in regarding how youre doing personally
and medically and then briefly identify and describe the session themes to be
explored. The remainder of the session will focus on pertinent exercises and
open-ended discussions associated with relevant meaning-centered themes.
Sometimes there will be homework or topics to think about between sessions.
One way to facilitate your understanding of our approach to meaning is by
reading Frankls Mans Search for Meaning. I can help you get a copy to read
for your first homework assignment. Feel free to read the book at a pace that
is comfortable for you.
Treatment Goals
The goal of these sessions is to help patients target what is meaningful
in their lives and to offer ways to maintain a sense of meaning, purpose,
and value in life while theyre living through their cancer experiences.
These sessions are more structured than traditional psychotherapy.
They will be more of a mutual learning experience between the therapist and patient, much like a learning partnership, where the patient
will be learning from the therapist and vice versa. It will involve weekly
Logistics
Briefly discuss intervention logistics with the patient. Inform the patient
that you will be meeting for seven (1-hour) sessions. (In our clinical trials
we attempted to complete the seven sessions within a 12-week period
allowing enough flexibility to adapt to the patients schedule or medical events yet intensive enough for the intervention to be sufficiently
detailed and coherent.) Each session covers a specific weekly topic (refer
to Handout 1.1). Some therapists may want to tape-record sessions, and
if one is conducting a replication research study, tape recording will be
essential for two main purposes:(1)to ensure adherence to manualized
treatment format specifying structured weekly topics; and (2)to actively
learn ways in which patients find meaning in and through their cancer
experiences. Patients should be informed/or consent if tape recording
takes place.
to human beings to create the meaning in their lives. Others, like Frankl,
held out the possibility of some ultimate externally determined meaning given to human being by a creator, and that it is our responsibility to
search for this ultimate meaning to our lives.
3. Freedom of will. We have the freedom to find meaning in our existence and to choose our attitude toward suffering. While there are many
aspects of suffering that we have no control over, Frankl suggests that
perhaps the last ultimate vestige of freedom that we have as human beings
is to consider and choose our attitude toward suffering, even when almost
every other freedom has been taken from us. Frankl came to this realization
while in a concentration camp. Certainly, cancer illness and treatment are
not to be compared to a concentration camp experience; however, cancer
illness and treatment do, in fact, create significant limitations, suffering,
and relinquishing of control. Despite all the limitations imposed by cancer, one has the freedom to choose how one responds, and to choose the
attitude one takes towards uncertainty and the cancer experience.
Therapist Note: To be an individual meaning-centered psychotherapist, one must be committed to the belief that the potential
for experiencing meaning always exists, no matter what the circumstances. Our role as therapists is to affirm the fact that we always
have the possibility to experience meaning in life, even in the last
moments of life. When a patient cannot see how he or she can find
true meaning in life anymore, the therapist must believe in the possibility of rediscovering and reconnecting with meaning. Meaning,
or the possibility of experiencing meaning, exists from the very first
moment in life to the very last, and it never ceases to exist.
Existential Facts of Life
Three facts of life that everyone must face in the course of life are
what Frankl termed the tragic triadguilt, suffering, and death.
Here guilt refers to existential guiltthe fact that few of us ever feel
that we have truly lived our lives to their absolutely unique and fullest
potential. So there are unfinished life tasks, regrets, and shortcomings
that produce this existential guilt. Acentral task of dying is to relieve
this guilt by completing life tasks, asking for forgiveness, forgiving
(refer to Handout 1.4). Ask the patient to read both definitions aloud
and reflect upon specific definition themes that stand out and that he or
she personally relates to.
At this point the therapist should try to briefly relate definition themes
back to the patients cancer stories and personal definitions of meaning
in a purposeful way. Acknowledge how specific concepts and sources
of meaning may relate back to the patients own experiences and illness
narratives.
Experiential Exercise
This experiential exercise (Experiential Exercise 1.1) will help concretize
the concept of meaning for participants through identifying meaningful
moments in their lives. Allow about 1015 minutes for exercise exploration.
Time permitting, the therapist should return to the Sources of
Meaning handout and make reference to ways in which the stories
shared reflect specific sources of meaning in the patients own life. The
therapist should be aware of the meaning source categories and be prepared to reframe specific examples given by the patient into the respective source categories.
Examples are as follows:
Realizing Historical Values. Historical sources of meaning derive from
past, present, and future meaningful experiences in life. Our living
legacyour personal story, the story of our family, things we have
accomplished and learned about life that we hope to pass on to othersis rooted in historical values.
Realizing Attitudinal Values. Attitudinal sources of meaning refer to
encountering lifes limitations and coping with unavoidable suffering
that is beyond ones consent and control. Examples are feeling pride
in getting through a painful situation (e.g., surgery), a feeling of rising above difficult circumstances (e.g., initial cancer diagnosis), or
simply getting through a difficult day or time (e.g., chemotherapy
treatment).
Realizing Creative Values. When realizing creative values, one is actively
engaging in life through some creative endeavor (work, art, hobbies)
10
Session Wrap-Up
Remind the patient of Homework 1.1 and Homework/Experiential
Exercise 1.2 to read Part 1 of Mans Search for Meaning, so that in
the next session the patient will be able to explore his or her homework and experiential exercise in light of Session 2s theme: Cancer
and Meaning. Ask whether there are any final comments or questions
before ending. The therapist should wrap up the session by thanking the
patient for coming and reminding him or her of the day and time of the
next session (see Handout 1.5).
11
12
Date:
Time:
SESSION 2
Session 2 Overview
1. Check-in (5 min)
Personal Check-in
Medical Check-in
2. Processing Session 1
Reflection on First Session (5 min)
Reflection on Homework Assignment Regarding Frankls Book
(10 min)
3. Cancer and Meaning (5 min)
Reference back to Session 1 regarding concepts of meaning
(e.g., exploring ways to find, maintain, and enhance meaning in
the face of cancer)
4. Explore Exercise1 Regarding Identity and Who IAm
Before Cancer (15 min)
5. Explore Exercise2 Regarding Identity and Who Iam
After Cancer (15 min)
13
Session Goals
The main goal for Session 2 is to reintroduce the basic concepts and
sources of meaning from the prior session and to explore the topic of
Cancer and Meaning in light of the guiding theme:Identitybefore
and after Diagnosis. By the end of Session 2, the patient should have
a general understanding of what ones authentic sense of identity is and
the impact cancer has made upon it.
Check-in
Welcome the patient to the second session of meaning-centered therapy.
Inform him or her that before each session gets under way there will be
a brief check-in to see how the patient is doing personally and medically
since the last session. This short session check-in should last no longer
than 510 minutes.
14
Process Session 1
Briefly return to the major themes of Session 1 and Handouts 1.2,
1.3, and 1.4 regarding definitions and sources of meaning. Ask the
patient whether he or she has given any thought to these themes
over the prior week and, if so, how? This should last no more than
5 minutes.
Homework Reflection
Remind the patient of Viktor Frankls work (Frankl handout) and ask
the patient to reflect on themes that he or she personally related to from
his book, Mans Search for Meaning. This homework reflection should
last 58 minutes depending on interest.
15
Session Wrap-up
In the remaining 510 minutes of the session, bring closure to the session by briefly reflecting on the session theme, Cancer and Meaning,
and how it relates to the patients sense of identity and his or her respective cancer experiences. Ask the patient whether he or she has any final
thoughts or comments he or she would like to share regarding this
topic before concluding the session. Briefly introduce the Session 3
topic, Historical Sources of Meaning by way of the theme: Life as a
Legacy. The following session will explore the dimensions of personal
legacy, The legacy given, the legacy we live, and will give. Hand out
Homework/Experiential Exercise 2.1, which prepares the patient for that
exact exercise to be explored in Session 3. Close the session by reminding
the patient of the day and time of the next session. Thank the patient for
coming, and let him or her know that you look forward to meeting again
in Session 3.
17
18
Date:
Time:
SESSION 3
Historical Sources
of Meaning
Session 3 Overview
1. Check-in (5min)
Personal/medical check-in
2. Processing Session 2 (10 min)
Reflection on second session
Reflection on homework assignment
3.
Introduce Session 3 Topic:Historical Sources of
Meaning (5 Min)
Briefly explore meaning in historical context (regarding pastpresent-future meanings of ones life)
Introduce the theme of life as a living legacy and ask the
patient to briefly define the concept of legacy in personal
terms
4. ExercisesLife as a Living Legacy [PastPresent
Future]
Past legacy: Reflection on familial lineage, upbringing, traditions, and so on (1520 min)
Present and future legacy: Reflection on current meaningful roles and accomplishments, life lessons, and what will be
passed on (1520 min)
19
Session Goals
The main goal for Session 3 is to introduce and explore the topic of
Historical Sources of Meaning and the guiding theme: Life as a
Living Legacy. The patient should be given the chance to describe his or
her personal understanding of legacy on his or her own terms, before
the therapist explores the concept of legacy in historical context (e.g.,
past, present, future legacy). By the end of Session 3, the patient should
have a solid understanding of the core theme through three temporal
legacymodes:
1. The legacy thats been given from the past
2. The legacy that one lives in the present
3. The legacy one will give in the future
Check-in
Welcome the patient back to the third session of individual
meaning-centered therapy. Begin the session by briefly checking in to
see how the patient is doing personally and medically since the last session. This short session check-in should last no longer than 5 minutes.
20
Process Session 2
Briefly return to Handout 1.1 on the weekly topic and draw attention to the progression of session topics through to Session 3 regarding
Historical Sources of Meaning. Ask the patient whether he or she has
given any thought to the prior Session 2 theme, Cancer and Meaning,
over the last week and, if so, how? This should last no longer than 510
minutes.
Homework Reflection
Remind the patient of Homework/Experiential Exercise 2.1 that was
offered at the end of Session 2.Begin initial reflection on the general
topic of Life as a Legacy and ask the patient what the term legacy
personally means. Use this discussion as a purposeful segue for introducing todays session of Life as a Living Legacy. Note that because the
homework is a replicate of this sessions experiential activity, try to use
the patients initial homework reflection as an active transition toward
the session exercise.
21
sense, we are the lead characters, with the people around us in supporting
roles, and with scenery, plots, lessons learned, and baggage inherited. In
another sense, though, we may choose to cast ourselves in the supporting role,
focusing on what others mean to us and need from us. Frankl suggested, He
who has a why to live for can bear with almost any howthis why springs
out of who you are, what values you have and have not yet realized, what
goals you may have, what is important for you. All this comes out of the story
of who you are. Part of this story is the legacy you have been given by your
family and your past, and part of this story is the one you create, perhaps
involving a transcending of this past legacy or an embracing of cherished
values and virtues that connect your past, present, and future. Thinking
about the story of your life helps reflect back on what you have found most
meaningful, what tasks you have undertaken, and what tasks may remain
to be undertaken. Telling your story connects you with the people around
you, and keeps you connected with them whether they are physically in your
presence or not. These tasks can be in any realmthey could be stories to
write, children to care for, lessons to learn or teach, relationships to attend to,
artistic endeavors like painting or sculpture, and so on. One can even find
meaning in the very act of bearing witness to the events of our lives. What is
important about these activities is that they are meaningful to you. Looking
at your life from a historical perspective is not the goal in itself but a means
to an end. For one, it helps you appreciate your own past accomplishments
at the same time that it helps elucidate goals by exploring for what and to
whom you feel responsible.
In this session, Iwould like you to begin to tell your story. How do you fit in
with the history of your family, your heritage, your friendships, your community, and so on? Ican begin to help you tell your story by going over the
questions Igave you last session. So lets begin to explore them together.
At this point, therapists should open the discussion up for the patient
to explore part1 of Homework 2.1 through this sessions experiential
exercise. This exercise discussion should last for 1520 minutes.
Therapist Note: Through this exercise, the patient should be given
the opportunity to explore and express meaningful past experiences,
in order to get an overall feel for the historical context of his or her
living legacy. The legacy that has been given is often multidimensional in nature: for example, biological/genetic legacy, familial
22
23
memories for our lasting legacy. So from this vantage point, we must begin to
evaluate how the legacy we live in the present might impact the legacy we
will give in the future. The meaningful questions then arise:What are the
life lessons we hope to pass on? How will we contribute to the greater whole?
How will we be remembered? What will endure beyond me?
At this point, the therapist should smoothly transition to the experiential exercise part2 of Homework 2.1, which will allow the patient to
explore and express his or her present and future legacy in context. This
exercise should last for the remainder of the session:1520 minutes.
Session Wrap-up
In the remaining 510 minutes of the session, bring closure to the
session by briefly reflecting on the theme of Life as a Living Legacy
and how it relates to the patients reflections on the legacy we have
been given, as well as the legacy we live and will give. Ask the
patient whether he or she has any final thoughts or comments to share
regarding this topic before concluding the session. Briefly introduce
the Session 4 topic, Attitudinal Sources of Meaning, in terms of the
guiding theme, Encountering Lifes Limitations. The following session will explore Frankls core concept of choosing our attitude in
the face of lifes limitations. Hand out Homework 3.1 and Homework/
Experiential Exercise 3.2 for the next session, which challenges the
patient to begin to share a legacy by telling his or her story.
Ask the patient whether he or she has any final comments or questions
regarding the session or homework assignment before ending. Close the
session by reminding the patient of the day and time of the next session
and that you look forward to seeing him or her again for Session 4.
24
Date:
Time:
Session length:
25
SESSION 4
Attitudinal Sources
ofMeaning
Session 4 Overview
1. Check-in (5 min)
Personal/medical check-in
2. Processing Session3
Reflection on third session (5 min)
Reflection/review of homework assignment (510 min)
3. Introduce Session 4 Topic:Attitudinal Sources of
Meaning (510 min)
Revisit Structured Weekly Topics handout and define progression to topic 4 (briefly reference transition process as segue to
session topic)
27
Session Preparation
The therapist should prepare for Session 4 by fully reviewing pertinent
manualized session information. During this preparatory period, the
therapist should reflect upon the session topic and goals, while tailoring particular session details and themes to the patients individualized
needs and experiences.
Session Goals
The main goal for Session 4 is to explore the topic of Attitudinal
Sources of Meaning and the guiding theme: Encountering Lifes
Limitations. The therapist should pick up where he or she left off
from Session 3 by continuing to explore the concept of legacy in
historical context (e.g., past, present, future dimensions) in light of
confronting the ultimate limitation of death and the lasting legacy
one will leave. By the end of Session 4, the patient should have a solid
understanding of attitudinal sources of meaning based on Frankls
core theme that our last vestige of human freedom is our capacity to
choose our attitude toward suffering and lifes limitations in any given
situation.
28
Check-in
Welcome the patient back to the fourth session of individual
meaning-centered therapy. Begin the session by briefly checking in
to see how the patient is doing personally and medically since the
last session. This short session check-in should last no longer than
5 minutes.
Process Session 3
Briefly return to Handout 1.1 on the weekly topics and draw attention
to the progression of session topics through to todays Session 4 regarding Attitudinal Sources of Meaning. Ask the patient whether he or she
has given any thought to the prior Session 3 theme regarding Life as
a Legacy over the last week and, if so, how? This should last approximately 5 minutes.
Homework Reflection
Remind the patient of Homework 3.1 and 3.2 that was offered at
the end of the last session regarding sharing his or her story with
loved ones. Ask how it felt to share ones life history with a loved
one(s). How did it feel to be attended to (i.e., heard, witnessed, or
validated) while reading ones personal story out loud? Allow 510
minutes for the patient to process his or her feelings regarding this
homework assignment, depending on homework completion and
interest level.
29
30
with his or her current physical and medical limitations regarding cancer
diagnosis and treatment, and then it transitions into how the patient may
face the finiteness of life and how he or she hopes to be remembered.
Therapist Note: Again, it is important to recognize the intimate
nature of this topic, especially concerning death and dying. Every effort
must be made to create a safe environment to explore this sensitive discussion. The patient should be encouraged to speak freely about his or her
feelings without passing judgment or attempting to remedy the situation.
Session Wrap-up
In the remaining 510 minutes of the session, bring closure to the
session by briefly reflecting on the session topic, Attitudinal Sources
of Meaning in terms of the guiding theme Encountering Lifes
Limitations. Ask the patient whether he or she has any final thoughts
or comments to share regarding this topic before concluding the session. Briefly introduce Session 5 topic Creative Sources of Meaning
by way of Connecting with Life. Hand out Homework 4.1 and 4.2 for
the next session, which nicely integrates legacy themes with the Session
5 topic, Creativity and Responsibility, through creating a Legacy
Project.
Ask the patient whether he or she has any final comments or questions
regarding the session or homework assignment before ending. Close the
session by thanking the patient for coming and reminding him or her of
the day and time of the next session.
32
Date:
Time:
Session length:
33
SESSION 5
Creative Sources
ofMeaning
Session 5 Overview
1. Check-in (5 min)
Personal/medical check-in
2. Process Session 4
Reflection on fourth session (5 min)
Reflection/review of homework assignment (regarding Legacy
Project) (510 min)
3. Introduce Session 5 Topic:Creative Sources of Meaning
(5 min)
Revisit Structured Weekly Topics handout:define progression
to topic 5 and reflect upon transitions process.
Briefly explore meaning derived from creativity and responsibility
35
4.
Explore Exercise: The Essence of Creativity and
Responsibility (30 min)
Past:Creative endeavors
Present:Creativity through courage and commitment
Responsibilityones ability to respond to life
Past-present-future responsibilities
Unfinished business
5. Session Wrap-up (510 min)
Wrap up session by briefly reflecting on Session 5 theme
Introduce Session 6 theme (Experiential Sources of Meaning)
Give homework assignment for following session
Session Prep
The therapist should prepare for Session 5 by fully reviewing pertinent
manualized session information. During this preparatory period, the
therapist should reflect upon the session topic and goals, while tailoring particular session details and themes to the patients individualized
needs and experiences.
Session Goals
The main goal for Session 5 is to introduce and explore the topic of
Creative Sources of Meaning and the guiding theme:Actively Engaging
in Life via Creativity and Responsibility. By the end of Session 5, the
patient should have a solid understanding of the significance of creativity
and responsibility as important sources of meaning in life.
Check-in
Welcome the patient back to the fifth session of meaning-centered therapy. Begin the session by briefly checking in to see how the patient is
doing personally and medically since the last session. This short session
check-in should last no longer than 5 minutes.
36
Process Session 5
Briefly return to Handout 1.1 on the weekly topics and draw attention to the progression of session topics through to todays Session 5
regarding Creative Sources of Meaning. Ask the patient whether he
or she gave any further thought to the prior Session 4 theme regarding Attitudinal Sources of Meaning over the last week and, if so,
how? This might be a good place to remind patient about transitions
and that the final session is soon approaching. Ask the patient to
share any thoughts/feelings surrounding the finality of the therapy.
This discussion should last for 510 minutes, depending on patient
interest.
Homework Reflection
Remind the patient of Homework 4.2 that was offered at the end of
Session 4 with regard to creating a personal Legacy Project. Inquire
about brainstorming for Legacy Project ideas and ask whether the
patient has any questions that will help him or her initiate this creative endeavor. Use this discussion as a segue for introducing todays
session regarding actively engaging in life via creativity and responsibility. Begin initial reflection on the general topic of Creativity and
Responsibility by asking the patient what these terms personally mean.
37
39
Session Wrap-up
In the remaining 510 minutes of the session, bring closure to the
session by briefly reflecting on the session topic, Creative Sources of
Meaning in terms of the guiding theme, Actively Engaging in Life.
Ask the patient whether he or she has any final thoughts regarding this
topic before concluding the session. Briefly introduce the Session 6
topic: Experiential Sources of Meaning by way of Connecting with
Life. Offer Homework/Experiential Exercise 5.1 for the next session.
Ask the patient whether he or she has any final comments or questions
regarding the session or homework assignment before ending. Close the
session by reminding the patient of the day and time of the next session.
Ask the patient to reflect upon any thoughts or feelings that may arise
over the next week regarding transitions and ending IMCP, which he or
she will have the opportunity to discuss and explore in the next session.
Thank the patient for coming and express that you look forward to seeing him or her again for Session 6.
40
Date:
Time:
Session length:
41
SESSION 6
Experiential Sources
ofMeaning
Session 6 Overview
1. Check-in
Personal/medical check-in (5 min)
Legacy Project check-in (510 min)
2. Process Session5
Reflection on fifth session (5 min)
Reflection/review of homework assignment (510 min)
43
Session Preparation
The therapist should prepare for Session 6 by fully reviewing pertinent
manualized session information. During this preparatory period, the
therapist should reflect upon the session topic and goals, while tailoring particular session details and themes to the patients individualized
needs and experiences.
Session Goals
The main goal for Session 6 is to introduce and explore the topic
of Experiential Sources of Meaning by way of the guiding
theme: Connecting with Life. By the end of Session 6, the patient
should have a solid understanding of the significance of connecting with
life through experiential sources of meaningparticularly through the
sources of beauty, love, and humor.
44
Check-in
Welcome the patient back to the sixth session of meaning-centered therapy. Begin the session by briefly checking in to see how the patient is
doing personally and medically since the last session. This short session
check-in should last no longer than 5 minutes.
Homework Reflection
Remind the patient of Homework/Experiential Exercise 5.1 that was
offered at the end of Session 5 related to todays session regarding
connecting with life through beauty, love, and humor. Use this initial discussion as a purposeful segue for introducing todays session
of Experiential Sources of Meaning. Begin initial topic reflections
by briefly exploring what the experiential sources of love, beauty, and
humor mean to the patient.
45
46
EXAMPLE6.1
Experiential sources of meaninglove, beauty, art, nature, humorallow
us to transcend ourselves by being transported in contemplation within these
experiences. They help us to feel a part of something greater than ourselves,
like individual waves which come together to comprise the ocean. Frankl
describes how even in the concentration camp, he and his fellow prisoners
experienced the beauty of the mountains of Salzburg or a particularly vivid
sunset more richly than before because of their circumstances. They found
solace in the fact that whatever their individual fates, the beauty of nature,
of which they were a part, would continue beyond them.
Experiential sources of meaning are perceived in more of a passive manner
of reverence and contemplation, as compared to the other two more active
sources of meaning (creativity and attitude). As one surrenders to the beauty
of love, art, or nature, one may lose oneself in the
moment of contemplation only to find oneself more authentically present to
life itself. Frankl offers an example:Imagine a music-lover sitting in the
concert hall while...his favorite symphony resounds in his ears. He feels
that shiver of emotion, which we experience in the presence of purest beauty.
Suppose now that at such a moment we should ask this person whether his
life has meaning. He would have to reply that it had been worthwhile living
if only to experience this ecstatic moment (1955, p.43).
Similarly, one can feel transported by feelings of love even when the loved one
is not physically present. Frankl spoke on many occasions about the enduring
love he held for his wife, and how her very memory allowed him to transcend
his suffering, if even for a few short moments. Humor also helps us rise above
difficult circumstances by lightening the moment and allowing for healthy
emotional distance from a distressing situation. Frankl went so far as to refer
to humor as another of the souls weapons in the fight for self-preservation
(1959, pp.5455).
47
Session Wrap-up
In the remaining 510 minutes of the session, bring closure to the session by briefly reflecting on the session topic, Experiential Sources of
Meaning in terms of the guiding theme Connecting with Life. Ask
the patient whether he or she has any final thoughts or comments to
share regarding this topic before concluding the session. Remind the
patient that the next session will be your final meeting. Ask the patient
to reflect upon any thoughts or feelings that may arise over the next
week regarding transitions and ending the treatment (Homework/
Experiential Exercise 6.1), which he or she will have ample opportunity
to discuss and explore in the next session.
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Date:
Time:
Session length:
49
SESSION 7
Transitions
Session 7 Overview
1. Session Check-in (5 min)
Personal/medical check-in
2. Transitions:Reflection on Previous Sessions (5 min)
3. Exploration of Legacy Project (20 min)
4.
Patients Therapy Experience: Experiential Exercise
Reflection and Feedback, Hopes for the Future (20 min)
5. Closure (510 min)
Wrap up intervention by briefly reflecting upon meaningful
moments
Share:thank-yous and good-byes
Reinforce:Its been a learning experience for both of us.
Session Goals
The goals of this final session are pretty straightforward. The therapist
should help the patient reflect upon his or her therapy experience in
51
light of the last six sessions. The therapist should facilitate dialogue
and reflection around the patients thoughts and feelings surrounding the finality of this IMCP experience, in light of facing important
transitions and endings in his or her own life. Explore what it has
been like for the patient to share his or her cancer experience and life
story within treatment, and how it has felt to have his or her story
witnessed and affirmed. Time should be given to share and explore
the patients final Legacy Project, as well as meaningful experiences
within the treatment process. Time should also be allotted for the
patient to offer feedback regarding his or her therapeutic experience
and hopes for the future.
Check-in
Welcome the patient back to the seventh and final session of
meaning-centered therapy. Begin the session by briefly checking in to
see how the patient is doing personally and medically since the last session. This should last about 5 minutes, but it may last longer if the
patient wants to share final statements regarding overall well-being.
Process Transitions
Briefly return to Handout 1.1 on the weekly topics and draw attention to the progression of session topics through to todays seventh and
final session, identifying and emphasizing weekly themes in the process. Inquire whether the patient has given any thought to what this
final session would be like over the last week. Ask the patient to share
any thoughts and feelings he or she might have surrounding the finality
of therapy. This transitions discussion should last about 30 minutes,
depending on patient interest.
Legacy Project
The therapist should then smoothly transition from discussing
endings to exploring new beginnings in and through the patients
52
Intervention Feedback
The therapist should use the remaining time in this final session to
receive the patients feedback regarding the overall intervention, as
well as to reflect upon his or her hopes for the future. Use Homework/
Experiential Exercise 7.1 to prompt intervention feedback and dialogue,
including hopes for the future.
Session Wrap-up
In the remaining 510 minutes of the session, bring closure to the
therapy by briefly reflecting upon meaningful experiences, moments,
or memories from the shared therapeutic experience. Ask the patient
whether he or she has any final thoughts or comments to share before
bringing final closure to the treatment. Thank the patient for being a
meaningful part of this therapeutic encounterfor the moments shared
and the mutual learning experiences that were offered along the way.
Finally, expressions of gratitude and a reflection by the therapist on the
legacy created within the therapy are shared. Often it is useful for therapists to remark on moments of courage, moments of connectedness, and
moments of self-care. It is not uncommon for therapists to acknowledge
the ways in which they have been impacted by the participant, the honor
and privilege of sharing in these intimate moments at a critical stage in
their lives, and affirm that the patient will not be forgotten.
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54
Date:
Time:
55
References
57
Handouts
Handout 1.1
Structured Weekly Topics for Individual Meaning-Centered Psychotherapy
Session 1:Concepts and Sources of Meaning
Session 2:Cancer and Meaning
Session 3:Historical Sources of Meaning
Session 4:Attitudinal Sources of Meaning
Session 5:Creative Sources of Meaning
Session 6:Experiential Sources of Meaning
Session 7:Transitions (Reflection and Hopes for Future)
59
Handout 1.2
Individual Meaning-Centered Psychotherapy
Inspired by the works of Viktor Frankl:Mans Search for Meaning
Meaning-Centered Psychotherapy Basic Concepts:
1. The will to meaning:The need to find meaning in human existence is a basic primary motivating force shaping human behavior.
2. Life has meaning: The possibility to create or experience meaning exists throughout our
lives, even up to the last moments of life. If we feel life if meaningless, it is not because
there is no meaning in our lives, it is because we have become disconnected from meaning.
3. Freedom of will: We have the freedom to find meaning in our existence and to choose our
attitude toward suffering and limitations.
He who has a why to live for can bear with almost any how.
60
61
62
Handout 1.5
Individual Meaning-Centered Psychotherapy Calendar
Sessions will take place at:
Session no.
Date
Time
Session 1
Session 2
Session 3
Session 4
Session 5
Session 6
Session 7
63
Handout 2.1
Suffering
Suffering
Physical
Mental
Emotional
Spiritual
Existential
FIGURE A.1
64
Find Meaning
(via: sources of meaning)
Lose Meaning
(Existential Vacuum)
Homework/Experiential Exercises
65
Homework 1.1
Reading:Viktor Frankls Mans Search for MeaningPart1
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67
68
Homework 3.2
Share Your Legacy:Tell Your Story
Tell your story to loved one(s) in your life, in any manner that is comfortable to you. The key is to
highlight experiences that have been sources of pride and meaning for you, or things you wish you
had accomplished but have yet to do. As you share your story, start becoming aware of how it feels
to have your words witnessed, validated, and affirmed by those who matter most.
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Homework 4.2
Legacy Project
We want to remind you of the theme Life as a Living Legacy through creating your own
Legacy Project. This is a project that you can undertake that integrates some of the ideas we
have already discussed (e.g., meaning, identity, creativity, responsibility), in order to generate
a sense of meaning in light of your life and illness. Some examples:creating a legacy photo
album or video, developing a music compilation of meaningful songs, mending a broken
relationship, undertaking something youve always wanted to do and have not yet done... the
legacy is up to you!
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1) _______________________________________________
2) _______________________________________________
3) _______________________________________________
Beauty
1) _______________________________________________
2) _______________________________________________
3) _______________________________________________
Humor
1) _______________________________________________
2) _______________________________________________
3) _______________________________________________
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75
Index
activities, creative, 71
antidepressant therapy, xiii
assisted suicide, patient requests for, xiv
attitudes, choosing, 7, 28, 30
attitudinal sources, of meaning, 7, 2733, 61
attitudinal values, realizing, 10
authenticity, as a complex concept, 3839
authentic sense of self, 16
beauty, 43, 46, 47
biography, judging, 31
brain metastases, cognitive deficits due to, xxv
business, unfinished, 71
cancer
effects of, 6
meaning and, 1318
of the patient, 9
Cassel, Eric, 30
check-in, 14, 20, 29, 36, 45, 52
closure, bringing to the therapy, 53
cognitive reframing, xxixxxx
commitment, as meaningful, 71
connectedness
to loved ones, 30
with something greater than ones self, 62
ultimate, 23
connecting with life, 11, 43, 44, 46, 73
connection/connectedness, 8
contemplation, 47
coping, optimizing, xxvi
core aspects, of identity, 16
counseling approach, utilizing IMCP as, xxiv
courage, 38, 39
courageous, being, 71
The Courage to Be (Tillich), 39
The Courage to Create (May), 39
creative activities, 71
creative and attitudinal sources of meaning, 46
creative calling, ability to respond to, 38
creative sources, of meaning, 8, 3541, 61
creative values, realizing, 1011
creativity, 37, 39
Creativity, Courage, and Responsibility theme, 35,
3839
Creativity and Responsibility, initial reflection on, 37
77
78
having meaning, 56
from a historical perspective, 22
knowledge of finiteness of, 31
never ceasing to have a meaning, 1
Life as a Legacy theme, 17, 21, 68, 72
Life as a Living Legacy theme, 19, 21, 24
life story, 60
limitations, 30, 31
living legacy, 10, 23
logistics, in Session 1, 4
logotherapy, xiii, xxix
loss of meaning, xv, xxiv
loss of spiritual well-being, xxiv
love, 43, 46, 47
loved ones, sharing ones life history with, 29
79
80
supporting role, 22
supportive group psychotherapy (SGP), compared to
MCGP, xvii
tape recording, purposes of, 4
terminal illness, diagnosis of, xv
themes
importance of seeking, xxviii
relating back to patients, 10
therapeutic massage (TM), xviii
therapist
authoritarian and patronizing, xxx
care tenor, xxxxxxi
final remarks by, 53
general guidelines for, xxiii
introducing himself or herself, 3
training required for, xxiii
Therapist Adherence Checklist, xxviii
Therapist Adherence Checklist and Group Process
Note, 12, 18, 25, 33, 41, 49, 54
The Treatment Manual for Meaning-Centered Group
Psychotherapy for Patients with Advanced
Cancer,xii
thoughts/feelings, surrounding finality of the therapy,
37, 45, 52
Tillich, Paul, 39
time, limited amount of, 31
tragic triad, guilt, suffering, and death, 6
transcendence, 30
transitions, 37, 45, 5154
treatment goals, 34
treatment overview, xxiiixxxi
Tuesdays with Morrie (Schwartz),xxix
unfinished business, 71
values, hammering out, 31
ways of doing, moving to ways of being,
16
will
freedom of, 6, 60
to meaning, 5, 60
The Will to Meaning (Frankl),xxiii, xxix
witnessed significance, 53
work, lifes, 71