INTRODUCTION
The presence of meaning in a person's life increases its quality and, if the person has cancer, has been found to also be predictive of well-being (Vickberg et al., Reference Vickberg, DuHamel and Smith2001; Bauer-Wu & Farran, Reference Bauer-Wu and Farran2005; Gall et al., Reference Gall, Guirguis-Youngerm and Charbonneau2009). Meaning in life appears to mediate the distress associated with cancer (Meraviglia, Reference Meraviglia2006; Lethborg et al., Reference Lethborg, Aranda and Kissane2007) and assist in making sense of the cancer experience (Richer & Ezer, Reference Richer and Ezer2002) and can balance the suffering involved in living with such a serious illness (Lethborg et al., Reference Lethborg, Aranda and Bloch2006). Through reviews conducted by researchers such as Lee et al. (Reference Lee, Cohen and Edgar2004) we are better able to understand the positive association that meaning in life has on reduced distress, increased social connections, and overall adjustment.
The kinds of interventions that have meaning at their core are informed by the early existential therapists from the 1950s (Yalom, Reference Yalom1980; Spiegel et al., Reference Spiegel, Bloom and Kraemer1989). These therapeutic models have been used in supportive-expressive therapy with those facing the end of life (Goodwin et al., Reference Goodwin, Leszcz and Ennis2001; Kissane et al., Reference Kissane, Grabsch and Clarke2007; Spiegel et al., Reference Spiegel, Butler and Giese-Davis2007) and in group-based meaning-centered psychotherapy for patients with advanced cancer (Greenstein & Breitbart, Reference Greenstein and Breitbart2000; Breitbart et al., Reference Breitbart, Gibson and Poppito2004, Reference Breitbart, Rosenfeld and Gibson2010). Recent results from a randomized controlled study indicate that meaning-centered group psychotherapy can significantly improve spiritual well-being and a sense of meaning (Breitbart et al., Reference Breitbart, Rosenfeld and Gibson2010). Built upon life review and the narrative approach (Viederman, Reference Viederman1983; White, Reference White1990, Reference White1997; Charon, Reference Charon2004), Chochinov's “Dignity Conserving Care” focuses on the palliative phase of illness and can be classed as a meaning-based intervention in its use of concepts such as transcendence and a focus on what has been meaningful in a person's life (Chochinov, Reference Chochinov2002).
Notions such as “purpose in life” (McKnight & Kashdan, Reference McKnight and Kashdan2009), “meaning-based coping” (Folkman & Moskowitz, Reference Folkman and Moskowitz2000; Holland et al., Reference Holland, Poppito and Nelson2009), logotherapy (Danhauer et al., Reference Danhauer, Carlson and Andrykowski2005) and existential psychotherapy (Cole & Pargament, Reference Cole and Pargament1999; Spira, Reference Spira, Chochinov and Breitbart2000) have all been used in recent interventions with patients to review, reconsider, and reclaim that which is most meaningful and significant to them. Although few researchers have undertaken large, randomized controlled trials to investigate the specific benefits of such interventions, all offer strong anecdotal evidence that these processes are a welcome focus for people who are engaged in life review and meaning-based coping processes.
Our own research has focused on the development of a theoretical foundation for an intervention based on meaning and purpose and developed specifically for the advanced cancer population through qualitative (Lethborg et al., Reference Lethborg, Aranda and Bloch2006), quantitative (Lethborg et al., Reference Lethborg, Aranda and Kissane2007) and translation research processes to develop a clinical model of care (Lethborg et al., Reference Lethborg, Aranda and Kissane2008). This model of meaning in adjustment to cancer directly informed the development of a brief meaning and purpose (MaP) psychotherapy.
Whereas overlap exists with every model of therapy, each brings something fresh in approach that eventually enriches the strategies and techniques adopted by the field. Breitbart's (2010) meaning-centered model follows a psycho-educational framework drawn from Frankl's logotherapy. Chochinov's (2009) dignity therapy has a key focus on fostering an expanded sense of self-worth, with legacy generation for those who follow. Viderman (1983) applies participants' narratives broadly, and hence responds to any crisis or transition that arises.
MaP therapy's specific focus is on two key domains of lived experience: “meaning” and “purpose,” closely linked with the notions of “significance” and ‘“intention.” The participant in MaP therapy is challenged to move beyond insights about meaning in life, toward action that will increase this meaning. MaP therapy utilizes a broad focus of meaning in that it incorporates cognitive, existential, and social aspects of meaning. In addition, the therapy is patient driven, in that the content of each session is derived directly from material that the participant shares. In this sense, the intervention requires considerable creativity on the therapist's part to appreciate the coherence, value, and direction of each individual's life, to give name to that person's accomplishments, and to affirm and reach consensus over what has been fulfilling in life.
This study describes the experience of a group of participants who undertook this therapy with the aim of verifying that the core ideas of our intervention were present in the patient experience, prior to pilot testing. In addition, we were interested in ascertaining the acceptability and usefulness of the therapy as perceived by participants. The development of the therapy will be briefly described prior to the participant's experiences.
BACKGROUND TO THE INTERVENTION
Three concepts arising from our previous research in particular were pertinent to developing this intervention:
1. Meaning is a notion about the value in life that has multiple perspectives. The existential perspective (meaning in life); the cognitive perspective (meaning of life); the social perspective (meaning in context) and the physical perspective (capacity for meaning) (Lethborg et al., Reference Lethborg, Aranda and Kissane2008).
2. Whereas the focus on meaning relates to those aspects of a persons’ life that are significant, the focus on purpose relates to the notion of intention where meaning directs actions and goals.
3. There is a drive or motivation toward meaning even within suffering, and this drive can be triggered by suffering itself. Frankl's (Reference Frankl1963) notion of “will to meaning” is essential in understanding this point.
The way that these concepts informed the goals of this therapy are illustrated in Table 1.
Table 1. Clinical implications of meaning in adjustment to cancer
The physical component of meaning was omnipresent as the clinician strove to understand symptoms and their treatment. The other three components (cognitive, existential, and social) illustrated in Table 1 offered a framework to develop our intervention. The goals of “promoting coherence,” “encouraging meaning and purpose while recognizing suffering,” and “strengthening meaning in relation to others” were considered a starting point. These goals represented a comprehensive breadth of focus that included the person and that person's social worlds, and directed the content and the psychotherapeutic techniques that we applied. In addition, a unique aspect of this model was that therapists focused on making links between meaning (significance) and purpose (intention) with the aim of increasing awareness and encouraging action or direction for future goals. Given our desire to develop a therapy that may be used in the acute setting, we also wanted to keep this intervention brief and focused specifically on “meaning” and “purpose,” a key clinical direction.
MaP THERAPY DESCRIBED
The name developed for this intervention is “MaP Therapy,” used to reflect both the acronym for “meaning and purpose” and the process of charting (or “mapping”) an understanding of meaning and purpose in the lives of individuals with advanced cancer. This intervention is a four session, individual, face-to-face therapy that uses methods influenced by narrative therapy, meaning-based coping theory, existential therapy, and cognitive therapy. MaP therapy has been manualized for training purposes and to assist in fidelity testing during the trial phase. The manual has been reviewed by a range of clinicians, and the study has been approved by the human ethics committees at St. Vincent's Hospital (Melbourne) and the University of Melbourne, in keeping with institutional review board approval.
The objectives of MaP therapy are to:
1. Identify the specific origins of meaning (generally and particular to their illness) in the participant's life.
2. Develop an individualized plan with the participant that focuses on desired cognitive and existential shifts required to enhance meaning, that is, when the participants' global meaning has been so challenged by their situational meaning (Park and Folkman, Reference Park and Folkman1997) that they would like to work toward coherence. To further illustrate, if a person believed that cancer does not happen to “good people” and saw themselves as “good,” then after diagnosis this belief will need to be reconsidered if the person is to adjust to the diagnosis with a sense of coherence.
Consider the life lived and life desired with a specific focus on goal setting toward a “life desired”; and
3. Consolidate and bring new understandings of self to the participant in relation to purpose, particular meaning, and the participant's social world.
Each of the four sessions of MaP therapy used narrative methods to encourage the participant to “tell their story.” The focus of the discussion around this story was the meaning and purpose participants described in their life. The personal impact that cancer has had was also addressed, but was not the focus. Hearing a person's story allowed for a context to be understood and current challenges and strengths to be placed within the continuum of the person's life. Within this discussion, questions were asked about how participants experienced the world, their place in it, and the people important to them, and whether their cancer had created any discontinuity in their life's story. Participants were also asked about the foundations of meaning in their lives, with the therapist being guided by the participants' narratives and also offering alternative ways of viewing the participants' personal stories in order to challenge beliefs and encourage insights.
Throughout the sessions, the therapist took notes of pertinent themes and information. These notes were used to develop a list of themes, contributions to meaning, and statements about or alluding to purpose in life and any inconsistencies they might have presented. These notes also helped to focus subsequent sessions and were presented back to the participant for clarification at the beginning of each session.
Questions were posed by the therapist to challenge narrative accounts, promote constructive alternatives to the framing of life stories, and direct attention toward positive and meaningful, purposeful goals. Discussions about relationships to others were framed to link with the aspects of meaning identified. The therapist brought together threads from participants' stories to develop a picture of their lives' meaning and purpose and their connection to a wider social framework. The final session focused on the aspects of meaning and purpose the participant might find helpful to focus on in the future. There was also a rounding off of themes in order to create cohesion. An overview of the aims, objectives, and processes involved with these four sessions is provided in Table 2.
Table 2. Overview of the aims, objectives and processes of “MaP therapy”
This study was undertaken in order to determine if the experience of participating in MaP therapy related to the therapeutic goals of this intervention, such as an increased sense of coherence, meaning, and purpose in life and meaning in relation to others.
Aims
The aims of the study were (1) to examine the themes arising from MaP therapy sessions in relation to therapeutic goals, and (2) To describe participant acceptability of number of sessions and processes used in MaP therapy.
METHOD
Participants
Inclusion criteria were advanced (stage 3 or 4) cancer, an ability to speak and read English, and a willingness to attend all sessions of the therapy.
Recruitment
An overview of MaP therapy was presented to cancer services staff who were asked to recruit patients who met criteria during the study period. Potential participants were offered a newly developed therapy that focused on meaning and purpose.
Procedure
Participants were offered MaP therapy within 1 week of being recruited. They were given a description of the therapy and session appointments were made at a time convenient to their needs. The therapist followed each session according to the MaP therapy manual.
Data Collection
Process notes were taken by the therapist throughout the sessions and immediately at the end of each session. Notes included specific quotes from participants, topics discussed, processes used, and links made between narratives and the participant's personal sense of meaning and purpose. At the end of the final session, participants were asked to describe what their experience of MaP therapy was, what was helpful about the sessions, if anything proved unhelpful, and how well the timing of the sessions (including number of sessions) met their needs. Notes from this interview and all session notes were used as data.
Data Analysis
As participants completed their fourth and final session of therapy, their interviews were analyzed by the first author and an independent reviewer skilled in both psychotherapy and qualitative research.
Using a content analysis (Weber, Reference Weber1990) approach, this process involved interrogating the data and searching for similarities and disparities in meaning. Reading and rereading the data enabled specific threads to be identified, coded, and categorized into themes (Patton, Reference Patton1990). These core themes were not seen to occur as abstract concepts, but as sources of referential meaning in relation to the therapy (Mishler, Reference Mishler1986). Similar themes were notionally grouped together. This analysis was inductive in that themes were identified from, rather than imposed on, the data (Patton, Reference Patton1990). To illustrate this process further, each theme will be described subsequently, with specific quotes from the interviews.
Analysis from both reviewers was compared for inter-rater reliability. Agreement between reviewers was reached for all components of analysis. When a repetition of themes occurred and no new themes were found, the cohort was considered complete.
RESULTS
Participants
Participants (n = 6) were recruited over a 6-month period for this study. Of the eight patients approached to take part in this study, six agreed. The two individuals who did not want to participate stated their reasons as feeling “too unwell” and “being about to travel interstate to visit relatives.” All patients who agreed to participate completed all four sessions of the therapy; therefore, analysis was conducted on 24 therapy sessions.
All participants were receiving outpatient palliative treatment for symptom management; 50% were female, and there were a variety of cancer diagnoses and ages (ranging from 39 to 86 years) with an average age of 61 years. Table 3 provides details of all patients asked to participate in this study.
Table 3. Participants and non-participants: “MaP therapy” study
The de-identified participants came from a range of backgrounds, age groups, tumor streams, treatment experiences, and worldviews.
• “Josef” was a 69-year-old professional man who had never had counseling and, by his own admission, had never considered that he would be in a therapeutic setting.
• “Anna” was a 39-year-old mother facing the prospect of leaving her beloved husband and 4-year-old son.
• “Meg” was a 54-year-old woman who described feeling “used up” from being a stay-at-home mother, the carer of her father, the helper at school, and the support person for many of her friends. She had initially viewed her cancer as a further hardship in a difficult life.
• “Mario” was an 86-year-old Italian man who had a life of regret and viewed the notion of talking about this with mild amusement.
• “John” was a 58-year-old man who had struggled with his homosexuality throughout his life, but had gained many friendships, and saw the chance to consider the meaning and purpose in his life as a welcome opportunity to review various dimensions of his life and important relationships.
• “Claudia,” 62, was a deeply spiritual person who had lived a life of meaning and authenticity and welcomed sharing her story, reviewing the events of her life, and pondering meaning in the future.
Themes
At the end of the analysis of the final sessions, a themes list was constructed. This list of themes included: (1) Beneficial Reflection, (2) Meaning Attribution, and (3) Living with Purpose toward a life desired. Each will be described separately using content from the actual therapy sessions and then considered in relation to the goals of therapy.
Theme 1: Beneficial Reflection
Despite having vastly different backgrounds, all participants shared the view that the quarantined time they had, which focused on reviewing areas of significance in their life and the people and events that have shaped them, was of particular benefit. Each came from very different places in their life story and in their conceptualization of therapy, but they all commented on the benefit they experienced from stopping to ponder meaning in their life.
All participants found reminiscence to be an evocative experience. Even for “Mario,” who found some of the experience to be quite confrontational because of his regrets, completing MaP therapy offered a setting in which to explore alternatives to regret and a balancing of regret with achievements. “Mario” explained
I never considered there was a different way I could look at things. Perspective is important, isn't it? If you view your life as a whole, there are “ups” and “downs” — I have been really wallowing in the “downs.” Perspective doesn't make them go away; it just balances them out a bit.
One of the discoveries in this study was that talking about meaning and purpose was not as confrontational as participants initially perceived that undertaking this therapy might be. The notion of “confrontation” here refers to the unexpected insights participants have when the therapist reflects back statements and responses made about the cognitive and existential understanding of their life experiences, which can include life regrets, unrealized goals, and death anxiety. There was a prior fear expressed by three of the participants that they might be encouraged to discuss cancer and mortality, but they found that they were able to discuss their life in a much broader context and that this was helpful to them in the present, as “Josef” explained
I came along to this (the therapy sessions) not really expecting it to be that helpful, you know, I think we've ascertained that I am a “people pleaser”. Anyway, I was pretty down when I met you but what was good for me was that we didn't start by talking about what I was down about, we both knew that cancer was a shadow over my life, but the focus was on my life, not the shadow!
“Anna,” the young mother in this study, also spoke about the benefit to her of having a forum in which to talk about meaning and purpose, given that the significant people in her life were so focused on the agony of her having to leave her baby son and the love of her life. She stated
Everyone is so caught up in the tragedy of this that they are not really “with me” in this, and they can't bear to let me focus on the things I need to focus on, finishing up, creating memories and just being with the ones I love without all the pain all the time.
Theme 2: Meaning Attribution
The second theme related to the value described by participants of having aspects of meaning and purpose drawn out of their narratives and reflected back to them. The therapist used a specific framework to highlight how participant stories relate to meaning and purpose. This process needed to accommodate a variety of narrative types and life stages and a range of aspects of meaning. Participants all commented on the benefit they found in being directed to view their life stories in a quite specific way. “Josef,” for example, recalled at the end of his first session the following encounter, which he later realized, was a turning point for him; “This is what made me turn to face the important things in my life.” To summarize
As the session time drew to a close the therapist relayed back to “Josef” some of what she understood from his story – the sadness that he carries from his childhood, the regrets about not being able to be “who he was” as a child and young man, but she also suggested that the feelings he was having following the progression of his cancer seemed to be causing a life reflection that was “a little one sided.”
“Josef” was surprised at this idea — he had nodded seriously throughout the therapist's account of his suffering, but looked up quizzically at her suggestion of a one-sided reflection of life. The therapist continued, “It would seem to me that you have taken a situation where you felt you had little freedom to be what you wanted to be, but out of respect to your father you became the lawyer he wanted you to be and made a success of it in spite of your inner desires. I understand the sacrifice that this must require but I also think that you could have not succeeded as a lawyer and not maintained a relationship with your father. You have also made the choice to stay married for 45 years, to maintain your love of the sea and have passed this love on to at least two generations. Can you see, these moments of great meaning, where you were ‘most happy, peaceful and joyous’ as you said; they too have had a place in your life?” “Yes, yes I can see that — very interesting” “Josef' replied. He returned to the following session with a different focus and a different view of his life story.
Similarly “Meg” found that the experience of MaP therapy raised new ways of looking at life experiences and her story
“Meg” had focused on one of the questions the therapist asked: “What did you long for in life?”, This question triggered memories of a childhood that was shrouded in loss and disappointment. She brought a list of losses to the next session. The therapist asked her to talk about these losses and to think about what each has meant in her life, why she had chosen these in particular to share and if she saw any meaning in them. “Meg” went through the list one by one and found herself countering each loss with things she had done in spite of them – for example, when her abusive father refused to buy her the only doll she had ever asked for, she spent hours making her own doll – the first of many. In the context of meaning, she found that the losses highlighted her resilience. “I guess we are thinking about significance here aren't we – not loss! Things that bring meaning and fulfilment as you have said. I am resilient! I am! And that should be my focus.”
In the final interview “Meg” said, “This [the therapy] has been a bit like someone holding up a mirror to my life and showing it to me with a different perspective. It's not like you gave me meaning, you just showed me mine!”
For “Anna,” reminiscence enabled her to take a broad view of her life and gain a specific clarity about what was important for her now:
I realised I am defined by my relationships with others, this is how I view myself, how I spend my time, what is important to me. A number of people have shaped me, but in particular my parents, my brothers, my husband and my baby. Each has given me what I need to grow…I knew that my family and friends were important to me, I would have said this to anyone and yet I hadn't sat down and said to myself, ‘This is what gives me meaning and so I should have more of that in my life’, I just hadn't viewed it like this
These examples show how guided reflection can bring about revelations that enable more clarity and focus in life. They are also examples of how not focusing on suffering but looking instead at meaning can help to “move” the person from a place of suffering to a place of meaning.
Theme 3: Living with Purpose Toward a Life Desired
Although this therapy did not require a project to be completed by participants, the focus on purpose in particular tended to trigger participants toward a specific goal or action. To give an example, “Josef” had discussed his regrets in relation to his fathering role and in relation to always doing what he felt was expected of him. Through each session the therapist illustrated areas of Josef's life in which he had indeed focused on his children and on aspects of his life that were meaningful, while offering understanding of the existence of regret. “Josef” had identified his love of boats and the ocean, and although he regretted not focusing on this as a career, he agreed that he had, in fact, kept boating as an important focus throughout his life. By session three, “Josef” had received the news that his treatment was no longer working and decided to ponder the possibility of focusing on a life of increased meaning. At the beginning of the final session the following exchange occurred
Therapist: “How was it useful to you to do this [consider what he would need to do to live a ‘life desired’]?”
“Josef”: ”Well, first of all it prepared me for the ‘Big Dinner.’ I decided to get everyone in my family together to share my treatment news and the ‘boat plan’ so we organised a dinner. In some ways it was a little ‘last supperish,’ but I decided to go with that — it was what it was and I wasn't going to be ashamed. So, I asked them all to listen to me and told them the news and then I went around the table, told everyone what they meant to me individually and asked each if they would help build a boat. A number of tissue boxes later, we had a boat plan, agreement that I would take the final chemo understanding it was for palliative reasons for as long as it held me without side effects. But most importantly, I told each person at this most sacred of tables,” Josef's' voice cracked, “what they meant to me and how much I loved them.”
For “Anna,” it was getting family portraits completed, for “John,” it was spending more time with chosen friends and for “Claudia” it was about going through old boxes of mementos. For “Meg,” the chance to stop and reflect on her life also offered a different perspective on her life's direction
You know, I am often so busy that I just don't stop to think about what is important to me, even when I have been so sick, it has been everyone else I have been thinking about. It is only now, telling you about what is meaningful to me that I am thinking; it is time for me…I had filled my life with things other than that which gave it meaning and these sessions reminded me what was meaningful.
As mentioned previously, the process of MaP therapy was particularly confrontational for “Mario.” There was a sense of regret in his narrative and as he progressed through the sessions he began to consider the possibility of balancing these thoughts with the positive aspects of life. “Mario” entertained the notion of self-forgiveness during his third session and concluded that his cancer was not a punishment. His stated goal post-therapy was to move further toward coherence in relation to his cancer, stating; “I want to understand, as you say ‘What cancer means to me,’ I want to make sense of this. I want to feel peace in my heart and I thank you that I have started this journey.” For “Mario,” it was the introduction of the possibility that he could look at life in different ways, consider options in how he saw his life and his cancer that was powerful to him. In order to continue this process in particular, “Mario” was referred back to his social worker for further counseling. The benefit of MaP therapy in this instance was to offer alternative ways of considering his experiences and help identify areas of importance for him to focus on. “Mario's” desire to pursue counseling was similar to “Josef's” desire to build a boat — it was the identification of purpose that was the outcome rather than the fulfilment of that outcome itself.
These three themes were agreed upon by both reviewers as encompassing the main components of the experience of participating in MaP Therapy. Importantly the themes all related to our goals of therapy: “beneficial reflection” encouraged a sense of coherence; “meaning attribution” and “living with purpose toward a life desired” illustrated the way in which the therapy enabled the encouragement of meaning and purpose while recognizing suffering. Finally, “meaning attribution” was experienced within each participant's social context.
Participant Feedback in Relation to Number of Sessions and Processes
Participants offered the following feedback after their final session. This included generally positive statements about the experience of MaP therapy despite the surprise that the therapy raised some difficult issues for participants. The kinds of responses offered by respondents included:
The experience of MaP Therapy was…
• Positive
• Comfortable
• Surprisingly deep (“While I thought talking about meaning would be an ‘easy’ therapy – that is, it would not require me to talk about ‘hard things’, in the end, it made me think more than other therapy experiences I've had” [“John”])
• An enjoyable time of reflection
Responses to the question about what was helpful were also positive and alluded to the therapeutic processes of narrative reflection and meaning attribution.
The experience of MaP Therapy was helpful because it involved…
• Being challenged to think differently
• Reflecting
• Being heard
• Not talking just about cancer
• Thinking about how I spend my time — my life
Most participants did not respond to the question about what was not helpful, however the following response was an important reminder of the complexity of this concept.
• ‘‘Some of the ideas like ‘purpose in life’ took a while to get my head around”[“Meg”])
Responses to the question of timing and number of sessions included
• I wouldn't have wanted the therapy to be any longer
• It was good to stay focused for the four sessions — it meant that I could sustain my focus
• I found it hard to get to two of the sessions due to lethargy and pain, I dragged myself in because it was important and knowing it was only for four sessions helped me to get there
• I would have liked some more sessions
DISCUSSION
The themes arising from this study suggest that the process of MaP therapy is one that encourages reflection and offers insights; can be confrontational but can also allow participants to “shift” their perspective and focus on meaningful goals. The focus of “meaning” and “purpose” highlighted the aspects of significance and intention in participants' lives in spite of their cancer and its treatment. Importantly, this focus resulted in goal setting that was either grand (building a boat) or straightforward (spending more time with specific people or having a family portrait done), but regardless of the magnitude, the sense of meaning was expressed. The themes in each participant's narrative also reflect the breadth of meaning (including cognitive, existential, and social meaning) suggested in our initial theoretical findings and were largely in keeping with our goals. It is the bringing together of these cognitive, existential, and social components of meaning with an added focus on purpose that is unique to MaP Therapy. The overall aim of developing an intervention that can be conducted in the acute setting by staff clinicians and that is effective and efficient has driven the need to create a therapy that is both broad and focused.
“Promoting coherence” was illustrated in discussions about making sense of the cancer experience as well as in life's reflections, including coherent threads and inconsistencies in an individual's narratives. This goal was core to the theme of beneficial reflection in that the therapist aimed to encourage reflection-with-purpose by challenging initial thoughts and following up with further questions to encourage more in-depth reflection and insight.
“Encouraging meaning and purpose while acknowledging suffering,” was first described by logotherapists, whereby suffering is empathized with but not focused on. This process is somewhat counterintuitive for the experienced counselor, but during these sessions, it was clear that it could be very powerful to pursue meaning. Rather than distracting from suffering as such, MaP therapy focuses toward discovering meaning by invited examination of intention and purpose, always encouraging participants to move toward the life desired in spite of suffering.
“Strengthening meaning in relation to others” was a thread purposely highlighted throughout these sessions. Given our strong findings of the importance of perceiving a sense of belonging and significance through our relationships (Lethborg et al., Reference Lethborg, Aranda and Kissane2007), the therapist made it a point to draw out the impact of loved ones in each participant's narrative. Questions that encouraged participants to ponder the influence of others, the lessons learned from others, and the deep value their life had had on others were raised, as well as checking about the impact of goals and plans on the people close to them.
Because the application of these goals was possible in all of these six people's experiences, this exploration of the relevance of MaP therapy was a success. All participants assessed the therapy as beneficial, attended all sessions, described a shift in how they thought about their situation (cognitive meaning) and described awareness of the profound manner in which their lives were now significant and meaningful (existential meaning). Although not measured as such, and allowing for variations in the magnitude of these benefits, all described positive outcomes of their MaP therapy experience.
It is clinically feasible to conduct a brief meaning and purpose intervention for participants with advanced cancer and through the techniques used; the intended goals of therapy can be achieved. Participants' feedback confirmed acceptance of the model. The therapists' active use of narrative summary, which offered an integrated coherence of the value and accomplishments of each person's life, proved to be a core feature of the model. In addition, the brevity of this therapy was acceptable to all but one of the participants, who would have liked more.
The Need for Pilot Testing
The insights gained from this exploration now empower pilot testing of this intervention. This feedback does not prove that MaP therapy is relevant or necessarily positive for all people with advanced cancer, rather it illustrates that the therapy offers what we intended it to. This cohort was “hand-picked” by staff as a group that they believed would find this helpful. Refuses were small in number, dropping out did not occur, and participants all gave feedback. We do not expect that consecutive recruiting would necessarily result in the same outcomes. The triggering of regret and the focus on future goals, past influences, and important relationships were all experienced as bittersweet during these sessions. MaP therapy then, may not be suitable for participants with specific traumas in their past, for example, who might need more directed and intense support to explore such experiences.
In addition, one therapist might develop a strong therapeutic alliance with a patient through his or her charisma. Therefore, the model needs formal testing for its reproducibility with a range of different therapists, demonstrating the ease of application and the model's efficacy. A rigorously conducted, pilot randomized controlled trial of the therapy is therefore now underway with a range of therapists, which will provide us with more information about the kinds of patients who might benefit the most from this intervention. This will further enhance our understanding of the model and its potential to influence adjustment to advanced cancer.
LIMITATIONS
There are a number of limitations to this study, first, the method of data collection involved the therapist herself collecting data from sessions and the follow-up interview and this could have encouraged a bias in responses caused by social desirability. In an attempt to counter this possibility, participants were told that the therapy was in development and that their responses were useful whether they were positive or negative. In addition, the use of an additional researcher during the analysis process, and a requirement for inter-rater agreement, encouraged independent scrutinizing.
Second, as mentioned previously, our sampling process was convenience driven, deliberately planned so that we could run through the therapy in its entirety to discover how MaP therapy is experienced rather than to “test” this for efficacy at this stage. However, our pilot trial will use a consecutive sampling approach to recruitment.
Finally, the study was further limited by the small cohort of participants. However, the size of the study (24 therapy sessions) was considered sufficient to explore the experience of undertaking the therapy and to “iron out” any practical concerns in conducting the therapy itself.
CONCLUSIONS
This study did not seek to demonstrate the benefit of MaP therapy as such, but to describe the experience of undertaking the therapy with people living with advanced cancer. Specifically, we were interested in examining the themes arising from participation in the intervention in relation to our therapeutic goals, and how acceptable both the number of sessions and processes used were.
Participants offered encouraging feedback about which techniques were useful to them, and how appropriate the number and number of sessions were. Results illustrate how the therapist creates a therapeutic frame that holds up a poignant portrayal of the meaning of life lived and mirrors this to the patient, such that the patient can grasp its rich texture. Participants were buoyed forward as a result with renewed vigor and enthusiasm, despite their illness and any related physical restrictions. In this sense, they are transcended, spiritually uplifted, and sustained and able to focus on purpose in life alongside the challenges of advanced cancer. A planned pilot test of this intervention will enable us to determine potential effect sizes of this therapy in reducing distress and increasing meaning prior to a full randomized controlled trial.
ACKNOWLEDGMENTS
The authors acknowledge the generosity and support provided by Dr. William Breitbart, Vice Chair, Department of Psychiatry and Behavioral Sciences; Chief, Psychiatry Service; and his meaning-centered psychotherapy team at Memorial Sloan-Kettering Cancer Center, New York during the development of this intervention.
This study is funded by the National Health &Medical Research Council of Australia (NH&MRC) and the Victorian Cancer Agency. Prof. Schofield is supported by an NH&MRC Research Fellowship.
