Interventions for Clients Coping with Cancer
Interventions for Clients Coping with Cancer - 10 CEUs

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Section 14
Meaning-Centered Group Psychotherapy for Clients with Cancer

CEU Question 14 | CEU Answer Booklet | Table of Contents | Cancer
Social Worker CEUs, Counselor CEUs, Psychologist CEs, MFT CEUs

Meaning-Centered Group Psychotherapy
The ultimate goal of the proposed intervention is to help men and women with advanced cancer focus on what has been, and can still be, meaningful in their lives given their circumstances, and to further develop their ability to reframe their experience from that of dying to that of living despite the threat of dying. A description of the intervention has been manualized and is in the process of being empirically tested, and, as of this writing, recruitment of patients has begun.

Groups will meet for eight ninety-minute weekly sessions. Possible sources of meaning will be explored through the combination of: 1. didactic teaching of the philosophy of meaning on which the intervention is based; 2. experiential exercises and homework assignments; and 3. open-ended discussion, which may include interpretive comments by group leaders. Participants are encouraged to prepare for the group by reading some of Frankl's work, particularly Man's Search for Meaning, before the first session.

Topics to be covered within the sessions include definitions of the concept and sources of meaning, the historical context of life, the effect of limitations on meaningfulness, and the importance of responsibleness, creativity, love, and humor in finding potentially transcendent perspectives on one's situation. Notes on the didactics also are to be included as handouts for group members to refer to later. It is important to note that, rather than being viewed as passive recipients of group leaders' wisdom, group members are seen as responsible for using the group and helping each other to discover the sources of meaning in their lives. It has been suggested that it is in part this sense of altruism that is responsible for the therapeutic value of groups in this population.
 
The Concept of Meaning
Though there has been some empirical research into the area of meaning, especially as it relates to individuals experiencing loss or terminal illness, this work has been hampered by fragmentation due to the variety of its conceptualizations and operationalizations.  Our use of the term is similar to Reker and Wong's definition of meaning, i.e., as, "the cognizance of order, coherence and purpose in one's existence, the pursuit and attainment of worthwhile goals, and an accompanying sense of fulfillment" ( p. 221). Of the cognitive, motivational and affective components they describe, Reker and Wong view the cognitive component as the most essential, and empirical research has focused primarily on the elucidation of the these processes. It should be noted as well that the concept of meaning is distinct from religiousness; while one's sense of order may derive from a predisposing belief in the existence of God, it is also possible to perceive order or purpose in the natural order without such a predisposing belief system.

The purpose of the group's early sessions is twofold. First, the concept of meaning is explored and concretized for participants. Second, group leaders introduce the concept of cognitive reframing of difficult or traumatic experiences, whereby potentially positive experiences are not precluded by one's cancer illness. Meaning, as it is used here, is a concept of some specificity--understanding what made those particular experiences meaningful for those individuals helps them to learn what it is that they value and wish to make a priority of in their lives now. They begin to do this through a combination of experiential exercises and open discussions of meaningful instances both before and after cancer illness.

Sources of Meaning
Frankl suggested three basic sources for a sense of meaning--creative, experiential, and attitudinal.

Creativity
The first is the actualization of creative values, a concept similar to Erikson's  description of generativity. Examples are work or artistic pursuits, as well as causes in which one can be active. Park and Folkman suggest that advocacy is a particularly common route to finding meaning for people suffering from traumatic loss or illness.

Experience of Relationships and Beauty
The second source of meaning concerns the actualization of valued experiences or "encounters," or what Samuel Beckett refers to as, "... the beauty of the way. And the goodness of the wayfarers" (p. 11). A primary example is the experience of love for others. Thus, a number of studies suggest that social support is one of the most important variables associated with good adjustment to cancer. The support of family and friends is found to be both a facilitator of coping with illness and an outcome of it, and patients endorse deepening relationships as the most frequent positive aspect of their illness.

Another instance of meaning through experience relates to the ability to appreciate beauty in nature or art. Something as simple as seeing a beautiful flower or sunset, or experiencing a kindness from another person can be enough for a phenomenological sense of connectedness and meaning.  Frankl, for instance, eloquently described moments when he and his fellow inmates experienced the beauty of the mountains of Salzburg or a particularly vivid sunset. They found solace in the fact that whatever their individual fates, the beauty of nature, of which they were a part, would continue. They further seemed to find a meta-cognitive solace in the idea that their continued ability to appreciate moments of beauty transcended the dehumanization of their situation. Sometimes, prisoners put on a cabaret show, and other prisoners attended despite their intense fatigue or the fact that they might miss their daily portion of food by going.

A related topic is humor, which helps one to rise above difficult circumstances. Rather than melding with something larger than oneself, humor often requires looking at one's situation from a distance, and separating oneself from it. Humor, therefore, has an important place in the group as it helps to foster a safe atmosphere in which to discuss very difficult topics. Being able to find and express humor is an important way of feeling one's own presence in the world, and can also help one define one's own values, especially when thematic connections to other discussions are noted.

Group participants will be encouraged to explore concretely these kinds of experiences in their daffy lives, whether they are instances of creativity, love, beauty, nature, or humor. These will be elaborated in a number of ways, including the details of the immediate experience, how these moments may have been experienced differently as a result of having cancer, as well as possible transcendent aspects of the experience.

Attitude and Fortitude
The third source of meaning is the attitude with which one bears suffering that is unavoidable. The initial reaction to encountering a crisis, such as illness, is likely to be an appraisal of what if anything can be done to alleviate the situation. If the situation is unchangeable or severely limited in its modifiability, one can exert control through adapting one's attitude to this new reality. Similar to Linehan's concept of turning lemons into lemonade, Frankl suggests that the one freedom left to the individual is the freedom to choose one's attitude in bearing one's suffering.

The attitude taken toward one's suffering, toward a fate that cannot potentially be changed, could refer to many things. For instance, it might include being a role model for coping with one's suffering, or experiencing suffering as a catalyst for changing some aspect of one's life. In other words, once it has been determined objectively that they do not have the control to remove the source of their suffering, people may reframe it and explore for what purposes it might be used at this point in their lives. Park and Folkman find that changing the meaning of the problem is the most common method of coping in such situations.

Finding meaning in the loss of a child, for instance, was related to well-being both at the time of the crisis and one year later. People cite the impetus to change their priorities, learn about what is truly important to them, and gain a new perspective. For some, a sense of meaning can be derived from the fact of being able to cope with crisis in a way one considers dignified. In addition, Thompson et al. found it was this kind of control--the belief that one has some control over one's emotional reactions--rather than the ability to control the course of disease--that was related to successful coping.

Meaning and the Historical Context of Life
People live in a historical context--there is a story to our lives. In one sense, we are the lead characters, with the people around us in supporting roles, and with scenery, plots, and lessons learned. 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. Let us allude again to Nietzsche's aphorism: "He who has a why to live for can bear with almost any how"--this why springs out of who one is, one's values, both realized and not, and one's goals. Recognizing that one has already achieved important goals can be a buffer against despair. In addition, telling one's story connects one with the people around him or her, a connection that may be maintained whether they are physically in each other's presence or not.

Thinking about the story of their lives helps participants to further reflect back on what they have found meaningful or joyful, which concrete tasks they have undertaken and which remain to be undertaken. These tasks can be in any realm--stories to write, children to care for, lessons to learn or teach, relationships to attend to, artistic endeavors, such as painting or sculpture, etc. Meaning can be found in the very act of bearing witness to the events of one's life. The key element of such tasks is that they be meaningful to the person setting out to fulfill them.

It is expected that an autobiographical stance may arise spontaneously in group members. In addition, they will be encouraged to complete autobiographical exercises both within the group and at home with family members. People who have become ill and caught up in their treatment and/or disease often lose track of the continuity of their lives since before the onset of their illness. Participants are therefore encouraged to view the shaping of their remaining time both from the perspective of their lives up to this point, and their hopes for the other people in their lives.

Particularly important are continuing themes and those aspects of participants' stories that seem fruitful for formulating specific and realistic goals and projects. These should be concretized to the extent possible, even in cases where goals involve more abstract areas, such as repairing a problematic relationship. As Zuehlke and Watkins suggested, having a sense of temporal continuity can help remind people of what has been joyful in their lives, and what may still continue to be so. As is explored further in future sessions, most important are self-transcendent goals--goals that involve others on whom to focus. Thus, one possible focus is on those life lessons members may want to pass on to loved ones.

Limitations and Realizing Attitudinal Values
The knowledge of the finiteness of life may be responsible in part for the need people have for a sense of meaning or purpose, and learning to cope with limitations is what allows us to appreciate those things that we do have. Viktor Frankl, for instance, viewed his own experiences during the Holocaust as tests of his inner strength, and he later looked back on his ability to cope in such desperate situations with a feeling of pride and accomplishment.

Recognizing limitations also challenges people to make the most of the time they have. Frankl uses the metaphor of a sculptor hammering away at an as-yet unshaped stone. Knowing that he has a limited amount of time to finish his work, while not knowing when exactly the deadline will be, forces him to use his time as best he can and make the most of every moment. The group itself can be used as a concrete embodiment of this fact, as the group is finite as well, and knowing this can serve as a catalyst for using the allotted time in the most productive manner. Processing the finiteness of the intervention, therefore, will be an important part of the therapeutic work of the group.

Fantasies about death and its aftermath, both for the person who has died as well as for his or her survivors, will be encouraged. Further exploration will include moments in the past when participants may have felt that they could not go on living, as well as what aspects of life still felt meaningful despite or because of their illness.

Much of the ultimate goal is to put suffering and death in a larger context, as part of ongoing life. For one thing, discussion of death is important to its detoxification; for another, feeling like part of something larger than oneself allows one to cope with death by seeing it not as an entrance into oblivion, but instead as part of a larger living community that in its continuity keeps a part of the person's spirit alive. This is most easily seen in families that continue after the death of loved ones, but also in works left behind, other people whose lives have been affected by group members, possibly even people one meets at the very end of life.

Responsibleness and Transcendence
Meaningfulness is not something that can be taken for granted, but is instead something one achieves or imposes, much the same way Bartlett's subjects imposed it on the to-be-recalled material. It is through such an achievement or imposition that one can experience a sense of transcendence, the feeling of being able to rise above one's situation through being part of something greater than oneself. Thus, Folkman found that bereaved caregivers of men who had died of AIDS associated positive mood states with the feeling of being part of a higher purpose or order.

The role of responsibility can be seen as central to the experience of meaning. First, it is the individual's responsibility to discover a sense of meaning, to recognize those tasks for which he or she may be irreplaceable, and to ask what life is expecting of him or her at this time. Second, feeling a sense of responsibility to others and having a task before one may also help to transform one's own suffering. For example, in their classic study of geriatric patients, Judith Rodin and her colleagues found that even a simple task having to care for a plant--significantly increased the quality of life for nursing-home residents, including not only their psychological well-being but their physical health as well.

Suffering may enhance one's sense of empathy and the desire to help others. There may also be therapeutic value in this kind of personal altruism. In contrast with the sense of isolation that may come with cancer illness or treatment, Yalom emphasizes the reparative function of modeling for, and learning from, one another in the psychotherapy group setting.

Thus, Professor Morris Schwartz, the subject of Tuesdays with Morrie, takes particular comfort from his ability to use his debilitating illness to teach his student important life lessons. This sense of responsibility can also emerge from professional goals (i.e., actualizing creative values). Frankl, for instance, felt that one of the things that helped him to cope with and ultimately survive his concentration-camp experience was his responsibility to publish the manuscript that was destroyed upon his arrival there, and to lecture at universities about the psychology of the concentration-camp experience.

Some exercises, therefore, will focus on individuals' sense of responsibility, to whom and for what they may feel responsible. Participants further elaborate their goals and tasks, as informed by the themes of previous sessions. This may include the use of cognitive restructuring, as there is potential for one's suffering to be part of one's "task," for example, modeling for others, supporting other patients, teaching medical personnel, etc.

Whether pursuing creative goals and experiential values or reframing one's attitude, one may attain a sense of meaning in part through transcendence. In other words, one may feel transported and experience oneself as a part of something bigger than oneself. This transcendent perspective may be easier for people who are religious, as they may be more likely to see themselves in a larger context, in which God has selected a place and role for them.

For nonreligious people, however, this perspective may come from feeling spiritually like a part of something larger--one's family, community, profession, the natural order, etc. It should be kept in mind that religiousness is here thought of as an active mentality--that of viewing oneself as having responsibilities before God, rather than a passive one of waiting for God to act on one's behalf. Similar to the findings regarding an active coping style, Holland et al. found that it was this active religious attitude that was correlated with increased coping, rather than the passive one.

Countertransference
Group leaders are provided with a detailed manual for facilitating groups, in order to standardize the treatment for future research. However, as Spiegel and Spira note, there are important countertransference issues that arise when working with terminally ill individuals, and that cannot be handled according to a formula. This is particularly true of interpretations based on cognitive reframing, where there is the potential for the therapist to be experienced as authoritarian or dismissive, a criticism that has been leveled at Frankl himself .

Cognitive restructuring can deteriorate into a patronizing game whereby the facilitator simply imposes a more positive spin on a participant's attitude, or imposes his or her own meaning on group members' experiences. It is important, therefore, to highlight aspects of group members' own experiences that are consonant with a sense of meaningfulness rather than imposing one's own theories on them.
 
Death anxiety inevitably will affect group leaders over the course of the intervention, as we are all subject to the same existential fears, albeit perhaps not as urgently. In addition to being dismissive, group leaders may find themselves disengaging from or overidentifying with participants as defenses against this kind of anxiety. Thus a period of apprenticeship training and/or concurrent supervision may be valuable in helping therapists recognize the effect group members may have on them.

The possibility of being strongly affected by group members should not be surprising, as the consistent theme in this intervention, and in the work on which it is based, is the human need for connectedness--with other people or aspects of life, as well as in one's own sense of temporal continuity. The sense of meaning or purpose may in fact derive from this transcendent feeling of being connected to a larger whole. It is our hope to help foster this sense in those cancer patients who feel they need help in making the most of the very limited choices they may be offered.

- Greenstein, Mindy & William Breitbart. Cancer and the Experience of Meaning: A Group Psychotherapy for People with Cancer. American Journal of Psychotherapy. Fall 2000. Vol. 54 Issue 4.
The article above contains foundational information. Articles below contain optional updates.

Personal Reflection Exercise #7
The preceding section contained information regarding meaning-centered group psychotherapy for clients with cancer. Write three case study examples regarding how you might use the content of this section in your practice.

Online Continuing Education QUESTION 14
What is the ultimate goal of meaning-centered group psychotherapy with cancer patients? Record the letter of the correct answer the CEU Answer Booklet.


CEU Answer Booklet for this course | Cancer
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