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Understanding the way therapy works is a complex undertaking. Historically, such enquiry has been dominated by “outcomes” leading to a lack of discourse about clinical processes. In the cancer setting, identifying clinical process can be even more complex because of the added challenges of an ongoing illness. This study investigated the therapeutic processes used in a meaning-based intervention developed for the advanced cancer setting: Meaning and Purpose therapy.
Four sessions of therapy were delivered to 24 participants. Transcribed sessions (n = 96) of the intervention were analyzed by two independent researchers to describe participant themes, therapeutic processes, and patterns of change related to common points in the intervention.
Although both suffering and meaning were present in all sessions, when we tracked the focus of the content across sessions, there was a clear progressive shift toward meaning-centered content for all participants. This finding is in spite of the fact that all participants had progressive disease and were living with ongoing challenges.
Significance of results
Processes such as focusing on meaning, reflecting a sense of significance, joining with participants to explore their unique meaning, and directing them away from a preoccupation with suffering were identified as clear influences of a shift toward a meaning-based focus. These processes offer a fresh focus on meaning and a buffer to the distress of advanced cancer.
Meaning and Purpose (MaP) therapy aims to enhance meaning-based coping through a life review that focuses on the value and worth of the person, key relationships, sources of fulfillment, roles, and future priorities in living life out fully. We sought to test the feasibility and acceptability of a six-session model of MaP therapy against a wait-list control cohort in a pilot study seeking effect sizes on measures of adaptation.
We randomized patients with advanced cancer to MaP therapy or wait-list control, with measures administered at baseline and after 6–8 weeks. Wait-list patients could then crossover to receive therapy, with further measures collected postintervention. Adherence to the manualized model was sustained through weekly supervision and fidelity coding of recorded sessions. We used generalized estimating equations to control for baseline and any correlation of data.
From 134 eligible participants, 57 (43%) consented, and 40 of 45 (89%) offered therapy completed 6 sessions. Key barriers to consenting patients were poor health (15 refusers and 4 withdrawals) and death intervened in 6 participants. MaP therapy generated adequate effect sizes in posttraumatic growth (new possibilities, appreciation of life, and personal strength) and life attitudes (choices and goal seeking) to permit calculation of power for a formal randomized, controlled trial.
Significance of results
Delivery of this model of existentially oriented therapy is feasible and acceptable to patients. A properly powered randomized controlled trial is justified to examine the efficacy of this intervention.
Health care professionals (HCPs) caring for people with primary malignant glioma (PMG) and their carers see many of the profound challenges facing this group, yet their perspectives are not documented. This study aimed to understand and document the unique perspective of HCPs in relation to the supportive and palliative care needs of patients with PMG and their carers, with a view to developing a model of care.
Qualitative study involving semi-structured focus groups and interviews with 35 medical, nursing and allied health staff actively engaged in providing care for this patient group. Purposive and theoretical sampling from two major metropolitan hospitals and one community palliative care service in Australia was utilised to seek perspectives from a variety of disciplines and health care settings. Thematic analysis was conducted by three independent researchers, using a constant comparative method influenced by grounded theory.
Key themes relating to the needs of people with PMG which were apparent from the HCPs included: The difference in the illness course of glioma compared to other cancers; Limitations of current medical care; Challenges in balancing hope with reality of the illness; and Recommendations to improve care, including recognising the role of family and moving from a model where services are offered in response to demonstrated needs.
Significance of the results:
Current models of care based upon the classic cancer trajectory are unresponsive to the needs of people with PMG. Care may be enhanced by moving towards a proactive approach, extending the goals of care beyond medical needs and broadening the focus of care to include family needs.
The objective of this study was to describe the experience of undertaking meaning and purpose (MaP) therapy for patients with advanced cancer, with an aim of refining therapeutic processes involved prior to pilot testing. 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.
A convenience sample of people living with advanced cancer was recruited to participate in this process, resulting in 24 therapy sessions for analysis.
A thematic analysis of each session illustrated that the process of MaP therapy is one that encourages reflection, offers insights, and can be confrontational, but can also allow participants to “shift” their perspective and focus onto meaningful goals. 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 they grasp its rich texture. Participants' descriptions showed how they were buoyed forward as a result, with renewed vigor and enthusiasm, despite their illness and any physical restrictions that it imposed.
Significance of results:
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. Understanding the processes involved and the experiences of participation in meaning-based therapies is crucial to the future strength of this area of psychotherapy.
In the clinical setting of cancer, meaning may well have a central role in the life changes the illness experience brings about. As health care professionals working with people with life-threatening illness, we are exposed to one of the major turning points in life and the ways people confront this transition. Meaning can assist coping by offering a framework, perspective, and counterbalance to the challenge of illness. However, the absence of meaning can be a precursor to profound despair.
This article brings together the clinical implications of two studies conducted by the authors that explored the role of meaning in adjustment to cancer, presenting a theoretical understanding of the experience of meaning in cancer and identifying some potential approaches to intervention.
Our findings point to some specific goals of care as well as a number of therapeutic modalities aimed to meet these goals. We examine four goals of care—acknowledging suffering, encouraging a search for meaning, strengthening connection with others, and ensuring optimal physical care—as foundational in any clinical approach and then examine the key models of therapy that assist the clinician in pursuing these goals.
Significance of results:
Our aim is to create an integrated approach to care provision that locates meaning centrally in any patient's adaptation.
This study builds on previous work that explored the lived experience of meaning in advanced cancer. The aims were to explore the associations of suffering (physical and existential distress) and coping (via social support) with psychological distress and global meaning using a battery of instruments among adults attending an Australian metropolitan cancer service (n = 100).
The contribution of suffering and coping via social support to psychological distress and meaning were examined using a variety of statistical methods. Multiple regression analyses were conducted to further examine relative contributions to both psychological distress and global meaning.
Physical and existential distress were found to be positively associated with psychological distress whereas high social support and personal meaning are related to lower levels of psychological distress. Social support was the strongest correlate of global meaning whereas high levels of existential distress were related to lower levels of global meaning. On the basis of this study, it is concluded that the factors related to suffering clearly promote psychological distress, and the reverse is true for global meaning for those living with cancer.
Significance of results:
This study speaks to the clinical complexity of the dynamic experience of suffering and meaning in cancer. We need to better understand the impact of physical suffering and meaning in the lives of this population and to actively work toward the enhancement of social support and connection with others for this group. Optimal palliative and family-centered care blended with therapies that promote a sense of meaning of life lived appear crucial to ameliorate suffering.
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