Meaning Centered Psychotherapy

February 14, 2020

Information

Angela Khairallah and Brian Jin

February 16, 2020

Yale Cancer Center

visit: http://www.yalecancercenter.org

email: canceranswers@yale.edu

call: 203-785-4095

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00:00Support for Yale Cancer Answers comes from AstraZeneca, a biopharmaceutical business with a deep-rooted heritage in oncology and a commitment to developing cancer medicines for patients. Learn more at astrazeneca-us.com.
00:13Welcome to Yale Cancer Answers with doctors Anees Chagpar and Steven Gore. Yale Cancer Answers features the latest information on cancer care by welcoming oncologists and specialists who are on the forefront of the battle to fight cancer. This week, it is a conversation about Meaning-Centered Psychotherapy for Cancer Survivors with Licensed Clinical Social Workers, Angela Khairallah and Brian Jin. Dr. Gore is a Professor of Internal Medicine and Hematology at Yale School of Medicine and Director of Hematologic Malignancies at Yale Cancer Center.
00:49<vGore>We all know about psychotherapy, Woody Allen taught us all about that. You sit there and you talk, and you talk and talk and talk and you talk, sometimes you get medicine and it is great, and everyone likes to talk about themselves so it is a really good business. What is meaning-centered psychotherapy, lets talk.
01:10<vJin>It is meant to sort of elicit out what is most significant in our life, what is our purpose, what gives us ways of coping. It is designed specifically for those who face and suffer with a cancer diagnosis.
01:24<vGore>For the patient, not for the family.
01:26<vKhairallah>Actually this curriculum has been adapted to be utilized with cancer caregivers, bereavement, palliative care, cancer survivors. It has even been used with nurses in hospice care. So, this is a modality that really can be utilized at any point in life, any of us could be thinking about purpose and meaning of what it means for us. It does not really necessarily mean going through cancer and cancer treatment, for us to think about what brings meaning to our lives. Now, this particular psychotherapeutic model was developed by Dr. William Breitbart and his colleagues at Memorial Sloan Kettering, and it is a fairly new psychotherapeutic model that really is rooted in helping patients identify a purpose and meaning in their life, to enhance their spiritual being as well as their psychological well-being, and it is based on the work of Dr. Viktor Frankl, who was a Holocaust survivor as well as a psychiatrist. And many of you might be familiar with the best selling book Man's Search for Meaning ini which Viktor Frankl talks about how all of us as human beings search for our existence and what meaning is in our existence. And that all of us even if we are being faced with suffering, have the ability to find meaning in our lives and that by finding this meaning in our lives, it would decrease our suffering and increase our overall psychological well-being. And based on this, was the birth of meaning-centered psychotherapy.
03:08<vGore> Is this different than basically existentialism?
03:14<vJin>It has got existential tenets built into it.
03:14<vGore> Now, I know I told you we cannot use 5 syllable words. Existentialism, it is 6 syllable, I broke my rules.
03:25<vJin>It does. He also weaves it into the practice, and Viktor Frankl has a lot of existential tenets built into it. They are freedom of will and that we define our own purpose in life, and it is built out of sort of existential dread, distress, existential guilt. These concepts have been a part of Kierkegaard, Nietzsche and Heidegger.
03:51<vKhairallah>In fact, a very famous quote that Viktor Frankl uses in his book as well as throughout the meaning-based psychotherapy curriculum is, he who has a why to live for can bear almost any how.
04:04<vGore>And that's cool. I just should disclose one personal story which is that in my tenth grade English class in an independent school in Chicago, very liberal, we walk into the room and the quote from Macbeth has "Life is but a walking shadow."
04:26<vJin>The candle of brief, brief.
04:27<vGore>Yeah, that one. I cannot think of how it starts. Tomorrow and tomorrow and tomorrow and we were told that our first unit is the negative you of life, and it was basically indoctrinating tenth graders into existentialism and beyond, and it was very, very impactful for me to the extent that I understood it actually, it was really pretty cool.
04:53<vJin>It is. Shakespeare has Hamlet who is the first individual who is sick from his consciousness and that is like existentialism - overthinking, being aware of our mortality, what is the purpose of life.
05:06<vKhairallah>Which often is what cancer patients are faced with right.
05:09<vGore> Here we go, back to cancer.
05:15<vKhairallah>You know, I got you. That's why we are here, right? We are here to talk about that.
05:16<vGore> You stole my line.
05:20<vKhairallah>It was planned. Also, according to Viktor Frankl, human beings create meaning from 4 different sources. The historical source of meaning, attitudinal source meaning, creative sources of meaning, and experiential sources of meaning. So these different types of sources of meaning are inter-woven into the curriculum of meaning-centered psychotherapy.
05:45<vGore>Can you elaborate a little bit on those 4, would that be like out of your faith, history.
05:51<vKhairallah>It is about your past or present and your future. So, where we came from, the life that we are living right now and the life that we will live in the future.
06:02<vJin>It is the spectrum. It is our values, it is our traditions, our spiritual practice. The example that we use from Man's Search for Meaning when Viktor Frankl is given a way out of Austria with his wife, but only his wife and he is deliberating on this decision of whether or not he can go out and leave his parents behind. and so, he is walking through the streets, he happens upon a piece of rock and stone, which he finds and has Hebrew on it, and he is walking with this and he brings it to his father who is a scholar and he goes, what is this and he tells him it is a fragment of the Ten Commandments — the part about honoring thy father and mother. And from that decision, he could not leave his parents behind and that is sort of a legacy or tradition of value of how we live our life and gives us purpose.
06:47<vGore> Well, that is interesting because another part of the Jewish faith tradition is anything to save a life and if leaving men saves their lives I think his father might have argued you should go, but that is a whole different question there. Okay, so that is historical.
07:06<vKhairallah>Right. So, attitudinal really has to do with the attitude. The attitude that you chose to take towards your suffering when going through cancer and cancer treatment, towards your challenges and your limitations that you are faced with in life, that we all have that ability to choose our own attitude. Really turning tragedy into triumph is attitudinal source of meaning.
07:25<vGore>Right and #3 was?
07:27<vKhairallah>Creative. The creative sources of meaning.
07:30<vJin>Our investment in life. What gives us joy, where do we spend our time. It does not have to be just painting, but it could be your work, every day you are going in and you invest in your passion.
07:39<vKhairallah>Your volunteer work, your hobbies.
07:43<vGore>Hosting radio shows?
07:42<vKhairallah>Absolutely, absolutely. And then the last is experiential sources of meaning. So, how we are connected to life through love, humor and beauty, our relationships are music, nature, travel that has to do with our experiential sources of meaning.
08:00<vGore> Seems connected to #3, but maybe you are thinking about at a more emotional level?
08:05<vKhairallah>Absolutely.
08:10<vJin>Like an individual stopped and they were driving and they just saw how red the leaves were and just being in that moment and truly living.
08:15<vKhairallah>That's right and everything is individual right. Something that is meaningful to me may not be meaningful to Brian or yourself Dr. Gore. And meaningfulness really can be something very simple and mundane or something very large and extravagant. So, what Brian said about the beautiful red fall colors outside, or your wedding or the birth of a child.
08:44<vGore> Marcel Proust's madelines, do you guys know about that. Marcel Proust which I have not read I admit it is like this 8 volume memoir. I remember it is things past, it starts out with the smell of a baking Madeleine's, the little French cookie that had particular meaning for him. I am not trying to show off here.
09:06<vKhairallah>No that's an excellent example though of a cookie and the smells and how meaningful that is.
09:17<vJin> It is very Zen, it is very in the moment.
09:16<vKhairallah>Absolutely, but it is really just helping patients identify what brings meaning to them and what is meaningful and purposeful to them in the light of suffering from cancer.
09:28<vJin>It is really exceptional in bringing that to the forefront. It is just the way it is structured, the way it is given to individuals that makes it very clear and accessible.
09:37<vGore>You know, I am totally getting this conceptually from you guys. I certainly understand and I fought a lot about this honestly, about the existential natures as a way out of a cancer diagnosis, particularly one that is likely associated with end of life and of course that is not limited to cancer. Many of us understand at some point that whatever process we are going through is going to be associated with end of life. I am interested in your use of the word suffering, which I would think there is something that we do not like to talk to cancer patients about, we kind of emphasize that most cancer patients who get the appropriate care hopefully are not suffering. So, I was just wondering about that, that kind of strikes me is as kind of dangerous language to be using.
10:35<vJin>Anytime we hit a limitation, we suffer. There is loss of identify, there is loss of function, there is loss being able to go to work. So, that suffering is present, we are just helping people process it and alleviate it. So, it is something that we do not want to shy away from, we want to tell them and help them through it.
10:56<vKhairallah>And I have adopted this curriculum to use with cancer survivors, and often with cancer survivorship, patients are faced with not only the fact that they have cancer but also the impact cancer has had and may even still be having on their lives because of those late and long-term effects. And so that again brings about challenges and limitations that patients have to move forward in facing.
11:20<vGore> Gotcha. So, who is eligible for this therapy? There are only two of you sitting here.
11:29<vJin>We have a lot of other individuals who have gotten trained, some in the palliative care team, solid tumors. We have an advanced cancer meaning center group, so any patient with stage III or IV that is feeling like they want to have more purpose or is struggling, and one of the concepts when we assess is if somebody has desired hastening for death.
11:58<vGore> A desire to hasten their death?
12:00<vJin>Not suicidal.
12:07<vKhairallah>They just want to give up, they are done.
12:06<vJin>And suffering is what this really addresses, if we are suffering and we do not have purpose, we are in despair, and so that person would truly benefit from this intervention. Anybody would benefit from this intervention, but that was designed specifically to address those individuals that are lacking purpose while they are struggling.
12:26<vGore> I know that when I have a guest on the show who is really impossible to draw anything out of, I am in despair, I am suffering and I want to terminate that interview as fast as I can. I am not joking okay? You know who you are.
12:37<vKhairallah>So, hopefully you can utilize some of these interventions and skills to help you bring about meaning while you are doing this radio show. But, also there are certain patients that would not be appropriate for this type of modality, so patients that may be have cognitive impairments that are psychotic, severe depression, who are suicidal, have a personality disorder, those would be patients that would not benefit from this type of modality.
13:10<vGore>Gotcha. This is very fascinating and I am totally engaged, that tells you probably more about me than anything else, but I am hoping that our audiences is as well and right now, we have to take a short break for a medical minute. Please stay tuned to learn more about meaning-centered psychotherapy with Angela Khairallah and Brian Jin.
13:27Medical Minute Support for Yale Cancer Answers comes from AstraZeneca, providing important treatment options for various types and stages of cancer. More information at astrazeneca-us.com.
13:41This is a medical minute about pancreatic cancer, which represents about 3% of all cancers in the US and about 7% of cancer deaths. Clinical trials are currently being offered at federally designated comprehensive cancer centers for the treatment of advanced stage and metastatic pancreatic cancer using chemotherapy and other novel therapies. FOLFIRINOX, a combination of 5 different chemotherapies is the latest advance in the treatment of metastatic pancreatic cancer and research continues at centers around the world looking into targeted therapies and a recently discovered marker HENT1. This has been a medical minute brought to you as a public service by Yale Cancer Center. More information is available at YaleCancerCenter.org. You are listening to Connecticut Public Radio.
15:10<vGore>Welcome back to Yale Cancer Answers. This is Dr. Steven Gore. I am joined tonight by my guests Angela and Brian. We were talking before the break about cancer patients who may be appropriate candidates for this type of intervention. How do they find you or find somebody like you, and how do they become aware of this? I mean, I was not aware of it until 15 minutes ago.
15:00<vKhairallah> They can just ask to be referred to their social worker with the cancer patients that they work with, but all of us utilize these skills in our work with patients.
15:07<vGore> And how prevalent would this be outside of Yale because many of our listeners may not be associated with Yale and New Haven Hospital and they may be very interested in finding out more about this for themselves?
15:17<vJin> Well, there is an NCI grant that provided a lot of training and produced a lot of individuals, I think it is across the nation.
15:26<vKhairallah>International as well.
15:31<vGore> I mean, is there a website or something where if you wanted to look up meaning-centered psychotherapy practitioners where one could find one?
15:38<vJin>I do not know if there is that specifically yet, because I reached out to the individuals who did training to try to get someone in New York, that was a private individual. I think it always helps to Google, you find a lot of information.
15:49<vGore> Some of it is good, some of it is not.
15:51<vKhairallah>I mean, just Google meaning-centered psychotherapy and you are going to find hundreds of research articles on this modality. It has been around for a while.
15:58<vGore>So, how does this work? Is it a one-on-one therapy or is it a group therapy or can it be either?
16:05<vJin>It started with a group. Group is just special, when people are helping each other and supporting each other and then they develop an individual component because they found there was attrition in group, so in that way you could have the continuity and complete an individual session of 7 classes.
16:21<vKhairallah>And it really runs for 7-8 sessions, weekly sessions of 90 minutes and as we have mentioned, it is curriculum based and so on a weekly basis, there is a topic that we are discussing, there is kind of an experiential group exercise that you do together and then there are some very small homework assignments.
16:41<vGore>So, it sounds like more like a class than like a classic Woody Allen psychotherapy.
16:46<vKhairallah>Absolutely.
16:46<vJin> Yeah. It is more psychoeducational.
16:49<vKhairallah>It is also very in-depth and process oriented. In fact, just me personally going through the training and I do not know if you can comment on this as well, you yourself go through the training, you are thinking about what brings purpose and meaning in your life, and so it was very impactful personally for me.
17:09<vJin> Questions that we should all ask ourselves.
17:12<vKhairallah>And every time I facilitate a group with my colleague Jessica Stein, same thing, it really has me thinking about what brings purpose and meaning to me in my life.
17:22<vGore>Well, what happens after the 7 or 8 sessions to the participant? What do they do and what is the follow-up?
17:33<vJin>It purposely is designed to end and that replicates life's limitations and finiteness. Groups, they struggle. Some groups meet like once a month or go to a cafe and they will go connect or they will go to a support group and they will connect there. So, the bonds that are there in the group cohesion are I would say lifelong. It is just impressive to see.
18:05<vKhairallah>I can honestly say that with the groups that I facilitated definitely friendships have formed amongst the group members themselves where I know they carried on once the group concluded.
18:17<vGore>There are no rules against that?
18:17<vKhairallah> No rules against that.
18:17<vGore> Gotcha. Is there followup for these participants? I mean do you do surveys or how do you know that it has been an effective intervention and how do you modify for future groups or patients?
18:35<vKhairallah>I can say we have not done any research here at Yale, but there has been a lot of research done. Research shows that by patients participating in meaning-centered psychotherapy that even up to 6 months afterwards, they show a decrease in depression, anxiety, decrease in distress as well as an increase or improvement in their overall psychological well being, quality of life and just sense of meaning in life.
19:05<vGore> Well, that sounds pretty good.
19:05<vKhairallah>It is wonderful.
19:06<vGore>How about this application to the survivors and the family and so on. How does one identify a cancer survivor who might benefit from such an intervention?
19:26<vKhairallah>I am the social worker in the Yale Cancer Center Survivorship Clinic, and pretty regularly I meet with patients who say things to me like I just don't know where to go from here. I don't know how to move forward, what does this all mean, why did I even get cancer, I want to be part of something bigger than myself, my priorities have changed. I had a patient, several patients actually have said to me, this job that I have been in for decades is not meaningful, I want to quit, I want go back to school, I want to do something else, I want to volunteer. I had another patient one time who actually was contemplating changing the religious affiliation just based on going through cancer and cancer treatment. So, it really is about purpose and meaning in life.
20:15<vJin>There is a level of self-actualization. You know, where people are finding who they really are and identifying what is most valuable to themselves and being true to themselves.
20:26<vKhairallah>And we know that cancer survivors themselves experience higher levels of anxiety, depression as a result of going through cancer and cancer treatment, have significant levels of distress and impact on the quality of life, and so by them utilizing meaning-centered psychotherapy, it helps decrease some of those things.
20:49<vJin>It is the unsought gifts of cancer, and I have had people say, before I had this diagnosis, I would not have the courage to do what I did to advocate for myself.
20:58<vKhairallah>And another very interesting aspect of meaning-centered psychotherapy is something called the legacy project, and the legacy project, maybe Brian you could talk a little bit about that.
21:11<vJin> Well, the legacy project is something tangible. It can be something tangible, but it can be something abstract as well, but it is part of the curriculum where people come up with something they want to give back to their family, to their friends and it can be wide open. I have had people create god boxes, I had one really special individual who said my life is my legacy, it is a rippling effect and she had a profound effect on everybody in the group with her courage. I have had people make cook books, make walls, mosaics of their family photos, but it is just something that transcends themselves.
21:46<vKhairallah>Right. And within context of the cancer survivorship curriculum, rather than use the term legacy, we use the term story. So, a life is a story that you were given, the story that you are living and the story that you want to live, and then instead of the legacy project, it is called putting the me in meaning project, and so some of the things that patients have done - somebody created a lending library at their local church parish, another patient took all of his photographs and catalogued them, somebody else wrote a memoir that he wanted to share with his children and grandchildren. So, again, and even something like getting back into exercise and eating healthy, the project, it does not have to be large and it does not have to be extravagant, it can be just very simple, just again something that brings meaning to you and helps you feel like you are living a purposeful life.
22:46<vGore> I have to imagine that there may be participants who continue to have depressive symptoms or anxiety, and I assume that some of these people would benefit from a more intense mental health intervention whether it be through medication route or psychodynamic psychotherapy or cognitive behavioral therapy or whatever is appropriate for that. I mean, you do not see this as, like a be-all for these people to the exclusion of other conventional modalities right?
23:20<vKhairallah>No, and I think absolutely not. It is just an addition to these other modalities and I know I can speak for Brian as well that when we identify patients that would benefit from additional psychotherapeutic modalities, we encourage them to get the services and make resources. I mean, we can provide some of that too within our clinics, but if we identify a patient that needs more than what we can provide, we definitely make referrals to the community.
23:49<vGore>Alright, now your patients already plugged into more conventional, if you will or therapeutic relationships somewhere else and then do this kind of in parallel?
23:58<vJin>Yeah absolutely.
24:00<vGore> Yeah. I would imagine that would be beneficial for some people, very interesting. What word of mouth do you find, you go into infusion areas in the hospital, in the clinics and some people develop these chatty relationships with people if they go that way, do you find people referring other people?
24:20<vJin>Yeah.
24:26<vKhairallah>Yes, and with the cancer survivorship group, really in order to qualify for the group, we want it to pretty be out of active treatment and in that cancer survivorship mode, and so I think sometimes what happens is patients hear about this and they want to participate, but they are still in active chemotherapy or in active radiation, so I have a running list of people that are on our waiting list. So, once they get done with treatment, they can start the group.
24:54<vGore> But you are also offering these interventions for people in active therapy right? So, that is more on an individual basis then?
25:03<vJin>We have groups as well. Our entire cluster is always reaching out to each other to identify people who would be appropriate and would benefit.
25:10<vGore>Okay. And what about for staff? When are we going to start doing it for staff?
25:13<vKhairallah>Do you know how many doctors have said that to me. A lot of my colleagues in the survivorship clinic as well as the breast center where I also work have said wow this would be wonderful, I would love to do something like this for myself.
25:33<vGore> What about reading? Is there any literature that you recommend to people you are working with or people who might want to learn about this or just get into the field a little bit just education wise, is there any kind of lay level literature?
25:52<vJin> You know, Man's Search for Meaning is given to each patient, that is the one that you want to go to. There are text books, there are text on individuals and groups and they are still doing the training, so that is always available to professionals.
26:07<vGore> Right, for just people?
26:10<vJin>Just people, Man's Search for Meaning would probably be the key one.
26:12<vGore> Is that a readable book or is it like heavy philosophy?
26:18<vJin>We tell people sometimes in this group, it can be traumatic to read that, and so we say go at your own pace. The first part is his experience in the concentration camp and then the latter part is his theories on psychotherapy and logotherapy, which he developed out of his experience.
26:36<vKhairallah>And I also say to patients it is not a requirement to read the book to participate in this group, you do not have to read the book. The group, meaning-centered psychotherapy was developed based on the works of Viktor Frankl, but you do not have to read it.
26:54<vGore>Maybe you guys should get together and write the lay person's cancer experience book based on your experiences, why not? Seems like that would be useful because I am sure that not everybody has access to this modality of therapy all over the country, all over the world necessarily. I mean it sounds like it would be great if everyone did, and I am sure you have some capacity limitations as well right in terms of how many people you can intervene with at a time.
27:29<vKhairallah>Absolutely and I would say a good-sized group is may be 6-8 patients because it is very process oriented and I would say even with 3 or 4 people.
27:45<vJin> Yeah, 6-8 is the max.
27:46<vGore>Are there always 2 facilitators?
27:49<vJin> Yes.
27:49Angela Khairallah and Brian Jin are Licensed Clinical Social Workers. If you have questions, the address is canceranswers@yale.edu and past editions of the program are available in audio and written form at YaleCancerCenter.org. We hope you will join us next week to learn more about the fight against cancer here on Connecticut Public Radio.