INTRODUCTION
The data on cancer incidence in Spain for 2012 reveal that there are 215,534 cases (about two-thirds were aged over 65 years), with 25.1% of the general population at risk for developing cancer before the age of 75. Population growth and aging primarily explain this increase (Sociedad Española de Oncología Médica, 2014). Moreover, according to Gómez-Batiste et al. (Reference Gómez-Batiste, Pascual and Espinosa2010), 75% of the population of Spain will die because of a chronic disease. Apart from this, advanced chronic care is one of the main challenges for public health systems, and it calls for greater efforts with respect to review and innovation (Mateo-Ortega et al., Reference Mateo-Ortega, Gómez-Batiste and Limonero2013). Cancer is one of the three major causes of death in Western countries, along with heart disease and traffic accidents.
Patients with a diagnosis of advanced cancer (stages III or IV) present a great degree of complexity in relation to control of physical and psychological symptoms (Gil et al., Reference Gil, Costa and Pérez2008; Reference Gil, Costa and Pérez2010; Reference Gil, Costa and Hilker2012). For this reason, they require an intervention tailored to their specific needs. Early psychosocial intervention post-diagnosis can have beneficial effects in terms of quality of life, and can prevent unnecessary suffering by encouraging patients to evaluate their lives and question the meaning they attribute to the fact of living with cancer (Lee et al., Reference Lee, Cohen and Edgar2004; Chochinov et al., Reference Chochinov, Kristjanson and Breitbart2011). Thus, for example, depression in advanced cancer not only reduces quality of life, but it also shortens survival time, reduces adherence to treatment, and prolongs hospitalizations (Breitbart et al., Reference Breitbart, Bruera and Chochinov1995; Pelletier et al., Reference Pelletier, Raymond and Crabtree2002; Irving & Lloyd-Williams, Reference Irving and Lloyd-Williams2010; Watson et al., Reference Watson, Haviland and Greer1999).
William Breitbart developed meaning-centered group psychotherapy (MCGP) in order to improve adaptation to advanced disease, a technique that has demonstrated its effectiveness in different groups of patients with advanced cancer Breitbart et al., Reference Breitbart, Bruera and Chochinov1995; Breitbart et al., Reference Breitbart, Rosenfeld and Gibson2010; Reference Breitbart, Poppito and Rosenfeld2012; Reference Breitbart, Ronsenfeld and Pessin2015; Breitbart & Poppito, Reference Breitbart and Poppito2014).
MCGP is based on the work of the existentialist psychiatrist Viktor E. Frankl (Reference Frankl2005), especially his classic Man's Search for Meaning. He posited that the desire to find meaning in life is a primary and basic motivation for humanity. He developed logotherapy, a psychotherapeutic approach that focuses on helping people discover the meaning and purpose in their lives and overcome feelings of emptiness and despair (van der Spek et al., Reference van der Spek, Vos and van Uden-Kraan2013; Reference van der Spek, Vos and van Uden-Kraan2014).
A cancer diagnosis involves a complex set of feelings—for example, threat and uncertainty—for the patient and his or her family. In stages III and IV of diseases such as cancer, the treatment has two main goals: to increase survival time for patients and to maintain their quality of life by increasing the survival rate and improving all aspects of quality of life (Watson et al., Reference Watson, Haviland and Greer1999). MCGP seeks to stimulate the patient's search for meaning through experiences, attitudes, life review, and development of their own legacy as a way of improving their emotional and spiritual well-being. Likewise, the goal is to help patients “live with meaning” despite their physical limitations and the feelings of threat and uncertainty that accompany their disease (Gil & Breitbart, Reference Gil and Breitbart2013).
The main aims of MCGP are to assist cancer patients to “live with meaning,” in a complete way, maintaining and expanding the meaning of their lives, and to live peacefully with purpose. The specific objectives of MCGP are as follows: (1) to encourage cancer patients to seek meaning in their lives, despite the uncertainties and limitations of the disease: (a) to rearrange/evaluate meaningful memories, (b) to look for new meaning in life, and (c) to look for ways to overcome practical limitations; (2) to find new ways to reengage with life—to transcend; (3) to learn how to distinguish between the limitations that one can change or overcome and to accept those that cannot be changed; (4) to integrate the cancer diagnosis into the history of the patient's life (Krikorian & Limonero, Reference Krikorian and Limonero2012); (5) to express feelings and emotions; and (6) to improve one's psychological adaptation by finding meaning in life.
According to the above, the present study aimed to identify the main issues arising from application of MCGP to treat patients with advanced cancer. It is important to note that this study is the first use of MCGP in Spanish advanced cancer patients.
METHOD
Participants
Our study sample comprised outpatients diagnosed with stage III or IV cancer who were receiving care in the Hospital Duran i Reynals of the Catalan Institute of Oncology of l'Hospitalet de Llobregat in Barcelona, Spain. Three MCGP groups participated from January to June of 2013, and a total of 22 patients belonged to these groups.
Regarding the inclusion criteria, all patients were adults (18 years old or older), diagnosed with advanced cancer (stage III or IV), and informed of their diagnosis and prognosis. Patients were excluded from the study if they were not aware of their prognosis or if they had a cognitive disorder. Before inclusion in the study, all patients signed an informed consent. Our study was approved by the ethics committee on clinical research at our institution.
Procedure
Our MCGP intervention involved eight sessions of group therapy that focused on encouraging spiritual well-being and a sense of meaning and purpose for patients. The groups followed a structured format proposed by the founders of MCGP (Breitbart et al., Reference Breitbart, Rosenfeld and Gibson2010) that had been modified and adapted for a Spanish population by an expert clinical psychologist. The course of sessions included the following: (1) concepts and sources of meaning; (2) cancer and meaning; (3,4) historical sources of meaning; (5) attitudinal sources of meaning; (6) creative sources of meaning; (7) experiential sources of meaning; and (8) transitions (final group reflections and hopes for the future). All sessions were videotaped with the consent of the participants.
We utilized ATLAS® (v. 7.0; Scientific Software Development GmbH, Berlin), which is based in grounded theory as developed by Glaser and Strauss during the late 1960s (Charmaz, Reference Charmaz2006), to identify the themes that arose during group therapy. Two independent coders analyzed the transcripts following the steps of the “framework approach” (Pope et al., Reference Pope, Ziebland and Mays2000). If there was some disagreement between coders, they met with a third researcher. After that, the issues or themes that arose were encoded and classified as a constructed theme according to Breitbart et al. (Reference Breitbart, Rosenfeld and Gibson2010) or identified as an emergent theme if it was a new issue not previously included. We considered a constructed or emergent theme as a single “unit” when several patient comments during sessions could be grouped under the same theme.
For each source of meaning proposed in MCGP by Breitbart et al. (Reference Breitbart, Rosenfeld and Gibson2010), as well as for emergent issues, we assigned a frequency. We employed the Statistical Package for the Social Sciences (SPSS, v. 20.0, IBM, Armonk, New York) to analyze the gathered data.
RESULTS
Table 1 presents the issues that arose during MCGP sessions. These themes were classified into: (1) constructed themes, if the issues were proposed by Breitbart et al. (Reference Breitbart, Rosenfeld and Gibson2010); and (2) emergent themes, if the issues were new and had not been proposed previously. We present herein the constructed and emergent themes along with some quotations, the direct expressions of our patients. We omit names or any identifying characteristics of the patients to protect their anonymity.
Definition of the themes that arose during MCGP
* New issue that arose.
Constructed Themes
Attitudinal Sources of Meaning
Encountering life's limitations can involve transforming personal tragedy into a triumph and succeeding despite adversity:
■ Coping, fighting spirit:
I want to live, I want to fight. I do not think “I want to die tomorrow.” We must give everything. There are very bad times, very bad times, but then you have to be strong and, … I trust the doctors and treatment they are giving me.
■ Avoidance:
I looked at the CAT scan … where a phrase with “tumor” came up, and another phrase with “metastasis” … I have not returned to look at anything else anymore.
■ Limitations:
Now I live mentored, as if they had tied my hands. They love me a lot. They take care of me. I am fine, but I think someday I will have to return to my old life. This is a nightmare. I mean, I do not control the situation. I am still in shock.
■ Personal growth:
Since it happened to me, I have no appreciation for money. What I want is to be alive, to live long.
■ Acceptance:
I will have to live with this tumor all my life. They have already told me, and I am mentally prepared.
■ Searching for meaning:
Now I will have to fight to see a grandchild! I have this objective.
■ Anger:
When I think about it is when I am alone in my bed. I think, “Why do I have this?” My God, we were so happy before.
■ Knowledge crisis:
When they detect cancer with a CAT scan and tell you that nothing can be done, … everything stops.
■ Resilience:
Sometimes you cannot move because of the pain, or because of the side effects from the chemo. You loose weight, well-being …, and there are times you say, “I have reached the limit.” But, hey, you must keep on going.
■ Death:
Once I was so ill, I had a headache … and I said, “God, take me, hopefully right now.” “Mom … I die … come to me. Do not make me suffer so.” I wished it with all my heart, and I felt peace when I thought that everything was going to end.
Experiential Sources of Meaning
Connecting with Life Through Love, Beauty, and Humor. The following issues were found in the transcripts of patient accounts:
■ Incomprehension:
My husband said to me, “I do not know if you are aware that there are some moments that you are wrong. I see that some moments you are active, and there are moments that you are not. I do not know if you do this because of the disease or because you want to abuse me.” Then I started to cry. For a long time, I have had problems with some people caused by the disease … “Why do I have to suffer?”
■ Connecting with life (nature and beauty):
Now you see things that you did not see before. I did not consider it. Now you breathe, and you see trees.
■ Connecting with beauty:
I love to travel. I feel most connected with beauty when I visit monuments and museums.
Creative Sources of Meaning: Creativity, Courage, and Responsibility
We can transcend our bounds by actively infusing something of ourselves into the world (Coward, Reference Coward2003):
■ Pleasant activities:
My work has given meaning to my life. It has always been very important to me, and then the things I liked to do, now I cannot do, like traveling, reading—my tastes.
I have stopped painting during these years because I have been working, and I have not had much time. And now I will go back to painting and making crafts on Tuesdays.
■ Things to do:
You have to enjoy yourself. I raised my daughter … Now there is only my wife and me. We have very few opportunities to enjoy. Although now I can still enjoy them.
I have many things to do! I always thought, innocently, “when I retire.” I wanted to live for short periods of time in many parts of the world.
■ The illusions:
The only goal I have is to reach May 28th, when my daughter gets married. My daughter's wedding will be the happiest day. From here on, it is in the lap of the Gods.
Historical Sources of Meaning: Life as a Legacy That Has Been Given
Life is a legacy composed of past memories, present accomplishments, and future contributions:
■ Legacy:
I thought of writing a diary, writing letters to people I love … Perhaps there are things that you are not able to explain because at that time you did not know how to explain it, … and you have so many other things inside, and you would like to keep it with them in the present.
I would let them know that I have been always a cheerful and friendly person, a person who liked to laugh and to live. Now I am not this kind of person, but I was like this before. I always wanted to do lots of things. I want to think that I was a person who desired to give everything to make people happy … So many things—too many things!
■ Issues past and present:
I have not been able to be the same person as him. I do not have what he had [referring to his father] … I have always been on the road. I have not been with them [children] for as long as I wanted to. Now I am more with them more than ever before. Now I am happy with what I have. […] My life has been happy. My mother also had to work hard—lived for us. I would like to be as she was for me.
■ I think that nowadays relationships between parents and children are much more sincere, more frank than they were before.
New Emergent Issues that Arose Using the Spanish Adaptation
Some of the themes constructed by Breitbart et al. (Reference Breitbart, Rosenfeld and Gibson2010) using their model of meaning-centered psychotherapy arose as the following emergent themes:
■ Threat:
Now 90% of people die of cancer.
■ Benefit from attending group sessions:
I must say one thing about the first day that I walked out of here … Well, today I am also very touched by the girl [a group participant who had passed away] and cannot stop thinking about her … She touched me, but I think it was good for me. Even last week I had a visit with my psychiatrist, and I explained it to her. I told her, “I am not able to go to the group.” I used to leave the group very touched, but I think I should keep on coming.
■ Sadness:
At New Year's Eve, I was not interested in anybody. We were 30 people, and on Christmas Day we were having dinner. I went up to take my pills and thought about not coming back. I did not care if I was happy or not.
It is very hard. I thought I would live many years. When I was diagnosed with cancer, I felt paralyzed. I thought that it was a dream.
■ Uncertainty:
I had to be operated on in a month! And they told me that I have to wait three months more … I am always afraid to wait.
■ Loss of social role:
They used to bring me my grandchildren from seven in the morning until seven in the evening, and for some reason they have taken them way from me. It hurts me a lot.
■ Current routine of patients:
Next Monday, I will not attend the group because I am going to the doctor. On Thursday, they will tell me if I will have to undergo surgery. It depends on the effectiveness of the treatment … I have a visit with doctors, and they will decide.
Table 2 presents the frequencies of occurrence of both constructed and emergent themes. There were 726 instances in the transcripts, which we subcategorized as constructed or emergent themes.
Frequency table of constructed and emergent themes
* Percentage based on each theme.
** Percentage based on total sample.
The most frequent theme mentioned was threat, followed by coping and personal relationships.
DISCUSSION
Adaptation of MCGP for Spanish patients has been accomplished. In the qualitative analysis of the patients who received MCGP, we identified six new issues that had not been previously identified in the foundational work on MCGP for English-speaking patients. We found the following new emergent themes or issues: threat, benefit of group therapy, sadness, uncertainty, loss of social role, and the importance of a patient's current routine. All of these are themes that are common across cultures.
Our results indicate that the most widespread feeling verbalized by patients was threat, which coincides with the results reported by van der Spek et al. (Reference van der Spek, Vos and van Uden-Kraan2013), who conducted MCGP with Dutch patients and found that for them “threat to identity” was one of the main factors related to meaning. The Dutch, Israeli, and Spanish adaptations of MCGP coincide in terms of the emotional and spiritual benefits of MCGP in advanced cancer patients (Young, et al., Reference Young, Nadarajah and Skeath2014).
However, many patients reported experiences of personal growth as a result of their disease process. They expressed a greater awareness of their own lives and even enhanced connections with nature and/or beauty (Scheffold et al., Reference Scheffold, Mehnert and Müller2014). Van der Spek et al. (Reference van der Spek, Vos and van Uden-Kraan2013) also found that their patients experienced life more fully. In addition, they had come to truly value the small things in life, both of which are considered as a sign of personal growth.
Another common issue that emerged among our patients was acceptance of their diagnosis and their prognosis, despite the sense of crisis that often accompanies a knowledge of these aspects of the disease (Stedeford, Reference Stedeford1984).
Other issues that arose included loneliness, isolation, and incomprehension. In accordance with this, Ryff and Singer (Reference Ryff and Singer1998) observed that psychological well-being depends on two key dimensions: living life with purpose and being connected to others.
As mentioned above, connection to others is one of the most important factors related to meaning in a person's life (Kim et al., Reference Kim, Han and Shaw2010). However, as Applebaum et al. (Reference Applebaum, Lichtenthal and Pessin2012; Reference Applebaum, Kulikowski and Breitbart2015) pointed out, the need to be connected to others coexists with a need to have one's own time.
In this sense, it is important to mention the benefits accrued by patients from attending group sessions. To share experiences with other participants who are coping with the same illness allows one to feel validated by the other members of the group (Kissane et al. Reference Kissane, Grabsch and Clarke2007; Limonero et al., Reference Limonero, Tomás-Sábado and Gómez-Romero2014). As one patient put it, “I'm learning a lot from you [the group], and also when I'm down, you're a good emotional support.”
According to prior research (Thornton, Reference Thornton2002; Tedeschi & Calhoun, Reference Tedeschi and Calhoun2004; Henoch & Danielson, Reference Henoch and Danielson2009) and in accordance with the results of our study, it is possible for patients living with cancer to experience the disease in an adaptive manner by drawing meaning from the experience and transforming it into a source of personal growth. It is therefore important to know the barriers to finding meaning in order to promote creation and adaptation of meaning-based interventions for patients with an advanced illness (Ryff & Singer, Reference Ryff and Singer1996; van der Spek et al., Reference van der Spek, Vos and van Uden-Kraan2013; Reference van der Spek, Vos and van Uden-Kraan2014).
The results of our study not only validate the themes proposed by Breitbart and colleagues' foundational MCGP work, but new emergent issues have been revealed. This it is important in the context of adaptation of MCGP for Spanish patients. Our first adaptation for Spanish-speaking patients could be employed in developing other Latin American adaptations in order to determine if our results are applicable to other Latin American patients, who share many sociocultural aspects with Spanish patients. Cultural similarities can play an important role in constructing personal meaning, which can be expressed along with implementation of MCGP. The uniqueness of the Spanish experience and its link to the meaning-centered model demonstrate the feasibility and acceptance of MCGP in populations of Spanish cancer patients.
LIMITATIONS OF THE STUDY
The most important limitation of our study is our small sample size. It is necessary to carry out new research with larger samples in order to consolidate the results obtained in the present research.
CONCLUSIONS
Despite the limitation of the small sample size, our research validates the use of Breitbart and colleagues' foundational MCGP work for Spanish advanced cancer patients. We have also presented new emergent issues that can be considered in the Spanish adaptation as well as in future Latin American adaptations of MCGP.
