Those of us engaged in clinical research and the compassionate clinical care of patients with life-threatening illnesses often find ourselves confronted with basic questions of the nature of human existence, and in particular how one creates and lives a mortal human life. We are human beings caring for human beings who are facing death as a more imminent and immediately concrete concern. Personally, I find it necessary to constantly struggle with understanding the nature of human existence as a way to find an attitude or approach to dying patients that is therapeutic and represents some advance in psychosocial and spiritual interventions in palliative care.

Readers of Palliative & Supportive Care may be familiar with my regularly appearing essays and editorials dealing with existential and spiritual themes. I take the opportunity of each upcoming issue of Palliative & Supportive Care as a way to expand on a recent epiphany or new understanding of a concept I thought I understood before, but now understand in a new and possibly more unique and clinically helpful way. Such is the case with this editorial. I had a new understanding of the nature and importance of “attitude” as a source of meaning and the role it plays in human existence.

Some of you may be familiar with meaning-centered psychotherapy (MCP) for advanced cancer patients, a novel intervention our research group developed and demonstrated to be effective in diminishing despair in a series of randomized controlled trials (Breitbart, et al., Reference Breitbart, Rosenfeld and Gibson2010; Reference Breitbart, Poppito and Rosenfeld2012; Reference Breitbart, Rosenfeld and Pessin2015; Breitbart & Poppito, Reference Breitbart and Poppito2014a ,Reference Breitbart and Poppito b ). MCP for advanced cancer patients was adapted from Viktor Frankl's seminal work on meaning and his logotherapy (Frankl, Reference Frankl1959). Central to both Frankl's work and MCP is the concept that there are several predictable and easily accessible sources of meaning in human life, which include: “creative sources” of meaning (e.g., work), “experiential sources” of meaning (e.g., love), “attitudinal sources” of meaning (e.g., turning a tragedy into a triumph), and “historical sources” of meaning (e.g., the legacy you are given, the legacy you live, and the legacy you give). Most of us live lives of meaning without consciously being aware that we are utilizing these sources of meaning. When plunged into turmoil by a terminal cancer diagnosis, it appears to be helpful for patients to have these sources of meaning delineated, described, experienced, and brought to conscious awareness so that one can “reach” for “each” source of meaning when overcome by a sense of loss or disconnection from the experience of personal meaning.

“Creative sources” of meaning are especially important to human existence and are central to the existential obligation (understood as the concept of “responsibility”) that each human being experiences when they become aware of their existence. Driven by both biology and existential imperative, once we realize that we exist, we must respond to the fact of our existence by “creating a life.” We each are driven to create a unique life, with direction and meaning, and growth and transformation, to become an effective and useful member of a larger culture or society in a world that we imbue with meaning. What drives this need or will to create a life has been the subject of much philosophical debate. Is it the will to meaning? Is it love or procreation, or mere survival? My understanding of creative sources of meaning has evolved over time and is reflected in not only the content of this editorial, but in the process of creating this editorial as well. For much of the last 10 years spent in the development of meaning-centered psychotherapy for advanced cancer patients in the Psychotherapy Laboratory I lead at Memorial Sloan Kettering Cancer Center, I had thought of creative sources of meaning as those aspects, values, efforts, etc., that go into the process of creating one's life. Frankl would often refer to “work” as the central creative source of meaning. But counseling advanced cancer patients, for whom work was no longer an available expression or source of meaning, I realized that work could not possibly be the sole element of this source of meaning. It soon became clear that “creative” sources of meaning also referred to what you really cared about in the world and the pursuit of fostering and creating that person, entity, value, virtue into being. Upon further reflection, I began to see that we create not only “what” we are, and “what” we care about in the world—we also create “who” we are and “who” we care about and love in this world.

Over the past 30 years, I have been involved in the fellowship training of 300 or more psychologists and psychiatrists in the field of psycho-oncology, as well as numerous palliative medicine physicians. I recently began to meet regularly with our palliative medicine fellows in order to help “debrief” them after the first six months of fellowship. The presumption was that, by that point, these physicians in training had encountered an overwhelming amount of pain, suffering, and death in the patients they cared for. The discussions were astounding, but not for the reasons I had expected. What was striking was that none of these extraordinarily bright and motivated young physicians could answer the following question: “Who do you want to become in this world?” The answer was always “I want to be a good palliative care doctor.” The answer was always an answer to “what” they wanted to be in the world. This made me realize that enacting one's responsibility to create a life of meaning and authenticity, of growth and transformation, and self-actualization in fact really involved the process of creating “who” you become in the world as well as the “what” (or work) that allows you to express who you are. So the process of becoming a “who” in order to discover the “what” in your life took on greater significance for me as an element of meaning–centered psychotherapy.

What comprises the “who” of a human being, and how does one create who one becomes? There are values, virtues, emotions, cognitions, and physical functions that all seemed like reasonable candidates in some combination or perturbation. Ultimately, I believe it is “attitude” that is at the core of “who” you are. The process of creating yourself, at its essence, involves the creation of the attitude you take toward life—life, love, and suffering. Creating your attitude is essentially creating your soul (from the Greek philosophical perspective, your mind and spirit). And suddenly it became clear to me why being loving, and empathic, and generous, and caring to others brought so much personal reward. It was because this is how we create, feed, and grow our attitude in the world and thus give birth to and nurture our very souls.