Meaning-Making and Psychological Adjustment to Cancer: Development of an Intervention and Pilot Results

Virginia Lee

S. Robin Cohen

Linda Edgar

Andrea M. Laizner

Anita J. Gagnon

ONF 2007, 33(2), 291-302. DOI: 10.1188/06.ONF.291-302

Purpose/Objectives: To develop an intervention that uniquely addresses the existential impact of cancer through meaning-making coping strategies and to explore the intervention's impact on psychological adjustment.

Design: Descriptive, qualitative approach to develop the intervention; one-group pre- and post-test design to pilot test the intervention.

Setting: Patients' homes or ambulatory oncology clinics affiliated with a university health center in eastern Canada.

Sample: 18 participants who were newly diagnosed in the past three months (n = 14), had completed treatment (n = 1), or were facing recurrence (n = 3) of breast (n = 10) or colorectal (n = 8) cancer.

Methods: Data were collected during interviews using a prototype intervention for trauma patients, and content was analyzed on an ongoing basis to fit the needs of the cancer population. Pretest and post-test questionnaires were administered to determine the intervention's effect.

Main Research Variables: Meaning-making intervention (MMI), patients' background variables, disease- or treatment-related symptoms, and psychological adjustment.

Findings: The MMI for patients with cancer consisted of as many as four two-hour, individualized sessions and involved the acknowledgment of losses and life threat, the examination of critical past challenges, and plans to stay committed to life goals. At post-test, participants significantly improved in self-esteem and reported a greater sense of security in facing the uncertainty of cancer.

Conclusions: Findings suggest that meaning-making coping can be facilitated and lead to positive psychological outcomes following a cancer diagnosis.

Implications for Nursing: The MMI offers a potentially effective and structured approach to address and monitor cancer-related existential issues. Findings are useful for designing future randomized, controlled trials.

Jump to a section

    References

    Andersen, B.L. (1992). Psychological interventions for cancer patients to enhance the quality of life. Journal of Consulting and Clinical Psychology, 60, 552-568.
    Bottomley, A., Hunton, S., Roberts, G., Jones, L., & Bradley, C. (1996). A pilot study of cognitive behavioral therapy and social support group interventions with newly diagnosed cancer patients. Journal of Psychosocial Oncology, 14(4), 65-83.
    Bowes, D.E., Tamlyn, D., & Butler, L.J. (2002). Women living with ovarian cancer: Dealing with an early death. Health Care for Women International, 23, 135-148.
    Bridges, W. (1980). Transitions: Making sense of life's changes. New York: Addison-Wesley.
    Cain, E.N., Kohorn, E.I., Quinlan, D.M., Latimer, K., & Schwartz, P.E. (1986). Psychosocial benefits of a cancer support group. Cancer, 57, 183-189.
    Carpenter, J.S., & Brockopp, D.Y. (1994). Evaluation of self-esteem of women with cancer receiving chemotherapy. Oncology Nursing Forum, 21, 751-757.
    Carpenter, J.S., Brockopp, D.Y., & Andrykowski, M.A. (1999). Self-transformation as a factor in the self-esteem and well-being of breast cancer survivors. Journal of Advanced Nursing, 29, 1402-1411.
    Carver, C.S., Pozo, C., Harris, S.D., Noriega, V., Scheier, M.F., Robinson, D.S., et al. (1993). How coping mediates the effect of optimism on distress: A study of women with early stage breast cancer. Journal of Personality and Social Psychology, 65, 375-390.
    Cella, D.F., Mahon, S.M., & Donovan, M.I. (1990). Cancer recurrence as a traumatic event. Behavioral Medicine, 16, 15-22.
    Chambless, D.L., & Hollon, S.D. (1998). Defining empirically supported therapies. Journal of Consulting and Clinical Psychology, 66, 7-18.
    Classen, C., Butler, L.D., Koopman, C., Miller, E., DiMiceli, S., Giese-Davis, J., et al. (2001). Supportive-expressive group therapy and distress in patients with metastatic breast cancer. A randomized clinical intervention trial. Archives of General Psychiatry, 58, 494-501.
    Cohen, S.R., & Mount, B.M. (2000). Living with cancer: "Good" days and "bad" days—What produces them? Can the McGill Quality of Life Questionnaire distinguish between them? Cancer, 89, 1854-1865.
    Cole, B., & Pargament, K. (1999). Re-creating your life: A spiritual/psychotherapeutic intervention for people diagnosed with cancer. Psycho-Oncology, 8, 395-407.
    Council of the Canadian Strategy for Cancer Control. (2004). The sixth vital sign. Retrieved September 8, 2004, from http://209.217.127.72/c5cc/pdf/bulletinsv7_en.pdf
    Coward, D.D. (1990). The lived experience of self-transcendence in women with advanced breast cancer. Nursing Science Quarterly, 3, 162-169.
    Coward, D.D. (1998). Facilitation of self-transcendence in a breast cancer support group. Oncology Nursing Forum, 25, 75-84.
    Coward, D.D. (2003). Facilitation of self-transcendence in a breast cancer support group: II. Oncology Nursing Forum, 30, 291-300.
    Crandall, R. (1973). The measurement of self-esteem and related constructs. In J.P. Robinson & P.R. Shaver (Eds.) Measures of social psychological attitudes (pp. 81-83). Ann Arbor, MI: Survey Research Center, Institute for Social Research.
    Creamer, M., Burgess, P., & Pattison, P. (1992). Reaction to trauma: A cognitive processing model. Journal of Abnormal Psychology, 101, 452-459.
    Crumbaugh, J.C., & Maholick, L.T. (1964). An experimental study in existentialism: The psychometric approach to Frankl's concept of noogenic neurosis. Journal of Clinical Psychology, 20, 200-207.
    Cunningham, A.J. (2000). Adjuvant psychological therapy for cancer patients: Putting it on the same footing as adjunctive medical therapies. Psycho-Oncology, 9, 367-371.
    Cunningham, A.J., & Edmonds, C.V. (1996). Group psychological therapy for cancer patients: A point of view, and discussion of the hierarchy of options. International Journal of Psychiatry in Medicine, 26, 51-82.
    Cunningham, A.J., Lockwood, G.A., & Edmonds, C.V. (1993). Which cancer patients benefit most from a brief, group, coping skills program? International Journal of Psychiatry in Medicine, 23, 383-398.
    Curbow, B., & Somerfield, M. (1991). Use of the Rosenberg Self-Esteem Scale in adult cancer patients. Journal of Psychosocial Oncology, 9, 113-131.
    Derogatis, L.R. (1986). The Psychosocial Adjustment to Illness Scale (PAIS). Journal of Psychosomatic Research, 30, 77-91.
    Derogatis, L.R., Morrow, G.R., Fetting, J., Penman, D., Piasetsky, S., Schmale, A.M., et al. (1983). The prevalence of psychiatric disorders among cancer patients. JAMA, 249, 751-757.
    Devine, E.C., & Westlake, S.K. (1995). The effects of psychoeducational care provided to adults with cancer: Meta-analysis of 116 studies. Oncology Nursing Forum, 22, 1369-1381.
    de Vries, M.J., Schilder, J.N., Mulder, C.L., Vrancken, A.M., Remie, M., & Garssen, B. (1997). Phase II study of psychotherapeutic intervention in advanced cancer. Psycho-Oncology, 6, 129-137.
    Edelman, S., Bell, D.R., & Kidman, A.D. (1999). A group cognitive behaviour therapy programme with metastatic breast cancer patients. Psycho-Oncology, 8, 295-305.
    Edgar, L., Rosberger, Z., & Collet, J.P. (2001). Lessons learned: Outcomes and methodology of a coping skills intervention trial comparing individual and group formats for patients with cancer. International Journal of Psychiatry in Medicine, 31, 289-304.
    Edgar, L., Rosberger, Z., & Nowlis, D. (1992). Coping with cancer during the first year after diagnosis. Assessment and intervention. Cancer, 69, 817-828.
    Emanuel, E., Fairclough, D.L., Wolfe, P., & Emanuel, L.L. (2004). Talking with terminally ill patients and their caregivers about death, dying, and bereavement. Is it stressful? Is it helpful? Archives of Internal Medicine, 164, 1999-2004.
    Epping-Jordan, J.E., Compas, B.E., Osowiecki, D.M., Oppedisano, G., Gerhardt, C., Primo, K., et al. (1999). Psychological adjustment in breast cancer: Processes of emotional distress. Health Psychology, 18, 315-326.
    Ersek, M., & Ferrell, B.R. (1994). Providing relief from cancer pain by assisting in the search for meaning. Journal of Palliative Care, 10, 15-22.
    Farber, J.M., Weinerman, B.H., & Kuypers, J.A. (1984). Psychosocial distress of oncology patients. Journal of Psychosocial Oncology, 2, 109-118.
    Fawzy, F., Fawzy, N.W., Arndt, L.A., & Pasnau, R.O. (1995). Critical review of psychosocial interventions in cancer care. Archives of General Psychiatry, 52, 100-113.
    Fawzy, F.I., Fawzy, N.W., & Wheeler, J.G. (1996). A post-hoc comparison of the efficiency of a psychoeducational intervention for melanoma patients delivered in group versus individual formats: An analysis of data from two studies. Psycho-Oncology, 5, 81-89.
    Folkman, S., & Greer, S. (2000). Promoting psychological well-being in the face of serious illness: When theory, research and practice inform each other. Psycho-Oncology, 9, 11-19.
    Frankl, V. (1959). Man's search for meaning (4th ed.). Boston: Beacon Press.
    Frank-Stromborg, M., Wright, P.S., Segalla, M., & Diekmann, J. (1984). Psychological impact of the "cancer" diagnosis. Oncology Nursing Forum, 11(3), 16-22.
    Frost, M.H., Suman, V.J., Rummans, T.A., Dose, A.M., Taylor, M., Novotny, P., et al. (2000). Physical, psychological and social well-being of women with breast cancer: The influence of disease phase. Psycho-Oncology, 9, 221-231.
    Goodwin, P.J., Leszcz, M., Ennis, M., Koopmans, J., Vincent, L., Guther, H., et al. (2001). The effect of group psychosocial support on survival in metastatic breast cancer. New England Journal of Medicine, 345, 1719-1726.
    Gotay, C.C., & Lau, A.K. (2002). Preferences for psychosocial interventions among newly diagnosed cancer patients from a multiethnic population. Journal of Psychosocial Oncology, 20(4), 23-37.
    Gottlieb, L., & Rowat, K. (1987). The McGill model of nursing: A practice derived model. Advances in Nursing Science, 9, 51-61.
    Green, B.L., Rowland, J.H., Krupnick, J.L., Epstein, S.A., Stockton, P., Stern, N.M., et al. (1998). Prevalence of posttraumatic stress disorder in women with breast cancer. Psychosomatics, 39, 102-111.
    Greenstein, M. (2000). The house that's on fire: Meaning-centered psychotherapy pilot group for cancer patients. American Journal of Psychotherapy, 54, 501-511.
    Greenstein, M., & Breitbart, W. (2000). Cancer and the experience of meaning: A group psychotherapy program for people with cancer. American Journal of Psychotherapy, 54, 486-500.
    Greer, S., Moorey, S., & Baruch, J. (1991). Evaluation of adjuvant psychological therapy for clinically referred cancer patients. British Journal of Cancer, 63, 257-260.
    Greer, S., Moorey, S., Baruch, J.D., Watson, M., Robertson, B.M., Mason, A., et al. (1992). Adjuvant psychological therapy for patients with cancer: A prospective randomised trial. BMJ, 304, 675-680.
    Grossman, M., Kenny, J.V., Lee, V., Chambers-Evans, J., Godin, M., & McHarg, L. (1999). Emotional distress in critically-injured patients three months after a potentially life-threatening accident. Journal of Neuroscience Nursing, 31, 159-173.
    Grossman, M., & Lee, V. (1998). Meaning intervention manual. Unpublished manuscript, McGill University, Montreal, Canada.
    Halstead, M.T., & Hull, M. (2001). Struggling with paradoxes: The process of spiritual development in women with cancer. Oncology Nursing Forum, 28, 1534-1543.
    Helgeson, V.S., Cohen, S., Schulz, R., & Yasko, J. (2000). Group support interventions for women with breast cancer: Who benefits from what? Health Psychology, 19, 107-114.
    Holland, J.C. (1999). NCCN practice guidelines for the management of psychosocial distress. Oncology, 13, 113-147.
    Holland, J.C. (2000). An algorithm for rapid assessment and referral of distressed patients. In M.C. Perry (Ed.), American Society of Clinical Oncology educational book (pp. 129-138). Alexandria, VA: American Society of Clinical Oncology.
    Horowitz, M., Wilner, N., & Alvarez, W. (1979). Impact of Event Scale: A measure of subjective stress. Psychosomatic Medicine, 41, 209-218.
    Horowitz, M.J. (1992). Stress response syndromes (2nd ed.). Northvale, NJ: Aronson Press.
    Hutchinson, S.A., Wilson, M.E., & Wilson, H.S. (1994). Benefits of participating in research interviews. Image: Journal of Nursing Scholarship, 26, 161-164.
    Ishiyama, F.I. (1990). Meaningful life therapy: Use of Morita therapy principles in treating patients with cancer and intractable diseases. International Bulletin of Morita Therapy, 3(2), 77-84.
    Janoff-Bulman, R. (1989). Assumptive worlds and the stress of traumatic events: Applications of the schema construct. Social Cognition, 7(2), 113-136.
    Kagawa-Singer, M. (1993). Redefining health: Living with cancer. Social Science and Medicine, 37, 295-304.
    Karnofsky, D.A., & Burchenal, J.H. (1949). The clinical evaluation of chemotherapeutic agents in cancer. In C.M. Macleod (Ed.), Evaluation of chemotherapeutic agents (pp. 199-205). New York: Columbia University Press.
    Kissane, D.W. (2000). Psychospiritual and existential distress: The challenge for palliative care. Australian Family Physician, 29, 1022-1025.
    Kissane, D.W., Bloch, S., Smith, G.C., Miach, P., Clarke, D.M., Ikin, J., et al. (2003). Cognitive-existential group psychotherapy for women with primary breast cancer: A randomised controlled trial. Psycho-Oncology, 12, 532-546.
    Kitchener, K.S., & Brenner, H.G. (1990). Wisdom and reflective judgement: Knowing in the face of uncertainty. In R.J. Sternberg (Ed.), Wisdom: Its nature, origins, and development (pp. 212-229). New York: Cambridge University Press.
    Kitson, A., Harvey, G., & McCormack, B. (1998). Enabling the implementation of evidence based practice: A conceptual framework. Quality in Health Care, 7, 149-158.
    Lauver, D., & Tak, Y. (1995). Optimism and coping with a breast cancer symptom. Nursing Research, 44, 202-207.
    Lee, V. (2004). A meaning-making intervention for cancer patients—Procedure manual. Unpublished manuscript, McGill University, Montreal, Canada.
    Lee, V., Cohen, S.R., Edgar, L., Laizner, A.M., & Gagnon, A.J. (2004). Clarifying "meaning" in the context of cancer: A systematic literature review. Palliative and Supportive Care, 2, 291-303.
    Lethborg, C.E., Kissane, D., Burns, W.I., & Snyder, R. (2000). "Cast adrift": The experience of completing treatment among women with early stage breast cancer. Journal of Psychosocial Oncology, 18(4), 73-90.
    Lewis, F.M. (1982). Experienced personal control and quality of life in latestage cancer patients. Nursing Research, 31, 113-119.
    Lewis, F.M. (1989). Attributions of control, experienced meaning, and psychosocial well-being in patients with advanced cancer. Journal of Psychosocial Oncology, 7(1/2), 105-119.
    Linn, M.W., Linn, B.S., & Harris, R. (1982). Effects of counseling for late stage cancer patients. Cancer, 49, 1048-1055.
    MacCormack, T., Simonian, J., Lim, J., Remond, L., Roets, D., Dunn, S., et al. (2001). "Someone who cares": A qualitative investigation of cancer patients' experiences of psychotherapy. Psycho-Oncology, 10, 52-65.
    Mahon, S.M., & Casperson, D.M. (1997). Exploring the psychosocial meaning of recurrent cancer: A descriptive study. Cancer Nursing, 20, 178-186.
    McCorkle, R., Cooley, M.E., & Shea, J.A. (1997). A user's manual for the Symptom Distress Scale. Unpublished manuscript, Yale University School of Nursing, New Haven, CT.
    McCorkle, R., & Quint-Benoliel, J. (1983). Symptom distress, current concerns, and mood disturbance after diagnosis of life-threatening disease. Social Science and Medicine, 17, 431-438.
    Merluzzi, T.V., & Sanchez, M.M. (1997). Factor structure of the Psychosocial Adjustment to Illness Scale (Self-Report) for persons with cancer. Psychological Assessment, 9, 269-276.
    Meyer, T.J., & Mark, M.M. (1995). Effects of psychosocial interventions with adult cancer patients: A meta-analysis of randomized experiments. Health Psychology, 14, 101-108.
    Moorey, S., & Greer, S. (1989). Psychological therapy for patients with cancer: A new approach. Washington, DC: American Psychiatric Press.
    Moorey, S., Greer, S., Watson, M., Gorman, C., Rowden, L., Tunmore, R., et al. (1991). The factor structure and factor stability of the hospital anxiety and depression scale in patients with cancer. British Journal of Psychiatry, 158, 255-259.
    Moynihan, C., Bliss, J.M., Davidson, J., Burchell, L., & Horwich, A. (1998). Evaluation of adjuvant psychological therapy in patients with testicular cancer: Randomised controlled trial. BMJ, 316, 429-435.
    Mullen, P.M., Smith, R.M., & Hill, E.W. (1993). Sense of coherence as a mediator of stress for cancer patients and spouses. Journal of Psychosocial Oncology, 11, 23-46.
    Norman, G.R., Sloan, J.A., & Wyrwich, K.W. (2003). Interpretation of changes in health-related quality of life: The remarkable universality of half a standard deviation. Medical Care, 41, 582-592.
    O'Connor, A.P., & Wicker, C.A. (1995). Clinical commentary: Promoting meaning in the lives of cancer survivors. Seminars in Oncology Nursing, 11, 68-72.
    Overholser, J.C. (1993a). Elements of the Socratic method: I. Systematic questioning. Psychotherapy, 30, 67-74.
    Overholser, J.C. (1993b). Elements of the Socratic method: II. Inductive reasoning. Psychotherapy, 30, 75-85.
    Park, C.L., & Folkman, S. (1997). Meaning in the context of stress and coping. Review of General Psychology, 1, 115-144.
    Pelusi, J. (1997). The lived experience of surviving breast cancer. Oncology Nursing Forum, 24, 1343-1353.
    Post-White, J., Ceronsky, C., Kreitzer, M.J., Nickelson, K., Drew, D., Mackey, K.W., et al. (1996). Hope, spirituality, sense of coherence, and quality of life in patients with cancer. Oncology Nursing Forum, 23, 1571-1579.
    Revenson, T.A., Wollman, C.A., & Felton, B.J. (1983). Social supports as stress buffers for adult cancer patients. Psychosomatic Medicine, 45, 321-331.
    Richer, M.C., & Ezer, H. (2002). Living in it, living with it, and moving on: Dimensions of meaning during chemotherapy. Oncology Nursing Forum, 29, 113-119.
    Rosenberg, M. (1965). Society and the adolescent self-image. Middletown, CT: Wesleyan University Press.
    Sadeh-Tassa, D., Drory, M., Ginzburg, K., & Stadler, J. (1999). Stages of breast cancer: An Israeli psychosocial intervention model. Journal of Psychosocial Oncology, 17(3/4), 63-83.
    Sarason, B.R., Shearin, E.N., Pierce, G.R., & Sarason, I.G. (1987). Interrelations of social support measures: Theoretical and practical implications. Journal of Personality and Social Psychology, 52, 813-832.
    Sarason, I.G., Johnson, J.H., & Siegel, J.M. (1978). Assessing the impact of life changes: Development of the Life Experiences Survey. Journal of Consulting and Clinical Psychology, 46, 932-946.
    Schag, C.C., Heinrich, R.L., & Ganz, P.A. (1984). Karnofsky Performance Status revisited: Reliability, validity, and guidelines. Journal of Clinical Oncology, 2, 187-193.
    Scheier, M.F., & Carver, C.S. (1987). Dispositional optimism and physical well-being: The influence of generalized outcome expectancies on health. Journal of Personality, 55, 169-210.
    Scheier, M.F., Carver, C.S., & Bridges, M.W. (1994). Distinguishing optimism from neuroticism (and trait anxiety, self-mastery, and self-esteem): A reevaluation of the Life Orientation Test. Journal of Personality and Social Psychology, 67, 1063-1078.
    Schnoll, R.A., Knowles, J.C., & Harlow, L. (2002). Correlates of adjustment among cancer survivors. Journal of Psychosocial Oncology, 20(1), 37-59.
    Schwarzer, R. (Ed.). (1992). Self-efficacy: Thought control of action. Washington, DC: Hemisphere.
    Silber, E., & Tippett, J.S. (1965). Self-esteem: Clinical assessment and measurement validation. Psychological Reports, 16, 1017-1071.
    Spiegel, D., Bloom, J.R., & Yalom, I. (1981). Group support for patients with metastatic cancer. A randomized outcome study. Archives of General Psychiatry, 38, 527-533.
    Steeves, R.H. (1992). Patients who have undergone bone marrow transplantation: Their quest for meaning. Oncology Nursing Forum, 19, 899-905.
    Stefanek, M.E., Derogatis, L.R., & Shaw, A. (1987). Psychosocial distress among oncology outpatients. Prevalence and severity as measured with the Brief Symptom Inventory. Psychosomatics, 28, 530-539.
    Taylor, E.J. (1993). Factors associated with meaning in life among people with recurrent cancer. Oncology Nursing Forum, 20, 1399-1407.
    Taylor, E.J. (2000). Transformation of tragedy among women surviving breast cancer. Oncology Nursing Forum, 27, 781-788.
    Thompson, S.C., & Janigian, A. (1988). Life schemes: A framework for understanding the search for meaning. Journal of Social and Clinical Psychology, 7, 260-280.
    Thompson, S.C., & Pitts, J. (1993). Factors relating to a person's ability to find meaning after a diagnosis of cancer. Journal of Psychosocial Oncology, 11, 1-21.
    Tomich, P.L., & Helgeson, V.S. (2002). Five years later: A cross-sectional comparison of breast cancer survivors with healthy women. Psycho-Oncology, 11, 154-169.
    Trijsburg, R.W., van Knippenberg, F.C.E., & Rijpma, S.E. (1992). Effects of psychological treatment on cancer patients: A critical review. Psychosomatic Medicine, 54, 489-517.
    Vickberg, S.M., Bovbjerg, D.H., DuHamel, K.N., Currie, V., & Redd, W.H. (2000). Intrusive thoughts and psychological distress among breast cancer survivors: Global meaning as a possible protective factor. Behavioral Medicine, 25, 152-160.
    Vinokur, A.D., Threatt, B.A., Caplan, R.D., & Zimmerman, B.L. (1989). Physical and psychosocial functioning and adjustment to breast cancer. Long-term follow-up of a screening population. Cancer, 63, 394-405.
    Waltz, J., Addis, M.E., Koerner, K., & Jacobson, N.S. (1993). Testing the integrity of a psychotherapy protocol: Assessment of adherence and competence. Journal of Consulting and Clinical Psychology, 61, 620-630.
    Ward, S., Leventhal, H., Easterling, D., Luchterhand, C., & Love, R. (1991). Social support, self-esteem, and communication in patients receiving chemotherapy. Journal of Psychosocial Oncology, 9(1), 95-115.
    Weisman, A.D., & Worden, J.W. (1976-1977). The existential plight in cancer: Significance of the first 100 days. International Journal of Psychiatry in Medicine, 7, 1-15.
    Weisman, A.D., & Worden, J.W. (1985). The emotional impact of recurrent cancer. Journal of Psychosocial Oncology, 3(4), 5-16.
    Zabora, J., Brintzenhofeszoc, K., Curbow, B., Hooker, C., & Piantadosi, S. (2001). The prevalence of psychological distress by cancer site. Psycho-Oncology, 10, 19-28.
    Zigmund, A.S., & Snaith, R.P. (1983). The Hospital Anxiety and Depression Scale. Acta Psychiatrica Scandinavica, 67, 361-370.
    Zilberg, N.J., Weiss, D.S., & Horowitz, M.J. (1982). Impact of Event Scale: A cross-validation study and some empirical evidence supporting a conceptual model of stress response syndromes. Journal of Consulting and Clinical Psychology, 50, 407-414.
    Zuehlke, T.E., & Watkins, J.T. (1975). The use of psychotherapy with dying patients: An exploratory study. Journal of Clinical Psychology, 31, 729-732.