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Meaning‐Centered Grief Therapy: A Clinical Intervention to Support Grieving Individuals

COPYRIGHT © 2021 by Wendy G. Lichtenthal. All rights reserved.

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Meaning‐Centered Grief Therapy: A Clinical Intervention to Support Grieving Individuals

Wendy G. Lichtenthal, PhD

Director, Bereavement Clinic, Associate Attending Psychologist

Department of Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center,

New York, NY, USA

Minnesota Coalition for Death Education and Support (MCDES) Spring Conference

April 30, 2021

Workshop Overview

• Part 1: Intro to MCGT

• Part 2: MCGT: The Early Sessions

• Part 3: MCGT: The Middle Sessions

• Part 4: MCGT: The Later Sessions + Q&A

Part 1

Introduction to MCGT

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Why Target Meaning?

• Meaning‐making is part of the normal process of coping and adaptation

• Finding meaning in one’s life and the loss experience is long believed to have therapeutic benefits

• Research has shown that meaning made of the loss drives the relationship between cause of death and prolonged grief disorder (PGD)

Davis & Nolen‐Hoeksema, 2001; Lichtenthal & Breitbart, 2015; Neimeyer, 2000, 2001; Park, 2010; Park & Folkman, 1997; Rozalski, Holland, & Neimeyer, 2016

But what do we mean by “meaning”?

“Meaning” is an umbrella term for several concepts

Lichtenthal, Currier, Neimeyer, & Keesee, 2010; Park, 2010; Park & Folkman, 1997

Benefit‐finding

Sense of Purpose Sense‐

making

Post‐traumatic Growth

Existential Well‐being

Identity

CoherenceLegacy

Sources of Meaning

Choice & Responsibility

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Many of these constructs overlap conceptually

Lichtenthal, Currier, Neimeyer, & Keesee, 2010; Park, 2010

Key Terms in the Meaning‐Making Literature

• Meaning‐making efforts: the processes that one engages in to find meaning

• Meaning made: the outcomes of such processes

• Situational meaning: appraised meaning of a challenging life event

• Global meaning: the existing cognitive framework (assumptions, beliefs) about the world and oneself that are used to interpret the event

– Park (2010): driven to make meaning to reduce distress caused by a discrepancy between situational and global meaning

– Davis et al. (2000): driven to search for meaning when preexisting assumptions are shattered or when our sense of identity depended on the lost relationship

• Sense of meaning: the conviction that one is fulfilling a unique role and purpose in a life

– Frankl (1955, 1959): often driven to find a sense of meaning during times of suffering

Bonanno, 2013; Davis et al., 2000; Folkman & Moskowitz, 2000; Frankl, 1955, 1959; Gillies, Neimeyer, & Milman, 2014; Lichtenthal & Breitbart, 2015; Park, 2010

Loss as A Crisis in Meaning

Armour, 2003; Begley & Quayle, 2007; Janoff‐Bulman, 1992; Lehman et al., 1987; Matthews & Marwit, 2003–2004; Murphy, Johnson, & Lohan, 2003;

Possick, Sadeh, & Shamai, 2008; Rando, 1986; Rosenberg et al., 2014; Wheeler, 2001

• Shatters assumptions about the way the world works

• Challenges both assimilation, trying to fit a sudden violent loss into one’s belief system, and accommodation, altering of one’s beliefs because of the loss and circumstances

• Threatens sense of identity and purpose

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Challenges to meaning‐making (and sense‐making in particular) have been associated with increased

levels of prolonged grief

Currier et al., 2006; Davis, Nolen‐Hoeksema, & Larson, 1998; Engelkemeyer & Marwit, 2008; Gilmer et al., 2012; Keesee, Currier, & Neimeyer, 2008; Lichtenthal, Currier, Neimeyer, & Keesee, 2010;

Meert et al., 2015; Murphy , Johnson, & Lohan, 2003

A meaning‐centered approach may be helpful because it can be validating and non‐pathologizing

Lichtenthal & Breitbart, 2015; Lichtenthal et al., 2015

Meaning‐Centered Grief Therapy

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Meaning‐Centered Grief Therapy (MCGT)Overview

• Adaptation of William Breitbart and colleagues’ Meaning‐Centered Psychotherapy

• Incorporates Viktor Frankl’s key concepts, focusing on the ability to choose one’s attitude toward suffering

• Assists with connection or reconnection to valued sources of meaning:

– Creative (Creating)

– Experiential (Experiencing)

– Attitudinal (Attitude)

– Historical (One’s Story)

Breitbart et al., 2012, 2015; Breitbart & Poppito, 2014; Lichtenthal, 2012 ; Lichtenthal & Breitbart, 2012, 2015; Lichtenthal & Neimeyer, 2012; Neimeyer, 2001

Sources of MeaningOverview

“He who has a why to live for can bear with almost any how.”

~Friedrich Nietzsche

• Your Story as a Source of Meaning

– Connections between the past, present, and future

• Attitude as a Source of Meaning

– Choosing the attitude one takes toward life’s challenges (e.g., loss, mortality)

• Creating as a Source of Meaning

– Actively engaging in life through roles, work, deeds, accomplishments

– The importance of courage, commitment, and responsibility

• Experiencing as a Source of Meaning

– Connecting to life through relationships, beauty, nature, humor

Breitbart et al., 2012, 2015; Breitbart & Poppito, 2014; Lichtenthal, 2012; Lichtenthal & Breitbart, 2012, 2015; Lichtenthal & Neimeyer, 2012; Neimeyer, 2001

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Meaning‐Centered Grief Therapy (MCGT)Overview (cont’d)

• Applies Neimeyer’s meaning reconstruction to facilitate meaning‐making through examination of cognitive schemas

• Incorporates attachment theory and cognitive‐behavioral/schema therapy approaches

• Assists with legacy building and development of one’s story, as well as the deceased’s story

• Helps maintain connection to the deceased

Breitbart et al., 2012, 2015; Breitbart & Poppito, 2014; Lichtenthal, 2012 ; Lichtenthal & Breitbart, 2012, 2015; Lichtenthal & Neimeyer, 2012; Neimeyer, 2001

“Widows and Orphans” by Kathe Kollwitz

• Initially adapted for parents who lost a child to cancer

• Designed to reduce prolonged grief symptoms by (paradoxically) helping parents to co‐exist with their grief

• Incorporated invaluable feedback from expert bereaved parents and grief

Meaning‐Centered Grief Therapy (MCGT)Development

Boelen, 2006; Bowlby, 1969; Lichtenthal, 2012; Lichtenthal & Breitbart, 2012, 2015; Lichtenthal & Neimeyer, 2012; Prigerson et al., 2009; Shear, Frank, Houck, & Reynolds, 2005; Young, 2006

“Widows and Orphans” by Kathe Kollwitz

• Uses didactics, written responses to reflection questions, discussion, and experiential exercises

• Structure allows systematic uncovering of important meaning‐related content while also creating a sense of predictability and a roadmap to assist in navigating intense emotional terrain

• Principle‐driven, flexible, and involves substantial provision of support and witness significance to the individual’s suffering, respecting that the griever is truly the “expert” in their grief

Meaning‐Centered Grief Therapy (MCGT)Approach

Boelen, 2006; Bowlby, 1969; Lichtenthal, 2012; Lichtenthal & Breitbart, 2012, 2015; Lichtenthal & Neimeyer, 2012; Prigerson et al., 2009; Shear, Frank, Houck, & Reynolds, 2005; Young, 2006

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1) Ability to choose one’s attitude in the face of suffering

2) Ability to use sources of meaning as “lighthouses” in the distance to transcend suffering

3) Ability to construct meaning—of our lives, of events, of circumstances, and of our emotional reactions—and to author our own story and deceased’s story

4) Ability to maintain a meaningful connection to the deceased

Core Meaning‐Centered Concepts

Lichtenthal & Breitbart, 2012, 2015

• Existing sources of meaning whenever heard

• Parent’s ability to tolerate (and thus co‐exist with) great pain

• Importance of self‐compassion

• Child’s specialness and unique way they has touched the world

• Strategies for maintaining sense of meaning beyond the end of treatment, during tougher times

Highlighted throughout Each Session…


MCGT Session Overview

• Session 1 Introductions and Overview of MCGT

• Session 2 Managing Challenging Emotions through Meaning: Permission to Grieve

• Session 3 Your Child’s Living Legacy: Continuing Bonds

• Session 4 Creating Your Story: Choosing One’s Life Narrative

• Session 5 Loss and Identity: Identity Before and After Loss

• Session 6 Your Story as a Source of Meaning: The Past

• Session 7 Your Story as a Source of Meaning: The Present

• Session 8 Your Story as a Source of Meaning: The Future

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MCGT Session Overview

• Session 9 Meaningful Connections: Identifying Support and Meaningful Relationships

• Session 10 Attitude as a Source of Meaning: Encountering Life’s Limitations

• Session 11 Creating as a Source of Meaning: Creativity, Courage, and Responsibility

• Session 12 Experiencing as a Source of Meaning: Experiencing & Connecting with Life

• Session 13 Revising Your Story: Recalling Emotion‐Evoking Events

• Session 14 Creating Significance: Reactions to Moving Forward

• Session 15 Living Legacies: Presentation of the Living Legacy Project

• Session 16 Reflections: Hopes for the Future

Sustains Connection

to Child

Connects to

Sources of

Meaning

Facilitates Meaning

Reconstruction

Highlights

Ability to

Choose Attitude

Sense of Identity& Purpose

(Sessions 5, 6, 7, 11)*

Personal Legacy (Sessions 8, 15)*

Child’s Legacy (Sessions 1, 3, 15)*

Sense‐making (Session 4, 13)*

Choosing One’s Attitude

(Sessions 2, 10, 14)*

Benefit‐finding & Growth

(Session 14, 16)*

* All constructs are explored in each session; these are examples of sessions placing an emphasis on this construct

Enhanced Sense of

Meaning

How the Structure of MCGT Allow for Multiple “Clinical Entry Points” to Enhance Meaning

Connecting to Others(Sessions 9, 12)*

Choosing How to Tell One’s Story(Sessions 4, 6, 13, 14)*

Reciprocal Pathway Theory of Meaning‐making

Multiple Clinical Pathways to Enhancing Meaning

• Sense‐making through examining the legacy one was given

• Sense‐making through benefit‐finding

• Benefit‐finding through sense‐making

• Reconciling sense of identity through benefit‐finding, exploring child’s legacy, and choosing one’s attitude

• Benefit‐finding through a identification of a sense of purpose

Lichtenthal & Breitbart, 2015

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Highlights Ability to Choose Attitude

Outcomes

• Prolonged Grief Sx

• Depression Sx

• Anxiety Sx

• Hopelessness

• Negative Affect

• Sense of Meaning

• Connection with Child

• Quality of Life

• Work Productivity

• Positive Affect

• Posttraumatic Growth

• Positive Health Outcomes

Sustains Connection to

Child

Connects to Sources of Meaning

Facilitates Meaning

Reconstruction

Pathways of Change

• Increased engagement with

meaningful activities and

experiences

• Adaptive sense‐making and

perspectives related to guilt,

regret, and anger

• Cultivated sense of child’s

presence in life

• Reconfigured sense of

identity

• Increased sense of coherence

in life story

• Enhanced ability to co‐exist

with grief

MCGT

MCGT Conceptual Model and Hypothesized Pathways of Change

Meaning Challenges

Prolonged Grief

Depression

Anxiety

Hopelessness

MCGT Session Structure

• Check‐in and review of previous week

• Introduction to theme or topic of session

• Discussion of reflection questions

• Completion of experiential exercise

• Wrap‐up and discussion of “steps for the week”

Session 1Introductions and Overview

• Introduce selves

• Sharing of child’s cancer story

• Provide overview of core meaning‐centered principles and the importance of choice

• Application of Nietzsche’s quote, “He who has a why to live for can bear with almost any how.”

• Definitions of meaningFriedrich Nietzsche

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Introduce Core Meaning‐Centered Concepts


Meaningful Moments

Please describe one or two experiences or moments when

life has felt particularly meaningful to you – whether it

sounds powerful or mundane. For example, a meaningful

moment could be something that helped get you through a

difficult day or a time when you felt most alive.

Part 2

MCGT: The Early Sessions

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Core Meaning‐Centered Concepts


Session 2Managing Challenging Emotions through Meaning:

Permission to Grieve

• Provide psychoeducation about prolonged grief, cognitive schemas, experiential avoidance, and mindfulness meditation

• Begin to formulate a narrative about parent’s story

• Highlight choice in how one makes meaning of one’s emotional reactions

• Facilitate self‐compassion

• Support emergent grief and highlight parent’s ability to tolerate the feelings



• Reflection questions: Permission to Grieve

1) What are your beliefs about experiencing distressing emotion? Do you believe they should be avoided? Embraced? Do you believe you can handle intense feelings as they arise? What are your beliefs about expressing emotion? Are they a sign of strength? Of weakness?

2) How do you feel you have coped with your loss? Do you feel you have permission (from yourself or from others) to grieve?

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3) What do you think of other bereaved parents who continue to experience grief? Do you feel there is a specific amount of time for which one should be able to grieve?

4) Sometimes, the way grieving parents think about their grief can make it harder for them to experience it, ultimately leading to avoidance. If you have difficulty experiencing, allowing, or tolerating your grief, are there other ways to think about these painful emotions that would give you more permission to feel them or make them more tolerable? For example, is it possible to view waves of grief as a reflection of your unending love your child and an opportunity to connect?

Session 2 Experiential Mindfulness and Guided Imagery Exercise

Close your eyes and breathe naturally. Find a comfortable position and relax your body. Now

begin to feel your body, moving from your head to your toes, noticing any sensations. As you

become aware of whatever you are feeling, just allow it to be, without judging it, just being fully

present with it. And if you notice your mind is wandering off, that’s okay, just gently bring your

attention back to your body. As you continue to move through each part of your body‐‐your

head…your neck…your chest…your stomach…arms… hands…legs…and feet…become fully aware of

any pain or discomfort you are feeling and just remain with it for a few moments. Now, try to

identify where in your body you feel your child’s presence most. Picture your child and stay with

the image, noticing the small details, imagining them smiling, taking in any smells, feeling their

touch. Allow whatever you are feeling to just arise and be. Stay in this moment, in the presence of

your child, cherishing this time together and this opportunity for connection, to give and receive

nurturance. Allow your body to react however is most natural, allow your feelings to emerge and

change shape, treasuring each moment, treasuring this moment with your child. Take a few more

moments to be with your child, and when you are ready, say goodbye just for now, knowing that

this connection is inside of you, always available to you. Slowly begin to come back to this room,

and when you feel ready, open your eyes.

Session 3Your Child’s Living Legacy

• Encourage sharing of photos, videos, and meaningful items

• Highlight choice in how you tell your child’s story

• Support continued connection to child and facilitate strengthening the connection

• Support emergent grief and highlight parent’s ability to tolerate the feelings

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Session 3Your Child’s Living Legacy

• Reflection questions

1) In what ways do you continue to connect with your child? Do you speak with them? Do you engage in any rituals to connect to them, such as going to a place them liked or to the cemetery? If not, is there anything you might do to more feel more connected to them? Do you anticipate anything that might get in the way of you connecting, such as emotional pain or finding quiet time?

2) What are some of the qualities you most admired in your child? What influence or impact do you think your child had on others?

Session 3 Meaningful Conversation Exercise

Close your eyes and breathe naturally. Find a comfortable position and relax your body.

Now you’re invited to speak with your child, picturing them happy and healthy, and sharing

with them what they have taught you and perhaps taught others. Share any lessons you

learned from your child or through your child’s experience with cancer.

Can you tell your child more about how they have influenced your current sense of

identity, who you are today, your values, and the type of person you would like to be in the

future?

Now, imagining your child’s voice (or if the child was too young to speak, imagining the

voice you believe your child would have), what would they say back? They would say,

“Mom/Dad, I want you to…”

Take a few more moments to be with your child, and when you are ready, say goodbye just

for now, knowing that this connection is inside of you, always available to you. Slowly

begin to come back to this room, and when you feel ready, open your eyes.

Session 4Creating Your Story: Choosing One’s Life Narrative

• Highlight choice in how you tell your story and how much your loved

one is a part of that story

• Explore the role that cognitive schemas may be playing in one is

telling their story

• Explore assimilation and accommodation processes

• Note that there may be “meaning transitions” in sense‐making as the

parents holds more than one meaning simultaneously

• Highlight parent’s ability to choose more helpful, adaptive meanings

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1) How we make meaning of life’s challenges is often shaped by our beliefs

about ourselves and the way the world works. What beliefs play a role in

how you make sense of (or struggle to make sense of) your child’s illness

and death? Have any beliefs you held about yourself or the way the

world works changed since your child became ill?

2) You are ultimately in charge of the meaning you make of life’s challenges

and of how you tell your and your child’s story. What is the story you

would like to be able to tell about your child’s life?

3) What is the story you would like to be able to tell about your own life?

How does the way your life looks now compare to the story you would

like to create?

Session 4Creating Your Story: Choosing One’s Life Narrative

Session 4 Letter Writing Exercise

You are invited to write a letter to your child and then to have

your child respond by letter. In your letter to your child, share

with your child how you would like to keep them an active

part of your story. Describe any symbolic gestures or rituals in

which you currently engage or can engage in to stay

connected to and to continue to nurture your child. In your

child’s response letter, have them affirm your plans and

express what they wants for you moving forward.

• Describe link between meaning and identity

• Highlight core aspects of identity that remain

• Assist parent with maintaining/transforming identity as “parent”

• Explore changes that are welcome or currently valued

• Highlight choice in how to think about your identity and whoyou want to be

Session 5Identity Before and After Loss

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• Reflection questions: Who Am I?

1) Think about a time before your child became ill. Write down fouranswers to the question, “Who was I before my child became ill?” based on how you viewed yourself then. These can be positive or negative, andmay include personality characteristics, beliefs, values, things you did,roles you had, relationships with people you knew, etc… For example,answers might start with, “I was someone who ,” (e.g., waspassionate, optimistic, organized, worried a lot) or “I was a ”… (e.g., homemaker, entrepreneur, sister, brother, mother, father).

2) Next, write four answers to the question, “Who was I while my child wasill?” These can once again be positive or negative responses, and include personality characteristics, beliefs, values, things you did, rolesyou held, relationships with people you knew, etc.



• Who Am I? (cont’d)

3) Now write four answers to the question, “Who am I now?” These can once again be positive or negative responses, and include personality characteristics, beliefs, values, things you did, roles you held, relationships with people you knew, etc. Take some time to think about how your loss has affected your answers and your sense of identity. How has what you’ve been through affected who you are, what you value, and the things that are most meaningful to you?

4) Finally, write down four answers to the question, “Who do I want to be?” Consider the person you would like to be in the future. Your responses may include characteristics, values, or roles you’ve already listed or some that you hope to work toward.

Session 6Your Story as a Source of Meaning: The Past

• Elicit information about early life that shaped schemas and values

• Highlight why parent’s “why’s became their why’s”

• Reflect powerful choice points, noting how they reflected what was most meaningful

• Highlight choice in how you view the past

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Session 6Your Story as a Source of Meaning: The Past

When you look back on your life and upbringing, what are the

most significant memories, relationships, values, and traditions

that have made the greatest impact on who you are today? You

may describe both positive and negative experiences. Some

examples include memories about your relationships with parents,

siblings, friends, and teachers; values that were passed down to

you; and past events or people who made a difference in your life.

How do you think your past influenced choices you have made and

what is most meaningful and important to you today? If you faced

difficulties in the past, were there any lessons or values learned

from these experiences?

Part 3

MCGT: The Middle Sessions

Session 7Your Story as a Source of Meaning: The Present

• Highlight how the story we are living is dynamic, ever‐changing

• Explain that this means it is continually open to possibilities of

growth, renewal, and “do‐overs”

• Explore choices in the present

– How to cope with suffering, choosing stance

– How to connect with what is most meaningful, including the

child

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Session 7Your Story as a Source of Meaning: The Present• Reflection questions: Creating Meaningful Moments in the Present

1) Sources of meaning are sometimes difficult to identify while we are suffering. To help with identifying what has previously provided you with a sense of meaning and purpose, please describe one or two experiences or moments when life has felt particularly meaningful to you – whether it sounds powerful or mundane. For example, a meaningful moment could be something that helped get you through a difficult day or a time when you felt most alive.

2) As you think about your present day‐to‐day life, which roles, activities, responsibilities and experiences do you believe have been most significantly impacted by your grief? Which of these do you think are most important to maintain? Are there ways to coexist with the grief while engaging in these valued roles, activities, responsibilities, and experiences? If finding ways to connect to your child is not currently part of your daily life, what might help you with maintaining a sense of connection?

3) What are some ways to continue to develop your personal story and your child’s story each day? What might be one small, but courageous step that you could take between now and our next session toward re‐engaging in genuinely meaningful activities or relationships from which you have felt more disconnected since your loss?

Session 8Your Story as a Source of Meaning: The Future

• Highlight how connecting to sources of meaning offers hope and the promise of a fulfilling and meaningful future

• Discuss how current sources of meaning can be maintained

• Troubleshoot challenges to connecting with these sources of meaning

Session 8Your Story as a Source of Meaning: The Future

• Reflection questions: How Does One Create a Life Worth Living in the Face of Grief?

We are the authors of our story, and while there are many aspects of life beyond our control, including painful losses, how we write the story of our lives is within our control. Having known unthinkable tragedy and a type of suffering that only those who have experienced it can understand, what do you think a life worth living looks like? What are its ingredients? Over what parts do you have control? In what ways would you like to keep your child a part of your story? What are two small steps you could take to take control and help to create this life?

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Session 9: Meaningful Connections: Identifying Support and Meaningful Relationships

• Review principles of MCGT for support provider

• Explore barriers to connecting with others

• Facilitate a meaningful conversation between the parent and support provider using the Speaker‐Listener Technique



1) What are some of the barriers you have faced in connecting with others? Which relationships do you believe are most important to preserve, repair, or develop?

2) What are some strategies to help reestablish or maintain your most meaningful connections? What activities can you engage in to help create a greater sense of belonging? Invite your support provider to brainstorm with you.


• Experiential exercise: Meaningful Conversation

Using the Speaker/Listener ground rules, speak to your support provider and share what you need and would like from them and what would help you feel most connected to them. Once you have finished speaking, your support provider should respond using the Listener ground rules. Your support provider should then share what they needs and would like from you and what would help them feel most connected to you. You and your support provider should continue the exchange using the Speaker/Listener approach for about 5‐10 minutes, allowing each of you to express your wishes about how to enhance your connection to one another. Conclude by indicating what you appreciate about your support provider, and allow your support provider to indicate what they appreciate about you.

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Session 10: Attitude as a Source of Meaning: Encountering Life’s Limitations

• Describe Frankl’s proposition that the last vestige of human freedom is the ability to choose our attitude in the face of suffering

• Provide psychoeducation about transcendence and the ability to co‐exist with grief and related suffering

• Explore “how” one faces adversity can be a source of meaning

• Highlight how have made choices in the past that were aligned with values

• Introduce Living Legacy Project

Session 10: Attitude as a Source of Meaning: Encountering Life’s Limitations

• Reflection Questions: Encountering Life’s Limitations

1) What are some of the life challenges you faced in the past? How did you cope

or deal with them at the time?

2) Since your loss, what are the specific challenges you have faced, and how are

you coping or dealing with them now? What choices do you make each day to

engage in life despite your grief?

3) Please describe a time when you felt especially proud of how your child faced a

challenge. This may of course include a time during their illness, or another

challenging time in their life.

4) Have you ever felt glad about or even proud of how you chose to face a

particularly challenging situation? In coping with your loss, what choices do you

feel you have in how you face it? What ways of responding to your grief would

be most aligned with your values and the type of person you strive to be?

Session 11: Creating as a Source of Meaning:Creativity, Courage, & Responsibility

• Provide psychoeducation about courage, responsibility, and existential guilt

– Courage to create a life despite pain and survivor’s guilt

– Ability to respond to the fact that one is alive

• Explore sources of meaning that involve “doing” and active engagement in life


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• Reflection questions: Actively Engaging in Life

1) Living life and being creative requires courage and commitment. Can you think of time(s) in your life when you’ve been courageous, taken ownership of your life, or made a meaningful commitment to something of value to you? This may include, for example, your experience caring for your child during their illness.

2) Do you feel you’ve expressed what is most meaningful to you through your creative activities (e.g., work, parenting, hobbies, causes)? Are there any creative activities from which you have become disconnected since your loss? What steps might you take to reconnect to these activities? If those activities are no longer as important to you as they once were, what steps might you take to identify and engage in new creative activities?


3) What are your responsibilities? Who are you responsible to and for?

4) What tasks have you always wanted to do, but have yet to accomplish? What obstacles get in the way of you accomplishing these goals? How might you take responsibility for your life despite these obstacles?

Part 4

MCGT: The Final Sessions + Q&A

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Session 12: Experiencing as a Source of Meaning: Connecting with Life

• Explore sources of meaning that involve “being,” experiencing, and receiving from life


Session 12: Experiencing as a Source of Meaning: Connecting with Life

• Reflection questions: Connecting with Life

1) Some of the things that are most meaningful are experienced and felt, allowing us to feel connected to life, such as receiving love (from a higher power, family, friends, or pets), appreciating beauty (in nature, art, music, other people), and through humor (through comedies, writings, with others, or about one’s challenges). List 3 ways in which you ‘connect with life’ and feel most alive through experiences related to:

Love

___________________________________________________________

Beauty

___________________________________________________________

Humor

___________________________________________________________

2) Describe any challenges you have faced connecting with any of these sources of meaning since your loss and consider how you might reconnect with them.

Session 13: Revising Your Story: Reconstructing Emotional Thoughts and Events

• Identify emotionally evocative thoughts or events that remain troubling (e.g., related to anger, guilt, regret)

• Highlight choice of how to view particularly challenging moments or experiences

• Facilitate meaning reconstruction, encouraging a stance self‐compassion and non‐judgmental acceptance where more maladaptive meanings have been made

• Provide psychoeducation about the hindsight bias and engaging a compassionate response, “What would you tell a friend…?”

• Begin to process feelings about upcoming termination of treatment

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Session 13: Revising Your Story: Reconstructing Emotional Thoughts and Events• Reflection Questions

1) In addition to the deep grief they typically feel, bereaved parents often experience feelings of regret, anger, or guilt related to their child’s illness and death. Looking at aspects of your experience that continue to cause you the most distress, is there a way to think about things with more compassion toward yourself?

2) Parents also often struggle with making sense of their child’s illness and death. What aspects of this do you continue to struggle with the most? Even if you do not believe it at this time, can you imagine a way of thinking about your and your child’s story that would be helpful and would feel more comfortable?

3) Another common and natural reaction for grieving parents to have is to ask, “What if…?”and to question how they cared for their child. Write a letter to your child focusing on your efforts to meet their needs before and throughout their illness.

Session 14: Creating Significance: Reactions to Moving Forward

“I was snorkeling alone in the warm, sunny, clear waters of a tropical lagoon and experienced, as I often do in the water, a deep sense of pleasure and coziness. I felt at home. The warmth of the water, the beauty of the coral bottom, the sparkling silver minnows, the neon‐bright coral fish, the regal angel fish, the fleshy anemone fingers, the esthetic pleasure of gliding and carving through the water, all in concert created an underwater elysium. And then, for reasons I have never understood, I had a sudden radical shift in perspective. I suddenly realized that none of my watery companions shared my cozy experience. The regal angel fish did not know that it was beautiful, the minnows that they sparkled, the coral fish that they were brilliant. Nor for that matter did the black needle urchins or the bottom débris (which I tried not to see) know of their ugliness. The at‐homeness, the coziness, the smiling hour, the beauty, the beckoning, the comfort‐ none of these really existed. I had created the entire experience! (... ) It was as though I peered through a rent in the curtain of daily reality to a more fundamental and deeply unsettling reality.”

‐ Irvin Yalom, Existential Psychotherapy, 1980, p. 219


• Highlight choice of how to view greater significance of loss

• Provide psychoeducation distinguishing meaning‐as‐comprehensibility from meaning‐as‐significance (Janoff‐Bulman & Frantz, 1997)

– Both negative and positive impact may be acknowledged, carefully, using parent’s own words

– Can be linked to attitude as a source of meaning and choice, highlighting Yalom’s (1980) passage, not a prescription for turning lemons into lemonade

• Normalize the ability of individuals to experience multiple emotions at once (e.g., sadness and pride) and discomfort with “forward” movement

• Highlight how chose to continue to engage in life may be something witnessed in the child and part of the child’s legacy

• Process feelings about upcoming treatment termination

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• Reflection questions: Creating Significance

1) One of the ways we create meaning of tragic life events is by considering their greater significance in our and others’ lives and their impact on the world. Have you thought about the significance of your child’s illness or death in this way? Are there any lessons that you learned from your child and your experiences? This may overlap with your thoughts about your child’s legacy that you have previously shared, so please feel free to reiterate those thoughts or share any new reflections.

2) Are there any ways that you feel you or others have changed in ways that you appreciate since your child’s death? For example, some parents have described a change in priorities, an increased sense of compassion for others, a change in the way they view certain relationships, improvements in relationships, or recognition that they can cope with stressful situations better. Have any of these or other changes occurred in you or your family? Has this experience deepened your gratitude about anything you have?

Session 15: Living Legacies

Living Legacy Project

The Living Legacy Project provides an opportunity to integrate some of the ideas we have discussed (e.g., meaning, identity, your and your child’s story and legacy, attitude, creativity, and responsibility) in order to help cultivate a sense of meaning in light of your loss and your child’s life.

Some examples may be: creating a legacy photo album or video, developing a music compilation of meaningful songs, becoming active in a cause important to your child or related to your child’s illness, choosing to pursue activities that reflect any changes in priorities or goals that you might have experienced, or choosing to do something you’ve always wanted to do and have not yet done.

While much has been beyond your control, how you face your challenges, how you live your life, and how you stay connected to your child is within your control. The legacy is yours to live and give.

Session 15: Living Legacies

• Review the concept of life as a living legacy, with continued opportunities to be shaped (if the term “legacy” is comfortable)

• Highlight the connection between the parent’s personal legacy and their child’s legacy

• Facilitate discussion about the Living Legacy Project, reinforcing the connected sources of meaning and connection to the child

• If no project was completed, inquire about ideas and address challenges to completing with normalization and validation

• Highlight the living legacy that you have observed over the course of therapy

• Process feelings about treatment termination

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Session 16: Reflections: Hopes for the Future

• Explore the parent’s feelings about this final session

• Review the MCGT treatment trajectory, personalizing what has been observed and shared

• Reflect on the parent’s journey and hopes for the future, obtaining feedback

• Discuss strategies for maintaining gains and continuing to connect with the child

• Reflecting on meaningful experiences, moments, or memories from the shared therapeutic experience

• Express gratitude and ways that have been impacted by the parent and the child

Session 16: Reflections: Hopes for the Future

• Reflection Questions: Hopes for the Future

1) What has it been like for you to go through this learning experience over these last 16 sessions? Have there been any changes in the way you view your and your child’s story having gone through this process? What might the title of this story be?

2) Do you feel like you have a better understanding of the sources of meaning in life and are you able to use them in your daily life? If so, how?

3) What are your hopes for the future?

Parents’ Feedback about MCGT

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Parents’ Descriptions of MCGT’s Impact on Connecting with their Child

“Some of the sessions were learning ways to keep my son close to me…to recognize the strength that he gave me in life and to be able to continue to benefit from that strength.”– 101

“All the questions through the sessions were so enriching for me and they helped me keep [child] in my life…reminded me of the things he taught me…reminded me of how he would want me and his family to

continue to live.”– 107

“It helped me to get to a place where I could really connect with [child].”–

202

“It really has taught me how to incorporate my child’s legacy into my life in a way that I could not have

imagined possible before the program.”– 201

Qualitative Feedback about MCGT

“It really… it helped me to have somebody who at least understood, maybe not personally the pain I was

going through but at least the process I was going through.” – 106

“The pain doesn’t really lessen so much, but as you get opportunities to go through it in a safe atmosphere, it

gets where you can live with it better, so in that respect, it really

helped.” – 101

“I’m not going to say it wasn’t painful, because that would be lying, it was very painful, especially in the beginning, but now after seeing the progress that I made, it was very

well worth it. My progress outweighed the pain, and I would do it again.” – 102

Acknowledgements

We are indebted to the bereaved parents who have shared so much as part of this research.

Special thanks to William Breitbart, M.D., Robert Neimeyer, Ph.D., David Kissane, M.D., Holly Prigerson, Ph.D., Lori Wiener, Ph.D., Janice Nadeau, Ph.D, and Sherry Schachter, Ph.D., for their mentorship and invaluable contributions to this work. My deepest thanks to Elizabeth Slivjak, Elizabeth Schofield, Corinne Catarozoli, Stephanie Napolitano, Kailey Roberts, Greta Jankauskaite, Melissa Masterson Duva, Aliza Panjwani, Maddie Rogers, Arielle Schwerd, Allison Marziliano, Talia Zaider, Caraline Craig Demirjian, Tom D’Agostino, Rebecca Shingleton, Lisa Kim, Susan Holland, Lauren Latella, Login George, Kristen Riley, Kate Herts, Ashley Polokowski, Sean Ryan, Amanda Balakirsky, Paola Vargas, Laura Montoya, Shaunna Beckford, Zeba Ahmed, Carol Fadalla, Taylor Coats, Amanda Watsula‐Morley, Susan Holland, and Elizaveta Suleymanova.

Dr. Lichtenthal’s research on bereaved parents has been funded by National Cancer Institute grants R03 CA139944 and K07 CA172216. Dr. Breitbart’s research on Meaning‐Centered Psychotherapy has been funded by National Center for Complementary and Alternative Medicine grant R21 AT001031, National Cancer Institute grants R01 CA128187 and R01 CA128134, The Fetzer Institute, and the Kohlberg Foundation.

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Q&A

Meaning‐Centered Grief Therapy Reading List

1. Frankl V. Man’s Search for Meaning. Boston: Beacon Press, 1992

2. Breitbart W, Poppito S. Individual Meaning‐Centered Psychotherapy for Patients with Advanced Cancer: A Treatment Manual. New York: Oxford, 2014

3. Lichtenthal WG, Cruess DG. Effects of directed written disclosure on grief and distress symptoms among bereaved individuals. Death Stud 2010; 34(6):475‐499. PMID: 24482856 PMCID: PMC3909885 https://www.ncbi.nlm.nih.gov/pubmed/24482856

4. Lichtenthal WG, Currier JM, Neimeyer RA, Keesee NJ. Sense and significance: A mixed methods examination of meaning making after the loss of one’s child. J Clin Psychol 2010; 66(7):791‐812. PMID: 20527057 PMCID: PMC3745996 https://www.ncbi.nlm.nih.gov/pubmed/20527057

5. Lichtenthal WG, Burke LA, Neimeyer RA. Religious coping and meaning‐making following the loss of a loved one. Counselling and Spirituality 2011; 30(2):113‐136.

6. Lichtenthal WG, Breitbart, W. Finding meaning through the attitude one takes. In R. A. Neimeyer (Ed.), Techniques in Grief Therapy: Creative Strategies for Counseling the Bereaved (pp. 161‐164). New York: Routledge; 2012

7. Lichtenthal WG, Neimeyer, RA. Directed journaling to facilitate meaning‐making. In R. A. Neimeyer (Ed.), Techniques in Grief Therapy: Creative Strategies for Counseling the Bereaved (pp. 165‐168). New York: Routledge; 2012


8. Lichtenthal WG, Neimeyer RA, Currier JM, Roberts K, Jordan N. Cause of death and the quest for meaning after the loss of a child. Death Stud 2013; 37(4):311‐342. PMID:24520890 PMCID: PMC3929231 https://www.ncbi.nlm.nih.gov/pubmed/24520890

9. Lichtenthal WG, Corner GW, Sweeney CR, Wiener L, Roberts KE, Baser RE, Li Y, Breitbart W, Kissane DW, Prigerson HG.Mental health services for parents who lost a child to cancer: If we build them, will they come? J Clinical Oncology 2015; 33(20):2246‐53. PMID: 26033819 PMCID: PMC4486343 https://www.ncbi.nlm.nih.gov/pubmed/26033819

10. Lichtenthal WG, Sweeney CR, Roberts KE, Corner GW, Donovan LA, Prigerson HG, Wiener L.Bereavement follow‐up after the death of a child as a standard of care in pediatric oncology. Pediatric Blood & Cancer 2015; 62(Suppl. 5):S834‐69. PMID: 26700929 PMCID: PMC4692196 https://www.ncbi.nlm.nih.gov/pubmed/26700929

11. Lichtenthal WG, Breitbart, W. The central role of meaning in adjustment to the loss of a child to cancer: Implications for the development of Meaning‐Centered Grief Therapy. CurrOpin Support Palliat Care 2015; 9(1):46‐51.

12. Lichtenthal WG, Breitbart W. Who Am I? In Neimeyer R (Eds) Techniques of Grief Therapy: Assessment and Intervention (pp. 165‐168). Routledge, 2015

13. Neimeyer, RA, Lichtenthal WG. The presence of absence: The struggle for meaning in the death of a child. In Stevenson R, Cox G (Eds.) Children, Adolescents, and Death: Questions and Answers (pp. 247‐261). Baywood, 2017.

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14. Lichtenthal WG, Lacey S, Roberts K, Sweeney C, Slivjak E. Meaning‐Centered Grief Therapy. In Breitbart W (Ed.), Meaning‐Centered Psychotherapy (pp.88‐99). New York, NY: Oxford University Press, 2017.

15. Lichtenthal WG, Masterson M, Panjwani A. The meaningful conversation. In Neimeyer R (Ed.) Techniques of Grief Therapy 3. Routledge, in press

16. Lichtenthal WG, Panjwani A, Masterson M. Consulting the deceased. In Neimeyer R (Ed.) Techniques of Grief Therapy 3. Routledge, in press

17. Lichtenthal WG, Catarozoli C, Masterson M, Slivjak E, Schofield E, Roberts KE, Neimeyer RA, Wiener L, Prigerson HG, Kissane DW, Li Y, Breitbart W. An open trial of Meaning‐Centered Grief Therapy: Rationale and preliminary evaluation. Palliat Support Care, 2019; 17(1):2‐12. https://www.ncbi.nlm.nih.gov/pubmed/30683164

18. Lichtenthal WG, Roberts KE, Catarozoli C, Schofield E, Holland JM, Fogarty JJ, Coats TC, Barakat LP, Baker JN, Brinkman TM, Neimeyer RA, Prigerson HG, Zaider T, Breitbart W, Wiener L. Regret and unfinished business in parents bereaved by cancer: a mixed methods study. Pall Medicine 2020; 34(3):367‐377. https://www.ncbi.nlm.nih.gov/pubmed/32020837

19. Lichtenthal WG, Roberts KE, Pessin H, Applebaum A, Breitbart W. Meaning‐Centered Psychotherapy and cancer: Finding meaning in the face of suffering, Psychiatric Times 2020; 37(8):23‐25. https://www.psychiatrictimes.com/view/finding‐meaning‐in‐the‐face‐of‐suffering

Thank you!Please feel free to email with

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