Reply to D. Spiegel

To the Editor

In his Letter to the Editor entitled “Existential Psychotherapy for Patients With Advanced Cancer: Facing the Future and the Past,” Spiegel¹ cites our randomized controlled trial of meaning-centered group psychotherapy (MCGP) in patients with advanced cancer, recently published in Journal of Clinical Oncology,^1a as an important contribution to the literature on existentially focused psychotherapy for patients with advanced cancer. The studies results indeed present a compelling case for the psychological benefits of our brief meaning-centered, existential psychotherapy. The constraints placed on authors to convey as much relevant information as possible within the limitations of a journal’s word count often do not allow for a full accounting of all that an author may want to include in a manuscript. In previous publications on meaning-centered psychotherapy,^2,3 we were able to give more adequate credit to influential existential psychotherapy figures who influenced and inspired our work, such as Viktor Frankl and Irvin Yalom. We were also able to give due credit to the works of Spiegel and Kissane (cited in Spiegel’s letter) in these same prior publications. Spiegel cites several studies of supportive expressive group therapy in which he feels we have mischaracterized this work. This was not our intent, and I am pleased the readers of Journal of Clinical Oncology can be reminded of this superb work. However, I would point out that we cited quite a number of studies and used terms such as “often” and typically” as modifiers. Perhaps we used too broad a brush.

I would, however, make a distinction between MCGP and what I believe is a central point that Spiegel is trying to make. Spiegel cites our study as an example of how a discussion of death (or “detoxifying” death) results in reduced depression and improved quality of life. MCGP is an eight-session intervention that focuses on sustaining or enhancing meaning in life, and living fully each day, even in the face of death. Of the eight session, there is one in which a discussion of death is the primary focus. MCGP is specifically an existential psychotherapy, with its roots in Viktor Frankl’s logotherapy,⁴ not merely a discussion of death or a discussion of end-of-life care planning. Spiegel presents Temel’s work on early palliative care consultation as an example of an existential psychotherapeutic intervention proven to be effective.⁵ Temel’s intervention cannot reasonably be characterized as an existentially oriented psychotherapeutic intervention study; it consisted of a discussion of end-of-life care goals by a palliative care nurse practitioner during a palliative care consultation. Spiegel also cites the 2011 dignity therapy randomized controlled trial by Chochinov et al⁶ as an existential psychotherapeutic intervention proven to be effective. As a coauthor of that article and a Site Principal Investigator of that multicenter international trial, one can imagine that I would have been delighted had dignity therapy been proven effective. The fact is that dignity therapy was not demonstrated, in that trial, to be more effective on any of the major outcome measures studied, compared with the control conditions.

Our past indeed informs our future. Spiegel’s (and Yalom’s) groundbreaking work in supportive expressive group therapy^7,8 deserves its due credit. The future, however, is being created right now. I hope to soon share with the readers of Journal of Clinical Oncology the results of our randomized controlled trial of individual meaning-centered psychotherapy in patients with advanced cancer, as well as the results of trials of adaptations of meaning-cenered psychotherapy for bereavement, caregivers, and survivors.^9,10