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In the United States, psychoanalysis has typically been a treatment for the wealthy upper-class. But according to Patricia Gherovici, PhD, this is not the case in her native Argentina, where “everybody does it—rich and poor.”

In this Mental Health Minute, Gherovici reveals the surprising political history of psychoanalysis in Argentina and tells the story of her efforts to bring psychoanalysis to the disenfranchised in the US.

is a psychoanalyst, analytic supervisor, and recipient of the 2020 Sigourney Award. She is associate faculty for the psychoanalytic studies minor at the University of Pennsylvania (PSYS). She is the author of 6 books, most recently 

Psychoanalysis in the Barrios: Race, Class, and the Unconscious

 (with Chris Christian). It received the Gradiva Award for best edited collection and the American Board and Academy of Psychoanalysis Book Prize in 2021. 

See previous coverage of the Sigourney Awards in 

How can psychoanalysts and psychiatrists better serve marginalized communities? 

Share comments with your colleagues by emailing 

. Comments may be shared online pending review and editing for style.

A psychoanalyst shares her experience working with patients whose lives are marked by poverty, migration, and race and gender discrimination.  

Latinx Psychoanalysis

During the last year of my residency in psychiatry, I watched a TV series called 

, a comedy-drama series that played for 6 years. Main character Joel Fleischman was a neurotic physician from New York City who had just completed his residency in family medicine. Joel had agreed to work for 4 years in Alaska in exchange for the state financing his medical education. He was assigned to work in the remote fictional village of Cicely, which had a lively and eccentric population.

One of my favorite scenes, which I can still vividly recall, was a conversation between Joel and Leonard, the local Inuit shaman. Leonard shares with Joel his wonder at the ways of modern medicine. He cannot understand how Joel can spend only 15 to 20 minutes with a patient and be able to construct a diagnosis and treatment plan from that brief encounter. Leonard explains to Joel that for him to diagnose and treat a patient he needs to live with that individual for several days to see what their stressors are, watch them while they sleep, understand their lifestyle and interpersonal interactions, and observe their diet patterns and exercise activity.

At that time, in 1990, insurance companies allowed us to meet with our patients for 1-hour visits each week. The first 10 minutes was usually focused on medication management, and the remaining 40 minutes were spent engaging in various types of psychotherapy. After my residency I practiced this style for a few years at a local community mental health center. Despite the weekly 50-minute appointments it often took me 6 to 12 months to begin to understand the complexities and biographical significances of each patient. I treated a man who presented with a classic major depressive disorder. He was a successful local businessman who rarely missed his weekly 50-minute appointment. It was only after meeting for 12 months that he started to discuss his chronic and disabling obsessive compulsive symptoms. He felt shame and embarrassment when he first began to share his dark secrets, but ultimately had a great response to treatment.

It was in the early 1990s that the ensuing 

 intruded into the medical profession, patients had to get authorization for their initial psychiatric evaluation and for 1 or 2 follow-up visits. I would then have to fill out a treatment plan form and request authorization for 3 or 4 more visits. After several years of this nuisance, the insurance plans determined they were spending more money to manage treatment authorizations than they were saving by managing us, so this protocol was discontinued.

The next step was a classic move-countermove battle of wits. Insurance companies decreased payments to psychiatrists for a 50-minute visit, because the insurance companies were of the opinion that lengthy visits could be provided by other professions who could be paid significantly less. As a result, psychiatric visits shrank to 30 minutes; payment for two 30-minute visits was significantly more than one 50-minute visit. The insurance companies executed their next countermove by lowering the payment amount for a 30-minute visit. A counter-countermove by some psychiatrists was to then see 3 patients per hour, allowing the billing for 3 units of treatment instead of 2. Alas, the response was a predictable counter-counter-countermove that ultimately led to the current general structure for psychiatrists to see patients for a so-called “

Leonard the shaman would be extremely impressed or, more likely, appropriately deeply saddened by how little time psychiatric providers in most clinics now spend with patients. I would like to propose a new model: the 16-minute medication check.

Think of all the additional information we could learn about or convey to our patients if we used that extra minute to simply ask 1 or more of these questions:

1. Tell me about the most important individuals in your life.

2. What is it like for you in your work environment?

3. Do you have any questions about any of the medications that I am prescribing for you?

4. Have you considered a trial to lower one of your medication’s dosage?

5. Could you remind me of your active medical problems?

6. What are your long-term goals in life?

7. Who lives with you, and how do you get along?

9. What is a typical breakfast, lunch, and dinner for you?

10. Do you feel rested when you wake up in the morning?

11. Who do you feel had the greatest influence on you growing up?

14. Do you exercise regularly? If so, what type and how often?

15. Would you like me to review the common and rare side effects of your medications?

16. What is the one bad habit you would like to change?

17. When do you feel most at peace with yourself?

18. Do you feel safe in your home and your neighborhood?

19. How do you feel your treatment here is going?

20. Do you have any questions about your diagnosis(es)?

A final reflection: if you were meeting with a psychiatrist for a 

, how would you feel if you were asked any of these questions? Just asking! ❒

 is medical director, Brain Health, Exeter, NH; editor in chief, 

; staff psychiatrist, Seacoast Mental Health Center, Exeter, NH; consulting psychiatrist, Exeter Hospital, Exeter, NH; consulting psychiatrist, Insight Meditation Society, Barre, MA.

If we had 1 extra minute with our patients, what question would we ask?

The 16-Minute Med Check

“An uplifting experience” is how a prominent Southern California aesthetic medicine specialist described to me the reaction from a notable number of his patients having botulinum toxin treatments during the 

 (COVID-19) pandemic. Multiple needle sticks in their face notwithstanding, these patients took particular relish in cocooning themselves (however briefly) in a 

 of self-indulgence, effectively sequestered from the barrage of unique stressors now understood to be associated with COVID-19.

This isolated anecdote may be simple serendipity or an example of a potential intervention. A recently published article might stimulate discussion about the potential of broadly effective management with neurotoxin injections.

 used the FDA Adverse Event Reporting System (FAERS) to analyze more than 40,000 botulinum toxin treatment reports across a variety of medical and cosmetic indications including hyperhidrosis, facial rhytides, migraine prophylaxis, spasticity, and spasms. They reported a significantly lower number of depression reports across all indications and injection sites compared with patients undergoing alternative treatments for the same conditions.

They also found a significantly lower incidence of depression-related adverse events (AE) with neurotoxin treatment compared with the control groups. For example, reporting odds ratios (ROR) of botulinum toxin’s depression AE frequencies were uniformly significantly lower compared with control, ranging from 0.12 (95% CI: 0.04, 0.33) to 0.60 (95% CI: 0.48, 0.74), irrespective of indication. The ROR analysis necessitates that 

k associated with neurotoxin use has a reasonable underlying pharmacodynamic hypothesis. Therefore, these findings should be considered cautiously, as they may not reflect actual number of cases or frequencies in the general population as the FAERS system is voluntary and open to the public.

Although botulinum toxin does not have regulatory approval for the treatment of depression in the United States, this information should offer food for thought that there is a possibility that neurotoxin treatment may show promise in mitigating depressive symptoms. In fact, numerous reports corroborate the efficacy of botulinum toxin in attenuating symptoms related to major depressive disorder,

 including several randomized placebo-controlled trials and observational studies.

 Some believe that the muscles involved in facial expression, such as the corrugator muscles that elicit frowning, play a pivotal role in modulating the brain’s emotional circuitry and neural activity.14-17 Put simply, it is postulated that expressive behavior can alter emotional states, likely through afferent sensory modulation.

Botulinum toxin injections have an excellent safety profile. 

 reported no significant differences in the overall incidence of AEs, including serious AEs, in almost 2000 patients treated with botulinum toxin compared with patients treated with placebo injections based on the pooled results of 9 trials. Specifically, in trials of major depression, corrugator and procerus neurotoxin injections have noted that treatment-emergent AEs were localized to the treatment site and were temporary (headache and injection site irritation).

 That said, it will remain critical to evaluate the comparative effectiveness of neurotoxin treatment versus established psychopharmacological options and psychotherapeutic strategies and determine if and where it might fit into the current treatment paradigm.

One of the barriers is training mental health professionals on how to perform freehand injections, particularly those that require dose accuracy at multiple injection sites as with neurotoxin injections. Even with extensive experience, injection dose accuracy is difficult to achieve. 

 recently calculated that the average accuracy error associated with freehand injection of 40 consecutive 0.025 mL doses from a 1.0 cc syringe was approximately 10% for 2 highly-experienced injectors. Recognizing the urgency to achieve dose accuracy, several neurotoxin-dedicated devices have been developed and are undergoing clinical and regulatory evaluation.

In conclusion, preliminary evidence suggests botulinum toxin may have a positive impact on depressive symptoms. Additional research needs to be conducted to better determine the safety and efficacy of this treatment. If the data indicate this may be a worthwhile treatment option, administration barriers also will need to be addressed

is an independent clinical trialist and medical device consultant in San Francisco, CA. Website: 

. The author reports no conflicts of interest concerning the subject matter of this article.

1. Salari N, Hosseinian-Far A, Jalali R, et al. Prevalence of stress, anxiety, depression among the general population during the COVID-19 pandemic: a systematic review and meta-analysis. 

2. Ettman CK, Abdalla SM, Cohen GH, et al. Prevalence of Depression Symptoms in US Adults Before and During the COVID-19 Pandemic. 

Postmarketing safety surveillance data reveals antidepressant effects of botulinum toxin across various indications and injection sites

4. Alam M, Barrett KC, Hodapp RM, Arndt KA. Botulinum toxin and the facial feedback hypothesis: can looking better make you feel happier? 

5. Finzi E. Update: Botulinum Toxin for Depression: More Than Skin Deep. 

6. Parsaik AK, Mascarenhas SS, Hashmi A, et al. Role of Botulinum Toxin in Depression. 

OnabotulinumtoxinA for the treatment of major depressive disorder: a phase 2 randomized, double-blind, placebo-controlled trial in adult females

8. Chugh S, Chhabria A, Jung S, et al. Botulinum Toxin as a Treatment for Depression in a Real-world Setting. 

9. Finzi E, Rosenthal NE. Treatment of depression with onabotulinumtoxinA: a randomized, double-blind, placebo controlled trial. 

10. Magid M, Finzi E, Kruger TH, et al. Treating depression with botulinum toxin: a pooled analysis of randomized controlled trials. 

11. Magid M, Reichenberg JS, Poth PE, et al. Treatment of major depressive disorder using botulinum toxin A: a 24-week randomized, double-blind, placebo-controlled study. 

12. Wollmer MA, de Boer C, Kalak N, et al. Facing depression with botulinum toxin: a randomized controlled trial. 

13. Zamanian A, Ghanbari Jolfaei A, Mehran G, Azizian Z. Efficacy of Botox versus Placebo for Treatment of Patients with Major Depression. Iran J Public Health. 2017;46(7):982-984.

14. Franca K, Lotti T. Botulinum toxin for the treatment of depression. 

15. Hennenlotter A, Dresel C, Castrop F, et al. The link between facial feedback and neural activity within central circuitries of emotion--new insights from botulinum toxin-induced denervation of frown muscles. 

16. Kim MJ, Neta M, Davis FC, et al. Botulinum toxin-induced facial muscle paralysis affects amygdala responses to the perception of emotional expressions: preliminary findings from an A-B-A design. Biol Mood Anxiety Disord. 2014;4:11.

17. Lewis MB. The interactions between botulinum-toxin-based facial treatments and embodied emotions. 

18. Brin MF, Boodhoo TI, Pogoda JM, et al. S

afety and tolerability of onabotulinumtoxinA in the treatment of facial lines: a meta-analysis of individual patient data from global clinical registration studies in 1678 participants

Maximizing botulinum toxin injections for cosmetic and therapeutic applications with a single use, disposable, exact dose injection assist device

20. Yoelin SG, Kwolek MS, Block JE. Commentary on Botulinum Toxin injections: a call for improved accuracy. 

Although botulinum toxin does not have regulatory approval for the treatment of depression in the United States, some reports indicate neurotoxin treatment may mitigate symptoms.

An Uplifting Experience: Can Botulinum Toxin Address Depressive Symptoms?

Looking through the holiday lens, what comes to mind when when you see the image below? 

suicide rates are reported to be lower during Thanksgiving and Christmas and higher during the spring and summer months

a common myth is that more suicides occur during these holidays when, in fact, the winter holidays represent a low point in suicide rates

one theory is that because of family togetherness, people are less inclined to act on impulse during the holidays than at other times of the year

college-aged adults are particularly vulnerable during summer and spring

Hermann Rorschach was a Swiss Freudian psychiatrist and psychoanalyst. Dr Rorschach is, of course, remembered for having developed  the Rorschach inkblot test in order to gain insight of psychotherapy patients.

1. Beauchamp GA, Ho ML, Yin S. Variation in suicide occurrence by day and during major American holidays. J Emerg Med. 2014;46:776-781.
2. Van Orden KA, Witte TK, James LM, et al. Suicidal ideation in college students varies across semesters: the mediating role of belongingness. Suicide Life Threat Behav. 2008;38:427-435.
3. Joiner T. Understanding and Overcoming the Myths of Suicide. Psychiatric Times. January 19, 2014. 

http://www.psychiatrictimes.com/suicide/understanding-and-overcoming-myths-suicide

This article was originally posted on December 24, 2014, and has since been updated. -Ed

Facts and myths about depression during the holidays.

Holiday Rorschach Test

From the time you greet your patient in the waiting room to the time you escort them to the door as they leave, everything you do is psychotherapy, explains John J. Miller, MD, editor in chief at 

In this Mental Health Minute video, Miller shares his tricks of the trade. For instance, he recommends beginning each visit with an open-ended question. Engaging your patient and letting them talk for even 30 seconds gives them an opportunity to share and gives the clinician insights into their patient’s status and overall well-being.

is Medical Director, Brain Health, Exeter, NH; Editor in Chief,

Staff Psychiatrist, Seacoast Mental Health Center, Exeter, NH; Consulting Psychiatrist, Exeter Hospital, Exeter, NH; Consulting Psychiatrist, Insight Meditation Society, Barre, MA.

The patient is watching and learning, even subconsciously, and it is an opportunity to enhance care. 

Making Psychotherapy Part of Every Psychiatric Visit

, despite significant decline in antipsychotic use in privately insured children since 2009, doctors continue to prescribe antipsychotic medication off-label for conditions not approved by the US Food and Drug Administration. These conditions include conduct disorder, attention-deficit/hyperactivity disorder, anxiety, and depression.

“We lack information on the effectiveness and safety of antipsychotics for treating those conditions in young children,” lead author Greta Bushnell, PhD, MSPH, a member of the Rutgers Institute for Health, Health Care Policy and Aging Research and an assistant professor at Rutgers School of Public Health, said to the press. “Guidelines recommend that psychosocial services are used before antipsychotic treatment and that children are carefully assessed before initiating antipsychotics. However, fewer than half of the children receiving antipsychotic treatment in our study had a visit with a psychiatrist or a psychotherapy claim.”

Journal of the American Academy of Child & Adolescent Psychiatry

, the study examined more than 300,00 antipsychotic prescriptions for privately insured children in the United States aged 2 to 7. The study also found antipsychotics were more often prescribed to boys aged 6 or 7.

“The low rate of use of safer first-line psychosocial treatments, such as parent-child interaction therapy or cognitive-behavioral therapy, potentially puts children at unnecessary risks associated with antipsychotic treatment,” Bushnell said to the press.

Risks associated with antipsychotic medication for children include weight gain, sedation, diabetes, high cholesterol, cardiovascular disease, and unexpected death.

The challenge for the future, the researchers concluded, will be improving antipsychotic prescriptions in young children.

1. Bushnell GA, Crystal S, Olfson M. Trends in Antipsychotic Medication Use in Young Privately Insured Children. 

https://www.jaacap.org/article/S0890-8567(20)31987-0/fulltext

2. Rutgers University. Prescriptions of Antipsychotic Medications in Young Children is Declining. News release. November 8, 2020. 

https://www.newswise.com/articles/prescriptions-of-antipsychotic-medications-in-young-children-is-declining?sc=dwhr&xy=5013482

Antipsychotic medications for young children are not being prescribed appropriately, according to a recent study. 

The Decline of Child Antipsychotic Medications

Spooky or cute? Scary or whimsical? What do you see in this image when you think about Halloween? 

Hermann Rorschach was a Swiss Freudian psychiatrist and psychoanalyst. Dr Rorschach is remembered for having developed the Rorschach inkblot test. The purpose was, in part, to analyze and interpret the nuances of each 

answer given by the patient in order to delve into the unconscious.

 cues also convey important information about the patient. Psychiatrists know this. Thousands of hours of training go into honing their skills to listen and observe how patients communicate with them and the world around them.

 report that well over half of communication is nonverbal. They also note that the clinical setting often places too much value on the spoken word: "Many nonverbal behaviors are unconscious and may represent a more accurate depiction of a patient's attitude and emotional state."

To gain insight into the patient's state of mind (or yours, if you're taking this test), observe her as she interprets a piece of art (in this case, a Rorschach-

 ink blot). Take in the information as you ask, “What do you see?”

Before the answer comes, ask her to think about Halloween. Gaze at the image and reminisce. Where is she looking? Down? Up? Around? At her hands? At the ceiling? Does she lick her lips as she recalls the sweet and salty flavors of treats from a decade ago? Does she crack a smile?

These cues may help us understand the true nature of the image--and perhaps one's state of mind.

1. Foley GN, Gentile JP. Nonverbal communication in psychotherapy. 

This article was originally posted on October 29, 2015, and has since been updated. -Ed

Scary or sweet? Read about the value of nonverbal communication and have some spooky fun.

Spooky Rorschach

These techniques may help promote self-efficacy and elicit patients’ commitment to resolve ambivalence about treatment.


Best Practices for Motivational Pharmacotherapy Sessions

Meaning-Centered Psychotherapy and Cancer

Cancer can lead to suffering in many forms: physical, emotional, spiritual, and existential. It limits patients’ ability to plan for the future and, too often, their lives. How can we help patients cope with their suffering and existential distress in the face of such challenges? Meaning-Centered Psychotherapy (MCP) may have something to offer. MCP is a brief, structured, manualized intervention that organizes and distills existential concepts so that they are more accessible and relevant to patients’ lives. Born out of research demonstrating that meaning can serve as a buffer against the depression and hopelessness that many patients with metastatic disease report, Breitbart and colleagues developed MCP to help enhance patients’ sense of 

and purpose in the face of advanced cancer.

 specific concepts highlighted in MCP include:

: There is always the possibility of creating or experiencing meaning, even in the last moments of life. The feeling that “life is meaningless” therefore reflects a disconnection from what gives our lives meaning.

 The desire to find meaning in our existence is a primary motivating force in human behavior that drives us to search for and create meaning throughout our lives.

We have the freedom to choose how to think about and respond to what comes our way, including limitations, challenges, losses, and uncertainty. This is a core concept in MCP, as the ability to choose our attitude toward suffering is something we always have control over, even in the worst of circumstances.

 A sense of meaning can be derived from connecting to sources of meaning, including those described in MCP as historical, attitudinal, creative, and experiential (see 

Guided by structured questions in each session, MCP helps patients systematically reflect on what matters most to them and how sources of meaning can be accessed during challenging times. If a given source of meaning is not accessible, because of physical limitations or concerns about contracting 

, for example, MCP therapists brainstorm with patients about how to tap into the meaningful aspects of these activities or experiences in adapted forms. Therapists repeatedly highlight sources of meaning in the patient’s life that can be used as resources to buoy the patient during difficult moments.

This is the sentiment behind Nietzsche’s quote, “He who has a Why to live for can bear almost any How” that Frankl often referenced. In essence, MCP helps patients connect to their “Whys”—that is, their reasons for living—despite the suffering they endure. Frankl viewed suffering as a potential springboard for seeking and finding meaning. Patients’ drive to make sense of the challenges they face may lead to growth and identification of positive sequelae that can emerge as a byproduct of their adversity.

However, therapists should be clear that MCP is not a prescription for turning lemons into lemonade; instead it provides an opportunity to reflect on patients’ free will, highlighting adaptive perspectives as a choice in attitude. Therapists guide the development of a coherent narrative about how meaning and values influenced past choices, which can help address regrets. The enhanced sense of meaning resulting from such processes can improve patients’ quality of life and reduce distress.

Research demonstrating the efficacy of MCP

MCP has demonstrated efficacy in enhancing meaning in the lives of patients with advanced cancer in several large-scale trials and has been designated a National Cancer Institute Research-Tested Intervention Program. In 2 randomized controlled trials (RCTs) with patients who had advanced cancer, Meaning-Centered Group Psychotherapy (MCGP; an 8-session version of MCP) demonstrated efficacy over supportive group psychotherapy in improving spiritual well-being, quality of life, and sense of meaning, as well as decreasing anxiety, hopelessness, and desire for hastened death.

While MCGP showed efficacy, challenges with attrition in groups prompted development of an individual format that would allow for more flexible scheduling for patients.

 Thus, the 7-session format of Individual Meaning-Centered Psychotherapy (IMCP) was developed.

 In a pilot RCT comparing IMCP to therapeutic massage, participants receiving IMCP experienced significantly greater improvement in spiritual well-being, symptom burden, and distress.5 There was also less attrition compared with MCGP trials. A larger- scale RCT of IMCP demonstrated its superior efficacy in improving quality of life and sense of meaning compared with Supportive Psychotherapy and Enhanced Usual Care (see 

 IMCP also resulted in greater reductions in anxiety and desire for hastened death than Enhanced Usual Care. These studies provide strong support for the efficacy of both MCGP and IMCP in treating psychological and existential distress among patients with advanced cancer.

MCP should be delivered in the context of a supportive therapeutic relationship; an exploration of how to find meaning in suffering can only work effectively when the therapist acknowledges, supports, and validates the patient’s suffering. The structured nature of MCP, which includes a combination of didactics, experiential exercises, and guided discussion, enables the deep exploration of powerful concepts in a short period of time (

). MCP capitalizes on its time-limited format to propel patients to engage with emotionally provocative topics and take steps toward addressing unfinished business. MCP concludes with a Legacy Project to encourage patients to connect to sources of meaning and actively engage in something they have wanted to do but have not yet done.

Each MCP session introduces key existential concepts followed by an experiential exercise to help patients apply these concepts to their lives. Patients are encouraged to reflect on the exercise before the session, in writing if possible. Ultimately, the goal is for the sources of meaning identified to serve as coping resources that patients can continue to draw upon after therapy has concluded. Patients’ ability to shift from one source of meaning to another is emphasized, as some sources may become less available due to disease progression. Therapists support the concept of moving from ways of doing to ways of being to assist patients to recognize that meaning can also be derived more passively.

Additional existential concepts, including responsibility, transformation, authenticity, and existential guilt are also woven throughout the treatment. Therapists assist to detoxify death by speaking openly about it as the ultimate limitation in life, which is directly discussed in the session on attitudinal sources of meaning. They may challenge a patient’s resistance to exploring difficult existential realities, such as death or existential guilt, by using a gentle “existential nudge” to encourage reflection. In addition to facilitating the exploration of sources of meaning and existential concepts, the therapist plays a powerful role in enhancing the impact of MCP by witnessing the patient’s suffering, unique legacy, identity, and sense of meaning. Thus, the therapist becomes another figure through which patients can experience meaningful connection and share their “living legacy.” Therapists are encouraged to offer genuine reflections throughout MCP about patients’ meaningful impact on them, which can be particularly powerful for socially isolated patients.

Because MCP focuses on the universal struggles with existential distress in illness, it is not linked to a specific psychiatric diagnosis. MCP is not designed to treat acute psychiatric symptoms (eg, 

); therapists should refer patients to first-line stabilizing treatment (eg, medication) prior to attempting MCP. Patients with sufficient physical or cognitive limitations (eg, advanced dementia) to preclude participation in psychotherapy are not suited for this intervention. In research, MCP has demonstrated particular efficacy in improving outcomes in patients with moderate to severe distress (scoring 4 or higher on the Distress Thermometer).

The individual and group formats of MCP are nearly identical in content but differ in length. MCGP has 8 sessions, providing additional time to focus on the historical sources of meaning, which involves patients sharing about their past, present, and future legacy. In MCGP, group members each share responses to the experiential exercises and commonalities are emphasized. Group facilitators acknowledge the “co-creation of meaning” between themselves and group members; everyone present becomes witnesses, or repositories of meaning, for each other, and thus are part of a meaningful legacy created within the group.

In facilitating MCGP groups, the basic tenets of group processes remain important.

 Facilitators should intentionally honor each member’s unique values. IMCP is structured similarly yet affords more flexibility and the opportunity to deepen the meaning-centered work with fewer time constraints. Ideally patients should attend all sessions to get the maximum benefit, as there is a logical progression of content. However, in-person attendance is not necessary as MCP has been successfully 

“Dr Smith” was a 40-year-old, married physician with one child who began MCP shortly after he received a diagnosis of advanced pancreatic cancer. Although skeptical of how meaning could help him, Dr Smith was hoping for relief from the overwhelming distress he was experiencing about his diagnosis. He was particularly upset by changes in his ability to work as a physician and fulfill responsibilities to his wife, children, and aging parents.

During Session 2, Identity Before and After Cancer, it became clear that being suddenly thrust into the patient role threatened Dr Smith’s sense of identity as someone who provides care for others and strives for perfection. While Dr Smith acknowledged gaining a greater understanding of the existential nature of his distress through discussion, he expressed frustration that there was no way to “fix” this suffering.

In Session 3, Historical Sources of Meaning, the concept of legacy proved to be the key to shifting the meaning Dr Smith made of his current struggles. He realized the distress around perceived changes to his identity were connected to the legacy he was given, as he had been encouraged by his family to be perfect and “fix things.” He realized he could choose to respond differently to the legacy he was given, leading to changes in how he parented and allowing things to be imperfect and messy more often.

As sessions progressed, ways that Dr Smith creatively responded to the physical challenges he faced were identified, reinforcing the concepts of choice and courage in how he faced his predicament. This included the choice to engage in MCP despite his skepticism and to accept help from others, which became a meaningful lesson he wanted to model for his child. In his final session, Dr Smith expressed feeling more connected to the people who mattered most to him, recognizing new ways he could continue to share his legacy of responsibility and caregiving with those whose lives he touched personally and professionally.

Given its demonstrated efficacy, efforts are underway to disseminate MCP by training clinicians who work with cancer patients through a National Cancer Institute-funded training program. Additionally, many replication and adaptation studies are ongoing, including efforts to adapt MCP for cancer survivors, parents bereaved by cancer, cancer caregivers, and patients in hospice.

 Cultural and linguistic adaptations have also been conducted.

MCP may be especially helpful in working with patients struggling with adversity and situations that feel beyond their control. This may be more relevant than ever in context of the 

 pandemic, which, in threatening lives and imposing limitations on access to sources of meaning, has increased existential distress for patients, caregivers, and health care providers. Patients living through the pandemic are facing isolation, restrictions on their freedom, personal losses, and even greater threats to their and their loved ones’ mortality than they have previously experienced.

MCP empowers patients to focus on the choices they have in the face of limitations, helping them to connect to what matters most. It reaffirms the idea that meaning is always possible. When we are feeling disconnected, MCP facilitates reconnection. Therapists from a variety of theoretical orientations may find it helpful to draw on MCP concepts to support individuals through these uncontrollable and extraordinary circumstances. In turn, we derive meaning from the uniquely reciprocal nature of MCP, in that, as we accompany patients in their exploration of meaning, we co-create meaningful connection and our own personal legacies.

 is Assistant Attending Psychologist, Department of Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center, and Assistant Professor of Psychology, Department of Psychiatry, Weill Cornell Medicine; 

 is Postdoctoral Research Fellow, Department of Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center; 

 is Research Project Manager, Department of Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center; 

 Assistant Attending Psychologist, Department of Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center, and Assistant Professor of Psychology, Department of Psychiatry, Weill Cornell Medicine; and 

 is Chair, Department of Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center, and Professor of Clinical Psychiatry, Department of Psychiatry, Weill Cornell Medicine. The authors report no conflicts of interest concerning the subject matter of this article.

Research on MCP has been supported by the National Cancer Institute (R01 CA128187, R01 CA128134, R25 CA190169, T32 CA009461, P30 CA008748), the National Institute of Nursing Research (R21 AT01031), The Fetzer Institute, and the Kohlberg Foundation.

1. Breitbart W, Rosenfeld B, Pessin H, et al. Depression, hopelessness, and desire for hastened death in terminally ill patients with cancer. 

2. Nelson CJ, Rosenfeld B, Breitbart W, Galietta M. Spirituality, religion, and depression in the terminally ill. 

3. Breitbart W, Gibson C, Poppito SR, Berg A. Psychotherapeutic interventions at the end of life: a focus on meaning and spirituality. 

Meaning-Centered Psychotherapy in the Cancer Setting: Finding Meaning and Hope in the Face of Suffering

. New York, NY: Oxford University Press; 2017.

5. Breitbart W, Poppito S, Rosenfeld B, et al. Pilot randomized controlled trial of individual meaning-centered psychotherapy for patients with advanced cancer. 

6. Breitbart W, Rosenfeld B, Gibson C, et al. Meaning-centered group psychotherapy for patients with advanced cancer: a pilot randomized controlled trial. 

7. Breitbart W, Rosenfeld B, Pessin H, et al. Meaning-centered group psychotherapy: an effective intervention for improving psychological well-being in patients with advanced cancer. 

. Revised ed. New York: Washington Square Press; 1959/1984.

10. Applebaum AJ, Lichtenthal WG, Pessin HA, et al. Factors associated with attrition from a randomized controlled trial of meaning-centered group psychotherapy for patients with advanced cancer. 

11. Breitbart W, Pessin H, Rosenfeld B, et al. Individual meaning-centered psychotherapy for the treatment of psychological and existential distress: a randomized controlled trial in patients with advanced cancer. 

Individual Meaning-Centered Psychotherapy for Patients With Advanced Cancer: A Treatment Manual

Meaning-Centered Group Psychotherapy for Patients With Advanced Cancer: A Treatment Manual

14. NCCN. Distress management: Clinical practice guidelines. 

The Theory and Practice of Group Psychotherapy

16. Lichtenthal W, Roberts K, Jankauskaite G, et al. Meaning-centered group psychotherapy for breast cancer survivors. Breitbart W, Ed. 

Meaning-Centered Psychotherapy in the Cancer Setting

. New York, NY: Oxford University Press; 2017: 54-66.

17. Lichtenthal WG, Catarozoli C, Masterson M, et al. An open trial of Meaning-Centered Grief therapy: rationale and preliminary evaluation. 

18. Applebaum AJ, Kulikowski JR, Breitbart W. Meaning-centered psychotherapy for cancer caregivers (MCP-C): rationale and overview. 

19. Rosenfeld B, Saracino R, Tobias K, et al. Adapting Meaning-Centered Psychotherapy for the palliative care setting: results of a pilot study. 

An added component of cancer treatment is discovering what is most meaningful in the patient’s life and using that to buoy them during difficult moments. That, in a nutshell, is the psychiatrist's role.

Finding Meaning in the Face of Suffering

Established in 1989, The Sigourney Award offers independent, international recognition and a substantial prize for outstanding work that advances psychoanalysis and psychoanalytic thought. The deadline to apply for this year’s award is October 4, 2020 (scroll down for video details).

In light of many crises taking place today, it is important to celebrate and recognize the contribution of psychoanalytic practice to society.

Psychotherapy