Developing and testing the effectiveness of a videoconferencing,meaning-centered coping program among Turkish women with breast cancer: A pilot randomized trial

Abstract

This pilot randomized controlled trial (RCT) investigated the preliminary effects of an 8-week videoconferencing meaning-centered coping program (MCCP) on women diagnosed with breast cancer. Forty-one participants with stage I, II, or III breast cancer were randomly assigned to either the MCCP or the waitlist control (WLC) group. Data were collected at baseline and after the intervention. MCCP recipients were also assessed at a 2-month follow-up. The results showed that the MCCP group had significantly greater improvements in the presence of meaning, posttraumatic growth, appraisal of breast cancer as a challenge, and anxiety, with a large effect size, compared with the WLC. In addition, improvement in the presence of meaning was observed from baseline to post-intervention and maintained at the 2-month follow-up in the MCCP group. These findings suggest that videoconferencing MCCP is a promising intervention for supporting patients’ meaning-making processes.

Keywords

breast cancer coping intervention meaning posttraumatic growth psychological distress randomized controlled trial

Introduction

Recent studies have indicated that breast cancer is the most common type of cancer among women worldwide (Christensen and Marck, 2017) and in Turkiye (Özmen et al., 2019). Although the incidence of breast cancer is on the rise, mortality rates have significantly decreased, with a 5-year survival rate of approximately 90% (Özmen et al., 2019; Sung et al., 2021). Despite medical advances and improvements in survival rates, breast cancer remains a complex experience, profoundly impacting women’s lives and their psychological well-being. Many women undergoing diagnosis and treatment experience a range of losses, both visible (e.g. loss of breast, loss of physical function, changes in life roles and responsibilities; Koçak et al., 2022; Martino, et al., 2019) and hidden (e.g. loss of perceived control over their lives, disrupted predictability, loss of a sense of invulnerability; Lepore, 2001). Consequently, people diagnosed with breast cancer often embark on a journey of “search for meaning” or “existential plight” endeavoring to comprehend the implications of their diagnosis (Kernan and Lepore, 2009; Lee, 2008). Individuals searching for meaning may attempt to find explanations for fundamental questions such as “Why me?” “Why did I receive a breast cancer diagnosis?” and “What is the meaning of life?” (Henry et al., 2010; Kernan and Lepore, 2009), reflecting their efforts to find meaning in their experiences, even when answers may be elusive.

Researchers have increasingly focused on how people interpret and find meaning in their illnesses (e.g. Hartog et al., 2020; Iani et al., 2020; Moye et al., 2020). The Meaning-Making Model, as outlined by Park and Folkman (1997), has significantly contributed to our understanding of meaning-making, especially when facing adversity. This model distinguishes between global meaning—an individual’s overarching beliefs, goals, and sense of meaning in life—and situational meaning, which refers to the meanings attributed to specific events like breast cancer (Park and Hanna, 2022). Stressful or traumatic events, such as a cancer diagnosis, can disrupt an individual’s global meaning system, causing situational meanings that conflict with their beliefs, goals, and sense of meaning in life. This can ultimately lead to psychological distress. To cope, individuals may engage in meaning-making strategies that include positive reappraisal, acceptance, exploration of life values, and discovery of the meaning of life. These efforts can lead to positive changes in both situational and global meaning (Park, 2011; Park and Hanna, 2022). Changes in situational meaning involve reframing difficult experiences in a more positive way or finding new perspectives. Meaning-making efforts can also change global meaning, enriching one’s overall sense of meaning in life, or facilitating posttraumatic growth (PTG; Park, 2010; Park and Hanna, 2022). Therefore, if successful, meaning-making efforts can enhance psychological resilience and well-being (Park and Hanna, 2022). Conversely, the struggle to find meaning in their illness may lead to psychological distress and greater difficulty in coping (Park and Folkman, 1997). This emphasizes that the positive effects of meaning-making are realized only when individuals successfully find meaning in their experiences (Park, 2010). For instance, difficulties in finding meaning during the breast cancer experience are linked to increased psychological distress, particularly depression and anxiety (Pintado, 2018). On the other hand, finding meaning is associated with lower levels of psychological distress, higher levels of life satisfaction, and better psychological adjustment (Collie and Long, 2005; Loeffler et al., 2018; Winger et al., 2016). Therefore, the presence of meaning seems to shield against psychological distress, yet many individuals diagnosed with cancer struggle with meaning-making and need support (Van der Spek and Verdonck-de Leeuw, 2017).

Several psychological interventions have been developed to address the psychological distress caused by breast cancer diagnosis and treatment. Within this context, cognitive-behavioral therapy-based interventions (Jassim et al., 2015), cognitive-behavioral stress management interventions (Tang et al., 2020), mindfulness-based psychotherapy (Zhang et al., 2016), and acceptance and commitment therapy (Li et al., 2021) have been shown to improve levels of anxiety, depression, and emotional distress. However, traditional psychological interventions often overlook existential issues related to meaning in life (Vos, 2016). Furthermore, in recent years, there has been an ongoing conversation about the need for psychological services to focus not only on alleviating individuals’ psychological distress but also on improving their sense of meaning in life (Seligman et al., 2005). As a result, there has been a growing interest in psychotherapies that address people’s questions about the meaning of life (Park et al., 2019).

Several meaning-centered psychotherapies for patients diagnosed with cancer have demonstrated efficacy in enhancing a sense of meaning, quality of life, and spiritual well-being (e.g. Breitbart et al., 2010, 2012, 2018; Henry et al., 2010; Quílez-Bielsa et al., 2021; Van der Spek et al., 2017). Additionally, some have shown positive effects in alleviating symptoms of depression or anxiety (e.g. Breitbart et al., 2010, 2018; Quílez-Bielsa et al., 2021; Van der Spek et al., 2017), although not all studies have reported such psychological improvements (e.g. Breitbart et al., 2012; Henry et al., 2010; Wagner et al., 2016). Given these outcomes, meaning-centered interventions offer promise for addressing meaning-related concerns and reducing psychological distress among individuals diagnosed with cancer. The majority of these meaning-centered psychological interventions were primarily conducted during the palliative phase of treatment and predominantly utilized an existential psychotherapy approach (Ülbe and Dirik, 2023). However, the literature has revealed a comprehensive exploration of meaning-making beyond existential psychotherapy. Cognitive therapies implicitly emphasize the role of meaning in trauma treatment, often using terms like core beliefs to express this focus (Steger and Park, 2012). Similarly, most theories behind cognitive interventions for changing cognitive distortions caused by trauma can be viewed from a meaning-making perspective (Iverson et al., 2015). Additionally, acceptance and commitment therapy (ACT), one of the third-wave cognitive behavioral therapies, is considered potentially helpful in facilitating meaning-making after traumatic events (Secinti et al., 2019). ACT aims to increase psychological flexibility by encouraging the acceptance of challenging emotions, thoughts, and experiences and by helping individuals act on their core life values (Hayes et al., 2006). In this concept, techniques within ACT that focus on the acquisition of more adaptive perspectives such as acceptance, exploration of values, and value-directed action, have the potential to support meaning making processes by reducing rumination and engagement with negative interpretations of events, thereby enhancing an individual’s sense of meaning and purpose in life (Bergman and Keitel, 2020). Therefore, meaning can be addressed using components from various therapeutic approaches in an eclectic manner. In this context, our study introduces an intervention tailored for patients with breast cancer, using multiple theoretical perspectives to facilitate meaning-making, and includes preliminary pilot results.

Meaning-Centered Coping Program (MCCP)

The current study developed an individual psychotherapy program, the Meaning-Centered Coping Program (MCCP), for women diagnosed with breast cancer. This program is based on the theoretical model of the Meaning-Making Model (Park, 2010; Park and Folkman, 1997) and incorporates principles from Wong’s (2010) Meaning Therapy, which adopts a holistic approach to finding meaning. While rooted in existentialism, Meaning Therapy integrates elements from cognitive, behavioral, narrative, and positive psychotherapy, emphasizing that even in the face of adversity, there remains something worth living for (Wong, 2010). By embracing life’s dualities, individuals can manage both positive and negative aspects simultaneously. Meaning Therapy empowers individuals by tapping into their potential for growth and providing the necessary tools to navigate adversity and discover meaning in their experiences (Wong, 2010). This approach is similar to ACT, with its emphasis on acceptance, values, and commitment to actions. Therefore, in developing this intervention, we drew extensively not only on the existing literature on breast cancer and meaning-centered psychotherapies, but also on ACT. More specifically, the MCCP incorporated elements from a range of therapeutic approaches, including meaning-centered therapies (e.g. Breitbart et al., 2014), meaning-making therapy (e.g. Lee, 2008; Lee et al., 2006), acceptance and commitment therapy (e.g. Harris, 2009), cognitive behavioral therapies (e.g. Antoni, 2003; Beck, 2011; Moorey and Greer, 2014), and PTG intervention (e.g. Tedeschi and Moore, 2016). Consequently, in light of this theoretical background, the MCCP was developed to support people diagnosed with breast cancer in their meaning-making process, to enable them to find positive meanings in their experiences, and to facilitate adjustment to breast cancer by adopting an integrative approach.

The MCCP aims to foster psychological adjustment by focusing on both situational and global meaning, thereby promoting a more meaningful life. It uniquely integrates meaning-centered approaches with ACT, allowing participants to accept unchangeable realities while pursuing a meaningful life. Each session of the MCCP explores specific themes based on the Meaning-Making Model (Park, 2010; Park and Folkman, 1997). In this regard, the first five sessions focus primarily on situational meaning. According to the Meaning-Making Model, a critical aspect of the meaning-making process is the cognitive and emotional processing of challenging experiences (Park, 2010). In this context, the first two sessions address the changes and impacts of breast cancer on life, helping participants express and process their emotions throughout the experience. Furthermore, as the model suggests, negative meanings attributed to breast cancer can bring about psychological distress (Park and Hanna, 2022). Since patients often struggle with negative, and sometimes unrealistic, thoughts about their condition that affect their quality of life (Moorey and Greer, 2014), the third and fourth sessions are designed to address this issue. These sessions concentrate on identifying these thoughts and employing cognitive techniques to reframe them and reduce their negative impacts, aiming to uncover more positive meanings and meaningful aspects of life. The Meaning-Making Model emphasizes that beliefs about coping abilities and the controllability of cancer are crucial for psychological adjustment (Park and Hanna, 2022). Identifying personal strengths to cope with the difficulties is also recommended to find positive meaning in this experience (Ochoa and Casellas-Grau, 2015). Thus, the fifth session focuses on identifying participants’ strengths. As for the last three sessions, the focus is on the global meaning. Discovering life values is an essential part of meaning-making efforts (Park, 2011). Commitment to these values enhances resilience and fosters a meaningful life (Harris, 2009; Wong, 2010). Thus, the sixth session focuses on identifying life values and committing to value-based actions. Lastly, meaning-making efforts can lead to positive changes in individuals’ sense of meaning, life philosophies, priorities, and goals (Park, 2010; Tedeschi and Calhoun, 2004). Therefore, the seventh and final sessions encourage participants to reflect on the positive changes and to plan actions for leading a meaningful life in the future (see Supplemental Table 1 for detailed content).

Lastly, people diagnosed with cancer often encounter obstacles in accessing face-to-face psychological support due to factors like ongoing treatments, time constraints, distance, and costs (Kelleher et al., 2019). The COVID-19 pandemic has heightened these challenges by introducing fears of death, infection, and transmission (Özyer, 2023), further complicating face-to-face psychological treatment. Online psychosocial interventions present a promising alternative to address these limitations. Hammond (2015) suggests that online psychotherapeutic settings, where individuals have the opportunity to question their beliefs and explore different perspectives, could also promote meaning-making processes. Consequently, the MCCP was delivered via videoconferencing to support patients with breast cancer who have limited access to psychological support, with the goal of overcoming barriers to participation.

Aim of the study

In light of the current literature, this pilot randomized controlled trial (RCT) aimed to develop a videoconferencing MCCP and assess its effectiveness in patients with breast cancer compared to a WLC group. Our hypothesis posited that individuals receiving MCCP would report greater meaning in life and PTG, along with a reduced search for meaning (primary outcomes), in compared to control participants. Furthermore, we also expected greater improvements in stress appraisal (i.e. threat, challenge, controllable by self, controllable by others, and uncontrollability) and psychological distress (i.e. anxiety and depression) among MCCP recipients. We also hypothesized that these variables would continue to improve in the MCCP group from post-intervention to 2-month follow-up.

Methods

Participants

Participants were recruited based on specific eligibility criteria. Participants were required to meet the following inclusion criteria: (i) age between 18 and 65 years; (ii) being a native Turkish speaker; (iii) female gender; (iv) diagnosed with stage I, II, or III breast cancer; and (v) diagnosed within the last 6 months to 3 years. This criterion included patients attending follow-up appointments or undergoing treatment. The exclusion criteria were: (i) psychiatric diagnosis or current psychiatric medication; (ii) current psychological intervention; (iii) history of cancer diagnosis; (iv) diagnosed with advanced (stage IV) breast cancer; and (v) concurrent diagnosis of another cancer.

Design and procedure

The trial, approved by the University Ethics Committee (#2021/12-39) and registered on ClinicalTrials.gov (#NCT05963412), was conducted as a randomized controlled trial. The data from the corresponding author’s doctoral dissertation was utilized in this research. Following ethics approval, participants were recruited online and data collection took place between October 2021 and October 2022. Potential participants were reached through cancer charities and announcements posted on social media platforms in Turkiye (i.e. Instagram, Facebook, Twitter, and LinkedIn). A preliminary telephone interview was conducted to provide detailed study information, assess the participant’s eligibility for the intervention program, and obtain consent. Prior to participation in the trial, verbal and written consent was obtained from all participants. Consenting participants were asked to complete a baseline assessment via Google Forms, which was used for online data collection in the present study. After baseline assessment, the participants were randomly assigned by one author to either the MCCP group or the WLC group in a 1:1 allocation ratio using Research Randomizer (randomizer.org). The randomization was not revealed after all participants were recruited and baseline measurements were taken. In this way, researchers and participants did not know which group each participant would be assigned to at the beginning of the randomization process, thus ensuring allocation concealment. However, neither participants nor intervention provider could be blinded to their group allocation due to the use of a WLC condition. Those in the WLC group had the option to participate in the MCCP after completing the final measures.

Sample size

The sample size for the study was determined based on guidelines for pilot studies. According to Whitehead et al. (2016), a minimum of 10 participants per group is required for 80% power at a 0.05 significance level. Additionally, Julious (2005) and Sim and Lewis (2012) recommend 12–25 participants per condition. Consequently, the study aimed to recruit at least 20 participants per group.

Intervention

The MCCP is an eight-session intervention with weekly 1-hour individual sessions. Individual sessions are considered more suitable for addressing meaning-making issues (Lee et al., 2006) as well as sharing personal concerns and tailoring to participants’ needs and treatment schedules. All sessions were conducted remotely via videoconferencing using Zoom or Google Meet. The program employed an integrative approach combining didactic, existential, cognitive, and behavioral elements. Participants received in-session materials and homework assignments to reinforce their skills and awareness. All learning materials were supplied in PDF format. An exercise on the acceptance of emotions was provided as MP3 audio recording. Key therapeutic strategies included life review, Socratic questioning, exploring alternative perspectives, acceptance, engagement with life values, goal setting, and meaning-centered inquiry (see Supplemental Table 1 for detailed content).

Measures

At baseline (T₁), all participants completed sociodemographic and cancer-related information forms, along with outcome measures. The intervention group was assessed within 1 week after the intervention (T₂) and at a 2-month follow-up (T₃). The WLC group completed the final measurement (T₂) after an 8-week period. The same outcome measures, excluding the socio-demographic form, were used for assessments at post-intervention (T₂) and 2-month follow-up (T₃).

The Sociodemographic and Cancer Related Information Form was developed by the authors to assess sociodemographic (i.e. age, relationship status, education level, employment status, number of children) and breast cancer-related characteristics (i.e. time since diagnosis, stage of breast cancer, type of treatments and surgical operations) and for screening purposes.

Primary outcomes

The Meaning in Life Questionnaire (MIL) was developed to assess individuals’ search for and perception of meaning in life. It consists of two subscales, the presence of meaning in life and the search for meaning in life, with 10 items scored on a 7-point scale (Steger et al., 2006). Higher scores indicate higher levels of presence of meaning and higher levels of search for meaning. The Turkish version of MIL demonstrated good convergent and discriminant validity (Akın and Taş, 2015). The internal consistency coefficients were 0.77 for the presence of meaning and 0.83 for search for meaning, with test-retest reliability of 0.89 and 0.92, respectively (Akın and Taş, 2015).

The Posttraumatic Growth Inventory (PTG), originally developed by Tedeschi and Calhoun (1996), assesses positive changes following traumatic events. A revised version, the Posttraumatic Growth Inventory-X (PTGI-X), includes additional items (Tedeschi et al., 2017). This scale comprises 25 items, each scored on a 6-point scale. Higher scores indicate greater PTG. The psychometric properties of this version were assessed across samples from the U.S., Turkey, and Japan, demonstrating high internal consistency with coefficients of 0.97, 0.96, and 0.95, respectively, and good concurrent validity (Tedeschi et al., 2017). We used the Turkish version of PTG-X, which had already been adapted in the study of Tedeschi et al. (2017).

Secondary outcomes

The Stress Appraisal Measure (SAM) was developed to assess cognitive appraisal of stress (Peacock and Wong, 1990) and proposed by Park and George (2013) for evaluating situational meaning. It comprises 24 items covering primary (i.e. threat and challenge) and secondary appraisals (i.e. controllable by self, others, and uncontrollable), rated on a 5-point Likert scale. Higher scores indicate greater levels of each dimension. In this study, the Turkish version of SAM (Durak and Senol-Durak, 2013), which demonstrated good convergent and discriminant validity, was used. The reliability of the scale was confirmed with internal consistency coefficients ranging from 0.68 to 0.84 (Durak and Senol-Durak, 2013).

The Hospital Anxiety and Depression Scale (HADS), developed by Zigmond and Snaith (1983), evaluates anxiety and depression in individuals with physical illnesses using 14 items, divided into seven for each condition. Participants rate each item on a scale from 0 to 3, with higher scores indicating greater anxiety and depression levels. The Turkish version of the scale has demonstrated good concurrent and construct validity, with reliability coefficients of 0.85 for anxiety and 0.78 for depression (Aydemir et al., 1997).

Statistical analysis

IBM SPSS Statistics version 29 was used for the statistical analysis of the collected data. Descriptive statistics were utilized to explore sociodemographic and breast cancer-related characteristics. Before assessing the effectiveness of the MCCP, independent sample t-tests were conducted to check for baseline differences in the outcome variables between groups. A series of 2 (group) × 2 (time) repeated measures ANOVAs were then performed to evaluate intervention effectiveness, with significant group-by-time interactions indicating MCCP effectiveness compared to the WLC condition. In addition, changes in outcome variables across time points for each group were assessed using a one-way repeated measures ANOVA. The partial eta squared was used for calculating effect size, which followed Cohen’s (1988) guidelines, with values of 0.01, 0.06, and 0.14 considered small, medium, and large, respectively. Recently, effect sizes of 0.10 and above were also considered large when interpreting ANOVA results (De Rooij et al., 2023). Lastly, the Expectation Maximization (EM) method (Tabachnick and Fidell, 2013) was used to impute missing data for participants who did not complete follow-up assessments.

Results

Participants

Out of 117 initial applicants, 35 were excluded for not meeting inclusion criteria, and 38 did not respond further. Thus, 44 participants were randomly assigned to either the MCCP group (n = 22) or the WLC group (n = 22). The response rate among participants was notably high. In the MCCP group, 21 (95.45%) completed the post-intervention assessment, with 16 (72.72%) completing the follow-up assessment. In the WLC group, 20 (90.91%) completed the post-intervention assessment. Further details regarding participant flow are available in Supplemental Figure 1.

Baseline characteristics of participants

Supplemental Table 2 presents descriptive statistics of socio-demographic and breast cancer-related characteristics of the participants. No significant differences were observed in outcome variables between the MCCP and the WLC groups except for threat appraisal at baseline. As indicated by the findings, participants in the MCCP group perceived cancer (M = 29.95, SD = 5.16) as a greater threat compared to those in the WLC group (M = 26.55, SD = 4.43; Supplemental Table 3).

Primary outcomes: Intervention effects on Global Meaning (Meaning in Life and PTG)

The effect of MCCP on the presence of meaning and the search for meaning was examined (Supplemental Table 4). Compared to the WLC group, participants in MCCP demonstrated significant increases in the presence of meaning from baseline to post-intervention (F(1, 39) = 9.43, p < 0.01, η_p ² = 0.20). The presence of meaning significantly increased in the MCCP group from baseline (M = 23.86, SD = 7.03) to post-intervention (M = 28.52, SD = 4.53) and this improvement was sustained at follow-up (M = 28.25, SD = 4.14). No significant change was observed in the WLC group from baseline to post-intervention (Supplemental Table 5). Furthermore, there was no significant group-by-time interaction in the search for meaning, and no significant within-group changes were found in the search for meaning for either group across different time points.

A significant group-by-time interaction was observed for PTG (F(1, 39) = 4.97, p < 0.05, η_p ² = 0.11; Supplemental Table 4). Regarding the change in PTG across different time points, a significant increase in PTG levels was observed from baseline (M = 76.48, SD = 22.29) to post-intervention (M = 90, SD = 19.03) in MCCP recipients. However, a subsequent decrease (M = 84.06, SD = 16.39) in PTG levels was noted from post-intervention to follow-up assessment. No significant difference was found between baseline and post-intervention assessments in the WLC group (Supplemental Table 5).

Secondary outcomes: Intervention effect on situational meaning and psychological distress

To assess the effect of MCCP on situational appraisals of cancer, significant group-by-time interactions were found for challenge (F(1, 39) = 9.17, p < 0.01, η_p ² = 0.19), but not for other situational appraisal domains (Supplemental Table 4). However, there was a significant decrease in the challenge for the MCCP group from post-intervention to follow-up. In addition, there was an increase in the appraisal of cancer as controllable by others among the MCCP recipients from baseline to post-intervention, but a further increase was not achieved at follow-up. No significant differences were found in any domain of situational appraisal between the baseline and post-intervention measures for the WLC group (Supplemental Table 5).

As for psychological distress, a statistically significant group-by-time interaction effect was found for anxiety (F(1, 39) = 4.95, p < 0.05, η_p ² = 0.11), but not for depression (Supplemental Table 4). When the effect of time was considered, there was a significant reduction in the level of anxiety from baseline (M = 11.33, SD = 4.48) to post-intervention (M = 8.38, SD = 3.46) for MCCP recipients. However, although there was a slight increase in the level of anxiety from post-intervention to follow-up, this was not statistically significant. As for the WLC group, no improvement was reported for anxiety from baseline to post-intervention. The level of depression also improved from baseline (M = 7.10, SD = 4.57) to post-intervention (M = 4.76, SD = 3.28) in the MCCP group and from baseline (M = 7.60, SD = 5.21) to post-intervention (M = 5.45, SD = 5.02) in the WLC group. However, further improvement in depression was not observed at follow-up in the MCCP group (Supplemental Table 5).

Discussion

This pilot randomized controlled trial investigated the preliminary impacts of the MCCP among Turkish women diagnosed with Stage I, II, and III breast cancer. The MCCP is the first individual videoconferencing psychological intervention specifically tailored to address meaning-making processes among patients with breast cancer. It significantly increased participants’ sense of meaning, levels of PTG, challenge appraisal, and decreased anxiety immediately following the intervention compared to the WLC group, with moderate to large effect sizes (η_p ² = 0.11–0.20), indicating strong immediate effects. Notably, improvement in the presence of meaning was maintained at follow-up within the MCCP group.

The MCCP significantly increased the presence of meaning in the lives of patients with breast cancer compared to the WLC group, consistent with findings from other meaning-centered psychotherapies (e.g. Breitbart et al., 2012, 2018; Henry et al., 2010; Van der Spek et al., 2017). However, it does not notably influence the level of search for meaning. While meaning in life and the search for meaning are interconnected, they are not synonymous, and not all cancer patients actively search for meaning (Reker and Cousins, 1979). For example, research indicates that high levels of both meaning in life and search for meaning correlate with better psychological well-being, whereas low meaning in life and high search for meaning leads to poorer adaptation to chronic illness (Dezutter et al., 2013). Therefore, it can be concluded that the search for meaning is only beneficial when it enhances one’s sense of meaning (Kernan and Lepore, 2009). In light of this, our study suggests that while both MCCP and WLC group participants may search for meaning similarly, only MCCP recipients experience an increase in their sense of meaning, which is more adaptive.

The MCCP effectively increased PTG levels compared with the WLC group, with a moderate to large effect size (n_p ² = 0.11). Certain aspects of the MCCP were similar to other interventions targeting PTG, such as addressing cancer-related losses and promoting emotional expression, which help in processing traumatic events like breast cancer (Arnedo and Casellas-Grau, 2015; Ramos et al., 2018). Furthermore, the seventh session, which used the Posttraumatic Growth Workbook (Tedeschi and Moore, 2016), directly aimed to encourage positive changes after breast cancer. These components likely contributed to the increased PTG levels in the MCCP group. However, the lasting effects of the MCCP were not evident, possibly due to its short duration. Research suggests that interventions that promote PTG often require longer durations to achieve significant results (Roepke, 2015). Therefore, longer-term psychotherapy might be required to foster and sustain growth.

The MCCP effectively reinforced participants’ reframing of breast cancer as a challenge but did not alter their views of it as a threat or uncontrollable. This aligns with Wong’s (2010) theory of dualistic living, which acknowledges the coexistence of both positive and negative aspects of life. Given the ongoing negative effects of breast cancer treatment, such as fears of recurrence or progression (Tong et al., 2024), participants continued to view breast cancer as a threat and uncontrollable but also began to see it as a challenge to confront. However, this increase was not maintained at follow-up, possibly due to the need for longer-term interventions to sustain positive psychological outcomes as we observed in the findings on PTG. MCCP recipients also felt breast cancer was more controllable by others from baseline to post-intervention, although this improvement was not sustained at follow-up. This subdimension includes items referring to the presence of social support (Wong, 1993). Therefore, this perception might have been influenced by the emotional support provided by the MCCP and the positive changes experienced during the program, which may have led participants to seek more social support. Despite not being designed to increase social support, the MCCP may have indirectly helped participants view breast cancer as more controllable by others.

The MCCP significantly reduced anxiety in breast cancer patients compared to the WLC group. The literature indicated mixed results regarding the impact of meaning-centered interventions on anxiety, with some studies reporting significant decreases (e.g. Breitbart et al., 2018; Quílez-Bielsa et al., 2021) and others not (e.g. Breitbart et al., 2012; Henry et al., 2010; Wagner et al., 2016). The MCCP stands out from other meaning-centered therapies by using cognitive and emotional techniques, particularly from ACT, to reduce anxiety by defusing the anxiety-provoking meanings of breast cancer, offering alternative viewpoints, and accepting related emotions. These unique elements may make MCCP effective in both enhancing meaning in life and reducing anxiety. However, although not statistically significant, there was an increase in anxiety at follow-up, which has been attributed to the ongoing emotional fluctuations at the different stages of treatment (Coyne and Borbasi, 2007). This suggests that the coping skills learned may not have been fully adapted to new anxiety-inducing situations. It is also noted that the experience of anxiety in response to a life-threatening illness is generally normal and does not necessarily have to be pathological (Stark and House, 2000).

The intervention program did not show a distinct impact on depression, but both the MCCP and the WLC groups showed significant improvements from baseline to post-intervention. This is consistent with research indicating that the risk of depression naturally decreases over time after a breast cancer diagnosis (Maass et al., 2015). The similar reduction in depression levels in both groups may reflect this natural progression. Nevertheless, an increase in the level of depression was observed at follow-up, although it is not statistically significant. It is suggested that meaning-making processes are not devoid of psychological distress, but that such distress can facilitate meaning-making and coexist with positive emotions (Moye et al., 2020). Therefore, the persistence of depressive symptoms in some participants does not necessarily indicate poor adjustment or failure to find meaning in their breast cancer experience.

The MCCP program was delivered via videoconferencing, which offers real-time communication similar to in-person sessions (Lleras de Frutos et al., 2020) and is increasingly utilized for psychotherapy (Thomas et al., 2021). Although videoconferencing for psycho-oncology interventions does not fully replace face-to-face interaction, studies indicate no significant differences in the effectiveness between these two formats (e.g. Freeman et al., 2015; Lleras de Frutos et al., 2020). In this regard, using videoconferencing to deliver the MCCP is considered advantageous for overcoming geographical and mobility barriers, which is especially valuable during the COVID-19 pandemic. Furthermore, the promising outcomes of the MCCP demonstrated that online platforms can facilitate meaning-making under suitable conditions, as suggested by Hammond (2015). However, the MCCP, like all videoconferencing programs, has constraints such as difficulties in reading body language, initial discomfort with the modality for both patients and therapists and potential interruptions from distractions and technical issues (Thomas et al., 2021). Despite these limitations, the use of videoconferencing to deliver the MCCP is considered to be a reliable alternative for providing psychological support.

Limitations of the study

This study makes important contributions to the literature but has several limitations. Firstly, the lack of clear cutoff scores in measurement tools for meaning in life or psychological distress could lead to the inclusion of individuals with fewer concerns, potentially reducing the apparent benefits of the MCCP. Future studies should include criteria that identify individuals with lower meaning in life or higher psychological distress to obtain stronger results. Secondly, the timing of encouraging meaning-making processes for patients with breast cancer is uncertain. The study required participants to be at least 6 months post-diagnosis, assuming primary treatment would be completed by then (Groarke et al., 2017). Despite this assumption, some participants were still undergoing treatment, while others had completed treatment long ago. Patients in active treatment may have different meaning-related concerns compared to longer-term survivors (Park et al., 2019). Differences in participants’ treatment stages may have affected the effectiveness of the intervention, so specifying treatment stages is recommended to better understand the impact of the MCCP. Additionally, the study did not incorporate a comparison with an active treatment control group, which limits the strength of conclusions regarding the effectiveness of the intervention. The inclusion of such a group in future research could enhance the thoroughness of evaluating intervention outcomes. Furthermore, the absence of follow-up measurements in the control group also makes it difficult to assess the long-term effects of MCCP. Subsequent studies should include follow-up assessments for the control group to ensure a comprehensive evaluation. Another limitation is that the lack of blinding by intervention providers may bias the estimation of the treatment effect. Therefore, implementing blinding protocols for interventions is critical in future research to mitigate potential bias and maintain the reliability of study results. Besides, the study’s sample size, determined based on pilot studies and similar research, was relatively small, potentially affecting the results and limiting strong interpretations. Lastly, the study mainly involved highly educated and young female participants with stage I–III breast cancer, restricting the generalizability of the findings to other demographic groups. Randomized controlled trials with larger sample sizes that also include patients with advanced cancers, concurrent diagnoses, and diverse gender, age, and education demographics would help assess the effectiveness of the intervention across different clinical and demographic subgroups.

Conclusion

The MCCP, drawing on the Meaning Making Model (Park, 2010; Park and Folkman, 1997) and Wong’s (2010) principles of Meaning Therapy, effectively enhances meaning in life, post-traumatic growth, challenge appraisal, and reduces anxiety levels among breast cancer patients. At this point, MCCP has been found effective in both strengthening meaning in life and finding positive meaning in the experience of breast cancer, as well as promoting psychological adjustment to breast cancer. Although there was no cut-off score for inclusion in the trial, these results suggest that people may benefit from the MCCP even if they do not suffer from meaningless or clinically distressing symptoms. Furthermore, the MCCP stands out from other meaning-centered programs due to its multifaceted approach, combining existential, didactic, cognitive, and behavioral elements. In addition, delivering the MCCP via videoconferencing overcomes time and geographic constraints while offering the potential to enhance the meaning-making process for individuals diagnosed with breast cancer. To sum up, the MCCP emerges as a promising and effective intervention that supports individuals diagnosed with breast cancer in their journey to find meaning and cope with their challenges.

Supplemental Material

sj-docx-1-hpq-10.1177_13591053241307875 – Supplemental material for Developing and testing the effectiveness of a videoconferencing, Meaning-Centered Coping Program among Turkish women with breast cancer: A pilot randomized trial

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Footnotes

Acknowledgements

The authors would like to thank all the participants who made this study possible by dedicating their time, sharing their experiences, and providing invaluable contributions.

Data availability statement

The data generated during and/or analyzed in this study is not publicly available but it will be obtained from the corresponding author upon reasonable request.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This doctoral dissertation study was funded by a scholarship from the Scientific and Technological Research Council of Turkey (TÜBİTAK). However, TÜBİTAK was not involved in the study’s design, data collection, analysis, or interpretation, nor in the writing of the manuscript or the decision to submit it for publication.

Ethics approval

The current study adhered to the guidelines outlined in the Declaration of Helsinki. It was approved by the Dokuz Eylul University Ethics Committee (#2021/12-39) and registered on ClinicalTrials.gov (#NCT05963412).

Informed consent

All participants provided informed consent prior to their involvement in the study.

ORCID iD

Selva Ülbe

Gülay Dirik

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