Rationale, Foundations, and Goals of CALM

This chapter introduces the Managing Cancer and Living Meaningfully (CALM) treatment manual. It summarizes the intent and purpose of the manual, which outlines the essential features of the CALM intervention and provides clinical examples to elucidate its implementation. Although it has been challenging to manualize the key therapeutic elements of a semi-structured intervention such as CALM, treatment manuals are essential to ensure the reliability and integrity of treatment delivery.

The Experience of CALM Training

This chapter discusses the central role of Managing Cancer and Living Meaningfully (CALM) training and supervision in refining the CALM intervention and in building a supportive community of peers for clinicians. The elements of CALM training are outlined. In both the introductory and advanced CALM workshops, actual cases have been vital in illustrating CALM content and process. Representative clinical encounters have been provided with the aid of trained actors or by presentation of actual videotaped CALM sessions. These workshops have been highly rated by trainees, with clinician attendees often feeling inspired and supported in their work as a result of CALM training. The benefits of CALM training are evident in the implementation of CALM in various settings in Asia, Europe, and in North and South America.

Utilizing Measures in Clinical Practice and Supervision

This chapter specifies the quantitative measures that are regularly administered as part of Managing Cancer and Living Meaningfully (CALM) and describes the role of ongoing peer supervision in CALM therapy. The value of administering quantitative measures assessing death anxiety, attachment security, depression, quality of life at the end of life, and perceived clinical benefit is described. The format of CALM supervision is outlined and the benefits of ongoing peer supervision for ensuring treatment integrity, fostering skill development, refining the intervention, and managing the tensions inherent in psychotherapeutic work in the context of advanced cancer are emphasized.

CALM and the Desire for Death

This chapter considers the loss of the will to live, the desire for hastened death, and suicidality in patients with advanced disease. The challenge of distinguishing the loss of the will to live as a manifestation of depression from nonpathological death acceptance is explored and the clinical implications of such distinctions are examined. The quantitative findings from our longitudinal research regarding the prevalence, trajectory, and correlates of the desire for death in patients with advanced cancer are presented. The qualitative findings from this research revealed three distinct dimensions of the desire for death, only one of which reflects the literal wish to end life. The role of Managing Cancer and Living Meaningfully (CALM) in alleviating death anxiety, in examining the desire for death, in enhancing death preparation, and in improving communication with healthcare providers is considered here.

The Context of CALM

This chapter provides an overview of the range of psychotherapeutic interventions that have been applied to patients with advanced and metastatic cancer and the relationship of Managing Cancer and Living Meaningfully (CALM) to the field. Approaches to alleviate distress at the time of diagnosis of advanced or life-threatening cancer, those for patients near the end of life, and those for patients living with metastatic and advanced cancer are discussed. The latter include supportive-expressive, meaning-centered, cognitive-behavioural, mindfulness-based, and grief therapies tailored for individuals, groups, and families. Interventions tailored for the end of life, including Dignity Therapy, Short-Term Life Review, and narrative interventions, are reviewed. The barriers to the optimal delivery of psychosocial interventions for patients with advanced disease are also explored.

The Management of Terror

This chapter addresses the psychological impact of life-threatening disease of acute onset. Anxiety may be profound in this circumstance, with the severity of symptoms often meeting criteria for acute stress disorder (ASD) or posttraumatic stress disorder (PTSD) in both patients and family caregivers. The nature of traumatic stress and the ways in which it may be alleviated by Managing Cancer and Living Meaningfully (CALM) therapy are described here. Terror management theory (TMT), including the psychological pillars that protect individuals from the fear of death, is introduced as a model to understand how death anxiety is managed when mortality salience is heightened. The influence of TMT in formulating our research and in developing the CALM intervention is described here.

From Our Clinic, Across the Globe

This chapter outlines the engagement of both local and international colleagues with Managing Cancer and Living Meaningfully (CALM) and highlights its universal themes and applicability across various cultures and settings. The Global CALM program, which has trained thousands of individuals to date, is introduced and the keys to successful CALM implementation in international sites are presented. Finally, several current CALM research projects are summarized and the expanding international research supported by the Global CALM program is described.

One Thousand Lives

This chapter provides an overview of the foundational contributions of early leaders in psychosocial oncology and palliative care that informed the development of the Managing Cancer and Living Meaningfully (CALM) intervention. This includes the collective works of such pioneers as Kübler-Ross, Glaser and Strauss, and Pattison, which were instrumental in the development of psychosocial interventions such as CALM. The research conducted by our team with advanced cancer patients and their families over two decades is also described, highlighting the longitudinal Will to Live Study. In that study over 700 patients with advanced cancer were assessed at baseline and over 400 were followed longitudinally until the end of life, deepening our understanding of their experience over the trajectory of this disease. The findings of this research confirmed the need for an intervention such as CALM and helped to shape its nature and form.

Mentalization and Mortality

This chapter elucidates the concepts of mentalization and double awareness. Mentalization refers to the ability to reflect on and describe one’s own mental state and that of others and to connect feelings, thoughts, and beliefs to behaviours. This capacity varies amongst individuals and may fluctuate, based on the affective state, the relational context, and the nature of the conversation. Though it is often considered to be an individual capacity, we have argued that mentalization is a relational construct that is co-produced within therapeutic conversations. A mentalization-based therapy, such as CALM, can help patients to “think about their thinking,” and to consider multiple and alternate ways of viewing their situation. Mentalization may be supported by gentle invitations to patients to consider multiple perspectives and to expand the possibilities for living while facing the end of life, a capacity that we have termed “double awareness.” Using detailed conversation analysis, this chapter illustrates the process by which therapists encourage mentalization in CALM therapy.

CALM Therapy Cases

This chapter contains case summaries and brief case examples, based on actual patients treated with Managing Cancer and Living Meaningfully (CALM), to illustrate the process of CALM therapy and the common issues that may arise. The case summaries, which include individual and couples-based cases, elucidate the process of CALM as it unfolds from the initial session to the final meeting. Brief case examples are also presented to highlight potential CALM challenges.