The research emerged from a larger randomized controlled trial, known as the MELODY trial, that enrolled 300 adult cancer survivors and compared telehealth-delivered music therapy with telehealth-delivered cognitive behavioral therapy—the first-line psychological treatment for anxiety—for the management of cancer-related anxiety. Participants were eligible only if they were free of oncological disease, had not received primary cancer treatment for at least one month, and had experienced anxiety symptoms for at least one month, as measured by a score of eight or higher on the anxiety subscale of the Hospital Anxiety and Depression Scale. The trial was approved by the Memorial Sloan Kettering Cancer Center Institutional Review Board, and participants were enrolled between February 2022 and December 2023.

Within the music therapy arm of the trial, 147 participants met individually with board-certified music therapists for seven sessions of sixty minutes each, delivered over video connections. The therapeutic arc was deliberately structured. Early sessions relied on receptive music experiences—listening to personally meaningful songs and discussing them—to build rapport and open emotional territory. As the sessions progressed, therapists introduced more active experiences such as improvisation, deepening the emotional exploration and helping participants refine ideas for their own compositions. These explorations culminated in the writing and recording of an original song, typically spread across two to three sessions.

The songwriting process itself followed five broad phases: reviewing emotions and thoughts expressed in prior sessions; brainstorming song ideas from that review; collaborating to select, expand, and arrange ideas into lyrics while identifying important song elements such as emphasis on particular words or musical style; experimenting with melody, chord progressions, and accompaniment while refining lyrics; and finally recording or sharing the completed song. Participants and therapists worked with acoustic and electronic instruments, handwritten notation, and composition software including GarageBand and Soundtrap. All but one of the participants whose songs were analyzed created entirely original music and lyrics, with varying degrees of independence—some refined their tracks between sessions on their own, while others relied more heavily on their therapist to offer choices during sessions. Crucially, therapists were trained to write songs “with” rather than “for” participants, calibrating the level of structure to each person’s therapeutic needs while maximizing creative ownership. To guard against therapists unduly shaping the content, the study team reviewed session videos as part of the trial’s treatment fidelity procedures and discussed songwriting processes in weekly meetings.

For the new analysis, researchers from Drexel University and Memorial Sloan Kettering Cancer Center reviewed all songs written through September 2023—eighty-two in total—and identified a subset of twenty-six songs that focused specifically on participants’ needs and challenges. Songs devoted exclusively to other topics, such as nostalgia, self-affirmation, or fatigue, were excluded. The research team treated the lyrics as its primary data but supplemented them with song recordings, brainstorming notes from therapy sessions, and brief synopses grounded in conversations with the music therapists who had witnessed each song’s creation. This contextual grounding was considered essential, since lyrics are dense with metaphor and deliberately encoded meaning. The team applied Braun and Clarke’s six-step reflexive thematic analysis, coding the material both semantically, for explicit content, and latently, for interpretive meaning, using MAXQDA software. A music therapist experienced in thematic analysis but uninvolved in the clinical sessions served as primary coder, with a graduate student in music therapy providing secondary coding on roughly thirty percent of the songs and a senior qualitative researcher supervising the work.

Four themes emerged from the analysis, and the researchers stress that together they reveal how coping with one challenge typically activated another, often with ripple effects on participants’ relationships. The first theme was the need to use time wisely. Confronted with their own mortality, many songwriters described time alive as a resource that should not be wasted, calling survivorship their “second chance.” One participant wrote, “I will do what I must do, to hold onto today/Through rain or sunshine, I’m staying present,” explaining that worry kept them from the present moment, particularly during family time. Others used the metaphor of listening to their bodies—attending to pain and fatigue as signals—to reallocate time away from energy-draining activities toward restorative ones like exercise, time outdoors, and connection with friends and family. Perhaps most poignantly, many participants described the conflict that arose when prioritizing their own needs required them to decenter others. One songwriter used birds as a metaphor for a new relational perspective: “Blue jays looking over me/Put yourself first, they say/Build a new nest/Make a safe landing.” For this person, insights gained in early therapy sessions led to reprioritizing their own well-being, which in turn required setting boundaries with an ex-spouse.

The second theme, personal influences on coping, captured how participants’ internal experiences shaped their responses to adversity. Songs invoked past difficulties, fear, and anxiety, often contrasting a longing for change with fear of the unknown. Some writers described resisting fear; others insisted on embracing it while clinging to hope. In a song titled “Stay Afloat,” one participant compared procedural anxiety to being submerged in water, with light—the view upon emerging from MRIs and surgeries—serving as a focal point for hope: “I’m afraid in the darkness/When will I thrive again? Will I ever thrive again?/The light guides me through…The light brings me comfort/To make it through the storms.” Others wrote of summoning courage against waves of panic attacks. “Negative thoughts wash over me/They can’t wash me away/The waves are always there/I can learn how to surf,” one participant composed, describing in sessions how the lyrics represented an inner resolve to reclaim life from daily panic. Several songs also asserted self-worth and self-confidence explicitly, frequently tying a sense of deserving support to a sense of deserving rest and self-care.

The third theme—the need to feel others’ support—was the most striking in its asymmetry. Although nearly every song touched on support, only a few participants described feeling genuinely supported, while many more disclosed profound loneliness, emptiness, and desperation. The disconnection arose from a painful gap between appearances and inner reality: others underestimated the severity of participants’ anxiety, believed faulty narratives that everyone fully recovers after primary treatment ends, or offered what the researchers call “toxic positivity”—the expectation that survivors should always maintain a cheerful, recovery-oriented attitude. The pressure to appear well only deepened the isolation. One participant pleaded in lyrics: “There’s a pain that lives within me/That you’ll never see, but I feel…How I wish you’d try to see/Hear me, understand me/If you really care, then show me/Don’t judge me, don’t make me feel unseen.” Another wrote, “I am lonely, hidden loneliness/OK on the outside, Blue on the inside/Where were you? Where are you? Do you see me?” These are not merely artistic expressions, the authors argue; they are explicit appeals to be seen, heard, and understood, articulated more openly than many survivors can manage in conversation. By contrast, the few songs that conveyed feeling supported—whether through steadfast loved ones or the memory of a deceased sister’s guitar pick kept in a pocket—suggested that even remembered support bolstered hope, strength, and confidence.

The fourth theme concerned existential needs: the search for meaning and purpose after cancer, the renegotiation of identity, and the difficult work of accepting permanent changes and uncontrollable symptoms. Participants frequently turned to metaphors of journeying and seeking to express these quests. Several wrote about finding or reclaiming their voice. One song contained the lines that gave the study its title: “This is my voice, this is my story/I honor my journey here/Who I am, as I am here.” Parents and mentors drew motivation from their relationships with children—a phenomenon the authors connect to prior research on biographical disruption, which holds that a cancer diagnosis profoundly interrupts a person’s sense of self and future, prompting a reexamination of values, identity, and relationships. Acceptance, several songs suggested, was a painful but essential ingredient in moving forward: some events and symptoms lie beyond one’s control, and symptoms may even carry crucial information about self-care needs.

Beyond cataloguing what survivors wrote, the study highlights why songwriting may be uniquely suited to this kind of expression. Metaphors—of battle, journey, freedom, and confinement—are well-established tools for communicating emotionally difficult topics, and composing original songs makes those metaphors personally potent in ways that listening to someone else’s music cannot replicate. Musical and lyrical structure acts as cognitive scaffolding: verses hold stories and details, choruses crystallize central emotions or insights, and the repetition and predictability of form help participants organize seemingly contradictory truths—such as constant worry about recurrence coexisting with confidence that one is loved. Elements of music itself, from rhythm to harmony, can be deployed to support or reshape meaning; one participant asked the therapist to place rhythmic emphasis on the words “I am me” in a song imploring others to “see” them, while another used harmonic structure to simulate the arc of a panic attack.

The findings carry practical weight for survivorship care. Under-communication of cancer-related concerns is associated with increased psychological distress, yet survivors tend to avoid emotionally challenging conversations. A finished song can make such communication tolerable for both speaker and listener, and sharing a song with family or clinicians may open dialogue that would otherwise remain closed. The authors caution that their participant group had limited racial and ethnic diversity and self-selected into an expressive-therapy trial, so further work is needed in more varied populations. Still, the message of the songs themselves is unambiguous: survivorship does not end when treatment does, and the need to be heard—softly, shakily, but authentically—persists long after the last infusion.

The study’s principal investigator, Dr. Donald R. Sullivan, an associate professor at OHSU’s School of Medicine, highlights the profound shock many veterans experience upon learning of their cancer diagnosis. While the trauma of a serious illness might be expected to precipitate immediate mental health concerns, this research articulates that the psychological stress and risk of suicidal self-directed violence remain elevated for years. These insights challenge the prevailing clinical approach that often confines psychological assessments to the period during active cancer treatment, underscoring the imperative need for ongoing psychosocial support.

In this investigation, researchers expanded the conventional scope to include both fatal and nonfatal suicide attempts—a methodology known in psychiatric epidemiology as assessing suicidal self-directed violence. Leveraging the VA’s unique and comprehensive suicide surveillance infrastructure enabled identification of nearly 2,400 suicide-related events, with a staggering 90 percent classified as nonfatal attempts. The calculated incidence rate of suicide attempts among veterans with cancer was 203 per 100,000 person-years, markedly surpassing rates observed in the general population. This quantitative revelation signifies an urgent public health concern that merits enhanced preventive interventions.

Temporal analysis disclosed that the highest incidence of suicide-related behaviors occurred within the first six months post-diagnosis. This early period is characterized by heightened existential distress, acute physical pain, and the initiation of complex treatment regimens that often provoke debilitating side effects. However, the study’s most striking finding is the persistent elevation of risk, which remains significantly above baseline for up to five years in some individuals. Such sustained vulnerability indicates that the psychosocial sequelae of cancer cannot be fully mitigated by survival alone, necessitating a paradigm shift in post-treatment care strategies.

Certain demographic and clinical characteristics were identified as determinants of heightened suicide risk. Veterans under the age of 45 emerged as a particularly vulnerable subgroup, presumably due to the intersection of cancer-related stress with pivotal life responsibilities including career advancement, family commitments, and financial stability. Additionally, female veterans demonstrated disproportionately elevated rates of nonfatal suicide attempts, challenging the notion that psychological resilience varies markedly by gender in the oncologic context. This gender disparity calls for nuanced screening approaches sensitive to differential psychosocial needs.

Race and ethnicity also influence suicide risk profiles. Veterans identifying as American Indian or Alaska Native were at notably increased risk, signaling potential disparities rooted in systemic barriers to comprehensive care, cultural stigma, or healthcare access challenges. Clinically, the type of cancer diagnosed further stratified risk levels. Cancers involving the brain and central nervous system, pancreas, head and neck, liver, and thyroid were associated with greater suicidal self-directed violence, possibly attributable to tumor location-related neurological impacts, prognostic severity, and treatment toxicity profiles.

The study also elucidated the complex interplay between physical symptoms, comorbid mental health conditions, and frailty in modulating suicide risk. Veterans burdened with chronic psychiatric illnesses, debilitating pain, or profound frailty exhibited the highest rates of suicide-related events, underscoring the importance of holistic, multidisciplinary care models. From a preventive perspective, pharmacological agents—particularly opioids prescribed for pain management—were predominantly implicated in nonfatal suicide attempts, while the use of firearms was prevalent in fatal cases, consistent with existing epidemiological research on veteran suicide.

Importantly, receipt of palliative care emerged as a protective factor against suicide-related events. Palliative care’s emphasis on symptom alleviation, psychosocial support, and advance care planning may attenuate the existential distress and physical suffering that act as precipitating factors for suicidal impulses. These data advocate for early integration of palliative interventions within the oncology care continuum, not just for terminal phases but as an essential component of survivorship care.

The study’s findings are undergirded by the VA’s extensive data collection systems, which offer unparalleled insights into veteran health outcomes. This robust surveillance allowed researchers to discern patterns and risk factors invisible in civilian healthcare settings. Such granular data emphasize the critical necessity for healthcare systems to adopt similarly rigorous tracking methodologies to identify at-risk populations and tailor interventional frameworks accordingly.

Conclusively, Dr. Sullivan and his colleagues emphasize that cancer care must transcend tumor-centric approaches, embracing comprehensive mental health assessment and support paradigms from initial diagnosis through long-term survivorship. The integration of routine suicide risk screening tailored to individual patient profiles—including age, cancer type, mental health history, and symptom burden—is imperative for mitigating preventable mortality and enhancing quality of life.

The study underscores a pressing call to action within oncologic and veteran healthcare sectors alike: to develop and deploy sustained psychosocial services addressing both the immediate and long-term mental health ramifications of a cancer diagnosis. In the words of OHSU President Shereef Elnahal, M.D., M.B.A., these findings offer invaluable guidance for clinicians, administrators, and policymakers charged with reducing the tragic toll of suicide among those who have served their country and now face formidable cancer battles.

If you or someone you know is experiencing suicidal thoughts or a mental health crisis, urgent resources are available. Call the National Suicide Hotline at 9-8-8 or visit SpeakingOfSuicide.com/resources for confidential support and assistance.

Subject of Research: People

Article Title: Longitudinal Risk for Suicidal Self-Directed Violence Among Veterans With Cancer

News Publication Date: 28-May-2026

Web References: http://dx.doi.org/10.1001/jamaoncol.2026.1459

Keywords: Cancer, Suicide, Veterans, Mental Health, Suicidal Self-Directed Violence, Palliative Care, Epidemiology, Oncology, Psychological Distress, Survivorship

The impetus for this intervention stems from the understanding that cancer’s impact extends far beyond the patient to deeply affect family members, particularly parents, whose mental health often remains overlooked by mainstream clinical services. Building on this insight, the intervention takes advantage of the internet’s ubiquity, offering a guided self-help format grounded in cognitive behavioural therapy principles. Low-intensity CBT is known for its effectiveness in treating anxiety and depression by focusing on practical skills and cognitive restructuring. The internet-administered nature enables delivery that is not only convenient but also scalable across different geographic and demographic groups.

Crucially, the research team evaluated the initial acceptability and feasibility of EJDeR through the ENGAGE feasibility trial, which functioned as a pilot to assess the intervention’s real-world application. Early findings from ENGAGE indicated that both the intervention and associated study procedures were largely viable and acceptable to parents navigating the taxing aftermath of their child’s cancer treatment. Nevertheless, these preliminary results also revealed areas where modifications were necessary to better align the intervention with parent needs and technological realities, highlighting the importance of iterative refinement based on user feedback.

To deepen this understanding, the study incorporated a qualitative research component involving 52 parents—17 fathers and 35 mothers—who participated in semi-structured interviews. This qualitative approach allowed researchers to capture nuanced insights into parents’ experiences, perceptions, and challenges encountered while engaging with EJDeR. Notably, a public contributor group comprised of three parents who had firsthand experience raising children treated for cancer was integrally involved in data analysis, ensuring the findings were grounded in lived experience rather than purely academic interpretation.

The resulting analysis yielded a rich, multifaceted portrait of EJDeR’s perceived strengths and limitations. Parents found the intervention broadly acceptable and relevant to their mental health needs, appreciating its guided, flexible format delivered via the internet. Positive attitudes toward digital health support, especially when personalized guidance was available, underscored the potential of EJDeR as a transformative tool for mental health care access. These findings parallel broader trends that recognize digital interventions as essential complements or alternatives to traditional face-to-face therapy, particularly in vulnerable populations.

However, significant opportunities for improvement emerged from parental feedback. Participants called for a more comprehensive incorporation of family-wide dynamics within the intervention, suggesting that exclusive focus on individual psychological factors insufficiently captures the ripple effects of a child’s cancer journey. Further, the traumatic nature of cancer and its enduring psychological imprint necessitated heightened sensitivity and content depth addressing trauma-related issues. This refinement would better resonate with parents’ lived realities and potentially enhance therapeutic efficacy.

Technological barriers also surfaced as critical determinants of engagement. Some parents reported difficulties interfacing with the platform, citing challenges in navigation and functionality. Moreover, compatibility with smartphones and tablets—a necessity in an era where mobile device usage eclipses desktop computing—was identified as a key area for enhancement to optimize user-friendliness and accessibility. Such technical obstacles could undermine the very feasibility and acceptability the intervention seeks to promote if not adequately addressed.

The study procedures themselves, including recruitment and assessment processes, were generally acceptable but elicited recommendations for streamlining. Parents suggested that the informational materials provided could better clarify distinctions between involvement in the intervention versus research protocols, reducing confusion and enhancing informed consent. Additionally, the volume and frequency of assessments were perceived as burdensome, indicating a need to balance data collection with participant convenience and retention.

Strikingly, the involvement of public contributors in the qualitative analysis enriched the interpretive depth of the findings. Their lived experience facilitated the identification of subtle nuances that the research team initially overlooked, such as difficulties parents faced in differentiating the intervention activities from study-related procedures. This collaboration exemplifies the value of patient and public engagement in enhancing the relevance, clarity, and empathy embedded in healthcare research, turning abstract data into actionable insights firmly rooted in real-world contexts.

From a broader perspective, EJDeR’s development and evaluation represent a significant stride towards democratizing mental health support for families navigating the aftermath of pediatric cancer treatment. By leveraging digital platforms paired with therapeutic guidance, this approach seeks to dismantle traditional access barriers, including geographical constraints, stigma, and the scarcity of specialized psychological services. The intervention’s low-intensity framework also aligns with efficient resource allocation, allowing mental health professionals to extend their reach without compromising quality.

The researchers’ transparent acknowledgment of the needed refinements underscores a commitment to responsive innovation. They advocate for iterative revisions informed by comprehensive qualitative feedback, technological enhancements focused on user experience, and clearer communication surrounding study and intervention concurrent participation. Such iterative cycles are fundamental in digital health intervention development, ensuring tools remain adaptable, user-centered, and effective in diverse real-world settings.

Ultimately, findings from this qualitative study provide compelling evidence that digital, guided CBT interventions like EJDeR hold promise within psycho-oncology and pediatric family mental health domains. The results encourage further research through expanded trials incorporating these modifications, with the aim of validating efficacy, broadening demographic reach, and integrating such tools into standard care pathways. Moreover, the study models best practices in co-production and public involvement, showcasing how partnerships between researchers and lived experience experts can elevate scientific rigor and ethical integrity.

As mental health needs continue to escalate globally, particularly among populations affected by chronic and life-altering illnesses, innovations such as EJDeR may redefine therapeutic landscapes. They illustrate how technology-enabled, person-centered care can bridge gaps in conventional service delivery, enhancing resilience and well-being among those who bear the emotional toll of childhood cancer. This research not only advances clinical science but also sparks vital conversations about inclusivity, digital equity, and the future of psychological support in complex medical contexts.

The journey towards refining and disseminating EJDeR embodies a paradigm shift towards embracing digital mental health solutions tailored to unique, underserved groups. The study’s comprehensive qualitative insights provide a roadmap for overcoming barriers to engagement, optimizing user interfaces, and ensuring interventions reflect the intricate realities of affected families. Through continued interdisciplinary collaboration and technological innovation, such endeavours could transform health outcomes for countless parents and their children worldwide.

In sum, the detailed exploration of EJDeR’s acceptability and feasibility underscores the immense potential of internet-administered, guided, low-intensity CBT in meeting the psychological needs of parents of children treated for cancer. While refinement remains paramount, this research lays critical groundwork for future intervention development, emphasizing inclusivity, public involvement, and user-centered design as cornerstones of effective digital mental health strategies.

Subject of Research: Psychological support interventions for parents of children treated for cancer; feasibility and acceptability of digital guided low-intensity cognitive behavioural therapy.

Article Title: The acceptability and feasibility of an internet-administered, guided, low-intensity cognitive behavioural therapy intervention for parents of children treated for cancer: findings from a qualitative study involving public contributors.

Article References:
Thiblin, E., Lundgren, J., Bergqvist, M. et al. The acceptability and feasibility of an internet-administered, guided, low-intensity cognitive behavioural therapy intervention for parents of children treated for cancer: findings from a qualitative study involving public contributors. BMC Psychiatry 25, 499 (2025). https://doi.org/10.1186/s12888-025-06897-y

Image Credits: AI Generated

DOI: https://doi.org/10.1186/s12888-025-06897-y