Successful Therapy Requires Bond with Therapist, Makes Life More Meaningful

Clients finding more meaning in life is an important way that the therapeutic alliance effectively decreases psychological distress.

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Recent research published in Person-Centered & Experiential Psychotherapies finds that meaning in life is an essential element of the therapeutic relationship that contributes to effective psychotherapy. However, meaning in life has not been a central focus in many forms of psychotherapy, even within person-centered and experiential therapy traditions that emphasize the therapeutic relationship.

The Belgian researchers, led by Charlotte Fortems, considered how a strong bond between therapist and client can provide clients the experience of connection to encourage meaning-making processes, such as meaning in life, that lead to therapeutic change.

In talking about the various aspects of meaning in life, the researchers write:

“[Most scholars] distinguish at least three components in the experience of meaning in life. The first one is purpose, which means that one has valuable goals in the future and that one engages in fulfilling these goals. The second one is coherence. A coherent life is one that makes sense, where one can see patterns in the world and the world is predictable. The third component is significance, also referred to as mattering. This indicates the feeling that one’s life matters, that it is worth living, and that it has significance beyond this moment. In addition to these three components…the importance of some form of connection to experiencing meaning in life. This might be connection to past and future, to tradition or history, to religion or spirituality, or to others.”

The search for meaning in life is central to existentialism and existential therapies, where clients and therapists work to find meaning in clients’ unique experiences and suffering and connect these to shared experiences.

Even in other therapies, engaging in meaning-making processes of panic symptoms can help clients re-interpret panic experiences that lead to positive therapy outcomes. Meaning in life has been positively associated with well-being and cognitive functioning and negatively associated with elements of psychopathology, including “self-injury, somatic complaints, social dysfunction, addiction, and drug use, aggression, and apathy… anxiety… depression… suicidal ideation and suicide attempts.”

It’s been well-established that the working alliance between client and therapist (goal agreement, task collaboration, therapeutic bond) has repeatedly demonstrated a positive association with psychotherapy outcomes. Whether through therapists’ empathy, or other therapist effects that lead to better alliances, the researchers mentioned that good therapeutic relationships provide a safe relational context for patients to receive support and guidance to engage in core meaning-making processes. While this has been theorized, the connection between therapeutic alliance and outcome mediated through meaning in life has not yet been scientifically tested.

Different humanistic psychotherapy traditions focus on different meaning-making processes and aspects of meaning in life. Considering Carl Rogers’ writings, the researchers identified four therapeutic approaches that foster meaning in life in person-centered therapy.

These include: (1) a genuine, accepting, and empathic therapeutic relationship; (2) micro-meaning-making of one’s inner experiences, attaching personal meanings to them and articulating them to be more authentic; (3) meso-meaning-making of one’s self-concept and worldviews to a more flexible, coherent, and purposeful sense of self; and (4) macro-meaning-making that focuses on clients’ being or life itself on an individual, interpersonal, and universal level. Across these meaning-making processes, the therapeutic bond is thought to provide a corrective experience where clients feel cared for, and their existence is validated.

“With this study, we aimed to gain a deeper understanding of how meaning in life, the therapeutic relationship, and therapy outcome might be connected in person-centered psychotherapies,” the authors write.
“We assumed that experiencing meaning in life would be an underlying dynamic in the relationship between therapeutic relationship and therapy outcome. In addition to investigating the overall therapeutic relationship, we also zoomed in on the three sub-aspects of the relationship, namely the therapeutic bond, task collaboration, and goal agreement… We hypothesized the different aspects of the therapeutic relationship to be significantly related to the presence of meaning in life, which in turn we expected to be associated with lower levels of distress (therapy outcome).”

In a Belgian naturalistic study of person-centered and experiential psychotherapy, 96 clients from 23 different therapists in various outpatient settings who completed at least five sessions with a therapist (average of 13 sessions) were included. Data collected by the researchers included clients’ self-reports on the: Meaning in Life Questionnaire (MLQ) to assess the presence of meaning in life; the Working Alliance Inventory (WAI) to assess therapeutic alliance; and the Outcome Questionnaire (OQ-45.2) to assess their own psychological distress globally with three subscales – symptom distress, interpersonal relations, social roles.

Using multilevel structural equation modeling, the researchers simultaneously tested the relationship between this model’s variables (alliance, meaning in life, and distress). Specifically, they tested whether therapeutic alliance predicted a higher presence of meaning in life and better therapy outcomes. They then looked at each aspect of the alliance (goal agreement, task collaboration, therapeutic bond) to see if they individually predicted either presence of meaning in life and distress.

The researchers found that the “therapeutic alliance is significantly positively correlated with meaning in life and significantly negatively correlated with therapy outcome.”
In addition, they report:
“We found a moderate negative correlation between the presence of meaning in life and distress (therapy outcome). Bond correlated with meaning in life and with distress (therapy outcome). Goal agreement significantly correlated with therapy outcome but not with meaning. The task collaboration aspect did not significantly correlate with meaning, nor with therapy outcome.”

The researchers also found that the presence of meaning in life fully mediated the relation between the total therapeutic alliance and therapy outcome. Since the therapeutic bond was the only significant aspect of alliance that was shown to be associated with meaning in life and outcome, researchers tested and confirmed that meaning in life mediated the relation between bond and distress and demonstrated a full mediation effect.

Since this study was cross-sectional rather than longitudinal, no causal mechanism can be determined. Rather than a one-directional mediation process, the researchers posited possible bidirectional relations between alliance and meaning in life, as well as with meaning in life and outcome. They also noted that because of its dyadic nature, a more accurate working alliance measurement should include therapists’ ratings.

Notably, the researchers examined whether clients’ gender or age may have influenced therapy outcomes (it did not) but neglected to collect information about the race, ethnicity, or sexual orientation of clients and therapists. This is relevant because power dynamics within the therapeutic relationship include these differences between client and therapist that, if not addressed, can lead to less effective therapy.

Meaning-making processes should be central to person-centered and experiential therapies and should be given more attention in clinical practice and theory. If we want to improve clients’ presence of meaning in life through treatments that lead to psychological well-being, this research demonstrates that therapists should be focused on the quality of their bond with their clients.

“However, based on our study, we cannot differentiate between the relative importance of specific micro-, meso-, or macro-dimensional meaning processes. Nonetheless, the fact that it is especially the bond aspect of the alliance that correlates with meaning in life, could suggest that meaning-making processes that help people to establish a different kind of connection, and to make sense of this connection, might lead to better outcomes. This supports not only the idea that connection is at the core of the experience of meaning in life, but also reveals that meaning in life, as it might be fostered in person-centered and experiential therapies, runs through connection.”

The researchers conceptualize that meaning in therapy is facilitated through a deeper connection with the client’s self, which is facilitated by a genuine, empathic connection with the therapist. Through feeling therapists’ existential empathy (the capacity of the therapist to resonate with the client’s ultimate concerns), clients can engage in self-exploration that allows for the symbolization of this experience, which facilitates the will to live and act towards self-congruence.

However, they propose future research exploring the causal link between alliance, meaning in life, and therapy outcome, such as mixed method case studies focusing on meaning-making processes in person-centered therapies.

 

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Fortems, C., Dezutter, J., Dewitte, L., & Vanhooren, S. (2022). The mediating role of meaning in life between the therapeutic relationship and therapy outcome in person-centered and experiential psychotherapies. Person-Centered & Experiential Psychotherapies, 21(1), 73–93. https://doi.org/10.1080/14779757.2021.1938184 (Link)

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Javier Rizo
Javier Rizo is a graduate student-trainee in the Clinical Psychology PhD program at UMass Boston. His current area of research is qualitative psychotherapy research, with a primary interest in promoting human rights-based framework in psychiatry through the education and training of mental health clinicians and researchers. Javier is committed to building a social justice psychiatry, working to incorporate humanistic, interdisciplinary and critical perspectives on mental health, with particular interest in the role of healers and common factors models of psychotherapy.

25 COMMENTS

  1. Nonsense, since heaven forbid a client/patient tells the “therapist” things like how life is awful and how life is not worth living then after further honesty by the client/therapist he/she will end up in a psych ward since they have a legal obligation to protect their license and for liability purposes.

    • “A strong relationship makes life more meaningful – No shit Sherlock!”

      Thank you, John Hoggett. I couldn’t have said it better myself.

      This article provides ample evidence of psychologists’ extensive use of and dependence on intellectualized gobbledygook, or psychobabble, or, as I like to call it, intellectual masterbation. It demonstrates how the psychological field is as tedious and as meaningless as the psychiatric field.

      What I find most objectionable (as well as amusingly asinine) is the extent to which this bumbling crowd of pseudo-intellectual, pseudo-compassionate, and emotionally-grifting “psy-professionals” fail to see the irony in what they’re doing, which is using other people’s “meaning making” for their own personal money-making – and that, for me, makes the whole process of “psychotherapy” utterly meaningless—and completely parasitic, (on the psychologists’ part).

      This article is a sad commentary on just how much people have been brainwashed into believing that they need to pay some idiot “professional” to find meaning in their lives – which for me, is EXACTLY what can make life seem hopelessly meaningless.

      And FYI: I’ve found a heck of a lot of “meaning” in NOT depending on or pouring money into the pockets of some impossibly smug and incredibly stupid “psy-professional” —

      • Only an idiot needs a “study” to find out if people do better when they like the people they’re dealing with.

        So what does that make most psy-professionals? A bunch of over educated, pretentious fools who can’t see themselves clearly, much less anyone else.

        And don’t make me gag using that infuriatingly stupid term, “therapeutic bond”. For crying out loud, just call it what it is: INFANTILIZATION —

      • And FYI: I’ve found a heck of a lot of “meaning” in NOT depending on or pouring money into the pockets of some impossibly smug, incredibly stupid, AND DEFINITELY OVERPRICED psych “professional” —

        People need to know there’s better, safer, and cheaper ways to “make meaning” than spending their time and money inflating the ego and pocketbook of some nitwit “psychotherapist”. Read a good book, watch a good movie, take a walk, call a friend, help someone out, do ANYTHING but make your disappointments and dissatisfactions some nitwit “professional’s” payday. And who knows? You just might find the most valuable bond is the one you cultivate WITH YOURSELF.

        And btw, what’s the most disconnected, disconnecting and disgusting manifestation of capitalism? It’s the psychological and psychiatric fields, UNQUESTIONABLY —

  2. When therapists try to impose their scientifically “invalid,” “life long incurable genetic” (none of which is true), DSM stigmatizations on a person – who is not brainwashed to believe in the DSM. It distracts from, rather than helping one, find meaning in their distress and/or life.

      • It seems near impossible to get reliable data on how widespread the phenomena is. Among the issues include – five years ago I would’ve said I “believed in” the construction of mental illness my therapist was attempting to “cure”.

        At present, I now view those interactions as unintentionally abusive and traumatizing. Not out of direct malice. But out of buy-in to a core theory of mental health that is staggeringly flawed.

        Five years ago, that opinion wouldn’t show up in any survey I took, because I was never exposed to alternative viewpoints and had to spent years of work critically questioning existing theory, often while under extreme antagonism, to come to my own authentic conclusions.

  3. The really wonderful part of that alliance is when the patient’s sense of self has crumbled under the weight of psychiatric oppression to the point that the therapist can say anything and the patient stops trying to even defend herself. Yes, I’m a non-compliant unlikeable time suck who really gets to people and only goes in circles and has very poor coping skills and poor judgement and will probably wind up completely alone. Yes, I will take the high dose antipsychotics exactly as prescribed and yes I’ll check myself into the psych ward for an ECT consultation even though ECT is the thing that disabled me. Yes, I’ll use my crisis survival kit and stick my face in ice water and not bother anyone or be willful. This patient is well on her way to recovery.

    • And, yes, Dr, at some point I AM going to need a complete personality makeover and I am so sorry that I haven’t responded appropriately to decades of drugging, ECT, and now TMS and I’m a huge disappointment who also needs to take more care with my appearance and, no, lithium does not cause weight gain. How are you so right about everything while I am just wrong in every conceivable way. My friends and family see it, too. They’re on your side. They notice that every intervention I’ve ever had has gone sour, that I don’t respond to massive amounts of help, and they say they care but that they just don’t know how to help me out of the hole I’ve dug for myself and wonder aloud if I’ve “hit my rock bottom.”

      • Thanks, Kate, so much for your comment and your perspective. Yes, the therapists who DON’T really get how much harm they do with their “I have the answers” and “Come, ally with me” attitudes need to hear what you have written. Most, of course, probably won’t. Still, your perspective (same as mine, from a few years ago) very definitely needs to be heard

        I am out of the system — 8 years out — and I’m doing OK. But, of course, my family and other people (I had lost any friends I was somewhat able to make) saw me like yours apparently do you. It so really, really sucks. The “profession” really needs to recognize the harm they are doing to some people. Yes, perhaps, some people do well with strong bond with a therapist and that helps them find meaning. But for those of us for whom that was NOT true — and the fact that our experience is invalidated across the board — it is really awful.

        OK, for me, the last therapist DID retraumatize me, and that brought up the original trauma that I had dissociated from and which I had NOT been able to get in touch with despite my best efforts. Her one-sided termination triggered the rejection and abandonment feelings/experiences from my early life that my personality was built around defending. Fortunately I had a good support group who, 8 years down the road now, have NOT abandoned and rejected me and I do have, and have learned to have, a strong bond with them. Which has helped me in my relationships with other people, too, in ways that I find hard to describe. Which I could NOT have known 8-10 years ago.

        And, yes, now I am now in the midst of personality makeover. That is, my personality seems to be remaking itself. So, I think I’m very lucky. But I am already 75 and had been in and out of therapy for 50 years before that, so. . .

        Best of luck to you, Kate! Your “bad attitude” toward therapy is yourself knowing/recognizing their . . . stuff. . . for what it is. A good start toward the makeover, maybe.

        • Thank you, Mella! I’m so glad to hear that you have found a true support system, although I am sorry for what you experienced in therapy. I think it should be more recognized how easily and how often people get harmed/re-traumatized in therapy; often the therapist doesn’t want to acknowledge the harm because it interferes with their view of themselves as providing safe and effective treatment.
          I definitely don’t want to be stuck here for the rest of my life. I do want a “different personality” — except that now I know that I am the only one who can direct such a change — definitely not a psychiatrist who sold me on TMS in the first 15 minute appointment and who used that statement as a parting shot because I refused to say what he wanted to hear. (This psychiatrist knew almost nothing about me. The only aspect of my life he showed curiosity about, in our few brief interactions, was my health insurance coverage.)

  4. William Griffith Wilson (1895-1971)

    Prior to founding AA, Wilson was an extreme alcoholic, and was admitted to the hospital several times for it. He wrote of it like this:
    “My depression deepened unbearably and finally it seemed to me as though I were at the bottom of the pit. I still gagged badly on the notion of a Power greater than myself, but finally, just for the moment, the last vestige of my proud obstinacy was crushed. All at once I found myself crying out, “If there is a God, let Him show Himself! I am ready to do anything, anything!”

    Suddenly the room lit up with a great white light. I was caught up into an ecstasy which there are no words to describe. It seemed to me, in the mind’s eye, that I was on a mountain and that a wind not of air but of spirit was blowing. And then it burst upon me that I was a free man. Slowly the ecstasy subsided. I lay on the bed, but now for a time I was in another world, a new world of consciousness. All about me and through me there was a wonderful feeling of Presence, and I thought to myself, “So this is the God of the preachers!” A great peace stole over me and I thought, “No matter how wrong things seem to be, they are still all right. Things are all right with God and His world.”

    (Source: Alcoholics Anonymous World Services. 1957. Alcoholics Anonymous comes of age: a brief history. New York: Alcoholics Anonymous World Services, 64.)

    This experience had a tremendous influence on Wilson. After a seven day stay in the hospital he never drank again for the remainder of his life. He and Dr. Bob Smith, another hopeless alcoholic, began one of the greatest spiritual movements in the world. It sprang up mostly in the homes of drunks and in the basements of churches without leaders or finances, without promotions or earthy structure and guidance. Wouldn’t you know, God was found in places where no one was looking for him.

    He said his “awakening” was available to all.

  5. From their total brokenness and utter despair Bill Wilson and Dr. Bob Smith created a movement that has saved millions of people. Their meaning in life derived from helping others. When they faced difficult trials, they found that reaching out to others who were struggling, always lifted them out of self-pity and a lack of purpose and meaning in their lives.

  6. The entire notion of psychotherapy is predicated on an assumption that the individual is empowered to self-effect change regarding their emotional distress.

    It is asinine that “therapy outcome” as a concept fails to account for, reference, and acknowledge external psychosocial factors, to the point of outright distorting objectively correct views of circumstance.

    Even when it does correctly acknowledge external circumstance, it often then tries to normalize and control suffering, rather than diagnosis some portion of emotional/cognitive pain as impossible to remove until external circumstance is changed (which often the individual has little to no individual power to do).

    • Max McKay says, “It is asinine that “therapy outcome” as a concept fails to account for, reference, and acknowledge external psychosocial factors, to the point of outright distorting objectively correct views of circumstance.”

      Very true. But I think it’s asinine that people get talked into, or talk themselves into, “going to therapy” in the first place, which imo is a completely distorted way of relating to another human being.

      “Even when it does correctly acknowledge external circumstance, it often then tries to normalize and control suffering, rather than diagnose some portion of emotional/cognitive pain as impossible to remove until external circumstance is changed (which often the individual has little to no individual power to do.”

      Yes, and imo this points to the ultimate uselessness and futility of “psychotherapy” in most circumstances. But, fortunately, “going to therapy” is one external circumstance most adults have the power to remove. But, unfortunately, the effects of the one-sided, power-imbalanced circumstance called “psychotherapy” often leaves “clients” subjectively, objectively, and monetarily scarred, FOR LIFE —

  7. I would love to see a research about when clients do not, refuse or unable to connect with therapist and how this may play out without disparaging clients.

    If one had trauma from childhood where they never experienced trust and continued in life the same way. Why would any expectation be they need to bond with a relatively stranger to understand themselves or recover?

    No adult should trust anyone they do not know to some extent. Most people trust doctors because it is one time off and if it is serious diagnosis like cancer, most people have tests or second opinion or a circle of care…
    But when it comes to dissecting one’s most sacred organ (brain/mind), it is taken so superficially.

    The bond that most therapists are confusing as attached to them is, in fact, a budding bond of one’s self to their body but this is removed aggressively to say no the client is bonding with the therapist. The reality is the client is actually bonding their fragmentation and are becoming more integrated. The importance of the therapist is gaslighting. Every experience should be focused on the client as if the therapist is an instrument or a tool not a flesh like a mother or father. Yes it is that mechanical because it is transactional and paid service not so different than your surgeon. This does not mean dehumanizing the therapist. It means the focus, the attention, the experience is focused on the client and the therapist person is a peripheral force guiding the experience to some extent (there is a limit of knowledge here).

    If client says to the therapist I love you. Therapist job is to interject the projection back to the client not to take it as face value and run with it as a strong bond with the therapist. it can be both but a priviledged is given to the client’s benefit over the therapist’s triumph of success!

    A successful therapy, one should not even remember the therapist. Remembering the therapist is a sign of certain harm because what supposed to be about the client is taken as the therapist. The client has internalized the therapist which is no different than internalizing an ex whom you are no longer with. As in budda practice, the adult’s maturity is to let go of internalizations as we mature to live in the moment, in the present to experience life as if it is now. Trauma is internalizing those who harmed the clients and no replacement is needed. Thank you

  8. I am thinking, maybe this article suggests that in a clinical relationship, a therapist and their client can create meaning together? This might be someone’s fantasy.

    In a less than totally imperfect world, psychotherapy could be a trustful relationship. Commenters on this article show that, for them, psychotherapy cannot be a ‘safe container’ — for anything.

    To me, this goes to show how coercion –explicit or implied– in the healing arts causes real and lasting harm.

    The “higher power” thinking of AA has helped many, but may not be for everyone.

    I encourage attention to Marshall Rosenberg’s book, “Nonviolent Communication.” Even if full use of Marshall’s offerings is impossible for some (such as me), his work can be used to establish a template for self-empathy that may bring liberation!!

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