Successful Therapy Requires Bond with Therapist, Makes Life More Meaningful

Posted On Nov 25, 2022

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.