Meaning and the therapeutic relationship Prof. dr. Siebrecht Vanhooren

Meaning and the therapeutic relationship There is a robust relationship between meaning in life and psychological health and well-being (Steger, 2012) The therapeutic relationship is a pre-condition of the construction and experience of new meaning, and therapy is a meaning-making process as such (Angus & Greenberg, 2011) The therapeutic relationship – and especially empathy – is the most robust predictor of psychotherapy outcome (Norcross & Lambert, 2018; Wampold, 2015). Enough reasons to have a look how meaning, the therapeutic relationship and outcome are related

Three studies

Clients in this study Therapists: person-centered & experiential psychotherapists in training (Postgraduate program, KU Leuven, Belgium) Naturalistic setting: outpatients (private practices, outpatient clinics, mental health centers), with depression, anxiety, personality disorders

Measures Meaning in life Questionnaire (MLQ; Steger et al. 2006) Presence of meaning Search for meaning Outcome Questionnaire 45 (OQ-45) Working alliance inventory (WAI; Horvath & Greenberg, 1982; Dutch translation Werk alliantie vragenlijst, WAV-12 (Stinckens, Ulburghs, & Claes, 2009) Bond Goal Task

Studies Study 1: meaning at the start of psychotherapy. N=145 Golovchanova, Dezutter, & Vanhooren; submitted Study 2: meaning in life as a mediator between the therapeutic relationship N=96 Fortems, 2019 Study 3: Four mixed-method case studies Vandebeek, 2019

Study 1: Meaning profiles at the start of therapy Golovchanova, Dezutter, & Vanhooren; Submitted

Meaning and the therapeutic relationship at the start of psychotherapy Outpatient Clients (N=145) (Golovchanova, Dezutter, & Vanhooren; submitted)   Therapy clients Students Adults Current study Hill et al., 2017 Steger et al., 2006 Park et al., 2010 Mean SD Presence of Meaning 20.84 6.30 20.28 3.90 24.80 6.50 25.10 7.80 Search for Meaning 23.04 6.51 25.58 4.42 24.50 8.20 24.10 8.30 Table 1. Comparison of presence of meaning and search for meaning average scores in various populations

Preliminary analyses Correlations between age and study variables 1 2   1 2 3 4 5 6 7 8 9 10 1. Age 2.Presence of Meaning .058 3.Search for Meaning -.137 -.407** 4.Task -.094 .295** -.043 5.Goal -.085 .245** -.105 .732** 6.Bond -.204* .255** -.083 .576** .586** 7.Total Symptomatology .008 -.607** .358** -.059 -.093 -.120 8.Symptom Distress -.064 -.583** .327** -.032 -.049 -.035 .941** 9.Interpersonal Relations .163 -.353** .271** -.048 -.148 -.242** .662** .434** 10.Social Role .032 -.465** .247** -.104 -.079 -.128 .725** .563** .379** Correlations between age and study variables Note: Listwise N=114 *. Correlation is significant at the 0.05 level (2-tailed). **. Correlation is significant at the 0.01 level (2-tailed).

Meaning profiles at the start of psychotherapy Clients (N=145) (Golovchanova, Dezutter, & Vanhooren; submitted) Differences between profiles on distress, not on appraisal of the therapeutic relationship

Study 2: Meaning in life mediates between therapeutic relationship and distress Fortems, 2019

Session 5 (N=96) (Fortems, 2019) Table 1 Descriptive statistics of the study variables (n = 96)   Mean SD Minimum Maximum Therapeutic alliance (WAV-12) 44.53 7.401 24 60 Presence of meaning (MLQ-P) 20.87 6.706 5 35 Psychological distress (OQ-45) 74.04 22.369 12 140 Total OQ score of 55 or higher is considered clinically significant (de Jong et al., 2007).

Session 5 (N= 96) (Fortems, 2019) Table 2 Pearson correlations among age, therapeutic alliance, meaning in life and psychological distress   Age Therapeutic alliance Meaning in life Psychological distress — Therapeutic alliance -.084 .063 .234* Psychological distress -.016 -.251* -.371** * Correlation is significant at the .05 level (2-tailed). ** Correlation is significant at the .01 level (2-tailed).

Session 5 (N= 96) (Fortems, 2019)

Mediation analysis (therapeutic alliance)

Mediation analysis (bond)

Study 3: Mixed-method case studies Vandebeek, 2019

Client ‘Charlotte’ (Vandebeek, 2019) 47 years, married with children 23 sessions Eating disorder, depression Measures MLQ OQ-45 WAI (WAV-12) HAT (Helpful Aspects in Therapy: SBL) Significant changes: Leeds Relyable Change Index (RCI)

Presence & search for meaning

Presence of meaning

Distress

Therapeutic relationship (bond)

Therapeutic relationship: bond and goals

So… Meaning in life significantly drops Therapeutic bond significantly increases Negative relationship therapeutic bond and presence of meaning!?! Level of distress doesn’t change

Content therapy Charlotte reports small new insights in the first sessions Session 5: insight in the causes of my eating disorder Session 6: about meaning in life, but arrives at a deep fear (angst) Session 7: About angst, freedom, and responibility Session 9 & 10: experiencing a deep need to come to herself

Presence & search for meaning

Content Session 12: meaning in life Session 13: ‘existential depression’ as the real cause of her unhappiness Session 14: exploring a pinched feeling inside (felt sense) Session 15: new insights and seeing new connections, and as a result feeling the neccessity to make some hard decisions. Experiencing anger because she does not feel seen at home and at work.

Presence & search for meaning

Content therapy Sessions 16-18: more emotional awareness; allowing feelings as important steps (It is confronting that I een cannot allow positive feelings) Session 19: quit job Session 21: the need to say to her partner was is important to her. Unmet needs in the relationship. The emotional burden of taking care of the children. Further evolution…?

Meting van  Session 2 4 6 10 12 14 18 20 22 Therapist involvement, feeling supported & confirmed 5 7 8 Openness & genuiness Empathy & understanding Exploration Confrontation, feedback & advise Positive feelings & experience of progress Insights & new perspectives Relationship with the therapist I belief that my problems will be changed through therapy I expect that I will feel better through therapy I hope that the therapy will be succesful Cijfermatige feedback van Charlotte uit de SBL+ Opmerking: scoring tussen 0 en 10

Early conclusions? Hm… A lot of questions

Concluding questions There seems to be a relationship between the therapeutic relationship and meaning in life. However… It is an intricate one The therapeutic relationship can be A pre-condition for change in meaning (Angus & Greenberg, 2011; Rogers, 1957, 1980)

The therapeutic relationship (bond) can be… A pre-condition for change in meaning (Angus & Greenberg, 2011; Rogers, 1957, 1980) Safe space to explore issues Can initially cause a loss of meaning And become fully aware of a lack of meaning

The therapeutic relationship (bond) can be… A pre-condition for change in meaning (Angus & Greenberg, 2011; Rogers, 1957, 1980) A place where skills are learned in order to create/find meaning, make sense of one’s life Empathy and its influence on emotion-regulation and attachment A place to find/create meaning and make sense Empathy, reflection, integration New meaning

The therapeutic relationship (bond) can be… An interpersonal connecting place where meaning in life itself is sensed The clients matters to the therapist The experience of therapy makes the client’s life feel more meaningful The client feels hope through the therapeutic relationship to develop deeper relationships with other people as well

The therapeutic relationship (bond) can be… Facilitated by the initial meaning in life of the client The client’s general sense of connection and ease to make connection

Future studies should focus on… The change in meaning in life in long term therapies The interplay between Meaning, Relationship, and Outcome are part of a proces of change… The role of perceived empathy in meaning-making, depth of experiencing, emotion-regulation Use different measures for meaning MLQ: too unidimensional? Sources of meaning Aspects of meaning

Prof. dr. Siebrecht Vanhooren KU Leuven Faculty of Psychology and Educational Sciences Research group Clinical Psychology Tiensestraat 102 3000 Leuven Belgium siebrecht.vanhooren@kuleuven.be