Joel Vos* and Mick Cooper, Dept. of Psychology, University of Roehampton, United Kingdom
Clara E. Hill, Dept. of Psychology, University of Maryland, United States
Robert A. Neimeyer, Dept. of Psychology, University of Memphis, United States
Kirk J. Schneider, Saybrook University & Teachers College, Columbia University, United States
Paul T. P. Wong, Trent University, Trinity Western University & Saybrook University, Canada
*Corresponding author: Dr Joel Vos (Joel.Vos@roehampton.ac.uk)
What is meaningful in life? This is a question that many individuals ask at least once in their lifetime. Many researchers have also asked this question, and a large body of literature seems to answer what meaning in life is in theoretical and academic terms. But what is the meaning of meaning in clinical practice? That is: what is the role of meaning in psychotherapy, recovery, and positive mental health? And how could meaning in life be addressed in practices: what clinical competencies are needed? To answer these and other questions, a broad panel of researchers and practitioners met each other at the world conference of the International Network for Personal Meaning (INPM) in Toronto in July 2016. A passionate debate followed, particularly on the question of the meaning of meaning in clinical practice. In this article, five panel members elaborate their perspective on these two questions: Mick Cooper, Clara Hill, Robert Neimeyer, Kirk Schneider, and Paul Wong. At the end of the article, the moderator Joel Vos summarises their differences and agreements, and suggests a pluralistic multi-dimensional perspective on meaning for practitioners. Despite some fundamental differences, the authors report many similar perspectives on the meaning of meaning in clinical practice and on clinical competencies. This debate could be used as an example of how practitioners could also converse with their clients; the process of exploring the question, “What does meaning mean to you here and now, in our therapy room?” could be meaningful in itself.
There is possibly nothing as unique as meaning. What one person experiences as meaningful may lack meaning for another. Individuals may differ in the process of how they develop their unique sense of meaning. How practitioners can help clients can also be different for different individuals in different situations (cf. Vos, 2014, 2016a). Despite this uniqueness, many researchers have tried to identify common themes amongst individuals, and a large body of literature discusses what meaning in life is in theoretical and academic terms (e.g., Batthyány & Russo-Netzer, 2014; Wong, 2012).
Similarly, different meaning-centered researchers and practitioners have different perspectives on the meaning of meaning in psychotherapy, recovery, and positive mental health. They also offer a wide-ranging array of clinical competencies. For example, systematic literature reviews have identified over 30 different schools of meaning-centered practices, and over 39 unique clinical competencies emphasized by one or more of these schools (Vos, 2016b). This wide diversity has been explained as the consequence of the unique nature of meaning, and the “gurufication” and rejection of standardisation in the field of meaning (Vos, 2016a).
Researchers and practitioners showed a similar pluralism during a panel discussion at the world conference of the International Network for Personal Meaning (INPM) in Toronto in July 2016. A passionate debate followed, particularly on the question of the meaning of meaning in clinical practice. In this article, five panel members elaborate their perspective on two questions: what role does meaning have in clinical practice, and which clinical competencies are required? At the end of the article, the moderator Joel Vos summarises their differences and agreements, and suggests a pluralistic multi-dimensional perspective on meaning for practitioners.
Mick Cooper: A Pluralistic Perspective on the Meaning of Meaning
What is the meaning of meaning in the context of clinical practice, and how should therapists work with it? From a “pluralistic” therapeutic standpoint (Cooper & Dryden, 2016; Cooper & McLeod, 2011), meaning may have a multiplicity of meanings in therapy, and may be effectively addressed in a variety of ways.
A first point of diversity may be the significance of meaning to individual clients. For some clients, as the research shows, issues of meaning may be of paramount importance (Vos, 2016a). However, for others, it may only be a subsidiary concern, or not be salient at all. We can also differentiate between the significance of this issue at the explicit level and at the implicit level. For instance, as proposed by Frankl (1986), a client may come to therapy with alcohol addiction, only later to find that the underlying issue is a profound sense of existential vacuum. On the other hand, a client who is explicitly concerned about meaninglessness in his or her life may subsequently find that his or her real fear is of death or isolation (Yalom, 1980). Closely related to this, there may be differences between clients who have a need to find meaning and purpose in their lives, and those who need to come to terms with a sense of meaninglessness. We can also distinguish concerns about meaning from concern about purpose—the latter having a more future-oriented and motivational component. A client with the former concerns may be asking “What is the meaning and significance of my life? Why am I here? What is the reason for it?” By contrast, a client with the latter concerns may be asking, “What do I want to achieve in my lifetime? What are my medium- and long-term goals?”
Addressing each of these meanings of meaning may require a different—albeit overlapping—set of clinical competences. However, given the potential for issues of meaning to be implicit as well as explicit, it is probably important that therapists of all orientations have some basic skills in working with issues of meaning and purposes. With respect to the former, perhaps the most basic skill is the ability to recognise when clients have underlying concerns about the meaning of their lives, and the capacity to respect this as an issue in its own right. This means being able to engage with this concern in a respectful way, rather than pathologizing it or reducing it to some other theoretical construct, such as irrational thinking or transference. Here, an important meta-competence may be the ability to acknowledge and validate clients’ feelings of meaninglessness while, at the same time, helping clients to explore and discover new meanings.
With respect to issues of purpose, a useful contextual competence may be the ability to help clients set—and work towards—goals in therapy. Although not all clients find this helpful, our research suggests that many do find it a valuable process (Cooper et al., 2015). Helping clients to think about their life goals, more broadly, may also be a valuable competence; along with the capacity to attune to, and reflect back, the future-oriented elements of a client’s narrative (Bohart, 2001). Having the skills to then help clients work towards their goals, developing plans and “implementation intentions” (Gollwitzer, 1999), may also be a valuable competence. This may draw on knowledges and practices from a variety of orientations. For instance, psychodynamic strategies, such as developing insights, may help clients identify their blocks to achieving their goals; while behavioural strategies, such as role plays, may help them rehearse methods for overcoming them.
From a pluralistic standpoint, however, perhaps the most important meta-competence is the ability to work collaboratively with clients to help them identify the ways of working—or not working—with meaning that are most suited to their individual wants and needs.
Clara Hill: An Integrated Approach to Working with Meaning in Life in Psychotherapy
Meaning in life (MIL), which I have defined as: a global intuitive sense of meaning, which may be partially manifested in a felt sense of meaning, the feeling that one matters and is significant, one has purpose or goals, and one’s life is coherent or makes sense (Hill, in press), seems to be an important component of well-being and identity. For example, research has shown that people who rate themselves as having low MIL are depressed and neurotic, whereas people who rate themselves as having high MIL have high life satisfaction, positive emotions, and well-being (Steger, Frazier, Oishi, & Kaler, 2006).
Given this definition and these data, it makes sense that, although it may not always be an explicit focus, MIL is at the heart of all psychotherapy. We try to help clients make sense out of their lives, feel that they matter, have a more coherent narrative, and sometimes work on their goals and purposes.
My approach to working with MIL in psychotherapy is based on the foundation of therapist self-awareness (therapists need to have reflected about their own MIL to feel comfortable helping client reflect about MIL), conceptualization (so that therapists have an understanding of how MIL figures into client dynamics), and a good therapeutic relationship (so that therapists provide a safe place for client disclosure). Then, once an MIL concern is identified, I suggest a flexible three-stage model of exploration, insight, and action. First, the therapist helps the client explore MIL concerns, focusing on related thoughts and feelings. The therapist then facilitates the discovery of insight so that the client gains a new understanding and sense of coherence. Finally, the therapist works with the client to determine new and more appropriate actions to gain MIL.
In terms of specific interventions to recommend, I have found three highly-rated interventions suggested by experienced therapists for working with MIL (Hill, in press). These include offering support; helping clients examine thoughts, feelings, and behaviors to discover hopes and goals; and facilitating exploration. Insight and action skills varied more across clients. These results provide support for the importance of the exploration stage before moving to other stages.
In addition, MIL work varies across client presenting problems, stressing the need for therapists to be responsive to individual clients. Although a few clients explicitly state MIL as a concern, our research (Hill, in press) suggests that clients more often talk about other concerns that have MIL as an underling component. Hence, physical health, career, interpersonal problems, transitions, trauma, deaths, and depression all can be explored for concerns related to MIL, with different interventions recommended for each concern (see Hill, in press).
In conclusion, I suggest that therapists reflect about their own MIL concerns to be humble and prepared for working with clients about MIL; listen attentively for hints of MIL concerns with their clients; then allow clients to explore these concerns in a safe, trusting setting; and finally facilitate clients in gaining insight and deliberating about action in relation to these MIL concerns. Encouraging clients to engage in specific exercises related to MIL could also be helpful for raising awareness. See Hill (in press) for more details about this approach and related research findings.
Robert A. Neimeyer: Intervening in Meaning
Viewed through a narrative constructivist lens, psychotherapy is a process of intervening in meaning. As inveterate meaning-makers, human beings punctuate the continual process of living by discerning recurrent themes in experience, and use these to orient to the patterns and consistencies of the natural and social worlds (Kelly, 1955). Mostly, this inherent and inescapable organization of living proceeds at the level tacit knowledge, skilled performance, spontaneous interaction and communal ritual, which rarely require conscious reflection and mediation (Polanyi, 1958). However, when the anticipation of this implicit order and sense-making is invalidated, and the narrative coherence of people’s life stories is profoundly disrupted—as through personal failure, relational betrayal or profound loss—they are commonly cast into a search for meaning to accommodate what has transpired, and to reconstruct what to make of their lives in its aftermath. Psychotherapy as a profession stands ready to partner in this effort.
One specific illustration of this process arises in the context of bereavement, the loss of a significant attachment figure through death. With the substantial disruption of their previous self-narratives this entails, mourners commonly strive to reaffirm or reconstruct a world of meaning that is challenged by the loss (Neimeyer, 2006), and they do so not only in the intimate recesses of their private thoughts and feelings, but also in a social world populated by others, some of whom are mourning the same death. Accordingly, grieving can be viewed as a situated, interpretive and communicative activity, not merely an intrapsychic state (Neimeyer, Klass, & Dennis, 2014). By “situated,” we mean to emphasize that mourning is a function of a given social, historical and cultural context; by “interpretive,” we draw attention to the meaning-making processes it entails; by “communicative,” we stress the essential embeddedness of such processes in written, spoken, and nonverbally performed exchanges with others; and by “activity,” we underscore that grieving and mourning are active verbs, not merely states to be endured. Thus, “grief work,” in this view, involves a pursuit of new comprehensibility and significance in a life made strange by loss. This unfolds both at the level of trying to process or make sense of the “event story” of the death itself and its implications for our ongoing lives, and at the level of attempting to access and reconstruct a connection to the “back story” of our life with the deceased, to restore a modicum of narrative consistency and attachment security (Neimeyer & Thompson, 2014). A great deal of quantitative and qualitative research over the last ten years has lent support to this meaning-making model, as an anguished search for meaning consistently has been linked to complicated and prolonged courses of grieving, whereas a capacity to make sense of the loss and perhaps even find benefit or life lessons in it has been linked to more adaptive outcomes, including longer term positive emotional states and posttraumatic growth (Neimeyer, 2016a).
What clinical competencies are needed to facilitate this more favorable outcome in the context of meaning-oriented psychotherapy? These can be summarized by the triad of presence, process and procedure (Neimeyer, 2009). At a foundational level, as with other existential and humanistic psychotherapies, therapist presence in the form of authentic personal engagement with the client, in a way that is undistracted by issues of “case conceptualization” or “treatment plans,” provides the essential container or “holding environment” for the work. Beyond this, attunement to the process of therapy, in the form of nuanced attention to the client’s emotional need and readiness to take a further step in self-exploration or change, provides the orientation required in each conversational turn to contact, symbolize, articulate and renegotiate the emergent meanings that will suggest new actions. Finally, the collaborative and often improvisational use of specific procedures to explore significant emotion schemas or to enact inner, imaginal or interpersonal dialogues with self and others, allows the therapist and client to spark “innovative moments” in and between sessions that conjure into being new possibilities beyond the constraints of the problem-saturated narrative. Hundreds of such procedures of a meaning-oriented kind have been identified, described, and increasingly researched in the context of grief therapy (Neimeyer, 2012, 2016a). In sum, therapy can be understood as a process of intervening in meaning, a special class of social construction in which clients and therapists courageously explore and reconstruct a world of meaning that has become stagnant, stressed or shattered by life events, opening it to a fresh reading.
Paul Wong: Working with Meaning in Meaning Therapy
Since human beings are meaning seeking and meaning making creatures, meaning is indispensable to psychotherapy. Beyond the fundamental linguistic meaning of clear communication between therapist and client, the following types of meaning are important areas for psychotherapy:
- Cognitive meaning—interpreting situations/people
- Narrative meaning—stories about one’s life/events, reminiscence, life review
- Unconscious meaning—repressed desires/memories, dreams, projections
- Cultural meaning—ethnic/cultural background/upbringing, cultural norms/values
- Motivational meaning—understanding motives, values, desires, wants, intentions, aspirations, future direction
- Existential meaning—covering all existential questions regarding meaning of life, suffering, death, self-knowledge
Meaning therapy (MT) addresses all the above types of meaning because the construct of meaning is inherently holistic. Although meaning in life (MIL) issues primarily involve motivational and existential meaning, other types of meaning do have an indirect impact on one’s sense of meaning, purpose, and significance.
MT assumes that psychological difficulties are more likely to occur when one’s basic need for meaning, purpose, and significance (at work, in relationships, or in life overall) are missing. Recovery and positive mental health depend on equipping clients with the knowledge and skills to pursue meaningful life goals and cope with life’s demands.
MT is a pluralistic approach (Cooper & Dryden, 2015) with meaning as the central integrative construct in the climate of a trusting relationship. Clients are free to choose their preferred therapeutic modality and are informed that interventions will be tailored to their needs and some psycho-educational elements will be introduced regarding the vital role of meaning and purpose in healing and well-being.
Unique to MT and logotherapy is the assumption that life is inherently meaningful and meaning can be discovered in every situation, no matter how bad. Frankl (1985) has made a compelling case that such affirmation is adaptive in surviving trauma and suffering. Braaten and Huta (2016) have demonstrated empirically the adaptive benefit of such worldviews.
MT operates from the conceptual framework of PURE (Wong, 2012) which is an acronym for (1) Purpose (motivational dimension)—values, life direction, intentions, needs, wants, desires; (2) understanding (cognitive dimension)—coherence, comprehension, sense-making; (3) responsibility (behavioural dimension)—self-determination, commitment, action; and (4) enjoyment (emotional dimension)—satisfaction, sense of significance. Purpose, responsibility, and enjoyment have been widely accepted as the components of MIL in meaning research (Martela & Steger, 2016). Understanding is implied in research on self-determination and internal locus of control. Consistent with existential therapy, MT emphasizes the responsibility to choose one’s preferred future and authentic self.
Clinical Competences in addressing MIL Issues include:
- Explore the meaning dimension and cultivate a meaning-mindset: This helps clients gain new insight on life’s predicaments and re-orients clients to the adaptive benefits of eudaimonia and self-transcendence.
- Use the ABCDE framework for coping with adversities (Wong & Wong, 2012): (1) Accept and confront reality—the reality principle; (2) believe that life is worth living—the faith principle; (3) commit to goals and actions—the action principle; (4) discover the meaning and significance of self and situations—the aha! principle; and (5) evaluate the above—the self-regulation principle.
- Discover and cultivate sources of meaning (Wong, 1998): achievement, acceptance, transcendence, intimacy, relationship, religion, fairness, and positive emotions.
- Practice skills in meaning-focused coping (Folkman & Moskowitz, 2004; Wong, 2016): (1) adopt a defiant attitude towards adversity (courage); (2) reframe problems into a larger context of meaning (self-transcendence); (3) reframe problems as challenges (re-appraisal); (4) seek benefits in suffering (existential coping); (5) let go what cannot be changed (existential coping); (6) re-author and connect one’s life story to a meta-narrative; and (5) encourage goal-striving of something bigger than oneself.
Kirk Schneider: The Sense of Awe
The core issue concerning the meaning of life in my view is not so much a concept, a thing, or even a person, but the sense of awe, that is humility and wonder or sense of adventure that informs the background of all that we love. To the degree we can experience this sense of awe, discovery, whole-bodied openness to the mystery of simply being, to that extent we can experience any and all in our life as meaningful.
Frankly, I think this holds even if we see life in strictly materialist terms as a random event that just happened to produce a habitable planet, plants and animals, and human consciousness — even if all is some crazy cosmic accident, it is still incredible and awe-inspiring, and this is the part that too many secular people miss in my view.
When we genuinely open to the tremendous mystery of being, that is with our whole-body experience, and the capacity to be deeply moved, I don’t see how we can get around how awesome it all is, and hence infinitely meaningful. One doesn’t have to believe in a traditional religion or ideology to see and feel this. One simply (and not so simply!) needs to cultivate a profound presence to life, which encompasses our deepest dreads as well as most dazzling desires—the whole astonishing “banquet.’
And when we can tune in on that level we can recognize a much bigger picture than the oppressive judgments/identifications to which most of us fall prey. We are those also, to be sure, but we are perpetually MORE, and that’s the crux, the dynamic tension of an awe-filled, meaningful path. Just ask Stephen Hawking, Albert Einstein, or Viktor Frankl—or better yet read their testimonies and see if you can live their wisdom (Schneider, 2008, 2009, 2013, 2017).
Joel Vos: Discussion
The reality of meaning-centered practices may be compared with a multi-faceted diamond, which needs lights to be cast from many different angles to see as many facets as possible (Vos, 2014). Similarly, all five authors seem to subscribe the importance and uniqueness of meaning for individuals and the clinical work with them. Meaning is a subjectively lived, contextualised and awesome experience, which can only be accessed with an open attitude from both clients and practitioners. It is also an experience that requires authentic commitment and translation into daily life activities.
Practitioners need to attune to the unique meanings and processes of their clients, and are only able to do so via a positive practitioner-client relationship; their relationship is like a prism through which light is cast on the experience of meaning. Meaning-centered practitioners also do not seem to have the monopoly on helping clients to develop a meaning mindset. On the contrary, the authors advocate a pluralistic approach: meaning seems to be a common factor to all effective therapies, although not all practitioners and clients can, must or want to explicate the topic of meaning in every situation (cf. Vos, 2016a, 2017b).
As unique as the experience of meaning are the different ways how the authors work with clients. To understand their differences and overlaps, I conducted content analyses of the texts and contributions to the panel discussion, using the six-step method of thematic analyses (Braun & Clarke, 2006). This revealed three thematic dimensions: the authors differed in regards to their theoretical foundations, their perspectives on the nature of meaning, and clinical competencies. Details of these dimensions of differences could be found in Table 1. These dimensions seem in line with other systematic literature reviews on the meaning of meaning in therapy and counselling (Vos, 2016a).
First, different authors seem to have different theoretical foundations. For example, some authors explicitly used a pluralistic framework (e.g. Cooper, Wong). Some focused on being (e.g. Schneider), while others relatively more on doing and reflecting (e.g. Cooper, Wong). Wong explicitly described how meaning is given, while Neimeyer proposed a constructivist approach to meaning-making as a dynamic process. Cooper focused on goals and purposes, and although others such as Hill and Wong also mentioned these to be important, they also explicitly acknowledged that meaning can be more than that, such as Schneider who promoted the generic sense of awe and presence. All authors agreed on a non-reductionist perspective on meaning, which implied acknowledging meaning in its own right without pathologizing or conceptualising. Most authors focused on the future orientation (“where am I going towards”), although Breitbart (as a panellist) also explicitly mentioned the importance of finding meaning in one’s life history, and the legacy that one lives here and now (Breitbart & Poppito, 2014). Although Wong described a wide range of emotions, he seemed particularly interested in positive emotions, while Schneider and Neimeyer started more explicitly with the full flow of experiences, including both positive and challenging emotions. Furthermore, Wong described how individuals are always able to transcend themselves and their situation, and can intuit the absolute difference between what is meaningful and what is not.
Second, the authors cast different perspectives on the nature of meaning. For example, Cooper and Neimeyer focused on the meaning of specific events and specific experience (“micro-scale”), while Wong and Schneider focused more on a global sense of meaningfulness. Cooper wrote how meaning can sometimes be relevant, albeit as an underlying hidden cause of other manifest problems, a position which others such as Hill whole-heartedly embraced. While Schneider seemed to suggest that meaning is primarily experienced as an intuitive receptive process, Cooper, Wong and Neimeyer seemed to focus more on the active creation of meaning. Most authors acknowledge that both explicit reflections and implicit experience/action play a crucial role for individuals, although different authors seemed to put more accent on the affective dimension than others (e.g. Schneider), behaviour (e.g. Cooper), context (e.g. Neimeyer) and the significance of the self (e.g. Wong). Wong described how individuals could find meaning via specific sources of meaning, while others seemed to describe meaning as a dynamic process with unlimited sources. Some authors elaborated the importance of experiencing meaning in the context of accepting meaningless and loss (e.g. Neimeyer, Wong).
Third, different clinical competencies were mentioned. Almost all authors explicitly mentioned the importance of person-centered skills of being responsive to the client’s unique subjective process. Some authors were more explicitly pluralist and non-reductionist than others, and address the topic of meaning more explicitly with their clients. Wong and Breitbart help clients explicitly to focus on something bigger than themselves and their situation, while others focused more on accepting the here and now or on specific goals. Neimeyer added the importance of validating the experience of loss and meaningfulness, and supporting clients to find meaning despite life’s challenges. Most authors recommend exploring a wide range of meanings, while some—such as Cooper and Wong—also suggest focusing on setting and working towards specific goals. Additionally, Cooper and Wong recommended developing the client’s self, via self-insight, identifying blocks and developing a sense of personal significance. Most authors, such as Cooper and Hill, explicate the importance of cultivating a supportive and safe practitioner-client relationship. Authors also differed in their focus on creating coherent narratives (Neimeyer, Wong), using specific procedures and techniques (Hill), explicit didactics (Breitbart, Wong), positive emotions (Wong), accepting reality as it is (Neimeyer, Wong) and restoring faith in life as worth living and the significance of the self (Wong).
These dimensions and examples are only identified for didactic purposes, and the conceptual positions and practices of the authors are undoubtedly more nuanced. These dimensions are identified to show how wide-ranging meaning-centered practices can be. All authors seem to agree on the uniqueness of the therapeutic process, and they may take different positions on these dimensions with different clients in different situations. These dimensions may be regarded as a broad toolkit, from which practitioners may use different tools in different contexts.
Unity in Diversity
Of course, there are also some fundamental differences about some unverifiable assumptions, such as the finding or creation of meaning, and faith—or the lack thereof—in the absolute difference between what is meaningful and what is not. As Hill described, it is recommended that practitioners are aware of their own position with different clients, for instance by imagining how they stand on each of the dimensions in Table 1. This could particularly be relevant when they feel stuck in the process or relationship with certain clients, as this may be due to their position. Subsequently, practitioners should inform their clients about this, and help them to make a well-informed decision about the aim and method of therapy (Cooper & McLeod, 2011). The skills identified in this article may be used to develop educational training programs for meaning-centered practitioners.
More evidence-based research seems required to identify the meaning of meaning for clients, and for clinicians to use this as the basis for their practices. For example, many meaning-centered practitioners explicitly discuss three sources of meaning that Frankl identified: experiential, productive-creative and attitudinal sources. However, there is little empirical support for this triad. A systematic literature review of 108 studies in over 45,000 participants world-wide already showed that clients experience materialist-hedonic, self-oriented, social, higher and existential-philosophical meanings (Vos, 2016a, 2017a; cf. Wong, 1998). Meaning-centered practitioners may consider structuring some of their practices around these evidence-based sources of meaning.
More research is needed on which clinical competency should be used with which client in which context. Meta-analyses of 60 clinical trials show that on average, all different meaning-centered practices are equally effective (Vos & Vitali, 2017; Vos, 2016a). That is, despite their differences, the practices of all authors seem similarly beneficial for improving the quality of life and reducing the level of psychological stress of clients. This meta-analysis also showed that some skills are significantly more effective than others: using non-religious-spiritual formulations, structure, mindfulness/experiential exercises, practical goal-setting exercises, focusing on one type of meaning per session, and addressing self-worth, existential limitations, coherence of time, and establishing positive therapeutic relationships. These findings validate some of the clinical competencies mentioned in this article. However, these findings are based on cross-sectional comparison, and not on systematic experiments with different competencies.
This panel discussion shows the benefits of coming out of the silos of our individual research and practices, sharing our experiences and accepting our differences. We recommend organising more spaces for conversations like this. We can and want to find unity in diversity. As all of us share the common aim of helping clients—each in their own unique way—to live a more meaningful and satisfying life, despite life’s challenges.
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