Keywords

Introduction

In all times and cultures, individuals have most likely asked questions about what makes their life meaningful, for example: ‘What is important to focus my limited time and energy in life on?’ ‘How can I live a fulfilling life?’ ‘What do I really want?’ Although sceptical scholars criticise meaning in life as a tenuous construct, research shows that many individuals perceive there to be a larger direction and orientation in their daily lives, and when they lack this experience, they seem more prone to developing depression, anxiety and other psychological problems (cf. Shin & Steger, 2014). Although the answers to these questions differ between individuals, many people construct meaning socially in the context of their wider group, such as the traditional context of a tribe or religion (cf. Chao & Kesebir, 2013; Mikulincer & Shaver, 2013; Neimeyer, 2001; Stillman & Lambert, 2013). However, in our individualistic and secular age, individuals also search for answers inside themselves, focusing on what they see as their authentic true self (cf. Berman, 2009; Schulze, 1992/2005). Consequently, many have turned to therapists for their individual quest for meaning.

Little is known about this new approach, that is, meaning-centred therapy (MCT). It can be asked how psychologically trained meaning-centred therapists support clients to construct a sense of meaning and how effective is their support. This chapter systematically reviews the practices of such therapists and examines their empirical evidence base. As will be described, meaning-centred therapists have traditionally steered away from standardisation and systematic research , as this would not do justice to the totality of the individual’s subjective experience; instead, MCT practitioners often base their practices on individual therapy experiences and philosophy. However, it has recently been argued that systematic empirical research is important for pragmatic reasons such as receiving professional recognition and financial support; with this in mind, empirical MCT studies have been published in recent years (Vos, Cooper, Correia, & Craig, 2015). Therefore, this chapter is based on a systematic literature review of quantitative and qualitative studies on MCT, covering 52,220 citations and 60 trials in 3713 participants, as described elsewhere (Vos & Vitali, 2016).

As this review revealed that some MCT therapists differ in their philosophies and practices, the current chapter starts with an overview of different types of MCT and how these differences have emerged. Subsequently, six fundamental clinical and aetiological assumptions that these schools have in common are described alongside their empirical evidence. This is followed by a review of evidence for the most common therapeutic skills and an overview of the content of the therapy sessions. These MCT types, assumptions, skills and sessions have been identified via thematic analysis (Braun & Clarke, 2006), that is, themes in each individual study are identified, thematic groups across different publications are created, and the most frequently reported themes are presented. Subsequently, this chapter briefly describes the effectiveness of MCT with meta-analyses as detailed elsewhere (Vos & Vitali, 2016). Finally, the findings are critically discussed, followed by recommendations for practitioners.

History and Types of Meaning-Centred Therapies

Founding Fathers of Meaning-Centred Therapies

At the start of psychology as a profession around 1900 , meaning-related questions received little attention in psychological treatments, as meaning was considered to be irrelevant, a psychopathological symptom, a defence mechanism or a cognitive bias. This scepticism has been attributed to the mechanistic–deterministic world views of some psychoanalysts and behaviourists of that time, reducing human beings to either steam engines of drives and defences or behavioural–cognitive machines (cf. Lukas, 2014; Marshall & Marshall, 2012). However, psychologists and psychiatrists such as William James, Karl Jaspers and Alfred Adler tried to open this reductionist world view and revealed how existential experiences are essential to the psychological realm. For instance, Adler showed how the experience of meaning is engrained in our personality and fulfils crucial functions in our psychological development. Meaning seems particularly beneficial in situations of suffering, pain or death, which Jaspers (1925/2013) called ‘boundary situations in life’. At such inevitable crossroads, we can choose to sink into despair and resignation or take a leap of faith towards ‘transcendence’, that is, transcending the situation in space and time, accepting our freedom to decide and developing a larger, more authentic and meaningful perspective on life.

Self-transcendence was also at the heart of Frankl’s paradigm-shifting book about his experiences as inmate and psychiatrist in Nazi concentration camps, originally entitled ‘Saying Yes to Life in Spite of Everything’, better known as Man’s Search for Meaning (1985). Frankl wrote that the inmates’ ability to identify meaning and imagine the future affected their longevity. He concluded that meaning in life can be found in every moment of living; life never ceases to have meaning, even in suffering and death. From his experiences, Frankl developed the idea that a prisoner’s psychological reactions are not solely the result of his or her life situation but also from the freedom of choice he or she always has, even in severe suffering. That is, every individual has the freedom in every situation to modulate their inner attitude towards it, in a similar way that Jaspers had described the inner leap of faith from despair and resignation towards experiencing a meaning transcending the situation. Life ultimately means taking the responsibility to find the right answer to its problems and to fulfil the tasks which it constantly sets for each individual. Frankl believed that people are primarily driven by a striving to experience meaning in life and that it is this sense of meaning that enables people to overcome painful experiences. Life always has a potential meaning transcending the here and now, even in the most dehumanising and painful moments.

The three conceptual pillars of Frankl’s work included the assumption that all individuals have an inner striving towards meaning (‘will to meaning’), that everyone is always free to take a stance towards any condition in life (‘freedom of will’) and that every situation has the potential of being meaningful, even in times of the tragic triad of suffering, guilt and death (Lukas, 2014). Frankl called his new nondeterministic therapeutic approach ‘logotherapy’ and ‘existential analysis ’.

Although many techniques and exercises have emerged over the years, three techniques dominated Frankl’s work and are still practised by many existential therapists (Correia, Cooper, Berdondini, & Correia, 2014). First, paradoxical intentions are based on the assumption that individuals can choose the stance they take towards their psychological difficulties and that their symptoms are exacerbated by avoiding problems or feeling saddened or anxious. Frankl invited clients to deliberate practice or exaggerate a neurotic habit or thought, so that they stopped fighting and instead identified and undermined their problems. This technique has proven to be particularly effective in anxiety disorders (e.g. Hill, 1987). Second, de-reflection techniques are based on the assumption that individuals can become obsessed with themselves and their problems, which exacerbates their symptoms. Frankl encouraged clients to distance themselves from themselves and their problems, by stopping reflections and paying attention to the world around them, for instance, via humour and art, and focusing on something meaningful. De-reflection seems similar to defusion in acceptance and commitment therapy, which has been shown to be effective (e.g. Hayes, Luoma, Bond, Masuda, & Lillis, 2006). Third, modulation of attitudes (‘Einstellungsmodulation’) means that clients are stimulated to develop a more positive and meaningful attitude towards the situation; that is, clients change their perspective or coping style to create the opportunity of living a meaningful life despite the limitations of daily life which gives them a sense of creative freedom (cf. Lukas, 1986, 2014). One way of transforming attitudes is via Socratic dialogues, which are questions helping clients to become aware of the freedom, creativity and meaning they already have; this technique has been shown to be moderately effective for self-improvement, cultivating virtue in everyday life as well as psychological well-being (Overholser, 2010). These three main meaning-centred techniques have over the years been extended with relational–humanistic skills such as having a respectful approach, empathically exploring clients’ life situations and intuitively exploring what is meaningful for them (cf. Lukas, 2014). Furthermore, existential analysts have elaborated a hermeneutic-phenomenological stance, which implies an open description of the client’s experiences without imposing on them the therapist’s reflections and values (Langle, 2014).

Frankl ’s Legacy

In contrast with other types of therapies, logotherapy has not developed into one unified therapeutic school (Raskob, 2005). This may be explained by Frankl’s belief that logotherapy is a “supplement rather than a substitute for psychotherapy ” (1985, p. xii). He also insisted that therapies should not be developed by ‘gurus’ but by individual therapists (Frankl, 1980/2014). Furthermore, Frankl’s anthropology centres around the uniqueness of individual clients, implying that treatments are tailored to individual clients and therefore “a standardised guide would be more hindrance than help” (Lukas, 1986/2014, p. 129). Consequently, there is little standardisation of meaning-centred therapies. For instance, only in recent years have treatment manuals been developed and tested in clinical trials. This lack of research has created the scientifically unsatisfactory situation that there are a large number of meaning-centred practitioners and training institutions worldwide (cf. Correia et al., 2014) which use practices that have not been validated in accordance with current academic standards. Possibly due to this lack of validation, meaning-centred practices only seem to play a marginal role in public mental health care and are excluded from health guidelines such as the British NICE guidelines . Therefore, despite ideological arguments against standardisation and trials, there are pragmatic reasons that justify conducting rigorous outcome studies (Vos, Cooper, et al., 2015). In line with this pragmatic approach, a literature review by the author of this chapter uncovered an exponential growth of the number of MCT trials since the turn of the millennium (Vos & Vitali, 2016). Were there no more than fourteen clinical trials before the year 2000, there are now over 60 studies. Why has meaning in life suddenly become fashionable? Four answers are possible.

First, an impressive body of qualitative and quantitative studies has validated the core assumptions of MCT, namely, that many individuals experience meaning in life , that this experience can be differentiated from other psychological experiences and that it predicts long-term well-being. These studies have been summarised in several handbooks (e.g. Batthyany & Russo-Netzer, 2014; Hicks & Routledge, 2013; Reker & Chamberlain, 2000; Wong, 2012).

Second, meaning is one of the cornerstones of the increasingly popular movement of positive psychology , which transforms mental health care from merely treating mental illness to including positive psychological experiences such as meaning. Many trials have supported positive psychology interventions (Seligman, Steen, Park, & Peterson, 2005). However, some authors argue that positive experiences cannot be artificially disentangled from negative psychological and existential experiences such as awareness of our finitude, and they therefore propose an integrated positive–negative approach (Batthyany & Russo-Netzer, 2014; Ivtzan, Lomas, Hefferon, & Worth, 2015; Kashdan & Biswas-Diener, 2014; Vos, 2013; Wong, 2011).

Third, meaning has been promoted as essential to the personal recovery that all clients undergo in therapy: “recovery is about building a meaningful and satisfying life, as defined by the person themselves, whether or not there are ongoing or recurring symptoms or problems” (Andresen, Oades, & Caputi, 2011, p. 2). This is based on over 70 studies indicating that clients perceive meaning-making as essential to their therapeutic recovery process (Andresen et al., 2011). That is, therapy helped them to live a meaningful life, although their life situation or psychiatric disorder may not be changed. This reminisces of the Jasperian–Franklian transcendence: ‘saying yes to life in spite of everything’. This may even suggest that supporting meaning is a common factor of all effective therapies (cf. Goldfried, 1982). Policymakers in several countries including the United Kingdom and United States have promoted the recovery model as more consumer-oriented, pragmatic and cost-effective than the traditional medical-cure model.

Fourth, a large body of studies shows that many clients struggle with meaning-related questions, particularly in response to sudden negative life events. For instance, a majority of individuals report meaning-related questions or request meaning-related support in confrontation with the diagnosis of a chronic or life-threatening disease, the loss of a loved one or a disaster; these individuals seem to benefit from meaning-based coping styles (e.g. Henoch & Danielson, 2009; Lee, Cohen, Edgar, Laizner, & Gagnon, 2004; Neimeyer, 2001; Park, 2010; Park & Folkman, 1997; Schulenberg, Drescher, & Baczwaski, 2014).

Overview of Types of Meaning-Centred Therapy

In the empirical literature, 30 different types of MCT can be identified (Vos & Vitali, 2016).

The first type of therapy explicitly aims to improve meaning in life via systematic and directive techniques such as didactics, guided exercises and relational–humanistic skills. All publications cite Frankl as their basis, although most schools have elaborated their own clinical, aetiological and therapeutic models . Classical logotherapy, general meaning-centred therapies and logo-analysis (e.g. Frankl, Lukas, Fabry, Marshall, Hutzell and Crumbaugh) directly use Frankl’s core methods as previously described in standardised, relatively directive manuals for a wide range of clients. Existential analysis has elaborated the logo-therapeutic theory within a phenomenological, client-directed and dialogical approach. It seeks to help clients develop an authentic and responsible attitude towards their lives and contexts, so they can experience themselves freely and thus ‘say yes’ with an inner consent to the world (feeling we exist), life (feeling life is good and valuable), self (feeling and showing authentic uniqueness) and meaning. Thus existential analysis helps clients to say: ‘Yes, I exist, my life is good, I can be myself, and I can achieve my goals’ (Langle, 2014, p. 23). Meaning-centred counselling or meaning therapy (Wong, 2013) is a short action-oriented therapeutic approach with specific exercises, based on the theoretical ABCDE model : helping clients to accept events in life, believe in strengths and the possibility of change, commit to actions, discover hidden meanings and evaluate change and progress. Meaning-centred group psychotherapy is a brief manualised group for cancer patients developed by Breitbart and Poppito (2014), which uses specific self-reflection exercises to focus on creating a sense of coherence between the life before and after cancer, grieving over how the disease challenges meaning and explaining and experientially connecting with the three main pathways to meaning proposed by Frankl (see below). Meaning-making interventions involve a narrative approach , helping clients to review their lives and chronologically embed the cancer experience in the historical context of other important life events, which also pays attention to themes such as self-worth, controllability of events, justice, coping and life priorities (Lee et al., 2004). Meaning-based group counselling for bereavement helps individuals to reconstruct meaning during grief over the loss of a loved one (MacKinnon et al., 2013).

Several therapies address meaning as one core aspect of the intervention, sometimes using different terminology such as ‘values’ or ‘life goals’, along with other aims and processes in therapy. These studies will not be discussed in the remainder of this chapter to avoid conflation with therapeutic aims and methods not focusing on meaning. Empirical studies suggest modest to large effects for these therapies on improving psychological well-being; the following cited studies are reviews or representative examples: meaning-centred marital and family therapy (Lantz, 2000; Schulenberg, Schnetzer, Winters, & Hutzell, 2010), meaning therapy via the use of photography (Steger, Shim, Barenz, & Shin, 2014), acceptance and commitment therapy (Hayes et al., 2006), structured life review and guided autobiography (Bohlmeijer, Smit, & Cuijpers, 2003), dignity therapy in palliative care (Chochinov et al., 2005), positive psychological interventions (Sin & Lyubomirsky, 2009), goal management intervention (Arends & Bode, 2013), salutogenic therapy (Langeland et al., 2006), spiritual interventions (Anderson et al., 2015), psychosynthesis (no empirical trials found), humanistic and person-centred therapies (Elliott, 2002) and existential therapies (Vos, Craig, & Cooper, 2015). Additionally, several therapies indirectly or peripherically address meaning, with small to moderate psychological effects: hardiness interventions (Maddi, 2014), transactional analysis (Khalil et al., 2007), schema therapy (Masley, Gillanders, Simpson, & Taylor, 2012), hope therapy (Weis & Speridakos, 2011), motivational interviewing (Lundahl, Kunz, Brownell, Tollefson, & Burke, 2010) and Jungian therapies (no systematic trials identified). Meaning is also addressed by nontherapeutic approaches which have not been studied in trials such as life coaching, philosophical counselling , meaning in life education nationwide in Taiwan and occasionally in other countries and art of life education in the Netherlands and Germany (e.g., Kekes, Dohmen, Schmid, Bohlmeijer).

Validation of Clinical–Aetiological Assumptions

The difference between quack therapies and evidence-based therapies is not only that outcome studies prove the effectiveness of the latter but also that there is empirical evidence and conceptual coherence for the underlying clinical and aetiological models and that the therapeutic mechanisms are logically built on these clinical–aetiological models (Kazdin, 2008; Vos, 2014b). A clinical model is the conceptualisation of the main psychological problem that the therapeutic intervention focuses on and an aetiological model describes how this problem has developed. The therapeutic mechanisms should logically follow from these clinical–aetiological models.

It seems difficult to validate the clinical–aetiological assumptions in meaning-centred therapies, as most publications do not explicate these assumptions and do not present one unified model. Most of the evidence is also philosophical-deductive in nature or merely reflects personal therapeutic experiences from key authors. For instance, two of Frankl’s three main conceptual pillars are fundamentally unverifiable as these are anthropological and philosophical in nature, i.e. the assumptions that we are free in our decisions and that life is meaningful (Lukas, 1986/2014). The sociological causes of existential frustration and meaning-centred/noogenic neuroses are also difficult to verify empirically (Marshall & Marshall, 2012). Additionally, Frankl has developed a diagnostic system (1999/2005) which has not been systematically validated, although Lukas (2014) has conceptually connected this with psychiatric diagnostic manuals. However, six verifiable aspects can be identified in MCT publications, which will be discussed alongside their empirical evidence.

First, meaning is assumed to be correlated with, but phenomenologically distinct, from other psychological phenomena. This assumption has been confirmed by many questionnaire studies (e.g. Melton & Schulenberg, 2008; Shin & Steger, 2014; Steger, 2012). The MCT publications consistently describe five aspects of meaning, and empirical research confirms that the experience of meaning consists of (1) being motivated by purposes, drives and/or self-transcendence in life; (2) living according to one’s own values; (3) understanding and having a sense of coherence of the world, life and self (sometimes associated with ‘cosmic meaning’); (4) experiencing one’s own life as worthy, significant and relevant (‘existential meaning’); (5) committing to goals and actions in daily life (‘situational meaning’); and (6) evaluating and adjusting one’s way of living (‘self-regulation’) (e.g., Batthyany & Russo-Netzer, 2014; Reker & Chamberlain, 2000; Wong, 2012). Thus meaning in life seems to be a valid and reliable concept.

Second, all MCT authors hypothesise that humans strive and crave for meaning, and this contains an internal contribution, i.e. the individual who is striving and craving, and an external contribution, i.e. the meaning potential of the situation (Lukas, 1986/2014). Indeed, many individuals search for and/or experience meaning or purpose in life, as confirmed by studies with instruments such as meaning in life questionnaire and purpose in life, although the precise percentages differ per instrument, population and study (e.g. Brandstätter, Baumann, Borasio, & Fegg, 2012; Shin & Steger, 2014; Steger, 2012).

Third, a low sense of meaning is often associated with an overall low psychological well-being and psychopathology, while a strong sense of meaning correlates with better overall well-being in the long term (e.g. Reker & Chamberlain, 2000; Shin & Steger, 2014; Steger, 2012). However, most of this evidence comes from studies with nonexperimental designs, that have not clarified the causal direction (e.g. King, Hicks, Krull, & Del Gaiso, 2006). Nevertheless, indirect evidence for causality may be found through cross-sectional studies which show that, following negative life events, individuals search for meaning. Individual resources of meaning act as resources for coping, since a high level of life meaningfulness seems to act as a buffer against the negative consequences of stress, and meaning-based coping contributes to better psychological adjustment during or after stressful events (e.g. Folkman, 2008; Henoch & Danielson, 2009; Park, 2010). Like Frankl predicted, when individuals are frustrated in roles and activities that they highly value, they seem to experience lower psychological and physical well-being (e.g., Krause, 2004). More specifically, Frankl used the term ‘existential vacuum’ to describe the result of a long-standing frustration of the will to meaning, characterised by a sense of lack of meaning and purpose, combined with feelings of emptiness and boredom (Lukas, 2014). Frankl cited his own observation that 25 % of European students and 60 % of American students experience this (Marshall & Marshall, 2012). Due to the complexity of this concept, this hypothesis seems difficult to verify (Dyck, 1987), although one study indicated that particularly individuals of young and old age experience existential vacuum (Reker, Peacock, & Wong, 1987).

Fourth, it is assumed that individuals experience meanings as more important when these are concordant with their true or authentic self, instead of when these meanings reflect inauthentic or externally imposed meanings (cf. Schlegel, Smith, & Hirsch, 2013). Although the concept of a true self may be called ‘tenuous at best’, the perception of a true self is closely related to the experience of ‘values consistent with the true self’. Empirical studies show that choices consistent with the true self-concept are more valuable for an individual. Furthermore, perceived true self-knowledge strongly influences what an individual experiences as meaningful and that this is related with satisfaction about decisions and with feeling confident in past and future decisions (Schlegel, Smith, & Hirsch, 2013).

Fifth, Frankl hypothesised that individuals experience an absolute hierarchy in their meanings: certain meanings are more valuable than others. Our ‘conscience’ can discover this absolute hierarchy of meanings in our life via intuitive sensing (‘Spüren’), which is a valuation process in which not only abstract cognitions are involved but our full person with all our senses and experiences (Längle & Bürgi, 2014; Lukas, 1986/2014). This intuitive process would, for instance, imply that we need to peel off the superficial layers of our everyday emotions before we can sense the underlying values in our deeper layers of experiences that resonate with our true selves and the hierarchy of values in the situation (cf. Vos, 2014). Consequently, MCT should not help clients to ‘create’ meaning in their lives but to help them ‘discover’ meaning, “like finding the right answer in a multiple choice quiz. Several answers are possible; only one is right. Several interpretations of a situation are possible; only one is true” (Fabry, 1980, p. 53).

Correlational research, indeed, identifies different types of meaning. Illusionary or defensive meanings are, for instance, meanings that correlate with denial and avoidance coping styles, while constructive or authentic meanings correlate with an accepting stance (e.g. Pat-Horenczyk et al., 2015; Schlegel et al., 2013; Zoellner & Maercker, 2006). Additionally, individuals who primarily focus on materialistic–hedonic values experience life as less meaningful and satisfying and experience more long-term psychological problems, while social and transcending values are associated with better well-being (e.g. Baumeister, Vohs, Aaker, & Garbinsky, 2013; Nielsen, 2014; Gantt, & Thayne, 2014). Furthermore, empirical research seems to confirm the existence of an innate functional capacity to intuit what is ‘right’ and ‘wrong’ in a situation (Hauser, 2006).

Notwithstanding this correlational and functional evidence , the metaphysical truth underlying the absolute-hierarchy hypothesis cannot be verified. Possibly due to this lack of verifiability, many meaning-centred practitioners have moved away from this Franklian radical absolutism and merely offer a phenomenological exploration of what the client experiences as valuable. These therapists remain metaphysically agnostic about the question how absolute these experiences of the client are. This pragmatic shift seems to answer traditional criticisms that MCT may have authoritarian overtones (May, 1978; Yalom, 1980) and are based on “unvalidated assumptions and unalterable truths” (Cooper, 2003, p. 65). For instance, relativistic MCT therapists mention that on the one hand they recognise their client’s wish for clarity about what is truly valuable and what is not, while on the other hand, recognising that in life full metaphysical truth may not be achievable; this dual awareness combines the client’s wish for certainty with accepting their existential uncertainty (cf. Vos, 2014).

Sixth, all publications mention that according to Frankl there are three ‘main streets’ (‘Hauptstraße’) to a meaningful life, that is, via realising the values of ‘experiencing’ (‘Erlebniswerte’), the values of ‘creativity and productivity’ (‘Schöpferische Werte’) and the values of ‘inner attitudes’ (‘Einstellungswerte’) (Lukas, 1986/2014). That is, individuals experience many different types of meanings that are unique for them and for their current life situation, but the reason why they experience something as meaningful is because it realises a broader underlying value. For instance, a client may experience her job as meaningful because she highly values being productive and creative, but this value could also be realised in other situations such as being productive in volunteer work or parenting. Thus, meanings are ‘values realised in daily life’ and ‘the most valuable option in the current situation’. In this context, the will to meaning can be defined as ‘saying yes to a value’, that is, ‘a decision to commit to a chosen value’ (Längle & Bürgi, 2014, p. 180). Most MCT authors assume that these three most common types of values that individuals experience can be categorised into these three specific groups of universal values. Subsequently, they use this meaning triad as a cornerstone for the treatment manuals : after some introduction sessions, most manuals address one session for each of the three values, which is often followed by sessions in which the three values are translated into concrete goals and actions for daily life.

Although specific definitions differ between authors, the group of values about ‘experiencing’ describe a wide range of meaningful experiences, such as enjoying nature, music and art, physical well-being, entertainment, relationships and love; on the most fundamental level, value can be found in the human capacity to experience anything at all. ‘Creativity and productivity’ are not only about our visible contribution to the world via our profession, art or offspring but also about having a creative stance in life such as being able to find creative solutions to difficult life situations. This is also connected with the third group of values relating to ‘inner attitudes’, and this concerns the inner freedom all of us have to distance ourselves from the situation and decide our response to it. For instance, individuals could act as a victim to a diagnosis of the terminal stage of a disease or instead try to live life meaningfully despite their disease; for example, Frankl (1980/2014) writes that a dying individual has the ability to change his attitude to his situation. This value triad is a cornerstone for many therapy manuals (Vos & Vitali, 2016).

One may argue that these three values can only be philosophically validated, as they reflect three existential modes of being and not three operationalisable aspects. However, it is possible to ask individuals which meanings they experience and subsequently analyse which values their answers reflect. For instance, Lukas conducted such a survey and found that 50 % of the individuals reported experiencing, 25 % creativity–productivity and 25 % inner attitude as main values (Lukas, 1971, in Lukas, 2014). Since Lukas, many researchers have asked individuals in different countries and of different ages what they experience as meaningful. A recent systematic literature review included 79 studies with 2435 participants, which confirmed that individuals indeed experience these three main values (Vos, 2016b). However, other values were more frequently reported as important, which led to a different categorisation (and which appeared to be in line with a smaller review by Wong & Reker in Reker & Chamberlain, 2000). Here, values were categorised in terms of materialistic–hedonic values, self-oriented values, social values, higher/transcendental values and meta-values (see Table 1). This review also revealed the multiple interpretability of values: an individual could, for example, not only pursue sports achievements for the hedonic-pleasurable feelings they evoke but also for the sake of the self and others or to achieve a higher goal. The Franklian value triad does not need to conflict with this quintet. For instance, experiencing, creativity–productivity and certain attitudes could be applied to each of the five categories: creativity–productivity could be realised in the materialistic–hedonic, self-oriented, social and transcending domains of life.

Table 1 Overview of life domains and hypothetical underlying values, as identified in a systematic literature review of 79 publications on what individuals’ experience as meaningful in life and categorised via thematic analyses (Vos, 2016a)
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Thus, compared with the Franklian value triad , the value quintet reflects the experience of more clients in multiple studies around the world, while the triad is based on philosophical assumptions and few empirical studies. However, the majority of MCT manuals are centred around the triad. Consequently, therapists impose their normative selection of values to clients by exploring a non-exhaustive range of possible meanings in life. Subsequently, some clients may feel that MCT is not relevant for them, leading to drop out or smaller effectiveness (cf. Applebaum et al., 2012). For instance, paying only limited attention to hedonic–materialistic values may alienate clients who have never reflected on ‘higher values’. Therefore, to be applicable to a wider client population, it could be recommended to structure MCT manuals around this inclusive evidence-based value quintet instead of the traditionally narrow value triad.

In conclusion, meaning-centred practices are based on some unverifiable clinical and aetiological assumptions , but research indicates that individuals experience meaning in life as a multidimensional phenomenon which seems important and predictive of their general well-being. Individuals experience different types of meaning, with hedonistic–materialistic meanings as less beneficial and with social and transcendent meanings as more beneficial for their well-being. This evidence seems to justify offering MCT to clients experiencing meaning-related problems, in particular those in boundary situations in life, who often ask such questions and would benefit from meaning-oriented coping styles.

Therapeutic Skills

What do meaning-centred practitioners actually do when they work with clients, and how is this supported by empirical evidence? Thematic analyses of the literature review divulged 38 skills (see Table 2).

Table 2 Overview of therapeutic skills identified via thematic analyses of the studies in a systematic literature review of therapies explicitly and systematically addressing meaning in life (Vos & Vitali, 2016)
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Assessment Skills

These skills are about evaluating the life situation, needs, preferences and capacities of the clients, to develop a specific meaning-related plan together with the clients to help them with the problems they are currently facing in life. More specifically, the practitioner tries to understand how the problems of the client relate to meaning and to ascertain whether the client has the capacity for and could benefit from directly and systematically working with meaning in life. The foundations for a positive therapeutic relationship are laid, and potential iatrogenic damage of the diagnostic process should be avoided, for instance, by not only focusing on the client’s weaknesses but also their strengths and positive meanings (e.g. Lukas, 1986/2014). Scientific evidence seems to confirm that—in therapies in general—assessing and tailoring therapy to the needs, skills and wishes of the individual client can to some extent improve the effectiveness of therapies (Eifert, Schulte, Zvolensky, Lejuez, & Lau, 1997; Schulte, 1996), in particular when client and therapist agree on therapeutic goals and processes to achieve these goals (Tryon & Winograd, 2010).

Meaning-Specific Skills

These skills aim at explicating, systematically exploring and improving meaningful aspects of the client’s experiences. They include skills that have been shown to be effective in other therapies such as providing psychoeducation, rephrasing/reframing the stories of the clients in terms of meaning, conducting guided exercises and connecting the topic of therapy, namely, meaning , with specific situations in everyday life (cf. Cooper, 2008; Roth & Fonagy, 2013). Frankl and other logotherapists often explicate their belief that the client will be able to find meaning in life again, and studies confirm that an unconditional positive regard and hope are important factors in therapy (Farber & Doolin, 2011). Furthermore, it seems beneficial for the client’s well-being to focus on long-term meaning in life rather than on short-term gratification and pleasure (cf. Wong, 2013). This often involves focusing on the larger timeline, that is, helping clients to develop a sense of continuity between past, present, future and their possible legacy for future generations. Although the main focus of meaning-centred practices is on the present and the future, the first sessions often review meaningful aspects of the past to enable clients to become aware of their meaning potential again and mourn over lost meanings. Conducting such a life review has shown to be effective (Westerhof, Bohlmeijer, & Webster, 2010).

Many manuals suggest that practitioners should not only help clients find one specific meaning in life but explore meaning potentials in multiple domains in life, experienced in multiple senses, conscious and unconscious. With the exception of the previously mentioned evidence for differentiating levels of meaning, there are no experimental studies on the effectiveness of addressing the totality of meanings. Additionally, several meaning-centred practitioners stimulate effective goal managements, such as helping clients to set concrete aims for their day-to-day lives, to make a plan, to experiment in daily life, to evaluate and adjust the aims and method and to make long-term commitments. The effectiveness of this type of intervention is supported by several trials (e.g., Lapierre, Dubé, Bouffard, & Alain, 2007).

Several manuals address both the importance of the clients’ autonomy and their social connections in meaning-making; the effectiveness of this balance between self and context is indicated by multiple studies (e.g., Mikulincer & Shaver, 2013). Furthermore, self-discovery has been described as important by existential analysts, which seems indirectly supported by research indicating that it may be difficult to experience life as meaningful when one is not in touch with oneself and does not experience one’s own worthiness (cf. George & Park, 2014; Mikulincer & Shaver, 2013; Schlegel, Smith, & Hirsch, 2013).

Existential Skills

These skills are about MCT therapists embedding the experience of meaning in the broader context of life, although these skills are less often practised by classical logotherapists and meaning-centred psychotherapists. Research confirms that clients experience existential moods and struggle with life’s limitations, and it seems beneficial to address these existential moods (e.g., Vos, 2014; Vos, Cooper, et al., 2015). However, studies on the effectiveness of addressing existential themes without simultaneously addressing meaning in life, for example supportive–expressive or experiential–existential therapies, have only small or no significant effects (Vos, Craig, et al., 2015). This suggests that addressing existential limitations—such as freedom of decision and mortality—may help clients to accept life’s limitations and create realistic goals and expectations about life as part of, for instance, MCT, but this may not be effective as a stand-alone therapeutic technique.

Meaning-centred therapists often explore the defence mechanisms of clients and help them to find positive meaning in adversity. Several empirical studies confirm that clients cope better with existential frustrations when they focus on larger meanings behind their current life situation or when they change the situational meaning or inner attitude. Research indicates that individuals may indeed respond to existential threats with existential denial and avoidance, for instance, by shifting their attention from the threatening information or experiences (Greenberg & Koole, 2013). Although such defence mechanisms may relieve stress in the short term, they predict a lower sense of meaning and fulfilment about life in the long term (Jim, Richardson, Golden-Kreutz, & Andersen, 2006). Thus, it seems important that individuals can flexibly switch between different styles of coping, so that they could, for instance, temporarily use denial and avoidance to immediately lower their psychological stress levels, but in the long term also use other ways of coping. This coping flexibility predicts better long-term well-being (Cheng, Lau, & Chan, 2014; Vos, 2014). Therefore, it seems beneficial for individuals to learn a dual attitude, which means that they learn to tolerate the possible tensions between their wish for meaning and life’s limitations (cf. Vos, 2014; Wong, 2015). For instance, it seems beneficial to have illusions about life—such as feeling invulnerable, immortal and in control—while at the same time being (cognitively) aware of their illusory character (e.g., Janoff-Bulman, 2010). For example, after a negative event it seems beneficial to not maintain the notion of predictability and unchangeability of life but to re-evaluate life, values and goals and find new meaning (e.g., Batthyany & Russo-Netzer, 2014).

Relational–Humanistic Skills

These skills focus on establishing an in-depth, authentic therapeutic relationship, along with reflection on and analysis of the relational encounter, combined with a phenomenological exploration of the client’s experiences, which is particularly practised by existential analysts. Empirical research strongly supports the emphasis on the quality of the therapeutic relationship, with the APA Task Force concluding that “the therapy relationship makes substantial and consistent contributions to psychotherapy outcomes independent of the specific type of treatment” (Norcross & Lambert, 2011, p. 423) by means of empathy, congruence and the capacity to repair alliance ruptures (Kolden, Klein, Wang, & Austin, 2011; Safran, Muran, & Eubanks-Carter, 2011).

The phenomenological practices follow from the idea that everyone can intuitively sense meaning through their conscience (see above). The focus on the client’s subjective flow of experiencing may help therapist and client to avoid biases and blind spots and do justice to the totality of the client’s inner experiences and gain deeper self-awareness (‘eidetic reduction’). The phenomenological method traditionally includes temporarily setting aside our assumptions and biases (‘rule of epoche’), neutrally describing the phenomena (‘rule of description’) and avoiding placing any initial hierarchies of significance or importance upon the themes of description (‘rule of equalisation’) (Spinelli, 2005). Existential analysts use four phenomenological steps in ‘personal existential analysis ’ to help clients with their problems (Langle, 2014): after description of the external facts of the situation, phenomenological analysis explores the client’s experiences in more depth, followed by inner positioning in which clients evaluate their inner attitude and values, and finally clients reflect on the responding performance (act) they want to do. Although pure phenomenological therapeutic approaches seem relatively ineffective (Vos, Craig, et al., 2015), specific techniques associated with the phenomenological approach are effective, such as the Socratic dialogue, which helps to elicit what the client already knows instead of pouring information into the client and which is known for its moderate positive psychological effects (e.g., Overholser, 2010).

Spiritual and Mindfulness Skills

These skills regard the therapist’s openness to the client’s spiritual–cultural context, stimulating de-reflection, self-distancing and a general accepting stance in life, including nonintellectualising exercises such as mindfulness and focusing techniques as developed by Gendlin (1982). Many studies have confirmed the beneficial effects of mindfulness and meditation on the well-being of individuals, in particular for those in stressful life situations such as those caused by a somatic disease (e.g., Hofmann, Sawyer, Witt, & Oh, 2010). There is also some modest evidence for including nonintellectual techniques such as art, drama, poetry and drawing (e.g., Elliott, Greenberg, & Lietaer, 2004). Existential analysts also foster acceptance of world (e.g., accept physical limitations of a disease), life (e.g., accept your own experiences), self (e.g., accept and show who you are) and what clients experience as meaningful; however, these phenomena are unverifiable due to their abstract nature (Langle, 2014).

In conclusion, the publications reviewed revealed 38 different practitioner’s skills, ranging from assessment, meaning-specific, existential, relational–humanistic and spiritual–religious skills. Most skills were shown to be supported by empirical research evidence, although some skills were unverifiable or need further validation. In addition, several practitioners integrate evidence-based techniques from other therapeutic approaches such as group psychotherapy (e.g., Leszcz & Yalom, 2005) and pluralistic therapy which focuses on the adequate positive responsiveness of the therapist to the client, such as shared decision-making about the aims, method and structure of sessions (e.g., Cooper, 2015). This review is limited by a risk for self-serving bias, as only evidence confirming the effectiveness of the practitioner’s skills was searched for. The results suggest the potential benefits of these meaning-centred practitioner’s skills.

Session Structure

How are the therapeutic skills translated into specific therapeutic practices and sessions? Over the years, possibly hundreds of standardised MCT procedures have been published, especially in the International Forum for Logotherapy, but most procedures were only described briefly and tested in nonsystematic case studies. Seventy studies systematically tested clear semi-structured therapy manuals (Vos & Vitali, 2016), which will be the basis of the following overview of therapy sessions. Most manuals described between 5 and 15 sessions and consisted of three phases.

The assessment and introduction phase focuses on understanding the facts of the client’s life situation, problems and strengths, exploring hopes and expectations, exploring the relevance and history of meaning for the client and building a constructive therapeutic working alliance. This assumes strong assessment and relational–humanistic skills. Often, acute suffering and recent life events are explored, such as the experience of having a life-threatening physical disease and how life has changed on account of this. This exploration of the recent history frequently focuses on grieving lost meanings or a lost meaning potential, and clients are invited to explore how they could experience meaning despite the loss and thus transcend their suffering in the current life situation. Several manuals position the clients’ current experience of suffering and loss in the broader context of their life history, for instance, via an autobiographic life review, and clients may be asked to describe what they experienced as meaningful in the past and how they have overcome previous hardships in life.

The meaning-exploration phase is the backbone of many manuals and consists of systematically exploring clients’ values and meaning potential. In this phase, meaning-specific and existential-therapeutic skills are used. Usually, one session is spent on each group of values from the Franklian–Lukassian value triad (one session on the value of experiencing, one on productivity–creativity and one on attitude modulation), although it may be recommended to replace this with the value quintet (see Table 2).

Clients are guided in their explorations of what they experience as valuable and meaningful via practical exercises and direct questions or structured techniques such as the value awareness technique (Hutzell, 1990). The urgency and intuitive hierarchy of values is sometimes strengthened via Yalom’s ‘write your own epitaph’ exercise’ or ‘death bed experiment’, by which clients are asked to imagine that they are dying and to identify how they need to have lived their lives to be able to die with a feeling of meaning and fulfilment (Yalom, 1980). In meaning therapy, fast-forwarding and encouraging clients to imagine the differences that particular choices could make in their life (‘what would your life look like?’) and ‘miracle questions’ help overcome limiting thoughts by asking, for instance, what the client would do if money were not an issue or if God granted three wishes in life (Wong, 2013). Clients could be asked to describe their life as a movie, with questions such as ‘who would play you?’ and ‘how would the ending look like?’ (Lantz, 2000). Another creative form is to invite clients to bid on a limited number of values (Schulenberg, Hutzell, Nassif, & Rogina, 2008). In existential analysis , techniques are used such as identifying and integrating biographically relevant experiences in the present (biographical existential analysis ), exploring and accepting fundamental fears (gates of death method) and imagining living up to values (value-oriented imagery).

The evaluation and application phase aims to evaluate the values and potential meanings that were explored in previous sessions and apply these to everyday life. Clients are, for instance, invited to create an intuitive hierarchy of values and meanings, for example, by drawing a mountain and putting different meanings/values at different heights reflecting differences in value and authenticity (e.g. Ernzen, 1990). This evaluation is followed by assessing to which extent the clients already live their lives according to this hierarchy and what may need to be changed in their lives to re-create the mountain range exercise in their daily lives. Subsequently, clients are stimulated to translate this into concrete goals and plans and actually experiment with this. The following sessions could help to evaluate these experiments and, if necessary, adjust the aims and methods and make long-term commitments to goals. In this phase, clients are often confronted with limitations in life such as meanings that are difficult or impossible to actualise; in response to this, meaning-centred practitioners use their existential skills to help clients explore and tolerate imperfections, tensions and paradoxes in life, while stimulating pragmatic problem-solving. The last session often explores existential feelings of termination, autonomy and being responsible for their own life (cf. Lukas, 1984/2014).

An average session starts with an emotional check-in and discussion about the previous session and about the homework. The aim of this is to understand any developments in life since the last session and to connect with the emotional process and progress of the client. This is often followed by explicit psychoeducation on the theory and practice of a central topic, for instance, the value of productivity–creativity. Clients are often invited to participate in interactive psychoeducation by giving examples. Often, a guided exercise is performed to help clients apply the theory to their own lives, for instance, by searching for examples of how the theory manifests in their own lives. Some practitioners introduce these exercises with a guided mindfulness exercise to help the clients connect with the topic not only on an intellectual level but also on an experiential-embodied level (e.g. Elliott et al., 2004; Hofmann et al., 2010; Van der Spek et al., 2014). The guided exercise is sometimes followed by exploring hierarchies in the client’s experiences and by identifying which examples in their daily life feel most valuable and authentic. This sometimes leads to an evaluation and a decision regarding questions such as ‘what do I want to change in my life’, ‘what can I realistically change’, ‘what do I need to accept that it cannot be changed’, and ‘how can I cope with this situation in a positive way?’ These questions sometimes lead to the decision to change something in one’s life, to set goals and to make a plan for how to achieve them. Most sessions end with homework and an evaluation of the session.

Effectiveness

The systematic literature review on which this chapter is based included 60 trials (total sample N = 3713) of which 26 were randomised-controlled trials (N = 1975), 15 nonrandomised controlled trials (N = 709) and 19 nonrandomised noncontrolled pre-post measurement studies (N = 1029). Twenty-five studies with a large risk of bias in selective reporting or presenting unlikely positive study results were not included in these analyses. Samples included physical illness (26 trials), transition moments in life (12 trials), psychiatric diagnosis (8 trials), carers (7 trials), substance misuse (4 trials), and other (3 trials). Studies were conducted in the Middle East (18 trials), North-America (16 trials), South-East Asia (14 trials), Europe (6 trials), South-Africa (3 trials) and South America (2 trials). The average number of sessions was 8.65, with some as short as two sessions and some as long as 52.

The combination of all 60 trials showed large improvements from baseline to immediate post-treatment and follow-up measurement on quality of life (Hedges’ g = 1.13, SE = 0.12; g = 0.99, SE = 0.20) and psychological stress (g = 1.21, SE = 0.10; g = 0.67, SE = 0.20), although effects varied between studies (large heterogeneity as indicated by I 2 > 50 %). Additional analyses were done in the controlled trials only, which showed large homogeneous effects compared with control groups (mostly active treatment or care as usual, some waiting lists), both immediate and at follow-up on quality of life (g = 1.02, SE = 0.06; g = 1.06, SE = 0.12) and psychological stress (g = 0.94, SE = 0.07, p < 0.01; g = 0.84, SE = 0.10). Immediate effects were larger on general quality of life (g = 1.37, SE = 0.12) than on meaning in life (g = 1.18, SE = 0.08), hope and optimism (g = 0.80, SE = 0.13), self-efficacy (g = 0.89, SE = 0.14) and social well-being (g = 0.81, SE = 13).

Additional meta-regression analyses indicated that the improvement in meaning in life strongly predicted a significant decrease in psychological stress (β = −0.56, p < 0.001). This seems to confirm the assumption that meaning-centred therapies reduce psychological stress, thanks to explicitly addressing and improving meaning in life in therapy. The more different types of meaning were explicitly explored in MCT, the larger the effects were on both quality-of-life and psychological stress (resp. β =.32, p<.01; β =.21, p<.01). This confirms the recommendation to use the most exhaustive list of meanings -such as the meaning quintet- as the core structure of MCT instead of, for instance, the smaller Franklian triad.

A wide range of moderators were not significant, implying that the effects were similar, for instance, for different types of MCT, control conditions, countries, populations and sample sizes. Larger effects were found in analyses of the 70 trials, when the treatment manuals were more structured, included mindfulness/meditation exercises, explicitly encouraged clients to set and experiment with achievable goals in their daily lives, explicitly discussed one type of meaning per session (e.g., one session on social meanings, one on self-oriented meanings, etc.) instead of using another therapy structure (e.g., existential analysis ), explicitly paid attention to self-worth, explicitly addressed existential limitations such as life’s finitude and freedom, discussed the totality of time (past, present, future and legacy) and not only the present and/or past and described how a positive therapeutic relationship can be created.

Discussion

What is the evidence base for MCT? First, the meta-analyses indicate that MCT strongly improves the client’s existential, psychological, physical and general well-being, not only compared to the baseline measurement but also compared with other active interventions in control groups. These findings are corroborated by the positive effects in studies on therapies that discuss meaning as one of multiple core aspects, which were not included in these analyses, such as acceptance and commitment therapy and dignity therapy (see references above). Second, although several aspects of the clinical and aetiological models are unverifiable, the main assumptions seem valid: individuals experience meaning as important for their well-being, especially in crisis situations in life, and it seems beneficial to support them in exploring higher levels of meaning via social and transcending values. Third, many MCT skills are corroborated by effectiveness studies. Fourth, the meta-regression analyses confirmed the clinical assumption that the well-being of clients improves, thanks to improvements in meaning in life, which is in line with a review of 57 studies that placed meaning at the heart of therapeutic recovery (Andresen et al., 2011). That is, clients seemed to feel much better in many domains of their lives, thanks to their increased sense of meaning in life, which had improved thanks to MCT. In conclusion, these findings seem to indicate that MCT is mostly bona fide (Wampold et al., 1997) and has beneficial effects for many clients.

This review is limited by its focus on effectiveness trials, as case studies, for example, were not described. It is possible that the description of therapeutic skills and their effectiveness are not representative of MCT conducted by therapists rejecting standardisation. However, several manuals were based on the works of key authors such as Frankl, Langle, Lukas and Marshall.

Additionally, conceptual dissimilarities between different MCT schools seemed large, especially regarding the extent to which the practitioner was directive and normative. Despite these differences, the meta-analytic effects seemed statistically homogenous after exclusion of studies with a large risk of bias, and many moderators were tested but shown to be not significant. This seems to suggest a general commonality in the underlying therapeutic practices, as all studies directly and systematically addressed different levels of meaning in life. It is these meaning-centered therapy skills that differentiate meaning-centred practices from other therapeutic approaches such as other existential therapies. The humanistic framework also differentiates meaning-centred practices from behavioural approaches such as acceptance and commitment therapy. However, these are not hard distinctions with other approaches but seem to imply an integrative or pluralistic approach that focuses on being responsive to the individual clients, their needs, preferences and skills (cf. Cooper, 2015). This unity despite diversity seems to indicate that the conceptual differences between meaning-centred schools may be less important than what they have in common. Thus, it may not be necessary to stick to one particular manual, but therapists may develop their own version on the basis of different evidence-based therapy skills (although it remains unclear whether adherence to the manual is important or not, as few studies tested adherence).

Which clients should be offered to work with meaning in life? In most trials, MCT was offered to individuals in boundary situations in life, which is in line with the underlying clinical–aetiological assumptions, stating that particularly individuals in these situations ask meaning-related questions. Some authors, such as Breitbart and Poppito (2014), did not only require their participants to be in a certain boundary situation—such as being patients with advanced cancer—but also to be experiencing clinical levels of depression or anxiety . Although from the perspective of routine outcome monitoring in traditional health services, it is understandable that such clinical diagnoses are used as inclusion criteria, both the clinical–aetiological assumptions and meta-analytic findings would not require clients to have clinical levels of psychopathology . It is recommended to develop meaning-centred screening questionnaires, asking not only whether clients experience meaning in life or search for meaning—which does not directly mean that they need or would like to receive therapy for these issues—but also directly ask them whether they experience meaning-related problems and whether they would like to receive help with these meaning-related topics; we have started to develop such a screening instrument which needs further validation (Vos, 2011, unpublished report). Until such screening instruments are validated, meaning-centred practices could be offered to all individuals who explicitly ask meaning-related questions or who are in boundary situations in life. Subsequently, the therapist could explain the aims and methods of working with meaning in life, and the client and therapist could decide together how much this therapeutic approach fits the needs and preferences of the client. One could argue that clients may not know that they need to work with meaning in life, due to their existential defence mechanisms; therefore, therapists are recommended to be sensitive towards manifest and latent meaning-related themes in the work with their clients and, if needed, to explicate the possible relevance of meaning for the client. The literature review in this chapter does not indicate negative effects of explicitly addressing meaning in life.

A continued concern could be the possibly authoritarian attitude and the unvalidated assumptions of some meaning-centred practitioners, although this review seems to suggest that some practitioners have moved from traditional Franklian radical absolutism to a more relativistic–pragmatic position. It is recommended to base the meaning-centred practices on validated assumptions and continuously check to which extent norms and values of the therapist reflect those of the client, possibly via a meta-therapeutic dialogue (Cooper & McLeod, 2010). Shared decision-making and tailoring the values and aims in therapy seem more consistent than an authoritarian approach with the relational–humanistic skills and values that are at the heart of most meaning-centred manuals. Moreover, the relational–humanistic and phenomenological approach does not exclude the relatively directive use of a structured manual when the client and practitioner have decided together to use this, and the practitioner remains sensitive and phenomenologically open to the micro-experiences of the client (cf. Eifert et al., 1997). This means that on the therapeutic macro level, client and practitioner could decide together on the aims and structure of therapy, which presupposes strong relational–humanistic skills in the therapist. On a meso-level the practitioner could offer—possibly quite directively—structured practices, which require strong meaning-centred skills. On a micro level the practitioner could phenomenologically explore the unique individual experiences of the client and be sensitive to the spiritual–religious experiences of the client, which presupposes strong existential–spiritual skills.

In summary, the evidence in this chapter confirms that a wide range of individuals benefit from a broad range of meaning-centred interventions, supporting the recent surge in MCT. Therefore, the inclusion of meaning-centred practices in mental health-care guidelines is strongly recommended (cf. Vos, 2016a, 2016b).

Key Takeaways

  • Develop a therapeutic sensitivity for the important role that meaning often has in the therapeutic recovery of any clients receiving any type of therapy.

  • Offer MCT to individuals who explicitly ask meaning-related questions and to individuals who are experiencing negative life events, such as a chronic or life-threatening disease.

  • Systematically explore different types of meaning in separate sessions: materialistic–hedonic, self-oriented, social, higher and meta-meanings.

  • Develop assessment, meaning-specific, existential, relational–humanistic and spiritual/mindfulness therapeutic skills.

  • When offering MCT, include mindfulness/meditation exercises, encourage clients to set and experiment with achievable goals in their daily lives, stimulate self-worth, address existential limitations and the totality of time (past, present, future and legacy) and develop a positive therapeutic relationship.

  • Offer MCT to any relevant populations: MCT is, for instance, equally effective in clients with and without psychopathology.

  • Be aware of the risk of therapeutic authoritarianism, reflect together with the client whether MCT is the most suited therapy for this client at this moment and explore the client’s individual experiences with an open, nonjudgmental attitude.