SOURCE_DOCUMENTS/journal_004_1.txt

Volume 4, Number 1 Spring/Summer 1981 
CONTENTS 
The Frontiers of Logotherapy 
Joseph Fabry .............................................. 3 New Ways for Dereflection Elisabeth Lukas ............................................ 13 Logotherapy: New Help for Problem Drinkers James C. Crumbaugh .......................................29 The Executive in an Age of Alienation Frank E. Humberger .......................................35 Teacher Frustration in the American Public School System Bianca Z. Hirsch ...........................................45 Life Review and Life Preview Mignon Eisenberg ..........................................49 Application of Paradoxical Intention by Other Schools of Therapy 
L. Michael Ascher ..........................................52 Letter to an Unknown Lady 
Elisabeth Lukas ............................................ 56 Book Review ..................................................59 Bibliography ...................................................61 
International Forum for I ,ogotherapy Vol. 4, No. 2, Fall/Winter 1981 
The Future of Logotherapy* 
Viktor E. Frankl 
When I was asked to give the opening address at the First World Congress of Logotherapy, I was given the theme-and I quote literally: "How I envisage logotherapy after I am gone." In other words, I was to deliver a swansong, deposit a legacy. But I am not a prophet to foresee the future of logotherapy, even less a guru to decree what its future should be. My recent address at Temple University was called "Psychotherapy on its Way to Rehumanization. "8 It would be most appropriate to choose as the title for an address "Logotherapy on its Way to Degurufication. " The future of logotherapy is dependent on you logotherapists and in determining it you should be independent. After all, logotherapy regards man as a being in search of meaning, who is responsible for the fulfillment of meaning, and logotherapy sees its specific assignment in making him conscious of his "being responsible." This also holds true for the logotherapist himself because he, too, should be aware of his being free and responsible, an independent spirit. It is true, I am a descendent of the Maharal of Prague, the legendary rabbi who is said to have made the Golem, a robot created of clay. But my interest lies neither in creating robots nor in raising parrots that just rehash their master's voice. Yet, I do have a wish for the future: that the cause of logotherapy be carried on by independent and inventive, innovative and creative spirits. 
It goes to the credit of Reuven P. Bulka4 to have defended logotherapy against the accusation of being "authoritarian." However, we logotherapists are tolerant not only vis-a-vis each other. Elisabeth S. Lukas 12 states that, throughout the history of psychotherapy, there has never been a school as undogmatic and as open as logotherapy. In fact, logotherapy may well be called an open system. However, we do not only confess to its openness, but also to its being a system. J.B. Torello'4 even went so far as to claim that in the history of psychotherapy, logotherapy is the last school whose teaching body has been developed in terms of a systematically organized structure. 
Whatever I have said does not do away with my being "The Father of Logotherapy," as the journal Existential Psychiatry called me. No doubt the Latin dictum according to which fatherhood never is certain (pater 
*This essay is adapted from the opening address at the First World Congress of Logotherapy. 
0/9/-337918/ I 1500-0071 $00. 95 71 ,( ', /91? J /luman Sdences Press 
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semper incertus) is not applicable for logotherapy. But my being the father or, simply, the founder of logotherapy means no more than having laid its foundation, and a foundation offers others the invitation to build on it. Reading and rereading my books spares them from doing it all over again, and thus saves time for their share in the further development of logotherapy. Why should they waste their time reinventing logotherapy? 
In my address at the inauguration of the "Frankl Library and Memorabilia" in Berkeley, I pointed out that logotherapy is a system open in a twofold sense: toward its own evolution and toward the co-operation with other schools. This twofold openness has born fruit. So far 18 authors (myself not included) have turned out 31 books on logotherapy published in 8 languages, and 70 dissertations have been written on the same subject. All of these authors have been moving on various levels of sophistication-covering the whole spectrum from popularizing, not to say vulgarizing, literature to empirically oriented, even experimentally based publications-and they are moving in different directions. In the volume Logotherapy in Action1 30 logotherapists present their views. As their viewpoints sometimes deviate from each other, one may wonder what is still, and what is no longer, logotherapy. I could simply state that pure logotherapy is just what you find in my writings. But this does not mean that you have to quote from my books incessantly. After all, it was the very reason why I coined the term ''logotherapy,'' to be spared from continuously saying, "I think ... , I believe ... , I have found ... , " Instead, I can say, ''logotherapy teaches ... , it is a tenet of logotherapy ... ,'' or the like. I was spared speaking or writing in the first person. By the same token, you were spared saying again and again, "Frankl teaches ... , it is a contention of Frankl. .. " You can say, "We logotherapists hold ... " 
Members of the logotherapeutic movement need not subscribe to whatever I have said or written, but apply only what is convincing. You cannot persuade others of anything of which you are not yourself convinced! This applies particularly to the logotherapist's conviction that life does have a meaning and that it is unconditionally meaningful; that it retains meaning even under the most miserable conditions and literally up to our last moment. Even death itself may be endowed with meaning. If you believe this to be true, you must also be prepared to counter the arguments by which your patients may attack your standpoint, and that is why a rereading of my books from time to time is useful to strengthen your position with the arguments contained in them. 
Viewed in this light, members of the helping professions are seen as called upon to help their clients in the basic and ultimate human aspiration-to find meaning in their lives. By so doing, they themselves retroactively find a mission in their own lives. A few years ago, the editor of Who's Who in America had included me in 100 persons who were asked how they would 
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epitomize their lives. I had my answer in a sealed envelope when I met with a group of American professors who had come to Vienna to study logotherapy. "I want you to guess what I wrote," I said. And like a shot out of a pistol came the words of the young Toby Weiss: ''You see the meaning of your life in helping others see in their lives a meaning." Word for word, it was what I had written! 
VALIDATION OF LOGOTHERAPY 
Much work has been done by a host of authors to consolidate, corroborate, and validate those findings which, for too long, had been based on solely intuitive grounds, more specifically, on the intuitions of a teenager named Viktor Frankl. Now, logotherapy has become scientifically established on the grounds of research based on tests, statistics, and experiments. 
So far, 9 logotherapeutic tests have been developed by Walter Bockmann, James C. Crumbaugh, Bernard Dansart, Bruno Giorgi, Ruth Hablas, R.R. Hutzell, Gerald Kovacic, Elisabeth S. Lukas, and Leonard T. Maholick. As to statistics, we are indebted to the research conducted by Brown, Casciani, Crumbaugh, Dansart, Durlak, Kratochvil, Lukas, Lunceford, Mason, Meier, Murphy, Planova, Popielski, Richmond, Roberts, Ruch, Sallee, Smith, Yarnell, and Young. They have found empirical evidence that, indeed, people can find, and fulfill, a meaning in their lives regardless of sex or age, IQ or educational background, environment or character structure, and finally regardless of whether or not they are religious, and if they are, irrespective of the denomination to which they may belong. The authors must have computerized hundreds of thousands of data obtained from thousands of subjects in order to find empirical evidence of the unconditional potential meaningfulness of live. 
Statistics also have confirmed my early hypothesis that the feeling of meaninglessness may result in a noogenic neurosis. Ten research projects conducted independently from each other arrived at the consistent conclusion that about 20% of neuroses are noogenic in origin. These research projects were carried out by Frank M. Buckley, Dietrich Langen, Elisabeth S. Lukas, Eva Niebauer-Kozdera, Kazimierz Popielski, Hans Joachim Prill, Nina Toll, Ruth Volhard, T.A. Werner, and Eric Klinger. 11 
As to experiments, L. Solyom, J. Garza-Perez, B.L. Ledwidge and C. Solyom13 were the first to offer the experimental evidence that the logotherapeutic technique of paradoxical intention is effective. More recently, L. Michael Ascher and Ralph M. Turner2 · 15 have conducted a controlled experimental validation of the clinical effectiveness of paradoxical intention in comparison with other behavioral strategies. 
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Although we can appreciate the scientific foundation of logotherapy, we are aware of the toll it takes. I suspect that logotherapy has become too scientific to become popular in the proper sense of the word. At the same time, it is too revolutionary to be fully acceptable in scientific circles. Small wonder. Our concept of a will to meaning as the basic human motivation runs counter to the current motivation theories, which are still based on the homeostasis principle. These regard man as a being who is out to satisfy drives and instincts, to gratify needs, and all this merely to maintain, or restore, an inner equilibrium, a state without tensions. All the fellow beings he seems to love, and all the causes he seems to serve, are seen as mere tools serving him to get loose of the tensions aroused by unfulfilled drives and instincts and needs. Self-transcendence, which logotherapy considers the essence of human existence has been totally left out in the picture of man that underlies the current motivation theories. Yet man is neither a being who is just abreacting his instincts, nor a being who is just reacting to stimuli, but is a being who is acting into a world, a "being-in-the-world," to avail myself of the (often misinterpreted) Heideggerian phraseology, and the world in which he lives is full of other beings and meanings toward which he is transcending himself. But how can you come to grips with the ills of our time which are grounded in a frustration of the will to meaning, unless you adopt a view of man that focuses on the will to meaning as his 
motivation? 
What is revolutionary, however, is not only our concept of the will to meaning but also our concept of meaning in life. Indeed, we logotherapists have broken a taboo. What has been accepted in literature, is still a taboo in the medical field: to talk about life as if it had any meaning. But we logotherapists do venture to talk about life as always having meaning. This is mandatory in cases of noogenic neurosis or existential frustration. Here, logotherapy lends itself as specific therapy. 
SELECTING THE METHOD 
This brings up the question of how to determine the treatment in a given case. As I have repeatedly stated, the "method of choice" in a given case can be expressed by an equation with two unknowns: 
\J-1 = X + y. x stands for the unique personality of the client and y for the equally unique personality of the therapist. In other words, not every method is applicable to every client with the same success, nor is every therapist capable of handling every method with equal success. As to adjusting the method to the client, I agree with Beard who introduced the concept of neurasthenia into psychiatry and maintained that if you treat two cases of 
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neurasthenia in the same way, you have mistreated at least one of them. And as to adjusting the method to the therapist, let me quote another author: "This technique has proved to be the only method suited to my individuality; I do not venture to deny that a physician quite individually might feel impelled to adopt a different attitude toward his patients and the task before him." The man who said this was Sigmund Freud. 10 
As you see, you cannot individualize too much. But, you have to modify the method not only from person to person but also from situation to situation; thus, you have not only to individualize but also to improvise. Both methods can be taught and learned, preferably by case demonstrations in a classroom setting, and also through publications. Believe me, among the best logotherapists from all over the world there are some I have neither met nor had any exchange of letters. They turned out publications on their successful application of logotherapy, having based their work solely on reading my books! 
Some people have even applied logotherapy successfully on themselves, also after just reading a book on the subject. They deserve to be commended on their creation which one may call auto-biblio-logotherapy. 
As I have often stated, logotherapy is no panacea. It is open toward cooperation with other schools and, indeed, its combination with other techniques is to be encouraged. In that way its effectiveness can be expanded. Anatole Broyard3 in reviewing one of my books, wrote: "If 'shrink' is the slang term for the Freudian analyst, then the logotherapist ought to be called 'stretch."' So, let us continue to stretch the reach of logotherapy, as you have done it all along. 
THERAPIST-PATIENT RELATIONSHIP 
Methods, however, are not the whole story. Psychotherapy is always more than mere technique, and it is so to the extent to which it necessarily includes an element of art. Psychotherapy is always more than mere science, and it is so to the extent to which it necessarily must include an element of wisdom. Art and wisdom form a unity wherein dichotomies such as technique and encounter dissolve. Usually, the psychotherapeutic treatment contains both ingredients, techniques and an I-Thou encounter. Only in exceptional situations do these extremes form a basis for psychotherapeutic intervention. 
An American girl, a student of music, came to see me in Vienna for analysis. Since she spoke a terrible slang of which I could not understand a word, I tried to turn her over to an American physician in order to have him find out for me what had motivated her to seek my advice. She did not consult him, however, and when we happened to meet each other on the 
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street, she explained: "See, Doctor, as soon as I had spoken to you of my problem, I felt such a relief that I didn't need help any longer.'' So I do not know even now for what reason she had come to me (p. 79). • 
This was an extreme example when human encounter, without any technique, was therapeutic. 
In contrast, here is an example of the other extreme: In 1941, I was called one morning by the Gestapo and ordered to come to headquarters. I went there in the expectation of immediately being taken to a concentration camp. A Gestapo man was waiting for me in one of the offices; he started a cross-examination. But soon he changed the subject and began to question me on topics such as: What is psychotherapy? What is a neurosis? How would one treat a case of phobia? Then he began to elaborate on a specific case-the case of "his friend." Meanwhile, I guessed that it was his own case that he wished to discuss with me. I started short-term therapy (more specifically, I applied the logotherapeutic technique of paradoxical intention); I advised him to tell "his friend" what he should do in case anxiety cropped up. This therapeutic session was not based on an I-thou relation, but rather on one of I-he. At any rate, the Gestapo kept me for hours, and I continued treating him in this indirect manner. What effect this short-term therapy had I was, naturally, not able to discover. As for my family and myself, it was lifesaving for the moment, for we were permitted to stay in Vienna for a year before being sent to a concentration camp (pp. 79-80).6 
We must not disparagingly dismiss techniques. The logotherapeutic technique of paradoxical intention is even unique, as L. Michael Ascher has pointed out: 
Most therapeutic approaches have specific techniques, and these techniques are not especially useful for, nor relevant to, alternative therapeutic systems. But there is one notable exception in this observation, namely, paradoxical intention. It is an exception because many professionals representing a wide variety of disparate approaches to psychotherapy have incorporated this intervention into their systems both practically and theoretically.' 
I do not think that we should object to such "incorporations." After all, we do not treat patients for the sake of enhancing the reputation of logotherapy, but for the benefit of our patients. 
But, rather than looking forward, into "the future of logotherapy," we can look back, into its past. Some authors have called logotherapy "the third school of Viennese psychotherapy." I was affiliated, one way or another, with the Freudian and the Adlerian schools. As a high-school student I corresponded with Sigmund Freud; as a medical student I met him and when I introduced myself: "My name is Viktor E. Frankl," he 
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immediately responded by saying: "Viktor E. Frankl? Czerningasse number 6, apartment number 25-right?" "Exactly." He knew my address by heart, after years of correspondence. As early as in 1924, he published a paper of mine in his International Journal of Psychoanalysis, and one year later, in 1925, I published a paper in Alfred Adler's International Journal of Individual Psychology. To be sure, two years later he insisted on my being expelled from the Adlerian school-I had become too unorthodox. 
It has often been said that each founder of a psychotherapeutic school in the final analysis describes in his system his own neurosis and writes in his books his own case history. I am not entitled to speak, in this context, of Sigmund Freud or Alfred Adler, but as far as logotherapy is concerned, I readily confess that as a young man I had to go through the hell of despair over the apparent meaninglessness of life, through total and ultimate nihilism. But I also wrestled with it like Jacob with the angel until I could say "yes to life in spite of everything," until I could develop immunity against nihilism. I developed logotherapy. It is a pity that other authors, instead of immunizing their readers against nihilism, inoculate them with their own cynicism which is a defense mechanism or reaction formation that they have built up against their own nihilism. 7 
This is a pity because today more than ever the despair over the apparent meaninglessness of life has become an urgent and topical issue on a worldwide scale. Our industrial society is out to satisfy every need, and our consumer society even creates some needs in order to satisfy them. The most important need, however, the basic need for meaning remains too often ignored. It is so "important" because once man's will to meaning is fulfilled, he becomes happy, but he also becomes capable of bearing suffering, of coping with frustrations and tensions, and-if need be-he is prepared to give his life. Just look at the various political resistance movements throughout history and in the present time. On the other hand, if man's will to meaning is frustrated, he is equally inclined to take his life, and he does so in the midst, and in spite, of all the welfare and affluence surrounding him. Just look at the staggering suicide figures in such welfare states as Sweden and Austria. 
A decade ago, The American Journal ofPsychiatry, in reviewing a book of mine characterized the message of logotherapy as the "unconditional faith in an unconditional meaning" and asked the question, What could be more pertinent as we enter 1970? Now entering the 1980s, Arthur G. Wirth 16 expresses his belief that "logotherapy has special relevance during this critical transition," by which he means the transition to a "postpetroleum society." In fact, I believe that the energy crisis is not only a hazard but also a challenge. It may be an incentive to shift the emphasis from mere means to meanings, from material goods to existential needs. There is an energy shortage. But life can never become short of meaning. 
International Forum for logotherapy 
If there is a logotherapeutic "movement," it certainly belongs to the human rights movements. Logotherapy focuses on the human right to a life which is as meaningful as possible. 
I concluded my first book (The Doctor and the Soul) with the statement that logotherapy "is a no-man's-land. And yet-what a land of promise!" This was 35 years ago. In the meantime, the "no-man's-land" has become inhabited and the "promise" is on the way to being fulfilled. 
REFERENCES 
I. Ascher. L. Michael. "Paradoxical Intention," in Handbook of Behavior Interventions, 
J.A. Goldstein and E.B. Foa, Eds. New York, John Wiley, 1980. 
2. 
_____ and Ralph M. Turner, "A Comparison of Two Methods for the Administration of Paradoxical Intention." Behavior Research and Therapy, 1980, 18, 121-126. 

3. 
Broyard, Anatole. The New York Times, November 26, 1975. 

4. 
Bulka, Reuven, P., "Is Logotherapy Authoritarian?" Journal of Humanistic Psychology, 1978 18 (4), 45-54. 

5. 
Fabry, Joseph B., Reuven P. Bulka and William S. Sahakian, Eds. Logotherapy in Action. New York, Jason Aronson, 1979. 


6. 
Frankl, Viktor E. Psychotherapy and Existentialism: Selected Papers on Logotherapy. New York, Touchstone, 1978. 

7. 
_____. The Unheard Cry for Meaning: Psychotherapy and Humanism. New York, Touchstone, 1979. 


8. ____. "Psychotherapy on Its Way to Rehumanization." The International Forum for Logotherapy, 1980, 3 (2), 3-9. 
9. _____. The Will to Meaning: Foundations and Applications of Logotherapy. New York, New American Library, 1981. 
10. Freud, Sigmund, quoted from the American Academy of Psychoanalysis Midwinter Meeting, New York, NY, December 9-11, 1966. 
II. Klinger, Eric, Meaning and Void. Minneapolis; University of Minnesota Press, 1977. 
12. Lukas, Elisabeth S. Auch dein Leben hat Sinn: Logotherapeutische Wege zur Gesundung. Freiburg, Herder, 1980. 
13. Solyom, L., J. Garza-Perez, B.L. Ledwidge and C. Solyom, "Paradoxical Intention in the Treatment of Obsessive Thoughts: A Pilot Study." Comprehensive Psychiatry, 1972, 13 (3), 291-297. 
14. Torello, J.B. "Viktor E. Frankl, l'homme," Viktor E. Frankl, La Psychotherapie et son image de l'homme. Paris, Resma, 1970. 
15. 
Turner, Ralph M. and L. Michael Ascher. "Controlled Comparison of Progressive Relaxation, Stimulus Control, and Paradoxical Intention Therapies for Insomnia." Journal of Consulting and Clinical Psychology, 1979, 47 (3), 500-508. 

16. 
Wirth, Arthur G. "Logotherapy and Education in a Post-Petroleum Society." The International Forum for Logotherapy, 1980, 2 (3), 29-32. 


International Forum for Logotherapy Vol. 4, No. 2, Fall/Winter 1981 
The Existential Vacuum in Eastern Europe 
R.E. Stecker 
The writings of Frank\2,3 and Fabry1 have been invaluable in my work as pastor and pastoral counselor, as well as in my own life. Colleagues in the German Democratic Republic and other East European countries who had the opportunity to read and discuss these books agree that the basic ideas of logotherapy have special application in Communist states. 
At an international conference a Western participant raised the question whether the search for meaning was as important and the "existential vacuum" as widespread in the East as it is in the West. One of my Eastern colleagues immediately answered that in Communist countries everyone has a meaning and the feeling of emptiness as the result of meaninglessness is a purely Western phenomenon. 
In a subsequent more intimate group of counselors from East European countries we refined this "official" statement. The "will to meaning," we agreed, is a universal human, and not a political or economic phenomenon. If repressed, it can lead to emptiness, frustration, and despair in any country. 
There is, however, a difference in the search for meaning between the democratic and the socialist worlds. In the democratic West, the emphasis is placed on finding individual meaning-"finding yourself," selfactualization, self-fulfillment. In the socialist East, the emphasis is on finding a meaningful place within a prescribed societal structure. 
Finding their place in such a structure is highly meaningful for those who helped build the new society and believe in its benefits. Today this is true for the "old" Communists and for those in the younger generations who share the founders' values and ideals. In Frankl's terms, life is fulfilling for all those whose personal meanings agree with the values (or universal meanings) of their society. There are manifest reasons to believe in the benefits of the Communist society: no unemployment, low rents, free health care and education, low costs for public transportation, low prices for staple foods. 
But there is a built-in frustration in almost every area: work is highly circumscribed, housing is practically unavailable, higher education is limited to those who are selected (not according to student ability but according to the political record of their parents), the average waiting time for buying a new car is ten years, staple food is a closely limited category, and anything considered a "luxury" is expensive or unavailable except for 
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Western currency, while everything is complicated by waiting in line and a network of bureaucratic red tape. 
Meaning in the Eastern European states is available but it is determined officially, with little freedom to choose. The individual is made to feel like an object which is manipulated. One has little opportunity to commit onself to self-chosen tasks, but tasks are widely prescribed and forced upon the individual. 
My own experience, and those of others who have had occasion to meet with our Western colleagues, indicated that the existential vaccum and its consequences are present in the East as well as in the West. Both communism and capitalism, as practiced today, tend to shift the search for meaning away from human values and toward material values. Both reduce the human person to a thing which can be manipulated. Also, the worth of a person is measured by the values of the machine-productivity, utility, efficiency, cost advantages. Increasingly, human beings are considered as completely determined by forces beyond their control-in the West by the forces of psychology, in the East by economics. We are indeed controlled by these and other forces to some extent, but Frankl correctly warns of the "new nihilism" which is a belief not in nothingness but in "nothingbutness." In the West, we are considered "nothing but" the result of our drives, childhood traumas, and reaction formations; in the East we are thought to be "nothing but" cogs in a rigid economic system. This reductionism and pandeterminism may result in a feeling of inner emptiness-the existential vacuum. 
According to logotherapeutic theory, the existential vacuum is likely to open up when our will to meaning, the basic motivation for living, is repressed, frustrated, or ignored. For different reasons, this happens both in the East and the West. In the East, meaning is dictated by the authorities in power, and the individual's will to meaning is frustrated. In the West, where people are generally free to pursue meaning as they see it, the will to meaning is often ignored. Affluent people tend to chase after pleasure, rather than pursue meaningful goals. The chasing after power as an end in itself, or the direct seeking of pleasure, are two ways in which people mistakenly try to fill their inner emptiness. Alcoholism and violence are two other unhealthy ways to fill the existential vacuum. Both are evident in the East and the West. 
But, as Frankl also points out, the existential vacuum itself is no disease but simply proof that we are human beings concerned, and often frustrated, about finding meaning. The noogenic neurosis develops when a conflict of values or conscience enters the vacuum. Such conflicts are evident with most clients who come for help. 
Some conflict between the values of society and individual conscience is unavoidable under all economic or political conditions, but it is more 
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critical in totalitarian countries. The basis for many complaints prompting people to seek counseling in our centers is found to be noogenic. A women suffering from severe stomach pains, with no apparent organic causes, realized after a Socratic dialogue that she "could not stomach" the pressure put on her to not go to church: the consequence would be that her son, a gifted high school student who wanted to study architecture, would not be allowed to enter a university. Her husband, too, tried to persuade her to stay away from church because her attendance threatened his promotion at work, and the increased salary would be needed to buy extra food considered a "luxury." When she realized the noogenic roots of her trouble, she was able to make a decision. Talking over her available choices with her husband and son, they came to the conclusion that her religious roots were most important to her. Her husband took on extra work as a handyman to increase his income, and the son decided to be a draftsman in an architectural firm, which he could do without a university education. Once her conflict of conscience was resolved, in accordance with her authentic self, the stomach trouble disappeared. 
Another woman developed headaches when her twins entered school. Again a Socratic dialogue was employed. In the course of the discussions the woman's fear became conscious: that fear that her children would be endangered by her liberal outlook-the friends she saw (including foreigners), the books she read illegally, the discussions that went on in her home. She knew that the teacher's assignment was to find out, from the children, what their parents did and thought. She was not ready to give up her readings and meeting people, nor did she want to tell her children a lie. Relief came once she realized the cause of her headaches, and when she saw that her children, even at their young age, were able to differentiate between what they could tell the teacher and what they kept to themselves. 
Our experiences have shown that this conflict of young children who live in a world with two different sets of "truths" -that of their parents and that of the school-is much less damaging than what one would expect. Children seem to be able to perceive a deeper truth that transcends both sets of values. This seems to confirm logotherapy's belief in the human spirit that can tune in on a suprahuman dimension, with laws which humans can disregard only at their own peril; and the belief in a human conscience that can take a stand against influences of the "superego" in any formparental, societal, or political. My colleagues agree with my own observations that lead me to believe that no amount of indoctrination will be able to completely bury our will to find meaning as we see it. 
Children and adults are placed under special stress in a totalitarian society, but in many cases this stress seems only to strengthen their spiritual muscles. Counselors in East Germany speak of Einigelung ("hedgehogization")-the tendency of people to roll up into a ball, with their bristles 
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outside, preventing anyone from coming close. They refuse to answer any questions, and even don't ask themselves any question that might disturb their artificial equanimity. They refuse to take responsibility for their deeds; everything is decided for them by outside authorities. Sometimes such hedgehogization leads to noogenic neuroses, and the clients have to be made to see that equilibrium, the adjustment to a society with an unacceptable value system is not healthy. The clients need help in learning that even under conditions of limited freedom, responsibility still remains theirs. 
In East Germany the value conflict is widened by the fact that television programs from West Germany can be watched, and the double standard of "truth" (between what the East German authorities say about the West, and what the West really is like) becomes obvious. I have heard of an unusual case where this problem caused a noogenic depression. 
The man had a good job and a pleasant apartment in Dresden. His family life was happy, and he had relatives in West Germany who sent him hard currency that enabled him to buy some of the "luxury" items not available for East German marks. Yet, he suffered from increasingly deep depression. It turned out that he wanted to listen to West German television, but Dresden is one of the few places in East Germany that lie in a pocket where Western television cannot be received. He wanted to move to Leipzig-some 50 kilometers to the West. But he was unable to get permission for a job transfer, nor could he find housing in Leipzig. His depression deepened as he realized that this simple move of 35 miles was impossible. It lifted when he became aware that he had a choice and a responsibility within the limitations of his restricted freedom. He had to make his choice: access to Western television in Leipzig, or a well paid job and comfortable living quarters in Dresden. He opted for staying in Dresden, but kept up his efforts to get a job transfer and permission to find an apartment in Leipzig. These goals, together with awareness that, even in this trap, choices were available, provided him with a task that gave meaning and direction to his life. 
R.E. STECKER is a pseudonym for a pastoral counselor in the German Democratic Republic who wishes to remain anonymous. 
REFERENCES 
I. Fabry, Joseph B. Das Ringen um Sinn. (Paper) Freiburg, Herderbucherei, 1978. 
2. 
Frankl, Viktor E. Der Wille zum Sinn. (Paper) Bern-Stuttgart-Wien, Verlag Hans Huber, 1972. 

3. 
_____. Artzliche See/sarge. (Paper) Miinchen, Kindler Taschenbiicher, 1975. 


lnlt:rnat1011al l·orum for I ogo1herapy Vol. 4. No. 2, Falli\Vinter 1981 
Logotherapy in Tanzania Lou is L. KIitzke 
The students at the University College Dar es Salaam in Tanzania are alive and dynamic, frustrated and confused. They live in the paradoxes created by the transition from domination to freedom, via education. The principles of logotherapy, as a humanistic and existential psychology have proved more relevant in this emerging country than the deterministic explanations of human behavior. This contention is supported by the writings and actions of many Africans, students and leaders. 
Students at Dar es Salaam come from all parts of Tanzania, and from other eastern African countries such as Kenya, Uganda, and Zambia. Nearly all have been away from their family and tribesmen for years. They are familiar with European and American teachers because most of their secondary and high school teachers were expatriates. They wonder what the future holds for them in this architectural marvel with its faculty from so many different eastern and western countries. Their twelve-story dormitories and the massive library are a far cry from the mission and government schools they attended, where they slept in wards of eight to twenty, and where the library was in a room too small to serve as a classroom. The educational culture shock that began for them the first day of school, typically fourteen years earlier, increases. Now their common characteristic is not so much their background as it is their present and future. They share a common hope for and faith in education. 
BETWEEN THREE WORLDS 
Students see themselves as "hung up" between three or more cultures: the world of their family, clan, and tribe; the different world at school; and yet another, of the nation. They find themselves in a series of dilemmas because they are being educated in a relatively uneducated society. They have become Western in some of their attitudes, ambitions, and values, yet are still influenced by tribal and family traditions and values. Often this conflict is experienced by the young person who is trained and qualified to take on responsibilities, but is hampered by several societal priorities: elders do not take advice from their young sons; positions of responsibility are given to family and friends rather than to those most qualified; the young 
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lack the initiative and confidence necessary to sell themselves to an employer, and the employer does not trust a younger person with foreign ideas and strange education. Whatever the reason, the young persons view themselves as cultural misfits. They believe they are being held back without reason and unfairly. 
The "Three Worlds" conflict intensifies the students' dilemma in deciding which course to follow-the traditional attitudes or the modern methods of teaching. A perceptive student wrote to me after his first year in Education at University College: 
We (students) appreciated your lectures and seminars, but psychology is a new subject for us. The difficulty was more than just a lack of background in psychology. Psychology seems to be explaining in new ways the things our tribes and families do. We've never questioned or even thought to question the role of child-rearing practices and their effects upon school children. In fact, I've always thought it was wrong to question anything that is a tribal custom. Psychology was hard but interesting. It created a conflict between what we were taught at college and what we have always believed. 
Is this "Three Worlds" predicament what Frankl sees as existential frustration? "Noogenic neuroses do not emerge from conflicts between drives and instincts but rather from conflicts between various values, from moral conflicts or, to speak in a more general way, from spiritual problems.''3 
Tanzanian students go through a period of confusion, frustration, and uncertainty. Their values, partially rooted in the tribe, partially in colonialism, and partially in a new self-governing society, are supposed to fit both past and future. They are being asked to develop and live by a new set of values, beyond their families and tribes; values which are defined by the government as a national ethic. Logotherapy is helpful because it places emphasis on the person's unique meaning which may differ from the values (the universal meanings) of society. By becoming aware of this difference, the conflict can be resolved by conscious choice, and the noogenic neurosis can be prevented. 
SELF-TRANSCENDENCE 
A second aspect of logotherapy's importance in developing countries concerns the relationship between self and society, especially in terms of self-transcendence. The Arusha Declaration spelled out the role of the political leader and his relationship to the society. This Declaration and 
Louis L. K/itzke 
other documents presented as the ideal that individuals should serve society willingly to the extent of their capabilities and in the best interest of the needs of the nation, but without exploiting others. The educational system and the family unit were seen as the basic instruments for developing such self-transcendent attitudes, along with self-confidence. 
Frankl writes, "human existence is not authentic unless it is lived in terms of self-transcendence. " 4 The question arises whether human existence can be authentic when self-transcendence is forced upon a person. The Arusha Declaration asks for self-transcendence of the political leaders. The Education for Self-Reliance pamphlet, which was published a month after the Declaration, describes the teachers' roles and responsibilities as, in part, creating and developing self-transcending attitudes in pupils, students, and in themselves. 
Can self-transcendence be taught to children? Can it be encouraged effectively by people who do not themselves demonstrate this trait? Is it best taught by example? Can we find examples of "forced self-transcendence" in societies where sharing, cooperation, social dependency, and the like are so traditional that they are thought to be instincts? 
Self-transcendence, in this connection, is nation-building: it requires the decision to continue the good aspects of the culture and change the parts believed to be bad. Conflict arises when an outsider goes too far in saying that an aspect of culture is no longer effective and should be changed. When the outsider advances beyond the people's recognition of what is good and what is not good, the outsider tends to be rejected. If he is white, he may be called an imperialist or colonialist. If he is black, the rejection produces deeper conflicts. Accusations of tribalism may result. 
In education, forced self-transcendence can create problems for students and teachers. Some children come from homes where magic, witchcraft, and witch doctors are important. These children believe that rain falls and the moon changes as a result of the witch doctor's magic and no amount of explanation by the science teacher can make them change their minds. Genuine problems arise since these children have to pass examinations and subscribe to mainstream educational concepts. 
A THREAT TO BASIC VALUES 
Independence gained by education is also considered a threat to basic values. Independent children are lost to their parents. Modern education contributes to this idea of personal freedom. Children who have caught a vision of the personal freedom that can be achieved through education, but who live in the traditional family, experience pain. A son who believes in 
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nationalism and the self-service in nation-building will tend to challenge the purposes of his traditional family. His money will go for taxes to the nation rather than to make his father and family members wealthy. The parents of the educated child also experience pain. Some will prefer to hold their child at home rather than allow them an education which will lead them away. Alienation undoubtedly does exist between the educated child and uneducated parents. 
One student wrote about this problems of tribes: 
Many secondary schools are made up of many tribes who have status over each other. For example, ...when a boy from the Masai tribe is in a class where the prefect is of a lesser tribe there is bound to be trouble. Many troubles arc also caused when different age groups are in the same class. The big (older) boys almost have to be bullies over the little ones because that is tribal. Yet the younger ones are usually the ones getting better marks. When the younger boy in a class gets the highest mark, it rebuffs the tribal belief that the older person is the more intelligent. 
Today, students are supposed to see "nation" as synonymous with society and culture. The Kiswahili word Ujamaa which literally means "of the family" is now being used as a guideline for attitudes toward the nation. The students are being asked to stretch their attitudes so that they think of their nation as they think of their family. The teacher is being asked to inculcate these expanding attitudes into the minds and personalities of pupils. The development of "self and society" from child-parent relationships to self-nation relationships recalls Leonard Doob's' description of patriotism and nationalism as manifestations of family attitudes. 
The principles of logotherapy are useful here because they hold that "self-transcendence" means reaching out beyond one's own circle of interests, without abandoning one's own interests. The students see that they can work for the nation without giving up the self. They can help themselves by helping to make society better because they find personal meaning in taking on tasks and commitments for the sake of the nation. Logotherapy is useful, further, because it counteracts the students' feeling that their childhood, their family, their environment have determined the rest of their lives. They learn that they can always change, by expanding-and not rejecting-the values of their family. 
The University College students can be led to find meaning in changing their culture even ever so slightly, to make their mark, to bend history somewhat, and at the same time to express themselves by putting their intelligence to use, by achieving innovative solutions to their own problems, by helping others. Conflicts and frustrations arise when they are not given recognition for their contribution, especially if their intelligence and creativity is seen as not leading to the improvement of society. Conflicts 
Louis L. Klitzke 
also arise when others indicate that the students' expressions do not fit "our way of life." 
The students want to identify with things that are positive interpretations of their own history and the history of their country. Perhaps this explains why some expatriate teachers are not accepted by students. Teachers justify their being back in Tanzania in terms of what the students lack. They come with an attitude of "helping the Africans" solve their problems and meet their needs. Consequently the teachers unintentionally appear to the students to be negative, to talk down to them, to belittle them. Psychologists and sociologists are particularly vulnerable in this regard. Outsiders are inclined to overemphasize the people's needs and shortcomings to justify their own presence in the country, without enough emphasis on the positive aspects of the people's potentials and their history. Compliments and the ensuing feeling of confidence are vitally important to the students. Of course, this may also be true elsewhere, but it is certainly true at University College. President Nyerere is trying to encourage selfconfidence by urging his people to commit themselves to "intelligent hard work" and self-reliance. Meaning is found by one's desire to improve society. 
Frankl's "will to meaning" as the main motivation for living and acting is an important concept here. Motivation for the students goes beyond their desire to live, to learn, and to continue their culture. They are also motivated by the commitment to build a new culture where more selfexpression is possible and where positive experiences will lead to confidence. 
ATTITUDE AND VALUES 
President Nyerere and his cadre of leaders are asking the people to change their attitudes toward work, education, achievement, and themselves. But they do not want them to change the value they place on sharing, cooperation, accepting others openly, and the dignity of work. Nyerere sees the Tanzanian society based on three principles; equality and respect for human dignity; sharing of the resources which are produced by their own efforts; and work by everyone, exploitation by none. Everyone, including the expatriate, is charged with the responsibility to help this sort of society to develop. Nyerere wants his people to break away and develop, but with their feet firmly planted on solid values relevant to Tanzania. 
Frankl' writes, "man's search for meaning and values may arouse inner tension rather than inner equilibrium. However, this is precisely what is an indispensible prerequisite of mental health." Barry and Wolf1 write: "another important characteristic of the motivations is that they always produce conflict in the individual. Man's struggles to live, learn, 
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perpetuate, express, and enjoy himself often run counter to each other." In a way, President Nyerere is asking his people for a reorientation toward the meaning of their lives. He seems to recognize that inner equilibrium will not produce the innovation, problem-solving, and self-reliance the country needs. Logotherapy has been of value because it diagnoses and deals honestly with the pain existing in emerging countries as they face new meanings. 

Horowitz' summarizes a great deal of sociological and anthropological research and experience into one idea: developing peoples are usually unsure and therefore it is difficult for them to make decisions of commitment. Taking full responsibility for their actions is not their usual way. Yet President Nyerere and other leaders in emerging countries are asking for precisely this. The result is an existential frustration during the post-independence period of a new country. A high desire to eliminate the dependencies upon the colonial mother country is present, but not enough people are qualified to "Africanize" all the important posts. Some tribal traditions and attitudes seem to be a detriment to development, but people are unsure how to integrate or replace them. Which traditions are benign, which harmful? Which are still meaningful and purposeful? Who decides? 
This existential frustration is apparent in the students. They want to learn the new, the modern; yet they seem to resist that which is different. It is difficult for these youthful aspiring leaders, with one foot in the past and the other in the future, to reconcile the intrinsic struggle between their being and their becoming. 
The existential conflicts arising from the being-becoming and the continuity-change paradoxes are conflicts that must be studied and understood together because they are experienced together. There is an interplay between social order and being, social change and becoming. Logotherapy is well suited to help solve these conflicts because its philosophy recognizes existential conflicts and it has developed methods to deal with them. 
LOUIS L. KLITZKE was a lecturer in Educational Psychology, University, Dar es Salaam, Tanzania. This essay is based on material from his article in the Journal of Humanistic Psychology, 1969, 9, 105-126. 
REFERENCES 
I. Barry, R. and B. Wolf. Motives, Values, and Realities. New York, Teachers' College, Columbia University, 1965. 
2. Doob, L. Patriotism and Nationalism: Their Psychological Foundations. New Haven, Yale University Press, 1964. 
3. 
Frankl, V.E. Man's Search for Meaning. Boston, Beacon Press, 1959. 

4. 
_____. "Self-Transcendence as a Human Phenomenon." Journal of Humanistic Psychology, 1966, 6, (2). 

5. 
Horowitz, I.L. Three Worlds ofDevelopment. New York, Oxford University Press, 1966. 


lnrcrnatinnal Forum fen Lugnthctapy Vol. 4, No. 2, ral]i\\'irncr 1981 
Applications in Korea 
Byung-Hak Ko 
For the past year I have added some logothcrapcutic methods to my general practice for psychiatric patients, primarily those suffering from anxiety phobias, neurotic and psychotic depressions, obsessive compulsions, insomnia, and psychosomatic illnesses. 
From my experiences, I would say that there are no culturally determined limitations to logotherapy. The reason for this cultural boundlessness is that the dimension of the spirit is universal, therefore the basis of logotherapy is applicable in all human circumstances and cultural backgrounds. While differences exist in the human spirit between individuals, accounting for their uniqueness, no such difference exists between cultures. There may be socially and culturally conditioned variations and emphases, but the interaction between the spirit and the psycho-physical dimension is universal; that is, every human being can use the resources of the spirit to take a stand toward and even against limitations of body and psyche. 
In Buddhism, humanity is divided into three categories: the high rooted, the middle rooted, and the low rooted. To the first category belong those who have been given the mercy of Buddha from birth; to the second belong those who have the potential of obtaining the mercy of Buddha-and so may become a Buddha if they try hard enough; and to the last belong those who are unable to become a Buddha regardless of how hard they try. Almost all human beings belong to the middle rooted. 
I would like to think that this classification is based on an innate individual spirituality which may or may not be seen but can be recognized by its effects such as humor and self-transcendence. However, the highrooted and middle-rooted person can sometimes become low-rooted as a result of somatogenic (brain) disorders. In such cases, medication may be used to cure the disorders or at least alleviate the symptoms, and thus help the patients regain access to their spiritual dimension which, according to logotherapy, may be blocked but is always existent. In such cases logotherapy can be applied after the block has been removed (by physiotherapy or psychotherapy) to help the patients regain their potentials which may have been weakened or ignored during their sickness. 
A 17-year-old high school boy had been treated for first-ranked Schneiderian schizophrenic symptoms. The acute symptoms had subsided but he had a strange complaint. 
UJYl-3379/8/ I /500-0089$00. 95 89 1981 Human 5icu'!U'('5, Pre.\'.\' 
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"Sir, I cannot keep myself from persistently thinking of pretty girls I meet. The more I try to stop myself the more their pretty faces cling to my mind. What can I do?" 
"These images trouble you, don't they?" 
"Yes, I am afraid they will become another recurrent symptom." 
"I don't think so. I don't think that a young student imagining a pretty girl is abnormal. If I were you I'd rather be happy to imagine such pretty girls. (He smiled and the residents, the senior medical students and the nursing student in attendance laughed). Please continue to imagine the last girl you saw. (He and the others laughed again). Only promise me that you will think of a pretty girl at least once every half hour. I see you have an alarm wrist watch. Set it for every half hour so you won't forget. Promise?'' 
"Yes, sir." 
Two days later I asked him about the girls. He admitted he imagined them only two or three times a day. I pretended to be angry and asked him to try harder. After all, he had promised. 
Two weeks later he was trying in vain. The girls were gone. His therapy continued, on an outpatient basis, mainly by neuroletics, to ward against a relapse. His social life was fair. 
This variant of paradoxical intention prevented him from being caught in a circle of fear that something which was quite normal might grow into another "symptom." But not all patients can raise themselves from a lowrootedness, especially those who have no sense of humor, whose sense of humor cannot be mobilized. 
A 65-year old grandmother suffered from insomnia. Nothing physically or emotionally abnormal was found. I tried to find a way to use paradoxical intention: "Why try to sleep? We all spend a third of our lives sleeping. If you sleep one hour less every night you can live one hour more during the day. Don't you want to live more? Try not to sleep instead of trying to sleep." 
"Don't joke, doctor. I cannot live with sleeplessness." 
I prescribed microcirculation-improving agents and sleeping pills. 
ZEN BUDDHISM AND TAOISM 
Because the existential quality of the self and transcendent quality of the conscience are functions of the human spirit, I would say that Frankl's spiritual dimension implies the same as the highest good in the human being as seen by Zen Buddhism and Taoism. The ideas of nonattachment, enlightenment (satori, spiritual breakthrough) in Eastern cultures are 
Byung-Hak Ko 
expressed by the image of flowing with the stream of life. In Western terms they come close to responsibleness and maturity. 
The parallels become apparent when we understand the Taoist philosopher Chuangtzu's explanations of three concepts: emptiness, "being seated in forgetting," and the brightening of the morning. 
Emptiness. Do not try to hear with the ear (somatically), do not try to hear with the mind (psychologically), but try to hear through the spirit. The functions of the ear are limited to the sense of hearing, the functions of the mind are limited to phenomena and conceptions, but although the spirit has no content-emptiness-it can accept all situations of change. Tao is "being in this emptiness," which is like a gleam let into a dark room, illuminating and warming everything around. 
"Being seated in forgetting." This represents forgetting the self and all beings in a broad sense. This forgetting takes place any time and under any circumstances. 
The brightening ofthe morning. Human beings can transcend themselves when they can transcend their attachments to life. Their minds then come into a state of brightening of the morning and can see not only the reality of the self but can transcend present and past, life and death. According to Chuangtzu, we can attain this state by experiencing, feeling, and passing through the trials of life and sufferings. As Frankl lived through the concentration camps, a man who can confront death in a positive way can transcend his own death, and meaning will be revealed to him through the choice of his conscience and the power of his spirit. 
DEATH PHOBIA 
The success or failure of logotherapy depends on the therapist's spiritual power and his ability to mobilize the power of the spirit in the patient. Paradoxical intention and dereflection are two of the main techniques to trigger the functions of the spirit more intensively. But the therapist who relies only on techniques will fail; the success depends greatly on the interrelationship between therapist and patient. It is difficult to describe case histories since the relationship between the spirits of the two persons does not lend itself to clinical description. 
Mr. T, 37, married, an only son, chief manager of a large company, lost his father six years ago through a sudden stroke. Since then, T. suffered from a death phobia and several somatic and emotional symptoms he associated with his father's hypertension leading to his death: dizziness, palpitation, blushing, perspiring, and disturbed sleep. He avoided official meetings that were part of his job. Previous therapy had included 
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medication which improved his sleep, but did not remove any other symptom sufficiently. When he came to my office, he was accompanied by a friend and reeked of alcohol which he usually drank whenever he faced an anxiety-provoking situation. Medical examinations did not reveal any organic pathology. I had him make a list of situations that provoked anxiety, and asked him to mark several such events he anticipated within the next few days. 
"The worst is an official meeting with about 100 people, to discuss future plans for my company." 
"What do you expect will happen to you in that meeting?" 
"I am sure I will have severe dizziness, perspiration, palpitations and choking. I won't be able to stay in that room-this has happened to me often these past six years." 
"You become afraid in such a situation, don't you?" 
"I don't want to let my fear show before such people. If I collapsed and lost consciousness, what would they think of me? It is so terrible that I cannot cope with it, it's shameful too." 
"What do you do in such situations?" 
"I usually run out to a nearby clinic to be sedated by an injection." 
"You are afraid of dying like your father, aren't you?" 
"Yes, that's true. I am always in fear of a sudden stroke, and death." 
"Imagine you died in front of these people. Would you feel any shame and fear in death?" I described paradoxical intention, how it works, and my experiences with it. 
"You mean to say, doctor, I should try to make my condition worse?" 
"Exactly. At the meeting, try to be more dizzy, have faster palpitations, and choke more. Try to die in front of the people." 
Together we made up the phrases he was to say to himself, paradoxically intending to blush, to sweat, to choke, to die. He seemed to be amused in finding some absurd formulations. When he left, he said smilingly: "I'll try. I'll venture my life." 
The next time he entered my office cheerfully and reported success. I prescribed tranquilizers for severe sleep disturbances, and we practiced some Zen exercises in preparation for saying to himself his paradoxical phrases. 
During the next five sessions he reported new experiences-climbing mountains he had not been to climb for years, going to a public bathhouse, being able to go anywhere he wanted. After 12 sessions his symptoms had almost completely disappeared, the tranquilizers were gradually withdrawn, and the therapy was terminated. 
The longer I work with logotherapeutic methods, the more I become convinced that the therapists, too, must become the type of human being 
Byung-Hak Ko 
able to utilize their spiritual powers spontaneously-unintentionallywithin themselves. Here lies a fertile field of future research, and in concert with this method I would suggest some kind of Zen training or meditation. 
BYUNG-HAK KO, M.D. is assistant professor in the Department of Psychiatry, Chungnam National University, School of Medicine, Republic of Korea. 
THE SECOND WORLD CONGRESS OF LOGOTHERAPY 
The Second Congress of Logotherapy will be held at the new Parkview Hilton Hotel in Hartford, Connecticut, from Thursday, April 22 through Saturday, April 24 (please note the changed date from that announced in the last Forum). 
The Congress will be sponsored by the Institute of Logotherapy, in cooperation with the University of Connecticut School of Social Welfare, Division of Staff Training and Education for the Profession. The general theme, "Logotherapy-Education for Responsibility," will be addressed by the special guest speaker, Dr. Viktor E. Frankl. Other sessions and discussions will also deal with the theme of education. Special emphasis will be given to the areas of individttal development, social implications, moral and ethical considerations, and cross-cultural relevance. The program wiII also include a diverse and interdisciplinary series of addresses, symposia, panel discussions, and workshops dealing with the application of Logotherapy to the fields of medicine, psychiatry, psychology, philosophy, religion, applied health sciences, social work, and counseling. Among the planned sessions is a presentation aimed at the business community for the integration of Logotherapeutic techniques in personnel management. 
Registration at the door will be $30 (Institute members $25), but a preregistration price is offered to those registering by mail before February 
15. Preregistration is $25 for nonmembers of the Institute, $15 for members, full-time students $15. New membership will be accepted together with the preregistration. 
Send preregistration and check to the Institute of Logotherapy, 1 Lawson Road, Berkeley, CA 94707. 
Send papers or inquiries about papers to Professor Sandra Wawrytko, Ph.D., Director of the World Congress of Logotherapy, Department of Philosophy, San Diego State University, San 9iego, CA 92182. 
Hotel reservation blanks can be obtained from the Institute of Logotherapy. Single rooms at the Parkview Hilton will be $52, doubles $68. Rooms in nearby motels will also be available. Specific information about reservations may be obtained from Professor Norman Goroff, Ph.D. Chairman of the On-Site Committee, World Congress of Logotherapy, University of Connecticut, 1800 Asylum Avenue West Hartford, CT 06117. 
International Forum for Logolherapv 
\'ol. 4, No. .2, l---all/W'1ntcr 1981 
My Use of Logotherapy with Clients 
Edith Eva Eger 
Man's Search for Meaning, which I read as a university student had a profound effect on my personal and professional life, partly since I had similar experiences in German concentration camps. The book provided me with a view of human nature, a philosophy, a usable methodology, and specific helping techniques which I was able to incorporate, with some variations, into my therapeutic efforts with clients. 
To Frankl, mental health is a dynamic state, and not merely a matter of inner equilibrium. Mental health is based on the tensions resulting from the polarity between what we have accomplished and what we have further to accomplish, how we are and how we perceive we could be. Logotherapy suggests that health requires a noodynamic state (as contrasted to a homeostatic state) in which spiritual dynamics occur "in a polar field of tension where one pole is represented by meaning to be fulfilled, and the other pole by the person who must fulfill it."' I shall discuss six aspects of logotherapy which I have found relevant in my work with clients. 
HUMANS HAVE THE "DEFIANT POWER OF THE HUMAN SPIRIT" 
This aspect of logotherapy emphasizes the essential nature of humans as being free, able to take a stand, to find meaning, to make choices. They are not merely the slaves to their animal instincts, drives, impulses. I remember while in Auschwitz that I made a conscious decision to survive. Different people in this same situation responded to the same outward circumstances by different choices. Some chose to "give up," and in a little while, although there was nothing organically wrong with them, they lay down in the fetal position and died. Some chose to walk into the power-fence and were electrocuted. Others chose to pick fights with the guards, and were either shot or taken to the gas chamber. I particularly remember what happened in April of 1945, two weeks before liberation, when our rations were nearly exhausted, and the ordeal of our confinement had drained us to the lowest physical and psychological ebb. The inmates of my camp were 
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Edith Eva Eger 
gathered in the middle of Gunzkirchen Forest when suddenly cannibalism broke out. When this happened, I made up my mind that I would never eat human flesh. On a lovely warm spring day, I remember sitting in a field. I was weakened with hunger and fever. I sat there and studied the grasses around me, and I chose to eat one kind of grass over another. 
Between stimulus and response, there is an intervening variable, the existential choice, the freedom to choose our attitude toward any given external stimulus. 
No matter what their personal crisis, I guide my clients to see that they still have the freedom to choose their attitude toward their situation, that they have the power to make a decision which is put into action. They have the power to say "yes" or "no" to any happening, to mentally control the circumstances rather than being controlled by them (i.e. smoking, drinking, etc.). If the clients do not reach this insight, and if they do not use the resources of their spirit, then their habits, their compulsive behaviors will continue to control them. 
"You know, that really wasn't me," I frequently hear clients say about some undesirable behavior of theirs. I always ask them, "Whu was it?" I will point to them and say, "In one way or another, you must take the responsibility for choosing: you can decide whether you will 'eat one blade of grass or another!' '' 
For related reasons I am careful about arranging for the medication of my clients because they might feel that the medicine caused them to make a decision. They must not use the "cop out" that they are unable to take care of themselves, unable to make responsible choices. Throughout the ages, women have been encouraged to be like children, not to make responsible decisions. Society has brainwashed women into thinking that they cannot take care of themselves. Society has, in subtle social ways, kept women like children. But one thing I learned in the death camp is that people who were passively "waiting" to be rescued were pushed from one situation to another, and they did not make it. What was required was a positive "will to live," the ability to size up situations quickly, to make decisions and act upon them, even though risk was involved. Many clients are afraid to risk, fearing rejection, a wrong choice, anger, or being hurt, so they stay in a cocoon, withdrawn within themselves. They choose, for whatever reasons, a child-like, passive state, depression, inaction. Overdependence equals depression. The logotherapist guides them to choose, to risk, to act. 
HUMANS CAN FILL THEIR EXISTENTIAL VACUUM WITH 
MEANING 
Many clients who suffer from depression really suffer from their existential vacuum. They are bored, they lack goals and personal aims, they 
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lack some dynamic aspect of personality. The depression is the manifestation of a personal message, accepted at some point in their development, that life is meaningless. Their depression may be a subtle form of rebellion against a self-imposed lifestyle of blind conformity, submissive adherence to the requirements of a group, or to some demanding authority. 
In treating depressed clients who fit this description, I listen to indications from them that allow me to suggest viable options to fill their vacuum. I challenge them to plan short-and long-term goals, to design a specific routine for each day, to be creatively active rather than passive. Once I know their interests, I may suggest classes to take, or the keeping of a diary to make them aware of their negative choices that sabotage their own goals. Frankl once described himself as being "an ophthalmologist who helps people see." I see myself as a museum guide who, on my "tours," points out various opportunities and options, and lets the individual clients choose what they want to see, enjoy, or linger over. Our clients have the ability to think, and we must urge them to use it. I assist my clients in confronting what seems to them a gigantic task-taking full responsibility for ordering their lives positively-by breaking the task down into small steps. My effort is to get some action, to somehow get the client "off center." 
THE USE OF PARADOXICAL INTENTION 
In using paradoxical intention I encourage clients to face their fears, especially a specific phobia. One of my clients suffered from an obsessive fear that she was "going crazy." I urged her to go crazy right in my office, where she could receive attention and care. However, the more she tried to "go crazy" the less she was able to do so. 
One unusual case of paradoxical intention (along with some treatment of stuttering and insomnia, similar to those reported in the literature) concerned the phenomenon of demon possession. The patient called me at two-thirty a.m. requesting an emergency session. He complained of such great fear and terror during the previous days, that he felt he would "blow up." The fear was nameless and powerful, verbalized as a sense of a demonic presence. The patient had been told during childhood, by a grandmother, that if he did anything bad the "devil will get you." 
A version of paradoxical intention, laced with humor and activated through suggestive verbal imagery, relieved the patient's internal pressure. He described this pressure as growing stronger, going to the top of his head, and giving him a feeling that he would explode. My immediate goal, therefore, was to desensitize the patient to the fear, and to provide him with an instrument that might later help him deal with similar experiences 
Edith Eva Eger 
without outside intervention. I felt this would raise his self-esteem, his independence, and make him function better. 
I asked the patient to relax in a soft chair. Through a dialogue I evoked verbal imagery to create an exaggerated emotion of terror. I asked him to open his eyes wide and look at me, thus favoring spontaneous laughter and interjecting natural humor into the exercise. After fifteen minutes of dialogue, the patient was relieved of the crisis fear. We achieved reorientation through dialogue, by having the patient recognize the relationship between his present behavior and the origins of the crisis situation which allowed dormant fears to become "payoff" items in the present. At one point in the dialogue, as we mimicked the evil looks and vile words of the devil, the patient stopped and said, "I wonder if the devil is really as stupid as we seem!" Frankl's theories were the key for attempting the method used in this case. 
Paradoxical intention makes use of the human capacity to laugh at the world and at oneself, even though there is anxiety, stress, and fearful concern. Even at Auschwitz, humor was a saving means for personal survival. The prisoners found distance from their fate by joking about their powerlessness and complete inability to change anything, and that ability to laugh added a bit of sanity to a senseless situation and made it more bearable. 
On arrival in Auschwitz my older sister Magda and I were stripped naked and our long hair was completely cut off. Magda had long, blond curls and was in the habit of tending them for hours. Now she was standing there in a state of utter humiliation. When she asked me how she looked, I said to her, "You have very beautiful eyes!" 
I recall this incident whenever I have depressed clients who tend to see the dark side of everything and consider most things, situations, and relationships, pessimistically. In counseling the depressed, I look for something about them that may be good, or at least not all bad, and which tends to break their circle of foreboding. I will say something like, "You have a beautiful complexion!" When they respond negatively, I say to them, "Convince me that you don't have a beautiful complexion!" Since they cannot do this, we indirectly and humorously establish a bit of lightness and positiveness. I may also point out to the client who feels he can do nothing right, "Oh, but your pants are not on backwards," or, "Your blouse is buttoned correctly." 
FACILITATING AUTHENTIC SELF-EXPRESSION 
Some difficulties clients experience come from a thwarted selfexpression. Suicidal teenagers, youthful and adult drug abusers, and 
International Forum for Logotherapy 
alcohol users with control problems need to discover themselves on their own. Teenagers often want to assert their own individuality, especially when they have not been allowed this freedom, usually by parents who too rigidly have regarded them as mere extensions of themselves. The children find themselves being compelled to live up to their parents' expectations rather than their own. Frankl talks about the fact that, depending on the way we are brought up, we either have to do what we are told to do, which constitutes totalitarianism, or we are asked to be like someone else, which constitutes conformism. Between these two, no room is left for individual expression. In totalitarian homes the self-esteem of the children tends to be low because the rules are so rigid that the children have no opportunity to participate in any kind of decision-making. 
To carry this further, the ideal interrelationship between married couples requires an "I-Thou" level of personal regard, individual expression and awareness arc needed long before marriage, within the nuclear family. Many parents, however, cut off such individual expression in their children. This authoritarian approach pushes children into a "tyranny of shou/ds" which is not a casual matter for them, but a survival issue because they fear that if they do not conform, their growth supply might be cut off. 
The rigid rules and patterns, learned in a totalitarian family, often are carried into a marriage and the creation of a new family. A husband or wife makes demands, requires each partner and children to behave in a certain way. They say, "This is the way it will be," rather than, "Wouldn't it be nice if.... " They require rather than inspire. They do not accept individual differences. They are basically insecure, and incorrectly assume that no one can ever replace them. Such an attitude leads women to feel genuinely that they "cannot make it by themselves outside the marriage." Children from totalitarian homes tend to create another totalitarian home in which they feel they must punish any infringement of their own will by their offspring. The only real language that couples in such homes understand is: Power! There is always a Victim and a Victimizer, one who is Ordered and an Orderer. In their relationship, someone is always "on the top," and someone always "on the bottom." There is no mutuality, no walking together. 
In treating such couples in sexual therapy, I discover that sex is viewed as something that is "done to" rather than "with." One partner must conquer, the other must surrender. Such couples, have to be led to see that "sex is communication," that a sound marriage is built on good communication, both verbal and physical. Intimacy in marriage cannot exist without basic trust. Logothcrapy, as it focuses on the individual through its Socratic dialogue, strengthens the clients' awareness of their individual assets. They gain in self-confidence and soon the need for having a "scapegoat," someone to dominate and blame, diminishes and 
Edith Eva Eger 
disappears. Once an atmosphere is created where individuals do not need to have absolute control, they can "give up" control and power, and can trust themselves in the hands of another individual such as a spouse. Control is no longer an issue, mutual interdependence comes to the fore, the "I" and "Thou" is established between the couple, they become a team rather than being exclusively in a relationship of Leader and Follower. 
Sometimes I use the symbol of dancing in marital counseling. In the dance there is an harmonious trust in the leading-following and in the tempo and rhythm of the marriage. Ballroom dancing requires a weaving together rather than a pushing and a pulling. I once told a wife that she was like someone dancing alone, on her toes, anxiously, as though on eggs, afraid of cracking them. She was dancing in an unnatural fashion and her effort was doomed to failure because what she attempted to do was not genuine nor her true self. Nowadays, many popular dances do not appear to require much togetherness, and the emphasis sometimes seems to be individual gyrations and impersonal performance. Nevertheless, dancing with someone always requires mutual agreement, cooperation, a desire to be together in following and leading, and although it takes some discipline, it is more fun than dancing alone. 
THE "ACT AS IF" PHENOMENON TO FACILITATE PERSONAL CHANGE 
This technique helps persons to "act as if" they were the persons they are capable of becoming. In therapy, for example, clients are treated with basic human respect, "as if" they were actually their best selves. Generally, this is a good approach with all people, and I try to observe it even in dealing with murderers. The client may be a criminal, but is still a human being who deserves to be treated as such. 
The idea behind this approach is logotherapy's belief in the existence of the human spirit which is found in all persons although it may be housed in a defective body or psyche. Failure in one area does not mean that a person "is" a failure and must fail in all areas. We must acknowledge those areas of a person's life which are as they should be. A human being should not be "crossed out" simply due to a failure in one part of his or her life. Depressed persons view the world and themselves as totally black or white, all one thing or nothing. This negative perception emerges from a negative state of mind. 
The "act as if" approach works well, especially with adult women, in helping them build their self-confidence, but I have used it successfully with teenagers and with men. For example, I will ask a young man who is shy, "Who is your ideal, the person you would most like to be?" I will gather in 
International Forum for Logotherapy 
this way a list of traits and characteristics which I write out. Then I urge this man to place the list on a wall where he can see it, and where it can encompass him totally. This list is to become part of the person he wants to become, as it embodies the desirable traits satisfying to him. I will encourage the young man to "act out" the desirable traits, on a day-by-day basis. He will start out clumsily at first but gradually the admired traits become part of his character. And, doing this, he will discover what his own expectations are rather than those of mother or father or anyone else. 
MAKING A HIERARCHY OF FEARS 
This is a useful technique in challenging phobias. I help phobic patients to arrange their fears, from the least anxiety-producing to the worst. We start from the bottom up, and gradually the patient is helped to gain confidence and strength in overcoming the phobic system. The least anxiety producing situation is gradually faced first, the next one is then addressed. For example, with a male client who was deathly afraid of heights, I started out by having him stand on the kitchen table, providing emotional support by talking to him all the time. Then I took him to a balcony on the second floor, and later to the fifth, always talking to him. While this is not a logotherapy technique per se, I have found it useful in helping people reach the goals of logotherapy. I also have found it effective in treating various phobias associated with sexual dysfunction. For example, a woman who really loved her husband, had developed an irrational fear about her mate's sexual organs. She would actually get sick at the prospect of having sexual intercourse with him. The husband thought his wife did not love him when the real problem was that she was afraid of close physical contact. In this case, we employed the hierarchy of fears by having the woman daily touch flowers, then her cat, touch and hold her children when they arrived from school. Gradually she was urged to touch and stimulate herself sexually, while looking at herself in a mirror. Then she was asked to touch her husband, without any demand for genital contact, and then she was finally able to fondle his sex organs and, of course, soon my prohibition against genital contact with her husband was completely forgotten. As a matter of course, dereflection also was part of the therapy. 
EDITH EVA EGER, Ph.D. is a licensed clinical psychologist and a national and international consultant. 
REFERENCES 
I. Frankl, Man's Search for Meaning. New York, Pocket Books, 1963, p. 166. 
International Forum for Logotherapy 
Vol. 4, No. 2, Fall/Winter 1981 
Rehabilitative Nursing and Logotherapy: A Study of Spinal Cord Injured Clients 
Patricia L. Starck 
Health care in contemporary society seeks to promote the highest quality of life rather than simply the cure and prevention of disease. Yet, the objective of satisfaction and fulfillment in life may seem beyond the reach of many who are physically disabled and must struggle to maintain survival, having little energy and few resources to face the frustrations that never cease when living with a disability. 
One of the most devastating of all long-term physical disabilities is that of spinal cord injury (SCI). Each year approximately 30 people per million population sustain SCI, amounting to some 10,000 to 20,000 new cases per year. Furthermore, the incidence rate is highest for initial injury among 15-20 year olds in the prime of youth. It is estimated that only 20% of SCI clients are successful rehabilitation candidates because certain characteristics are usually needed, such as educational background and supportive family. The remaining 80% represent a significant challenge to the health care profession. 
NOOGENIC PROBLEMS 
Evidence of existential vacuum or problems of a noogenic origin are suggested by findings from Hopkins6 that the suicide rate for the disabled is higher than that for the general population. Other studies have documented that between 12-48% of deaths among persons with SCI can be related to self-destructive behaviors. According to Seymour, some SCI clients who do not find adequate rewards in life cease to care for their bodies and commit "psychological suicide" through self-neglect. Such self-neglect behavior includes inadequate fluid intake, failure to relieve pressure on skin by turning or lifting up in the wheelchair, and exposure to inclement weather. 
U/9I-3379,RI, 1500-0/01 $00.95 101 ,-198/ lluman Sciences Pre\.\ 
International Forum for Logotherapy 
STUDY OF PURPOSE IN LIFE IN SCI CLIENTS 
In delivering care which optimizes health and well-being in SCI clients, the question arises as to meaning and purpose of the disabling condition and subsequent modifications required in lifestyle. Can the 21-year-old football player suddenly rendered a victim of total body paralysis find a reason to go on, much less find a unique life task to be accomplished? If not, then why not commit physiological suicide? The challenge to healthcare professionals is to find the key to motivating behavior; to guide the client in developing an attitude toward a fate that cannot be changed. 
In my experiences as a nurse, I had observed that some clients with a physical disability would take to their beds and become hopeless invalids while others with the exact same disability would overcome great odds to achieve extraordinary feats and serve as an inspiration to others. I also observed that the successful clients had positive attitudes and feelings that their lives had purpose and meaning to self and others. It seemed a valid assumption that promoting successful coping behaviors enhances rehabilitation. 
Building on the work of Crumbaugh and Maholick who designed the Purpose In Life (PIL) test, and the work that has been done in testing normal populations as well as clients with mental health problems, I extended the scope to the physically disabled by administering the PIL to a sample of 25 SCI clients referred by the staff of a regional spinal cord injury center within a university medical center. Criteria for participation in the study included: 
1. 
Residency in the immediate vicinity of the county in which the medical center was located 

2. 
12 months or more post injury 

3. 
Incomplete achievement of potential according to 

4. 
Willingness to sign the informed-consent form. 


a.  self-care activities  
b.  psychological adjustments  
c.  vocational attainments as judged by nursing personnel  

The clients were randomly assigned to control and experimental groups. All clients were pre-and posttested using three instruments-the Purpose in Life test, the Seeking of Noetic Goals test, and an investigator made tool which assessed client needs. Nursing care using Frankl's logotherapy approach was given to clients in the experimental group through six home visits over a fourmonth-period. At the end of the period all clients were asked to evaluate the experience using an anonymous, mail-in response. A total of 102 home visits were made by one investigator. The retention of subjects during the study period was 100 percent. 
Patricia L. Starck 
Demographic Data 
Of the total study group (N = 25), 60% were males; 40%, females. Fifty-six percent of the subjects were black; 44% were white. Educational level ranged from Grades 1-5 (4%) to 3-4 years of college (4%). Only 16% of the clients lived alone, the remaining 84% lived with spouse, parents, or others. The majority (52%) had incomes below the poverty level of $6000 per year, and 76% had incomes below $9000. All clients were unemployed and all were in wheelchairs. 
Framework 
To conceptualize the client dilemma, a model was constructed (see Figure I) using Frankl's theory of the will to meaning. The human person is seen as having a core of needs as described by Maslow. Maslow's philosophy seems consistent with that of Frankl in that Maslow declared that an individual's inner nature persists even in the face of sickness or denial, and that each person has a tendency to press toward the realization of one's potentials and the fulfillment of a mission in life. 
The model reflects the person as surrounded by life experiences. Significant events include birth, growth, development, change, and death. Pain, suffering, illness, and disability, as well as positive experiences, would be a part of this circle. The environment surrounds the person and the life experiences and influences both. One's environment has a positive or negative effect on the core needs of the person. 
The person, the life experiences, and the environment are seen as a unit which can fluctuate in movement toward no meaning and existential vacuum or toward meaning and purpose in life. The pathway to existential vacuum is seen as selfindulgent hyperreflection, or being overly concerned with the self. The pathway to meaning and purpose in life is seen as self-transcendence or getting outside the self in fulfilling unique life tasks. Movement toward either end is controlled by factors intrinsic or extrinsic to the person. The nurse or helper can intervene at the level of intrinsic factors by (a) becoming involved, (b) stimulating motivation for search for meaning, (c) guiding the client in choosing meaningful direction, (d) lending strength, and (e) facilitating the experience of hope. The helper can also intervene at the level of extrinsic factors to manipulate the environment to assist clients to actualize potentials in their life experiences, and to be a client-advocate in capitalizing on resources available. 
Strategies designed by Frankl-paradoxical intention and dereflection-were used with the experimental group to guide their movement along the self-transcendence axis. Efforts were made to lead the client away from hyperreflective self-indulgent behaviors, such as exhibited by one client who had been shot 5 years ago. He was still consumed with bitterness and hostility, complaining of nightmares and lack of trust in others. 
Through the use of logotherapy this client participated in a project to assist victims of crime. He also did volunteer work at a nursing home. In sharp contrast to his earlier state of unhappiness, he later married and assumed the roles of husband and step-father. 
SCI clients must exert concentrated effort in meeting basic physiologic needs, such as drinking adequate fluids to avoid renal problems, shifting body positions at regular intervals to avoid pressure sores, and eating the proper diet. Clients who exhibit behaviors characteristic of existential vacuum often neglect these basic needs. Nursing personnel are continually frustrated because clients do not take care of themselves as they have been taught in the rehabilitation center. My approach is not 

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Fi!!ure 1. A Model for the Use of Loi:,otheranv in Rl'hahilitativP Nnr~in11 
Patricia L. Starck 
to focus on these bodily needs, but to assist clients to find meaning in their life conditions, and thereby give them a reason to practice good health habits. 
FINDINGS: TOT AL GROUP 
Comparison of the total group (N =25) of SCI clients revealed no statistically significant difference (p > .05) in either the Purpose in Life (PlL) test or the Seeking of Noetic Goals (SONG) test scores against the established norm values. This finding would suggest that SCI clients were no different from the general population in feelings about meaning and purpose in life. However, my clinical impression during first administration of the PIL suggested that in some cases there was a discrepency between the client's answer and the observations made in the surroundings. Some clients answered as if giving superficial responses. Other subjects appeared to use defense mechanisms, displaying a veneer of acceptance of all life conditions for which no immediate solution was visible, a forced cheerfulness probably conditioned by rehabilitative therapy or perhaps induced by society, to protect them from confronting painful situations with which they felt impotent to deal. For example, Client #9, a black male with a third grade education who was living alone replied very positively and indeed had the highest PIL pretest score recorded among the 25 subjects. While taking the PIL he responded by professing confidence in his unique purpose in life under the guidance of a grand design. However, after questions on the standardized tools, PIL and SONG, were completed and he was responding to the investigator's questions about need satisfaction, he quite unexpectedly began to cry, venting bitter loneliness and frustration with his inability to cope with the heavy burden of being handicapped and alone. It seems conceivable, then, that false highs related to superficial responses or defense mechanisms for coping may have been obtained on pretesting. Although clinical impressions indicated that some clients were responding more positively than observations would indicate as reality, no suggestion was made to correct the client's answer choice to avoid biasing client response as well as to avoid stripping the client of his defense mechanisms for coping. 
FINDINGS: CONTROL GROUP 
The control group (N = 12) members were visited twice during a four month period for pre-and posttesting. These clients received the traditional care for disabled clients in the home according to the established system of health care. Comparison of scores for the control group revealed a 
105 
International Forum for Logotherapy 
statistically significant drop (p< .01) from pre-to posttesting. In addition, there was a correlation of .87 indicating that client scores were fairly stable from pre-to posttesting. The conclusion, then, is that there was a consistent loss of scores rather than a few clients being responsible for the drop. Only two clients did not have a decrease in scores. Coincidentally, these two clients were married to each other, suggesting that they may have been able to lend support to each other as they pondered the questions on the tests they had taken. 
There are at least two possible explanations for the decrease in scores since the PIL had not been previously used with the physically disabled. The clients could have given false highs on the pretests and then given more realistic answers on the posttest, having given more serious thought to the reality of the situation. Client #10 who demonstrated the highest loss (25 points) had a burn on his foot which had occurred early during the study period and had not been reported until the investigator's posttesting visit. In the meantime, he had moved into a nice home with a female friend who was also in a wheelchair. This client had on pretesting expressed an attitude that was positive, self-assured, and confident in the meaning and purpose in his life and his ability to cope with it. In the second interview however, his responses were dejected, and seemed to follow a pattern of staying to the left of neutral regardless of the direction of the scale. This posttest scoring pattern raised questions as to the reliability of this subject's scores. Consequently, a third visit for informal discussion was arranged t0 probe gently his real feeling toward the meaning and purpose of his life. He was able to substantiate the answers he previously gave on posttesting. Although on pretesting he said he had never given suicide a second thought, on posttesting he indicated he had given it some consideration as a way out. During dialogue he said he must admit he had prayed while in the hospital that God would take him so he would not have to suffer anymore. In other words, he had been more open on posttesting on this item. 
A second possible explanation for a drop in scores is that taking the PIL and SONG may trigger reflective thinking and raise awareness about lack of meaning and purpose in life. If so, this situation may indicate that all such clients need professional help to resolve ambiguities about their lives. (Clients in the study were referred to the SCI center with an individual, written report for follow-up care.) 
FINDINGS: EXPERIMENTAL GROUP 
During the four month interval between pre-and posttesting, the experimental group received home visits from the investigator using nursing care based on logotherapy principles. There was no statistically significant difference (p>.05) in pre-and posttesting. However, nearly one-half of the 
Patricia L. Starck 
subjects showed a gain in scores over the study period. Furthermore, the two clients with the largest drop in scores had unusual situational stresses at the time of posttesting. Client #19 (19 point loss) began his first day as a student at the local university on the day after the first administration of the PIL and was very optimistic about his future. During the study period he had many struggles regarding transportation, tutors, and adjustments to college life. In addition, he reported having been ill with a temperature of 104 ° the day before the PIL posttesting. Client #21 had the largest number of loss points (33) of all clients. She was a sophomore at the local university. On the day of posttesting, she greeted me expressing grave concern for her future. She reported being on academic probation and expected a test the next day for which she felt unprepared with no hope of accomplishing all the assignments and correcting her academic standing. Such hopelessness caused her to recall other tragedies in her past life when she had shot and killed her stepfather while he was in a drunken rage and later when she herself had been shot during a lover's quarrel. Her answers on the posttest PIL reflected her unhappy feelings on this day. 
One of the clients who showed improvement during the study period was Client #24, D.L., a 17-year-old girl who had a score in the second percentile of normative scores on pretesting with the PIL. She was repeating the eighth grade for the second time and had poor attendarn.:e records this year. Her apathetic state is revealed in excerpts from my notes: 
There are many deep mud puddles in the yard. The front porch is made of wooden boards and there are many holes where the wood has rotted. 
D.L. is in the living room alone. It is sparsely furnished, everything looks old and tattered. There is practically no light in the room. She looks like a typical 17-year-old teenager with long straight hair and jeans, but she is sitting in a wheelchair. There is an air of sadness and depression in the way she speaks. She seems quiet and shy. 
As she is signing the consent form, her mother comes in the front door. She is a large woman, probably once attractive but now obese and weary with the responsibility of six children as a divorced woman, living as she says on only Aid to Dependent Children. She witnesses the form and signs Mother as D.L. is underage. 
D.L. 
admits that her main problem is boredom. She says she has no goals and responds to the question of where she would like to be in five years with, "I don't know. I may not even be alive." 

D.L. 
says she is taking ampicillin for kidney infection. I advised her to drink buttermilk to avoid secondary yeast infection. She says at most she drinks five glasses of fluid per day. Her urine is concentrated and there is a film on the bag. She seems disinterested in the cleaning procedure for the bag. She shows no enthusiasm for anything. 

D.L. 
was out of school again today. She appears listless and apathetic. Her hair is not clean, she looks depressed. 


International Forum Jor Logotherapy 
Over the study period, the relationship between D.L. and me deepened, and she began to show some response. In order to stimulate goal setting and to get her to dereflect on her present state of disability, I asked her to make a collage of what she'd like to be five years from now, with pictures from magazines. Each week I left her a card with a thought written on it. I asked her to think about it during the week, and we would discuss its meaning when I returned. Some of these thoughts were: 
Never to discover your own power and your own potential is to be mentally bedridden all of your life. 
What has being dependent on others taught you about life? ls there a meaning and purpose in having to depend on others? 
There were two frogs who fell into a churn of milk. One said I have no chance, so he sank to the bottom and drowned. The other said, "I may not have a chance, but I'll go down fighting." He splashed around and soon the milk had turned to butter, and he was al1oat on top. 
As D.L.'s emotional state improved so did her physical one. She groomed her hair better, was able to maintain eye contact, and she spoke with more animation. She asked questions about returning to the driver education program at the rehabilitiation center. Toward the end of the sessi.Jns she expressed an interest in vocational training for secretarial work through a local training center for the handicapped. She was scheduled for the preadmission medical examination during the fourth month of the study and planned to begin training in the fall when she would be 18 years old. She set goals to complete secretarial school and find a job within two years and to receive her driver's license by her next birthday. At last report she was well on her way to accomplishing these goals. 
CONCLUSION 
The use of logotherapy in rehabilitation nursing for clients with spinal cord injury and perhaps other long-term physical disabilites is promising. An evaluation by the clients revealed that they enjoyed the experience of taking the tests and working with the nurse in a new approach to meeting their needs and enriching their lives. 
The possibility of false highs on PIL pretesting needs attention. Recommendations for replication include using an investigator known to the client where such a relationship would promote realistic response. The 
Patricia L. Starck 
environment may also be important in the testing situation. Whereas in a hospital, a client expects to be tested, such is not the case when a nurse makes a home visit and raises the issue of determining need for help. 
Improvement in individual cases and a gain in score for approximately one-half of the clients in the experimental group imply that logotherapy may be beneficial for the physically disabled population. Strategies other than home visits conducted in one-to-one sessions, such as intensive therapy, group therapy, self-help groups, or peer counselling should be considered. A larger sample size could also establish valid baseline data for this population. 
Clinical impressions during the study indicate that the physically disabled client is eager for this type of care. Finally, there is great satisfaction for the professional who witnesses rehabilitative progress for clients as they find a meaning and purpose in their lives. 
PATRICIA L. STARCK R.N., D.S.N. is dean of the School of Nursing at Troy State University with programs in Troy, Montgomery, Dothan, Alabama. 
REFERENCES 
I. Crumbaugh, J.C. and LT. Maholick. "Purpose in Life Test." Munster, Indiana, Psychometric Affiliates, 1976. 
2. 
Crumbaugh, J.C. "The Seeking of Neotic Goals Tesl." Munster, Indiana, Psychometric Affiliates, 1977. 

3. 
Frankl, Y.E. Man's Search for Meaning, New York, Pocket Books, 1977. 

4. 
_____ . The Doctor and 1he Soul. (Paper) New York, Vintage Books, 1978. 

5. 
. The Unheard Cry for Meaning. New York, Simon and Schuster, 1978. 

6. 
Hopkins, M. "Patterns of Self-Destruction among the Orthopedically Disabled." Rehabilitation Research Practive Reviews, 3, 1971, 5-16. 

7. 
Kerr, W. and M. Thompson. "Acceptance of Disability of Sudden Onset in Paraplegia." Paraplegia, JO, 1972, 94-102. 


8. Maslow, A.H. Molivalion and Personulily. Harper & Row, 1970. 
9. 
Nyquist, R. and E. Bors. "Mortality and Survival in Traumatic Myelopathy during 19 Years, from 1946-1965." Paraplegia, 5, 1967, 22-48. 

10. 
Price, M. "Causes of Death in 11 of 227 Patients with Traumatic Spinal Cord Injury over a Period of Nine Years." Paraplegia, JI, 1973, 217-220. 

11. 
Seymour, C. "Personality and Paralysis I: Comparative Adjustment of Paraplegics and Quadriplegics." Archives of Physical Medicine and Rehabilitation, 36, 1955, 691-694. 

12. 
Wilcox, N. and E. Stauffer. "Follow-up of 423 Consecutive Patients Admitted to the Spinal Cord Center, Rancho Los Amigos Hospital, I. January to 31. December, 1967." Paraplegia, JO, 1972, 115-122. 


International forum for Logotherapy Vol. 4, No. 2, Fall/Winter 1981 
Suffering, Tension, and Human Service 
Arthur Hoffer 
Human service work deals with people who are suffering in a way that is interfering with meaningful functioning. Human service workers must be able to distinguish what constitutes human suffering and what doesn't. Unless they take a committed stand on what is and what isn't human about a human being they are prone to collude with suffering rather than eradicate it. Human service practitioners who comprehend the human state of affairs and what interferes with it, will want to help clients find meaning. By taking a stand for human re-emergence they must take a stand against any form of human injustice. They must challenge any action which is demeaning toward the individual or toward others. Their role is that of encourager. They must display the courage to interrupt actions that are humanly wrong and stand up for what is right from the human perspective. Frankl defines "good" and "bad" as "what promotes, or blocks, the fulfillment of meaning irrespective of whether it is one's own meaning or that of someone else" (p. 68). 2 
The goal of human service work is to assist clients to disentangle the confusion that suffering forces upon them so that they again can choose freely, and be in charge of their affairs. Clients are helped to change their perspective from that of trauma or tragedy to one of challenge and opportunity. The job of human service workers is to bring out the best in people. "Ifwe are to bring out the human potential at its best, we must first believe in its existence and presence" (p. 30). 3 
To bring humanization to the forefront in the human service field workers must, on an ongoing basis, rid themselves of the mechanical rigidities which operate out of their own past sufferings. They must humanize themselves. To convince clients that humans are a much better lot than they have been given credit for, workers must begin by coming to that conviction for themselves. Human services imply working in ways that empower the human to act. Rather than reminding clients of their weaknesses, we must remind them of their strengths hidden beneath the suffering. We focus on what is right with the individual, not on what is wrong. We remind people of their power to pursue a direction for themselves. It takes human action to ignite the power of another human. In one sense human service workers are rescue agents. Rather than rescue clients away from feeling their suffering, which is a subtle form of human 
0/91-3379 8/ "/500-0110$00.95 110 !9R I llwnan Science.s Press 
Arthur Hoffer 
betrayal, clients are rescued from succumbing to the tensions which hold in the suffering. 
In work which is worthy of the name human service, emotional tension such as fear and grief must be tackled head on if human capacities are to be mobilized. These tensions associated with experiences of suffering restrict entry into the noological dimension. The challenging task of humanization is separating the pain from the experiences or, to put it another way, separating the feelings that have merged with the facts. This separation allows clients to gain distance from the confines of their psyche and to dereflect their attention away from themselves to others. When emotional tensions are released from their hold on the person, the gateway is opened to the human sphere where intelligence or conscience can make sense of the suffering and then properly store the information so that it no longer remains a burden on the person. Helping in a human sense assists the client in detaching the hold of the past and placing it in its proper perspective, converting the past into an historical event rather than a recurrent one. When this process is accomplished the client can take charge of the information rather than being taken charge of by it. 
TENSION RELEASE-LAUGHTER AND TEARS 
To see how emotional or subjective tension is released, we must understand how tension release can be recognized. The two natural forms of tension release which particularly aid in the mobilization of selfdetachment and self-transcendence are manifested by laughter and tears. 
Laughter loosens the hold that embarrassment has on the individual. Embarrassment is an aspect of fear. Thus laughter dissipates the fearful emotional tension that holds the rigid fear pattern in its illogical place and begins the practice of distancing oneself from the pattern's hold. The technique of paradoxical intention becomes effective when laughter is elicited. Basically, paradoxical intention confronts the fear patterns through ridiculing and scorning the fear. This is accomplished by providing unsuspecting information to the psyche that upsets the control which the fear pattern has on the person. This allows the intelligence to take a peek at what is happening, recognize the absurd meaning of it all and discharge it with laughter. Laughter is a function of the noetic sphere. Only humans laugh. 
As far as we know, only humans cry as well. The process of tearful crying is a natural discharge mechanism that releases the tensions caused by the emotion of grief. Crying is a meaningful prelude to removal of the blocks that prevent ongoing human liberation. Tears drain the tensions from the 
International Forum for Logotherapy 
bad situation. For generations crying has been confused with being hurt, and so efforts are made to stop the crying in order to stop the hurt. Actually, tears are the evidence that the healing process is taking place from hurts resulting from past suffering. Accompanying the healing is the reemergent capacity to listen for and respond to the meaning of the present moment. 
"FREE" ATTENTION AND CONTRADICTION 
The way to facilitate tears is through free attention and contradiction. The "free" aspect of attention implies responding to others from a personal space devoid of self-preoccupation. Subjective bias stemming from past distress or suffering becomes suspended. Addressing our free attention outward to others provides the opportunity for them to do the same. The helper provides an environment of a benign reality which contradicts the distressed reality of the client's psyche. Basically, free attention is an act of self-transcendence and is actualized principally through nonverbal means. Warm, caring, unconditional attention from the helper provides a direct opposition to the suffering circumstances of grief lodged in the client's psyche and draws the client's attention away from his distress onto the healthy environment represented by the helper. Once the client's attention is equally balanced between the distressed internal subjective reality and the contrasting external objective reality of benign humanness displayed by the helper, tears tend to emerge spontaneously. These tears represent tears of relief from past grief or suffering. 
Along with the nonverbal free attention, tearful discharge is encouraged when verbalized messages containing emotional pain are directly challenged by contradicting messages which contain a truer statement of reality. Crying is facilitated by asking the clients to dereflect their attention away from the self-preoccupied messages of distress to messages that depict a more affirmative reality. 
A situation where a client was harboring doubts about her meaningfulness to her family may serve as an illustration. She was asked to state and repeat the phrase "my presence is very important to my family," which contradicted her feelings of insignificance. In addition, free attention was offered to allow her to discharge, through tears, some of the tension of grief caused by the misperception of herself as insignificant within her family. This process allowed her to see the meaning contained in the more accurate reformulation. She, indeed, was important and valuable. The discharge aided her in discovering the meaning of her value and helped her 
Arthur Hoffer 
gain glimpses of how her thoughts of being unimportant happened to get lodged in her psyche in the first place. 
This procedure must not be confused with asking people to repeat affirmations indiscriminately in the hope, if repeated often enough, they will become believable. Such repetitions are merely self-indulgence and do not engage them as human beings. When people are encouraged to contradict internal messages which are linked with past suffering, they benefit by the emotional discharge that will in turn free their intelligence to discover and act upon meaning. 
Both laughter and tears are instrumental for human re-emergence. Both puncture the balloon of tension so that air is released to allow room to breathe meaning in and out. 
RELATIONSHIP AND TECHNIQUE 
Human service workers must avoid the fallacy of thinking that giving help means the helping people become comfortable. Experiencing discomfort is appropriate and necessary, providing it relates to the felt tensions of the past rather than adding new discomforts. 
Here one should consider the relative importance of techniques and relationship. Frankl comments "one has long ago come to realize that what matters in therapy is not techniques but rather the human relations... " (p. 6)2 and further states "what matters is never a technique per se but rather the spirit in which the technique is used" (p. 28). 2 The helping professions have become technique-conscious without relation to an adequate philosophy of the human being. Techniques, however, can be used to manipulate clients and thus reify them. This danger is eliminated when clients are viewed from the human dimension. By stepping outside their psychological dimension, the clients are helped to understand that dimension, and thus can better understand and assess their particular ills. 
LOOSENING THE THINKING PATTERN 
Human service workers, through their capacity for self-transcendence, can relate humanly to clients and at the same time employ techniques that manipulate their distress patterns. Manipulating a pattern of thinking differs markedly from manipulating a person. The former is permissable and useful. A pattern of thinking is a rigid recording which has become installed in the psyche as a result of past experience with suffering. The person appears stuck with it, yet it is not an integral part of the person, only 
International Forum for Logotherapy 
a foreign attachment. Contradiction to a pattern of thinking is a manipulative technique designed to loosen the pattern's grip on the person fixated by tension. 
The successful loosening of a thinking pattern results in self-detachment for the client. Self-detachment appears to be a necessary forerunner to selftranscendent action. When a pattern of thinking is manipulated through contradiction, tensions are loosened, become conscious, and are felt. When this happens, the tensions can be spontaneously discharged if the environment is safe enough to permit it. Once tensions are released the person becomes more relaxed, and free to correctly decipher the meaning present in the environment. 
The rationale for the loosening of the clients' thinking pattern is to free their intelligence to pick up and act upon meanings as they present themselves moment to moment. The most meaningful techniques are improvisational-discovered or rediscovered in the momentary present. When helpers employ techniques unawarely or rehearse what techniques to use beforehand, the reality and meaning of the moment is lost. 
Human service workers must never forget that they are dealing with other human beings. They must pay attention to a whole dimension that has been largely disregarded and unrecognized even when it emerges. Helpers must operate from their human dimension to assist their clients with their (the clients') humanness. What prevents human service workers from functioning in a human way are their own patterns resulting from past emotional tensions that serve to occlude awareness of the true separateness of self from others. Recurring conscious or unconscious reminders of these tensions, without adequately dealing with them, eventually lead to the "burn-out" syndrome, a malady which suggests that human service work is becoming more dehumanizing despite the best of intentions to be otherwise. To assist in rehumanization these tensions must be discharged. By the nature of human service work, this is a continuous undertaking because clients will tell us exactly where our tensions are. In this sense our best helpers may turn out to be our clients. 
The eminent social psychologist, Kurt Lewin, has been said to have made the statement: "there is nothing so practical as a good theory" (p. viii).4 What Viktor Frankl has done is provide us with a theoretical grasp of the meaning of being human that has immense practical implications for both individuals and society as a whole. Logotherapy, being an open theoretical system has been acknowledged by its originator to be developing from the groundwork which has already been established (p. 155).1 
ARTHUR HOFFER is an associate professor on the faculty of Social Welfare, The University of Calgary in Calgary, Alberta, Canada. 
Arthur Hoffer 
REFERENCES 
I. Crumbaugh, J.C. "Exercises of Logoanalysis," in Logolherapy in Action. Fabry, J.B., 
R.P. Bulka, and W.S. Sahakian, eds. New York, Jason Aronson, Inc., 1979. 
2. 
Frankl, V.E. The Will to Meaning. New York, New American Library, 1969. 

3. 
____. The Unheard Cry.for Meaning. New York, Simon and Schuster, 1978. 


4. Marrow, A.J. The Practical Theorist: The Life and Work of Kurt Lewin. New York, Basic Books, Inc. 1969. 
The Proceedings of the First World Congress of Logotherapy 
ANALECTA FRANKLIANA 
can be ordered now from the Institute of Logotherapy. This 384-page book, indexed and containing a complete English-language bibliography of works of Logotherapy, will become a historical document and a collector's item as well as a record of current thoughts and methods of Logotherapy. 
Its 38 contributions cover the following fields: 
A Brief History of Logotherapy 
Two addresses by Viktor E. Frankl 
Logotherapy and the Philosopher 
Psychological Principles 
The Meaning of Suffering, Hope, and Death 
Applications in Medicene 
Logotherapeutic Techniques 
Applications in Education, Corporate Management, and Social Work 
Logotherapy as an International Phenomenon 
Paperback $12.95. 
Hardcover, limited and numbered edition, with gold lettering $50. 
The first 100 hardcover copies ordered will be hand-signed by Dr. Frankl. Add postage to the price of the book: US $2, other countries $3, airmail to other countries $12. Send your orders and checks to the Institute of Logotherapy, 1 Lawson Road, Berkeley, CA 94707. 
International Forum for Logotherapy Vol. 4, No. 2, Fall/Winter 1981 
A Validation Of Logotherapy 
Elisabeth Lukas 
Logotherapy is difficult to validate because it concerns itself with the (noetic) dimension of the human spirit where patients are free to take a stand toward and even against all measurable factors and limitations of their biology and psychology. 
The biological dimension-the concern of medical therapy-is the area of the electro-chemical and physical life processes which are visible, testable, and repeatable. Research is more difficult in the psychological dimension, the concern of psychotherapy. The substance of the psychological dimesion is invisible and must be measured or estimated by projections and manifestations. Also, observations, emotions, and the intensity of drives are highly subjective. Even so, a substantial amount of regularity and interdependency has been discovered, especially by behavior therapy. 
But in the noetic dimension the area of freedom is so immense that it has been doubted whether scientific research can be carried out here at all. The individual's capacity to accept, ignore, or oppose the limitations of body and psyche seemed to make empirical research questionable. 
And yet, despite a person's freedom and individuality there exists a regularity in the human dimension. Frankl calls it "the will to meaning." My own term for it is "the meaning postulate." The prerequisite of human health and inner satisfaction is that human beings perceive their actions as meaningful, that they see a goal to reach for, or a value to actualize-in short, that they see in their existence a meaning, that they do not vegetate aimlessly up to their death. 
The meaning postulate is the only firm condition to be found in the highly diversified area of the human spirit. To explain and justify logotherapy, a connection between the meaning postulate and health must be proved. 
THE LOGOTEST 
In 1969 I developed a logotest (p.233)1 from the answers of 1,000 randomly selected persons on the streets of Vienna. They were asked whether they considered their lives as meaningful and, if they replied positively, in what areas of their lives they saw meaning. 
Of those questioned, 51 OJo stated that their lives had meaning, and 11.9% replied in the negative. Of the remainder, 20.9% were inconclusive; of these, 9.2% walked on without answering, and 11.7% declared that they were still searching. In 
0/91-3379 "R / '/500-0/ /6$00. 95 116 1981 Jlunwn Sutncn Pres\· 
Elisabeth Lukas 
Table I Meaning Orientation of Random Sample of I ,000 Persons 
Percent Computation in Percent 
Cannot see positive meanings 11.9 all 11.9 
Ridicule question of meaning 3.0 half 1.5 11.75 negative 
Reject question of meaning 12.7 half 6.35 
Refuse to answer 9.2 all 9.2 
20.9 inconclusive Sti11 searching 11.7 all 11.7 
See positive meanings 51.0 all 51.0 51.0 positive 
The replies of the 51 % who answered positively were grouped by meaning areas: 
Personal well-being (happiness) 
Self-actualizing 
Family, children 
Career 
Friendships 
Interests, hobbies 
Experiences (nature) 
Service in a cause 
Overcoming distress (hunger, sickness) 
addition, 15.7% indicated a negative answer without expressively saying so: 3% ridiculed the question, and 12.70/o rejected it. It was assumed that at least half of these two groups, by their cynical or negative attitudes, could be added to those who had found no meaning in life. When this was done, a total of 19.750/o had either stated outright or indicated that they felt their lives had no meaning (see Table !). This table parallels clinical research that showed the noetic origin of all neuroses at around 20%. 
The results of the groupings were used as the basis for the logotest. The test consists of statements which meaning-oriented persons would answer positively, and those in existential frustration negatively (p. 262).' After checking the statistical relevance, a test was available which indicated the degree of a person's positive life content or, in the other direction, the danger of a noogenic neurosis. 
In an extensive scientific investigation, lasting almost two years, the logotest was applied to 340 persons-285 persons randomly selected, and 55 patients of the psychiatric clinic of the University of Vienna. All these persons were also tested by other psychological methods, using strict criteria, in order to check the reliability of the results. 
International Forum for Logotherapy 
The three most important interrelationships are illustrated in Figures I, 2, and 3. The connecting lines indicate a least significant difference of one percent, that means a probability of 990/o. The three illustrations confirm the assumption of logotherapy that the well-being and stability of a person directly depends on how meaningful life is to him or her. 
Objective high meaning orientation 


high meaning orientation indications 

of 
frustrations 
Good general psychohygiene 
Figure 1. 
The interrelationships shown in Figures I, 2, and 3 are not coincidental concurrences but interconnected factors: any one factor missing causes, with high probability, the other factors to be absent. The illustrations show a regularity within the human dimension of the spirit, the only regularity that is demonstrable in the face of individual freedom-the basis of logotherapy: the meaning postulate. 
THE PREMISES 
From my own and other empirical investigations emerges the theoretical structure of logotherapy: 
Axiom: The human being possesses a noetic dimension. 
From this axiom a number of premises follow. I shall discuss six. 
Elisabeth Lukas 
Low Objective general 
low psychohygiene 
meaning orientation 

Premise 1: The human being has three dimensions (assuming the biological and psychological dimensions are granted). 
Premise 2. In each ofthe three dimensions the dependency on given circumstances is different. 
A. Within the biological dimension the dependency on given circumstances is almost total and hardly manipulable. 
B. Within the psychological dimension the dependency on given circumstances is flexible and highly manipulable. 
C. Within the noetic dimension there exists the possibility of a free decision of attitudes to given circumstances. 
Premise 3: The three dimensions form an inseparable unit. Premise 4: No dimension must be disregarded in psychotherapy. From 
this premise follows the obligation of the psychotherapist to include in her considerations also the question of meaning. But "also" does not mean "exclusively." The fourth premise simply says that the therapist 

International Forum for Logotherapy 
Figure 3. 
must treat her patients in their totality, and that therapy must include all dimensions, at least marginally. The minister must not limit himself to religious wisdom when a member of his congregation comes to him with family problems. The surgeon must not confine herself to the amputation of a leg when a patient suffers from bone cancer. And the psychologist must not restrict herself to the interpretation of test results when her client questions the meaning of life. All members of the helping professions have the obligation to respond to a genuine call for aid, if not on a professional then on a human level. If they feel not competent in a certain area, they must refer the patients or clients to others who can provide adequate help. 
Premise 5: In each of the three dimensions the feedback mechanism works differently. 
A. Within the biological dimensions, feedback mechanisms bring about automatic processes in the automatic nervous system that help the body adapt to the changed situation. 
B. Within the psychological dimension, feedback mechanisms bring about reinforcement processes and lead to changes of behavior. 
Positive attitude to suffering or success 
Objective high meaning orientation 
High psychological ability to adapt 
Good general psychohygiene 
Elisabeth Lukas 
C. Within the noetic dimension, feedback mechanisms bring about changes in self-understanding and lead to a new interpretation of the self. 
Premise 6: For each of the three dimensions the principle of homeostasis has a different validity. 
A. Within the biological dimension the homeostasis principle is always valid. 
B. Within the psychological dimension, the homeostasis principle is valid most of the time. 
C. Within the noetic dimension, the homeostasis principle is not valid. 
Nearly all theories about human nature see homeostasis, the absence of tension, as desirable therapeutic goal. Frankl, however, points out that in the noetic dimension, homeostasis is not a desirable condition but rather a warning signal of an existential frustration. A tensionless state in the noetic dimension would denote complete satisfaction, that is, a lack of goals. Goals are beckoning only when conditions are not completely satisfying and leave room for change. When people lack the necessity to change, to create, to finish a project, to experience, or at least to brave an unchangeable fate, the necessity of continuing to live may be questioned. 
Frankl speaks of a "healthy noodynamism," a field of tension between what we are and what we have the vision of becoming. Such noetic tension stands in opposition to being in balance with oneself and the world. Balance is enormously important for all life forms, but for the human being it is not enough. 
THE METHODS 
From these premises it follows that the psychotherapeutic practice cannot be effective with logotherapy alone, but neither can it be effective without logotherapy. 
During the past six years I have treated and kept records of 300 persons with logotherapeutic methods, either exclusively or in combination with other methods. The logotherapist who keeps the noetic dimension firmly in mind, can also use reinforcements, client-oriented discussions, free associations, autogenic training, assertiveness training, or other techniques. 
Combination treatments are helpful to clients but make scientific investigations difficult because it is not always clear which method in the combination was instrumental in reaching the therapy goal. Nevertheless, I can present some data from my statistical evidence covering four basic logotherapeutic techniques: 
International Forum Jor Logotherapy 
Modification of attitudes:  110 clients (37%)  
Paradoxical intention:  91 clients (30%)  
Dereflection:  60 clients (20%)  
Appealing technique:  39 clients (13%)  
In  each of the  four  techniques I divided  my  cases  in  two  groups:  

application in pure form, and in combination with other methods (see Figure 4). 

Figure 4. Logotherapeutic Methods Used on 300 Clients 
To judge the success of each method three criteria were considered: a) Degree of success: I-very good; 2-good; 3-medium; 4-bad. b) Time to reach the therapy goal: in weeks. c) Recidivism: in number of clients, and average time-in weeks-when new treatment was necessary. 
Elisabeth Lukas 
Modification of Attitudes 
Of the 300 persons under investigation a total of 110 were treated by modifying negative, unhealthy, or reductionist attitudes into attitudes that opened the clients' readiness to see or at least to search for meaning. 
Table 2 
Application Number of Degrees of Weeks to reach Recidivism clients success therapy goals Number After of clients weeks 
Pure 36 2.1 3.3 9 18 
Combined 74 1.4 4.8 15 41 
Results with modification of attitudes were very good to good, were achieved within three to five weeks, and showed a varied degree of recidivism. Combination with other methods was more successful for securing lasting effects (see Table 2). 
Paradoxical Intention 
Paradoxical intention was applied to 91 of the 300 clients -to 30 in pure form, and to 61 combined with other methods. Paradoxical intention is successfully applied in combination with autogenic training, progressive relaxation, medication, assertiveness training, and raising self-esteem. 
Table 3 
Application  Number of  Degrees of  Weeks to reach  Recidivism  
clients  success  therapy goals  Number  After  
of clients  weeks  
Pure  30  2.5  4  6  67  
Combined  61  1.3  8  None  None  

Paradoxical intention reached the therapy goal well, quickly, and with lasting results. No client treated with paradoxical intention in combination with other methods (usually autogenic training) suffered a relapse (see Table 3). 
International Forum for Logotherapy 
Dereflection 
Dereflection was used on 60 clients-on 15 in pure form, and on 45 in combination with other methods, often with goal-oriented reinforcement. 
Table 4 
Application  Number of  Degrees of  Weeks to reach  Recidivism  
clients  success  therapy goals  Number  After  
of clients  weeks  

Pure 15 2.8 JO 6 19 Combined 45 1.6 13 9 33 
The degree of success was good but length of treatment and inclination to recidivism greater than with paradoxical intention (see Table 4). 
Appealing 
The appealing technique operates in the psychological dimension of the human being but opens the way to activating the resources of the spirit. Because the forces of the human spirit are identical with the will of a person I have designed a logotherapeutic "suggestive training of the will" which can be used when patients are not able to cooperate actively with a therapy because they are too primitive, too old, too young, too sick, or too upset to make decisions and act upon them. 
The suggestion must not concern the goal of the therapy; that is what the clients will have to reach by themselves. Their freedom to decide must remain theirs; only the obstacles that may block that freedom can be removed by the appealing technique. The suggestive training of the will, therefore, may be formulated along these lines: 
I am not the helpless victim of my drives and my emotions. I have a free will, and I am going to strengthen my will, to reshape my life in a new way, in a direction of goals that are meaningful to me, in a direction of ideals which are honestly mine. I feel this inner will, it awakens in me, becomes stronger and stronger, it gives me strength to persist, I shall master my life, in spite of all the drawbacks. The greater the difficulties, the greater will be my strength .... 
In my practice the appealing technique was used on 39 persons-on 9 in pure form, on 30 in combination with other methods, mostly assertiveness training. 
Elisabeth Lukas 
Table 5 
Application  Number of  Degrees of  Weeks to reach  Recidivism  
clients  success  therapy goals  Number  After  
of clients  weeks  
Pure  9  2.4  9  6  11  
Combined  30  2.9  15  12  8  

The appealing technique showed good to medium therapy success, in a relatively short time which, however, was longer than with the other methods, and a medium tendency to recidivism. It must be remembered that the technique was used on clients with the greatest resistance to therapy (see Table 5). 
REFERENCE 
I. Lukas, E. "Zur Validierung der Logotherapie" In Der Wille zum Sinn. Bern-StuttgartWein, Verlag Hans Huber, 1972. 
ELISABETH LUKAS is the director of a counseling center in Munich, Germany. 
International Forum for Logothcrapy Vol. 4, No. 2, Fall/Winter 1981 
The Disabled And The Authentic Self 
Carol Lynn 
Logotherapy has special significance to those with cerebral palsy. The more the individual tries to accomplish a difficult task-tying a shoe, walking up a set of difficult steps, or communicating with a stranger-the more impossible the task becomes. Anticipatory anxiety blocks communications from the brain to the muscles involved in a particular task. Stepping off a curb into the street can be the hardest task one is called upon to perform, even if one has accomplished the task many times before and the curb is only two inches high. Dereflection is a great help in these areas. 
In addition to the threat of falling, there is the threat of failing, which follows the disabled all through their lives, challenging their future autonomy, their physical and emotional independence. These factors are, for some, life itself and they have to be met with the defiance reserved for one's instinct for self-preservation. Individuals with cerebral palsy must develop an attitude that overrides their limitations-when falling, they can get up; spilling a cup of coffee is no disgrace, their friends will understand, and others will not remember for long-they have other concerns. The goal of perfection in the disabled is self-centered and small, keeping them from possible self-transcending goals. The striving for perfection or improvement beyond some realistic point leads to frustration and prevents the individual from accomplishing anything at all. 
Since being revived from anoxia at birth, I have been a victim of-no, an individual with cerebral palsy. Reading Frankl's books made me see the lifesaving difference. Of course, I was a victim, with certain physical limitations. But I also had the resources of the exclusively human dimension which enabled me to take a stand toward my limitations. I had gone through the normal stages toward independence-childhood (reared as a freak), college (an attempt to renounce my freakhood), marriage (normal enough) ending in divorce, and an agonizing period of finding my place as a single person. 
Then I found the position as a research librarian, in which my particular expertise outweighed my physical limitation. I was ecstatic, at first. I rented an apartment, bought new clothes, told my friends about my exciting new life, and then everything went dead, and I couldn't understand why. 
0191-33 79/8/ I 1500-0126$00. 9, 126 /9111 Jluman S'nences Prec;c, 
Carol Lynn 
Everybody assumes roles at one time or other, roles they don't even know they are playing, and I was no exception. Roles I have played have been: the sweet evader, the Stoic, the supernormal, the defier. The trouble with playing roles is that they are played to audiences. Audiences come and go, and when they go, one is left with one's inauthentic self-an existential vacuum. 
What I learned from Frankl's The Doctor and the Soul was that the existential vacuum must be filled with meaning content, and that one way to fill it was to discover the authentic self. From this book I gleaned three ways to find meaning: 1) turning unavoidable suffering into a human triumph; 2) experiencing a value; 3) taking action. 
Frankl's experiences in the Nazi concentration camps intrigued me. I remember in my childhood someone saying that Hitler might be good; he'd get rid of some of the Jews who had all the money, which some of us could then acquire. The speaker was a relatively successful businessman whose wife had transformed her personal insecurity into an imagined lack of money. I identified with the Jews who were so unjustly judged, and saw them as an example of how to see the challenges, rather than the defeat, behind my own unfair limitations. 
Here was my task: To show the world that I could overcome my limitations as the Jews had overcome theirs. But turning my unavoidable suffering into a triumph was not enough. When I had achieved my "triumph" in the form of my new office and my new apartment, I experienced the existential vacuum. My puzzlement was solved when I understood what Frankl was saying. My triumphs were triumphs according to the values of others, according to a society that gave high priority to material success. They were not triumphs according to the values of my authentic self. It was in my new office and new apartment that I confronted my pervading sense of loneliness and worthlessness. My deepest longings, which I had denied for so long, came to the surface only when my material drives had been satisfied. 
I then started the third path to meaning: I took action, according to my authentic self: I acted as a person, not as a victim. I made friends, including men friends who took me wherever I wanted to go. But this was not enough, either. I bought a car and proved to the licensing bureau my ability to drive. 
I started going to a nearby beach to walk in the sand in my bare feet. I later bought a house near that beach. I found a church in which I could develop my own personal beliefs and whose membership offered friendship and concern. I formed a friendship with a man dying of cancer. We talked of things which mattered. I went to Mexico three times on my own. On my first trip I met a man, a minister from my own liberal denomination, single and as alone and as seeking as I was. We talked as children do, with too 
International Forum for Logotherapy 
much to say and too little time to say it. We had but two days together, and never met again. Soon after he was killed in an automobile accident. 
I could have romanticized about my true love lost, taken to my room and written poetry the rest of my life. A victim again. I chose not to do this. I responded to the meanings offered to me by life. I compromised at times, watching inane television shows, going to inane movies, engaging in inane conversations, but sometimes-quite often when I was alone-things came together. I felt part of the universe and I mattered. I could touch, I could write, I could love, and therefore I could expand. This was the meaning of my life, and my creative responses supplied the means. 
I dance now. I can dance when my partner knows how to hold me so I can relax and let the rhythm take over. I didn't know how far I had come in my sense of an authentic self until one night I danced with a man who felt selfconscious and moved with exaggerated steps. Although we finished the dance, it wasn't the most graceful experience. A friend of mine was incensed on my behalf-the man was making a mockery out of my triumph. I comforted my friend and we experienced a value. This man's uneasiness was not a part of me. I was able to delight even in the mockery of my partner because he had touched me in his way, and I was not diminished. 
I was disabled but I was getting closer to my authentic self. 
CAROL LYNN is a research librarian and writer in Tarpon Springs, Florida. 
lnkrnatiunal Forum fur Logolht:rapy Vol. 4, No. 2, Fall/Winter 1981 
What The Will To Meaning May Achieve 
Guido Korfgen 
One step in the logotherapeutic treatment is the modification of attitudes of patient toward their sickness, especially in cases of incurable diseases. The following case allows the speculation that a modification of attitude may have a curative effect. 
Four years ago, cancer of the colon was diagnosed in H.R., a 74-year-old man, and an immediate operation was recommended. Although the diagnosis was confirmed by two other specialists, H.R. refused to be operated on because it would have required his wearing a colostomy bag, and he had recently happily remarried and did not want to burden his wife with this difficulty. Repeatedly he declared, "I'll show the world that a person can also live with cancer!" 
Beyond a minor adjustment in his diet no treatment was applied. I have seen H.R. from time to time and was amazed at his continued well-being. Now, four years later, he feels well, remains active, travels widely with his wife, and reports that he has no blood in his stool. If he didn't hold back with his eating, he says, he would gain weight. 
I am aware that his well-being may have many reasons. But I believe that a contributing factor, at least, was that he saw the meaning of a commitment to his wife whom he loved. I have seen patients who give up their fight against their disease because they see no meaning in their lives; the prognosis for them is not good. Also I have seen patients improve, in spite of their sickness and pain, if they see the challenge of a meaning. H.R. is a special case, and there may be other explanations for his continued wellbeing. But I am inclined to believe that his strong will to meaning has helped him add four years to his life. 
GUIDO KORFGEN, M.D. is a psychotherapist in Schwiibisch Gmund, Germany. 
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