SOURCE_DOCUMENTS/journal_008_1.txt

Volume 8, Number I Spring/Summer 1985 
CONTENTS 
Letter from the Editor. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 
Recollection from the Early Days Lotte Bodendorfer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 
The Meaning of Logotherapy for Clinical Psychology Elisabeth Lukas ............................................... 7 
Viktor Frankl's Meaning for Psychology William S. Sahakian ........................................... 11 
Viktor E. Frankl's "Place" in Philosophy George Kovacs ................................................ 17 
Viktor Frankl's Meaning for Pastoral Counseling Robert C. Leslie ...............................................22 
Logotherapy in the Psychotherapeutic Smorgasbord James C. Crumbaugh ..........................................28 
Education for a Synthetic Planet: Logotherapy and Learning for Responsibility Arthur G. Wirth ..............................................34 
Logotherapy: A Critical Component of Modern Nursing Patricia L. Starck .............................................41 
Rehumanizing University Teaching Mignon Eisenberg .............................................44 
Logotherapy's Impact on Counseling the Executive Frank E. Humberger .......................................... .47 
Logotherapy and Buddhistic Thought Hiroshi Takashima ................... : ........................54 
The Promise of Logotherapy in the Socialist World 
R. E. Stecker .................................................57 
Photos on cover and page 2: Evan Golder 
Logotherapy Comes of Age: Birth of a Theory 
Patricia l. Starck 
As members of the mternational c,,!nmunity come together regular!\' m \\orld congn:sse,; oflogotherapy. pcrhar~ it ist1meto step hack and stand in awe of what the concept oflogot herapy ha~ u>ntri hutt:d to humankind in just haifa century. The comprehensiveness of logotherapy i~ evidenced by the\ ariel\ of program topics and the di\·crsity of cultural represcntatiYcs in these congresses. However, we lrn\e been so im·olved m th: t1ppl!cation of logothcrapy that we may have neglected a vital factor which will ,'murc the viabiiity of this school of thought for future generations. This factor is the arduous academic and schoiarly process of theory construction. Tk· tend~ of logothcrapy and the body of scientific knowledge evident in the iitcrnn;re do indeed meet the critt:ria to add this ~chool ofthought to the an nab of human kmw,ledge in the form of theoric:s that describe, explain, and predict hum:rn behavior. The ta~k 1\:4uires synthesizing Frankl\ writings with the worb which have followed in the form of empirical research, case study rcpo; ts, and other forms of development of the basic tenets --a mcgasynthesi~, a-; it were. 
To initiate the formaliled proce-:s of theory building, this article analy,.es the lexical meaning of "logothernpy'" and proposes other comprehensive terms for this body of knowletlge. It also expl0fes the need for theoretical formulatinn, including the purpo,;e. function. and corn ponents of theory, giving examples ol component parts of a theory for \ogotherapy. And finally, it discusses directives for future action fer building theory in order to establish its rightful place in the hi,,tory of human knowledge. 
Lexical Meaning of "Logotherapy" 
FrankF ex plai ncd the origin of his term ··Jogothcrapy" as heing derived from '"logos." the Greek word denoting "meaning." The concept is based on 1:rankl's premise that the striving to find a meaning in our life is our prim,:ry motivational force. ·1 hi, '·will to meaning"' i, contra:;ted with Freud\ "will to pleasure" ,rnd to Adler's "will to power." 
The word "therapy" connotes treatment for disorders and maladjustments. Variations in the term logotherapy have heen developed by Crumbaugh1 and others, expanding the field to logoanaiysis for the healthy in coping with the stresses of everyday life. Other disciplines have adopted "logos" to fit their special interests. such as logocounseling. logoeducation, and logoministry. 
The nature of logotherapy can be further delineated by characterizing the roles of the therapist. These roles include healer, counselor. teacher, catalyst, and others. FrankF· r 1s2 uses humor to describe a logotherapist hy contrasting his actions with that of a psychoanalyst. The latter makes patients lie down on couches to tell disagreeable things, whereas in logothcrapy "the patient may remain sitting erect, but he must hear things that sometimes are very disagreeable to hear." Logotherapy is less retrospective and introspective and focuses more on the future. In logotherapy the patients are confronted with and reoriented toward the meaning of their lives. 
The purpose of logotherapy is to assist the individual to find meaning and purpose in life and to move in a positive direction toward self-transcendence. The uniqueness of logotherapy stems from its perspective and methodology rather than its object of inquiry. 
Proposal for New TerminologJ 
Because the term "'logotherapy" describes the action of the therapist and the ultimate aim of treatment, the term focuses on the application of a set of principles. But what is the name of this set of principles? Alas, we have been so busy helping patients and communicating our methodologies and results that we have paid little attention to naming and classifying the knowledge base of practice. Perhaps the most comprehensive name in the literature to date is "The Third School of Viennese Psychiatry." However, the field now reaches beyond both Vienna and psychiatry. Assistance may be sought from the outcome ofthe first two schools of Viennese psychiatry. Freud's work has been dubbed "psychoanalytic theory." Adler's work has become known as the field of"individual psychology" made up of a number of component theories, including birth order position and the family constellation, inferiority and superiority complexes, and others. 
An umbrella term appears to be needed to describe the efforts and aims of logotherapists throughout the world. Possible terms are suggested as "Meaning Psychology," "The Theory of Meaning," or "Spiritual Science." It seems appropriate to have the founder of logotherapy, Dr. Viktor Frankl, as well as other pioneers in the field select an appropriate name to ex press the comprehensiveness of the nature of this discipline. For the purposes of this presentation, the term '"Theory of Meaning" will be used. 
Need for Theoretical Formulation 
Definition of Theory. A theory has been defined as a "set of interrelated constructs (concepts. definitions, and propositions) that present a systematic view of phenomena by specifying relations among variables, with the purpose of explaining and predicting phenomena."6· P· 9 A theory in the beginning stages must describe reality and evolve toward predicting phenomena and be able to prescribe appropriate measures to control these phenomena. 
Purposes of Theory. The fundamental aim of science is to explain events, objects, and persons in the world. Such explanations are called theories. Theories provide guidance to collect facts in a systematic way and to extend the range of useful knowledge. The goal of theorizing, then, is to systematize and unify knowledge. The fundamental aim of philosophy is to unify scientific findings so the human heing a~ a holistic individual can emerge. The philosopher is concerned with such matters as the purpose of human life, the nature of being and reality, and the theory and limits of knowledge. Intuition, introspection. and reasoning are some philosophical methodologies. The Theory of Meaning is concerned with all aspects of the human being and combines the scientific as well as the philosophic approach to understanding the uniqueness of the individual. This theory fulfills the aim of all theory, to provide new insights and to contribute to the discovery of new knowledge. The Theory of Meaning, like other sound theories, is characterized by openness; openness to expand, modify, and revise, as theoretical constructs arc refined in the practice world arena. Each research study contributes to the theory with the addition of new dimensions or verification of earlier findings. 
Components ofa 771eor_r. Theories are generally comp,1scd ofthree clements. and these clements evolve in three stages: 
Element Stage 
Concepts Specifying, defining, and classifying the concepts used to describe phenomena in the field. ;\ taxonomy is needed to communicate meaning of concepts and key terms. 
Postulates Developing statements or propositions which demonstrate a relationship among propositions. 
Hypotheses Subjecting the postulates to tests to provide support or non-support and thus strengthen the theory. 
Concepts arc the building blocks of theory. They may be abstract ideas that can be described in order to grasp facts, principles, and laws of the theory. For example, the concept of"meaning" could be described and defined by specifying the uniqueness ofthe purpose-of-life events for each individual, by determining the interpretation of the set ofcircumstances at a certain time. Other concepts in the Theory of Meaning include existential vacuum, existential frustration, suffering, and noogenic neuroses. The laws of dimensional ontology3 are component parts of this section of the Theory of Meaning. It is essential that each term be operationally defined for replication research and theory vertification. 
Postulates arc the central core of theory. These generalized statements of truth serve as essential premises for the body of knowledge. Postulates of the Theory of Meaning taken from Frankl's work2 include: 
It does not matter what we expect from life, but rather what life expects 
from us. (p. 122) 
Everything can be taken from a man but one thing: the last of the human 
freedoms~ to choose one's attitudes in any given set ofcircumstances, to 
choose one's own way. (p. 104) 
Suffering is an ineradicable part of life, even as fate and death. (p. 106) Although developed over a period of many years, another postulate was specified by Frankl in 1980: 
"Phobias are characterized by circular patterns; the more patients fight their obsessions and compulsions, the stronger these symptoms become. Pressure induces counterpressure, and counterpressure, in turn, increases pressure. "4· P-5 
Hypotheses are deductions or conclusions reached by logically proceeding from definitions of concepts to relationships among variables. Hypotheses are used as the basis of testing, which can have three results: (a) confirming the validity of the theory, (b) failure to confirm, and thus rejecting the theory or its component part under study, or (c) modifying the postulate and thus refining the theory. 
Theories are guides to further research. Their usefulness is based on the deductions that can be made from them. The process oftheory building includes the formulation and testing of hypotheses which have been deduced from the postulates derived from scientific knowledge or philosophical beliefs. 
An example of recent hypotheses testing which contributes to the Theory of Meaning is the work of Nackord7 when he correlated scholastic performance of students with three variables: (a) scores on the Purpose in Life test, (b) signs of collective neurosis, and (c) choices among the will to pleasure, power, and meaning. Such empirical research assists in theory building. Yet, the task remains for someone to synthesize all relevant research to incorporate findings into the overall theory. Likewise, the plethora of articles and books on logotherapy has valuable elements to be gleaned for the Theory of l\kaning. 
Future Directions: How to Proceed 
Frankl has met all the qualifications of a true theoretician. At this point, the theory can be delineated in a comprehensive manner. Guidelines for future direction are offered for discussion and debate among all logotherapists. The following activities are sugge5ted: 
l. Develop a glossary of key terms used in logotherapy. These terms will come from the original writings of Frankl, plus other concepts developed hy his followers. 
2. 
Operationally define each term in the glossary so that researchers use the terms consistently. 

3. 
Develop a taxonomy, classifying all components of the Theory of Meaning. One such classification system might be Frankl's categories of meaning: creativity, experiential, and attitudinal. Another classification set of noogenic neuroses would he a part of the taxonomy. The taxonomy will be developed from the original writings of Frankl and other qualified logotherapists. 

4. 
Develop a comprehensive set of postulates. This collection of postulates should represent the whole of values and beliefs upon which the practice of logotherapy is based. These postulates will come from the original works of Frankl. 

5. 
Collect research studies including dissertations which have used hypotheses and statistical analyses to verify and validate postulates. These studies should he scrutinized by experts in research to identify those utilizing rigorous research methodologies and statistical techniques. Research which merely describes may be used in glossary and taxonomy development, hut not in hypo


theses testing. Those studies with empirical validity can be used to ~upport the Theory of Meaning and give guidance for future research needs. 
6. 1-'\,tluate the Theory of Mcanin12 :1,·cording to establi,hcd c,alua11,m criteria. Such criteria proposed hy Hardy'.; includes meaning and logical adc4uacy. operational and empirical adequacy. generality. contribution tn understanding. prc<lictahility, and pragmatic ade4uacy. 
7 Publish a comprehensive work ,rn tlw Theory of Mcanin/! with all the above documentation set forth. It I\ ant1cipatcd that such a book would be· useful to ~tudents and to academic scholars a~ \,i,ell as to prolcs,ion,li practitioners. 
This author mvites comments and di1:cu~s1on on thi~ i,suc of synthesi1ing ali logolhcrapy writings ill the important task of theoretical formulation. l! anticipated that the hirth of such a theory w1il validate that logothcrapy ha~ truly come pf ilt!C. 
PA TRICIA L. STARCK, R.N, D.S. N.. /1 Dl'an and Professor (~f Nwsin;;. Universil r o( TPxas, Schou! of Nursing, How tun, LY. 
RFFFRENCF~ 
I l 'rumbaugli. .L C Even 1i11ng to Gain: 4 (,'uide ln ~'J'cl(-Fl,lfi/lnu'nl through LoRnanlfh-,J, 
Chic.,go, Nelson-Hali, 1973. 
2. 
J-rnnkL V. E. Man\ Search_/,,,. llfrani11g: .-·1n J111md11crion 10 i.ogo1hera11r Boston. Bc;:con Press, l 959. 

3. 
-------·· 1he Will tu Meaning. New Ymk. The !\ew American library. 1969 


4. 
_____"Psych,)1.herapy on Its Wa~ to Rl'iwm;:ni,,m "19!<0, '1111' /nternalional Fwwnfor Logutlwrapr. 3(2). ,-9. 

5. 
Hardy. M. f. "Theories: Components. Dndoprnc-nt. Fvalua1ion." .Vursin1-; Re1e1,r, Ii. 1974, 


}3(2), 100-107. 
6 Kcrlingcr. F·. H. Fnwulalions ol Research 2nd ed. :\cw Ymk. Holt, Rinehart and Wmsu,n. !973 
i. N«ckord, f·. .I "A College Test of l.ogot hcrarc11tic Concepts." 19~:1. The !nternatwnal fim1111 for f,,,;,,thcrll/J_l. 1983. 6(2). 117-122. 
New Hope for People in Chronic Pain 
Michael F. Whiddon 
I could not keep from smiling when I realized I was reaching for a cane that wasn't there. It was hanging on a doorknob several rooms away, and I \1as standing at the nurse,· ,tation. My thoughts so intensely focused on my client\ progress that I had walked down the hall unaided --and without the usual pain. Frankl descnbe~ this phenomenon 1 stating that patients cin n,ntinuc to say "yes" to lifr in the face of pain if they remain aware of a meaning to be fulfil led. 
Patients li\ing with chronic pain may become so focused on nep1tive conditions that they lose sight of the things still available to them. Despite pain and suffering, human beings have the capacity of self-transcendence. 
My walking without a cane is a small example of how negative conditions can be ignored by looking outside oneself toward meanings to fulfill. people to encounter, and causes to represent. 
Frankl\ technique ofdereflection helps patients to focus attention away from self. pain. and suffering toward meaning potentials. Because excessive attention to negative conditions is an important aspect of the dysfunction caused by pain, dereflection offers new hopt: for those living with chronic pain. 
I have found dereflection a necessary component of treatment for patients with pain problems. They switch attention and expectations away from the pain and also deal directly with the human will to meaning. 
This article reports on seven case~ in my private practice. one of them in detail. Similar results were found in 22 more cases I trca[cd for the Veterans Administration. In each of these cases: 
• 
The experience of pain had physical, psychological. and philosophical components, such as the illness/injury, learned inactivity, and lost meaning in life. 

• 
Functioning of the patients was reduced, preventing them from relating to others and from usual activities. 

• 
Depression, dissatisfaction with lite, and negativism were problems. 


The treatment I developed has physical, psychological, and philosophical components. 
The physical treatment is of course medical care. The psychological treatment is primarily management of the rewards and punishments affecting pain behavior, and guided imagery for distraction from pam. The philosophical treatment is based on logotherapy. Its goals: 
• 
Make attitudes and expectations positive 

• 
Increase awareness of inner resources 

• 
Focus attention awa'.) from 11egali\C condition~ towarJ source, o! ,at1~faction 

• 
Increase awarene,s nl meaning potcntiab. 


In each ofthe cases measurable 1mprnvements were made in normal functioning and satisfaction with life. Medication use and attention to negative conditions were significantly reduced. This was achieved by dereflection --a new hope for tho,e living with chronic pain. 
Sample Case 
Jan. 30. had been hospitalized for depression. For several years she had back pain resulting from an accident. Tim had k:d to other problems such as missing work as a secretary and reduced \cxual activity straining a supportive marital situation. Increasing lethargy. dcpres~ion. and suicidal thoughts led to ho~pitalin1tion. three back surgeries. and medication including norpramin for depression and codeine for pain. 
In the hospital Jan passively complied with medical and psychological diagnostics. She participated at a minimum level in milieu therapy. in ward activities, and in psychotherapy. with 1vi change in her deprcs,ion and no improvement in her physical comfort. When l was asked to hcij) Jan. she was taking codeine daily and spending se'.eral ,dternoons and evc-nings lying on her hcd with an ice pack against her back 
A traditional, physical approach to understanding Jan\ problems would concentrate on the impulses from her injury and the negative effects of her medications. J\ psychological approach would focus on the rcinlorcers of pain ( e.g., PRN medication and sociaIattention) or of inactivity (avoidance of pain). 
Logothcrapy helps us understand pain problems as they affect human life. by focusing on such factors as excessive attention to negative conditions, negative expectations and attitudes. and the effects oC lost meaning in life. 
Jan had a real injury and had rcn:1ved much reinforcement of her pain and inactivity. She also was able to accurately identif\ how she had focused most of her time and attention on her pain. becoming inactive and interacting Jes, with others. She had lost awareness of previous sources of meaning. e.g.• having time to spend v.·ith her husband and mother. making craft items, and being independent her own boss. 
Treatment 
I first helped her assess her pain and the things that previously had been meaningful. Using a method similar to that developed by l.ukas2 I alternated questions of her current conditions with questions about her interests. aspirations. and relationships. This distracted her attention from her discomforts. and helped her rediscover meanings. 
Guided imagery was then provided because it can affect physical. psychological. and philosophical aspects of the total pain problem with a single technique. With imagery and therapeutic suggestion we attempted the following: 
• 
Suggest psycho-physiological blockage ot painful 1mpubes 

• 
Reduce muscle tension and stress by promoting relaxation 

• 
Teach distraction techniques to reduce the pain experience 

• 
Encourage positive expectations and attitudes 

• 
Stimulate awareness of meaning potentials. Imagery changed her mental set from her usual discomfort to a relaxed sense of peace and comfort, with her attention focused on something pleasant -a peaceful country road to walk down, calm rivers, pretty green meadows. All words were spoken slowly and softly.* Once relaxed and distracted, Jan was given suggestions relating directly to her pain experience. Some suggestions were direct, such as "feeling numbness." Others were indirect and analogous, such as "allowing unwanted sensations to be drawn away from you by a cool stream." These suggestions are intended to take advantage of the mind's capacity to block or rechannel pain impulses. Finally, as she imagined being "comfortable beside a stream," I made suggestions to dereflect her from identifying herself with her painful, dysfunctional condition -for instance, to remember a time when she "shared an experience with someone else" or "did something she felt good about." There were also moments of quiet so she could "think about what she could do now to regain a sense ofsatisfaction." It was my intention to reflect her to her conscience -our uniquely human organ that detects meaning potentials offered by life. It was an appeal to that human dimension that helps us deal with the existential questions life requires us to answer: what do we believe about the world, about ourselves, and about how we fit into the world? Such suggestions result in an inner dialogue that mobilizes our human resources, gives us strength, and helps us recognize meaning as it emerges from the background ofour human condition. Guided imagery was provided three times during our first week, with only minor changes in the scenes used. Jan was encouraged to practice this imagery daily as a self-help technique. We met three times during the next two weeks with a new task. No guided imagery was provided. Pain and other problems purposely received no attention. Instead, her attention was focused on the pursuit of meaning. "You have begun a process you will be able to use from now on. I hope you use it and it will 


work well for you. We now move on to the task of looking for meaning in life." A set of exercises to help her increase her self-knowledge included: 
• 
Listing positive and negative characteristics 

• 
Identifying positive and negative circumstances 

• 
Values clarification in creative, experiential, and attitudinal areas 

• 
Practicing positive affirmations 

• 
Describing what she "could be" in terms of things to do, experiences to have, causes to serve. 


Jan responded well to our sessions. She reported that she spent much time thinking about these suggestions, including the times when she practiced her imagery. As she remembered past values, and future possibilities emerged, she was encouraged to set specific goals, and we discussed concrete steps she could take toward those goals. 
Jan recalled that she had at one time planned to go into business for herself. She felt creative and liked to be in charge of her own time and activity. She chose developing her own craft hmines, as a goaL an area where \he had knowledµe and ability. She spent time planning the products she would make. and the 111,trkets in which she would sell them. She discussed these plans with her husband and mother. As she focused more and more attention on these avocational and vocational interests. she spent less time seeing herself as just "a person in pain." She began to see herself as a person who could produce pretty items, sell them, and he independent. Sharing these ideas with others normali1ed her relationships with the hospital staff and family. Her depression faded. 
Jan described herself as feeling that she "had life under control again." These changes resulted in reduction of her medication and eventually in her discharge from the hospital. 
Results 
Three measurements were taken: 
• 
Number of PRN pain medications taken daily 

• 
Number of hours spent in bed 

• 
Jan's subjective ratings of her comfort. 


The self-report was based on a simple rating scale from I to 10, with 1 representing complete comfort and IO pain so intense that codeine and bed rest with ice pack were necessary. 
During the first week Jan reported a high level of discomfort in the morning, and a dramatic reduction during therapy (at 3 p.m.) when she actively imagined being comfortable. The guided imagery helped distance her from her problem. However, the pain gradually returned in the later afternoon and evening. 
By the third week her subjective ratings began to reflect improvement in her level of comfort all the time to a level at which she could function. This leveling continued, and in the follow-up, six months after the start of the therapy. it remained on a low level all day long. 
During the first week, Jan made four daily requests for pain-relieving medication, codeine. She spent three hours in bed, as reported by the nursing staff. By the third week her codeine requests were down to one per day, and time in bed was reduced to the point that the staff no longer monitored it. Her antidepressant, norpromin, was reduced during the three weeks from 150 milligrams to zero. She was discharged on no medications. The same level of medication and hours in hed still was retained at the six-months follow-up. 
Jan's case helps us understand that pain problems are more than just physical. Factors such as reinforcement, expectation, attention, and awareness of meaning potentials contribute to the effects of chronic pain on human life. 
*A casS('ttc tape, "Meaningful lrna!,!C" ior -I hosL' in Pain" 1s aY;1il~1hk frorr *':'-· :wthor. Vctc,an, Administration Medical Center. Knoxville. IA 50 I 38. 
Logothcrapy allows us to deal with these factors directly. thereby reducing the 
devastating impact of pain. 
Jan had focused her attention on her negative condition to such an extent that 
she had lost awareness of positive possibilities for a meaningful existence. She 
had stopped functioning normally and withdrew from her usual activities and 
relationships. When encouraged to call on her own human resources she 
reported that energy and positive feelings returned. She redirected attention 
from negative conditions toward meaning potentials as they emerged. She 
actively pursued a meaningful existence. The by-products of that pursuit 
included increased satisfaction with life, a more positive self-image and outlook, 
and less physical discomfort. 
In the cases I treated, chronic, painful conditions such as arthritis. cancer. 
headaches, and injury led to debilitation and despair. By treating pain directly 
we may be able to reduce the experience of pain for a while. It appears, however, 
that when patients focus attention and energy on the pursuit of meaning, the 
results are more lasting; pain and dissatisfaction are replaced by comfort and 
peace. Meaning is healing. It mobilizes the inner resources and makes it possible 
to endure negative conditions such as pain. 
Six Other Cases 
My six other cases showed similar results although the source of pain was different in each. The treatment always included evaluation of current conditions, guided imagery, and focus on meaning potentials. 
P., 67, a terminal patient with cancer ofthe pancreas, on powerful drugs, was seen 17 times during the last three weeks of his life. Guided imagery helped to reduce pain. Since no future goals were possible, we talked about his freedom to determine attitude. He reported benefits from remembering pleasant and meaningful events in his life -raising his children, helping friends, traveling. He promised to tell me a story or a joke at every visit, and did, giving me permission to use the stories to help others. 
R., 69, suffering from severe breathing difficulties and headaches, had cut off contact with his family. He thought of little more than "the day I can't get another breath." During the logotherapy treatment he became aware of values -being with his grandchildren, woodworking, hunting. He began visiting his grandchildren, using a portable respirator. He could not work in the woodworking shop so he handcarved ducks, and read hunting magazines. His anxiety and headaches were greatly reduced. In a one-year follow-up he reported satisfaction with life although his sickness had not objectively improved. His wife plays the role of "logo-reminder." 
G., 54, hurt his back while working for the city, and is drawing workers compensation for his injury. He was totally inactive. After identifying his interest in gardening, fishing, and being with his pet dog, his activities increased dramatically, and so did his satisfaction with life. 
J., 29, suffering bone and skin pain because of cancer, had a long history of criminal behavior, and was considered to have a character disorder. He was depressed, would not take medication he had to have, felt guilty ("why have I survived? I don't deserve it"). He found meaning in helping his younger brother who was in prison. They planned a noncriminal life for the brother after his parole. The patient reunited with his family and volunteered for radical medical research. His pain and depression decreased significantly. He died one year later. 
D., 31,suffering from neck pain secondary to a Vietnam injury, had spent two years in a trailer park, paying rent by doing lawn mowing, trying to get a pension. He took motrin for his severe depression. After identifying his interests he found meaning in helping others, wanting to find his family he had deserted, and wanting to feel he was taking care of himself. He enrolled in school to become a social worker, wrote letters that led to finding his wife and son whom he visited. He worked part-time in a hospital as an orderly while going to school. A two-year follow-up showed satisfaction with his life and reduced pain. 
S., 53, suffering from crippling arthritis. foot infection, and diabetes, was in extreme pain and despair, confined to a wheelchair and having to take excessive dosages of demerol. Guided imagery and assessment of previous meanings (creativity, cooking, needlework, grandchildren) helped her identify goals still realiLable: making cookies for the grandchildren and their friends, and making large objects of craft to help visually disabled to do crafts. A one-month folhw-up revealed a greatly reduced intake of demerol, mood elevated on the "satisfaction rating" scale, a following through with her plans, and ability to attend church after a long absence. 
S .. 50, in the hospital with severe headaches and shortness of breath (black lung), needed help with his smoking habit and learning a non-narcotic way of dealing with his headaches because the combination of COPD and codeine ---which suppresses respiration --caused a lack of oxygen to the brain which probably was responsioble for his chronic headaches. He had become inactive and indifferent. 
Logotherapy treatment rekindled his activity in woodwork (his favorite hobby), his taking trips to see his grandchildren. and his overcoming negative attitudes toward family, friends, and hospital personnel. After nine sessions in 14 days, codeine was replaced by tylenol #l, smoking was reduced to two cigarettes a day, headaches were gone. and he was discharged after 16 days. A six-month follow-up showed significant improvement in activities (he had traveled for four months, visiting family and friends, made gifts ofwood for his children and grandchildren). His pulmonary functions, although improved 28%, were still poor but he stayed away from codeine. 
MICHAEL F. WHIDDON, Ph.D., is a clinical psychologist at the Veterans Adrninistration Medical Center, Knoxville, Iowa, and in private practice. 
REFERENCES 
I. Frankl. V. D. "The Ca,e of a Tragic Optimism," in Frank l's Man'.5 Search for Meaning. New York. Washington Square Press, 1985. 
2. I uL!,, Flisahcth. "The Best Possible Advice." lhe lnrernational Forumf,,r Logotherapr. I9X0. J(2). IJ-24. 
Logotherapeutic Enlightenment in Therapist and Client: A Case Study 
Wynand du Plessis 

Nolene. 26, was treated periodically at the Institute for Psychotherapy and Counseling, Potchefstroom University, Republic of South Africa, between 1979 and 1984. The client's response shifted from an initial near-psychotic level of functioning to meaningful involvement with people and a higher state of personality integration. The course of therapy is divided into two pha~cs: 1979-1983 and 1983-1984. 
Phase I: 1979-1983 
In February 1979, Nolene, a final-year student of Law was admitted to our hospital because of her agitated depression and aggressive outbursts. Under medication her depression lifted and psychotherapy commenced. Nolene's parents had divorced during her early childhood and she had been molested sexually by one of her mother's lovers. She had experienced difficulties during her adolescence and undergone psychiatric and electro-convulsive treatments. She had attempted suicide on sev-:ral occasions by cutting her wrists. She had also been taking drugs. 
Her present conflict centered around a love affair with a married member of the faculty of Law whom she perceived as a substitute father figure. The relationship caused painful guilt feelings, self-reproach, and intense anger. Nolene was allowed to ventilate her anger; she also kept a diary of thoughts. memories and dreams which led to additional ventilation. 
A while after her discharge from the hospital in 1979, Nolene's academic career came to an abrupt halt when, under pressure from her fiance, she married him and moved to another town. 
At the end of 1979 she reappeared for brief therapy. At this time a schizoaffective disorder2 was diagnosed and she was medicated accordingly. Although she returned to her husband her marriage was rapidly deteriorating. 
In 1980 she returned once more and was again treated briefly on an in-patient basis. An attempted suicide necessitated a transfer to a larger institution with a more favorable staff-patient ratio. She received further chemotherapy. After her discharge she took up a position as an assistant librarian and shared a flat with her brother. During 1981 she received further electro-convulsive treatment for depression. At the end of l 982 Nolene decided to continue her studies and requested continuation of therapy. 
My pessimistic view of Nolene's prognosis in view of her diagnosis of a schizo-affective disorder, as well as her past explosiveness, resulted in a nondirective therapeutic approach. Sessions were left open so that she could introduce her own priorities. Themes ranged from intense negative feelings about herself, her bodily appearance, difficulties in relating to men, and bothering dreams ofa bizarre nature. N olene wrote many letters and drew sketches which indicated severe stress and the fragmentation of her vulnerable defense mechanisms. 
As could be predicted, Nolene's inner recourses were blocked by anxiety when the mid-year examinations approached, and she had to be hospitalized once more with depression. Like before, a swift recovery was effected through intravenously administered anti-depressants. Yet Nolene was able to complete her examinations only partially. 
Phase II: 1983-1984 
After encountering the concept of the defiant power ofthe human spirit3 and other logotherapeutic concepts during the Third World Congress of Logotherapy in Regensburg, 1983, I realized how limited my own conception of people really was and how, in turn, this limited my response to clients, in particular to Nolene. For instance, the therapy had been structured too little because we had been afraid to shift too much responsibility on her, and we had paid no attention to her positive potentials because ofthe diagnosis ofa schizo-affective disorder. 
In resuming therapy with Nolene, after the Third World Congress of Logotherapy, I discussed with her my newly won insights. We decided that further therapy would focus more on Nolene's positive aspects. Crumbaugh's exercises of logoanalysis I were completed. N olene appeared to be more motivated and I also felt a sense of direction. 
Although some setbacks occurred because of Nolene's emotional instability, gradually a new level of communication emerged. Spontaneously Nolene produced a number of cassette tapes on which she disclosed personal feelings and thoughts interspersed with "typical music ofyoung people" -especially "angry songs." At this stage she also reiterated a theme from the past -her conception of three worlds: her world of private thoughts and feelings; the world of everyday mundane life (which she despised and resisted vehemently) and the world of angels and fairies. She was obviously resisting to become involved in the world of objective reality. 
By then the academic year had moved into exam time and regular weekly sessions ceased. When Nolene once requested a session and it could not be arranged soon enough for her liking, she slammed down the phone and two days later swallowed an overdose of tablets. On being discovered by friends in the residence, she was rushed to the hospital and revived. At the first contact afterwards she could or would not provide a clear reason for her suicide attempt, but insisted on continuing her therapy during 1984. Nolene's distressed mother was also interviewed. 
In view of Nolene's persistent sense of meaninglessness as evidenced by her suicide attempt at the end of the previous year, therapy was focused on her attitude to life. This led to the reluctant acknowledgement of an aspect she referred to as "tragic queen" -a tendency to identify with the negative side of life and to derive pleasure from experiencing rejection. Once she had admitted the self-destructive effects of this way of construing events, she became more willing to test her perceptions and to start changing her attitude. Having lived a life-style of extremes, it was especially difficult to start integrating seemingly opposites like her feelings and her intellect. 
During the Fall she was very depressed. She demanded to know why she had to bear with so much misery (depression) in her life. I mentioned the possibility of a meaning behind her suffering and helped her explore various possible meanings in her situation. When she became willing to look for meaning behind her situation instead of merely intellectualizing her debacle, she felt prepared to go on with life in spite of her illness. In the next session she reported two stimulating encounters with friends. 
She started dereflecting away from her depression toward the world ofother people and other issues, as a prelude to the change that was to follow. She became more active in the Student Community Service (SCS). She began reading for a blind student, and feeding autistic children at a local educational setting. She also recruited other students for work at the SCS and reorganized their schedule of activities. Having experienced the delight of mastery in this field of interpersonal relationships, she considered a public-relations career. 
The emphasis of therapy was now shifted to her relationships with men. In one session she had an impromptu conversation with a senior male student. Feedback from this interaction led to a realization ofhow she manipulated men in order to protect herself. Afterwards she reported small gains in her interaction to men: feeling more confident, and willing to engage in small talk, without feeling overwhelmed by the man. Later she stated that she had previously "emptied herself' in relationships and realized that males then projected all their own fantasies onto her, thus distorting the relationship. 
Sessions were reduced to one every two weeks, then she agreed to end them. "I don't feel like being all legs, arms, head and trunk any more, "she commented. "l feel l am a person." 
In the final session various ways of coping with stress were discussed. In November 1984 she completed the requirements for the Bachelor of Law degree and took up a position as a librarian at the art library of a Technical College. 
The Place of Logotherapy 
The question needs to be answered whether Nolene improved as a result of maturation and/ or medication, and whether the concepts of logotherapy (responsibility, self-transcendence, a search for meaning, etc.) had helped. It can be stated that her maturation was the result of logotherapy (education to responsibility). Medication had helped ease her problems on the physiopsychological dimension, but logothcrapy was needed as an important complement for the noetic dimension. Thus I was initially trying to provide an accepting relationship according to Rogerian notions. As the full extent of Nolene's prohlcms unfolded, my vision was dominated by the apparently overwhelming deterministic forces at work. Thus Nolenc's vulnerable personality structure and the ever present potential to become psychotic made me cautious and inhibited. However, the encounter with logotherapy's emphasis on the human spiritual capacities, prompted me to broaden my perception of Nolene and to reorganize my therapeutic approach, so I felt less responsible for her actions and let her be more in control of her life which now was oriented toward meaningful tasks and relationships. 
Though logotherapeutic techniques were combined with behavioral and cognitive methods, the logotherapeutic thrust which helped her bear her suffering and to gradually transcend her personal predicament served as a major influence i!l the therapeutic process. 
No matter what the future will bring to Nolene, the course of therapy has revealed the value of specific logothcrapcutic concepts and procedures which have impacted both the client and the therapist. 
WYNAND DU PLESSIS, Ph.D., is psychologist in the Institute for Psychotherapy and Counseling, Potchefstroom University, Repuhlic ofSouth Africa. 
REFERENCES: 
I. Crumbaugh, J. C. Everything to Gain: A Guide to Self-Fulfillment 1hrough Logoana~rsis. Chicago, Nelson-Hall, 1973. 
2. Diagnostic and Statistical Manual of Mental Di,orders. American Psychiatric Association. !981 
3. Frankl. V. E. "The Case for a Tragic Optimism." Paper read at the Third World Congress of Logothcrapy, Regensburg. !983. Published in Man '.5 Search/or Meaning, New York. Washington Square Press, 1985. 
New Life Through Logotherapy Observations by a Former Patient Barb Steidl 

My first step under the guidance of a logotherapist led to a new way of 
thinking. I learned that I was the master, not the victim, of my feelings. The 
logotherapeutic insight, "You don't have to take every nonsense from yourself" 
expresses the wisdom of the ages and is based on common sense. Perhaps this 
was what was new to me! 
While previous therapies had pointed out that my setbacks.~ loss of partner and job --were the unavoidable consequences of my past, logotherapy provided me with many suggestion~ that gave my life new and unexpected directives. 
Step by step I gained a new understanding of my life and its meanings. Gradually I lost the feeling that I was exchangeable, that I could be replaced in my work or in a human relationship. Instead I slowly came to feel. "lam, and this is good in itself." I learned that even my greatest distress, the loss of my partner, was an emotional problem, and that my frustrated search for meaning had led to resignation. A further step was the realization that my behavior, despite all unchangeable factors, was in the last analysis not dictated by outside conditions but by my own decisions. This was a new experience because a previous therapy, after a period of "unmasking," had let me understand that I would become a permanent patient ofa psychiatric clinic. Logotherapy, on the other hand, taught me that I could lose everything I had but not my freedom to decide whether this loss would lead to despair. 
The logotherapist, hy offering me concrete help, but never taking away my responsibility, showed me the way from despair to freedom. He made me realize that my past, unchangeable as it was, did not determine the way I was and that I could decide to change despite my past. 
I hcgan to see that my resignation was not caused by existing conditions but hy my own decisions. I had made these decisions, and now I could decide differently by calling forth the defiant power of my spirit. At the core ofall these considerations was my responsibility which other therapies never had mentioned. I was not responsible for my emotions, but I was responsible for my actions because I was free to take a stand in the face of these emotions, in the face of the personal suffering. 
Meaning Potentials 
My attention was redirected from a past that could not be changed, to things in the present that rnuld be changed. This moved my unhappiness from the center of attention, and opened my eyes to values that existed all around me, which I never noticed. This did not happen overnight: again and again I was tempted to imagine how beautiful it would be to share some experience with my lost partner. 
Slowly I was made aware that many attitudes are possible in one and the ~arm: situation, and that it makes no sense to brood about unhappiness, to run away from it, or seek revenge. I learned to stop fighting the inevitable and directed my attention to tasks that seemed worth fulfilling. The therapist made me aware of my potentials and by his caring helped me to come closer to actualizing them. The human dimension was presented as a "medicine chest" in our unconscious which logothcrapy makes accessible. 
Meaning possibilities emerged slowly, surely. I realized that it was hopeless in my case to win back my partner, that I could find other goals beckoning in the world around me if I would only open myself to them by reaching out in love to others. This helped me free myself from my shackles, not because I changed the situation but hecause I found (and am still finding) a new attitude toward the world. Instead of reacting with sadness, anger, or disappointment, I learned to act, to do something for the sake of a value. 
Forgiveness Instead of Hate 
I began to see that hate prevents the search for meaning. I came to realize that my anger toward my father (which an.ilysis had reinforced) led to unproductive hate. I began to think about reconciliation but I became discouraged because he had become more and more distant during the past ten years in which I had only written contact with him. Logothcrapy showed me the meaning potential of forgiveness. I saw that my father in his old age could not easily change hut that I could change my attitude toward him. l saw that this was not a matter of a dialogue between him and me but between my emotions and my conscience. My emotions, perhaps with reason, rejected my father, but my conscience pleaded for forgiveness. I knew that I myself had shortcomings and needed the forgiveness of others. These thoughts affected my emotions so my hate diminished and almost vanished. I could even imagine that I could place a kiss on my father's check, as a symbol of reconciliation between my emotions and my conscience. What for years had seemed impossible became a meaningful possibility. My wish became so powerful that I took a train and went to visit him. I found an opportunity and gave my father a kiss on his check. The result amazed me. My hate melted away completely and he gave me a silent hug. An inner peace came over me and I felt for the first time that L too, had parents as I had always wished for. Healing forces had been released that helped me make peace with the past, master the present, and have confidence in the future. 
I also gained new insights about that overpopularized word "self-actualization." In the past I hated my job as pharmacist because I found it boring and burdensome. The only way I thought I could "actualize" myself was to make myself indispensable to my boss. Soon these attempts to he "perfect" made me unpopular rather than indispensable. I began to see my work as a meaningful task by turning my attention to the customers whom I could help and to my colleagues who worked under me. This shift of attitudes made me feel needed. Today I enjoy my work while inner growth and success have come my way as by-products of my endeavor to lead a meaningful life. 
A "Discovering" Psychology 
It was equally helpful that the logotherapeutic interaction centered not on my sickness but on me as a person who, with all my distress and worries, was being taken seriously. Logotherapy is, in contrast to many others. not an "uncovering" but a "discovering" psychology; it helps us discover our healthy potentials, even if they are overshadowed by sickness. My attention was redirected from the closed doors to those still open. This, for the first time, meant hope. I became aware that what counted was not living as such, but living meaningfully, and that life did not owe us meaning but provided opportunities to search for it. I no longer insisted on having "a right to happiness and fair breaks," but rather sought answers to existing conditions. It took me a long time to realize that happiness does not come to those who expect to "have it good" but to those who feel they "arc good for something." It took me even longer to see that instant gratification is not the answer but that many little sacrifices for the sake of others can result in big meanings, with happiness as a by-product. 
I have experienced what Frankl means when he calls logotherapy a "rehumanization of psychotherapy." Elisabeth Lukas expresses this aim on a practical level: "We cannot promise our patients that their lives will always be pleasant but we can assure them that life can be mastered, and that it is worth the effort even though it contains suffering." 
BA RB STE/DL is a pharmacist in Hamburg, Germany, who has been a patient in the Klinik of Dr. Heines, Bremen, Germany. 

Can Logotherapy Help Cancer Patients? 
Elisabeth Jahoda 
This article is dedicated to the late Edith Weisskopf-Joelson. 
Today, people tend to regard sickness as a kind of mechanical breakdown that can be repaired as one fixes a defective car. The role ofthe doctor is reduced to a mere mechanic. Physicians complain that patients, too, expect quick "fixes," such as pills and injections which at best relieve symptoms temporarily. The possibility that illness may have a potential meaning for a person's development is not taken into consideration. Yet, patients also complain about the impersonal three-minute examination. Doctors don't have time for long conversations which could reveal deep-seated problems. They don't ask themselves whether the life situations and psychological conflicts of patients are related to their sickness. Treatments only enable patients to continue functioning. At night they get sleeping pills, in the morning pep pills. The result is a chemically controlled work machine. 
Wcinreb,5 in his profound and deeply human book, The Meaning of Sickness, came to the conclusion that "Man is not, as Nietzsche maintains, a sick animal; instead in his sickness he is a godly being, for being sick he suffers. he despairs and he hopes. In his sickness he even believes in miracles and perhaps when he is suffering his most profound crisis he is closest to the miraculous." 
I began to study medicine because my mother was dying ofcancer and had to endure terrible suffering. I was confronted repeatedly with dreadful forms ot this sickness during my studies, internship and further specialiLation. Unable to face its hopelessness, I interrupted my studies and tried to forget about cancer. I managed to deceive myself for a while. After clinical studies. pathology, and research I ended up as a dentist. Finally I had to face the disease; I was myself afflicted with breast cancer. Through a series of coincidences I learned about logotherapy and asked myself whether it could _be a useful support, an additional source of help for cancer patients. Although I have never studied psychology or psychiatry, and still pursue my dental career, l am increasingly involved with logotherapy. Dr. Elisabeth Lukas encouraged me to continue my efforts in this direction. 
After leaving the hospital in deep despair, I found consolation in the following parable: "Ben Sarok, a cruel man, could not sec anything healthy and beautiful without destroying it. At the edge of an oasis he came upon a young palm tree. That irritated him, so he took a heavy stone and placed it right on top of the tree. Then, with an evil grin, he strolled off. The young palm tried to throw off its burden, but in vain. Then the little tree tried a different tactic. It dug deeper into the ground to support its weight, until its roots came upon a hidden source ofwater. Then the tree grew taller than all the others, it towered above all the shadows. With water from the depths of the earth and the sun from the heavens it became majestic. Years later Ben Sarok returned to take malicious delight in the crippled tree he thought he had destroyed. But he couldn't find it anywhere. Finally the tree bowed down, showed the man the stone and said: 'Ben Sarok, I have to thank you, your burden made me strong."' 
Two weeks after my operation Viktor Frankl gave a lecture about logotherapy in our little town. I knew his book, Man '.1· Searchfor Meaning, and found it very moving, especially having survived a crisis myself. I became convinced that logotherapy could help cancer patients if combined with insights from two other authors. 
The first is Carl Simonton4 who has been successful employing a psychotherapeutic method in his Texas clinic, which includes diet, meditation, relaxation exercises, visualizations, and a spiritual approach to life. With this therapy, life expectancy of his patients is twice that of those in institutions as the Mayo Clinic. Simonton maintains that we expend a great amount of energy to pursue a way of life for which we are not suited and leads to chronic despair. The therapy helps patients reorient themselves toward what, deep within, they know they are, and to regain an optimistic attitude. Simonton uses visualized selfsuggestion, an original although not entirely new method. His patients learn to activate their own healing powers. 
The second insight comes from Lawrence LeShan2 who interviewed more than five hundred cancer patients. He found that they shared four typical features: 
I. During adolescence they had few intensive relationships. 
2. 
In early adulthood they established a strong meaningful relationship with another person or found satisfaction in their work, which became the center around which their lives revolved. 

3. 
Then, in a drastic change, the roles or relationships ended and the old childhood wounds again opened. 

4. 
The patients were not able to express their despair. It gnawed at them. They couldn't show others when they were hurt, furious, or hostile. They seemed easy to get along with, friendly, kind, ready to help. 


LeShan comes to the conclusion that the affability and kindness of his patients was really a manifestation of despair and lack of self-confidence. 
In her book, Meaningful Living, 3 Lukas mentions Stanislav Kratochvil's theory about the relationship between a person's value system and health. He divides people who consider their lives meaningful into two categories: those with a parallel and a pyramidal value system. 
Persons with a parallel value system have a number ofsignificant contents in their lives -family, profession, faith, social ties, hobbies. In contrast, persons with a pyramidal value system have one dominant source of meaning -a person, a profession, a mission. Kratochvil found people with a parallel value system psychologically healthier and more stable than the others. The values of the second group are like a pyramid balanced on its top. When the uppermost value is lost, the entire structure becomes unstable. This group is reminiscent of LeShan's typical cancer victims. They, too, have only one predominant value. 
Logotherapy is more than a psychological method. It is related to religion in this sense: a deep belief and trust in God can give life greater significance. Logotherapy helps people who cannot believe. Today, many people, indifferent to religion, have no faith to help them in critical situations. As I have observed with many patients I talked to, logotherapy can help such people when they arc afflicted with chronic and malignant ailments. It can be of use in pre-and post-operative patient treatment. 
Pre-Operative Help 
When people find out they have cancer they experience a deep crisis. They have no choice but to accept their sickness. The only alternative is to give up. Cancer is the most feared illness of our times. For its victims all other facets of existence become secondary -wit, charm, intelligence, their roles as parent, boss, lover. Their human identity is that of cancer victims. Doctors and others, obsessed with the malignancy, lose sight ofthe person. Therapy is directed only at the body of patients, not at their being. 
Another dehumanizing factor is the awe-inspiring technology of modern medicine. Doctors are almighty, patients seem insignificant in comparison. It is difficult for them to realize that their inner resources arc important for recovery. 
Logothcrapy can help patients rediscover their human identity: it can enable them to accept mutilation resulting from cancer operations. 
Post-Operative Help 
Patients have two alternatives: recovery or sickness. They can confront their tribulations or evade the challenge. It is therefore important that doctors not only treat patients with medication but also~-as Pascal says -help them make good use of their disease. Diagnosis of a malignant disease means a rupture in patients' normal routines. Brutal confrontation with existential questions which have been ignored can enhance maturation. One of the physician's most important duties is to help patients learn and grow from their illness. 
Recovery from illness involves biological processes which have physiological and chemical components. Mental energy can influence these processes in a similar manner that temperature accelerates chemical reactions. We are, however, not yet able to measure this hypothetical energy. 
The body is an organism; its parts are dependent on one another and with the whole. Science, however, is analytical. It studies the separate parts but not the totality, the entire person. Therefore, doctors try to heal patients by only treating their organs. 
Logotherapy deals with the entire person and can provide patients with the mental energy they need to recover. If recovery is not possible, it can still help them toward a fulfilled and relatively healthy life during the time remaining. 
When the illusion ofeternal health is destroyed, the alternatives are creativity or destructive rebellion. To be creative, patients must attain inner harmony, accepting their condition. The goal is not achievement of immortal artistic or intellectual work. Often it suffices to help patients examine themselves in a more open fashion, become more relaxed. Instead of a passive, embittered rejection, they accept their condition actively, courageously. 
Acceptance is not capitulation, resignation. According to LeShan and Simonton2A passive resignation is one of the factors which can lead to malignancies in the first place. Resignation means either admitting defeat or suppressing reality. Genuine acceptance, in contrast. is active and positive, but possible only after an intense personal development has taken place. Logotherapy can contribute to this development. 
Personal creativity is an important component of both logotherapy and Simonton'straining program for cancer patients. In logotherapy the therapist helps the patients constructively plan their future. The tip of their valuepyramid may have broken off, but the logotherapist can help them revise values to become more parallel oriented while finding new inspiration, new sources of mcamng. 
The Example of Courage 
How else can cancer lead to renewed creativity? It is necessary to impart courage to patients. This can't be taught, it is shown by example. It can be experienced in self-help groups of mastectomy patients. Each participant is inspired by the others, and one's own confidence, too, serves as an example. Dercflection techniques, as suggested by Lukas,3· P· 89 may also be applied. 
To have confidence one must be courageous. This is not the same as optimism, and doesn't necessarily mean believing in a rapid convalescence, or improvement. Optimism is the appropriate attitude to combat a brief illness. The situation is different in chronic or malignant ~:seases where progress depends on the courage of the patient. 
Joy often radiates from the faces of courageous invalid patients where healthy people are often glum and downcast. Perhaps the life of an invalid simply requires constant courage. In one respect, courage is similar to love the more one expends, the more one has. Patients experience the joy of victory over fate•--not the victory of a single day, but an enduring one. The secret of their overflowing joy is the stream of mental energy which permeates them the defiance of the human spirit. 
Cancer is an invitation for patients to ">cgin new lives free of deception. The challenge is to find their strength, to openly express their feelings, develop genuine relationships, and search for meanings. 
The illusion of eternal life, eternal health, is shattered and will never come again. Patients ask themselves questions forgotten in the course ofeveryday life -the meaning oflife and death, suffering and sickness, maybe even about God. They can't return to routine. But there is personal creativity, hidden, smothered by conformity, still there, deep within them, an essential part of human nature. 
Courage and hope are rekindled when we believe that we can profit and grow through our suffering. This increases the chance ofrecovery, and thus provides more reason to strive and to hope. 
The diagnosis of a potentially fatal illness is an important moment in one's life. It is a time when many people reflect how little they have really accomplished. For cancer patients, values fall into place. Many things that were important suddenly seem irrelevant: money, possessions, prestige, ambition. Before the sickness was diagnosed they were preoccupied with roles in society. 
They were so busy being active that they had no time to simply be human. Now they are compelled to stop, collect their thoughts, and decide what their real goals should be. 
We do create our lives. Many cancer victims believe their destinies are now unalterable, but logotherapy can help them become masters of their fates. 
Medicine, having developed into a purely physical and chemical science, has neglected to activate the healing potential of the human spirit through courage, self-confidence, the will to live, the will to meaning, and active optimism. Frankl speaks of a "tragic optimism."1 
The predominance of technical thinking, which has come late to medicine, has converted healing to a purely objective process. In former times, sickness meant intrusion ofthe abnormal into a person's existential world. Now it is seen as normal, typical, its duration predictable. its process mechanical --a thoroughly rational, statistically determinable process. 
The challenge is for patients to oppose their sickness with their will, their entire personal being. To communicate this attitude physicians should be willing to accept supportive psychological therapies, even if their physiological basis is not yet understood. Paracelsus realized their significance when he wrote: "You should know that the will is an important factor for medicine." People have been cured by appeals to human resources. Contemporary physicians laugh about therapies which our ancestors found effective, and specialists in the future will probably find current methods quaint if not dangerous. The effectiveness of any met hod --whether it be ancient magical incantations, modern nature-and miracle-healers, or scientifically oriented treatment ---depends to a large extent on its ability to mobilize the patients' inner forces. As all great doctors know, the presence and influence of another person can be more important than any pill. Logotherapy and similar methods can utilize healing forces that orthodox medicine is unwilling to admit. At the very least, we should be ready to explore their potential. 
ELISABETH JAHODA, M.D., is a dentist in Frankenburg, Austria, who has made the study oflogotherapeutic approaches to cancer her vocation. 
REFERENCES 
I. Frankl. Vik tor. "The Case for Tragic Optimism,,. in Frankl, Man's Search for Meaning. New York, Washington Square Press. 1985. 
2. 
LeShan. Lawrence. You Can Fight for Your Life. New York, Harcourt-Brace-Jovanovich, 1977. 

3. 
Lukas, Elisabeth. Meaning/it/ Living. Berkeley, Institute of Logotherapy Press, 1984. 

4. 
Simonton. 0. Carl. Gelling Well Again. Los Angeles, J. P. Tarcher, 1978. 

5. 
Weinreb, Friedrich. Vom Sinn des Erkrankens. Bern, Origo Verlag, 1979. 



Reduction of Depression in Relatives of Schizophrenic Clients James E. Lantz 
Schizophrenia is viewed by most authorities7•9-10 as both a basic biochemical illness and a reaction to stress, In this view schizophrenics are considered to have a perceptual and integrative deficit reactive to the biochemical illness which leaves them vulnerahlc for psychosocial deterioration when presented with high expressed emotionality in their family environment. 1-6 -9 Dereflection and similar techniques have been found useful in preventing rehospitalization of schizophrenic clients when used with their families. L6 It is hypothesized that such techniques help the clients' families decrease hyperreflection (guilt, depres,ion) ahout the schizophrenic clients and in this way reduce the amount of expressed emotionality presented to the clients in their family environment. L6 This reduction in family-expressed emotionality results in a decreased need for hospitalization or rehospitalization of the schirnphrenic clients. L6 Although dereflection with the clients' families does appear to have an impact upon hospitalization and rehospitalization rates, studies have not yet shown that dereflection can or does in fact help the clients' family members reduce feelings ofdepression or guilt. This article presents the results of a four-year study ofthe effects ofderctlection in helping family members ofschizophrenic clients reduce feelings of guilt and depression. 
Need for Dereflection 
Studies have shown that the relatives ofa schizophrenic client are exposed to several stresses and personal hardships. DolF has found that families of the mentally ill consider themselves to be living under severe stress and that having a schizophrenic living at home is viewed as disruptive to the personal life of the other family members. Kreisman and Joy5 report that keeping a schizophrenic at home does increase family stress and that this family burden has been underassessed, This underassessment has had the consequence that the mental health community is not meeting the needs of such families.5 Hatfield4 has found that families ofschizophrenics experience formidable emotional burdens and recommends that more programs, social supports, and counseling services be created to help such families minimize and cope with their distress. Hatfield also found that more than 90 per cent of the family members in her study reported that they had experienced severe anxiety and depression which was in their opinion reactive to their experience of living with a mentally ill relative. These researchers2,4,5 agree that such families could benefit from counseling and social services which would help them minimize and cope with stress. Frankl,3 Lukas,8 and Lantz6 have suggested deretlection as a useful treatment approach in this or similar clinical situations. 
A Clinical Study 
In our study eleven families with a schizophrenic member were provided counseling focusing on teaching them how to use dercflcction to decrease feelings of depression about their schizophrenic family member. All eleven families were seen at the Bridge Counseling Center in Columbus, Ohio, during 1980. Each family was seen weekly for at least two months. During this period the family members were taught to decrease hyperretlection by using dereflection methods such as learning about the chemistry of schizophrenia to reduce depression, learning how to give up the role of psychotherapist to the schizophrenic, and how to develop and increase nonschizophrenic-connected family interests and activities.6 After the initial two-month period of weekly sessions most of the families dropped down to once-a-month counseling sessions. Each nonschizophrenic member was given a self-rating of depression inventory, developed by Zung, 10 during their first counseling session and again after eight counseling sessions. Eight of the families were found, contacted, and again given the self-rating of depression scale four years later. A low score on the depression inventory indicates less depression, with a possible scoring range of 25-50 (normal), 51-59 (mild depression), 60-69 (moderate depression) and 70-100 (severe depression).10 
Study Results 
The mean depression index score for the eleven families was 179.9 in the initial counseling session. This mean score changed to I I 6.6 at the end of the eighth counseling session and represents an average decrease of• 63.3 for each family group. The mean depression index score for each individual family member was 71.8 at the end of the first counseling session. This mean score changed to 45.3 at the end of the eighth session and represents an average change of -26.5 for each individual family member. The mean total family depression index score changed from 179.9 (first session) to 13 I .6 at the time of the four-year follow-up (eight families). This represents an average family score change of -48.3. The mean individual family member depression index score changed from 71.8 (first session) to 50.4 at the time of the four-year follow-up, for an average individual depression index score change of -21.4. 
The results of the clinical study indicate that the use of deretlection in supportive-educational family counseling was helpful to all eleven families in their efforts to minimize their feelings of depression. The changes were maintained to a great extent in the eight families contacted in the four-year follow-up. 
Study Limitations and Conclusions 
This study is descriptive in nature and, therefore, only shows what happened when family members ofa schizophrenic client were provided family treatment services focusing on learning to use deref1ection to decrease guilt and depression. The study also shows that the family members were successful in initially decreasing depression, and that in the eight families contacted in the follow-up, a significant decrease in family depression was maintained for over four years. 
The study does not demonstrate that the approach described is more effective than other treatment approaches, that this approach would be useful with families that do not include a schizophrenic family member, or with families that include a member suffering from a different form of illness. Previous research I and case studies 1.6 have shown that the use of family dereflection and similar techniques can be effective in decreasing rehospitalization rates for schizophrenic clients. The present study supports previous research in that it clearly shows that dereflection can be extremely useful to family members in their attempts to decrease depression which is reactive to hyperref1ection about a schizophrenic family member's illness. 
JAMES E. LANTZ, Ph.D., is Assistant Professor, Ohio State University, College ofSocial Work, and Clinical Director ofVillage Counseling Associates, Columbus, Ohio. 
REFERENCES 
I. Anderson, C., G. Hogarty, and D. Reiss, Family Treatment of Adult Schizophrenic Patients: A Psychoeducational Approach. Schizophrenia Bulle1in, 1980, JO, 490-505. 
2. 
Doll, W. Home is not Sweet Anymore. Mental Hrgiene, 1975, 59, 2204-2206. 

3. 
Frankl, V. The Will to Meaning. New York, American Library, 1969. 

4. 
Hatfield, A. Psychological Costs of Schizophrenia to the Family. Social Work. 1978, 23, 355359. 

5. 
Kreisman, D. and V. Joy. Family Response to the Mental Illness ofa Relative: A Review ofthe Literature. Schizophrenia Bulletin. 1974, 6, 34-57. 

6. 
Lantz, J. Dereflection in Family Therapy with Schizophrenic Clients. International Forum for Logo therapy. I982, 5, 119-122. 

7. 
_____ Responsibility and Meaning in Treatment of Schizophrenics. International Forum for Logotherapy. 1984, 7, 26-28. 

8. 
Lukas, E. Meaningful Living: A Logotherapy Book. Berkeley, Institute of Logotherapy Press, 1984. 


9. Snyder, S. Biological A!,pectsof Mental Disorders. New York, Oxford University Press, 1980. 
10. Zung, W. The Measurement of Depression. Milwaukee, Lakeside Laboratories, 1974. 
An MMPI Existential Vacuum Scale for Logotherapy Research 
Robert R. Hutzell and Thomas J. Peterson 
It has been said that logotherapy does not lend itself to scientific research because it stresses the uniqueness, and, therefore, unpredictability of the individual. However, recently Michelson and Ascher10 reviewed evidence that the Iogotherapeutic technique of paradoxical intention produces testable questions and that the resulting investigation, when conducted by sophisticated research methods, fits well within mainstream mental science research. 
Logophilosophy is well accepted by the philosophic community and, as the quantity and quality of research increases, so will its acceptance and understanding by the scientific community. This paper provides information that may serve to increase the frequency of investigation into another important aspect oflogotherapy, existential vacuum. A screening device to make available large quantities of already collected data is described. 
The Existential Vacuum Screening (EVS) Scale is to help detect groups with or without existential vacuum who have completed the Minnesota Multiphasic Personality Inventory (MMPI). The MMPI is the most frequently used psychological test of personality, and huge quantities ofcompleted MMPI's along with additional data have been collected and stored by many institutions over the years. Questions about existential vacuum can be assessed from this existing data if a sufficiently accurate scale of the MMPI can be developed. Development and use of an initial version of such a scale are described below. 
Initial Development 
The EVS Scale selects MMPI items that correlate with either Purpose-in-Life (PIL) Test scores or Life Purpose Questionnaire (LPQ) scores. Crumbaugh4 designed the PIL Test to measure the degree to which an individual lacks meaning in life. Hutze116 developed the LPQ to measure this same concept in a geriatric population, and later its use was extended to younger, alcoholic populations.9 
In previous investigations5 the Depression Scale of the MMPI consistently correlated with the PIL. Therefore, to minimize the quantity of necessary statistical calculations, only the 60 Depression Scale items were considered in our investigation. 
The initial step 1n the item selection was to identify MMPI items related to total PIL and LPQ scores. To accomplish this, t tests were performed on PIL and LPQ scores for True vs. False responses to each MMPI Depression Scale item from pre-existing data which had been obtained for clinical purposes from a group of 32 male, geriatric, organic, neuropsychiatric inpatients (Age: M = 
61. 7, SD= 12.0). Of the 60 MMPI Depression Scale items, 23 were statistically significant (p < . IO) and were retained for further analysis. 
The second step was to select items that change in relation to changes in feelings of life meaning. The 23 selected MMPI items and the PIL were administered before and after Logoanalysis group therapy to 32 male, alcoholic, inpatients (Age: M= 40.l, SD= 10.7). Logoanalysis was developed by Crumbaugh2 and its specific format for the groups in our study was described by Hutzell.7 Previously, Logoanalysis was demonstrated to increase life meaning among alcoholic patients.3-~ For our study, MMPI items that indicated an increase in life meaning from before to after treatment were retained. Two criteria were used in this decision: (a) the response of the item had to change at least 10 percent of the time, and (b) the change had to be in the direction of increased meaning 67 percent of the time. A total of 13 ofthe 23 items met these criteria. 
The final step in the item selection was to assure that the relationship between the individual MMPI items and the PIL would generalize to additional populations. The correlations between the 13 selected MMPI items and PiL scores were calculated with data from 41 college students enrolled in an introductory psychology course. Any items that did not correlate at a statistically significant level (.05) with the total PIL score and that similarly had not been statistically significant in the above alcoholic group were eliminated. There were two items which did not meet these criteria and were dropped. The final I I EVS Scale items and their scoring are as follows: 
8(F)  -My daily life is full of things that keep me interested.  
32(T)  -I find it hard to keep my mind on a task or job.  
4l(T)  -I have had periods of days, weeks, or months when I  
couldn't take care of things because I couldn't "get  
going."  
43(T)  -My sleep is fitful and disturbed.  
88(F)  -I usually feel that life is worthwhile.  
104(T)  -I don't seem to care what happens to me.  
I07(F)  I am happy most of the time.  
152(F)  -Most nights I go to sleep without thoughts or ideas  
bothering me.  
l60(F)  -~ I have never felt better in my life than I do now.  
I89(T)  -I feel weak all over much of the time.  
259(T)  -I have difficulty in starting to do things  

In the EVS Scale high scores indicate the presence and low scores the absence of existential vacuum. 
Cross-Validation 
To be assured that the relationship between the EVS Scale and existential vacuum did indeed generalize to additional persons, the scores oftwo additional patient groups were employed. A group of 37 male, alcoholic, inpatients (Age: M = 37.0, SD= 9.7) who had completed a 6-week alcohol treatment program and had entered a IO-week extended alcohol treatment program were administered the MMPI, PIL, and LPQ along with several additional psychometric instruments. EVS Scale scores were extracted from the MMPI's and showed a correlation of-. 75 (N = 37,p < .01) with the PIL and a correlation of -.83 (N = 26, p < .01) with the LPQ. In addition, a mixed group of 31 male, geriatric, extended-care, neuropsychiatric inpatients with principal diagnoses of organic psychoses, functional psychoses, or major affective disorders (Age: M = 63.4, SD= 13.3) were administered the EVS Scale and the LPQ. The correlation between the EVS Scale scores and the LPQ scores was -.69 (p < .01). 
Reliability 
One measure of scale reliability is internal consistency as measured by Cronbach's coefficient alpha. 1 Internal consistency of the items was similar across the groups reported above and therefore the data for all groups were pooled for the internal consistency statistic. The average inter-item correlation (coefficient alpha) was .77. 
So that the EVS Scale can be used as a screening device, the data for all groups were pooled, regression equations for predicting PIL Scores were calculated, and cut-off scores were established. Crumbaugh and Maholick5 suggested that PIL scores below 92 indicate a significant lack of meaning in life, 92 to 112 are of uncertain definition, and above 112 indicate definite meaning. Based on the regression equation [PIL: X =61.0 + 5.32 (11 =Y); N =130], cut-off points for the EVS Scale are: 0-1-No Existential Vacuum, 2-5-Uncertain Definition, and 6-1 I-Existential Vacuum. 
Discussion 
The initial stimulus for the development of the EVS Scale was its potential for screening for existential vacuum with the M MPI, thus making possible the use ofconsiderable archival data in logotherapy research. The correlations between the PIL or the LPQ and the EVS Scale, the high internal consistency, and the cross-validation data all support the usefulness of the EVS Scale. 
As with the development of any new psychometric scale, numerous cautions apply. Of particular relevance here is the generalizability of the EVS Scale because the effectiveness of the scale and the cut-off scores may be altered when the scale is used with different populations. Although we attempted to include a variety of populations in the development of the EVS Scale, additional validation research needs to include different populations. Particularly needed is more research with females. 
Overall, the results of the present investigation are encouraging for the potential use of the MMPI to assess for existential vacuum. Due to limited resources, only the Depression Scale items of the MMPI were incorporated into the EVS Scale investigations, but other MMPI scales have shown significant correlations with the PIL5 and thus there are likely a number of untried MMPI items that correlate significantly with existential vacuum. The positive results of the present investigation lend justification to conducting the more sophisticated and expensive studies that can incorporate all possible items, that can use better sampling techniques rather than archival data, and that can conduct additional analyses such as test-retest reliability and predictive validity. 
The current results are positive enough to suggest that the EVS Scale can be used effectively to detect group trends and tendencies. The results are also positive enough to suggest that conducting the new studies recommended here may result in a scale accurate enough to make individual as well as group predictions. Such a scale, when imbedded in the complete MMPI, may prove less subject to distortion than the PIL when employed in competitive situations because the intent of the scale will not be obvious. 
ROBERT R. HUTZELL, Ph.D., is a senior level clinical psychologist at the Veterans Administration Medical Center at Knoxville, Iowa, and regional director for the Institute ofLogo therapy. 
THOMAS J. PETERSON, M.A., is a counseling psychologist at the York County Counseling Center at York, Nebraska. This research was supported in part by VA Western Research and Development qffice. Special thanks go to Lisa Phillips for her voluntary work in data gathering and data analrsisfor this pro;ect. 
REFERENCES 
I. Cronbach, L. J. "Coefficient Alpha and the Internal Structure of Tc,ts." Psychometrika, 195 I. 16, 297-334. 
2. Crumbaugh. J. C. Everything to Gain: A Guide to Se/f-Fuljillment through Logoanalrsis. Chicago, Nelson-Hall, 1973. 
3. 
____ and G. L. Carr. "Treatment of Alcoholics with Logotherapy." lnternalional Journal of1he Addictions. 1979, 14, 847-853. 

4. 
____and L. T. Maholick. "An Experimental Study in Existentialism: The Psychometric Approach to Frankl's Concept of Noogenic Neuroses." Journal cfClinical Psychologr, 1964, 20, 200-207. 

5. 
____"Manual of Instructions for the Purpose In Life Test." Munster. Indiana: Psychometric Affiliates, 1969. 

6. 
Hablas, R., and R. R. Hutzell. "The Life Purpose Questionnaire: An Alternative to the PurposeIn-Life Test for Geriatric, Neuropsychiatric Patients." In S. A. Wawrytko (Ed.), First Analecta Frank/iana. Berkeley, Logotherapy Press, 1982, 211-215. 

7. 
Hutzell, R. R. "Practical Steps in Logoanalysis." The International Forum for Logotherapy. 1983, 6(2), 74-83. 

8. 
____ "Logoanalysis for Alcoholics." 1he International Forum for Logotherapy, 1984, 7( I). 40-45. 

9. 
____and T. J. Peterson. "lJse of the Life Purpose Questionnaire with an Alcoholic Population." The International Journal ofthe Addictions, in press. 


JO. Michelson, L., and L. M. Ascher. "Paradoxical Intention in the Treatment of Agoraphobia and Other Anxiety Disorders." Journal of Behavior Therapy and Experimental Psychiatry, 1984, 15, 215-220. 
Conscience in Logotherapeutic Counseling 
James D. Yoder 

Clients seek counseling and therapy because they are aware of experiences, feelings, dread, anxiety, guilt, incompleteness. Some clients may be only partially aware ofwhat is disclosed, and this partial awareness nudges them to seek dialogue with a therapist, priest, teacher, even with themselves as they seme '"something disclosed to them." 
What is disclosed to consciousness is something that is; ... what is revealed 
to conscience is not anything that is, but rather, something that ought to be . 
. . . Insofar as that which has been disclosed to conscience is still to be 
actualized ... how could it be realized unless it were somehow anticipatrd 
in the first place.3, r. 34 
Considering the unconscious basis and the intuitive nature ofconscience, it is clear that it has a reference point. It is the function of conscience, according to Frankl, to point to this reference, "the one thing that is required." Conscience "reveals" to a concrete person a unique possibility to actualize in a specific situation. 
What matters is the unique "ought to be"which cannot be comprehended by any universal law ... and above all, it can never be comprehended in rational terms, only intuitively. 3, p. 35 
Logotherapy methods used in counseling that bring about an increased awareness of consciousness are Socratic dialogue, dereflection, and selfdistancing leading to self-transcendence. 
Dereflection and Self-Transcendence 
Linda, 37, with a long hi<;tory of mental problems, sought therapy because of despair and feelings ofresponsibility when moving her father, who was dying of cancer, into her apartment. Her intention was to care for him until his death. 
Though she was on medication and had been hospitalized previomly in two psychotic episodes, the power of the noetic, the defiant power of her human spirit, showed through. 
The fact that she chose to minister to another, a dying father, testified to her ability to self-detach from neurosis, psychosis, and risk-taking, and to her feeling of responsibility in an emotion-laden situation. 
Linda had been dialoguing with a counselor whether to place her father in a nursing home. In our session she extended herself to the meaning of her relationship with her father. 
Client: You know, last week my former counselor told me to put him in a nursing home. An out-of-sight-out-of-mind, get rid of him, situa-
tion. Maybe it is the best for me but I don't see it as best for him. Counselor: You have important reasons for not putting him in a nursing home. Client: Yes. Counselor: Talk about that. Client: Well, I don't know, I wish I could say that I think it has to do with 
duty and obligation ... I feel like I should be helping my father ... I 
can't justify it. I cannot believe that God commanded me to do this . Counselor: Sounds like commitment. Client: Yeah. Counselor: Coming from deep inside yourself, a conscious commitment and 
that has to do partly with love, doesn't it? If you love someone it 
goes along with commitment. Client: Yes, I think it does. Counselor: 1t is your commitment to your father that is evident in your actions 
and your giving of yourself. 
Clienf: What the previous counselor said made me question that commitment. It made me feel like I'm having to justify it and I don't feel any justification is necessary -just like 1 wouldn't hurt an animal. l shouldn't hurt another person if there is a way to avoid it. 
Counselor: Well, that has to do with your world view, what is important to you as a person in the world. How you treat animals -how you treat people -a commitment, between a father and a daughter -the reciprocity that is there, love and commitment. 
(Next she focuses on the possibilities of becoming overwhelmed by the task she has chosen to do.) 
Client: If I ever did get to a point where I couldn't take care of him any 
longer I would put him where he would get the care he needed. Counselor: Which would be reasonable and responsible. Client: It's a matter ofunderstanding myselfand what's going on with him. 
I just don't know now where this disease is going to take him. It could take him to a place where I couldn't take care of him, and I'd have to accept that. It would be an extremely difficult decision ... but I would make it. 
Counselor: I hear your faith coming through. "I can make it even if it gets very difficult --I believe I can do it. If there are logical reasons why he needs to be in the hospital, I would make the decision." You have faith in your ability to take care of your father and yourself. 
In this encounter, Linda's conscience is revealed, drawing her to the one thing necessary -caring for a dying father. She identifies deep motives which are not fully conscious. 
"I wish I could say it has to do with duty or obligation. " "I can't justify it. " "I cannot believe God commanded me to do this" 
Here we see a client in a healthy "dia-logos" with herself. Frankl writes: "I cannot be the servant of my conscience unless I understand conscience as a phenomenon transcendent of man. So I cannot consider conscience simply in terms of its psychological facticity but must also grasp it in ih transcendent essence. I can be the servant of my conscience only when the dialogue with my conscience is a genuine dia-lugus rather than a mono-logos --when it 1s a mediator of something other than myself."~-r 115 
Frankl defines conscience as a means to discover meanings. to "sniff them out."-'· r. 115 What conscience reveals to Linda in this difficult time also related to an increase in meaning potentials: Counselor: I wonder if it's possible in a situation like this to learn some deeper understandings about yourself? Client: I didn't think I was capable of it. I'm aware now of some personal needs. I've been wanting a child. and feeling sorry for myself because I wasn't married. I'm thirty-seven. and it has been worrying me a lot. Now I'm rethinking what responsibility this entails. Counselor: You've become more aware of your needs as a person, distinct from your father, giving you opportunities, nudging you a little to see if they are still alive. Client: ... It kinda goes with what you were saying about the one thing that you can always do is change your attitude. I'm trying to look at my situation not so much as a burden, but see the opportunity side ofit . . . . I wonder if I've always seized my opportunities as I look back on my life. Counselor: We probably do not always seize our opportunities. That's human. That's another thing we feel guilty about. Client: I have at times. Counselor: I don't hear any overtones of guilt in taking care of your father. l hear the positive, "I choose to do this and I choose to do it lovingly." Client: I really feel that way. That's what makes me. I've done a good job on guilt, I've learned through two nervous breakdowns ... no one helped me understand ... I think the chief factor was guilt. I see the reasons for it and I've pretty much learned, the way I've stayed healthy lately -I've got this internal clock. you know, internal monitor ... Counselor: You could not go against your inner truth. When one goes against one's inner truth, one ends up diminished. You say, "I got to the point where I had to say no ... I had to be honest with myself." Client: There are things I cannot do, you know, and I just don't do them. Counselor: What do you call this wonderful inner monitor? Client: l don't know what to call it. I don't understand the real basis for it. Whether it's anything intrinsic or whether it's early childhood training ... I don't really know what it is. It's something to investigate. Counselor: Kind of like a conscience, isn't it? Client: Yes it is. It is. Counselor: You raised the question, "Can I be still and listen to myself -can I 
find a guide that shows me the way?" 
Client: I feel that way, and I try to do what I can work with. To tell you the 
truth, l have more morals than most Christians -but I just do 
what I can live _with. 
Linda clearly reminds us of the transcendent dimension of conscience sounding through her. Frankl says: 
Through the conscience of the human person a trans-human agent personat-which literally means "is sounding through." It is not up to us to answer the question of what this "agent" is, anthropological rather than theological. Nevertheless we may claim that this trans-human agent must necessarily be of a personal nature."J, P-53 
By dereflecting from herself and her many problems, the client gives freely of herself -she risks in a trying and difficult circumstance, The therapist emphasizes the positive in her felt inner strength and in her lived experiences. 
"Sounds like a commitment." 
"It is your commitment to yourfather that is evident in your actions andyour giving ofyourself. " "The reciprocity that is there -love and commitment." "/ hear your faith coming through. " "You've he come more aware ofyour needs as a person. " "/ hear the positive, I choose to do chis." "You could not go against this inner truth. " "/ rnnfind a guide that shows me the way." This vignette reflects an ontological personal search within. The client, 
proclaiming atheism, is able to discover an inner monitor which she labels "conscience" which propels her toward her ought ~-nursing her dying father. 
Socratic Dialogue 
Socratic dialogue aims at heightening self-awareness, deepening the look within. It helps clients verify their most defining attribute, "freedom." Socratic dialogue contains questions about information such as, "What did you do?" about feelings. "What did you fee!?" rather than "How did you feel?" and about decisions concerning meanings, values, and judgments, such as "What does the present situation demand?" "How can you respond to it?" "Where does the 'should' of your response come from?" 
The client was a man, highly educated. who reared his children, supported his family, and bound their lives together with important themes from their religion. He came to counseling because of a deep inner conflict which emerged from the psychological dimension. 
The client previously revealed to the therapist his growing compulsion to engage in sexual activities with other men. Although he had refrained from doing so, he felt anguished and torn. 
Client: 1 . .. I have this problem. I don't know if I can even talk about it to anyone. 
Counselor: The fact that you are here shows that you are on your way. There's 
something you want to talk about. What is it that you want to tell me? Client: I ... I have this problem ... I ... I'm afraid that I will start acting in direct and overt homosexual ways. 
Counselor: You have discovered you have warm feelings for men. You worry about how you will express yourself sexually. What keeps you from becoming involved sexually with other men? 
Client: Well, I'm a married man of some twenty years. My relationship with my wife is close and intimate. Our sex is good. The main thing, I guess, is I believe that homosexuality is wrong. I feel guilty. 
Counselor: Let's look at your values and feelings, where you're coming from. Client: I travel a lot. I seek out places where I can be with other men, the spas, baths ... I want to have sexual experiences with them. Counselor: What keeps youfrom it? You tell me you use your freedom to find 
places where you will be able to do just that. Client: Yes, and I want to use my freedom just that way. Oh, I feel so guilty. Counselor: Something keeps you from behaving this way. What is it? Client: When I feel guilt like this I know it is my conscience. I love my wife, 
I have so much. I've reached so many of my goals, now it can all crash in if I give in to these urges. 
It became clear that the problem the client was facing went beyond the psychological where he felt the strong drive, or urge, that he experienced a noetic guilt -a nudge from conscience. Though he had been taught by his church that "to be homosexual" was wrong, and though this was his own personal belief, the major problem related to the noetic arena, to conscience. 
Exploring this with the client by explaining Frankl's dimensional ontology -the somatic, psychic, and noetic dimensions -the client was able to distinguish his psychic urges from his noetic values, and the developing noogenic neurosis over the conflict between the two. 
Counselor: You tell me you have discussed your recent feelings with your wife. What did you discover from that experience? Client: I discovered that I have a deep relationship and commitment to her. Counselor: But you have these urges ... a part of you says "go ahead." What is this something that holds you back? Client: I can't. I cannot do it. I have a commitment to my wife, a relationship that means commitment. 
Counselor: Your values quickly come to surface. Your conscience tells you that relationship is primary. In some ways it takes precedence over sexual drives and urges. What are you learning about yourself as you experience this very human struggle? 
Client: I'm -I'm learning that I don't have to give in to a drive and violate my commitment. Having sex with someone other than my wife would break this commitment. 
(Here dialogue reveals that the problem is not just one of sexual urges, but one of "how to keep a commitment.") 
Through eight sessions of caring, supportive therapy, the client grew in his noetic dimension, realizing that when he had become successful and "had everything," a drive appeared making him vulnerable. He was challenged to find ways to widen his meaning horizons, and some of them involved his wife. The case shows the power ofthe human spirit transcending urges and drives. In spite of his drives, the client chose not to act upon them and to continue to bring order into his life. Sex with anyone other than his wife meant a violation for both of them. 
The client discovered his deepest meanings were in his relationship with his wife and that the deeper meanings of sexual expression resided in this relationship and commitment. 
Frankl comments on love and conscience. "Love is that capacity which enables him to grasp the other human being in his uniqueness. Conscience is that capacity which empowers him to seize the meaning ofa situation in its very uniqueness and in the final analysis meaning is something unique ... Because of the uniqueness of the intentional referents of love and conscience, both are intuitive capacities. However, ... there is a difference between them. The uniqueness envisaged by love refers to the unique possibilities the loved person may have. On the other hand, the uniqueness envisaged by conscience refers to 
-r-19
the unique necessity, to a unique need one may have to meet. "2 
Though this client was encouraged to widen his perspectives by reading and dialoguing about homosexuality, the major difficulty arose not because of sexual drives, but because of values. 
Frankl clarifies that the experience of one value (in this case love and commitment in a relationship) includes the experience that it ranks higher than another (the value of sexual drives and fulfillment). There is no place for value conflicts. However, the experience of the hierarchical order of values does not excuse the person from making decisions. Persons are pushed by drives, but pulled by values_2. P-19 
By Socratic dialogue, the counselor urges the client to look beneath the surface, not to be content with generalities and quick explanations about his behavior. The method aims toward specificity. 
"Something keeps you from behaving this way. What is it?" 
"What did you discover from that experience?" 
"What are you learning about yourself as you experience this very human struggle?" 
Combining Methods 
Socratic dialogue is combined with dereflection in the case of a twenty-three year old young woman who had recently become a step-mother when she married a man with two children. However, she soon discovered that she could relate warmly to the oldest boy, but could hardly stand the five-year-old. In desperation she whispered ... "I can't love him." 
She was overcome by guilt from her aggressive and rejecting behavior. By utilizing methods of Socratic dialogue and dereflection --focusing away from trying to love ---she was able to make a change. 
Client: l cannot love this child. I want to wring his neck every time he gets 
in my way. I know I have to change if I am to keep my marriage. 
Counselor: What do you believe you owe this child, or any human being, for 
that matter? 
Client: Why, aren't you supposed to love everybody? I can't love him. 
Counselor: You cannot force love. All you owe another human being 1s 
respect. 
Client: (thinking) You mean I don't have to love him? 
The therapist raised the possibility that she may be projecting feelings of 
anger and rejection she felt when her parents separated when she was the same 
age as this child. The new step-son, forlorn and from a broken home, had 
triggered the neurosis. We began to focus on "respecting"the other, not to try to 
love. 
The client agreed to make every attempt to respect this child as a human being. She was not to attempt showing any excessive warmth or feelings she did not have. Within two weeks, her husband reported happily how close together the family was becoming. Concentrating on respecting herself by responsible behavior to a child whom she also could respect ~-a deepening relationship between stepmother and child ensued. She started out by showing respect and ended up responding with love. She had freed herself from her own prison by transcending toward the child. 
Frankl reminds us that true morality begins "only when man has begun to act for the sake of something or someone, but not for the sake of having a good conscience or of getting rid of a bad one. ''1, r. 42 
Summary 
This article demonstrates the irreducible personal force within each human being, conscience. Through counseling that raises consciousness and insight to freedom and responsibility, the dimension of conscience becomes elevated. Whether persons were religious or not did not seem to be a question. What became apparent in a time of anxiety in decision making was the fact that all were pulled toward values and meanings by this noetic power. 
"Only conscience is capable of adjusting the "eternal' generally-agreed-upon moral law to the specific situation a concrete person is engaged in. Living one's conscience always means living on a highly personalized level, aware of the full concreteness of each situation. Indeed, conscience has comprehended the concrete whereness (Da) of my personal being (Sein) all along. "1, P· 36 
The net understandings about focusing upon conscience through counseling are: 
1. 
Irreducible conscience points to a concrete situation in a particular time, and to ultimacy. 

2. 
Socratic dialogue aids the client in self-distancing through dialogue with another, and even more through a self-dialogue that may precede a client response. 

3. 
Self-transcendence -reaching out into the objective world of people, 


causes, and things --may be not so much a method of counseling, but an indication that conscience is responding to the one thing necessary (even toward ultimacy) and that counseling and psychotherapy are effective in freeing a person to hear the voice clearly, only partially anticipated in the unconscious. 
4. 
Clients, through knowledge gained about themselves, by use of selfdistancing, dereflection, or nudged by Socratic dialogue, become aware of a commitment to being responsible. Some may even indicate its unconscious and pre-rational origin: "I can'tjustify it." "I wish I could say it has to do with duty or obligation." 

5. 
The dialogue with conscience in the search for value and meaning points out that conscience "mediates" this noetic power with the voice of something other than the self. 

6. 
Dereflection, which involves self-distancing, opens a client to self-dialogue and therapist-client dialogue where the implicit becomes explicit, and the intuitt:d is acted upon and energized. 

7. 
Socratic dialogue urges the client to look beneath the surface, not to be content with easy generalities. It is always aimed at specificity. "Something keeps you from behaving that way, what is it?" "What is this something that holds you back?" 

8. 
A person may be guided by conscience in search for meaning, but can be misled by it as well. It is always a human conscience. 


JAMES D. YODER, Ph.D. isacounselorinprivatepracticein Kansas City, MO, and Regional Director ofthe Institute of Logotherapy. 
REFERENCES 
I. Frankl, V. E. Psychotherapy and Existentialism. New York, Simon and Schuster, 1967. 
2. 
_____ The Will to Meaning. New York, The New American Library, 1969. 

3. 
_____ The Unconscious God. New York, Simon and Schuster, 1975. 


Meaning in Life of Cancer Patients Receiving Adjuvant Therapy 

Victor Florian 

With the increasing complexity of modern society, individuals have become more aware and concerned over the issue of the meaning of life. Because this issue is difficult to define and measure, relatively few studies have devoted empirical resources to its investigation. Battista and Almond' reviewed the relevant theoretical literature, distinguishing between philosophical versus relativistic approaches to meaning in life. According to philosophical models, positive life regard is assumed to derive from only one true, intrinsic meaning of life. According to relativistic models, on the other hand, any system of beliefs can provide a framework for the development of positive life regard. The latter model place-; emphasis on the commitment to a belief system rather than the nature of that system. Based on an existential viewpoint, Frankl8 emphasized that the ~earch for meaning is the main motivation in the life ofa human being. He suggests that this meaning is seen from three viewpoints: I) what the individual gives to life (work, creativity); 2) what the individual receives from life (experiences, values); 3) the manner in which the individual relates to unalterable fate. 
Furthermore, Frankl8 maintains that it is the transitoriness of life that gives life meaning: an appreciation of the full meaning oflife has its foundation in the certainty of death. 
The threat of death and dying seems to intensify the immediacy ofthe need to clarify meanings in life. When persons must adapt to a fatal illness. they must reorient themselves by coping with the meaning and fact of personal extinction. 16 In a recent empirical study, 15 slightly over half of the respondents reported that the cancer experience had caused them to reappraise their lives. Therefore, it may be assumed that in prolonged life-threatening situations such as cancer. the search for meaning takes on particular significance. 
YalomY basing his claim on his clinical observations of cancer patients, emphasized the importance of meaning systems to human existence. He noted that "those patients who experience a deep sense of meaning in their lives appear to live more fully and face death with less despair than those whose lives are devoid of meaning." Zuehlke and Watkins,19 providing some empirical support to this view, report that logotherapy with cancer patients resulted in increasing sense of worthiness, meaningfulness and purposefulness. The patients experienced a greater sense offreedom to change their attitudes and saw themselves and their lives as meaningful and worthwhile. 
In another study. Spiegel and Yalom 14 described positive outcomes ofgroup psychotherapy techniques with cancer patients. In assisting group members to cope with their condition, the authors stressed the importance of putting death into perspective and maximizing the quality of the remaining life span and the clarification of the meaning of life on a personal basis. 
Despite some initial exploratory studies, "meaning-in-life" has not received the attention it merits by social scientists and practitioners. Battista and Almond3 emphasized the importance of such questions as "What is the meaning of life?"; "What does an individual consider meaningful?" and "What are the conditions under which an individual will experience life as meaningful?" It can be assumed that these questions, important to a healthy population, will be highly relevant for cancer patients. 
Demographic variables, such as age and sex, also may have a differential impact on the meaning in life for people with and without cancer. Yalom, 18 for example, points out the differential meaning in life in a healthy population of males and females: "Middle-aged women, who early in their lives devoted themselves to marriage and motherhood, seek different meaning to their lives than their middle-aged male counterparts." 
Within the cancer patient population, important demographic variables are discussed in the literature. In their review ofthis literature, Mages and Mendelsohn12 note that "individual differences affect both the significance and the mode of handling the disease and its consequences." They show that important variables ofage, sex, and personal history have been relatively neglected. Based on empirical data, they conclude that living with cancer had different meanings for different age groups. Young adults felt threatened by the possible end to incipient careers and marriages, mid-life adults were more concerned about the welfare of their families, older adults appeared to be threatened by accelerated aging and concurrent losses of health, vigor, friends, jobs, social and economic status. Nonetheless, because of age, older adults were able to deal with their illness with greater equanimity than younger age groups. In regard to sex, the same authors reported clear evidence that cancer had a more negative effect on males than on females, regardless of age. Mages and Mendelsohn12 speculate that because men defined themselves and their worth in terms of striving and activity in the external world, cancer was a heavy blow to their sense of masculinity because of loss of vigor, physical prowess, and capacity for sustained effort. Women, on the other hand, tended to sustain themselves with the help of family and friends, as well as by professional sources for support and reassurance. 
The above review supports the assumption that cancer patients can find certain areas in life to give meaning to coping and adjustment to illness. 
If these areas can be identified, they may contribute to a better understanding of patients' conditions, and assist in effective application of future psychosocial interventions. 
The purpose of our study is to identify specific areas perceived as providing meaning in life among cancer patients, in comparison to a healthy population. In addition, the study examines the influence of demographic variables, rnch as sex, age, and level of education, on the meaning-in-life of the two research groups. 
Subjects 
A total of 188 subjects took part in our study; 95 (51.3%) ofthem were cancer patients, receiving adjuvant therapy, and 93 (48.7%) were healthy people who served as a control group. The cancer patients received radio-therapy and chemotherapy at the oncological institutes affiliated with the two largest hospitals in Northern and Central Israel. These out-patients were being treated for various types of cancer once a week (mainly for breast cancer and gastric cancer). Patients were aware that total remission could not be expected, but that treatment could improve their physical condition and prolong their life-span. Based on the clinical impression of their social worker, most cancer subjects in the study were in a general condition similar to what Weisman 17 described as "existential plight" while only a few functioned in what Weisman described as the psychosocial stages of "mitigation and accommodation." 
For ethical reasons, specific diagnoses were not revealed to researchers. 
The control group of healthy individuals was taken from various places in the same communities as the main research group. Special effort was made to achieve optimal group matching between the two with regard to sex and age variables. In the cancer patients group, 43 (45.2'!+) were males and 52 (54.8%) were females. In the healthy control group. 45 (48.4%) were males, and 48 (51.6%) were females. Table I shows a cross tabulation of demographic data of the two research groups. 
Table I. Demographic data of the two research groups. 

•unmarned sub-group consisted of widowed and divorced subjet"ts almost equally 
diVJded within each of the research groups. 
X2 test revealed no significant differences between the two groups on the age variable (X2 =5.93; p > .05). Significant differences between the groups were found on the other three demographic variables. 
The healthy control group had higher educational attainments than the cancer patients (X2 =17.33; p< .00 I). In the healthy control group the majority were working, as against a relatively small number of cancer patients (X2 = 11.71; p < .01). 
As for family status, there were significant differences: 95. 7% of the control group were married compared to only 66.3% of the cancer patients (X2 =24.02; p < .00 I). These differences between the two research groups are taken into account in the statistical analysis in the results. 
Instruments 
A review of the literature revealed the existence of only a few instruments which measured meaning-in-life. These instruments, based mainly on samples ofcollege students. were designed to measure this concept, either by measuring the intensity of meaning, i.e., The Purpose of Life Test6 or by measuring the ability of individuals to fulfill life-goals. i.e.. Life Regard lndex.3 Neither instrument measured the type or contt'Xt of meanings reported. For our study, an attempt was made to design a simple instrument which in concrete terms meas_ured the context of the meanings in life for the research population. 
The construction of the instrument was di\'ided into five stages: 
l. Protocols of group-dynamic sessions of cancer patients attending an outpatient oncological clinic were collected over a period 0f six months. 
2. 
A panel of three clinicians, experienced in working with cancer patients (two social workers and a psychologist) analyzed the contents of these protocols in order to reveal the main issues reflecting meaning-in-life of participants. This panel selected 19 items related to meaning in life that focused on personal coping activities, family and social relations, religious beliefs, work and aesthetic pleasures. 

3. 
To check the comprehensibility of the questionnaire and response distribution, a pilot study, using the selected 19 items, was carried out on l5 healthy persons. Four items were found to have either a skewed distribution or to be ambiguously phrased. These were eliminated, leaving a total of 15 items for the final questionnaire. 

4. 
In its final version, the questionnaire was built around the question "What, in your opinion, gives meaning to your life at present?" Responses were measured according to ratings of each of the 15 items, on a 5-point scale. ranging from I (does not give any meaning at all to my life), to 5 (gives very much meaning to my life). The questionnaire, in this form, was filled out by the 188 participants. 

5. 
The final stage in the construction of the instrument was a factor analysis of the data obtained. A principle component factor analysis with varimax rotation was performed. This analysis revealed the existence of 3 factors with eigenvalues over one, which accounted for 53% of the variance. Inspection of the factor loadings showed that four items had significant loadings on each of 


the 3 factors. Therefore, these items (Feeling that I am in control of what is happening to me; Enjoying aesthetic pleasures; Performing hobbies: Feeling of good health) were excluded from further analysis. 
A second principle components factor analysis was performed on the remaining 11 items. This analysis revealed three clear factors which accounted for 57% of the vari'ance. The items receiving loadings of more than 0.50 are shown in Table II according to their corresponding factors. 
Table II. Rotated factor matrix of the mianing-in-Iife questionnaire 
Factors 
What gives meaning to my life at present: 
3
2
I 
-0.02 
0.06
I. Interest in work 
0.77 
-0.14
2. Ability to be active 
0.14
0.76 
3. Feeling that I am useful 
-0.29
0.24
0.68 
4. Ability to feel and to think 
0.32
0.67 
0.33 
5. Ability to cope with problems :rnd 
0.20
0.17
0.64 
solve them 
0.07
6. Feeling that I accomplish achieve
0.47
0.53 
ments in my life 
-0.02
7. Family relations 
0.07 
0.77 
0.06
8. Raising children and the sense of 
0.71
0.01 
continuity it brings 
-0.21 IO. Social relations 
9. Being loved 
0.34 
0.60 
-0.11
0.57
0.29 
-0.08
11. Religious belief 
0.88
0.04 
The first factor consisted of six items on the meaning-in-life scale which had in common the theme of self-actuali1.ing behavior*through active functioning. The second factor included four items of meaning-in-life related to the common denominator of family and social relationships. The third factor had only one item, related to the meaning-in-life derived from religious belief. 
In addition to the meaning-in-life questionnaire, the subjects filled out a short demographic questionnaire which included details on age, sex, family status. level of education and employment status. 
Procedure 
The original intention was that patients waiting for oncological treatment should fill out the questionnaire on a voluntary basis. It soon became apparent that the patients were not willing to cooperate as the questionnaire aroused considerable anxiety. Therefore, social workers at the two institutes and their trainee students personally approached each patient who agreed to participate and helped fill out the questionnaire. In completing the questionnaire the patients felt a great need to furthc-r comments ofemotional and clinical importance. Thus, the entire process of data collection took about an hour for each pi!tient. Much clinical data that had not previously been known to care personnel was revealed, and a byproduct ofthe research project was the possibility for the patients to express emotional catharsis. Because participation was impossible to control systematically, the result was a cumulative convenience sample. However, experienced staff social workers estimated that respondents to the q ucstionnaire were quite representative of the treatment population. (To ensure the best possible representation, the interviews were carried out over about three months --a period that covered an entire cycle of cancer patients visiting the institute for adjuvant treatment.) 
The subjects in the control group were recruited from different sources in the community (in the same geographical areas as the cancer patients) and included participants in different leisure activities, university extention courses, handicraft groups in community centers, lay volunteers in social agencies. and clubs for old-age pensioners. The questionnaire was distributed directly to each subject who then filled it out at home, and returned it after a few days. Filling out the questionnaire averaged about half an hour. Seven subjects out ofthe I 00 initially contacted refused to fill out the questionnaire because of lack of interest. 
*Note from the editor: Dr. Florian's use of the term '"self-actualizing" dillers from Frankl's. As Frankl explains ( Will to Meaning, p. 38), "Self-actuali1ation is not man\ ultimate destination. It is not even his primary intention. Self-actualization, if made an end in itself, contradicts his seli~transcendcnt quality of human existence. Like happiness, self-actualization is an effect, the effect of meaning fulfillment. Only to the extent to which man fulfills a meaning out there in the world, does he fulfill himself. If he sets out to actualize himself rather than fulfill a meaning. selfactualization immediately loses its justification." As Dr. Florian uses the term "self-actualization" in this paper, it comes close to Frankl', definition of selt~transcendence. 
Results 
To examine possible differences between the two research groups on the three factors of meaning in life, a 2 x 3 Manova test with repeated measures was performed. This analysis had two advantages. First, it took the correlation between factors into account, and second, it revealed the differences between the three factors. 
Table III shows the means and standard deviations for the two groups on the three factors of meaning in life. 
Table III. Means and Standard Deviation for Cancer Patients and the Control Group on the Three Factors of Meaning-of-Life 
Factor J  Factor 2  Factor 3  
Patient Group  Mean  3.84  4.12  3.09  
Std  0.92  0.79  1.44  
N  95  95  95  
Mean  3.91  3.99  1.87  
Healthy Group  Std  0.70  0.79  0.96  
N  93  93  93  

The Manova test revealed a significant difference between the three factors. (F(2,185) = 115.45; P< .001). A contrast test between the means of the factors showed that factor 1 -self-actualizing behavior* (m =3.88) and factor 2 -family and social relations (m =4.06), were different from factor 3 -religious belief (m = 2.49). 
The analysis also revealed an overall significant difference (F(l, 186) =16.82; P< .001) between cancer patients (m =3.69) and the control group (m =3.25), and significant interaction effect of groups by factors (F(2, 184) = 19.03; P < .001). 
Contrast test ofthis interaction showed that the third factor -religious belief -was the main source of significant groups and factor effects. Both research groups had a smaller mean in this factor. Moreover, differences between the groups were found only in this factor in which the cancer patients had a greater mean (m = 3.09) than the control group (m = 1.87). 
The second stage of the data analysis examined the influences of three main demographic variables (sex, age and education level) on the meaning-in-life factors. Table IV shows the means and standards deviations of the three meanings-in-life factors as related to gender, age and education level. 
Table IV. Means and Standard Deviations of the Three Meaning-in-Life Factors to Gender, Age and Education Level ,------,--------:,_P_a_t-ie~~-G_r_o__u_p_F-_a_c_t_o_r_s__H_e_a_l;h_y_G-ro_u_p_F_ac-·t-or_s_ 7 

2 -' I
! i l 2 I J 
--M-E,_A._N__ j 3.65 4.13 2.87 
3.97 1.96 :
I 4.19 I Female L1-STD I I 0.83 I 0.82 
1.01
0.70 0.76

1.36 
48 
s 
1---~ -:u, ,:: ! 4 :: 
,:: 
3 :: ,:: 
I 78 
E ! Male I -Sl~) 097 0.7t-,--t-'-l-.5-0__,i_(_l._70-+;-o-.7-8--,-0-.90
x I :_:--~;,J~~Ei~:: 1 ,t__--_~-4_--~=:=:1==4·=:=:=-+-:-1-:-:~j 
<4'5 l STD r 0.96 I 0.86 1.58 0.64 i 0.45
1
l 1 --N--------r--2s7 25 1---2-5--ti'--l8-.-+:--l-8--1'----1x7,· 
1
r---------MEAN I J.92 f-4~29 ! 3.00 I 3.93 .U<O : 1.92 J 
1 
A ~ 46-64 srn o. 77 jo65 I 1.21, I o. 69 o.86 1.0-1 ! 
G ----N 35 j 35 35 I 52 52 52 
l 
MEAN 3.62 ! 3.93 3.40 3.70 4.13 !8:l i E -----t-----,f----+---+------1 
_J_~64_---,[_-:_,-T:D:_-_-_-_--++---_'=-~=:====O=·=~:=,====l=·:=:==-~=O-:-~--+-:__o_;-~----+--~----:.9-,_-J 
E i ~ ME/\N 3.61·--+--~~~--J.55 3.53 :1.86 i 206 j D , Elemen-I S f D / 0. 95 : 0. 79 i I 43 I 0. 78 0 9~ 0 85 -
1 
1 lJ f tary [N------+----40---~~=40____+--4-0--t--16---L lb I 16 i 
C 
Secon-t MEAN 4.05 4.14 3.14 3.91 3.97 i.74 
-------1---------+-----+----+------+---+-------, 
dary 
STD 
0.71 
0.92
0.75 
0.65 
0.83
1.25 
A N 
53
37 
37 
37 
5353 
T MEAN 
204 I
4.17 
4.25 
2.00 
4.13
4.18 
I 
I Aca-
STD 0.97 
0.94 
1.08
1.28 
0.64 
0.60 
I 
N 
24
18 18 
24 
24
18
0 
l-~~~ic
--~----~---~--~--~--~--~---' 
N 
To examine the sex differences between the two research groups, a 2 x 2 Manova was performed. This analysis revealed a group X sex interaction. (F(3, 188):: 3.15; P < .05). To find which of the three factors contributed to the interaction mentioned above, a univariate A nova was performed. A significant group X sex interaction revealed that factor l. self-actualizing behavior, (F( I, 184) =5.19; P <.05), and factor 3, religious belief (F( 1,184) =3. 74; P <.05) were the sources of the differences. In both factors, a difference was found between sexes only in the cancer patients group, males receiving greater score~ than females. 
To examine the effect of the age variable, the two research groups were divided into three subgroups: young (25-44), middle age (45-64) and old (65 and above). A 2 x 3 Manova test (2 research groups x 3 age groups) revealed a significant age effect, (F(6,360) = 2.29; P < .05). A 2 x 3 univariate Anova for each factor showed a significant difference among the ages in the first factor -self-actualizing behavior (F(2, 182) = 4.51; P < .05). In both research groups the young group received the highest scores, and the old group the lowest. 
The analysis also revealed an interaction effect (group X age) (F(6,366) = 2.59: P <.05). A 2 x 3 univariate Anova showed that this interaction stemmed from the second factor --family and social relations -in which the oldest patients and the middle-aged healthy subjects received lower scores compared to the other four subgroups. 
To examine the influence ofeducational levels on the meaning-in-life factors, all ~ubjects were divided into three subgroups: 1) elementary school, 2) secondary school, and 3) academic and higher education. A 2 x 3 Manova test (2 research groups x 3 levels of education) was performed. The analysis revealed an overall significant difference with regard to education level. (F(6,360) =5. IO; P < .001). Univariate Anova revealed significant differences in the first factor -self-actualizing behavior (F( 1,94) = 9.39: P < .001) --and the third factor --religious belief (F(2,182) = 5.58; P < .001). 
In the first factor, the subjects with elementary education received lower scores compared to the other levels ofeducation. In the third factor, the subjects with elementary education received higher scores than the other two. This difference on the third factor stemmed mainly from the patients group as revealed by the significant interaction of two research groups x 3 levels of education effect. (F(2, 182) = 6.29; P < .001). 
Two additional variables were tested. To examine the influence of the employment variable, the two research groups were divided into 3 subgroups: I) subjects who never worked, 2) subjects who are working, and 3) subjects who had been employed in the past. 
The aim of the second examination was to look at the influence of marital status on the three factors of meaning-in-life. For this purpose all subjects were divided into 2 subgroups: married and unmarried. It was found that most of the healthy subjects were married and working. 
Two separate analyses were performed. The first tested the effects of these variables among the patients, and the second tested the differences between married and working patients, and married and working healthy subjects. A Manova test between married and unmarried patients on the three factors revealed an overall significant difference (F(3,9 I)= 9.03; P <.001). A univariate Anova revealed significant differences in the first factor --self-actualizing behavior, (F(l,94) = 4.05; P < .05) -and in the second factor -family and social relations (F(l,94) = 23.28; P < .001). In both factors, married patients received higher scores compared to unmarried patients. A Manova test which compared married patients with married healthy subjects revealed significant differences ( F(3. 148) =69.0 l: P < .001 ). A univariate Anova revealed significant differences in the second factor ---family and social relations ( F( l, 150) =28.0 I: P <.001) ---and in the third factor -religious belief (f( l.150) = 180.09: P < .001). In both factors the patient group received higher scores than the healthy control group. A Manova test among the three levels of employment status, revealed a significant difference (F(6, 182) = 3.24: P < .05). A significant difference was found llnly in the first factor----\elf-actualizing behavior (F(2.92) = 
8.43: 
P < 00 l ). In this factor patients who had never worked recei vcd lower score~ compared to the other groups. 

A. 
Manova test between the working patients and the working he;.:dth\ suh:ccts on l he t hrcc factors of meaning-in-life revealed a significant difference (F{2.!C1) 1(93: P < .001). However, it was found that only the third factor 


0 
religim,s beiief --contributed to this difference, (F( l ,89) = 20.09: P < .00 l ). Working ps1ticms received higher scores than healthy subjects, but this m.1y he due 10 overall difference, between the patients group and the healthy subjects gi m;r,s as inttially demon~trated in the general analvsis (see Table lI l). 
Discussion 
Living with a prolonged life-threatening condition like cancer requires considerable psychosocial ener!,,y. Having clear meanings in life seems to serve as an i.mportant em:rgy source in providing motivation to cope with the experience of such a stressful situation. 
The results of our study indicate the existence of three main meanings in life factors .. self-actuaiizing behavior, family and social relations, and religious belief. It seems that the psychological content of these three factors represents universal life areas, and that people with and without cancer give similar weighing to these three factors ofmeaning in life. The identification of these lilc areai: seems to provide some support for the theoretical propositions of MountL3 and Ahmed 1 who emphasize the major importance of psychological, spiritual, and interpersonal areas when cancer patients try to cope with their condition. 
The finding that these cancer patients view religious belief as a more important source of meaning in life than do the control group may support the assumption that in periods of prolonged stress even people who would not define themselves as religious, tend to turn to spiritual faith as a source of meaning. This and its interpretation is congruent with the claim ofCrandall and Rasmussen5 that genuine, intrinsic religious orientation may help to foster greater perceived meaning and purpose. 
An interesting result of our study is the apparent differential impact of demographic variables on the subjects' meaning-in-life factors. Sex differences revealed in the study emphasize the importance ofa professional approach that differentiates cancer patients according to gender. Male cancer patients, in general, found more meaning in life in the self-actualizing and religious-belief factors. The first finding may provide some support for the speculation by Mages and Mendelsohn12 that "because men define thcmselvc, and their worth 111 terms ol striving and activity int he external world. cancer constitutes a hea\'Y blow to their sense of masculinity." Therefore, it can be assumed that giving a high meaning-in-life ;mportance to ~elf-actualizing beha\'ior clfecti\ely help~ the male cancer patients in their struggle. The fact that the religious-belief factor is perceived as highly meaningful by the male cancer patients may perhaps be explained by the Jewish background of our study population. In general, the Jewish religious tradition provides a relatively clear differentiation between the expectations of religious outlook and practice for men as opposed to women. This tradition puts greater emphasis on the duties and the demands req uircd of males. In our study participants defined themselves as nonreligious, but it can be assumed that due to traditional expectations of the sexes in Jewi~h Israeli ~ocicty, the cancer male subjects find in religious belief a greater source of meaning of life. 
Our findings concerning age differences reflect various life expectation in relation to different developmental stages.rn The youngest research group with and without cancer view the self-actuali1ing behavior factor as a more important meaning-in-life source, while the oldest subjects in both research groups gave to this factor the lowest importance. These findings are only partly congruent with the claim of Mages and Mendelsohn12 who suggest that the developmental stages of the person play an important role in coping with malignant disease. It seems that emphasis on self-actualizing behavior is a general trend among younger people and apparently not influenced by the presence or the absence of cancer. If this interpretation is correct, then encouraging self-actualizing behavior in young patients might serve as a particularly effective motivational resource in psychosocial interventions. 
The interaction effect that was found between the ages among subjects in the two research groups on the second factor -family and social relations -is difficult to explain. It can be speculated that for the oldest cancer patients this factor ceases to play an important role in their lives, because of a general tendency to detach themselves from former family and social ties, and turn to more spiritual resources. This and the fact that the middle-aged healthy control group also received low scores on this factor, should be explored further in future studies. 
The relationship between educational level and meaning-in-life factors should be carefully examined. It will be remembered that the two research groups differed significantly in their level of education. Therefore, the findings that the cancer-patients group with elementary education put more emphasis on the religious belief factor must be seen with regard to the general lower education level of the cancer-patients group. Probably, when people with an elementary education have to cope with a threatening disease, the most useful and available motivational resource for them is the comfort of religious belief. At the same time, despite initial research-groups differences, both research groups with elementary education received the lowest scores in the first factor --selfactualizing behavior. It can be assumed that at this level ofeducation, the inner resources of active coping behavior, in general, and the ability to cope with the disease in particular, do not serve as effective motivational resources for the individual. These people, therefore, tend to turn to relatively passive external resources like religious belief. This line of interpretation may receive partial support from the deprivation theory of religious commitment. 2•7•9 According to this theoretical approach, religious belief may have a strong impact on people and their view of life, especially in circumstances in which they feel deprived. In such circumstances, religious belief is the way of coping with their deprivation. In any case, the aforementioned speculative interpretation should be viewed with reservation, and only further empirical support would validate this explanation. 
Regarding the last two demographic variables, it should be noted that in contrast to the patients group, the majority of the healthy control group were married and working. The result of the study indicated that when married and unmarried cancer patients were compared, the married group found more meaning in life due to the self-actualizing behavior and family and social relations factors. When married patients and married healthy control group were compared, it was found that the cancer-patients groups considered family and social relations, and religious belief, a more important source of meaning than did the married control group. These findings provide further validation to the well-recognized general importance of interpersonal and marital relations in dealing with the stresses of severe illness.4 In fact, Mages and Mendelsohn,12 emphasized that for cancer patients living in a couple situation, the stressful condition of cancer illness may lead at times to positive effects as expressed in improved communication that strengthens interpersonal bonds. Lichtman11 also mentioned that cancer patients reordered their priorities, giving mundane concerns low priority, and relationships with spouse, children, friends, and personal projects high priority. 
The results dealing with the relationship between the employment status and meaning-in-life factors are similar to previous findings. Cancer patients who had never worked, received the lowest scores in the active self-actualizing behavior factor. When the working patients group was compared with the healthy working subjects, the cancer patients found in religious belief a more important source of meaning in life. 
In general, the findings of our study seem to indicate that people with and without cancer emphasize various meaning-in-life factors according to their demographic background. In the words of Taylor15 "for many patients the meaning derived from the cancer experience brought new attitudes toward life. For others, the meaning gained from the experience was self-knowledge and/ or self-change." 
The different possible patterns of meaning-in-life factors found here may be useful to professional staff in their evaluation and assessment of the potential motivational resources of patients. The identification of a specific meaning-inlife system for each patient may serve as a useful tool for revealing the sources of psychosocial energy required in struggling with this life-threatening disease. 
For the staff member, the knowledge oftheir patients meaning-in-life system may be helpful in planning and choosing the best strategy for appropriate psychosocial intervention for each individual. For example, when treating a male cancer patient with only elementary education, one of the initial steps could be to find out the role of religious bclid" in the life framework of that 
patient. If the patient is a young male with relatively high education. special emphasis could be given to self-actuali1ing behavior. In fact. a byproduct ofour 1-c,c,1rch was that the social workers who conducted the interviews discovered much information of clinical value that proved helpful in understanding the patirnts' psychosocial situation. 
Finally. it should be stressed that our findings should be approached carefully because of a certain methodological limitation related to the selection of the control group. In spite of this limitation. it may be useful to conduct further studies with similar cancer patient populations, and comparison with persons in other life-threatening situations like dialysis, heart disease, and life-shortening progressive diseases. By revealing the meaning-in-life framework characteristic of each group important motivational resources could be uncovered. Such knowledge would assist professionals in designing of effective psychosocial intervention programs in health care settings. 
REFERENCES 
Ahmed. P.. Livinf; and Drinf;: f<elwhilitlllion Prohlems and Predictors u( Renn·en. Else\ icr. Nc'w York, Oxford Press. 1981. 
2. Argyle. M., and B. Beit-Hallahmi, The Sucia/ P.,ycholog\ o/Re/1gion. London, Routledge and Ke!!an Paul. 1975. 
J. Battista. J., and R. Almond, "The Dcvclorrncnt of Meaning in Life." P\ychwrr_r. 1973. 36, 409
427. 
4. 
Cohen, F.. and R. S. l.atarus, R. S. "Coping with the Stresses ol Illness." In Ilea/th Psrchol

o,rr: A Hant/hook. G. C. Slone. F. Cohen, anrl N. F. Adler. (eds.), San Francisco. Josscy-Hass, 1980. 

5. 
Crandall, J.E.. and R. D. Rasmussen, "Purpose in Life as Related to Specific Values," Clinical Psychology, 1975 31(3), 483-485. 

6. 
Crumbaugh, J. C .. and L. T. Maholick, "An Experimental Study in Existentialism: The Psychometric Approach to Frankl's Concept of Noogenic Neurosis," Journal ol Clinical Psrchologr, 1960, 20, 200-207. 

7. 
Ebaugh, H. R. F., K. Richman, and J. S. Chafetz, "Life Crises Among the Religiously Committed: Do Sectarian Differences Matter?" Joumalfor the Scientifi'c Studr ol Reli,rion, 1984, (23(1), 19-31. 


8. Frankl, V. The Doctor and the Soul: An Introduction to Logotherapy. l\icw York, Knopf, 1955. 
9. 
Glock, C. K. "The Role of Deprivation in the Origin and Evolution of Religious Groups," in Reli,rion and Social Conflict. R. Lee, and M. E. Marty, (eds), New York, Oxford University Press, 1964. 

10. 
Levinson, D. J ., The Seasons ofa Man'.,· Li/e. New York, Knopf, 1978. 

11. 
Lichtman, R.R. Close Relatiomhips After Breast Cancer. Doctoral dissertation, University of California, 1982. 

12. 
Mages, N. L. and G. A. Mendelsohn, "Effects of Cancer on Patients' Lives: A Personalogical Approach," in Health and Ps\'Chology: A Handbook. G. C. Stone, F. Cohen, and N. E. Adler (eds), San Francisco, .Jossey-Bass, 1980. 

13. 
Mount, B. "Advanced Malignant Disease and the Person under Stress," in Cancer, Stress and Drnth, .I. Tache, H. Selye, and S. B. Day, New York, Plenun, 1979. 


14. 
Spiegel, D., and I. D. Yalom, "A Support Group for Dying Patients." International Journal of' Group P~ychotherapr. 1978, 28(2), 233-245. 

15. 
Taylor, S. E. "Adjustment to Threatening Events: A Theory of Cognitive Adaptation," American P~ycholof;ist. 1983. 


16. 
Weisman, A. D. On Dying and Denying: A Psychiatric Studi· of Terminality. New York, Behavioral Publications. Inc., 1972. 

17. 
_____ Copinf; with Cancer. New York, McGraw-Hill Book Company, 1979. 

18. 
Yalom, I. D. ExiHential Psrchotherap_i·. New York, Basic Boob, Inc., 1980. 

19. 
7uehlkc. T. E. and J. T. Watkins. "The llse of Psychotherapy with Dying Patient,;: An Exploratory Study," Journal ofClinirnl Psychology, 1975, 3, 729-732. 


The International Forum for 
LOCOTH E RAPY 
JOURNAL OF SEARCH FOR M~ANINC