SOURCE_DOCUMENTS/journal_019_1.txt

What's Not In Frankl's Books  1  
Joseph Fabry  
Logotherapy Revisited As Love Therapy  9  
James C. Crumbaugh  

Coping With Life-Threatening Illnesses Using A Logotherapeutic Approach--Stage 1: Health Care Team Interventions 15 Jared Kass Stages And Treatment Activities In Family Logotherapy 20 Jim Lantz Karen Horney and Viktor Frankl: Optimists In Spite Of Everything 23 Robert C. Leslie "A New Course For Management" Revisited 29 Michael W. Wright Experiences With Logotherapy: Nursing The Elderly 34 Charlotte Stefanics The Death Of A Logotherapist 39 Mignon Eisenberg Meaning Potentials Of Burnout In The Helping Professions 41 Robert Shields Experincing Joy And Sorrow: An Examination Of Intensity And Shallowness 45 Zipora Magen, Menucha Birenbaum, & Dvora Pery 
Logotherapeutic Aphorisms by Elisabeth Lukas 56 
A Report On The Tenth World Congress On Logotherapy 57 Robert C. Barnes Information Of Interest To Logotherapists 59 
Volume 19, Number 1 Spring 1996 

The International Forum for Logotherapy, 1996, 19, 65-72. 
LEGAL RESPONSIBILITY OF LOGOTHERAPISTS 
Robin W. Goodenough 
Logotherapists have a special position among therapists with regard to their legal responsibility. They are more aware of responsibility because logotherapy is "education to responsibility." Second, they practice a "humanizing" therapy, emphasizing compassion, empathy, personal support, caring, and opt1m1sm. Patients with this kind of treatment rarely sue the therapist. Thirdly, logotherapists are non-drugprescribing therapists. Along with other such therapists, they have been 
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fortunate in having only a negligible number of complaints or lawsuits alleging malpractice. 
However, the trend to sue is expanding rapidly, and punishment may take many forms. Most cases are settled out of court by the insurance companies. Even innocent therapists cannot stop lawsuits; and the stigma of settling the lawsuits may follow the therapists for the rest of their professional careers. Legal sanctions can result in warnings, letters of reprimand (which frequently make their way into the public domain), suspensions of practice, and revocations of license. 
Boundaries 
Litigation for therapists is growing more intense in two major areas-sexual misconduct and suicide. Insurance companies do not cover therapists for sex peccadillos. 
Boundaries are the latest strategy to avoid malpractice and other legal problems. They deal with the most sensitive phases of human behavior. 
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The following boundaries can be key to malpractice prevention: 
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Time of day of the treatment and length of sessions (abnormal times of day and unusual session lengths can raise suspicion and spell trouble); emergency treatment excepted. 

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Confidentiality (even the names of clients are strictly confidential). 

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Arguments over fees and payment policy. 

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Lack of informed consent of patient as to the course of treatment. 

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Treating people outside the office (logotherapists using paradoxical intention in crowded or open places, bridges, or high buildings must be sure of a trusting patient-therapist relationship). 

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Offensive or unacceptable personal contact (romancing is a violation and, if sexual, could mean the end of the therapist's career in all jurisdictions). 

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Careless dumping of the therapist's personal problems onto the patient. 

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Arbitrariness, aggression, indifference, coldness, callousness, and abandonment by the therapist, engendering hostility. 


To help offset some of these possible boundary violations and thE threat of malpractice: 
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Keep office hours at regular times and therapy in your office. Avoid meetings at patient's home--in these cases, possibly bring a chaperon, preferably opposite the therapist's gender. 

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Minimize all physical contact. 

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Strictly observe the law of privacy and confidentiality. Never talk about other patients. 

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Don't get involved in the commercial business or irrelevant private life of the patient. 

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Tactfully avoid gifts from patients--especially valuable ones. 

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Genuine pro bona work is encouraged; however, a therapist should be circumspect about free sessions for a variety of reasons. 

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Don't spend the patient's time and money talking about your problems. 


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In addition to boundaries, examine other major areas which dominate malpractice litigation: 
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Breach of confidentiality and privacy. 

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Duty to warn and protect third parties. 

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Suicide (danger to self) and homicide (danger to others). 

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Negligent psychotherapy and misdiagnosis. 

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Failure to keep up with skills and training (professional continuing education). 

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Failure to keep adequate records. 

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Abandonment of patient. 

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Failure to get a consultant. 

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Defamation: libel or slander. 

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Harassment. 

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Guaranteeing results (done often--always wrong). 


Sexual Misconduct 
Sexual misconduct is one of the leading causes of professional downfall. Both innocent and guilty therapists have been trapped in sexual adventurism, real or imagined, by the patient. The paradigm is usually a male therapist and a female patient. Judge and jury often jump to the conclusion that the therapist took inexcusable advantage of the client. usually meaning loss of time, money, and reputation for the therapist. Many authors speak of the sexual attraction between therapist and patient at one time or another. However, social conduct must be kept under strict control by the therapist. The American Psychiatric Association recently canceled their sexual misconduct coverage because the numbers of claims and amounts recovered by the patients increased sharply. The American Psychological Association has always made therapists pay for their own sexual misconduct claims. 
What are the boundaries of sexual misconduct in psychotherapy? An example of a plain boundary might be a simple handshake. On the other hand, a hug, though used in some therapeutic techniques, could be considered a hazardous crossing in many situations. Hugs can play a very healing role. Conversely, there have been hugs which have resulted in litigation. Some patients may interpret and experience a hug as a sexual intrusion. 
Romancing would be a violation and if sexual could mean the end of the therapist's career in all jurisdictions. Sexual misconduct may include harassment, which is strongly discouraged by all professional 
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organizations and by the law as unethical, immoral, and unprofessional. There is no legal defense for this boundary violation. 
Boundariesshould be clearly stated to minimize patient complaints. Caution is especially applicable because the logotherapistis faced with the challenge of being as close and compassionate as possible, yet must keep a safe physical, social, and psychic distance for the protection of both patient and therapist. The patient easily can turn a deep sense of trust into a fierce sense of betrayal. And what may seem to the therapist like a safe boundary or an innocent boundary crossing, may be misinterpreted as a gross violation, upsetting and estranging the patient. 
Widespread disagreement exists as to whether a therapist should ever have sexual relations with a former client. California says no contact for two years. Some authorities say "never." The "never" position is based on the theory that the transference process from patient to therapist lingers indefinitely--thus the power differential between patient and therapist always will be unequal. The therapist might take advantage through skills, fund of knowledge, and control over the vulnerable former patient. For some jurisdictions, the therapist is not protected even by marriage to the patient during or after treatment. CAVEAT! In our paradigm, even if the female patient consents to and initiates the sexual relationship, the therapist alone is solely responsible. This pertains even if the relationship is of long duration and mutually agreeable. The law states that the therapist should stay strictly to the practice of therapy. 
Restraint is indicated--it is better to err on the side of caution. The ethics codes of most of the professions prohibit sexual contact in any form. In many states these ethics codes have the force of law. Violation results in censure and/or cancellation of the right to practice. 
Dangerousness 
Dangerousness is a major area fraught with peril for all therapists. The basic reason is the lack of empirical knowledge and hard scientific ability to predict danger. The best predictor of potential violence is the past pattern or behavior of the individual. Some jurisdictions require a decision for dangerousness to include a "recent, overt dangerous act." .....a This unpredictable element of danger in a patient is what challenges -. those who try to assess the "duty to protect" and the "duty to warn." In light of the flood of litigation today, persons picked up for dangerousness (a recent overt act is often required before detention) 
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are usually held--sometimes infinitely--if there is any doubt about their threat. Once detained, the police and institutions may choose to "play it safe" and keep in confinement those who have been violent, rather than expose the institutions to civil and criminal penalties for releasing a dangerous subject. 
The best advice to logotherapists would be to protect themselves and not trigger an incident; to protect the patient who is a "danger to self"; and consider it a duty--ethical, moral, and legal--to warn and protect the public if the patient is a "danger to others. 
Suicide 
Suicide also is extremely difficult to predict with any acceptable accuracy. The suicide of a spouse or close relative creates maximum stress, guilt, and pain; and the survivors look for someone to blame. Often the therapist is sued for negligence for things done or left undone. Signals of suicidal thoughts, prior attempts, or any indication that suicide is imminent require immediate action by the therapist. The therapist takes a calculated risk if patients resist attempts to enter an institution voluntarily. If the patient does enter voluntarily, the institution may not let the patient out voluntarily because the institution may be liable if the patient gets in trouble outside. The patient may sue all parties, including the therapist, for false imprisonment, grievous mental distress, defamation, and a host of other torts. 
Logotherapists must realize that psychotherapy alone often is not considered sufficient to treat endogenous depressions. In such cases it may be malpractice to rely solely on logotherapy and ignore biologic causes. A psychiatrist should be consulted. Consultation is also in order if the logotherapist wishes to use paradoxical intention in cases of a phobia to commit suicide. The patient must be diagnosed as definitely a phobic fearing to commit suicide, and not as suicidal. Frankl warns of the danger in this area. 
Logotherapists frequently are called upon by patients who are suffering from depression, either transient or chronic. Depression is a major precursor of suicide. The stress, pain, and guilt felt by those close to the suicide, often translate into lawsuits. This is triple tragedy. The patient is lost. The therapist is the target of the blame and litigation, interrupting or ending the professional career. And those suing usually get short shrift--the civil suit can run three to five years and about 80 percent of the litigants lose their case. 
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Confidentiality 
Confidentialityis a sensitive area for logotherapistsbecause of their close trust relationship with patients. The more leaks in the wall of confidentiality, the more patients will hesitate to communicate information to the therapist, thus impeding success in healing. But the law sees the need for much confidential information to be put on public record. One prominent area comes in child custody battles. The child's interest takes priority over confidentiality. Another common area is in the field of torts when an injured party claims mental and emotional damages. 
It can be dangerous practice to keep minimal or no records of the history and progression of the patient. In one famous case the therapist suffered a tremendous loss because the client committed suicide, and the therapist had not checked the client's prior history of suicide attempts. Also, records can prove invaluable if the therapist consults or sends the patient out for an examination. It is prudent to have enough of a formal record available to validate key data--to refresh your memory and to add to your defense arsenal. One might be guided by the advice to only put in the record what will bear up under public scrutiny. 
Althoughconfidentialitycan be pierced in many ways, the therapist is strictly bound to respect it. Even divulging that someone is your client has career-wrecking potential. Discussing a patient's problems and the progress of the therapy (even to the spouse) without the patient's permission, is malpractice. 
There is, however, a trend for laws to give more protection to society and victims of violence, child abuse, and contagious diseases (for example, AIDS)--this means revealing confidential data. The Tarasoff case shattered confidentiality when the lives of outsiders are threatened. The case spawned two holdings: a duty to warn, and a duty to protect. In the Tarasoff case, the defendant's therapist had substantial evidence that the defendant was planning to murder a coed. The therapist had the campus police pick up and confine the defendant. The therapist was overruled by a supervisor who ordered the campus police to release the defendant and destroy the patient's records. The patient then murdered the coed. The coed's family sued the supervisor and won damages for negligence. The Tarasoff case has llll been extended to protect identifiable groups and the pubic in general. If patients show a danger to others or themselves, the therapist has a duty to break confidence and take action. 
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Informed Consent 
Informed consent is a recent development which says that properly informed patients know best what sort of treatment they are willing to accept. The decision, by an informed patient, may be to take no treatment at all. Although the therapist's recommendation may be the route taken, the decision has to be made by the patient. If there are different choices, the therapist must tell the pros and cons of all alternative treatments (including no treatment), the recommended actions, and the probabilities of success. Logotherapists, as all in the healing arts, should give no guarantees. They should explain the nature of the particular treatment approach, the intended results, the risks, the role expected on the part of the patient, plus any other pertinent information. Therapists should ask for and answer all questions. Therapists might do well to consider an informed-consent sheet with a summary of all of the above data and a statement that all questions that were answered were understood; and have the patient sign it. 
Many therapists oppose informed consent procedures as an erosion of their decision-making authority. But it is clearly the law that the patients are to decide what to do with their minds and bodies. Mutual discussion of the client's presenting problem and alternative treatment approaches can help establish a valuable dialogue. It also can be the start of the best malpractice defense--a friendly patient-therapist relationship. Mutual understanding and trust help both the therapist and the patient legally as well as in the healing process. 
Sources for Additional Reading 
Inasmuch as there are many legal issues especially relevant to a therapist's legal duties, readers may wish to conduct additional reading. Thus, a few recommended sources include the works of Viktor Frankl; an audio set by Dr. Tom Gutheil, "How to Avoid Malpractice," CME Library 1-800-447-4474;Gutheil, T., "Concept of Boundaries in Clinical Practice," American Journal ofPsychiatry, 150 (2), 1993, p. 188-196; Slovenko, R., Psychiatry & the Law, Boston: Little Brown; Reisner, Law and the Mental Health System, West Publishing, 2nd Ed.; Menninger Letter, Vol. 3, No. 4, 1995. Also Dr. Walter Menninger deals with "Inappropriate Patient-Therapist Relationships" in the above listed Gutheil audio tapes. The landmark Tarasoff Case is at 551 P.2nd 334 (1976). 
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Final Comments 
By knowing the major malpractice areas and the concepts of boundary crossings and violations, logotherapists can shape a better strategy for avoiding legal trouble and for improving the healing process for the client. Liabilities face the therapist when the patient experiences the following situations: the unexpected; the unreasonable (including billing); surprises; "hero worship" by the patient (the therapist must be a partner, a facilitator); patient belief that therapist has magical powers; transference; and meeting at non-standard times and places. Therapists drawing up a written instrument along the lines of the proposed treatment, the protocol outlining the rules, fees, and mode of payment, will have a healthy, binding strategy for avoiding malpractice, and at the same time a legally binding malpractice defense and a legal contract. 
ROBIN W. GOODENOUGH, JD, PhD, [2378 North Danville Street, Arlington, Virginia 22207 USA] is a Dip/ornate in Logotherapy, a licensed Clinical Psychologist, Professor ofLaw & Psychiatry and Law & Medicine at the State of Maryland's University ofBaltimore, School of Law. He was mayor of Coronado, California (held electives offices in California for 17 years), served in WWII and Korea as Navy SEAL, Navy Captain, Combat Wounded veteran with distinguished combat awards, and a Special Assistant in the Office of the Secretary of Defense. He serves "Of Counsel" to USA Viktor Frankl Institute of Logotherapy, and is a Member of the World Board of Scholars, Viktor Frankl Institute in Vienna. 
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The International Forum for Logotherapy, 1996, 19, 73-79. 
LOGOTHERAPY IN DIVORCE COUNSELING: THE MYTH OF MR. WONDERFUL 
Pamella Monaghan 
During my divorce counseling, I have found many of the theoretical constructs of Viktor Frankl to be helpful. Among them are "the will to meaning" and "the development of the noetic dimension." In discussing these concepts and the various types of values--creative, experiential, and attitudinal--clients often are able to move from a noetic neurosis toward the discovery of meaning in life.2· p.79 
Many of my women clients see ~ me shortly after their husbands have either moved out or filed for divorce. They usually are in a state of shock: bewildered, distraught, wondering what on earth has happened. As I begin to obtain background information the image of the husband begins to emerge surrounded by a roseate glow. He is described as a wonderful person, who has all of the virtues, without whom life is impossible. As these women describe the marriage and recent events, it becomes clear that the marital situation has been anything but idyllic. They are not able to see the conflict between the way in which they view the husband and what has been the reality of the marital situation. I have come to call this belief in the husband's perfection the Myth of Mr. Wonderful. 
Divorce Therapy Step One: Establishing a Relationship 
In divorce counseling, it is necessary first to establish a relationship with the client. She is suffering greatly and finding all of her usual coping strategies inadequate for the current situation. She is facing the loss of her marriage, her role definition as well as her meaning in life. I must help her find a new meaning; and restructure her life and her vision of herself. While it is tempting to belittle the spouse, it is of critical importance not to do so because clients in despair are likely to 
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defend lost goals and become fixated on them. While the client's marriage may be over, possibilities for meaning in life are not.4• P·79 
As long as these clients focus on the lost loved one, they bind themselves to the past. As long as they are bound to the past, they are not able to see any meaning for themselves in the present. For these women, the belief in the husband's perfection is seen as the only route to happiness. In these situations it is often helpful to use the Mountain Top exercise where the clients recall persons and events that were important to them, times when they felt complete and happy, in contrast to the present situation. 1 
Step Two: Surveying the Field for Strengths 
At this point, it is useful to consider this belief--that the relationship with the husband is the only source of gratification--as an addiction. Addiction exists when "a person has an attachment to another person, sensation, or object, and has become increasingly dependent on the experience as the only source of gratification. · P· 61 Addiction to a
"6 relationship is as powerful as any other, and the process of helping the client overcome it is as challenging and difficult. It is necessary also to consider what is required in a loving relationship. Fromm points out that love is given freely and not the result of a compulsion. Love can only occur when we love another person as they are, not as we need them to be. 3· P·28 Freud goes even further in comparing being in love to hypnosis, "From being in love to hypnosis is evidently only a short step. The respects in which the two agree are obvious. There is the same humble subjection, the same compliance, the same absence of criticism toward the hypnotist as toward the loved object. There is the same sapping of the subject's own initiative... The hypnotist [as a model of a loved other] is the sole object and no attention is paid to any but him. "6· P 72 The key to unlocking the myth of Mr. Wonderful seems to lie in the client's capacity for self-distancing, to step outside the self, and see a new horizon and discover other aspects and meanings in a situation. In this way the noetic dimension becomes the agent for change, allowing the client to become aware of the need for meaning. In order to increase self-esteem and help the client access the realm of meaning it is critical for the counselor to supply warmth and lllli, empathy.5 · P· 120 It is important to identify past sources of meaning and to recognize the variety of sources from which meaning arises. I begin the process by exploring meaningful elements from the client's past experiences. In doing this it is imperative to support them in recognizing 
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their feelings. Typically, these are not far removed from awareness, and, with support, the clients are able to identify and work through them. When this happens, the past redraws itself. The pain of both the past and the present situations is acknowledged and experienced by the client. This process of acknowledgement is often the first step taken by the client in consciously recognizing the myth of Mr. Wonderful. It is crucial that hope be kept alive during this process of reframing the view of the husband. This hope enables the client to accept the past rather than struggling to preserve it. The focus of the discussion has to be not on the "why" but on the "how" of suffering. Only then can she bear it and transform suffering into achievement.4• P-79 
When the client is at last able to relinquish the myth of Mr. Wonderful she is able to move ahead into the noetic dimension. As Frankl has pointed out, life without access to this dimension is unbearable. He also has said that happiness is a by-product of having a meaningful goal and not a goal in itself. Previously the client tried to find happiness by heading directly toward it--obviously without success. Now that she has access to the noetic element she has the capacity to find meaning and then experience happiness. Her prior attempt to find happiness without first finding meaning was doomed to fail. Now she has another chance at life, meaning, and happiness.2• P-34 
Step Three: Reframing (Dereflection and Modification of Attitudes) 
A critical step in this process is the reframing of the client's current situation. It may be an end, but it is also a beginning. Frequently, I find this is the first time the woman has experienced independence, that she has been cognizant of meaning in the experiential sphere outside of her relationship to her spouse. She now can take a stand and recognize it. This involves the discovery of freedom as well as responsibility, finding meaning, and understanding the demand quality of life. The three realms of meaning are now explored with the client.2• P-34 
Usually it is easiest to begin by helping the client identify the small satisfactions in life: a good cup of coffee, a bird song. This allows her to go on and develop a deeper awareness and find other possible sources of meaning in the experiential sphere. 
Most people seem to have access to some sort of creative activity, and it is helpful to explore with them creative acts whether they be crafts or something as small as caring for a plant. As the client begins to find meanings in the experiential and creative realms, this paves the way toward finding meaning in the attitudinal sphere. When these 
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happen it is a sign that the client has accessed the noetic dimension and 
has begun to modify attitudes. 
Case Examples Case 1: Emma 
Emma was in her late 50's. She was referred to me by her family doctor. Her husband had walked out on her unexpectedly and filed for divorce. This came as a big shock. She was desperate. They had been married for over 30 years and had three grown children as well as a 1 5year-old son still at home. Emma was devastated and was willing to do anything to get her husband to return. However, he would have nothing to do with her. Soon it became clear that he was involved with another woman. Despair and anger overwhelmed Emma. Whenever she talked about her husband she would be angry but then would break down and say how impossible life would be without him, what a wonderful person he was, and how everyone loved him. This continued for months. As she told me about their married life it became clear that the husband had a serious drinking problem, had frequent blackouts, and had been arrested three times for drunk driving. She raised the children mostly on her own as he was frequently traveling on business. Money had been tight in the early years and she had struggled to make do for the children and still be available whenever the husband was home. A lifelong faithful Catholic, she stopped going to church. God had let her down as she saw it. Her life had been spent raising her family and living her life in accord with the teachings of the Church. The husband had become very successful in business in the past few years, and they now had the money and time to enjoy life. It can be said that Emma worshipped the ground her husband walked on, her whole being revolved around him, and now she was caught in a dance of rage and longing. As she saw it, the loss of her husband meant a complete loss of meaning in life, and with that her only chance for happiness. 
Whenever I would point out that something her husband had done must have been very painful for her, she would agree, often shed a few tears, and then quickly assure me that he really was a wonderful person. But most of what I heard about him was not wonderful at all. A great deal of time was spent helping her work through her feelings of abandonment and anger with an emphasis on refrarning her view of her Ill husband in a more realistic light. This took several months, but eventually she started to imagine life being meaningful without her husband. 
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The only interest Emma showed was in relation to her family. She did not want to work and insisted she could not even take classes until the divorce was over. During the two years of the divorce proceedings, Emma was not interested in church, had no friends, no interests, no hobbies. Attempts at dereflection failed. Her interest was focussed on her family. She was deeply involved with her children as well as her seven brothers and sisters. I encouraged this interest and she made the 500-mile drive to visit her siblings. She stayed for a week and had a wonderful time. Upon her return she began to talk about what courses she would take in the fall at the community college. Her affect was brightened and she started to see the possibility of a future. 
I helped her express her anger and do the necessary grieving and then move on to making a life. Our Socratic dialogues focused on her family history, her ability for form relationships, and her intellectual ability. We finally reached the point where she saw meaning in life again. At this point she was still separated from the church, but in our last meeting she told me about some good things that were happening for her daughter and that "maybe God is listening to some of my prayers." Her relationships with her children and her siblings improved markedly. In addition, she began classes at the local community college and finally developed some sources of meaning as well as having an increased access to her noetic dimension. 
Case 2: Faye 
Faye came to see me the day after Christmas, a 30-something woman whose husband walked out on her Christmas eve. They had been having problems for quite some time, but she was not aware that he wanted a divorce. The couple had been married for eight years, the second marriage for each. Faye had two daughters from her previous marriage, one a senior in high school and the other a sophomore in college. Her husband, Jim, had a 17-year-old son from his previous marriage. Jim had custody of his son, but when he moved out he left his son with Faye. At our first meeting she cried and was very upset. It was obvious that she was very invested in the marriage and wanted to have an idealized family life. Faye belonged to an evangelical church which reinforced the idea that a woman's role was to be a wife and mother. Even though Faye had a successful small business, little emotional value was placed on it. 
The main source of conflict in the marriage seemed to be that Faye wanted a traditional family life, but Jim was invested in his work as a policeman, fireman, and ambulance attendant. When he was not at 
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work on one job, he was on call for another. As a result, he was never at home for meals, holidays, or any family activities. It was up to Faye to care for the children and do all the parenting. Over the years there had been a great deal of conflict over this issue, and it had reached the point where there was very little, if any, communication between the two. Faye continued to put Jim in a very idealized light even though he had disappointed her and the family continually. Once again, I was told how wonderful he was and how much everyone thought of him. His only fault was that he could not leave his emergency work. 
It became clear that Faye was committed to her family and church and very much wanted to have a "model family." With Jim leaving, she felt all hope of having a family was gone. She saw Jim as being the key to having a family. Being a divorced woman put her in a bad light with the church. As we began to discuss her frustrations and anger that had accumulated over the past years, she refused to say anything critical of Jim. Although he clearly had not participated in family life for many years, Faye saw him as this incredibly sensitive, caring individual. While this may have been true in regard to his work, he did not show this to her or the children. When I mentioned that to her she was shocked, but over time she came to see that he was not what she had pictured in her fantasy life. She finally was able to see him in a more realistic light. 
During my work with Faye we focused on her relationships with family and church because these were very important to her. She had a real gift for relating to others, and this was where I felt that we could make the most use of her noetic dimension. We spent time discussing how she and her girls could be a family; that it was not Jim's presence that defined the family. Faye began to have a family dinner twice a week--the girls were expected to attend. Prior to this time they never ate as a family; everyone was busy with their own schedules. The daughters responded favorably to this. They liked being a family even if it did not include Jim and his son. 
The turning point was when Faye was able to move her focus from Jim to what she could do to strengthen her family. Given the age of her daughters, it was important for her to look at her own identity and develop her own definition of self. "Who am I?" became a critical question. The "demand quality of the situation" provided the structure within which Faye was able to answer this question. llllll 
Faye developed a more realistic relationship with her daughters and a renewed relationship with her twin sister. She left her church--it did not approve of divorced people in leadership positions. She started looking for a new church. In addition, she expanded her business. Now 
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she finds a great deal of fulfillment in her family relationships and in her relationship with God. The divorce provided her with the opportunity to address these issues. 
Conclusion 
When the myth of Mr. Wonderful is recognized, the woman discovers freedom of choice as well as responsibility for herself. In this process she discovers aspects of self and others that previously have not been apparent to her. This approach helps the client, who has endured suffering, to transform it into something meaningful. In exploring what happened in the relationship, the client is able to recognize prior accomplishments and become aware of strengths that previously were not acknowledged. This provides her with means to grow and the capacity to develop further meaningful tasks. 
Just as new, green shoots follow a forest fire and offer new life, a person can go through a divorce and have it be the occasion for discovery of meaning and development of an independent and authentic self. 
PAMELLA MONAGHAN, M.S.W., A.C.S.W. (601 Pleasant Street, Grand Ledge, Michigan 48837 USA] is in private practice in the central Michigan area. She has extensive experience working with persons with disabilities, where she finds logotherapy to have particular relevance. 
References 
1. 
Ernzen, F. (1990). Frankl's mountain range exercise. The International Forum for Logotherapy, 13, 133-134. 

2. 
Frankl, V. (1988). The will to meaning. Markham, Ontario: Meridian. 

3. 
Fromm, E. (1956). The art of loving. NY: Harper & Row. 

4. 
Lukas, E. (1985). Meaning in suffering. NY: Grove Press. 

5. 
Mowatt, M. (1987). Divorce counseling. Lexington: Lexington Books. 

6. 
Peele, S., & Brodsky, A. (1975). Love and addiction. NY: Taplinger. 


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The International Forum for Logotherapy, 1996, 19, 80-84. 
AN EXPERIMENTAL INVESTIGATION OF THE RELATIONSHIP BETWEEN ANGER AND AL TRUISM 
A. A. Sappington. S. Goodwin. & A. Palmatier 
(ABSTRACT) Twenty-four college students who reported anger problems and who expressedinterest in a study of techniques to reduce anger completed the Purpose-In-Life test and the State-Trait Anger Inventory. Participants randomly assigned to one group received selfadministeredbooklets designed to increase the number of altruistic acts (i.e., "giving to the world"). A second group received self-administered booklets with placebo exercises. A third group received no treatment. 
The group who received the altruism exercises increased their lifepurpose scores more than the other two groups, but not at a statistically significant level. The altruism group decreased their trait anger scores, and this difference did reach statistical significance. 
Logotheory offers a possible way to understand violence and anger. Frankl proposes that a sense of meaning in life can be important for both physical health and adaptive psychological functioning. Indeed, previous research shows that perceived life-meaning correlates significantly with effective functioning in a number of different areas.2 
Purpose-In-Life (PIL) test scores have been found to correlate significantly and negatively with anger problems. 4 However. correlational research does not allow us to establish the direction of causality. It is possible that the relationship is explained by anger problems making it more difficult to find meaning, rather than by meaning decreasing anger problems. To resolve the issue, it is necessary to experimentally manipulate sense of purpose in life and then observe the effects, if any, upon anger. Sappington3 previously developed self-administered booklets which 

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contained exercises that helped users increase either the number of their pleasurable activities or the number of acts of kindness in their daily routine. Both booklets increased PIL scores significantly more than did control booklets. Either booklet might thus serve as a technique for increasing perceived meaning in order to determine the effect upon anger. 
Sappington and Kelly4 found that altruism correlated negatively with anger problems. Once again, causal conclusions could not be drawn. However, this finding does suggest that increasing sense of purpose in life by increasing acts of kindness might indeed decrease problems with anger. The present study attempted to determine experimentally whether "giving to the world" in the form of altruistic acts can reduce anger. 
Method Participants 
A group of 195 undergraduate students completed the Anger and Hostility Scale5 and a brief questionnaire about interest in participating for no extra credit in a study of techniques for reducing anger. Of these, 60 qualified for the study by indicating interest in the study of anger management techniques and by scoring in the upper third on the Anger and Hostility Scale. These students were invited to participate in the study, and 24 agreed. 
Measures 
Participants completed the Purpose-In-Life (PIU test1 which served as a measure of the extent to which participants felt that their lives had meaning; and the Spielberger State-Trait Anger Inventory,5 which provided a measure of trait anger. These two instruments were administered at the start of the study and again three weeks later at the end of the experimental period. The dependent measures were difference scores on these instruments from before to after the study period. 
Experimental groups 
Participants were randomly assigned to one of the following three experimental conditions: 
Altruism group. Participants were given the booklets developed previously to increase the number of helpful acts engaged in each day. The booklets were designed for completely independent use. They 
81 
instructed participants to mentally review (each morning) the probable events of the coming day and to indicate on a worksheet possible opportunities for doing something nice for others. During the day, they were asked to take advantage of as many of these opportunities as possible as well as any unexpected opportunities that arose. In the evening, they were instructed to put checks by those expected opportunities that they had taken advantage of and to write down any unexpected opportunities that they had taken advantage of. They were asked to do this for two weeks. 
Pleasant news (placebo) group. Participants were given booklets instructing them to jot down on worksheets each day any TV or newspaper stories about positive events. They were asked to do this for two weeks. The rationale given was that this would increase positive thinking. This condition was included to control for the effects of hope and activity. 
No treatment group. Participants simply took the measures at the same time as participants in the other two groups. This group was included to control for the effects of the passage of time. 
Participants in the Altruism and Placebo groups were administered a brief five-point Expectancy of Success measure immediately after reading the instructions for their group. This was to determine the extent to which they had confidence that their intervention would be beneficial. 
Results 
The participants completed the worksheets on at least 60 % of the days. No significant differences were found between the Altruism and Placebo groups on the Expectancy of Success measure. 
The table shows the mean difference scores for the groups on both measures. The Altruism group participants increased their PIL scores more than did participants in other groups, although the difference was only statistically significant at the . 1 0 level (F2,20 = 2.63). The Altruism group participants decreased their trait anger more than did participants in the other groups, a difference which was statistically significant at the .05 level (F2,20 = 3.56). 

82 
Pre-post Difference Scores for Purpose In Life and The Trait Subscale of the State-Trait Anger Inventory (STAX!) 
Altruism Placebo No Treatment 
PIL +6.22 +2.05 -3.41 
STAXI -3.45 +2.03 +2.92 
Discussion 
As predicted, increasing "giving to the world" in the form of helpful acts did decrease anger. This result cannot readily be explained away as being due to the effects of hope or the passage of time as these were controlled for. This finding suggests that the negative relationship between altruism and anger previously found in correlational data is a causal one. It is plausible that altruism decreases anger by increasing perceived meaning. However, the case here is weaker because the differences among groups on the PIL reached only the trend level. 
One implication of the present results is that we may help people deal with anger problems by encouraging them to become more helpful to others. In this respect, it is worth pointing out that the present intervention was a relatively weak one. The technique used was entirely self-administered with no therapist supervision or coaching, and it lasted for only two weeks. It seems likely that the intervention could readily be made stronger with therapist supervision and support and by a longer period of intervention. On the other hand, such self-administered interventions are cost effective and might be a useful supplement for therapist interventions. 
It should be pointed out that the population studied can be characterized as an analogue population. We would argue that this population is of intrinsic interest in its own right. We have other data suggesting that students who meet the criteria used in this study report just as many problems with anger as do a group of spouse abusers, and that the majority report being aggressive against other people. Nevertheless, it is true that these participants did not come to a clinic for anger problems and it would be desirable to replicate the present results with a truly clinical population. 
It should also be pointed out that these data are of limited utility in demonstrating the effectiveness of logotherapy proper with anger problems. While it is true that encouraging people to seek meaning by "giving to the world" is often one element in logotherapy, there are a 
83 
number of other techniques that get used. But precisely because logotherapy uses a variety of techniques and tailors treatment to individuals, it seems likely that logotherapy could prove to be even more effective with anger problems than the approach used here. 
ANDREW SAPPINGTON, Ph.D. [Psychology Department, University Station, UAB, Birmingham, Alabama 35294 USA] is an Associate Professor at the University ofAlabama at Birmingham. He has published articles on free will and a book on the psychology of adjustment. He conducts groups for spouse abusers and consults at a prison. 
J. STEVEN GOODWIN began his first career in electrical engineering. He returned to the University ofAlabama at Birmingham in 1990 to pursue a B.S. in Psychology. He is currently pursueing his Ph.D. in Clinical Psychology at Auburn University. 
ANDREW D. PALMATIER graduated from the University of Alabama at Birmingham with a B. S. in Psychology. Currently, he is working for Spain Rehabilitation Center at UAB as a Psychology Assistant in the Department of Rehabilitation Medicine. Research interests include cognitive-behavioral treatment of male batterers, the use of electromyography for detecting spontaneous eyeblinks in fearful and schizotypal individuals, social remediation ofhead injury individuals, and coping and problem-solving in spinal cord injury individuals. 
References 
1. 
Crumbaugh, J. (1968). Cross-validation of the Purpose-In-Life test based on Frankl's concepts. Journal ofIndividual Psychology, 24, 74-81. 

2. 
Harlow, L., Newcomb, M., & Bentler, P. (1986). Depression, selfderogation, substance abuse and suicidal ideation: Lack of purpose in life is a mediational factor. Journal of Clinical Psychology, 42, 5-21. 

3. 
Sappington, A. (1990). An experimental investigation of Viktor Frankl' s theory of meaningfulness of life. The International Forum for Logotherapy, 13, 125-130. 

4. 
Sappington, A., & Kelly, P. (1995). Purpose in life and self-Iii perceived anger problems among college students. The International Forum for Logotherapy, 18, 74-82. 

5. 
Spielberger, C. (1988). State-trait anger expression inventory: Professional manual. Psychological Assessment Resources. 


84 
The International Forum for Logotherapy, 1996, 19, 85-90. 
COMPARISON OF LOGOTHERAPY AND BRIEF THERAPY 
Bianca Z. Hirsch 
Because of the magnitude of social problems and the intensity of everyday problems, more people are being referred for psychotherapy than in the past. Yet while there are many more mental health workers than ever before, psychiatrists, social workers, psychologists, and counselors are being restricted by insurance companies and HMO organizations as to length and duration of the treatment. 
Long before insurance and HMO restrictions became important factors in therapy, Viktor Frankl proposed that long-term focussing on the past does not necessarily improve adjustment in the present or in the future. He pointed out that homeostasis is not always a desirable outcome; rather patients need to be challenged to reach beyond themselves toward meaningful goals. Therapy should help them be pro-active toward a life experience, unavoidable suffering, and guilt. In search of meaning, they should learn to self-distance themselves from a situation and transcend their own personal desires to attend to the needs of persons they love and causes they value. 
Frankl quotes Friedlaender: "A psychotherapist should not belong to any school, but all schools should belong to him. · p.io Frankl adds
"4 that schools do not make the psychotherapist but the psychotherapist makes something out of the schools: it all depends on how and what. Logotherapy does not treat neurosis as a mental illness but as a state of loss of meaning. The road to wellbeing is not based on a sickness model but on the human spirit (a specific human dimension) and the will to meaning (a growth dimension). The aim of logotherapy is to help others see the meaning in their lives. 2 

85 
Techniques used by logotherapists include: paradoxical intention, to counteract anxiety; dereflection, to counteract compulsive selfobservation; self-distancing, to distance oneself from oneself or from the world; and self-transcendence, to increase awareness that human existence always is directed toward something or someone other than oneself. The individual is encouraged to become responsible and take responsibility. The logotherapist's role consists of "widening and broadening the visual field of the patient so that the whole spectrum of meaning and values becomes conscious and visible to him. "2 · P· 100 
Logotherapy does not set a specific time period of sessions. Many times, issues can be resolved in a few sessions. Contrary to psychotherapies steeped in psychodynamics, logotherapists do not dwell on history, review of adjustment or guilt feelings, and mulling over actions and reactions. Motives, drives, and instincts are not needed to interpret reactions. Logotherapy does not look for psychopathology but focuses on helping the client find meaning in otherwise meaningless trauma and find peace when feelings and thoughts are at war. If there is an unalterable situation, clients are helped to change their attitude toward the situation. 
We become human in devotion to a cause, in service of a deed, and in love toward another. Seeing beyond personal issues and forgetting personal interests allows the individual to find meaning in life. Frankl illustrates: " ... the eye sees the world but never itself. When is the eye aware of itself? Only when it has a cloud--a cataract or a disease that causes a clouded or a rainbow-colored vision to mar its clarity. "3· P·50 
The Brief Therapy Model 
In the 1950's John Weakland, Jay Haley, and Don Jackson, at the Palo Alto California Mental Research Institute, joined others in the Family Therapy movement which included Paul Watzlawick and Virginia Satir.1 Their focus on problem resolution is known under a variety of names such as brief therapy, focused problem resolution, and strategic family therapy. They use some of the ideas Frankl developed in the 1930's but in many ways differ. 
111111 
86 
Brief therapy interventions were developed originally to shorten the process of treating psychological problems which are viewed as interactional and non-pathological in a social context (school, family, etc.). Brief therapy was not meant to modify underlying family relationships (as is done in family systems therapy) but to target interactional patterns around the problem behavior and non-productive patterns of interaction: to initiate more productive patterns as soon as possible. Brief strategies focus on changing entrenched beliefs and response patterns. 
Brief therapists believe that the problem and efforts to solve it are recursively entwined: "A problem arises out of efforts to solve it while attempted solutions arise from experiencing the problem" (which is a 
0
loop). 1· ·26 The primary focus of treatment is the individual's problem behavior and the cycle of interaction around the problem behavior (problem-bearers and those involved with them). Basic assumptions include: 
1. 
While one family member exhibits pathology (the identified patient), the problems underlying these symptoms reside in the way the family functions as a group. 

2. 
This group behavior is understood as a rule-governed system, exhibiting homeostasis, feedback, redundancy, 


and other cybernetic principles.  
3. Treating  the  family  means  changing  the  family's  
interactive  behavior,  i.e.,  changing  patterns  of  
communication.  

In general, proponents of the brief therapy model believe that while past experience or current relationship structures can be the cause of a client's attitudes, behaviors, and needs, the focussing of attention on such internal or structural variables only lengthens the treatment. Therefore, brief therapists do not search for information that will alter underlying psychic structures or family relationship patterns. Their target for change is the symptomatic behavior and its accompanying vicious circle of reaction and counter-reaction. Steps include: clear definition of the problem, review of methods tried previously, focus on desired outcome, and formulation of a plan to produce desired changes.5 
87 
The specific area of concern determines who will be involved in the change process. Unlike family systems approaches, which have predetermined assumptions about who is involved in the problem and who must be involved in the change process, brief therapy interventions allow variable composition of the target group, depending on who is involved in maintaining the problem behavior. This may apply to any interpersonal grouping, including immediate family, extended family, friendships, work-related problems, and/or therapist-patient as a treatment unit. 
The focus remains on resolving the problem, deliberately planning interventions to fit the problem, and having the therapist assume an active role in designing and directing the change effort. Great care is given to anticipate how people may respond to the therapist's directives and to plan strategies aimed at motivating the client to try new ways of behaving. 
Proponents of brief therapy state that "inappropriate behaviors can be interrupted most quickly by reframing the problem and prescribing actions, opposite to those originally applied. "1· P-8 
In the brief therapy approach, the therapist's influence is consciously indirect. Although a direct assignment to perform new actions is given, the delivery of such assignment is non-authoritarian. This increases collaboration, relying on tentatively made suggestions or questions rather than direct orders or even on an appearance of ignorance and confusion. In addition, it is crucial in brief therapy interventions for the therapist to convey an implied agreement with, and subtle reframing of, the patient's position. 
Brief therapy is a distinctive way of thinking and working to bring about change in a client. Although it shares with behavior therapy an emphasis on changing concrete, observable behavior, and with strategic family therapy an emphasis on using indirect tactics, it differs markedly from these two approaches in its definition of what is to be focused upon and altered. To use this approach effectively, the therapist must understand the distinctive premises abol:lt the development of problems, their resolutions, and how these premises are translated into actual practice. 
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Techniques and Objectives of Brief Therapy and Logotherapy 
BRIEF THERAPY 
Orientation: 
Problem oriented No delving into past Problems are interactional Problems are non-pathological 
Individual is part of social system 
Objective: 
Change concrete, observable behavior Change communication patterns 
Dysfunction: 
Wrong solution for problem 
Change Techniques: 
Reframe problem and solutions 
180 degree turnabout 
Identify interaction around problems Paradox Therapist can be direct but nonauthoritarian Therapist can be indirect 
Time Frame: 1 0 sessions or less 
LOGOTHERAPY 
Orientation: 
Meaning oriented No delving into past 
Problems are due to lack of meaning Individual is unique 
Objective: 
Assume responsibility 
Change attitude toward unchangeable situation 
Dysfunction: 
Lack of purpose/meaning 
Change Techniques: 
No prescribed verbal messages--it is dynamic, spontaneous Self-transcendence Innovative; invokes defiant power of human spirit Humor Dereflection 
Paradoxical Intention Therapist clarifies client's statement 
Time Frame: 
No predetermined number of sessions 
89 
BIANCA Z. HIRSCH, Ph.D. [115 San Anselmo Ave., San Francisco, California 94127 USA] is Past-President of the Viktor Frankl Institute of Logotherapy, a School Psychologist in the San Francisco Unified School District, and Associated Clinical Professor ofthe University of California Medical School, Division of Behavioral and Developmental Pediatrics. 
References 
1. 
Amatea, E. (1991). Brief strategic interventions for school behavior problems. San Francisco: Jossey-Bass. 

2. 
Frankl, V. (1962). Man's search for meaning. NY: Simon & Schuster. 

3. 
Frankl, V. (1967). Psychotherapy and existentialism. NY: Simon & Schuster. 


4. Frankl, V. (1986). Die psychotherapie in der praxis. Muenchen: 
R. Piper GMBH & Co, KG. 
5. Watzlawick, P. (1974). Change principles of problem formation and problem resolution. NY: Norton. 

90 

The International Forum for Logotherapy, 1996, 19, 91-94. 
THE PURSUIT OF DEMOCRACY IN NIGERIA 
Rachel B. Asagba 
Logotherapy has shown that the direct pursuit of happiness ends in failure. Happiness is a by-product of finding meaning.3• P-39 I believe that, analogously, the direct pursuit of democracy in Nigeria would end in failure. I suggest that democracy in Nigeria can result as a by-product of finding the meaning of democracy. Thus I believe if democracy is to be established in Nigeria, as many individuals and groups have called for, there is need first for education about the meaning of democracy. 
Most people crying for democracy in Nigeria really don't know its meaning. They do not practice it in their daily living, even within the groups they belong to. They need to understand that it is not just the absence of a military regime, "just as democracy does not automatically establish itself when a king is overthrown."2· P-96 
Some advocate democracy without adjusting it to Nigerian factors, such as the tradition of authoritarian leadership and a hierarchial system of government. They merely shout "democracy!" They do not form different non-governmental organizations (NG Os) and establish democracy at the grassroots level to educate themselves and the masses (in their own local languages) so that people are able to understand the meaning of democracy. They need to learn: 
• 
the reason for voting for their right choice--without giving or receiving money and other material things. 

• 
to know their candidates well--what they promise to do for the people. 

• 
all members of a party should have a say and a vote within their individual parties--not just the most powerful, the richest, or elders. 

• 
all people should be educated from the grassroots to the elite--not just those who have wealth and power. 


91 
After the annulment of 1993 election, calls were made by the CD (Campaign for Democracy) group on three occasions asking people to stay home--no work and other outdoor activities. To the first call about 70% of the people responded, to the second call about 30%, and to the third call almost nobody. Most market women did their normal business--their understanding of what was going on had nothing to do with democracy. They needed to be educated in their own languages about the meaning behind staying home--to protest against the actions of the military regime. Then they could have mobilized their fellow market women. 
Different groups with different names claim to fight for democracy but do not share the same meaning and reasons for democracy. Most of them have their hidden agenda--from free traveling outside the country to getting of monetary rewards or sponsorship from international organizations for "fighting for democracy." If they had been trained to listen to the voice of their conscience to tell the truth, most would have to admit to controlling, dominating, or using the group for selfish reasons. 
Without understanding the meaning, whenever the Nigerian people had freedom, they did not know what to do with it. This was why civilian regimes usually failed, and everyone wanted to win by all means. The losers always complained and were unwilling to work with the winners. During the civilian regime the constitution and laws were there but the restrictions affected mainly the poor masses--this was not true to the meaning of democracy. Until the meaning and reasons are made known to the people, there will be no true democracy just as there is no happiness without a reason to be happy. 
Suggestions 
The following suggestions are made for individuals, groups, or organizations interested in promoting democracy: 
• 
Introduction of democracy could be compulsory as part of the curriculum from kindergarten to high school through technical/trade school to university level. This would prepare future generations to the fullest for democratization. 

• 
Law and justice could be improved, either by a military regime or a democratically elected government, because these will lay the foundation of democracy. Everyone must see that law and justice are respected and used as building blocks tor the foundation of democracy. Ill 

• 
The definition of democracy could be given in layman's language and in a way that both the democratic and military governments are able to perceive, understand, and share the same meaning. This would bridge the communication gap. 

• 
The military training curriculum could include democracy. The curriculum could emphasize reasons and meaning of democracy and how important it is to the society. Continuing education and inservice training could also be included. This would enhance the soldiers' understanding of democracy. 

• 
Dialogues and collaboration are needed between the military regimes, governments, the American government, UNESCO, the Trans-American Organization, and other groups interested in democracy, to find a lasting solution. For example, each group could have an office where dialogues take place with governments and with the people themselves. These offices could initiate studies with the grassroots people, to know what level of knowledge they have of democracy. They would be like the logotherapists who do not dictate meaning but turn on a light for their patients in a dark room, so they can see meaning themselves. 

• 
Information of democracy could be disseminated to the grassroots level, emphasizing the reasons and meaning of democracy, through TV, radio, newspapers, magazines, plays, and books. People who call themselves democratic advocates could form organizations across the country to help pass the information to the grassroots level. Instead of merely shouting about the democratic lifestyle, they could let people see it by their example. A market woman, literate or not, would be able to explain the meaning or reasons for democracy in her own language. 

• 
American university lecturers and those from other Western countries could be sent to universities as exchange programs. This would allow the Western academicians to brainstorm democracy and the factors that hinder democracy. Having experienced the culture themselves, they would be able to relate better in the quest of find solutions. Both students and staff could, through research and other measures, find suitable solutions to the best possible ways of democratization. At university level, monthly seminars and workshops would enhance this democracy education. 

• 
Yearly or bi-annual conferences on democracy could be held at state, national, regional, and finally world-wide levels. Scholars, researchers, and other people could bring problems and solutions from their countries' democratization processes, sharing and working in partnership. 

• 
Traditional chiefs and other elders could also be educated in each local government with frequent seminars and workshops on democracy, voting systems, etc. 

• 
The three major languages of Nigeria could be made compulsory 


92 
93 
from kindergarten to high school level. Teachers could be exchanged from the north with those from the south. Incentives and free accommodations could be given to non-indigenous teachers to encourage and compensate their being away from their origins. Excursions of school children to other parts of the country where other languages are spoken could be encouraged. This would bring trust and good communication between ethnic groups. If everyone could trust, discuss, and understand each other, it would be easier to establish lasting democracy. 
Conclusions 
Like logo-education is needed to promote logotherapy, democracy education is needed to promote democracy. This education is not just a transmission of tradition and knowledge but also the use of the Socratic dialogue where the objective is to let everyone be "informed, sensitive and responsible." Logotherapy is "education to responsibility."2 • p.x,x Not only responsibility, but also "responsibleness" is required. As logotherapy uses these terms, "responsibility is imposed from outside; responsibleness is freely chosen."2 • P-120 
Everyone should help build the country. There is no leader that can do everything for the citizens. Everyone must contribute to the country, and all must work together regardless of religious or political background. The traders must learn to be considerate to the buyers, and the transporters to the commuters. People traveling abroad should contribute their expertise when they come home; and those living outside of the country should come home to contribute theirs. 
Finding meaning in developing countries is like finding democracy.1 If one applies all the principles of logotherapy in Nigeria, democracy would surely become a lasting institution. 
RACHEL ASAGBA [U.I., P.O. Box 19695, Ibadan, Nigeria] is Managing Diretor/Consultant of the Medical Counselling and Referral Centre and at the same time she is a Mphil/PhD Candidate at the Institute of African Studies, University of Ibadan. 
References 
1. Asagba, R. (1993). Logotherapy's knowledge and wisdom. The International Forum for Logotherapy, 16, 51-54. p 
:t
2. 
Fabry, J. (1987). The pursuit of meaning. Berkeley: Institute of Logotherapy Press. 

3. 
Frankl, V. (1981). The will to meaning. Berkeley: Institute of Logotherapy Press. 


94 
The International Forum for Logotherapy, 1996, 19, 95-99. 

LOGOTHERAPEUTIC PRINCIPLES IN THE TREATMENT OF PANIC ATTACKS WITH AGORAPHOBIA: A Case History 
Richard I. Hooper. Mary K. Walling, & W. D. Joslyn 
This case history illustrates how logotherapeutic principles can blend with a variety of therapeutic approaches. We hope it will stimulate confidence in therapists by reminding them that even when they feel they have failed to facilitate change, they may have sown the seeds for future growth. 
Mr. P was a 33-year-old alcoholdependent man who avoided crowds for fear of having panic attacks. His social discomfort was first apparent in grade school, and the panic attacks appeared some years later. This anxiety disorder eventually led to alcohol abuse, blocked his attempts to go to college, and led to social isolation. The Psychiatrist who identified the disorder found no medical basis for the panic attacks but prescribed antidepressant medication to dampen the physiological overreactivity associated with the attacks. She referred the client for psychotherapy. 
Logotherapy with Paradoxical Intention 
After noting that Mr. P had a sense of humor, the therapist used Paradoxical Intention following the sequence suggested by Fabry1 and outlined by Yoder2 : 
1. 
Medical examination to rule out an organic anxiety disorder. 

2. 
Self-distancing from the symptoms to gain perspective. 

3. 
Detailed explanation of Paradoxical Intention and the sharing of case histories. 

4. 
Collaborative creation of exaggerated symptoms in ways that appeal to the client's unique sense of humor. 

5. 
Role playing the humorous formulations during therapy sessions until the client's sense of humor is fully activated. 

6. 
Practicing the humorous formulations in actual feared situations. 


95 
A humorous formulation developed with Mr. P consisted of going into a classroom with the intention of shaking uncontrollably, dropping his books, and losing bowel and bladder control. After role playing this episode, the client attended an actual class lecture in the company of his therapist (who had permission from the instructor). In spite of the client's intention to embarrass himself, he became absorbed in a lecture on ecology! His humor and conscious effort to produce the symptoms interfered with the fear response and freed him from the anticipatory anxiety that had been fueling the phobia and panic attacks in the first place. 
The therapy occurred in eleven 50-minute sessions spaced over a 17-day period. At one-month follow-up, the client reported having used Paradoxical Intention in several social situations, including his own wedding. After two months, he was hospitalized for a relapse of his alcohol dependence, but he reported no recurrence of his phobic or panic symptoms. However, 2 ½ years after treatment, panic attacks with agoraphobia began again. The client came back for outpatient therapy but did not change after five sessions of Paradoxical Intention. At this point, marital conflict became the focus of therapy. 
Self-Transcendence with Cognitive-Behavioral Therapy 
A year after the marital therapy, Mr. P was referred to a second therapist for further therapy for agoraphobia and panic attacks. Using a cognitive-behavioral orientation, the therapist explored the role of hyperventilation in Mr. P's panic attacks and taught him to shortcircuit the attacks by slow abdominal breathing. She also helped him identify and challenge cognitive distortions such as all-or-nothing thinking, catastrophizing, and other dysfunctional automatic thoughts. She gave him educational materials and homework llll assignments, which the client diligently completed. These weekly therapy sessions were an hour long and lasted for nine months. 
96 
Shortly after beginning this phase of therapy, the client shared his ambition to organize a residential living center for persons recovering from chemical dependency. This self-governed center would allow individuals to live together and be responsible collectively for each other. When he accepted this challenge it became a self-transcending vehicle for his own therapy. This project required many activities that were in direct conflict with his phobias, including making telephone calls, arranging meetings with local business people, and talking to groups. 
Another self-transcendentgoal of the client was to strengthen his relationship with his son, which required sobriety maintenance. Having remained sober for a year, he began to appreciate the degree to which alcohol dependency had masked his strengths. 
These self-transcendentgoals gave Mr. P increased motivation to learn the cognitive and behavioral skills required to achieve the goals. With growing recognition and acceptance of his increasing abilities, he met each challenge and gained confidence with each success. 
Self-Distancing with Hypnotherapy 
A telephone phobia was another obstacle in the way of Mr. P's establishing an independent living center. This fear led to procrastination around any task requiring telephone communication and added to his social isolation. This phobia, having originated 20 years earlier with the avoidance of bill collectors, had generalized to the initiation as well as the receiving of phone calls. The anticipatory anxiety accompanying this phobia included physiological events such as a racing heartbeat, dry mouth, and shakiness. 
While engaging in the cognitive-behavioral therapy, Mr. P approached a third therapist for focused treatment of his telephone phobia. This therapist chose short-term hypnotherapy with homework assignments. 
Mr. P was able to enter a deep trance, which he found to be a positive, relaxing experience. After learning the skill of self-hypnosis, he followed a three-stage process of deconditioning. First, while in trance he recalled a very distressing memory involving the telephone. Second, he shifted his attention back to the therapist's office. Third, he returned to the distressing memory while receiving the suggestion that each time he returned to the memory the negative emotion would decrease in intensity. 
97 
After mastering the three-stage deconditioning process, Mr. P actually practiced using the telephone while in trance. To the surprise of the therapist, he spontaneously used the Paradoxical Intention he had learned previously. He reported, "I pictured how silly it was to be afraid of the phone. I thought, 'What's going to happen when I take the phone? Is it going to wrap its cord around my throat and strangle me?"' 
The client described the self-distancing he had learned as follows: "I came to realize there was the 'me' who I am now and another 'me' who was afraid to use the phone." In logotherapeutic terms the "me who was afraid to use the phone" was in the psychological dimension of conditioned reactions, whereas the "me who I am now" resided in the noetic dimension where freedom exists to take a stand against self-defeating habits in the psychological dimension. 
After hypnotherapy Mr. P's telephone phobia disappeared completely. He remained symptom free at two-year follow-up. This new-found freedom increased Mr. P's self-esteem and reduced his social isolation. He said, "It's hard for a person who has never been boxed in like that to realize what a big thing being able to use the telephone can be! Now the only worry I have is getting the phone bill!" 
Comments 
This case history illustrates no new principles or techniques of psychotherapy. However, it does remind us of things we sometimes forget. 
First, logotherapeutic principles can be and often are combined with other types of effective therapy. These principles may or may not be recognized explicitly. They often are labeled and understood according to different frames of reference. 
Second, therapists cannot take all credit or blame for a client's success or failure. Therapists sometimes forget that the most important therapist is the client. This was true for our client, who was "not to be denied." In spite of the eventual relapse after his initial treatment, Mr. P had laid much of the groundwork for his success in subsequent therapies. Ill 
Finally, clients go through different stages of growth. They may find one therapist a good mentor for one stage of development and another therapist more helpful during a later stage. Just as we can't 
98 
imagine a person learning everything they will ever need to know from one teacher, it is no more plausible that clients will learn all they will ever need from one therapist. Fortunately, therapists do cooperate with one another, even if they are not always aware of it. 
RICHARD I. HOOPER, LCSW, MBA is currently a DoctoralStudent at Portland State University. At the time of writing this paper, he was a StaffSocial Worker at the Departmentof Veterans Affairs Medical Center, Knoxville, Iowa. 
MARY K. WALLING, Ph.D. is a Clinical Psychologist currently working as a Family Counselor at the Children's Home Association of Illinois in Peoria. She is a formerpredoctoralPsychology Intern at the Department of Veterans Affairs Medical Center, Knoxville, Iowa. 
W. D. JOSLYN, Ph.D. is a Clinical Psychologist at the Departmentof Veterans Affairs Medical Center, Knoxville, Iowa. He is a Dip/ornate in Logotherapy. 
References 
1. 
Fabry, J. (1982). Some practical hints about paradoxical intention. International Forum for Logotherapy, 5, 25-30. 

2. 
Yoder, J. (1989). Meaning in therapy: A logotherapy casebook for counselors. Columbus, GA: Quill Productions. 


99 
The International Forum for Logotherapy, 1996, 19, 100-103. 
LOGOTHERAPY TRAINING: THE WORTHINGTON MODEL 
Jim Lantz 
In the early days of the American logotherapy movement, many of our 
5
pioneer logotherapists1A, went to Vienna and studied directly with Frankl at the Polyklinic Hospital. In more recent years, the Viktor Frankl Institute of Logotherapy has developed a multi-leveled training program leading to the credential of Diplomate ,n logotherapy. This training program has utilized American and European logotherapists as trainers in a way that 

has provided a strong curriculum and a high level of competence in its graduates. The major difficulty with this training program is that it is not easily accessible to interested potential logotherapy students on a local level. This articles presents a local-level logotherapytraining program developed at Lantz and Lantz Counseling Associates in Worthington, Ohio. 
The Worthington Model Logotherapy Training Program has been used since 1988 to train social workers, psychologists, counselors, ministers, nurses, psychiatrists, and family physicians in the basic concepts, principles, and philosophyof logotherapy. It includes reading assignments, individual logotherapy supervision, group logotherapy supervision, attendance at a pre-training workshop, pre-training educational requirements, and a verbal final examination before the student receives a certificate of completion. 
Educational Requirements ? 
Logotherapy students of the Worthington training program must have completed their profession'sterminal practice degree. Psychology logotherapy trainees must have a Ph.D., psychiatrists and family physicians an M.D. and completed their Residency, social workers an 
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M.S.W., counselors an M.S. or M.A. degree. pastoral counselors an M.Div., and nurses their R.N. credential. On occasion, practitioners with many years of experience are accepted in the program, even without having completed the above degree requirements. 
Pre-Training Educational Requirements 
Students must attend at least one logotherapy workshop before acceptance. This expectation ensures that students understand basic ideas and concepts of logotherapy prior to acceptance. It is not difficult for potential students to attend such workshops because I offer five or six each year in the Central Ohio region. Also, many potential students are social workers who have learned about logotherapy by taking one or more of my classes at The Ohio State University College of Social Work which are always infused with logotherapy concepts. 
Reading Assignments 
Prior to completion of the program, students must be very familiar with the major logotherapy books published in English. They are required to have read all of Frankl's English books, as well as a good selection of the books produced in English by Bulka, Crumbaugh, Fabry, Hutzel! and Jerkins, Lantz, Leslie, Lukas, Tweedie, Ungersma, Walters, and Yoder. All of these books are available through the library at The Ohio State University. 
Individual and Group Logotherapy Supervision 
The central core of the Worthington Model Logotherapy Training Program is the supervision experience. Students are expected to successfully complete 70 hours of logotherapy supervision before they are given a certificate of completion. These 70 hours must include both individual and group supervision. All students start out in individual logotherapy supervision. When they demonstrate that they have a good basic knowledge of logotherapy concepts, treatment techniques, and treatment methods, they are moved into a supervision group. Some students move into the supervision group rapidly, others need the special attention of individual supervision for a longer period. It is my observation and opinion that the group supervision is the most valuable part of the training program. 
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The focus of the group experience is on Frankl's formula of T = X 
+ Y. 2 In this formula T means good therapy, X means the unique and individual treatment needs of the client, and Y means the strengths and unique capacities of the therapist. As a result, the supervision group focuses upon understanding the treatment needs of each student's clients and understanding each student's strengths and unique abilities to help clients notice, actualize, and honor meanings and meaning potentials. 
Each Worthington Model supervision group consists of six students; 1 ½ hours every other week. Each student is expected to present case material. The group leader and the other group members reflect with the student in ways that help the student better understand how service to the client might be improved through a better understanding of the client's needs, the therapist's strengths, and how such needs and strengths can be addressed during the practice of logotherapy. This case material is presented by the student verbally or by audio-or video-tapes. Occasionally, a logotherapyclient comes with the student to the supervision group, and both are interviewed by the group leader. All members of the supervision group are expected to present clinical material, to offer both criticism and encouragement to other group members, and to consistently monitor their own countertransference feelings (which are helpful tools for assessment and empathic intervention as well as potential disruptions of the treatment process3). 
The Final Examination 
A certificate of completion is given after the student has successfully completed the 70 hours of supervision and passed a vigorous oral examination on the understanding of logotherapy as a treatment philosophy and a treatment approach. Students are quizzed on all aspects of logotherapy; if they do not pass the test, they are given special practice and reading assignments to prepare themselves for the second examination. Over the years, approximately70% of the Worthington Model students have passed this exam initially and 30% have needed to take the exam a second time. 
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Conclusions 
The Worthington Model program meets the training needs of mental health professionals who wish advanced training in logotherapy but who can attend only a training program offered in their own geographical area. It is an intense supervision model, presented on a local level. 
At this date, over 30 students have graduated from the Worthington Model Logotherapy Training Program. The program appears to be useful, effective, helpful, and to meet a training need in the Central Ohio region. 
JIM LANTZ, Ph.D. (6641 High Street, #6, Worthington, Ohio 43085 USA] is a Diplomate in Logotherapy, a Life Member ofthe Viktor Frankl Institute of Logotherapy, Co-Director at Lantz and Lantz Counseling Associates and an Associate Professor at The Ohio State University. 
References 
1. 
Fabry, J. (1968). The pursuit ofmeaning. NY: Harper. 

2. 
Frankl, V. (1969). The will to meaning. NY: New American Library. 

3. 
Lantz, J. (1993). Existential family therapy: Using the concepts of Viktor Frankl. Northvale: Jason Aronson. 

4. 
Leslie, R. (1965). Jesus and logotherapy. Nashville: Abingdon. 

5. 
Tweedie, D. (1961 ). Logotherapy and the Christian faith. Grand Rapids: Baker Booker House. 

6. 
Ungersma, A. (1961). The search for meaning. Philadelphia: Westminster Press. 


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The International Forum for Logotherapy, 1996, 19, 104-112. 
SERVING THE SUMMONS TO A TROUBLED WORLD 
Paul R. Welter 
The following summons would get our attention: 
You are hereby ordered to appear in Court Room# 849 of the Federal Building, Dallas, Texas, at 1:00 P. M., October 14, 1996, as a witness in the case of the people vs. John Smith. 
By Order of: 
The Federal Judge 
Viktor Frankl refers to a second kind of summons: 
You are hereby challenged to respond moment-bymoment with meaningful choices and responsible actions, given your unique self and potential, to the demands of your one-of-a-kind situations. 
By the Nudge of: 
Your Intuitive Conscience 
The intuitive conscience, this second summons server, does not order, but rather challenges us. An order requires us to take responsibility. A challenge invites us to move to a higher level: becoming responsible. Challenges are more life-changing than ultimatums because the former affords us freedom of choice. 
Because we are unique, no one else can respond to life the way we can. This is true for each person on earth. The second summons is to this kind of individualization. However, as Frankl has noted, we are also 
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summoned to improvisation. Each person has a situation to cope with that is one-of-a-kind. And this situation keeps changing. Therefore, we must redefine our meaning in all the big and little transitions of life. Because an existentialist philosophy asks us to respond with our unique resources to the demands of the moment and the situation, we are faced with applying Franklian philosophy. This application has to do with choosing life with meaning. 
Frankl often refers to ultimate meaning. At this point we pass from the psyche to the spirit: "...the ultimate meaning of man's life is not a matter of his intellectual cognition but rather the matter of his existential commitment....Through his personal religion, man takes a stand and makes a choice." 1· P·84 We can seize the moment, or miss it. By enhancing our ability to individualize and improvise, we will be able to seize more moments, and help others to seize the moment. 
The focus of this article is on our responsibility as logotherapists to serve as referral resources. We are not the summons servers. That is the function of the intuitive conscience. We refer people to that summons server. We have a humble but significant task. Our mission is to awaken family, friends, co-workers, fellow members of churches and synagogues, and strangers to the call of their intuitive consciences. Frankl has given a useful guideline for our task in his discussion of the therapeutic relationship. 1· P-144 This relationship involves human closeness and scientific detachment, and the therapist must attend to both. Thus the therapist must build a relationship on the one hand, and remain objective on the other. We will assume this characteristic of the therapist-patient relationship is also true of us as we refer people to their intuitive consciences. Having examined this imperative to become change agents, we now turn our attention to its application. 
Methods of Referring People to Their Conscience 
The primary method of referring others to their intuitive conscience is to give a wake-up call. It may include such techniques as Socratic questioning, metaphors, and small group work. A common characteristic of all these methods is surprise. Surprise is a self-distancing method that frees others from thinking about themselves, thereby permitting selftranscendence. Since these methods were discussed in a previous article,8 only two additional techniques are discussed here: (a) relaying the wisdom of others, and (b) storytelling. 
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Relaying the Wisdom of Others 
I have tried to pass along the wisdom of children for many years. 7 Nietzsche said we have achieved maturity as adults when we recover the earnestness of children at play. I have used a university class, "Learning from Children," since 1982 to relay this wisdom. Children see it as their spiritual duty to awaken adults. Many sleepy parents have had a four-year-old Jump on their bed and say, "Mom, Dad, get up! It's daylight." Children, like larks, are heralds of the morning. Maria Montessori, the first woman medical doctor in Rome, spoke of a child waking up his parents, "In effect he says: 'I did not wish to wake you from your sleep, I only wanted to arouse your spirit."'3• P• 106 I have scores of stories of little children who awaken their parent's spirit and specifically, their conscience. They call adults to honesty and compassion. 
In addition to the university class, I pass on the wisdom of children in seminars, personal interactions, and a radio program, "Learning from Children." I grew up in a farming-trucking family, so my targets on the radio are farmers and ranchers, and truckers. My mission is to help awaken adults to regard children as master teachers in matters of life and conscience. Hopefully, these awakened adults will then treat children and others in ways that will reduce human suffering and increase meaning. 
The elderly are another group who have wisdom we can relay. They are also an immense and under-utilized intergenerational resource just waiting to be tapped. Bruce Blivins said, "What have I learned in 83 years ... if you get mugged in the street, don't yell help, yell fire. Nobody wants to come to a mugging, but everyone is interested in a fire. "6• P-25 
During 1 0 summers of training staff and residents in long-term care centers in counseling/caring skills, I collected a considerable amount of wisdom to relay to others. Older people do not pass on wisdom as readily as children do. The elderly have lost their innocence and gained restraint. Therefore, one has to work at tapping their wisdom in the same slow, careful way as one might draw maple syrup from a tree. 
The most effective way is to get stories going. However, a target needs to be given to an individual or a group for the stories, such as "You've been around quite awhile. Tell me one thing you have learned about life, and how you learned it." The "how" usually is answered by llll a story. The first responses may not all be useful. However, there is an arousal component in storytelling, so the stories keep going, and come closer and closer to the target. 
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We can collect wisdom not only from people at both ends of life, but also from biographies and from our next-door neighbor. Wisdom is knowledge applied to life, and so it tends to tug at one's conscience. One of the most effective ways to pass it on is storytelling. 
Storytelling 
Viktor Frankl, Elisabeth Lukas, and Joseph Fabry often use stories to refer others to their summons server. A story, like the conscience, permits and even encourages freedom of choice. Henri Nouwen said, "We can dwell in a story, walk around, find our own place. The story confronts but does not oppress; the story inspires but does not 
manipulate. "5, p.ee How might we work with persons who claim to be useless and do not see any reason to live? This may be an 89-year-old in a nursing home, someone in a mid-life crisis, or an adolescent mired in despair. We could tell them the following story to awaken them to the call of their conscience: Two carpenters walked through a forest in the heat of the day. They sat under a large old tree, gnarled and crooked. There they spread their lunch and refreshed themselves with food in the cool shaded area. The master carpenter asked the apprentice, "Do you know why we can enjoy the shade of this beautiful old tree?" "No, why?" "Because it's useless." "What do you mean?" "If it were straight and useful it would have been cut down and sawed up into lumber many years ago. But because it's twisted and useless for lumber, it grew tall 
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and beautiful and useful for travelers like us. "4• P-· 
There are many people working 60-70 hours a week, but their usefulness has already been harvested. They have no time or energy left for others. On the other hand, there are elderly people, those with poor health, or those in some other way impaired and "useless." They do have the time and energy to be useful to others if they can be awakened to the self-transcending challenge of their intuitive conscience. A story such as this can help. 
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Arenas for Action 
Some of the staging areas for referrals to conscience have been mentioned--family discussions, conversations with friends and coworkers, educational settings, churches and synagogues, and the media. An often overlooked medium is the newspaper, particularly the op-ed page, the opinion page opposite the editorials. The editors of small and large newspapers want opinion articles on contemporary 
issues. The following article on lotteries, "Take a Chance on Conscience," appeared in the Feb. 12, 1995 Omaha (Nebraska) Sunday World-Herald. I wanted to awaken people to listen to their conscience concerning the human suffering caused by gambling. 
Many have received a legal summons personally or by mail to appear in court as a defendant, juror, or witness. The conscience is a second server, one much more easily ignored, but with an even more important summons. Viktor Frankl, who is a 90-year-old survivor of four Nazi concentration camps, said the conscience cannot be reduced to the superego--the sanctions of family and society. Buckminster Fuller's statement supports Frankl's point of view: "I know things I have not been taught." The intuitive God-given conscience is a part of the human spirit, not the psyche. The conscience summons us to seize the moment by doing what is right or good, and saying no to what is wrong or evil. It is the best internal guide we have to moral choice. 
Take gambling as an example. Nebraska and many of its cities have established lotteries, viewing them from a business rather than a moral perspective. It is difficult to sell morality in this last decade of the twentieth century. Perhaps the point of view is "I don't want somebody else telling me what to do or not to do!" However, we can look at morality in a different way. God did not give commandments such as "Don't lie," and "Don't steal" just to be telling us what not to do. The point is that those who break the commandments cause unnecessary human suffering. That is what makes it wrong to lie and steal. Sometimes there is necessary human suffering; for example, when a nurse gives a one-year-old a vaccination. The child has some physical pain, and endures the mental anguish of feeling betrayed by a parent. The intuitive conscience knows it is wrong to inflict human suffering, although it takes some maturity to 

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distinguish necessary from unnecessary suffering. It can be useful to observe gambling in the clear light of conscience as an enterprise that is causing unnecessary suffering. 
Who suffers the most from gambling? Children. How about the lottery? The television commercials say, "Hey, it's only a buck!" So is bread and milk. (In fact, you can get two or three loaves of bread for a dollar at some day-old bread stores.) I've been in airports on paydays, and watched employees cash their checks, go to the lottery counter, and go again. Watch lottery counters and you will see that many people spend more than one dollar. The lottery is morally wrong because it takes money from families and causes unnecessary suffering. Those who profit from lotteries say it is only discretionary money that is being spent. How many people do you know who have much discretionary money in their paychecks these days? 
The gambling industry calls it gaming. This long stretch of the truth confuses children. Gambling technically qualifies as a game by virtue of the definition of game as diversion. However, a game as children and many adults think of it, is played on a level field where each side has, at least theoretically, an equal chance to win. This is not true with gambling. The house--a Keno parlor, casino, state, or city--sets up the "game" so over the long haul, the house wins more than the "players." The intuitive conscience knows such manipulations involve deception. Check the TV ads which imply that you have a good chance to win lots of money. Look at the effect of all of this on children. Morals, of course, cannot be taught. They are caught by children and youth from adults around them. Adults who thus violate their own conscience sound pious when they complain about students who cheat on a test. 
Gambling causes additional suffering because it is a nonproductive enterprise. There is nothing earned. Actually, the only ones worse off than the many who lose money are the few who win it. Look at the lives of many of the big winners after several years. They have lost their old friends, and are surrounded by a new kind of friends who have their palms up. Children and youth suffer because they need to learn to work for a living. The lottery pushes a myth that you will win big, and you won't have to work any more. Implicit in this push is an attack on the meaning of work. A friend of mine has correctly pointed out that the American dream used to be to work hard and make a better 
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life for our family. Now the American dream is to win the lottery. And the TV ads push this dream every night. 
Those involved in the lottery enterprise say, "We bring jobs to your state and city." But the intuitive conscience, if listened to, can be heard to say, "Jobs that are based on legitimized pilfering, which provide no useful product, and which teach our youth to depend on chance rather than work to make a living, bring emptiness to the soul in the long run." 
Because casino gambling is coming to Iowa, there are Nebraskans now saying, "Our people will go across the river to spend their money. If we don't have slot machines here, others will provide the opportunity." No, this won't wash with the conscience. If you are a parent with this perspective, how will you talk with your teen? You reprimand him for doing something wrong, and he replies, "Well, if I hadn't done it, someone else would," or "Everyone else is doing it." Can you then respond to him from a moral stance when you operate in other areas of your life on the basis of expediency rather than morality? What does your conscience say? Youth are caused to suffer when some of our community leaders do not listen to their summons server. 
Many states require seat belts to protect people from the thoughtless part of themselves. This law reduces suffering and death and teaches safety. Why is it then that state and city governments not only do not protect people from their thoughtless, irrational side ("I'm going to win at Powerball even though there's only a one in 20 million chance!"), but encourage this behavior, even push it? Many people in government say, "We need the kickbacks of money for educational and community improvement projects." But everyone knows there is more money being drained from the families and community than is being returned. A lot is taken from families and a little bit of it is returned for projects. Should we buy a little educational and community improvement at the cost of a great deal of human suffering? 
It is not just some community leaders who push an empty, non-productive enterprise which causes human suffering. It is often a majority of the voters. Why? It is clear from the study of compulsive gamblers that it is not only greed that caused the addiction. It is the thrill. Addictions provide a thrill. We live in a time when meaning, the central aspect of life, is fading. Because 

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of a lack of meaning, there is trouble in the workplace and violence in the streets. People who lack meaning are in despair. What are the symptoms of meaninglessness today? Look at the two great fascinations of life in the mid-nineties--Powerball and a murder trial in California. Powerball provides a chance at a thrill, and the trial is about suffering, guilt, and death, the deepest anxieties of modern lives that lack meaning. The existential concern about the transitoriness of life deepens when we repress or deny the need for meaning in our lives. 
There is a way out of this. When we have done something collectively or individually that violates our conscience, we rarely stay at that same level of wrongdoing. We either go up or down. The natural step is down, for example, to casino gambling. The other choice is to step up and out, that is, admit we erred, and stop the lotteries. It is the first step to freedom. Just stopping gambling, of course, is not enough. It would reduce human suffering, but would not take care of its emptiness. That emptiness which wants a thrill of Powerball proportions, needs a fresh search for meaning and mission in life. This is the second step, the search for meaning. This can happen as we inventory our unique strengths, collectively and individually, and discover what only we can give back to life. Kierkegaard was right: "The door to happiness swings outward." Our internal summons server can point the direction to that door. 
This particular op-ed article drew phone calls and letters from several states. Two of the most poignant responses came from my home state. A woman said, "I'm a clerk in a store and have to sell lottery tickets, but it's against my conscience. What should I do? I need the job." The op-ed article thus made possible a Socratic dialogue. 
The other response was from a person in charge of providing meals for the homeless and hungry. He said, "The most lottery tickets are sold at a store in the poorest part of the city." 
Comment 
Lawrence LeShan has been an effective psychotherapist to cancer patients for 35 years. His method of treatment is to help patients find their unique mission: "When we are actively singing our own song, we realize that it is only philosphers and depressives who ask what is the meaning of life. When we are using ourselves in the way we are built for, we know. • P-139 His work is a confirmation of Frankl's thesis: We
"2 
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are not asked to answer the question "What is the meaning of life?" but rather to respond with action to the demands of life each moment. 
It is imperative that we refer people to their consciences which can serve them a unique summons to respond with action to life's demands. You will find your unique methods and arenas as you respond to the summons from your own intuitive conscience. 
PAUL R. WELTER, Ed.D. [P. 0. Box 
235, Kearney, Nebraska 68848-0235 USA] is a Counseling Psychologist and Dip/ornate in Logotherapy who 
writes, leads seminars, and has a radio program. He has authored six books, including Counseling and the Search for Meaning (Dallas, TX: 
Word, Inc., 1987). 

References 
1. 
Frankl, V. (1967). Psychotherapy and existentialism. NY: Simon & Schuster. 

2. 
LeShan, L. (1989). Cancer as a turning point. NY: Penguin Group. 

3. 
Montessori, M. (1966). The secret of childhood. NY: Fides Publishers. 

4. 
Nouwen, H. (1974). (Story modified from) Out of solitude. Notre Dame, IN: Ave Maria Press. 

5. 
Nouwen, H. (1981). The living reminder. NY: The Seabury Press. 

6. 
Welter, P. (1981 ). The nursing home: A caring community. Valley Forge, PA: Judson Press. 

7. 
Welter, P. (1988). Childlike adults and meaning in life. The International Forum for Logotherapy, 11, 55-59. 

8. 
Welter, P. (1994). The element of surprise in the logotherapeutic treatment of adolescents. The International Forum for Logotherapy, lllli. 17, 8-13. 


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The International Forum for Logotherapy, 1996, 19, 113-118. 
COPING WITH LIFE-THREATENING ILLNESSES USING A LOGOTHERAPEUTIC APPROACH-STAGE II: CLINICAL MENTAL HEALTH COUNSELING 
Jared Kass 
A logotherapeutic approach can be used by clinical teams to help medical patients develop psychological resources for coping with lifethreatening illnesses. Such interventions include two complementary stages.8 In Stage I, primary health care teams build positive emotional alliances with patients through assessment of the psychospiritual crisis that accompanies a life-threatening illness. This alliance decreases patients' anxiety, helps them begin to form positive coping responses, and facilitates referral to clinical mental health counseling as an integral part of treatment. In Stage II, counselors help patients complete the development of positive coping responses by systematically addressing three central components of these crises: (a) loss of meaning; (b) loss of empowerment; and (c) need for an experienced connection with the transcendent element, the Spirit of Life. This paper presents a case study illustrating ways that counselors can help medical patients address these issues by combining a logotherapeutic approach with clinical methods utilized in behavioral medicine. 
During the Holocaust, Frankl observed individuals who were able to cope by maintaining or constructing meaning in the midst of evil conditions.4 They were able to live meaningfully despite their victimization. In order to find meaning in the midst of crises that are out of an individual's control, Frankl suggests that instead of asking "Why is life doing this to me?" we ask "What does life expect of me at this moment?"4 
However, there is a danger when applying this logotherapeutic intervention. The danger is our tendency to blame victims for their 

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problems (attribution bias). Clinicians can think they are helping patients take responsibility for their health by re-establishing meaning in their lives when in fact they are implying that patients have caused their own illnesses through lack of meaning.3 Evidence suggests that many patients receiving behavioral-medicine interventions have experienced attribution bias. 11 In this regard, the quality of the therapeutic relationship is crucial. Patients must experience empathy, congruence, and unconditional positive regard from the counselor over the course of treatment.10 In addition, counselors must recognize the psychological power they hold over medical patients, and counselors must actively avoid attribution bias. 
The purpose of a logotherapeutic approach is to help patients respond to crises in an empowered way. Frankl's work suggests that patients can do this by developing meaning-filled responses to crises. The powerful question "What does life expect of me at this moment?" addresses the heart of a patient's psychospiritual crisis. It requires patients to enter into a relationship with life itself, with the very forces out of their control, and with the Spirit of Life. It requires patients to treat life itself as a reality that is larger and more powerful than themselves. 
Finding an answer to the question "What does life expect of me?" is difficult. Our culture does not teach individuals to find such deep levels of meaning. However, I have found that individuals can develop this skill by using their intuitive capacities to change their world views.7 Intuition draws on the resources of a deeper, non-linear aspect of the self which contains an integrative function: the capacity to integrate feelings/thoughts/events, to see fragments as a whole, to find meaning.9 Changing one's worldview through the illumination of core levels of personal meaning requires intuitive processes that tap the depths of one's own being. 
Several steps are used in behavioral medicine that mobilize the intuitive processes. The first step is to quiet the discursive, rational mind through diaphragmatic breathing and progressive muscular relaxation. These exercises release body tension and deepen breathing. Patients then focus their minds on the inflow and the outflow of their breath. This mental focus, in which the electrical activity of the cortex diminishes from Beta rhythms to Alpha and then Theta rhythms, elicits a relaxation response that increases intuitive processes.1•2 •5 
Finally, when attention is focussed internally, patients can concentrate on the question of what life expects of them, and they can wait llli. receptively for an internally-cued answer. It may take considerable practice to focus the mind in this way. Further, intuition often expresses itself through imagery.6 For this reason, visualization techniques may be useful following the muscular relaxation. For example, it is helpful to ask 
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patients to imagine a place in nature that is beautiful and in which they feel comfortable and safe. It is usually best not to create a place for the patients, but rather to have them describe places of their own choice. Interestingly, patients can then be directed to find within this scene a "life-form" (person, animal, plant, or non-ordinary entity) to provide a personally meaningful answer to the question of what life expects of them. Such a life-form serves as a symbolic image that embodies a key aspect of the person's inner self and creates a vehicle through which the intuition can speak. 
Clinical Treatment of a Male in His Mid-50's 
This corporate executive was recovering from a myocardial infarction. He had high blood pressure and a family history of cardiovascular illness. Based on his cigarette smoking and symptoms of interpersonal hostility, his physician felt that he was at strong risk for a second heart attack. He had been referred to me for a preventive counseling intervention to reduce cigarette smoking and hostility by improving his coping skills. The patient, however, was resistant to counseling. "There is nothing wrong with me mentally," he insisted. From his viewpoint, this referral (which was supported by his family) was an "imposition." His heart attack itself was an imposition! As though he were separate from his own body, he treated his illness as an unfair interruption that was wasting the time he had left. Thus, he was indirectly expressing anger that he no longer had control over his life, as well as resignation that he would soon die. His attempt to reassert control was to reject the help that counseling might offer. 
The formation of a therapeutic relationship required the supportive but forceful challenge that he recognize how strongly he was rejecting help from others. He was asked to consider that his present behavior might reflect a pattern in his life. The accuracy of this challenge, coupled with his crisis, was sufficient to reduce his resistance. This allowed a positive alliance to form in which I could empathize with him while also continuing to confront self-defeating behaviors and attitudes. 
A balance of support and confrontation became the basis for an interpersonal climate that allowed the patient to face his underlying psychospiritual crisis of terror at the prospect of death and feelings of isolation from his family. It was a new idea to ask what life expected of him in this crisis. That he might be able to find meaning in, and have control during, this crisis (whether the outcome was recovery or death) was novel. Even more unusual was the possibility that he might discover this answer himself, from within. Our positive therapeutic alliance, however, helped him become a willing participant in such an exploration. 
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He made rapid progress in learning deep breathing and muscular relaxation. However, he had difficulty quieting his mind by focussing on his breathing. We quickly learned that guided visualizations helped his mental focus. After several sessions, we were ready to embark on a deeper exploration. In the guided visualizations, he had created a nurturing environment for himself. I asked him to imagine himself in this nurturing place once again, and this time I asked him to find a person, animal, or thing that might give him advice concerning his life. 
He noticed a large, old tree that had "lived a long and fruitful life." When he asked the tree to tell him what life expected of him, the tree replied: Life hoped that he, too, would have a long a fruitful life. My patient was visibly touched by this answer, which spoke, of course, to his deepest wishes. 
I suggested that he ask the tree how to live such a life. The tree replied that it had to "weather many storms." To do that, it had needed "a deep root system and flexibility." Once again, I could see that my patient was visibly touched--as though he were hearing an unexpectedly significant message. I asked him to consider how this message might be relevant. After several moments he replied, "I do lack roots. My lifestyle keeps me flying all around the country. I want to spend more time with my family." He paused, then continued, "And the flexibility--well, I need that too. Whenever I want something, I dig my heels in and fight for it. I never bend. Even if it's bad for me." I asked, "Do you mean like smoking?"--"Yes," he replied. He became silent. When he opened his eyes he said pensively, "I learned something valuable from this experience." 
A second valuable learning emerged as we discussed the experience. I asked what he thought about the tree's original statement that life itself hoped he would have a long and fruitful life. He responded that he had never before considered the possibility that life might care for him. He always assumed that life, and everyone in it, only wanted things from him. 
To close the session, I asked how it felt to sit near that tree. "Peaceful," he replied. When I suggested that he might benefit from sitting near that tree more frequently, he agreed. 
In subsequent sessions, he recognized that he never thought about life itself as an active, living, intelligent process. The guided visualization exercise had allowed him to consider this possibility. He began to regard his life as a gift to be valued. As such realizations developed, his lllll motivation to eliminate cigarette smoking rose. With a few relapses, he succeeded. His relationship with his family improved also. He reduced his travel schedule, invited family members to accompany him on trips when possible, and worked to improve the quality of his time with them. These 
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were changes that he enjoyed and that left him feeling happier. Although biological factors may yet contribute to a second heart attack, this patient reduced his behavioral and psychological risk factors significantly, and he has learned to cope with his medical condition in positive ways. 
Comments 
The above example illustrates how patients can be helped to address the three components of the psychospiritual crises that accompany lifethreatening illnesses: the need for meaning, the need for empowerment, and the need to experience a personal connection to the Spirit of Life. Of course, many patients have sufficiently advanced illnesses that they will not survive, irrespective of their psychological growth. Nonetheless, in these situations, too, a logotherapeutic approach is useful because addressing these issues improves quality of remaining life significantly. First, patients feel challenged to live in new ways; and they can develop the strength, courage, and resolve to respond to this challenge. Second, life begins to be seen as having intrinsic meaning. Of course, this is a meaning which patients must find for themselves, yet it comes from their interactions with deeper aspects of life. Finally, patients can begin to experience, with gradually increasing intensity, their connection to the Spirit of Life. This experience has a profound effect, because it diminishes the deep isolation that so many contemporary men and women feel. 
In summary, health care teams and mental health counselors, using a logotherapeutic approach, can help medical patients develop internal resources to cope with life-threatening illnesses. While further research is needed to fully establish the efficacy of these methods, growing clinical experience suggests their utility. To strengthen these methods further, collaboration should be developed between mental health counselors and local faith communities. Such collaboration, in which counselors could teach logotherapeutic methods as a life-skill to healthy individuals, would increase the capacity of these individuals and their communities to cope successfully during life-threatening illnesses. 
JARED KASS, PH.D. [Department of Counseling and Psychology, Graduate School of Arts and Social Sciences, Lesley College, 7 Mellen Street, Cambridge, Massachusetts 02138-2790 USA] is a Professor at Lesley College and Director of The Study Project on Well-Being. Portions of this paper were presented at the Second Annual Conference, Holistic Approaches to Cardiovascular and Pulmonary Rehabilitation, Lahey Clinic, Burlington, Massachusetts, July 22, 1993. 
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References 
1. 
Benson, H. (1975). The relaxation response. NY: Morrow. 

2. 
Borysenko, J. (1988). Minding the body, mending the mind. NY: Bantam. 

3. 
Dossey, L. (1991 ). Meaning and medicine. NY: Bantam. 

4. 
Frankl, V. (1959). Man's search for meaning. NY: Simon & Schuster. 

5. 
Green, A. (1984). Psychophysiology and health: Personal and transpersonal. In S. Grof (Ed.), Ancient wisdom, modern science (pp. 221-239).Albany, NY: SUNY Press. 

6. 
Kass, J. (1985, August). The use of person-centered expressive therapies in the health professions. Brennpunkt (Societe Suisse Pour L'Approche et La Psychotherapie Centree Sur La Personne, pp. 2033. 

7. 
Kass, J. (1995). Contributions of religious experience to psychological and physical well-being: Research evidence and an explanatory model. In L. Vande Creek (Ed.), Spiritual needs and pastoralservices: Readings in research (pp. 199-213).Decatur, GA: Journal of Pastoral Care Publications. 

8. 
Kass, J. (1996). Coping with life-threatening illnesses using a logotherapeutic approach--stage I: Health care team interventions. The International Forum for Logotherapy, 19, 15-19. 

9. 
Rew L., (1989). Intuition: Nursing knowledge and the spiritual dimension of persons. Holistic Nursing Practice, 3(3). 56-68. 

10. 
Rogers, C. R. (1963). On becoming a person. Boston: HoughtonMifflin. 

11. 
Travis, C. 8. (1988). Women and health psychology: Mental health issues. Hillsdale, NJ: Lawrence Erlbaum Associates. 



118 
The International Forum for Logotherapy, 1996, 19, 119-121. 
THE NATURE OF COUNSELING RELATIONSHIPS FROM THE PERSPECTIVE OF LOGOTHERAPY 
Maria Ungar 
Logotherapy teaches us that to 
be truly human means to be on a constant journey in search for meaning and purpose.4 Through the defiant power of the human spirit we can rise above death, guilt, and pain, and we can triumph over suffering because those conditions do not totally determine us; in our response 
6
to them, we are free. 2· Thus, healing through meaning is an art of living. 


One of the basic tenets of logotherapy is that we are three dimensional beings.3 In addition to our somatic and psychological dimensions, we have the noetic dimension (the dimension of the spirit). Our noetic dimension is not restricted solely to what we "must" do, but what we "ought" to do.2•3 This healthy tension--a process to which logotherapy refers to as noodynamics--is at the root of our search for meaning in life.5 We are free to choose the attitude we take toward life, and we have the responsibility of whether or not we choose to go in the direction our conscience, functioning as an inner compass, points toward. 1 
The body and the psyche are the instruments of the human spirit, through which the human being--the inner spiritual person--comes to the fore and expresses him-or herself. 1 While our body and psyche can be inherently weak and fragile or vulnerable to the influence of external conditions due to aging or disease, the human spirit can never get sick. Whether through a new creation, valuable experiences, or an exemplary attitude taken toward life's circumstances, the human spirit is triumphantly ever present. 1·2 Through the meanings realized, the human spirit is immortal. 
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It follows from the three dimensions of human existence that three types of human interactions are possible: (a) physical contacts, as manifested in touching, hugging, but also slapping and spanking--the readily observable components of everyday behavior; (b) psychological contacts, as manifested in reactions conveyed from one person to another through interpersonal communication, as inferred, rather than directly observed; and (c) spiritual contacts, whereby meanings that otherwise would have been impossible to communicate are transmitted and comprehended. 
Spiritual relationships are intimate. Through them we recognize the inner beauty and the unlimited dignity of the human person, as well as our own value and inner strength. Through the "eyes of the spirit" we are able to love beyond the physical dimension, and appreciate one's personhood beyond the psychological dimension.4 Spiritual relationships are characterized by shared growth toward a goal. 
In human relationships, true understanding--understanding at the spiritual dimension--makes us aware of the spiritual qualities of another human being, be that person physically and psychologically healthy or not. While the instruments of the spirit (i.e., body and psyche) might be affected by an illness that blocks the spirit's ability to come to expression in a manner readily observable to us, the spirit does not cease to be present in the spiritual person. 1 Only, it takes the "eyes" of the spirit to discern the spiritual being, when its reality is masked by disease, discomfort, or pain. Spiritual understanding is necessary to realize the unlimited dignity and meaning inherent in human life. 
Logotherapists contend that a therapist's attitude toward the client can be crucial in terms of the outcome of the therapeutic intervention. Seeing clients in their true reality--as having unlimited dignity--helps them on their way of becoming more of what they have been created to be. 1·7 Furthermore, it is one of the privileges of psychological counselors that throughout the counseling process their own self may become true. 1 Through their authentic living, therapists may assist their clients to get in touch with their own innermost feelings and inner meaning-oriented compass--their voice of conscience. The nature of counseling relationships, from the viewpoint of logotherapists, is a meaning-oriented, dynamic interaction through . which growth can occur. 
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MARIA UNGAR, M.Ed. [12731 Bonaventure Dr. S.E., Calgary, Alberta, T2J 4T9 Canada] is a former student of Drs. Robert and Dorothy Barnes, and a Doctoral Student of Counseling and School Psychology at the University of Alberta in Edmonton, Canada. The above article is based on her presentation at the Tenth World Congress on Logotherapy, held in Dallas, Texas, July 28, 1995. 
References 
1. 
Barnes, R. C. (1994). Logotherapy and the human spmt. Unpublished manuscript, Hardin-Simmons University, Abilene, Texas. 

2. 
Fabry, J. B. (1994). The pursuit of meaning. Abilene, TX: Institute of Logotherapy Press. 

3. 
Frankl, V. E. (1967). Psychotherapy and existentialism. NY: Washington Square Press. 

4. 
Frankl, V. E. (1969). The will to meaning. NY: New American Library, Plume Book. 

5. 
Lukas, E. (1986). Von der Trotzmacht des Geistes. Herderbucherei, Freiburg im Breisgau. 

6. 
Lukas, E. (1986b). Meaning in suffering. Berkeley, CA: Institute of Logotherapy Press. 

7. 
Lukas, E. (1988). Psychologische Seelsorge [Psychological Ministry] (2nd. ed.). Herder, Freiburg im Breisgau. 


121 
ISSN 0190-3379 IFODL 19(2)65-128(1996) 
The International Forum for 
LOGOTHERAPY 
Journal of Search for Meaning