SOURCE_DOCUMENTS/journal_025_1.txt

·The International Forum -· · for 
LOGOTHERAPY 
Journal ofSearch for Meaning 
HOW TO FIND MEANING AND PURPOSE IN LIFE · 
FOR THE THIRD MILLENNIUM 1 
James C. Crumbaugh and Rosemary Henrion 
A HOMEOPATH LOOKS AT 
SOMATI~ MANIFESTATION OF NOOGENIC NEUROSES 10 
lrmeli Sjolie 
HEALING AND GROWING AS A LOGOTHERAPIST f3 
Florence Ernzen 
LANGUAGE AND SELF-DISTANCING 16 William M. Harris · 
SAYING "THANK YOU": . 
ON THE ROLE OF GRATITUDE IN LOGOTHERAPY 20 
·Stefan E. Schulenberg 
SCHOOL AVOIDANCE AND' LOGOTHERAPY IN JAPAN 25 
Shunsuke Kanahara 
NOODYNAMISMS OF VALUE DEFICIENCIES 30 · Roberto Rodrigues VIKTOR AND ELLY FRANKL: DEFYING THE DANUBt 35 .. 
: Haddon Klingberg, Jr. · · INTRODUCING NEWDIPLOMATES IN LOGOTHERAPY AND THEIR QUALIFYING WORK FOR THE DIPLOMATE CREDENTIAL 51 
· BOOK REVIEWS 55 RECENT PUBLICATIONS OF INTERE-ST TO LOGOTHERAPISTS ' · 59
Susan L. Datson 
Volume 24, Number 1 Spring 2001 
The lnternat,onal Forum for Logotherapy, 2002, 25, 11-23., 
A LOGOTHERAPEUTIC TREATMENT FOR RELATIONSHIP THERAPY: EARLY EXPLORATIONS 
Michael R. Winters 
Relationship counseling is an important arena for psychological intervention. About 50 percent of first marriages in the United States will eventually end in divorce 4. So there is a great need for effective therapeutic intervention. Problems in relationship or marriage are the top ranked reason for seeking mental health services 37 • So there is a demand for relationship counseling services. But what is effective in relationship counseling? Is a logotheraputic approach to relationship counseling effective? 
12 1320
Logotherapists have developed theories of love I J. -, and 2124 26 33
conducted couples therapy 19-·--, 41• However, there is no widely accepted standard of logotheraputic relationship therapy (LRT). 
The psychological community has begun to demand that psychotherapeutic treatment demonstrate effectiveness before being accepted as a legitimate treatment. The American Psychiatric Association, the American Psychological Association, and the U.S. Agency for Health Care Policy and Research as well as some managed care companies have supported the emphasis on empirically validated (or supported) therapies 36 . If an LRT method is to gain wide acceptance, it will need to demonstrate its effectiveness empirically.* 
* At first T bristled at the idea of logotherapcutic treatment protocols. Tt seemed to confine the definition and scope of logotherapy and also to reduce logotherapy to component parts. This reductionism seemed counter to the foundations of logotherapy as a philosophy and therapy. However, when I shifted my perspective, I could see a treatment protocol as a definition of what relationship logotherapy is and a description of how it works. The treatment protocol should not limit the logotherapist, but provide a place to begin -a structure for approaching therapy, not a restrictive agent. 

11 
This paper will review the treatment evidence related to :-elationship therapy. outline steps an LR T would need to take to empirically demonstrate it's effectiveness, review logotherapeutic relationship treatments, and suggest a path toward developing an empiricaily supported LRT. 
Empirical Evaluation of Relationship Counseling 
.\1arital Therapv 
There is a relatively short history of empirical validation for relationship therapies. A recent guide to empirically validated treatment does not list any relationship-oriented therapies 36. Several forms of relationship therapy have received careful empirical evaluation: Behavioral, Cognitive and Cognitive-Behavioral, Emotion
8
focused, and insight oriented therapies have been examined 2-. Two criteria are relevant in evaluating these therapies: is there an immediate improvement in relationship functioning, and does the improvement maintain over time. Behavioral treatments have been found to meet the criteria for being empirically validated, both immediate and one year follow-up 2. Cognitive behavioral marital therapy was found to be just as effective as Behavioral marital therapy, but adding cognitive interventions did not enhance the therapy outcome. Emotion-focused and insight oriented approaches to marital therapy emphasize awareness and emotional understanding. Insight oriented therapy compared to Behavioral therapy had similar efficacy in the short run, but in a 4 year follow-up, the insight oriented approach had far fewer divorced couples than did the Behavioral treatment 39. Emotion focused therapy has been found to be efficacious with moderately distressed couples. It is as effective as behavioral therapy 2• Emotion focused therapy appears to be effective at follow up of 2 months. At 4-month follow-up Systemic couples therapy (focused on reframing, and prescribing the symptom) was superior to emotion-focused :herapy. 
In a meta-analytic study 8 behavioral, cognitive behavioral, and insight oriented marital therapies were all found to be more effective than no treatment. The insight--0riented approach was found to be most effective in producing long-term changes in ratings of overall satisfaction with the relationship. The cognitive-behavioral approach 
12 
was the only approach that significantly changed couples relationship related cognitions. In summary, behavioral, cognitive behavioral, emotion focused, insight oriented, and systemic couples therapies have all shown some efficacy. Each approach offers different advantages, and none has clearly shown to be superior over the others. Perhaps more significantly, no research to date has demonstrated which types of clients may benefit from which types of therapy. 
Specific Interventions -Active Listening 
There is an ongoing debate in the literature regarding the effectiveness of different aspects of relationship therapy. One crosstheoretical technique is active listening (also known as: couples dialogue, minoring, etc). This approach seeks to teach partners in a relationship new ways to communicate more cmpathically with each other. Typically, one partner will take on the role of the speaker and the other the role of the listener. The speaker wiJI describe a problematic aspect of the relationship. The listener will paraphrase what the speaker is saying and validate the speaker's feelings. The therapist coaches, demonstrates, and supports the couple in this process. Gortman and his colleagues 14 have claimed that there is little empirical support for this approach. Further, Gottman 16 claims that active listening training may be harmful in situations of high emotional reactivity -in that many people can not tolerate having negative comments made and still remain emotionally neutral. Stanley and others 40 , counter that there are significant methodological and conceptual flaws in Gortman' s research. Gortman' s team has replied, critiquing studies that have shown active listening to be effective and offering alternative treatments that have been demonstrated to be clinically effective 15 . Although it is widely used, there is not a consensus on whether active listening training is an effective approach to couples counseling. 
Client Perspectives Three studies have reviewed couples perceptions of what is effective in relationship or family counseling. Bowman and Fine 3 interviewed 5 couples who were in therapy or had just completed therapy and found two arenas for helpful and unhelpful therapist 
13 
characteristics: therapeutic atmosphere, and ideas and information. The helpful therapeutic characteristics included: trust in the therapist, safety in the session, couples ability to choose what to focus on in therapy, equal treatment of both partners, having the therapist refocus the session when the couple strayed from therapeutic topics, and the therapy itself (having a place to discuss the relationship). In terms of ideas and information, the positive factors were: coming to new understandings about the relationship, about themselves, about gender and making links between the content covered in each session. The unhelpful aspects of the therapeutic atmosphere included: unequal treatment of partners, therapist talking when clients want to talk, the use of the word "therapy", and the session length ( one hour seemed too short). Regarding ideas and information, the unhelpful component was a lack of carry over from therapy to real life situations. 
Estrada and Holmes 9 reviewed couples' perceptions of effective and ineffective elements of couple's therapy. Effective elements included: the therapist moderates and controls discussion; facilitates communication; increases awareness of interactional patterns; reflects and provides feedback; provides a safe environment; encourages participation; is empathic; asks questions; challenges the couple; helps resolve problems; is an objective third party, and provides structure to therapy. Elements that were found to be unhelpful included: using unclear techniques; wasting time; failing to help resolve problems; therapy unfocused and failure to act empathetically. 
Lantz and First 29 identified major theoretical orientations in family therapy: Psychoanalytic, Interactional, Structural, and Existential. From each of these four theoretical approaches, they identified the primary curative factor involved in each approach. The curative factors associated with each theoretical perspective follow. 
Insight-catharsis: Family therapy helped me and the other family 
members express hidden feelings and gain insight about our 
feelings. 
lnteractional: Family therapy helped me and the other family 
members improve our communication. 
Structural: Family therapy helped me and the other family 
members experience a more stable fan1ily atmosphere. 
14 
Noefic: Family therapy helped me and the other family members 
improve our ability to discover meaning in our lives. 
Four experienced therapists, one each for each of the special focuses were recruited. Each therapist counseled five families during the time of the study. Following therapy, each family member selected which factor was most influential for him or her. The Noetic factor was most often selected. Thus, finding meaning as an important aspect of family therapy was supported. 
Unfortunately, there are no long-term follow-up studies of these research efforts. Nonetheless, it is logically hard to imagine that couples that find the therapists behavior unhelpful will maintain in therapy. 
What does the Logotherapy Literature say about Couples and Marriage Counseling? 
Logotherapists have discussed both theory of family and couples therapy and intervention as well. Table l provides a listing of the articles that have appeared in The International Forum for Logotherapy regarding relationship or family therapy. In addition, 
12 13 20 •
Logotherapists have discussed love in some depth 11 --, As love is central to most relationships, this is important theoretical information to inform logotherapeutic relationship counseling. 
Several major works contributing to a logotherapeutic 
22 26
relationship therapy , will be discussed below. Nonlogotherapeutically trained therapists also have meaning as an 
16 17
important aspect of relationship counseling 5, -18. Guttman 16, makes meaning a central piece of his relationship therapy, but focuses on building meaning in the rituals, roles, goals and symbols. Thus, he does not use logotherapeutic techniques for discovering meaning that already exists within the relationship. 
15 
Table 1: Articles relating to relationship therapy in The International Forum for Logotherapy 
-·--
Focus of Article
Date 
Authors
~ol: #~gs 
Marriage rebirth 
1978 
Funke
I 1:1 29-30 
Meaning in family theraov 5:2 119-122 
I 5: 1 44-46 1982 Lantz Dereflection with schizophrenic families I 0:2 105-109 
1982 
Lantz 
Chemical dependency recovery 10:2 110-111 
1987 
Haines 
1987 
Lantz & First 
Family Treatment and noetic curative factor 11:1 2-4 
1988 
Lantz & Pegram 
A meaning model in family treatment 11:2 107-110 
Hypersomatic family treatment 11:2117-121 
1988 
Lantz & Harper 
Family logotherapy for weight reduction 12:1 57-58 
1988 
Lantz & Harper 
Existential vacuum analysis 14: 1 50-52 
1989 
Lantz 
Self transcendence in marital therapy 14:2 67-74 
1991 
Lantz & Harper 
Meaning-centered family therapy 16:2 65-73 
1991 
Lukas 
Treatment modalities in logo therapy 17: 1 14-19 
1993 
Lantz 
Treating traumatized families 18:2 109-113 
1994 
Lantz & Lantz 
1995 
Welter 
Meaning as a resource in marriage counseling 19: 1 20-22 
1996 
Lantz 
Stages and treatment activities in fam. therapy 
16 
Steps Toward an Empirically Validated Logotherapeutic Relationship Therapy 
There are several requisites for developing a validated treatment approach, which logotherapy does not yet possess. First, a set of valid and reliable outcome measures is needed to measure the effectiveness of logotherapy. Second, a treatment manual is needed to describe and define logotherapeutic relationship therapy. Third. a research plan will be needed. 
Several assessment instruments that assess individual meaning exist, for example the Purpose in Life Test 7• However. these measure individual meaning, rather than meaning related to a relationship. While these measures are a good start, they will not be adequate for empirical validation of a relationship therapy. A meaning in relationship test has been designed which is a modification of the Purpose in life test. However, this instrument has not been widely used or the results published 44 . Other instruments designed to measure relationships have been designed and widely used (for example the Locke-Wallace Marital Adjustment Test 35). However. these instruments do not measure meaning in the relationship. Developing a reliable and valid way of assessing meaning in the relationship will be important for meaning-oriented relationship psychotherapy. 
To test a therapy, a standard for treatment is needed 6 . Although several logotherapy texts provide guidelines for relationship therapy 22• 26, a comprehensive treatment manual does not exist. Fortunately, given the work already published, formalizing a treatment manual should be a matter of compilation, rather then starting form scratch. 
Once reliable and valid measures and a treatment manual are developed, experimental investigation will be necessary to demonstrate the relative effectiveness of a logotherpeutic approach to relationship counseling. At a minimum, one well-controlled study with couples randomly assigned to a treatment or control group and demonstrating significant improvement of the treatment group over the control group is needed. The one case-validating study would qualify the treatment as "possibly efficacious". To clearly establish the validity and superiority a treatment must be investigated by more than 
17 
one research team, with comparison of one treatment to other types of treatment and with assessment of long term follow-up of results. 
Tentative Outline for an LRT Manual 
This section outlines elements that this author considers important to include in an LRT manual. This section should be considered as a starting place for developing such a manual. Hopefully it will spur discussion and debate over what should be included in a manual. 
1-An LRT Manual Should Include Grounding In Logotherapeutic Principles 
Materials originally prepared for the Viktor Frankl Institute of Logotherapy training program could be adapted for providing grounding in Logotheraputic principles (for example see Logotherapy Introductory Course: Viktor Frankl's Logotherapy I and Logotherapy Intermediate "A": Franklian Psychology and Logotherapy 42 . 
2-An LRT Manual Should Emphasize The Therapist Characteristics Necessary For Performing Logotherapy 
Logotherapy is not just a set of techniques. One must adopt attitudes and beliefs about human beings and their ability to solve problems and resolve emotional difficulties in order to practice logotherapy 26 . 
3-Assessment 
Several levels of assessment should be addressed in the manual. The first assessment is whether LR T is indicated or contraindicated. At times an individual therapy may be more appropriate than a couples intervention. There may also be other reasons that logotherapy is contraindicated, or another therapeutic approach may be indicated. 
Second, an assessment of meaning for the partners in the couple and the couple as a unit should be conducted. This assessment may take place via objective instruments, or through clinical interviews. Instruments such as the Purpose in Life Test 7 could be used for assessing individual meaning. For meaning in the relationship a family meaning history 26 and a photo album interview 17 are suggested. 
18 
A third type of assessment is the type of therapy that may be given -e.g., premarital couples therapy, couples therapy with only one partner in treatment, relationship enrichment therapy, relationship crisis therapy, and relationship bereavement therapy. Premarital therapy may take a different focus than therapy with a couple that has already committed to each other -it may be more of an exploratory and educational therapy. Often only one member of a troubled relationship will present for therapy. A set of guidelines for working with these individuals could be designed for the manual. Some couples do not need or want "therapy", but may be willing to explore ways to enrich their relationships. LRT may have a lot to offer these couples. A marital crisis couple is what most of us probably think of when we think of a couple seeking marital counseling. These couples may be dealing with frequent conflict, an affair, or coming to therapy as a last ditch effort prior to divorce. Developing guidelines for couples with severe relational problems will be important for the manual. Finally, couples in bereavement may present for therapy. Logotherapy is particularly well positioned to help couples who are grieving. Loss or grief may accompany not only death, but also other types of loss as well. For example, after an affair the couple may feel that they have lost the "specialness" of their relationship. After the birth of a child a couple may feel that they have lost their bond with each other and rather are linked only through their child. Working with a couple to find meaning in loss may be more powerful or effective than working with individual partners. Variable methods and techniques may be warranted for couples with different types of problems. 
4-Modes of Treatment 
This section explores various modes of treatment that may be included in a treatment manual. A first level of intervention is psychoeducational, teaching couples about meaning in relationship. It may be helpful to educate couples about the three dimensions of human beings (physical, psycho-social, and spiritual or Noetic). Couples can then identify the dimension related to their motivation in relationship 43 . Educating couples about self-transcendence may also provide a different view of the purpose of relationship. Couples can 
19 
be taught about love 11 -13 and the three categories of values ( creative, experiential, and attitudinal). 
Other logotherapeutic interventions have been used successfully with couples. These interventions have been described in depth in other places so will only be mentioned here: Paradoxical Intention, Dereliction, and Socratic Dialogue, Provocative Comments 26, Active Listening as a logotherpeutic approach 22, and using rituals and symbols for discovering meaning 16, 17• Specific approaches have been structured for particular problems as well. For example, a treatment for a couple in loss could be adopted from a model for helping clients overcome blows of fate 22 -specific treatment approaches for schizophrenic families 24, sexual dysfunction 22, traumatized families 33, weight reduction 31 , hypersomatic families 30, chemical dependency recovery 19, and anomic depression 26• 
Conclusion 
Empirically supported relationship treatments are still in early phases of research. Little empirical research supports the clear superiority of any theoretical approach to therapy, and specific techniques like active listening are being debated, with no clear consensus. Though no logotherapeutic relationship treatments have been studied empirically, the variables couples find helpful fit with a logotherapeutic perspective. Logotherapy has much to offer relationship therapy. However, there is a great deal of work to be done in developing reliable and valid assessment instruments, developing a treatment manual, and conducting research studies before LRT can be considered an empirically supported therapy. 
MICHAEL R. WINTERS, Ph.D. is associate Direclor of the Rice University Counseling Center [Rice Counseling Center MS-19, 6100 Main St. Houston, TX 77030 winters@rice.edu] and a p:,,ychologist in Private Practice in Houston, Texas. He is an Associate in Logotherapy. 
References 
1. Barnes, R. C. (1994). Logotherapy introductory course: Viktor Frankl'.\' logotherapy. Abilene, TX: Viktor Frankl Institute of Logotherapy. 
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2. Baucom. D. H .. Shoham. V.. Mueser, K. T .. Daiuto. & A. D.. Stickle. T. R. ( 1998). Empirically supported couple and family interventions for marital distress and adult mental health problems. Journal of Consulting and Clinical Psychology. 66( I). 53-88. 
3. 
Bowman. L. & fine. M. (2000). Client perceptions of couples therapy: Helpful and unhelpful aspect:-.. American Journal of FwnihTlzerapy. 28(4). 295 -311. 

4. 
Bramlett. M. D. & Mosher. W. D. (200 I J. First morriage dissolution, diiDrcc, ond remarriage: United States. i\cfrancc data fi·o111 1·ital wul health statistics; 110. 323. Hyattsville. MD: National Center for Health Statistic-,. 

5. 
Carlsen. M. R. ( 1988 ). Marital 111eaning-11wki11g, in meuningmaking: Thcrupelltic processes in adult dt'l'c!opmrnt. New York: Norton. Pp. 207 -226. 


6. 
Chambless. D. L. & Hollon. S.D. ( 1998). Defining empirically supported therapies. Jounwl of Consulling and Clinical Psrclzologr. 66. 7 -18. 

7. 
Crurnbaugh. J. & Maholick. L. ( 1966). Pu1po.1e in Life Test. Murfrcsboro TN: Psychometric Affiliates. 


8. Dunn. R. L. & Schwebwl, A. I. ( l 995) Meta-analytic review of marital therapy outcome research. Journal of Famil_,· Psrcholog,·, 9( I). 58-68. 
9. 
Estrada. A. U. & Holmes. J. M. ( 1999). Couples perceptions of effective and ineffective ingredient:-, of marital therapy. Journal o/ Sex and Marital Jl1cm11y. 25. 151-162. 

10. 
Funke. G. ( 1978). ··Rebirth" of a marriage. The lntcrnatimwl Forwn for Logotherapr. I ( l ). 29-30. 

11. 
Frankl, V. E. ( 1984 ). Man ·s search for meaning (revised and updated). New York: Washington Square. 


12. Frankl. V. E. ( 1987). On the meaning of love. The International Forum fi,r Logotlzempy, I 0( I). 5-8. 
13. 
Frankl. V. E. ( 1998). A psychiatrist looks at love. The International Forum fi>r Logotlzerapy, 21 (I). 50-53. 

14. 
Gottman. J. M .. Coan, J.. Carrere. S. & Swanson, C. ( I 998). Predicting marital happiness and stability from newlywed interactions. Journal ofMarriage and the Family. 60, 5~22. 

15. 
Gottman, J.. Carrere. S .. Swanson. C. & Coan. J. A. (2000). Reply to 'From basic research to interventions·. Journal of' Marriage & Familv Therapy. 62( I), 265-274. 

16. 
Ciottman. J. M. ( 1999). The seven principles/hr making marriage work. New York: Three Rivers Press. 


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17. Gattman. J. M ( l 999). The marriage clinic A scienti/ically-hase:I marital therapv. New York: Norton. 
18. 
Gollman, J.M. (200 I). The relationship cure. New York: Crown. 

19. 
Haines. P. E. ( 1987). Logotherapeutic intervention for families in early chemical dependency recovery. The International Forum for Logotherapr. 10(2). 105-109. 

20. 
Lukas, E. (1983). Love and work in Frankl's view of human nature. The International Forum.fhr Logotherapy. 6(2). I02-109. 

21. 
Lukas. E. (1991). Meaning-centered family therapy. 7he International Forumfor Logotherapv, 14(2). 67-74. 

22. 
Lukas. E. ( 1998). Logotherapy lex/hook: Meaning-centered p.\ychotherapy (T. Brugger, Trans.). Toronto: Liberty. (Original work published 1998). 

23. 
Lantz. J. E. ( 1982). Meaning in family therapy. The International Forum for Lo?,othera1~v. 5( I), 44-46. 

24. 
Lantz. J. E. ( 1982). Dereflection in family therapy with schizophrenic clients. The International Forum.for fogotherapv. 5(2). 119-122. 

25. 
Lantz. J. ( 1989). The existential vacuum in Bergman's ·'scenes from a marriage ... The International Forum for Logotherapy, 12( 1 ). 57-58. 


26. Lantz, J. (1993). Existential family therapy: Using the concepts of Viktor Frankl. Northvale. NJ: Aronson. 
27. 
Lantz . .I. (1993). Treatment modalities in logotherapy. The International Forumfr.,r LogotheraP.v, 16(2). 65-73. 

28. 
Lantz. J. (1996). Stages and treatment activities in family logotherapy. The International Forum.fr.Jr Logolherapy. 19(1 ). 20-22. 

29. 
Lantz . .I. & First. R. (1987). Family treatment and the noetic curative factor. The International Forum.fr.Jr Logothera1~v, 10( l ), 110-111. 

30. 
Lantz . .I. & Harper, K. T. ( 1988). Logotherapy and the hypersomatic family. The International Forum for Logotherapy. 11 (2). 107-110. 

31. 
Lantz. J. & Harper, K. T. (1988). Family Logotherapy for weight reduction. The International Forum for Logothera1~v, 11 (2). 117-121. 

32. 
Lantz, J. & Harper. K. ( 1991 ). Self-transcendence in marital therapy. The International Forumfor Logotherapv, (14)1. 50-52. 

33. 
Lantz. Jim & Lantz, Jan (1994). Franklian treatment with traumatized families. The International Forum for Logotherapy. 17(1).14-19. 

34. 
Lantz, J. & Pegram, M. (l 988). A meaning rnodel in family treatment. The International Forum for Logothcrapy, 11 (! ), 2-4. 

35. 
Locke, H. & Wallace, K. ( 1959). Short marital adjustrnent and prediction tests: Their reliability and validity. lt1arriaf{e and F'ami(v Living, 2, 205-22 l .. 

36. 
Nathan. P. E .. & Ciorman.. J. M ( I Q98). Treatments that work and what convinces us they do in P.E. Nathan & J. M Gorman (Eds.) 4 Guide to Treatments that Work (pp. 3 --25). New Yode Oxford University Pres~. 


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37. Veroff, J., Klulka, R. A. & Douvan. E. (1981). Mental health in America: Patterns ofhelp-seekingfi-·om 1957-1976. New York: Basic Books. 
38. 
Snyder, D. K & Wills, R. M. ( I 989). Behav iora! versus insight oriented marital therapy effects on individual and interspousal functioning. Journal of Consulting and Clinit·al Psvchologv, 57( l ). 39-46. 

39. 
Snyder, D. K. & Wills, R. M. (199 l ). Long-tenn effectiveness of behavioral versus insight-oriented marital therapy: A 4-year follow-up study. Journal uf Consulting and Clinical Psyclwlo&,'V, 59, I 38141. 

40. 
Stanley, S. M., Bradbury, T. N. & Markman. H.J. (2000). Structural flaws in the bridge from basic research on marriag,~ to interventions for couples. Journal ofMarriage & F'amily, 620 )., 256-265. 

41. 
Welter, P. R. (l 995). Meaning as a resource in marriage counseling. The International Forum fhr Logotherapy, 18(2), l09~ l l 3. 

42. 
Welter, P .R. ( 1995). Logoiherapy intermediate "A". Franklian psychology and logotherapy. Abilene TX: Viktor Frankl Institute of Logotherapy. 

43. 
Winters, M. R. (1999). Developing meaning in marriage: A relationship development model, a program presented at the World Congress on Viktor Frankl's Logotherapy, Dallas, TX. 

44. 
Winters, M. R (unpublished data). The Meaning in Relationship test: An adaptation ofthe Purpose in Life test 


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The International Forum for Logotherapy. 2002. 25. 24-29. 
A LOGOTHERAPIST'S VIE\\' OF SOlVIATIZATION DISORDER A:\D A PROTOCOL 
lrmeli Sji)lic 
The csscnt1:il lcalun' ol' Som;1ti/:1tio11 !)ic;md,:r h :1 pattern or multiple. clintL':li!y ,1\111i!'ic:111t snm,i1i, complaints. Th,',c' 11rnlt1pk c.:1,mpl;1inh l·:rnnot h,cx.plaincd h\ :111_1, g,:lil'r:ilh k110\\ 11 rnc·dic:!I condition. Di:1g1w~-tic nikri:1 for S1 ,nu! 1/:111011 Disorder acu1rdi11g ltl tlhi Diagn,1•t1c nd Statistical :\:Janual 11f \'knui Dis(•rdus, 1 Ds;:,\l-! \' TR JOO.;-; l) include :1 hi:-,lory ol 111t,lt•11 1,· ld1:1h ,.,\l'I s1,,·, ,T:tl \L'dt, \\ it h seL: king medical trca t11h.'l11 \< u l ,1u1 ·,. uu: 1.'•; ,. C( in:-:,·q tk' 111 I> . significant impairment in c;ocia!. ,1<.c·up;ili\l:Lt! :,11d 1111,_-rpc-r._,1,:,;i! relationship:-, is e:xp,'ricncl'd T!H.' r,,l!o\\ in;!:--\ 111ptPl1J, !lHhl h: 111,:,L'lll according tP DSM-I\ 
I. Pain in\ ;1rious sii,.;s systems at leas! i'om 
2. Ciastrointcstin,d mpto111:-, other than pain at kast 1,,t1 
J. Sexual rcpn,ductI\L' sympt(1rns ,,tiler than pain at lc,1,;1 one 
4. PscudP-llL'UrologiL:,11 ,.-onditlilll'-mot lirn1lcd t,, pain) c11 k,ht 
one. The symptoms cannot be ,:\pL11J11,,'d h) :my knil\\11 rnedic;t! cond1ti<1n. They arc not intentional!) prndi:c"-'d hit the) arL' in ex,:,~,s to the medical complaint. ,, hen thL'l'C is one 
Associated Features and Disorders 
I. Promin,,.::111 ,mxicty "YlllPlPms and dcprL·sscd mond arc \L'rv common 
2. There may be impulsi, c a!ld ilntisocial bch,1, iur. 
J. SuiL·ide threats and attcm11h. 
4. Marital discord. 

24 
As can be seen the DSlvf IV considers only somatic symptoms when these disorders are classified. Logotherapists must look at associated features to understand the picture. When Logotherapists look at the somatic symptoms and the associated features they immediately recognize Viktor Frankl's ··noogenic neurosis··. Since the term neurosis is no longer used; this state might be called a ''somatization disorder" in which the maintaining cause is in the noetic dimension. Logotherapists, knowing what Viktor Frankl meant when he spoke of "noogenic neurosis'·, can relate to "the somatization disorder''. 
Noogenic Neurosis 
Although it has always existed, Noogenic Neurosis was not always recognized as an independent neurosis. It was Frankl who first recognized it. Logotherapy has clearly defined the human being as existing on three levels: the highest of which is the spiritual. ft is on this level that the human being makes all decisions, assumes responsibilities, and transcends adverse conditions. In short, it is where the human being fulfills personal meaning. However. sometimes it feels as if the functioning of this dimension is obstructed by difficulties encountered. and this feeling can develop into a neurosis. 
The neurosis is caused by a conflict in the life situation of the patient. This neurosis does not originate in the psyche of the patient and is not brought about by such traditional Freudian causes as repressed sexuality, childhood traumas, or conflicts between different drives or among id. ego. or superego. Noogenic Neurosis originates in the noetic dimension and is brought about by value collisions, conflicts of conscience, or an unrewardeJ search for the meaning of life (Frankl, 1984). 
Conflict of Values 
Values are time-tested rules of behavior that have universal meanings. Although they arc time tested and rest on tradition, they change as humanity evolves; sometimes slower, sometimes faster. especially in times of rapid progress. When old values crumble. new ones emerge. Logotherapy maintains that values can never disappear completely 
25 
because there arc typical life situations we all share. Problems faced today are due to the rapid changing of values. People are caught between "old" and '·new" values: taking over the family business versus becoming an artist: the virtue of virginity versus free sex: listening to the advice of the parents versus going one's own way; and the security of a permanent job versus the excitement of adventure and travel. Life was much easier when there were no questions about what to do. Tradition and accepted values gave a strong and secure framework to life. Today, because of changing values, individuals have a much greater responsibility towards life and have to make their own independent choices. This is what Frankl says "vhcn he affinns that we are free on the spiritual level to make our own decisions. lk goes on to point out however. that it is not freedom from anything. hut freedom to something. Freedom to make our own choices. and they have to be responsible choices (FrankL 1984). 
When we are faced with a conflict of values. and do not know which one to choose. we become neurotic. It is difficult to make a choice between two equally attractive alternatives. Other situations that can be even more difficult are when we know which choice we would like, but for practical reasons we cannot choose. 
Logotherapy teaches that under normal circumstances we can solve our value conflicts ourselves. since we arc not helpless victims of circumstances. However conflicts can overwhelm some and lead to a neurosis. For this reason. it is important to understand that values have a hierarchy and that this hierarchy is not arhitrary. Each of us must find our own values through personal effort and our own order of values cannot he imposed on others. 
Conflicts of Conscience 
Dr. Frankl defines conscienc1: as an intuitive capacity to "sniff out" the unique meaning inherent in a situation, to understand the "meaning of the moment". Conscience helongs to the noetic dimension and is not just a psychodynamic superego as has heen postulated. Conscience is a specifically human phenomenon and the key element of self
26 
transcendence. lt h•,·1p:,, u:-to C\ ,du;\lc \ · thereby tu make cho;,:cs 1!1,11:ki, \\i\.-J.). 


,_,hoici.:·s hasc·,.l respt1nsd,il1t) :, 
01 i:11h1I'C :·, 


dissa11sfoctio11..1 ,l\,,i:t\ 1): ,:k 
/ 1 .' ,.l i ! 't. JI\ , ,.i ! l .i I, '1 , ·,, , t: objectin:s ,ind 1ik·,1:i1n;.>, ,., :1:c i:.. l·ni;'i.., i)\'\·i il ,P ~ 
,
ancsthesiscd. tl1C\ ,h ,. 1 !L'dl! 'w,·1,: 1 \1,1 rd: th;,..f de !dl'i il violence or drui!:--. 
2. 
The c.'\i"-tL·1111al 1rustrnt1on ha inure -.:crt\llh cnnd111u11 li ! more serious bceciusL' ;x'1lpk n,it ,,nl:, k,·I the L'tllplinL'""· they :il.,i! icd the frustration. rhcy fCL'l sornm at ha\ inµ fa1kd. Tlin co1h1der themselves fotlurc..;_ 1mpcr!ect. and u1wbic Ill reach their !,:Uals. However there is also rebellion. a fight. and ;1 desire tu sw lllllllllt the obstacles. 

3. 
When the frustration develops into a neurosis. \VC obtain definite pathological symptoms. These symptoms belong to the area of the neurosis. The only difference is the origin of the neurosis. which iies in the noetic dimension. We can say that this state is a state of Jesperation fi._)r people when they do not fulfill the will to meaning. 


27 
Noogenic Neurosis is a flight from emptiness into the world of symptoms on the psychic or somatic planes. It affects our social behavior. This reflects negatively on us and our surroundings. thus feeding the neurosis. ,vhich becomes stronger and stronger as time passes, developing secondary and tertiary symptoms. Noogenic Neurosis exhibits all the characteristics of a neurosis -only the origin is different. 
The Four Steps Protocol 
1. 
Separate the patient from his or her symptoms. 

2. 
Modify attitudes. 

3. 
Reduce symptoms. 

4. 
Prophylaxis. 


According to Logotherapy. the noetic never becomes sick. We can tap into resources from the noetic to activate the "defiant power of the spirit'". We explain to patients that they are not identical with their fears, obsessions. inferiority complexes. or emotional outbursts. They are not helpless victims of their biological. psychological. or social fate. and they do not ha\e to remain the way they are. The logotherapist removes the structures of dependency the patient has built to explain the symptoms. Patients begin to see, what they unconsciously already know. They are, first of all. a human being \Vith a capacity to find meaning. Only secondly are they individuals with certain shortcomings. certain unwanted patterns that can be changed. 
Once patients have gained distance from their symptoms. they become open to new attitudes to\\ard themselves and their lives. Nev, attitudes cannot be forced upon patients: the therapist must listen f<Jr ""logo
28 
hooks" to find signs from the patients· spiritual unconscious indicating the direction in which they might v,am to change 
After successful nwdification of attitudes. the symptoms usua!i; disappear or hecome manageable. Logntberapists cannot replace an amputated leg. hut the) can help the indi\ idual to live with one kg. without succumbing to apathy or despair. 
The final step 1s to secure patients· mental health for the future. All meaning potentials are discussed. enriched. and extended. Value hierarchies are clarified to protect them from future existential frustrations. Clients are led to recognize responsibility 
IRMELI IVALO SJOUF. B.Sc.. Dip!. i!omeopath. Diplomatc and Faculty Member of the Viktor frank! Institute of Lngothcrar\. (Laivurinkatu 39AL00150 Helsinki. finland1 
References 
Diagnostic and Statistic Manual of lvtental Disorders. 1J994) 4th ed. American Psychiatri,.; Association. \Vashington. DC. 
Frankl, V. E. (1984). Psychotherapy and existentialism. New York: Washington Square Press. 
29 
The International Fowm for Logotherapy, 2002 25. 30-38 
ALCOHOL USE DISORDERS: ALCOHOL DEPENDENCE 
Rosemary Hendon 
"""1':-;
The existential feature ot' suhstancc dependence. includint' alcohol. is a cluster of cogmt1n:. lx:havioral. ~md physi1llngica! symptoms descrihing individuals ,d10 cunlinuc to use alcohol despite si}!ni !icant suhstanu:-r,·iarcd problems. "\ pattern ()! rq,caicd ,,c]fadministration \\f alcohol k,tds t;; ~·r;rnL'.l'. withdrawal. ur cn,11 pu ! , i, ,~-lak mt;' I1,_, ll~i \ irn Physiological d,:r1::,1,knc,: \.s; 1ndi1.:aL.:d ) k ranc .... ,·, r \\·ithdra\\:al syrnp1nn::,). \\·11hd ucni"ilr..>i~ ~t r:1,n·;.. ·-,<.'!1.' c!1 course o,crall. 
Definition Dependence is dcf1ncd as three or ,!Kire ol'thc 1~)i\c,1.1.1;T '.,:,mp1n111s occurring at any time in the same i ::'-month pl·riod: 
• 
Need for gr1.'ati:, increased amounts of ;ilcohol tn achieve intoxication or desired c!'kct. 

• 
Need for incn.:a!,;cd arnounts of alc(1!wl vdwn a rnarkedl: diminished L'ffcd is crcatc·d v, ith cunrim!l'd u:,c ()I° the same amount of ulcnhui. llll' cliniciai, '\:U lWl'd !o ;:sscss thl' degree of tolerance since it\ anl'S rn,.li\ iduath. 

• 
Withdr:m:d 




phy·:iol1)):.icc1l :md c\lµnitn ,' ,.. rn~c1im,Lrnt:, d1·,:i:rring \\ h,:n hlood/ti<-;uc akcdw! Ulnet:illf" dion., ckc1in1.· i11 indi\ iduals \\h•i 

indi\idu:d~; h:;:in !(, ,,'\;~;_nc KL ;1npk;1>,n~t ,\ithdrav,al symptoms. thl'\ \\ iIi t:1h.L' ak1 dwl tu I"l'! :1:\ l" Pl <I\ oid th..:· s:,.mp[O;lh. 
30 
Neither tolerance nor withdrawal is necessary at the time of diagnosis to determine alcohol suhstance dependency. Past history of tolerance or withdrawal associated with a more severe clinical course (higher levels of alcohol intake and greater number of alcohol-related problems) may determine the diagnosis. 
Some individuals experiencing compulsive alcohol dependency may take the substance in larger amounts or over a longer period than originally intended by continuing to drink until severely intoxicated despite having set limits of only one drink. They also may have had many unsuccessful efforts to decrease or discontinue the use of alcohol. Their daily activities may eventually revolve around alcohol and they may eliminate important social, occupational, or family activities. In other words, alcohol becomes the center of the individual's life. 
Treatment and Introduction of Logoanalysis 
Behavioral and cognitive therapies have been the major treatment modalities utilized with alcohol dependent individuals. In 1975 James Crumbaugh developed a five-step specialized program in Logotherapy named Logoanalysis. This program received Frankl's approval and was implemented at the Gulfport Division of the Biloxi VA Medical Center, especially for veterans diagnosed with alcoholism (Crumbaugh, 1980). Cmmbaugh retired in 1980, and this author became the primary therapist for treatment modality. Over the years Logoanalysis has proven to be therapeutic for veterans who needed real meaning and purpose in life after sustaining repeated losses. The medical and nursing staffs acknowledged that veterans who completed Logoanalysis were less likely to be readmitted to the Substance Abuse Program. In 1983 support groups were initiated in the Outpatient Department of the Gulfport Division for veterans who completed the program and chose to return to the group on a monthly basis. This group was therapeutic since the veterans knew they would ohtain assistance from their peers in resoiving conflicts in their personal or work life. 
In 1988 the Logoanalysis program was revised to a seven-step program and in 1992 it was implemented at the Pensacola VA Outpatient Clinic, Florida. Thousands of veterans were referred to this program by the mental health treatment teams and other professionals. 
31 
Logoanalysis: A Seven Step Protocol 
Three phases constitute this logoanalysis program: didactic content, realistic and workable exercises, and logo-psychotherapeutic sessions. Sessions are scheduled 1½ hours, twice weekly, for 4 weeks. Homework assignments include exercises for individuals to complete and return to class for a discussion on the significance of how the content relates to their present situation in life. The past is discussed only if it is connected with events occurring presently. Individuals verbalize the therapeutic effectiveness of each step since it is applicable in their daily life. At the end of the program they are able to assess the status of their past life, the influences concerning their present one, and the choices they make to alter their life for a more productive and meaningful future. The seven steps of Logoanalysis Protocol consist of the following clinical interventions: Choosing a view of life, Loss and grief, Developing self-confidence, Creative thinking, Initiating meaningful encounters, Dereflectioo, and Commitment. 
Two Views of Life 
In 5,000 years of recorded history two views of life continue t0 exist. One belief system is mechanistic; the other one is teleological. We, as individuals, must choose one of the belief systems if we wish to discover a genuine meaning and purpose in life (Crurnbaugh, 1980). Even those individuals who are unable to make a choice initially, will ultimately select one. 
Individuals who choose a teleological view of life develop more positive attitudes and transcend to the noetic dimension (human spirit) to become survivors. Individuals who arc mechanistic, experience a negative attitude, remain victims, and escape their emotional pain through the use of alcohol or other drugs to become oblivious to their problems. 
Loss and Grief 
If individuals live long enough, they will experience loss either through health, family, job, or relationships. When a significant loss occurs, individuals usually experience shock, denial. numhness, depression, and anger. Ultimately they begin to accept what has 
32 
hapr,;:ni:'d 1,, t'L', \t\nrk1.~(! i lit in1tL!'. 
!htnk ahciul d!~:c~: for these ~tat~c'-: !(, , .._ --i :tiJ ·.-:.re • H! 1 ~;1:,_H,, rt\'t-~·t
!:-•1 .. 1 differenth to tr.nrnu f ii:• i(,\•ul.h:r~iph1 ,k,c::; nril. i1 ,:nrnt in, 11, idrul:: it' re111ain \'lctirn;: [IP'" 1'·[,;!\"!" th··~: t~t',"f'S'.<~p-\' ., ht,~\ :··:P' :,~[H'~''.,H:trt~d tn transcend to the noc·t·: dimt:n:;i,,P rc!kctnw ,:uni,·(•;-,;lnp : t1c1r ,im,·r strength is more rcc,ili,'n'. ,ind the 11Hi:,111",11 :,nwr,,;;;: I,' ti·' 'W\', l\,'\ ,,:1 of attaining h!gl: .aitH:C: .\t thi•: ;,oPF rhc '\kr,m1 :, \IC!"! i':c huni:in spirit'' becomes :i~·1 i'-'.ill':i 


of their life. Sl·mc lifr <'\p1:ri-:nce'.; '.vi!l no.·w h,:-.,wd th<·:, '11!;1 ,::11 it is important ,hm :ndt\ ,,'.,fois ,is:-.uinc tr1v r(':·,r,;nsill;i1t'-:.,, c1,:u1s'c their attitude. i\tWuc1rncii \ t21uv ,,, n11,r;.: •,ii2n!f1e:uii :L,11, Ith ;;1lh: t,;," values--creati \ c and 1."< rr rn· nll,d. 
Developing Sclf:.cnnfidem:c 
The veterans· !Jr:-;i homi.:\\,1rk ,h:,1,.?nmcnt negins "iu•, \!ii-; ,l,Ti lt is the Power o/ Freedom LHr,1.,c ,( ;1rn1tMugh & lkH1111lL .:nol) which contains sd 1--;h'.·Hffllltc'-:,latcment:, 1k1t arc n:jH·;itL·d 1 ,\ 1c1;, daily 
(a.m. and p.1n.). -rh,::-; ~x..:rc1:)~ nrn"t Pl· con1pkk'1 ,1:-: optimal therapcutK hu1;,:i ll, ;i ,s ha'icd on t!w assumption of Loget!icrap:-, tliJt hurn,rn hcrn,_, ;,.;,~; ,m ,1r,d ,d :'rt·c will and all life is r1n1 (\JrLplt.:lci:~ 1.,L.'.t~:_,nJrh."U i'1 :. ;,:,~1hLti-:~nii!f/ piu:-heredity. Consequcml:c. iuJ1\1dua}, m~:\ ,hnp<,.: lr,.'civ li dl ,111.aLon'> and direct themsch ,,c·c, tn\\imi ,.::t1u:,u1 :;,1.th 

The second c:\:l'rt.\>C ,_l>dsi,vJ ;\d 11":·, .,tcp !:, :l;,, }1,/,,i;:,•, ,,,; C"'reurive .\,Jeanill/!;. r:·-:1:-: >,__',\.=-..i\.i>C. L,L-;")l,~,f·. 11i;..liv1Ju1sd:-. .1..1:<.!,..' !.ift'·lr '>~ choices. utili/ing ,1 ',c.1! .. t,u.. ut ,1.i,:P:,'li ,hr:tk.d c:·cc·,nl 1!J,, select the wisest :iu•t\1; fnr d1nn ,,H\c: thl· pn.·sl_'lll un'tl!1h\:H11.:...'~\Vhen indi\·iduals rctiH'{t ~\J l·la:_-,:~. the¾ di,\ ~J·~· ih1.. ,~•t 1 l' \\}n~ ;!-;v;r
J 

33 
number of decisions and choices Vlhik progn:ssmg through this program. They concur and are willing to take the chalkngi:. 
Creative Thinking 
As veterans continue to increase their self-confidence. they begin to think creatively about goals concerning their careers. Some of them change careers. transfer into a related field. or plan to become entrepreneurs. The Socratic Dialogui;: is therapeutic through the process of this treatment and brings to a conscious level answers that are already there. The veterans feel that having meaning and purpose in their daily activities climinak the need for drinking alcohol to cope with this boredom and emptiness. This docs not mean that they do not have the desire to have a drink periodically. hut they know they can never take another drink successfully for the remainder of their lives. 
Initiating Meaningful Encounters 
In existential tem1s an encounter is defined as a deep. meaningful relationship between two human beings with trust as the basis of this union (Crumbaugh & Henrion, 200 I). A number of people never progress through the superficial level lo even begin to learn to trust. Two people will need to proceed through sharing openly their thoughts and feelings that they would not share with just anyone. Atler a series of meetings and discussing intimate topics. a level of trust begins to emerge if they know that both parties will keep the topics confidential. This is time consuming. but it is worth every effort to experience such a genuine relationship. Crumbaugh states in the last analysis the real meaning and purpose in life is in relationships ( I 980). 
The assignment for encounter lasts two sessions since individuals with alcohol dependency usually experience broken relationships. The bottle becomes the center of their life and these individuals are willing to risk everything. even loved ones. for their periods of escape. An exercise is available for those individuals who are very shy and find it difficult to initiate a conversation with others. The Act As I( exercise is recommended. It includes five steps. progressing from solo. stranger. acquaintance. personal friend. to conflict settings. 
Dereflection The core of the logotherapeutic process is dereflcction. a term coined by Frankl. When individuals deretlect from shortcomings to 
34 
their successes and assets. they go beyond their self-centered needs and extend themselves to be needed or to serve others (Henrion, 1987). This process gives them the feeling of being worthwhile and they are motivated to develop meaningful goals. These individuals will also develop potential in being the best they can while progressing to higher values. Some of the people arc very surprised that they can accomplish much more in life than they ever thought they could. 
Another significant component of dereflection is prioritizing one's value system by completing the Meaning in Life Evaluation (MII.F) Scale. This is a 20--item scale in which each individual chooses the top five values. The individual develops goals as to how he/she will arrive at obtaining these values. From these chosen values will become the 
individual's meaning and purpose in life at the present time. recommended that the A1ILE Scale be reevaluated annually.  It is  
Commitment Commitment  is the  final  step  in this  program.  and  It  1s  very  

important that individuals continue to develop their potential while proceeding to higher values. Through higher values, individuals will have continuing goals to accomplish while increasing their abilities to be the best possible. A number of veterans expresseJ that this step is very significant since it may be the last viable opportunity to become that somebody they have always wa11tcd to he. Perseverance and determination are very important in follmving this seven-step program successfully. If these are not developed, the first difficult day after discharge from the hospital may be too overwhelming and the individual will revert to alcohol dependence to escape painful reality. 
Each veteran is pretested with the Purpose in Ltfe test to determine the level of existential vacuum manifested by boredom and emptiness. A posttest is given at the completion of the program to assess the decline ofthe two symptoms. Logoanalysis is the first formal program in Logotherapy to be taught in the United States. It contains elements of Frankl' s Logotherapy to make it a therapeutic and viable program. 
Case Presentation 
Tom is a male, divorced, and recently retiredfrom the Navy with the rank of Lieutenant Commander. He is the fat her of three teenage sons and one school-age daughter. Three years ago Tom was treated 
35 
for cancer. He admits to having a problem with alcohol dependencT and has not been treated ji,r this disease. Tom read about the Logoanalysis program in the newspaper and called lo request admission to this program. 
This veteran was reared in suburban area 1~/' a midweslern cily. Tom 'sfamily was a typical Midwestfamily who hi!lievcd in traditional values. His parent ·s role-modeled these values. and he felt that he always had high expectations o(himselfand others. He also applied these values to his Naval duties around the world 
Tom graduated from the Naval Academy v,:ith honors. He married 2 years after graduation to a person who was an introvert. At that time he did not realize that she would have a problem adjusting as a naval officer's w(fe particular(v with socializing with other wives or attending Naval command festivities. Tom was away on assignment most ofthe time, and his w(fe was re.\ponsihle _fi,r the children and all ofthe duties ofa military wf/e. After 15 year.~ <?fmarriage, Tom hegan drinking alcohol more heavily since he felt he was unable lo change things at home. The only time he felt any peace was when he was on assignments in the Navy. 
Logotherapeutic Interventions 
1. 
View of Life-Tom chose the teleological view since he believed in a Higher Power and felt that he was part of a plan to fulfill his life in a meaningful manner. He attended church regularly with his family hut he stopped going to church after he entered the Navy. Now he wants to become active in the church again. The spiritual aspect provided him with the inner strength to face daily challenges. 

2. 
Loss and Grief---Tom became consciously aware that he wanted a family like the one he grew up with, but it did not happen. The loss of family after leaving the military also affected him deeply. The private sector is very competitive and Tom found the adjustment to civilian life difficult. His alcohol dependency increased during these stressful times. Since Tom was a private individuaL he did not openly share problems with others. Through the process of logopychotherapeutic sessions (Socratic Dialogue) Tom began 


36 
to resolve some of the problems and his peers provided the emotional support that Tom really needed. 
3. 
Building Self-confidenee--Tom admitted, in-group, that he felt he was a failure in marriage and had lost self-confidence upon discharge from the Navy. In the Navy he was a member of a large family and he felt he was a Somebody with a personal identity. Tom began using the Power ,fFreedom Exercise as directed. He reaped the therapeutic benefits \vhcn he realized there is an area of free will in all situations in which he has some control. He would need to change his attitude to a positive one by transcending to the noetic dimension. 

4. 
Creative Thinking-Tom requested an appointment with the vocational psychologist to be tested for a secm1d career. As a result of the testing, Tom registered at the local uni vcrsity to pursue a Masters Degree in Criminal Justice. He was very pleased with the choice. 

5. 
Initiating Meaningful Relationships---Tom continued !ti become even more consciously aware of what kad tn n1s divorce. He and his wife did not have similar interests. She was unable to provide him with the emotional support as an officer's wife since she did not like military life. Consequently, Tom·s wife felt isolated and their relationship disintegrated after 22 years of marriage. Tom discussed the kind of woman he would like to marry if he had the opportunity '·to meet the right one.'' 

6. 
Dereflection-Tom complt~ted the Meaning in Life L'mfuatwn Scale and he prioritized bis five top values. From these vaiucs he began to work immediately in achieving the goals to experience the chosen values. He was not surprised when he selected authentic relationships as one of his top values. Tom verbalized that he felt comfortable with military retirees at social events. This was a beginning to meet others and possibly discover an authentic relationship with another woman. He hoped to have a happy marriage and family. 

7. 
Commitment---Tom's expectations of the therapeutic value of Logoanalysis were met and he learned how to cope effectively in the psychic (emotional) dimension and he transcended to 1he noetic dimension (human spirit). He also apprcciakd his 


37 
uniqueness as a human being in pursuit of a meaningful and fulfilling future. Consequently. Tom made the commitment to join the I.ogoanalysis group meeting monthly in an Outpatient Clinic. Results of the Purpose in Uk Test for Tom were: Pretest score --68 ~ no meaning and purpose in life, Post-test score --115 °~-definite meaning and purpose in life. 
Evidence of an existential vacuum. boredom. and emptiness had decreased significantly. I continue to communicate with Tom by phone annually at New Years. Ile completed the Masters Degree in Criminal Justice and is employed with the Military. He was transferred to Germany where he arTanged a meeting with Dr. Frankl. A few months before the planned meeting. Tom was diagnosed with a recurrence of cancer and he returned to the states !<)r treatment. Tom related that he has not been depressed nor had another drink. In 2001 when I spoke with him. he stated that he is teaching a friend how to cope with cancer using the principles ofLogoanalysis. 
ROSEMARY HENRION, M.S.N .. M.EJ., R.N .. is a Diplomate. Faculty Member. and long tirm: mcmher of the International Board of Directors of the Viktor Frankl Institute of Logotherapy. 
References 
Diawwstic and Statistical Manual of Mental Disorders. (2000). ( 41h 
ed). Washington D.C.: American Psychiatric Association. 
Crumbaugh, J. C. & Maholick. L., ( 1979). Afanual}Jr the instructions of the Purpose in Life Test. Abilene: Institute of Logotherapy Press. 
Crumbaugh. J. C.. ct al. (1980). Logothcrapy. /\di' help for prohlem drinkers. p 47. Chicago: Nelson-Hall Publishers. 
Crumbaugh, .J. C. & Henri on. R. (200 I). Ihm io discover meaninf and purpo.'it' in life jiJr the third millennium. Unpublished manuscript. 
Henrion, R. Making logotherapy a reality in treating alcoholics. 
Berkeley: Institute of Logotherapy Press, 10(2}. pp. 81 and 116. Lukas, E .. (2001 ). LogothcrapJ' u:xthook ·1 orontu: Lihc1ty Press. Webster ·s New Collcgiali: Diclionm:v. (1977 ). Springfield.. MA: G&C 
Merriam Company, pp 713. l 198. 
38 
The International Forum for Logotherapy 2002, 25 39-45 
LOGOTHERAPEUTIC TREATMENT PLANNING AND INTERVENTIONS FOR SPECIAL CONDITIONS 
Ann V. Graber 
The DiaRnostic and ,\'tatistico/ \Janual of ,\fcntu/ Disorders. Fourth Fdition. /hereafter ahhreviatcd DSM-IV) outlines conditions that may he a focn:-; of clinical attentilm. They foll into two catl'goric'.;. hoth arc coded V62.89: ( l) Religious and Spiritual Problem ldistressing prnhlcms associated with: loss of faith. questioning of faith. or conversion to a new foi th]: and ( 2) Phase of Life Problem fprohkms ass()ciated with developmental phase (e.g., leaving parental home) or other life circumstance (e.g .. marriage. divorce. retirement) that is not due to a mental disorder! (APA l99,,1._ 
p.685). 
When a person becomes aware of having ··Rcligwus nr Spiritual Problems:' that person will usually seek help first from clergy or from mentors in his or her faith tradition. ll is relatively rare for a client to seek clinical attention fi.1r religious or sr,iritual issues from a therapist except as a last resort. 
However. when the DSM-IV designation V62.89. "Religious or Spiritual Problems'" is seen in conjunction with "Phase of Life Problems." also categorized as V62.89. then religious and spiritual issues often go hand-in-hand with problems related to: leaving parental control. entering college. starting a new career. relocation. changes involved in marriage. divorce. loss of health. and retirement. 
Any phase in life that brings about major change and adjustment. which threatens our existential paradigm. may bring religious or spiritual issues up for rcvie\v. Logothcrapy has much to offer the client 

39 
struggling with the above named problems. When logotherapy is used :.is the primary intervention, it is well to remember the process leading to a meaning-centered outcome as outlined by Dr. Elizabeth Lukas in iifeaningful Living ( 1986, 27-39): 
1. Distancing from Symptoms through: 
Socratic Dialogue Paradoxical Intention ( where applicable) Dereflection Supplemental techniques compatible with logotherapy 
principles 
2. Modification of Attitudes: 
The Socratic dialogue, employing maieutic questions, serves the logotherapist well to activate the defiant power of the human spirit, and to help the client find new insights leading to a change in outlook. 
3. Reduction of Symptoms: Will follow as a result ofthe above mentioned interventions. 
4. Orientation toward Meaningful Activities, Experiences, and Attitudes: 
This is a crucial step; without it, the long-term goal of lasting change is difficult to achieve. 
At this point, pertinent case material will be presented to show by example how logotherapeutic interventions were applied to bring about a meaning-centered outcome for the DSM-IV designation V62.89: Religious or Spiritual Problem and Phase of Life Problem. 
Case Presentation 
Client Profile: 
Client is a 62-year-old male. He is a Catholic order priest with counseling expertise. Client was active in parish work and prison ministry until he suffered a heart attack the previous year. Since that time he has been languishing in despondency without motivation for 
40 
doing anything. He is under physician's care and was referred by his psychologist. (Henceforth, we will refer to the client pseudonymously as Fr. Joseph.) 
Reason for Referral: During a professional seminar a colleague. a psychologist. who was seeking help for one of his clients, approached me. This client. he explained. was a Catholic order priest who had suf1ered a heart attack. Although he was making a good recovery medically. he was despondent --going through the motions of living without being alive. His community was concerned and had sought help for his psychological malaise. 
My colleague had tried numerous interventions to no avail. Discouraged. he asked me if I would see his priest client, hopinµ that logotherapy could make a difference where other interventions had yielded little measurable improvement. 
Initial Assessment and Logotherapcutic lnttTycntion: When I met Fr. Joseph in the office. my initial impression was: Here is a noble soul -caught in an existential vacuum. He seemed to be at ease and readily told me how he began his religious formation at the pre-seminary level as a student at age 14. He liked the high ideals. which his religious order espoused. I le entered the religious life as a very young man and. in time. became a priest. For more than four decades he perfrmned the duties assigned to him faithfully and unquestioningl_y Then his heart stopped. 
Since his heart attack. he had been reviewing his life: questioning the value of some of the rules he had lived by: and fearing he would have another heart attack. 
I asked him if having another heart attack was his greatest fear. lie answered, "No. not the heart attack. per sc. But if that were the end. I'd stand there before God \vith my emptiness. \\iih no return on His talents he had entrusted to me '' 
41 
When I tried to point out his long years of faithful service as a priest, he brushed it aside, saying firmly, "I did my duty!" Then l asked him vvhat specific talent he felt he had been given by God that could yet he increased'.' A smile spread slowiy across his face. Shyly he said, "Somdimes l fancied myself a painter.... Oh, I've had art classes here and there, but there has never heen enough time to devote to painting." 
I suggested that perhaps now, while he was convalescing, there could be time made available for painting. He nodded thoughtfully. saying, "Ycs, I could take my easel and move into our hem1itage for a while and just paint. Yes .... I'd like that!" 
At last, I detected a spark ol' aliveness returning with the anticipation of a personally meaningful creative endeavor ahead. Noodynamic tension was being activated. lkre was something freely chosen that he warned to do; something that was not subject to compliance \Vith extrinsic rules. hut had intrinsic value for him. 
For several months Fr. Joseph paintt~d. Off and on. when he ,vas in town. he came to sec me. A transfonnative change was obscrvabk in him. On his last visit he described his experience \\hilc painting in this way: "You kno½. as a member or a religious order. prayer has played an important role rn my Ii re. I've prayTd for people. I've prayed with people. Prayer has been my way of cormnunicating wilh God and others. But this is different' \Vh:.:n I'm totally imml.'.rscd in painting. il's beyond communication. !l's like being in total communion \.\.ith my Creator and his entire ,'rrntion Ah..., if this is what heaven is ltkc. l'rn ready.'' 
Logotherapeutic Treatment Plan 
Short-tem1 gQ,!l_s: lkve!op meaning-centered strategics to reduce or eliminate behavior of lack of initiative. lethargy. fear of dymg empty-handed of another heart attack. 
42 
Long-term goals: Resoh t: noogcnic conflict which KL'l'fb him locked in ambiguity an<l despondenc) of existential vacuum. Client needs to he helped to cm ision vvho he may yet hen)mc. 
Strengths: Above awrage ]Q, keen spiritual awareness. authenticil). insightfulne'.'is. latent creativity. humility that manifosts as willingness to tr; recommendations made by IPgo1herapist. 
Initial Diagnosis: DSM-IV. Condition \'62.89: Phase of Life Problems. exacerbated h:, Reli~ious and Spiritual Problems 
Case Review: Application of Logotherapcutic Interventions Distancing from symptoms \, as brought about tbrnugh the ~0~._:nrtil: dialogue and maicutic 4ucstioning. Fr. Joseph t\.',hlil) t.' 11tcrcll rnlo ct dialogue that revealed the nature and the ,kpth of hi:--di!1..:mma. StJKC his doubts rcvohcd aruund questioning religious ruks. rather than spiritual values. it \Vas a matter of prioritiLing and son ing out \\ hat \\ a:-ccntral and what \\as peripheral for him. I2_~rcjli.;:1.:J11JJJ from h) perreflecting on his fears \\as achineJ through rinding a Ill'\\ focus painting. 
Modification of attitudes was primaril) brought about h) continuing the Socratic dialogu~ in ways that acti\ated the defiant po\\l'f uf tlJL· human spirit (Frankl. 1967. p. LB). The therapis(s attcnti,c listcmnl:' resulted in Fr. Joseph gaining new insights that kd to a changL' in outlook. Supplemental technique involved the usc of imagery tapes that helped client get in touch vvith his artistic side and fostered expanded av;areness (Graber & T\fadsen. 1995. audio cassette album). 
Reduction of symptoms could be observed with each visit. The joy of living was returning as he immersed himself in doing something he loved to do: a talent that had been yearning for expression was finding an outlet through painting. He was realizing a creative value (FrankL 1986. p. 117). By his fourth visit he \Vas far more cager to talk ahout his latest work on canvas than about his fears of ha\ ing another heart attack. 
43 
Orientation toward meaningful activities, experiences, and attitudes occurred when Fr. Joseph was able to ponder his long-term goals after finding meaning and fulfillment through realizing creative values through this artistic endeavor. We discussed life's transitoriness and our inescapable mortality (Frankl, 1959/1984, p. 143). Now he could face the thought of dying someday because he would no longer stand before God "in my emptiness with no return on His talents." He felt, in his own way, he was finally giving expression to a talent entrusted to him. 
Addendum: Fr. Joseph was late for his next scheduled appointment, which was very uncharacteristic for him. After waiting for some time, I called to see if he was on his way. A reluctant voice on the telephone told me, "No, he is not. Fr. Joseph will not be coming any more. He died of a massive heart attack yesterday." 
Case Summary 
In the foregoing example we saw a person suffering an inner emptiness, indulging in fatalistic thinking and experiencing an existential dread (fearing another heart attack). In his psychological malaise he exhibited a lack of initiative and general apathy. Conformity to unexamined values eventually led to a noogenic conflict, which Dr. Frankl termed "the existential vacuum" (Frankl, 1959/1984, p. 128). In this case, the condition involved "Phase of Life · Problems" brought on by a dramatic change in health. It also brought to light "Religious and Spiritual Problems," the questioning of religious values that were present for a long time, perhaps, but were never consciously addressed. Both of these conditions could be treated under the DSM-IV category V62.89. 
The client was seen for five sessions during a 3-months period and 
treated logotherapeutically as described in the "Case Review: 
Application of Logo therapeutic Interventions." In the end, not only the 
client's short-term goal of getting past his despondency, but also his long-term goal, if not life-long goal, of "communion with God and all His creation" was achieved -in this client's unique way. The client's 
44 
reservoir of strengths was tapped to bring about the transformation through immersion in creativity, thereby realizing a meaningful and cherished life goal. 
Empirically measurable outcome criteria is not available. This case is anecdotal. But I would like to include comments from client's religious superior that should be considered in substantiating treatment outcome. In a letter received shortly after Fr. Joseph's death, his religious superior stated that members of his community had commented to him that a noticeable change had occurred in Fr. Joseph during the weeks preceding his death: his despondency had lifted, and he had died in peace. 
Ann V. Graber, D. Min, Diplomate and Faculty Member of the V,. tor Frankl ,nstit!lte of Log:\thc:rapy, is in private prt(~1ce ,!S a Pastoral Counselor. She initiated the Distance Learning program for the Viktor Frankl Institute and currently serves as its Director. (E-mail: LTDistLmg@AOL.com) 
References 
American Psychiatric Association ( 1994) Diagnostic and Statistical 
(4th
Manual of Mental Disorders, ed.). Washington, DC: Author. 
Frankl, V. E. (1959/1984). Man's Search for Meaning. New York: Washington Square Press. 
Frankl, V. E. ( 1967). Psychotherapy and Existentialism. New York: Washington Square Press. 
Frankl, V. E. (1965/1986). The Doctor and the Soul. (3 rd edition). New York: Vintage Books. 
Graber, A.. Madson, M. ( 1995). Images of Transformation (Audio cassette album) Rochester, MI: Fountain Publishing. 
Lukas, E. (1986). Meaningful Living. The Institute of Logotherapy. 
45 
The International Forum for Logotherapy, 2002, 25, 46-51. 
A LOGOTHERAPEUTIC APPROACH TO THE TREATMENT OF OBSESSIVE-COMPULSIVE DISORDER 
Geoffrey Hutchinson 
Obsessive-compulsive disorder (OCD) is a lifelong anxiety disorder that hits about 2 percent of Americans, roughly about 5 million people (Robins & Regier, 1991 ). People plagued with OCD often have obsessions, described as intrusive ~tress-producing thoughts, and many engage in ritualistic behaviors designed to decrease anxiety, commonly known as cornpulsions. OCD has tradi rional ly responded well ro behavior therapy and the use of sclecti, e serotonin reuptakc inhibitors (Steketee, Pigott, & Schemmel, 1999). However. there i~ still a minority of patients who are treatmentresistant or achieve limited gains, especially when they suffer exclusively from obsessions (Jenike & Rauche, 1994; Salkovskis & Westbrook, 1989). It is this author's view that logotherapy can offer hope to patients afflicted with OCD, especially when other fr1rms of therapy offer limited success. 
Creative, Experiential, and Attitudinal Values 
In order to reorient themselves to the outside world and cut down on obsessions, OCD sufferers may benefit from actualizing their creative and experiential values. Frankl contended that human beings can not only "enrich the world by our actions," but also "enrich ourselves by our experience" (Frankl, 1986, p. 45). Experiencing the riches of life, such as music, art, poetry, nature, and social gatherings, can help OCD sufferers reduce the depression that often accompanies their disorder. OCD sufferers also can be challenged to become creatively absorbed in new tasks and to write down positive aspects of their world in a daily journal. Decreasing depression in OCD sufferers 

46 
also may help them respond better to behavioral treatments designed to reduce their compulsive symptoms (Tallis, 1995). 
People with OCD often feel like slaves to their disorder and often feel like they have little control over their symptoms. Therefore, OCD sufferers need to be challenged to accept their disorder with dignity and courage, and yet to take a stand against their symptoms by living a meaningful life. Frankl refers to this as the attitudinal value, which can be the highest or ultimate way a human being can find meaning (Lukas, 1986). People with OCD can tum their tragedy into triumph by transcending their own need to be obsession-free, and become a tower of strength for others. They may have a unique ability to relate to people who face all types of "unfair" circumstances in their life by sharing how they deal courageously with their inner turmoil. Interestingly enough, this self-transcendent motivation may buffer them from forming new obsessions and compulsions as well. 
Craziness and Humor 
One of the core components of OCD is that people afflicted with this disorder often fear they are "crazy." They believe that their obsessions will make them dangerous or immoral, and that they will act out on these thoughts. OCD sufferers are not aware that many people who do not have OCD also have many random, nonsensical thoughts, and yet are able to live productive lives. Logotherapists may wish to present OCD clients with a list of "intrusive thoughts" gathered from a community sample of people who do not present for therapy to show them that their thoughts are not that abnormal (Freeston, Rheaume, & Ladouceur, 1996). Once this fear is reduced, logotherapists can continue helping OCD clients change their attitude toward their disorder. The goal is to have the OCD client develop a relaxed attitude toward his or her symptoms. This can include using humor to ridicule the symptoms, and to help the client ultimately laugh at him or herself. 
OCD sufferers are encouraged to use humor to creatively distance themselves from their symptoms, such as singing their obsessions or replacing frightening images with fanciful cartoons (Foa & Wilson, 1991). They also can gain some control over their symptoms by making a paradoxical wish to face the "fateful event" that is causing them so much anxiety. OCD sufferers can face their obsession for 
47 
extended periods of time, until they have become habituated to their fears (Foa & Wilson). Over time, the obsessions may begin to diminish as the person learns that these thoughts are not that scary. Once the person's fear begins to decrease, the person with OCD can disengage him or herself from the obsessions, and fulfill life tasks that are awaiting him or her. 
Dereflection 
Dereflection also can serve as a good buffer against hyperreflection and hyperintention. It is all too tempting for people with OCD to want to fight their obsessions, often by engaging in an extensive analysis of what these thoughts might "really mean." Unfortunately, the more the person "gets involved" with the obsessions, the more the obsessions may persist and perhaps intensify. In this case, the person with OCD over-concerns him or herself with the obsessions and misses the meaningful opportunities of life that are presented to him or to her. OCD clients are notorious hyper-reflecters in this sense, and often spend a considerable amount of time trying to "fix" their OCD. In fact, OCD represents a pathological human phenomenon that is often seen on a sociological level. Frankl (2000) alluded to this when he wrote about the world's general obsession with self-interpretation. 
For OCD sufferers, dereflection can help them decenter their obsessions as they fulfill meaningful tasks. As the person with OCD begins to accept the obsessions as part of fate and becomes involved in life tasks, the symptoms may begin to remit. The OCD client even may learn to ignore the obsessions as he or she focuses on concrete goals. As these goals are fulfilled, OCD clients may feel happier, and overall decrease the dysphoria connected with their disorder. If the obsessions feel too distracting as he or she is pursuing goals, the person may want to postpone them until a later time, perhaps until a scheduled "worry time." The person may wish to delay the thoughts for increasing amounts of time, starting as little as 5 minutes and working up to several hours (F oa & Wilson, 1991 ). During these periods of delay, the person also could focus on self-transcendent tasks, that is, activities designed to benefit others. 
Schwartz ( 1996) developed an excellent self-help behavioral program used to reduce obsessions and compulsions. Interestingly 
48 
enough, it has some striking parallels to the logotherapeutic concepts of dereflection and value actualization. In his program, people with OCD are instructed to attribute their symptoms to their medical disorder (OCD) and not to their Self. This resembles logotherapy's position that in the spirit the human being "is" never sick, even though he or she may "have" a sickness. Schwartz also encouraged people to note their level of anxiety at the time their desire to obsess or compulse is prominent. He recommended that they not give in to the OCD, but rather fill the next 15 minutes or so with a task they enjoy. After this time, people should notice their anxiety has decreased, along with their desire to perfonn their original compulsion. After repeated attempts, people with OCD should be able to switch gears, in a sense, and ·'unlock" their brains, breaking the compulsive rituals. 
It is the author's contention that Schwartz's (1996) approach is a type of dereflection. OCD suffers can begin to disengage from their habitual mental ruminations and prove to themselves that they can decrease their obsessions by working around them. Creating a new task or encountering a new experience for a short duration, while still feeling the effects of OCD, can show OCD sufferers that they paradoxically can control their OCD by learning not to control their OCD. The augmentation of creative and experiential values, along with the technique of dereflection, may transform the obsessions into background noise. This is consistent with Frankl 's notion that a person with OCD even may learn to ignore his or her obsessions as he or she pursues meaningful goals. Schwartz's (1996) book may prove to be an excellent resource for logotherapists attempting to treat OCD. It also has the potential to help the OCD sufferer become more self-directed in his or her approach to living with the disorder, without having to rely on the therapist for prolonged support. 
Conclusions and Future Directions 
Logotherapy can offer comfort and courage to OCD sufferers who have not faired well with conventional treatments. The use of creative, experiential, and attitudinal values can help these people not only stand bravely against their disorder, but help them derive more enjoyment and fulfillment out of their lives. In particular, they can learn to experience the world despite their disorder and become a tower of strength for others. Logotherapy also can help OCD sufferers 
49 
develop a sense of humor, teaching them that they are not "crazy" as is often believed, but often suffer from thoughts that befall all of humanity. Learning to accept the disorder and dereflecting from the obsessions also are key components to living with the disorder. When people postpone their thoughts and become involved in meaningful, purposeful goals often designed to help others, they may be able to decrease their excessive brooding. Ultimately, as the OCD sufferer begins to focus on the meaning fulfillments that await him or her, the obsessions may decrease and possibly remit. 
Logotherapy may wish to examine other areas related to the "obsessive compulsive spectrum." This spectrum includes disorders that have many features similar to that of OCD, such as body dysmorphic disorder, hypochondriasis, and eating disorders. Logotherapists may wish to use similar Franklian concepts to offer relief to these clients who may have received limited gains elsewhere. Logotherapy also could explore the themes of hyper-responsibility and scrupulosity ( excessive religiousness) that permeate the lives of many OCD clients. Logotherapy may prove to be one of the best therapeutic modalities to study these concepts, given its existential therapeutic nature and its sympathy towards moral and religious values. 
In sum, the author believes that logotherapy may have some powerful philosophical and technical advantages over other therapeutic modalities, and can serve as a powerful adjunct to conventional therapies used to treat OCD. Its treatment incorporates the use of creative, experiential, and attitudinal values, a sense of humor, paradoxical wishes, dereflection, and acceptance of the disorder. 
GEOFFREY HUTCHINSON, MS All correspondence should be directed to: Geoffrey Hutchinson, University of North Texas, Department of Psychology, P.O. Box 311280, Denton, TX 762031280. Main Office: (940) 565-2671 
50 
References 
F oa. E., & Wilson, R. (199 I). Letting go of worries and obsessions. (pp. 79-104). Stop obsessing· How to overcome your obsessions and compulsions. New York: Bantam Books. 
Frankl, V. E. (1986). The doctor and the soul. (4th edition). New York: Vintage Books. 
Frankl. V. E. (2000). Man's search for ultimate meaning Cambridge, Massachusetts: Perseus Publishing. 
Freeston, M. H., Rheaume, J., & Ladouceur, R. ( 1996). Correcting faulty appraisals of obsessional thoughts. Behaviour Research and Therapy, 14. 433-466. 
Jenike, M. A., & Rauch, S. L. (1994). Managing the patient with treatment-resistant obsessive compulsive disorder: Current strategies. Journal ofClinical Psychiatry. 55, 11-17. 
Lukas. E. (1986). Meaning in suffering. Berkeley, California: Institute ofLogotherapy Press. 
Robins, L. N., & Regier, D. A. (Eds.). (l 991 ). Psychiatric disorders in America: The epidemiologic catchment area study. New York: Free Press. 
Salkovskis, P. M., & Westbrook, D. (1989) Behaviour therapy and obsessional ruminations: Can failure be turned into success? Behaviour Research and Therapy, 27, 149-160. 
Schwartz, J. (1996). Brain lock: Free yourself from obsessivecompulsive behavior. New York: HarperCollins Publishers, Inc. Steketee, G., Pigott, T. A., & Schemmel, T. (1999). Obsessive compulsive disorder: The la/est assessment and treatment strategies. Kansas City, MO: Compact Clinicals. 
Tallis, F. (1995). Obsessive compulsive disorder: A cognitive and neuropsychological perspective. New York: John Wiley & Sons. 
51 

The International Forum for Logotherapy, 2002, 52-59. 
LOGOTHERAPY AND CONDUCT DISORDER 
Stefan E. Schulenberg 
Conduct disorder is a danger to society in terms of its pervasive impact on people and property.20 Conduct disorder is a complex cluster of behaviors that involves aggression towards others (e.g., initiating fights), property destruction (e.g., fire setting), deceitfulness/theft (e.g., shoplifting), and serious rule violations (e.g., running away).1 
The purpose of this article is to describe how logotherapy may aid in the understanding and treatment of conduct disorder. Although the diagnosis of conduct disorder applies to both children and adolescents, this article is written with the adolescent in mind. It should also be noted that conduct disorder (a mental health diagnosis) is not necessarily the same construct as juvenile delinquency (a legal term), although both overlap in that they involve 
14
antisocial acts. 
Understanding Conduct Disorder 
Youths diagnosed with conduct disorder may also have a variety of related problems. These may include poor interpersonal relationships (with parents, teachers, peers), problems with school performance/ academic achievement, and deficiencies in problem-solving and social 
15
skills (e.g., misinterpreting social cues).14' Perhaps because of the many areas of functioning directly influenced by conduct-disordered behavior, treatment is a comflicated process that 
6
has been described as an "unproven territory"16 ' p. despite a variety of treatment modalities (psychopharmacology, individual therapy, group therapy, family therapy).16 However, more recently, it has been noted that treatments for conduct disorder have significantly advanced, with a variety of promising treatments available (parent management training, problem-solving skills training, functional family therapy, and multisystemic therapy).15 
Working with the family structure can sometimes be effective, but this intervention may be complicated by the abusive/neglectful/chaotic nature of some families, necessitating more patience, flexibility, and creativity on the part of the therapist.16 Parents of youths diagnosed with conduct disorder are more often inconsistent in their discipline styles, tend to 
52 
exhibit poor child supervision practices, are more likely to experience discord in their marital relationships, and to experience psychiatric
14 15
problems of their own. · A history of childhood physical and sexual abuse also appears to be associated with conduct disorder.20 
Many teenagers diagnosed with conduct disorder have other psychiatric problems, such as major depression, schizophrenia, substance abuse, anxiety disorder, attention deficit/hyperactivity disorder, and posttraumatic stress disorder. 16 Readers further interested in the complexities of conduct disorder are referred to Quay and Hogan's
15
Handbook ofDisruptive Behavior Disorders 19 and the work of Kazdin. 14· 
Conduct Disorder: A Logotherapy Case Formulation Approach 
"A psychotherapy case formulation is essentially a hypothesis about the causes, precipitants, and maintaining influences of a person's psychological, interpersonal, and behavioral problems."7· P-1 The case formulation is important because it organizes information, guides treatment, and facilitates understanding of the client on the part of the therapist.7 The case formulation approach targets the core of why a person behaves the way they do, and the "nature of this hypothesis can vary widely depending upon which theory of psychotherapy and psychopathology the clinician applies."7• P-2 How, then, might logotherapy aid in the understanding and treatment of conduct disorder? 
Logotherapy and the Existential Vacuum 
One of logotherapy's main principles is that a person needs to strive toward meaningful activity, and if a person's participation in meaningful activity is blocked or thwarted in some way then existential vacuum (feelings of meaninglessness) may result. The main manifestations of existential vacuum are boredom and apathy.9 
Fabry noted many maladaptive ways that people try to deal with their existential vacuum (defying authority, sex, alcohol, watching television).8 He also noted that the problem of existential vacuum, or a feeling of inner emptiness, is prominent among youth. Given that defiance of authority and related constructs such as violating rules and the rights of others are aspects of conduct disorder, the question arises: Do some youths use conduct-disordered behavior to fill their inner emptiness when their Will to Meaning is frustrated? 
In some cases it may be that conduct-disordered behaviors are used to fill the existential vacuum; however, it is more likely that conductdisordered behaviors are related to the Will to Pleasure ("I will do this because it feels good") or the Will to power ("I will hurt them so they cannot hurt me"), instead of the Will to Meaning. Conduct-disordered behaviors may temporarily serve to artificially fill the inner void, but 
53 
because they are not a genuine means, they will not suffice as a method of achieving authentic meaning. This lack of authentic meaning may serve to perpetuate further maladaptive behavioral/emotional expressions in a vicious cycle where further conduct-disordered behaviors are demonstrated as an ineffective means of dealing with existential vacuum. 
Logotherapy suggests that there is hope for youths with conduct disorder. For instance, in his work with male juvenile delinquents (the legal term), Barber noted that people have the ability to change through their ability to make choices; that is, they can choose who they are and who they will become.2 During adolescence, youths make important decisions about their identity. Logotherapy may be an effective means of assisting youths with developing their sense of who they are through its emphasis on taking a positive attitudinal stance. Logotherapy empowers youths to make positive changes should they choose to do so. Barber concluded that there is a significant relationship between a person's selfconcept and their values, with changes in self-concept and value structure being critical components to a successful intervention.2 Working with self-concept and the process of valuing are core strengths of logotherapy. 
Conduct Disorder and the Mass Neurotic Triad 
Although there are multiple variables influencing the development of conduct disorder (genetic, environmental), logotherapy emphasizes the individual's internal state. From the existential vacuum comes the mass 
11
neurotic triad of addiction, depression, and aggression.10· Conduct disorder is clearly aggressive behavior, and therefore these behaviors 
i 
may, at least in part, be an expression of the existential vacuum. Frankl noted that "people are most likely to become aggressive when they are caught in this feeling of emptiness and meaninglessness."11' P-104 Barber, as cited by Frankl from Barber's work with juvenile delinquents, indicated that meaninglessness is "a decisive factor driving youth to criminality"10• P69 Barber demonstrated that juvenile delinquency may be effectively 
10 11
treated with principles of logotherapy.2· · However, Barber's program was reportedly eclectic, relying on non-logotherapy principles as well.2 
From the logotherapy perspective, the underlying dynamic of aggression is despair, and people use violence in their despair in an attempt to control other people.2 Despair also underlies depression and addiction, and also helps to explain the co-morbidity between conduct disorder, substance abuse/dependence problems, and depression. The logotherapy curriculum indicates that the "etiological factor of underlying despair needs to be addressed, not just the presenting symptoms, to 
54 
bring about a lasting change. The person needs to be helped to choose a life with meaning that will replace the existing despair."12 
Given that the existential vacuum may play a role in the development of conduct disorder, what are the ways to adaptively deal with the existential vacuum? Lukas17 noted that dealing with the existential vacuum is one of the times that logotherapists explore a client's past in depth, in order to discover old avenues to meaning that may be used to lead to meaningful activity in the present. Lukas further noted that the purpose of exploring the past is not to relive unsuccessful experiences, but rather to discover meaning through asking questions (e.g., What was meaningful in the past for the client?). Thus, in the case of logotherapy as applied to conduct disorder, exploring the client's past, posing questions, and teaching the client to ask his or her own questions are ways to ameliorate symptoms more effectively and in more meaningful ways. 
Given that logotherapy concepts are applicable to conduct disorder in certain instances, how might such an intervention be applied? 
Conduct Disorder and the Phases of Logotherapy 
The phases of logotherapy have been described as self-distancing from symptoms, changing attitudes from negative ones to positive ones, reducing symptoms, and securing the client's mental health for the future.a 
Self-distancing from Symptoms 
Logotherapy's emphases on finding meaning, participating in meaningful pursuits, making adaptive choices, being responsible, and the uniqueness of each human being foster a strong and positive relationship between client and logotherapist. Although the nature of the therapeutic relationship is important for a positive outcome, it is especially critical when working with someone diagnosed with conduct disorder. These youths are often resistant to participating in therapy, and may be particularly difficult to engage. Logotherapy regards the client as an important person in his or her own right, not just as a cluster of symptoms. This is important because it is not desirable for the person with conduct-disorder to over-identify with the diagnosis. These youths may be mislabeled a "bad kid", a "juvenile delinquent", or a "criminal", but this does not have to be the case. Clients are free to take a stand, to act in more meaningful ways. Those diagnosed with conduct disorder are human beings who choose to express harmful acts. The logotherapist may help these youths to learn the importance of making responsible and meaningful decisions. The logotherapist does not accomplish this through persuasion. Persuasion may instill in clients a sense of resistance.a Instead, techniques such as Socratic Dialogue become increasingly 
55 
important, for as clients answer questions posed by the therapist they develop their ability to come to their own conclusions. These conclusions tend to be stronger if realized by themselves, not through the interpretations of therapists. 
Changing Attitudes from Negative Ones to Positive Ones 
"Once patients have gained distance from their symptoms, they are open to new attitudes toward themselves and their lives."8· P-132 Fabry noted that the new attitudes are not forced upon clients; rather, the therapist seeks from the client signals of a direction that the client might like to take. Even if choices do not work out, then the client has at least learned that there are choices that may be made.8 In the case of youths with conduct disorder, they may be redirected toward more meaningful pursuits, such as participation in school or after-school employment opportunities. Youths have the ability to become more open to learning how their attitudes create opportunities to discover authentic meaning. 
Reducing Symptoms 
Fabry noted that once a change of attitudes has been fostered, then symptoms become more manageable.a Youths with conduct disorder, once they learn that authentic meaning may be achieved through more adaptive pursuits, may be able to achieve a measure of success in their endeavors. Being more successful in work, school, and relationships may enhance self-esteem, decrease feelings of negative affect, and improve sense of purpose. These youths may also learn that in order to gain respect from others they must learn to respect themselves and other people. Moreover, they may benefit from an increased ability to make decisions that are adaptive, positive, and meaningful. Controlling others is not desirable because it is manipulative and pathological, and does not lead toward the discovery of meaning. If clients are able to self-distance from their behaviors, and they are able to express positive attitudes, then logotherapy posits that conduct-disordered behaviors should decrease. 
Securing the Client's Mental Health for the Future 
The final stage of logotherapy involves teaching clients to assume responsibility, to use their time and energy in more meaningful ways.a For the client with conduct disorder, participating in meaningful activities such as after-school employment, extra-curricular school activities, sports, volunteer work, and/or helping out more around the house are desirable activities because they may enhance sense of purpose, selfesteem, and orientation toward assisting others (self-transcendence). Problem-solving and social skills training may further assist clients with navigating their environments with greater effectiveness as they learn to 
56 
overcome encountered obstacles as they strive to participate in meaningful activity. Exploring the client's past may offer clues as to not only what is meaningful, but may lead to adaptive methods used in the past to overcome difficulties. 
Suggestions for Future Research 
It is imperative that researchers investigate constructs of meaning in youths with conduct disorder. Do these youths experience feelings of meaninglessness, and, if so, to what degree? Are certain aspects of conduct disorder more strongly associated with feelings of meaninglessness than others? Do people with conduct disorder have statistically significant differences in life purpose than persons not exhibiting conduct disorder? Logotherapy instruments such as the Purpose-in-Life test6 and the Life Purpose Questionnaire13 are potential means for conducting research with this population. 
Barber2 found that a program that incorporated principles of logotherapy, designed for males adjudicated as juvenile delinquents (Anglo-White, Mexican American, and African American 15 to 18 year olds), improved Purpose-in-Life test scores over a 6-month period (a mean change of 86.13 to 103.46). However, the number of participants was relatively small ili = 15), and the data applied to the legal designation of juvenile delinquent, not necessarily to conduct disorder. This study should be replicated with youths with conduct disorder. The number of participants should be much larger, with a wider range of demographic background variables being studied. The increase in the number of participants tends to allow for greater power in making statistical inferences. Once norms for logotherapy instruments have been established for populations diagnosed with conduct disorder, then these measures may become useful adjuncts to the clinical assessment of conduct disorder, and they may have efficacy with regard to providing benchmarks for the effectiveness of the therapeutic intervention. 
Although there is a clinical rationale to use logotherapy with conduct disorder in certain cases, the extent of logotherapy's potential effectiveness in the treatment of conduct disorder has not been empirically established. Outcome studies must be conducted to this end. An outcome study is a "systematic investigation of the efficacy of a therapeutic technique, or of the comparative efficacy of different 
680
techniques, with one or more disorders."5· p. Outcome studies should include evidence of the effectiveness of logotherapy at the termination of treatment, as well as long-term effectiveness. How well does logotherapy work with conduct disorder? Does logotherapy achieve better treatment results when combined with other approaches (e.g., parent-management training), and, if so, which ones? Moreover, which modalities of 
57 
logotherapy (individual therapy, family therapy, group therapy, milieu therapy) tend to be most effective, and in what combinations? Conduct disorder is a problem that affects so many areas of functioning that it is unlikely that a single treatment approach or modality
15
will be effective.14· A proliferation of outcome studies investigating the impact of principles of logotherapy on conduct disorder (and other mental health problems) is warranted. Such studies may also assist logotherapy in becoming a part of the growing empirically-validated treatment literature for mental health problems? 4· 18 
STEFAN E. SCHULENBERG [SESchulen2@aol.com] received the Ph.D. in Clinical Psychology with a specialization in Clinical/Disaster Mental Health from The University of South Dakota in December of 2001. He currently lives and works in Rock Hill, South Carolina. The author would like to acknowledge Carrie Nassif, M.A., for her assistance with editing this article. 
References 
1. 
American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. 

2. 
Barber, L. S. (1979/1995). Juvenile delinquents. In J. B. Fabry, R. 


P. Bulka, & W. S. Sahakian (Eds.), Finding meaning in life: Logotherapy (pp. 213-223). Northvale, New Jersey: Jason Aronson, Inc. 
3. 
Bergin, A. E., & Garfield, S. L. (EdsJ (1994). Handbook of psychotherapy and behavior change ( 4 h ed.). New York: John Wiley & Sons, Inc. 

4. 
Chambless, D. L. (1998). Empirically validated treatments. In G. P. Koocher, J. C. Norcross, & S. S. Hill, Ill (Eds.), Psychologists' desk reference (pp. 209-219). New York: Oxford University Press. 

5. 
Corsini, R. J. (1999). The dictionary of psychology. Philadelphia, PA: Brunner/Maze!. 

6. 
Crumbaugh, J. C., & Maholick, L. T. (1964). An experimental study in existentialism: The psychometric approach to Frankl's concept of noogenic neurosis. Journal of Clinical Psychology, 20, 200-207. 

7. 
Eells, T. D. (1997). Psychotherapy case formulation: History and current status. In T. D. Eells (Ed.), Handbook of psychotherapy case formulation (pp. 1-25). New York: The Guilford Press. 

8. 
Fabry, J. B. (1994). The pursuit of meaning: Viktor Frankl, logotherapy, and life (New rev. ed.). Abilene, TX: Institute of Logotherapy Press. 


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9. Frankl, V. E. (1988). The will to meaning: Foundations and applications of logotherapy (Exp. ed.). NY: Meridian. 
10. 
Frankl, V. E. (1992). Meaning in industrial society. The International Forum for Logotherapy, 15, 66-70. 

11. 
Frankl, V. E. (1997). Man's search for ultimate meaning. New York: Insight Books, Plenum Publishing Corporation. 

12. 
Graber, A. V., & Rogina, J. M. (2000). Logotherapy-lntermediate "B'': Viktor Frankl's logotherapeutic model of mental health. The Viktor Frankl Institute of Logotherapy, Box 15211, Abilene, TX 79698-5211 . 

13. 
Hablas, R., & Hutzel!, R. R. (1982). The Life Purpose Questionnaire: An alternative to the Purpose-in-Life test for geriatric, neuropsychiatric patients. In S. A. Wawrytko (Ed.), Analecta Frankliana (pp. 211-215). Berkeley, CA: Strawberry Hill. 

14. 
Kazdin, A. E. (1994). Antisocial behavior and conduct disorder. In 


L. W. Craighead, W. E. Craighead, A. E. Kazdin, & M. J. Mahoney (Eds.), Cognitive and behavioral interventions: An empirical approach to mental health problems (pp. 267-299). Boston: Allyn and Bacon. 
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Kazdin, A. E. (2001 ). Treatment of conduct disorders. In J. Hill (Ed.), Conduct disorders in childhood and adolescence: Cambridge child and adolescent psychiatry (pp. 408-448). New York: Cambridge University Press. 

16. 
Lock, J. (1996). Disruptive behavioral disorders. In I. D. Yalom (General Ed.) & H. Steiner (Vol. Ed.), Treating adolescents: A volume in the Jossey-Bass library of current clinical technique (pp. 43-76). San Francisco: Jossey-Bass Publishers. 

17. 
Lukas, E. (2000). Logotherapy textbook: Meaning-centered psychotherapy (T. Brugger, Trans.). Liberty Press: Toronto. (Original work published 1998) 

18. 
Nathan, P. E., & Gorman, J. M. (Eds.). (1998). A guide to treatments that work. New York: Oxford University Press. 

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Quay, H. C., & Hogan, A. E. (Eds.). (1999). Handbook of disruptive behavior disorders. New York: Kluwer Academic/Plenum Publishers. 

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Schulenberg, S. E., & Soundy, T. (2000). Epidemiology of physical and sexual abuse in young persons diagnosed with Conduct Disorder: A retrospective chart review. South Dakota Journal of Medicine, 53, 29-32. 

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Welter, P. R. (1995). Logotherapy-lntermediate "A": Franklian psychology and logotherapy. The Viktor Frankl Institute of Logotherapy, Box 15211, Abilene, TX 79698-5211. 


59 
The International Forum for Logotherapy, 2002, 25, 60-67. 
LOGOTHERAPEUTIC MASTERY OF GENERALIZED ANXIETY DISORDER 
Julius M. Rogina 
The experiences of anxiety have puzzled philosophers and clinicians alike for many years (Kierkegard, 1940; May, 1950; Beck, 1985). Neurophysiologists in recent times have taken the phenomenon of anxiety to the molecular levels (www.clinicalevidence.org). The development of pharmaceuticals for the successful treatment of anxiety disorders attests to the clinical significance of molecular sciences research. 
The literature about human experiences of anxiety is abundant in the fields of humanities and social sciences as well as medicine. The Norwegian painter Edward Munch profoundly expressed it also, beyond words, in his famous painting "The Scream." In fact, the word anxiety has become a household word. Even Leonard Bernstein's symphony is entitled "The Age of Anxiety." 
The central role of anxiety in motivational theories is evident for a learning, existential, and psychoanalytic theorist. The consensus among various schools of clinical research suggests that there is such an experience of normal anxiety as well as abnormal anxiety or anxiety disorder. 
The goal of this article is to outline the Logotherapeutic treatment of abnormal anxiety and assist the patient to live with normal anxiety. 
Viktor E. Frankl published The Doctor and the Soul in English in 1955. He states the following: 
"Insofar as existential analysis of a case of anxiety neurosis 
interprets the neurosis as ultimately a mode of existence, a sort 

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of spiritual attitude, the groundwork has been laid for Logotherapy as a specific treatment" (Frankl, 1986, p.181 ). 
Generalized Anxiety Disorder Diagnostic Criteria Generalized Anxiety Disorder (GAD) is characterized by persistent and excessive anxiety and worry (American Psychiatric Association, DSM-IV-TR, 2000). The excessive anxiety and worry co-exist with the following symptoms that are difficult to control: 
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Restlessness 

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Fatigability 

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Concentration difficulties 

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Irritability 

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Muscle tension 

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Sleep disturbance 


The GAD criteria as outlined in the DSM-IV-TR warn the clinician not to confuse the GAD with other mental disorders or a medical condition like hyperthyroidism or substance induced disorders that could mimic the GAD symptoms. 
Prevalence of Generalized Anxiety Disorder 
In a community sample, the I-year prevalence rate for Generalized Anxiety Disorder was approximately 3%, and the lifetime prevalence rate was 5% (Nutt, 1998; Gale & Oakly-Browne, 2001). In anxiety disorder clinics, up to a quarter of the individuals have GAD as a presenting or comorbid diagnosis. 
Assessment of the incidence and prevalence of GAD is difficult (Gale & Oakly-Browne, 2001, p. 10). There is a high rate of comorbidity with other anxiety disorders and depressive disorders. One US study has estimated that 1 in every 20 people will develop GAD at some time during their lives. One recent non-systematic review found that the incidence ofGAD in men is only half the incidence in women. One non-systematic review of seven studies found a reduced prevalence of anxiety disorder in older people. 
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Although anxiety disorders in childhood and adolescence have received little attention from researchers until 1980, they are among the most prevalent forms of psychopathology affecting children and adolescents (Vasey & Dadds, 200 I). Further, many adult anxiety disorders have their onset in childhood or adolescence (Burke, Burke, Regier, & Rae, 1990). 
Empirically Supported Treatments for Generalized Anxiety Disorder 
There are several empirically supported treatments for GAD available. One of these programs is Mastery of Your Anxiety and Worry. It is the psychosocial treatment program for which systematic research studies indicate effectiveness (Zinbarg, Craske, & Barlow, 1993). 
Another treatment program for GAD is called Overcoming Generalized Anxiety Disorder: A Relaxation, Cognitive Restructuring, and Exposure-Based Protocol (White, 1999). "This manual brings together the most successful and effective methods of treating GAD. When people with GAD complete this type of manual-based treatment, 70 percent of them show marked improvement" (White, 1999, p.6). 
The Clinical Evidence (The international source of the best available evidence in mental health care, BMJ Publishing Group, 2001) developed by the British Medical Journal, claims that Cognitive therapy with a combination of behavioral interventions such as exposure to anxiogenic circumstances, relaxation, and cognitive restructuring is more effective than remaining on the waiting list, anxiety management alone, or non-directive therapy. They found no evidence of adverse effects. 
Medications likely to be beneficial to treat GAD are Benzodiazepines and Buspirone. Buspirone had slower onset than Benzodiazepines but fewer adverse effects. 
Certain antidepressants like imipramine, trazodone, venlafaxine, and paroxetine are effective treatments for GAD. One trial found that paroxetine was more effective than a benzodiazepine. Adverse effects 
62 
of atidepressants include sedation, confusion, and falls (Gale & Oakley-Browne, 2001, p.9) 
Logotherapeutic Protocol for Treating Generalized Anxiety Disorder 
This protocol includes five steps of meaning-centered treatment interventions. The Logotherapy principles are sometimes implicit and sometimes explicit within each step. Keep in mind that the treating psychotherapist calls attention to the resources of the human spirit in all the stages of treatment interventions. Be mindful that a protocol suggesting steps in the treatment process needs to be creatively redesigned as necessary and as clinically appropriate for the particular situation. 
First Step: Naming the Worries 
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Assist patient to name and verbalize specific worries . 

• 
Do not stay in generalized or vague worry feelings . 

• 
Name one specific worry and make it the focus of treatment. 

• 
Facilitate birthing of awareness of patient's thought processes about specific issues that ferment worries. 

• 
Explore dynamics of hostility that perpetuate the cycle of anxiety and hypervigilance. 

• 
Teach patient to observe body sensations when thinking about a specific worry. 

• 
Direct patient's attention to the noetic resources of human existence and explore the meaning potentials offered by the specific situation. 

• 
Enlarge the awareness of the noetic resources using Logodrama techniques. 


Second Step: Emptying the Worry Storms 
• 
Give handouts and provide training in cognitive skills including the meaning of catastrophising, personalizing, and probability errors. 

• 
Provide skill training in Mindfulness, Progressive Relaxation, or Autogenic Training to accomplish somatic calm and centeredness. 

• 
Provide instruction in values clarification . 


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Third Step: Noetic Anchoring 
• 
Employ Socratic Dialogue. 

• 
Engage Guidepost to Uniqueness. 

• 
Focus on Modification of Attitudes. 

• 
Search for personal Logohints. 


Fourth Step: Opening up Willingness for Meaningful Behaviors 
• 
Initiate Self-Appraisal. 

• 
Start writing Autobiography. 

• 
Use "Act as if' method for taking meaningful actions. 

• 
Initiate skill training in Dereflection. 

• 
Apply Paradoxical Intention as clinically appropriate. 


Fifth Step: Learning to Live Meaningfully with Normal Anxieties 
• 
Participate in a Logotherapy sharing group. 

• 
Develop Meaningful tasks. 

• 
Pay attention to the "Meaning of the Moment potentials" by handling tension and managing Critical Situations of apparent meaning) essness. 

• 
A waken the Defiant Power of the Human Spirit and create space daily for quiet and solitude. 


Case Presentation 
The name, location, and other identifying details of the following case have been changed in the interest of protecting confidentiality. 
Ms. G is a 43-year-old married, Caucasian female who presents for treatment of Generalized Anxiety Disorder. She has been in treatment several times in the past with different clinicians. The treatment success has been at best minimal. She has been on a variety of antianxiety medications including Xanex, Ativan, and Prozac. She reports that using the prescribed medications temporarily relieves anxiety symptoms and gives her a better sleep. 
Psychosocial history reveals a person who grew up in a dysfunctional family system. Her parents divorced when she 
64 
was 4 years old. Her maternal grandmother raised her. Verbal and emotional abuse was moderate. Her mother would disappear for months. Her father was an alcoholic with anger problems. He held a job occasionally and did not provide for his children. 
Ms. G did above average m school and completed a high school diploma. At the age of 22, she married. After a turbulent start, she adjusted to her marriage, entered couple's therapy and is presently living in a loving and committed relationship. She and her husband have two children who are in college at this time. 
She complains of frequently experiencing "debilitating anxiety" and is unable to control her worries, be that about her children's safety or her employment. She complains of sleep disturbances, of "just staying awake" and of physical tension "all over my body." "I am so unfocused, restless, and my mind goes blank. I get easily irritable and feel fatigue all the time." 
Frequently Ms. G stays home from work and spends time in bed. Lately, she reports, "I have missed work very often. I call in sick and I tell them I have the flu. I know I lie and feel terrible about it." 
The patient plays a flute and apparently has a real gift, as suggested to her by her teachers. She finds playing the flute relaxing and feels drawn to music in general. She joined a local orchestra as a flute player. "It just makes me feel very good. I enjoy being a part of people who make beautiful music." 
The Logotherapy treatment for GAD was initiated, and within the first several sessions, Ms. G was able to focus her attention and name her worries, one by one. The list was long: my children, my work, my emptiness, my cleaning the house, my projects, etc. 
65 
The patient was taught the skill of "paying attention to the noetic resources of human existence." The skill was a simple way of observing her spiritual qualities like magnanimity, gratefulness, and loving commitment to her children and her spouse. She was skillful in recognizing her resources of the human spirit. 
As we moved to the step "Emptying the Worries" of her stormy and irrational thoughts and feelings, Ms. G clarified her values about employment and about her children in particular. 
Using the Socratic Dialogue technique, she allowed herself to discover her uniqueness in the world and her unique place in the context of her life. She was able to anchor herself noetically in affirming herself as a unique individual. She was ready for the next step oftreatment. 
The willingness to pursue music and obtain a B.A. degree in this field enabled her to redesign her job into her life work. She became a flute teacher. 
She is currently not experiencing GAD symptoms as she enjoys her new found meaningful work. She enjoys scheduling her work time as meaningfully appropriate. She is reporting that she is successful in letting her children "have their own lives." She is also moving away from fearful dependency on her spouse. "I want to share equally in our expenses. Imagine, we are starting to play tennis again." 
Ms. G reports that she is living with her normal anxieties "without much trouble. I am managing them quite successfully. I take time for my quiet and solitude every day. I am starting to like my solitude. My thoughts are not racing and I am more peaceful. I enjoy being mindful. It helps me pay attention to the meaning potentials of many different situations." She also reports that her management plan includes the use of occasional sleep medications. 
The total number of treatment sessions was 19. Ms. G was a patient who seems to have grasped and to have successfully applied the Logotherapeutic Mastery of Generalized Anxiety Treatment Protocol. 
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JULIUS M. ROGINA, Ph.D., Clinical Psychologist in Private Practice, Diplomate and Faculty Member of the Viktor Frankl Institute of Logotherapy ( 427 Ridge Street, Suite A, Reno, Nevada 89501-1738 Phone (775) 324-2000, E-mail jmrogina@aol.com) 
References 
Fabry, J. (1998). Guideposts to meaning: Discovering what really matters (An Institute ofLogotherapy Press Book ed.). Oakland, California: New Harbinger Publications. 
Frankl, V. E. (1955). The doctor and the soul. New York: Vintage Books. (Original work published Arztliche Seelsorge, 1946). 
Gale, C., & Oakley-Browne, M. (2001). Anxiety disorder [The international source of the best available evidence in mental health]. Clinical Evidence in Mental Health, February (2001), 9-18. 
Kierkegaard, S. (1941 ). Sickness unto death. Princeton, NJ: Walter Lowrie. (Original work published in Danish, 1849) May, R. (1950). The meaning of anxiety. New York: Simon & Schuster. 
Nutt, D., Argyropoulos, S., & Forshall, S. (2001). Generalized anxiety disorder: Diagnosis, treatment and its relationship to other anxiety disorders. London, United Kingdom: Martin Dunitz Ltd. 
Vasey, M. W., & Dadds, M. R. (2001 ). M. W. Vasey (Ed.), The developmental psychopathology ofanxiety. New York: Oxford University Press. 
White, J. (1999). Overcoming generalized anxiety disorder: A relaxation, cognitive restructuring, and exposure based protocol. Oakland, California: New Harbinger Publications. 
Zinbarg, R., Craske, M., & Barlow, D. (1993). Mastering of your anxiety and worry. San Antonio, Texas: The Psychological Corporation, A Harcourt Assessment Company. 
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ISSN 0190-3379 IFODL 25(2)73-128(2002) 
The International Forum for 
LOGOTHERAPY 
Journal of Search for Meaning