SOURCE_DOCUMENTS/journal_026_2.txt

LOGOTHERAPY AND QUIET EPIPHANIES Paul Welter  65-73  
THE GIFT: A CHERISHED LABOR OF LOVE Jerry L. Long, Jr.  74-80  
FROM HOSTILITY TO CO-EXISTENCE THROUGH MEANING: A POSSIBLE REALITY IN A MUL Tl-CULTURAL WORLD Gideon Millul  81-94  
INTEGRATION OF LOGOTHERAPY INTO A LIFESPAN HUMAN DEVELOPMENT COURSE Charles Mclafferty, Jr.  95-101  
LOGOTHERAPY AND MENTAL HEAL TH PROFESSIONALS: TRANSCENDING HISTORIES OF PERSONAL TRAUMA Stefan E. Schulenberg, Teri L. Elliott, & Jessica T. Kaster  102-109  
MEANING-CENTERED LEADERSHIP IN HEAL TH CARE Patricia L. Starck  110-113  
INTRODUCING NEW DIPLOMATES IN LOGOTHERAPY  

AND THEIR QUALIFYING WORK FOR THE DIPLOMATE CREDENTIAL 114-118 
BOOK REVIEW Dian Flowers 119 
BOOK REVIEW Julius Rogina 120 
RECENT PUBLICATIONS OF INTEREST TO LOGOTHERAPISTS 
D. J. Matchinsky 121-123 
Volume 26 Number 2 Autumn 2003 
The International Forum for Logotherapy, 2004, 27, 3-8. 
LOGOANALYSIS: FOR TREATMENT OF MOOD DISORDER DUE TO MEDICAL CONDITION 
Rosemary Henrion 
Logoanalysis is a special logotherapy technique and a program, initially developed in the early ?O's by James Crumbaugh, Ph.D., Clinical Psychologist. It presently consists of the following revised seven steps: 
Step One: Discovering Who You Really Are. 
Step Two: Handling Personal Loss. 
Step Three: Developing Self-Confidence. 

Step Four: Getting into the Mind-set necessary 
for Discovering New Meaning and Purpose. 
Step Five: Encounter: Relating to Significant Others of Both 
Sexes. 
Step Six: Dereflection: Defusing Liabilities and Infusing Assets. 
Step Seven: The Final Scene: Commitment. 
Viktor Frankl, MD, Ph.D., approved the technique and the program. Logoanalysis, as a formal program, was initiated 30 years ago and became a unique, holistic program. The program continues to be therapeutic and life changing for some clients after 30 years. 
Since my retirement from the Department of Veterans Affairs in 1998, I continue to use the Seven-Step program. 1 I volunteer my time with active duty military servicemen/women discussing Post Traumatic Stress Disorder and how to cope with its symptoms. With military dependents, I discuss the unusual behaviors of their husbands returning from the war in Iraq and how to cope effectively using the logotherapeutic principles, concepts, and techniques. I also have clients in the private sector who are experiencing family/medical problems. Another position that I hold is that of consultant/educator for the St Joseph's Homes for Therapeutic Foster Care Programs in Mobile, Alabama. All of the above entities are challenging as well as rewarding. 
Logoanalysis becomes preventive when clients learn in particular the process of transcending self from the psychological level (victim) to the human spirit level (survivor). The human spirit (noetic dimension) is the healing portion of the self. The individuals that I work with focus on "what 
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is left intact" rather than "the loss.'' 2 When healing becomes predominant, the defiant power of the human spirit is catapulted into action. In a nation that promotes victims, these clients become more positive about their future and develop visions of hope. Even in the concentration camps of World War II many prisoners who thought "what can I do in this meaningless situation" survived the horrific ordeal while those who anguished over "why me?" perished in the camps before the end of the war. This statement connects immediately with clients who presently encounter overwhelming trauma related to medical problems and who may be candidates for Logoanalysis. 
A Case Example 
One of the clients, let us call her Martha, who completed the Logoanalysis program created a lasting impression on me. She had a winning personality, and made acquaintances and friends wherever she went. However, Martha developed Multiple Sclerosis, a medical disease affecting her whole being. 
Multiple Sclerosis (MS) is a chronic, often debilitating, autoimmune disease affecting the central nervous system. Mild symptoms usually begin with numbness of the limb extremities, difficulty in walking, pain, and loss of vision due to optic neuritis. The precise etiology of MS is unknown but scientific research indicates a number of factors including immunologic/auto-immune, environmental, viral, genetic, and trauma. Three stages that occur with this disease are: primary, secondary, and tertiary. 
Personal History 
Martha was reaching the pinnacle of her career. She had worked hard to achieve many accolades. She had a devoted spouse and children. 
A short time later, Martha began to experience numbness, generalized weakness in her lower extremities, and periodic loss of balance. Neurological tests were completed, and Martha was informed that the diagnosis was Multiple Sclerosis. Immediately Martha felt that this could not happen to her since she had so much going for her. 
A few months after Martha received the diagnosis, her physical condition worsened. Her career ended abruptly. Her family became her major support system. 
The family moved to a lovely home with a swimming pool where Martha could exercise and live a less stressful lifestyle. After a few years, her spouse informed her without any warning that he was moving out of the house and taking the children. This was extremely painful emotionally for Martha, especially when she felt that her spouse would stay with her during the challenging periods of their marriage as well as the pleasurable 
4 
times. 
The isolation and alienation became so overwhelming that Martha referred herself to an outpatient clinic. By this time Martha was in an electric wheelchair, had obtained a special equipped van, and had the physical comforts of life; but she was emotionally distraught without meaningful relationships. 
Martha was given diagnoses of: Mood Disorder Due to a General Medical Condition, and Adjustment Disorder with Depressed Mood, in addition to the Multiple Sclerosis. She was referred to a mental health therapist. Upon entering the therapist's office, Martha said, "I don't have any meaning or purpose in life. I have no reason to go on. I have Multiple Sclerosis, am wheelchair bound, and my spouse left me and took our children with him." 
Martha s shoulders were bent over. She looked disheveled and was severely depressed with memory loss. I was notified to come meet this individual who needed Logoanalysis. I met Martha, spoke with her relative to her presenting symptoms, gave her a brochure describing the Logoanalysis program, and told her if she had any questions to call me. Martha would be admitted to Logoanalysis the following week when there would be an opening in the program. 
Logopsychotherapy Group Treatment 
The next Tuesday, Martha arrived promptly for class. She actively listened to the presentation on Your View of Life, the First Step of Logoanalysis. She learned that she had a free will, could make choices, and was responsible for her choices and the consequences for them. Immediately after the 45-minute presentation, logopsychotherapy group session began and lasted another 45 minutes. Martha was quiet, but she listened to her peers discussing their views of life. Toward the latter part of the session, Martha revealed some thoughts and feelings about her illness. Some of her peers who experienced similar feelings shared them with Martha. Martha's body language revealed that she wanted to share more about herself but was cautious. She needed to arrive at the point of lowering her "defense guard" enough to begin to trust the group. She was not at that point of trust. 
Martha felt a little more relaxed during the second presentation and logopsychotherapy group session. The topic of Handling Loss, the Second Step of Logoanalysis, was of particular interest to her since Martha lost her health, her career, and her family. Martha mentioned that she felt overwhelmed with loss since her biological family lived far away and she had no real support system in the immediate area. Her peers made some positive gestures in their getting together to socialize after the sessions in Logoanalysis. They would have lunch together somewhere in the city. 
5 
Martha liked this idea very much. At least she was beginning to structure her daily activities with a meaningful schedule. 
Martha attended the third session but she did not seem to be as alert and attentive as to what was occurring in class or in logopsychotherapy group. This presentation specifically focused on Developing Selfconfidence, the Third Step of Logoanalysis. Most of the participants had experienced major, career-ending trauma. Each member in the Logoanalysis group shared thoughts and feelings concerning the future. They learned there were a number of possibilities. Some of them planned to make appointments after this session regarding jobs where they could feel productive. 
During the fourth session, the topic discussed in class was Creative Thinking, the Fourth Step of Logoanalysis. After developing some selfconfidence, the participants would need to think about their future. They would need to begin to write short-term, meaningful goals for each day's activities so they would have something to look forward to; and they would need to begin to think about long-term goals. I shared that a number of persons who had completed Logoanalysis previously changed activities, jobs, and even careers. Some made choices at the crossroads of their lives. It was such a relief and they felt good about their choices, especially when their peers validated the information that was shared. Group members felt the validation was significant enough for them to test reality and receive the necessary emotional support. Martha felt that this step was very applicable for her to choose another career. 
The topic for the next class was on Encounter, the Fifth Step of Logoanalysis. In existential terms, encounter means developing a meaningful and trusting relationship with another human being. Three levels of relationship were discussed in detail -suprahuman, human, and subhuman. The suprahuman relationship includes a sense of presence or higher power. The higher power can be anything that the individual chooses it to be as long as it is greater than he or she. It is important to return to the first step of this Logoanalysis program and to further ascertain one's view of life. The human relationship occurs between two human beings sharing their innermost thoughts and feelings with one another. Trust is the basis of the relationship. If trust does not exist, a genuine relationship will not last. 
Two sessions are usually held for the topic of encounter since many clients have never experienced trusting relationships. The real meaning and purpose in life in the final analysis is in relationships. 
The subhuman relationship occurs between a human being and pets or animals. Some human beings are so deeply traumatized over a deep relationship(s) with another human being(s) that they prefer an animal so that they do not have to risk being hurt again on the human level. Martha 
6 
learned the difference between conditional love (I'll love you if you give me ___ ) as opposed to unconditional love (I love you for you) and the process for choosing future acquaintances, friends, and partners. 
The next session was concerned with Dereflection, the Sixth Step of Logoanalysis. This term, coined by Viktor Frankl, means taking the focus off one's problems and refocusing on his/her assets (what is left intact as opposed to the loss). The Meaning In Life Evaluation (MILE) Scale (developed by Dr. Crumbaugh) was administered during this session. The MILE Scale is a 20-item, forced-choice assessment of personal values that each participant uses to prioritize their five top values. From these top values will come meaning and purpose for each individual. Each participant discussed their short-term goals in attaining these values. They were encouraged to assess their values with the MILE Scale annually, since life experiences may produce changes as they progress to higher values. This exercise was (and continues to be) intriguing for most individuals who learn there is a hierarchy among their values. It is workable and realistic. The group participants recognized they were actually making progress in their lives. 
Martha began to take note of the values that she prioritized since she was offered a job working with underprivileged families in a major city. Lasting friendships and being of service to others were two of her top five values, so she assumed responsibility for the job immediately. This particular experience changed Martha's attitude about life tremendously since she met people who had no financial means to obtain housing, clothing, or even send their children to school. She elaborated in logopsychotherapy group one day as to her need for being creative in the job. She did not know what she would be doing until she arrived at work each day. Martha felt that she was blessed despite her not being able to continue her former career. She was more compassionate with others and felt this job was meaningful, fulfilling, and most satisfying. Martha looked forward to going to work every day. 
The Seventh Step in Logoanalysis is Commitment. If the participants are genuinely engaged in this program, they will continue to work on their goals and aspire for higher values as they progress in life. Martha took this step seriously, and she became involved in support groups. She invited me to speak at one of the meetings on meaning and purpose in life, and the audience was appreciative of my sharing this unique approach with them. They were grateful that Martha invited me to make this information available to them. 
After much cajoling on my part, Martha finally consented to write a letter to Dr. Frankl, informing him how Logoanalysis had been so influential in changing her life to a meaningful, fulfilling, and satisfying one despite the traumas that she experienced. Dr. Frankl responded to her 
7 
letter by phoning Martha and inquiring about the process of transcending the self from victim to that of survivor. After the 15-minute conversation, Dr. Frankl's final remark was "you have learned logotherapy." Martha was ecstatic over the phone call to think that Dr. Frankl would take the time to call her from Vienna, Austria. Martha called me immediately, feeling so overwhelmed but joyous beyond all of her wildest dreams. 
Here is a perfect example of happiness being a by-product of one who is living a meaningful existence. After her medical illness was diagnosed and her mood stabilized, she lived the remainder of her life productively by helping others, which, in turn, gave her the opportunity to progress to higher values. Logoanalysis provided Martha with the tools that she needed to experience heights that she never dreamed she could achieve. 
ROSEMARY HENRION, MSN, R.N., [19 Wen Mar Avenue, Pass Christian, Mississippi 39571] is a Diplomate in Logotherapy and Faculty Member and Member of The International Board of Directors of the Viktor Frankl Institute of Logotherapy. 
References 
1. 
Crumbaugh, J., & Henrion, R. (2004). The Power of Meaningful Intimacy: Key to Successful Relationships. Philadelphia: Xlibris Corporation. 

2. 
Lukas, E. (2000). Logotherapy Textbook. Toronto: Liberty Press. 


8 
The International Forum for Logotherapy, 2004, 27, 9-14. 
THE CHRONIC PAIN PATIENT: HOW CAN LOGOTHERAPY HELP? 
Geoffrey T. Hutchinson 
Viktor Frankl's insights into human suffering can be integrated into an interdisciplinary model used to treat chronic pain syndrome. These insights can be added to cognitive-behavioral therapy (CBT) to address existential issues related to a form of existential (spiritual) disorganization often found in these patients. Therapists are encouraged to pay attention to schemas (life traps), creative values, and iatrogenic neuroses that are often prevalent in the syndrome. The process of discovery and rational thinking, along with behavioral uses of dereflection and relaxation training, can have a substantial impact on this condition. Concepts like progressive existential disorganization (PED) and the two therapeutic processes mentioned beforehand will be explored further in this article. These combined logotherapy-CBT approaches can help clients possess a richer and cohesive "meaningful" narrative of their chronic condition. 
Chronic Pain and the Iatrogenic Systemic Neurosis 
Viktor Frankl's insights into human suffering provide a rich framework for the treatment of chronic pain. It is my contention that logotherapy concepts and cognitive-behavioral strategies will reduce both the physiological and psychological correlates of the syndrome. Chronic pain syndrome is a descriptive term for individuals who show persistent pain, poor coping strategies, functional limitations, significant life disruption, and dysfunctional pain behavior. 1 Symptoms frequently overlap with affective disorders, culminating in diffuse functional impairments (e.g., sleep disturbance, distraction, amotivation, inability to achieve goals, social isolation).9 
Presently, an interdisciplinary approach that integrates CBT, physical rehabilitation, and pharmacological agents offer the best hope for reduction of chronic pain symptoms.34 CBT techniques can include basic psychoeducation, cognitive restructuring, energy conservation strategies, relaxation, goal settin~, communicating with significant others, and sleep 
1
hygiene techniques. 10 Even so, many patients make modest gains or relapse, perhaps due to unaddressed co-morbid Axis I and Axis II disorders. ·8 In addition, many patients develop an "iatrogenic systemic neurosis". This is a psychogenic condition as a result of the constant frustration patients report when interacting with financial, health, and legal 

9 
systems. It is iatrogenic because the systems designed to help patients paradoxically multiply their stress, create mistrust and mild paranoia, and exacerbate depressive feelings. These patients tend to treat future interventions with suspicion. 
The Unique Contribution of Logotherapy 
Approaches designed to address existential questions in a brief setting can be integrated effectively into a biopsychosocial model of treatment for more treatment-refractory cases. 6 The synthesis of logotherapy modules and evidenced-based treatments (e.g., cognitive therapy) may compliment each other in significant ways.2 The synthesis may enable therapists to engage the patient at multiple levels of abstraction, a macro perspective (existential) and a micro perspective (daily functioning). This flexibility between the two perspectives allows therapists to address appropriate concerns as needed.7 This hybrid model may prove useful given that many chronic pain patients report a sense of existential meaninglessness following the onset of their symptoms. For example, they may wonder if they have been punished by God, or why life has been grossly unfair. 
Course of the Syndrome 
With many chronic pain patients, a form of progressive existential disorganization (PED) begins shortly after the onset of their chronic pain symptoms (see figure). I expanded PED from Frankl's ideas about the human being's struggles with meaninglessness. When life is experienced as having no meaning, it becomes empty. The PED captures this "becoming" process: it is the mechanism by which the existential vacuum slowly surfaces. It develops over time, until individuals finally realize that they feel worthless and feel like they have little sense of purpose. Part of this process involves the repetitive use of "meaningless" behaviors, e.g., compulsions, drugs, violence, food, sex, and, conversely, periods of inactivity that lead to apathy. From my experience, chronic pain patients mask their increasing feelings of meaninglessness by two extremes. Some fail to set goals that will challenge them in a healthy manner, and (because of their physical limitations) have pockets of idle time. Others are perpetually hyper-focused on their symptoms or the latest legal or medical iatrogenic event. 
During this period, patients experience significant and frequent disruptions with their social support and medical treatments. It is my contention that the number, extent, and time between insults to physical, psychological, and social support dimensions (e.g., abandonment from loved ones) directly impact this disorganization by reactivating schemas (will be discussed below) and creating general confusion about life. From the onset of the symptoms, many patients receive some types of palliative treatments or passive modalities (e.g., massages, cold/ice packs, rehabilitative exercises, even supportive psychotherapy), but for some these treatments produce only modest results. By the time they see a psychotherapist as part 
10 
of an interdisciplinary model of treatment, patients may appear to be cynical, resistant, suspicious, and angry as a result of the failure of previous forms of treatment. 
,..... 

11 
The trajectory shows that existential issues need to be addressed along with traditional cognitive-behavioral therapy. The intake process is a crucial first step for these patients. Many patients have memorized dates, facts, and figures related to their injuries and can easily hyper-reflect (i.e., over-analyze, be overly self-conscious about problems) if not directed properly. In addition to asking standard intake questions, applicable spiritual and religious coping information needs to be obtained. The clinician also needs to determine the level of the patient's social support, as this factor may have an impact on relapse prevention. 
Therapy Sessions: Life Maps, Discovery, and Creative Values 
During the initial stages of therapy, I have found it useful to assess life traps or schemas that have been re-triggered by the initial onset of chronic pain symptoms.12 Some of these may include, but are not limited to, vulnerability ( "I cannot cope with the future well"), powerlessness ("I have little control over my life"), avoidance ("I can't stand to deal with my problems"), and self-sacrifice ("Others' needs are more important than mine"). These themes can serve as powerful anchors that help bring consistency to treatment, given that many patients present with new crises each week. These elicited themes also help explain how patients exacerbate their symptoms with a negative, depressed, cognitive set. For example, one patient that I treated verbalized issues tied into the core belief that "After I had my injury, the world has become unsafe and unpredictable". More than likely, these schemas were simply activated, not birthed with the onset of the injury. These re-activated schemas also contribute to PED. The disorganization increases as lifelong coping styles are found to be ineffective in chronic pain management. 
Therapists can use discovery processes and cognitive-behavioral techniques concurrently to address chronic pain issues. They can help their patients discover meaning in what appear to be chaotic life narratives. And yet at the same time, they can teach their patients to use rational (simply meaning more scientific, clear, and flexible) thinking to practice cognitive, affective, and behavioral coping techniques to deal with daily stressors.7 One logotherapeutic/cognitive-behavioral technique that is successful here is dereflection. Patients hyper-focus significantly on their pain levels. One approach that I have found helpful is to validate the patient's pain complaint. I then address related psychological issues that are often tied to re-triggered schemas in an attempt to help patients dereflect from their pain. I also have patients elicit realistic, value-actualizing goals that they can fulfill in spite of their painful condition. For example, one patient agreed to spend more time with her granddaughter instead of being home alone and depressing herself. However, one warning about the use of dereflection is that it should never be used to distract both the patient and therapist from addressing issues related to practical survival (e.g., contacting charities to help pay for bills, home 
12 
health concerns, social work issues, making arrangements with psychiatrists for medications). 
Frankl's emphasis on creative values is extremely important for these patients.5 They can enrich their lives by simply doing or creating something new. Because chronic pain patients know they can no longer perform certain premorbid activities, therapists can use creativity to challenge them to meet parallel goals. For example, if patients can no longer go on a "ski jet", they can go to the lake and enjoy the surroundings. The actualization of creative values can serve as a strong protective factor against depression by helping patients realize that they can still achieve fulfilling goals. 
The End of Therapy: Measuring Success 
Successful therapy with chronic pain patients does not simply involve helping patients develop more adaptive behaviors, but empowering them to restore order to their PED. To aid this restorative process, patients become engaged in the discovery of meanings along with the adoption of healthier cognitions. Successful therapy can be measured by: (a) a reduction of the iatrogenic neurosis (the empathic therapist and pain program are introjected, i.e., positive attitudes or ideas towards healers are incorporated into one's personality unconsciously); (b) an increase in goal-setting activities; (c) better communication skills with their support group; (d) acceptance of the chronicity of their condition; (e) and an increase in the knowledge, sense of self-efficacy, and use of behavioral skills to lower pain symptoms. While successful therapy could be measured directly by self-reported lower pain levels, this does not have to occur always. Many times patients have a meaningful re-conceptualization of their chronic condition that allows them to face everyday with courage in spite of their pain. Some patients have shared that their condition has helped them mature spiritually as human beings. 
Conclusions 
Chronic pain syndrome is a debilitating condition that is responsive to a cognitive-behavioral approach often within an interdisciplinary pain program. The augmentation of this treatment with logotherapy ideas can help patients resolve their sense of existential meaninglessness. The course of therapy should not only include a restoration of the "progressive existential disorganization", but also a new skill set. Pain patients should learn effective behavioral techniques and better ways of attaining realistic goals. Dereflection is particularly important in this aspect, as pain patients are overly focused on pain symptoms. It is likely that a clear purpose in life may positively affect patients' sense of self-efficacy over their pain and act as a protective factor against depression. Future research may wish to examine the relationship between patients' perceived sense of pain control and their existential sense of meaninglessness. 
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GEOFFREY T. HUTCHINSON, M.S. [South Texas Veterans Health Care System, Audie L. Murphy Memorial Veterans Hospital Division, Psychology Services (116B), 7400 Merton Miner Blvd., San Antonio, Texas 78229-4404, E-Mail Geoffrey.Hutchinson2@med.va.gov] is a Doctoral Clinical Psychology student at the University of North Texas and is currently completing his Clinical Psychology Internship program with Veterans Health Care System in San Antonio, Texas. 
References 
1. 
Aronoff, G., Feldman, J., & Campion, T. (2000). Management of chronic pain and control of long-term disability. Occupational Medicine, 15, 755-770. 

2. 
Benware, J. (2003). On the compatibility of cognitive therapy and logotherapy. International Forum for Logotherapy, 26, 49-57. 

3. 
Bradley, L. (1996). Cognitive behavioral therapy for chronic pain. In 


R. J. Gatchel & D. C. Turk (Eds.), Psychological approaches to pain management: A practitioner's handbook (pp. 131-147). NY: Guilford. 
4. Fishbain, D., Rosomoff, H., Cutler, B., & Steele-Rosomoff, R. (1995). 
Chronic pain treatment metaspecific predictors of response. 
Proceedings: Integration of behavioral and relaxation approaches 
into the treatment of chronic pain and insomnia. NIH Technology 
Assessment Conference, Washington, DC. 
5. 
Frankl, V. (1988). The will to meaning: Foundations and application of logotherapy. NY: Penguin Books. 

6. 
Hutchinson, G. (2002). The medical ministry of a secular priest-intraining. Clio's Psyche, 9, 94-95. 

7. 
Hutchinson, G., & Chapman, B. (2003, June 25). Logotherapy and rational emotive behavior therapy: An integrative effort. Paper 


15th
presented at the World Congress on Viktor Frankl's Logotherapy, Dallas, TX. 
8. 
Kerns, R., & Haythornthwaite, J. (1988). Depression among chronic pain patients: Cognitive-behavioral analysis and effect on rehabilitation outcome. Journal of Consulting and Clinical Psychology, 56, 870-876. 

9. 
Turk, D. ( 1996). Biopsychosocial perspective on chronic pain. In R. 


J. Gatchel & D. C. Turk (Eds.), Psychological approaches to pain management: A practitioner's handbook (pp. 3-32). NY: Guilford. 
10. 
Turk, D., & Gatchel, R. (2002). Psycholo~ical approaches to pain management: A practitioner's handbook (2n edition). NY: Guilford. 

11. 
Turk, D., Meichenbaum, D., & Genest, M. (1983). Pain and behavioral medicine: A cognitive behavioral perspective. NY: Guilford. 

12. 
Young, J., Weishaar, M., & Kloska, J. (2003). Schema therapy: A practitioner's guide. NY: Guilford. 


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The International Forum for Logotherapy, 2004, 27, 15-20. 
LOGOTHERAPY AND MALE ADOLESCENTS WITH MENTAL RETARDATION/ DEVELOPMENTAL DISABILITIES AND SEXUAL BEHAVIOR PROBLEMS 
Stefan E. Schulenberg & Elizabeth D. Kolivas 
During 2001-2002, one of the authors (S. E. Schulenberg) worked extensively with two units of a high-management group home that were designated for treatment of male youths with mental retardation/developmental disabilities and sexual behavior problems (MR/DD/SB). Treatment for these youths included milieu therapy, individual therapy, group therapy, family therapy, recreational therapy, and on-site education. Some patients also benefited from medication management and/or speech therapy. The typical length of treatment for these patients was 
approximately 18 months, given the chronic and intense nature of their sexual behavior problems. These youths also met criteria for mild or moderate mental retardation consistent with the Diagnostic and Statistical Manual of Mental Disorders -Fourth Edition -Text Revision (DSM-IV-TR).1 Diagnoses relating to maladaptive sexual behavior included sexual abuse of child or adult (V codes), pedophilia (302.2), or conduct disorder (312.81, 312.82, 312.89). One of the DSM-IVTR criteria for conduct disorder involves forcing a person into sexual activity. 
The idea that logotherapy may be of help to people with mental 
11 15 17
retardation and sexual behavior problems has been noted previously. 10, , Similarly, Schulenberg noted the potential for logotherapy to assist in treating youths with conduct disorder.14 The purpose of this paper is to expand on previous work, further investigating a role for logotherapy in treating male youths with MR/DD/SB. 
Adolescents with MR/DD/SB 
Youths diagnosed with mental retardation/developmental disabilities and sexual behavior problems are similar in many respects to youths without cognitive impairments with regard to sexually abusive behavior.1219 Adolescents who commit sex offenses appear to deny or distort their sexually 
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aggressive behaviors, lack feelings of empathy for their victims, have poor social and interpersonal skills, and many have experienced childhood sexual abuse or other maltreatment.2 8 The various sexual offenses in youths range from exhibitionism or voyeurism to fondling or forced penetration. ·8 
While much is unknown in terms of causation, adolescents with MR/DD/SB differ in some respects from youths without disabilities in that they may be at a greater risk of being repeat offenders, are more likely to know their victims, and access ~rather than gender preference) is more likely
12 19
to be a factor in victim selection. · · 
Finding intervention techniques and strategies with demonstrated effectiveness for adolescents with MR/DD/SB can be challenging. 19 Focusing on the prevention of further victimization, treatment programs are similar to those for youths without MR/DD and may include family, individual, and group therapies combined with educational and pharmacological interventions.2 18 Primary treatment objectives typically include helping these youths learn to accept responsibility for their offenses, establish prosocial and age-appropriate peer and adult relationships, clarify their values, develop healthy interpersonal skills, gain insight and control over sexually abusive behaviors, correct cognitive distortions, and develop empathy for victims.2 5812 Given the importance of responsibility taking, adaptive choice making, and values clarification in treatment, logotherapy may be of assistance considering its focus on these areas. 
Accomplishing these treatment goals with an MR/DD population may be difficult due to problems with concentration and focus, coping and selfmanagement, and greater difficulty understanding maladaptive thoughts. 512 Research suggests that youths with intellectual, cognitive, or neurological impairments are in need of individualized interventions and techniques 
1318
designed to hold attention and facilitate learning.7· Readers interested in learning more about intervention strategies and characteristics of this population are referred to Day,5 Schulenberg,17 and Timms and Goreczny. 19 
Logotherapy Case Formulation 
Male youths with MR/DD/SB require intensive and comprehensive treatment. A single approach is of limited use. However, logotherapy may be of assistance in an adjunct capacity, particularly considering its emphasis on responsibility and adaptive choice making. With regard to meaning, there are some instances where these youths commit sexual offenses in order to feel loved, respected, or in control. These instances may be referred to as perversions of the will to meaning, which Crumbaugh defined as a sense of meaning achieved through maladaptive methods.3 Logotherapy has specific relevance in these cases. 
Applications of Logotherapy Techniques 
Given that logotherapy is one means of understanding and treating youths with MR/DD/SB, there have been several applications of logotherapy 
16 
techni~ues with these youths reported in the literature. Described by Welter, 0 two innovative movie exercises were reported by Schulenberg to be an effective group therapy technique with MR/DD/SB clients (mild mental retardation or borderline intellectual functioning). 16 Welter noted that the goals of the exercise are to highlight areas of life purpose up to the present time and to assist clients in planning to live meaningful lives in the future. The exercises further provide a useful means for clinicians to learn past experiences and future goals that are important to their clients. 
The first movie exercise presents clients with the opportunity to develop a movie based on past experiences. The second movie is a sequel to the first and takes place in the client's life from the present time forward. The client develops the sequel based on future goals, obstacles to overcome, and important relationships, while imagining the sequel (i.e., the story of the client's future experiences) as a substantial box-office success. Both exercises allow clients to choose the film's budget, determine its genre (based on past and projected future experiences), and select the actor who is to portray them in the film. 
In group therapy geared toward relapse prevention with adolescent male MR/DD/SB clients, Schulenberg found these exercises effective in "facilitating discussion of such issues as identity formation, stigma resulting from societal views on cognitive deficits and sexual aggression, effectiveness of treatment, interpersonal relationships, and avoidance of future sexually aggressive behaviors". 16· P 40 He reported that these exercises helped build rapport, enhanced these clients' ability to focus on their treatment, and gave them another way to tell their life stories, recognize values, find meaning in past experiences, and set future priorities. 
The Mountain Range Exercise (MRE) is another technique that has been utilized in group therapy with adolescent male MR/DD/SB clients (mild to moderate levels of mental retardation). 17 Ernzen described the MRE as a group activity in which clients are first asked to envision their lives as they would a mountain range, placing the most influential people on the mountain peaks.6 Clients then draw their mountain ranges, using paper and markers or colored pencils, placing the persons of positive influence on the peaks. Afterwards, clients are invited to discuss their drawings with the group. 
Schulenberg reported that this experiential activity assisted in accomplishing important therapeutic goals in a group therapy context specific to the treatment needs of male youths with MR/DD/SB, such as clarifying values over time and facilitating discussions of important positive relationships and influences.17 Moreover, as a result of many clients placing one or more of their victims on their mountain peaks, the MRE became a means of learning about victim characteristics, client preferences, and triggers of inappropriate sexual behaviors. 
17 
Research Needs 
There is strong need for research with male youths with MR/DD/SB. Given that there are a variety of research measures to assess meaning, such as the Purpose-in-Life Test and the Life Purpose Questionnaire,4 9 one may wonder about applicability of these instruments with this population. Currently, logotherapy research measures are not normed for this population, and youths with MR/DD/SB tend to not have the reading skills necessary to accurately complete logotherapy measures. How then, is meaning to be assessed in this population? 
There are no easy answers. One possibility lies in studying logotherapy measures with the goal of developing norms for oral administration. When conducting therapy, one of the authors (SES) found that these youths were quite capable and often interested in discussing what was most important to them (e.g., family, school, future jobs), however, care had to be taken to avoid jargon. A term like "meaning" is difficult to understand in the abstract. Therefore, research with regard to oral administration should focus on analyzing existing logotherapy measures to determine which items are most applicable, which items need to be adjusted, and which items should be eliminated. 
Another empirical issue is the development and validation of other-report measures of meaning -that is, measures of meaning filled out by people who know the client well (e.g., teachers, parents, facility staff members). There are assessment systems available that tap behaviors through self and other-report formats, but there is not currently a validated system available for the assessment of meaning. With regard to the assessment of meaning via self-report questionnaires, some may argue that we cannot adequately tap such a personal, intrinsic concept as meaning. This argument may be extended to other-report measures as well. Observers would not be able to comment on whether a person is living a meaningful life per se; however, there may be observable correlates of meaning that others may be able to address. For instance, if research suggests that people who are living meaningful lives appear to be better adjusted, more motivated, and more goal-directed, then these qualities may be operationally defined and tapped through other-report measures. 
In addition to descriptive case reports of logotherapy interventions, there is a need for outcome studies to be performed in order to better quantify logotherapy's effectiveness with this population. We do not know for certain if logotherapy will foster clinically significant improvements, and if so, to what degree. Would incorporating logotherapy make a difference in key areas of treatment, such as rates of recidivism? The definitive answer to this question is unknown at this time. What does seem clear is that logotherapy is applicable with male youths with MR/DD/SB in certain instances, and that it appears to be a useful means of facilitating treatment goals and assisting clinicians in better understanding these youths. 
18 
The interested researcher should be aware that conducting research with male youths with MR/DD/SB is fraught with complexities. For instance, research in this area is lacking, there are difficulties in properly obtaining informed consent given these youths' educational and intellectual deficits, and there are problems finding samples large enough for statistical analysis. Despite these difficulties, the number of these youths in treatment centers who may benefit from such research is growing. 
STEFAN E. SCHULENBERG, Ph.D. [sschulen@olemiss.edu] is an Associate in Logotherapy and an Assistant Professor in the Department of Psychology at The University of Mississippi, University, Mississippi 38677. 
ELIZABETH D. KOLIVAS, B.A. [ekoliva@olemiss.edu] is a graduate student in the Ph.D. program in clinical psychology at The University of Mississippi. 
References 
1. 
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders DSM-IV-TR (text revision). Washington, DC. 

2. 
Becker, J., Johnson, B., & Hunter, J. (1996). Adolescent sex offenders. In C. R. Hollin & K. Howells (Eds.), Clinical approaches to working with young offenders (pp. 183-195). Chichester: John Wiley & Sons. 

3. 
Crumbaugh, J. (1988). Everything to gain: A guide to self-fulfillment through logoanalysis. Berkeley, CA: Institute of Logotherapy Press. 

4. 
Crumbaugh, J., & Maholick, L. (1964). An experimental study in existentialism: The psychometric approach to Frankl's concept of noogenic neurosis. Journal of Clinical Psychology, 20, 200-207. 

5. 
Day, K. (2001 ). Offenders with mental retardation. In C. R. Hollin (Ed.), Handbook of offender assessment and treatment (pp. 453466). Chichester: John Wiley & Sons. 

6. 
Ernzen, F. (1990). Frankl's Mountain Range Exercise: A logotherapy activity for small groups. The International Forum for Logotherapy, 13, 133-134. 

7. 
Ferrara, M., & McDonald, S. (1996). Treatment of the juvenile sex offender: Neurological and psychiatric impairments. Northvale, NJ: Jason Aronson. 

8. 
Gilby, R., Wolf, L., & Goldberg, B. (1989). Mentally retarded adolescent sex offenders: A survey and pilot study. Canadian Journal of Psychiatry, 34, 542-548. 

9. 
Hablas, R., & Hutzel!, 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: The proceedings of the First World Congress of Logotherapy: 1980 (pp. 211-215). Berkeley, CA: Strawberry Hill. 

10. 
Hingsburger, D. (1989). Logotherapy in behavioral sex counseling with the developmentally handicapped. The International Forum for Logotherapy, 12, 46-56. 

11. 
Hingsburger, D. (1990). Relevance of meaning for the developmentally handicapped. The International Forum for Logotherapy, 13, 107-111. 

12. 
Lane, S., & Lobanov-Rostovsky, C. (1997). Special populations: Children, females, the developmentally disabled, and violent youth. In G. Ryan & S. Lane (Eds.), Juvenile sexual offending: Causes, consequences, and correction (New rev. ed., pp. 322-359). San Francisco: Jossey-Bass. 

13. 
Langevin, R., Marentette, D., & Rosati, B. (1996). Why therapy fails with some sex offenders: Learning difficulties examined empirically. In E. Coleman, S. M. Dwyer, & N. J. Pallone (Eds.), Sex offender treatment: Biological dysfunction, intrapsychic conflict, interpersonal violence (pp. 143-155). Binghamton, NY: The Haworth Press. 

14. 
Schulenberg, S. (2002). Logotherapy and conduct disorder. The International Forum for Logotherapy, 25, 52-59. 

15. 
Schulenberg, S. (2003). Empirical research and logotherapy. Psychological Reports, 93, 307-319. 

16. 
Schulenberg, S. (2003). Psychotherapy and movies: On using films in clinical practice. Journal of Contemporary Psychotherapy, 33, 3548. 

17. 
Schulenberg, S. (2003). Use of logotherapy's Mountain Range Exercise with male adolescents with mental retardation/developmental disabilities and sexual behavior problems. Journal of Contemporary Psychotherapy, 33, 219-234. 

18. 
Stermac, L., & Sheridan, P. (1993). The developmentally disabled adolescent sex offender. In H. E. Barbaree, W. L. Marshall, & S. M. Hudson (Eds.), The juvenile sex offender (pp. 235-242). NY: Guilford. 

19. 
Timms, S., & Goreczny, A. (2002). Adolescent sex offenders with mental retardation: Literature review and assessment considerations. Aggression and Violent Behavior, 7, 1-19. 

20. 
Welter, P. (1995). Logotherapy-lntermediate "A" : Franklian psychology and logotherapy. The Viktor Frankl Institute of Logotherapy, Box 15211, Abilene, TX 79698-5211. 


19 
20 
The International Forum for Logotherapy, 2004, 21-27. 
BORDERLINE PERSONALITY DISTURBANCES AND LOGOTHERAPEUTIC TREATMENT APPROACH 
Roberto Rodrigues 
Borderline Personality Disorder (BPD) is a psychiatrically difficult disorder, which is increasing in prevalence every year. It is still poorly diagnosed in the general population. BPD confounds its symptoms with the normal crises of life, especially in young and adolescent people who usually have tumultuous behaviors, but these are not considered at this phase of life as pathological. Nevertheless, persistence of symptoms, long periods of unremitting impulsive conduct, and instability of emotional resolution lead to the conclusion that BPD is a disorder that needs accompaniment by a mental health professional to avoid destructive consequences of existential frustration for the patient, to afford encouragement to the family, and to especially assist the patient and the family with development of a new attitude about life. Logotherapy has the potential of dealing with the required new life attitudes and with a humanistic comprehension of living with the existential frustration or vacuum, which may result from BPD. This paper shows that Franklian postulates should be useful in helping its psychiatric treatment and in monitoring the patient's family. A case report is summarized as an illustration. 
What is Borderline Personality Disturbance? 
It is a borderline syndrome that begins most frequently during the young adult years when a boy or girl starts getting strange feelings and emotional responses about other people; feelings which he/she cannot absolutely understand. The person feels like he/she is a no one, with no solid identification of space or occupation as a person. His/her emotions are not continuous, persistent, or understandable to other people. This individual is assaulted by feelings of hostility, abandonment, rejection, and insecurity. Thus, for practical reasons, it is possible to say that long term emotional dysregulation is the core disorder of BPD persons, 6 different from emotional disturbances of normal people. As the name poses, BPD persons are in the outer range of psychiatric mental illness vs. sound mental health. In consequence, their interpersonal relations are in disarray. They may start but never continue good relationships. Clinicians who deal with these persons never know what their reactions may be: hostility, emotional blackmail, 

21 
passivity, falseness, very strong aggression, or misshaping true words that harm by their crudeness or cruel evidence.7 
BPD persons are usually in the range of normal intelligence. They can have good ideas and work performances. But the problem is that they are not persistent. They often do not finish what they are doing: courses, school, jobs, tasks, etc. Also, those who do business with BPD people may become frustrated, or even may end up in financial problems. This happens not because there is bad intention or faking mental illness, but as a result of ambivalence, instability, and complete changes in plans with no coherent reasons. In marriage the problem is the same; BPD people may fall in love for some time and suddenly their passion, attraction, or deep love may disappear. 
Mood Disorders, Substance-Related Disorders, psychotic-like symptoms, and other psychiatric symptoms or illnesses are quite frequent in BPD. They never are satisfied for long; they feel empty, with a "hole in the soul". They feel frustrated when thoughts of self-reflection emerge from the depths of their heart. 12 As a consequence I could say that "existential vacuum" 4 -as postulated by Viktor Emil Frankl, the founder of logotherapy -may bother these persons continuously. Furthermore, values and meanings in life are hardly realized by BPD people. Therefore, they may feel unhappiness, abandonment, failure, and loneliness, as nothing they experience has significance, a real meaning, or a real transcendence. Altruism, solidarity, and interest in others are almost impossible -this takes them to egocentrism, selfishness, disguise, even hate for other people including family members.9 
Borderline Personality Disturbance and Logotherapy 
Psychotherapy, when possible and accessible, is the way to obtain positive results. The practitioner must first establish the diagnosis, and must differentiate BPD from existential vacuum, from depression, from psychosis, and from other pathologies. Most important is trying to understand the patient and his/her way of life, to establish a nice and good, trusted relationship even when the practitioner knows that it can be disrupted. 1 Meaningful relations, psychotherapeutic alliance, unconditional reception of all behaviors, emotions, words, and confessions in therapy are all essential. 
But therapy is not made only of amenities; appeal must be made to the responsibility of the patient; he/she must be confronted with inappropriate behaviors -of course, in a way that would not be frightening.8 Otherwise, he/she will leave treatment forever. The therapist must be very patient, cautious, flexible, human, and receptive. Friendship -an important way of helping the patient -may be sometimes necessary.5 
Following an existential orientation,13 my opinion is that logotherapy may often be efficient -at least in approaching the patient initially. The therapist constructs with the patient a series of value realizations -those values that are most meaningful to him/her. This may be one of the best ways to get 
22 
some positive results. As soon as the BPD patient starts executing significant actions for himself/herself, the mood may change, the abandonment feelings may recede, the self-esteem may increase, and the attitude about life may change once the patient decides freely to accept the noetic appeal. We must recognize that all of these are very difficult tasks. It is possible to stimulate the patient to search for meaning as a means to motivate oneself to look for the necessary changes in his/her life.3 I have found that psychotherapy groups of Existential Analysis Reflections are very useful,2 as patients may find meaning in exposing their values to other people in the group and may learn to trust others, and to construct new places for themselves in society.10 
Finishing this brief expose on BPD, we must say that the person who needs to change, no matter what pathology he/she presents, is the aim and focus of any psychotherapeutic approach. The therapist must "go to the patient" -of course without being submissive or manipulated. The psychotherapist must, nevertheless, appeal to responsibility, to freedom limited through consciousness, through the "spiritual-person nucleus." The psychotherapist as a professional must be pragmatic also; the psychotherapist must know that he/she may many times be deceived -even when the patient shows the contrary. The psychotherapist ought to recognize that BPD is still like a mystery; it is still a problem often insoluble. In acting in this manner the psychotherapist may ~et more results with some patients than if by feeling completely in control.1 Being humble is not the same as "to slip down"; it isto be human, to get up and to have a better outcome of the professional work. The BPD patient is one of the opportunities on this issue in mental health care. 
A Case Report of Borderline Personality Disturbance 
Let us call him Gustav. He is a university student who was brought to my office because of heavy use of marihuana, and because of very unstable emotions, including a crisis of hostility and strong fights with his parents. Gustav is a very intelligent boy, and in spite of all these turbulent behaviors, he has a high performance and abilities in his sciences coursework. But, he often misses classes and gets in trouble with some peers, teachers, and authorities at the university. The result is an almost complete failure in his graduate courses. Even his job is threatened. The last experience leading him to deep depression and strong feelings of abandonment was the breakup with his loving girl friend of several years. She could no longer tolerate Gustav's unstable, unacceptable, and drug dependent conduct. Then, he increased the use of alcohol and marihuana to alleviate depression and suffering. 
In panic, and afraid that Gustav could go into irreversible drug addiction, his parents brought him to my psychiatric office to begin therapy. After two introductory interviews, Gustav told me that many psychiatrists had tried to help him in the five past years. But, in all the treatments, he used to flee from the psychiatrists' offices after some therapy sessions because motivation and 
23 
will to get better suddenly vanished, in spite of his apparent confidence and sometimes pleasure about the therapeutic approaches. He used to lie and manipulate the therapists in the meetings. He was very glad when the therapists started to believe and have confidence in him. Then, he wanted to show them how wrong and frail their evaluations were about him. He used to be very excited to observe the therapists' doubt and disillusionment about his treatment. Then he could "dominate" the situation and terminate therapy, just telling them he would not come back because they failed. They "lost" the battle and he was the "winner". 
I asked him: who was the loser really? Was it the therapists who tried hard to help him, or maybe himself, with the cynical behavior he used? In spite of deceiving them and leaving treatment as if he dominated the situation, who was really the loser? I told him that with me he was free to be cynical, and, any time he wanted to, he could attempt to deceive me or could flee from the meetings. That, of course, would make me sad since I could not help him; but I never would close my door to him, as I believed that in the depths of his spirit he knew that he was responsible, and that he was capable to know and decide freely his behaviors and emotions. Thus, it was no use to cheat me. I never would be a loser or winner. The same would not be true about him; and neither of us would have a meaningful personal relationship. 
About drugs I would not comment, as he was sufficiently conscious to know all the consequences of using them; and he was the only person to decide what to do with this. My function was only to accompany, to be his friend, and to use all my knowledge and experience to make our meetings the most meaningful possible. He was, then, free to decide when to start deceiving me, or when to be responsible, when to manipulate me, or when to confront the truth about himself. Also, he was free to leave, and to make me feel sad for not being able to understand him, and thus experience a complete failure in our therapy. 
Gustav reacted telling me that my strategy was not having success. He felt that I should find someone else to help him as he had already "seen this film". Otherwise, he would have to get out of therapy. On the other hand, he said, he wanted to go for a year to Australia; there, at the nice beaches he could surf, have any drugs he wanted, and live freely, exactly the way he loved to live. I told him: once you have the money, once you get a financial way to sustain yourself there, you can leave freely for Australia. You are the only one who knows the pros and cons and who is responsible for that. 
Gustav was surprised: he was beginning to be conscious that he was the only one who could lead his life. Thus, why deceive others if it was not constructive? He was the only one who could respond to what life asked from him. It was up to him to respond to his parent's panic, and to change his conduct. His conduct had caused his failure at the university, broken up the loving relationship with his girlfriend, lost him jobs, and interfered with friendship maintenance. 
24 
When he told me these statements, I answered him that he was free to go now, free to leave therapy, to deceive me, and to harm our meaningful relationship."The door is open for you anyway. If you leave, if you stay, if you come back another time, I will not blame you for that, I will not finish our relationship. Maybe you want to experiment now, leave therapy, increase greatly your parent's anxiety, go to drugs, leave your studies, give up your job, go to Australia, and work in a cargo ship to pay for the trip! Then, if you want, afterwards come to my office to report what happened. I will receptively listen to your report without any comments." 
Gustav could not control his emotions and cried deeply. He was starting to see how sick he was; how foolish he had been all those years! "No", he told me, "I want to stay and improve. I want to respond to life and find my truthful life, find who I am, while not relying on others!" 
Treatment continued for about 20 weeks. Gustav did not miss any sessions. He took almost no medication, except those for a chronic depressive crisis and debilitating anxiety. The medication prescriptions were always negotiated with him. 
Then, unexpectedly, he fell deeply into drugs and legal difficulties. Later, he had a very bad accident while using alcoholic beverages. He was hospitalized to recover. 
One day he called me from hospital. He wanted to have me visit for a meeting in his hospital room. I went there and stayed in silence after a friendly greeting. He started saying that I was his only friend, because with me he was motivated to see the truth and face his anguish with a new attitude. Now he had the opportunity to confront himself. Who was he? What did he want from life if he now saw himself as a simple human being and not the owner of anything? His greatest desire was to continue to face life and what life demanded from him, to continue changing with my help. Then he felt a deep cry within; sobbing mixed with genuine sadness. 
I replied, "Gustav, as I told you, my door is always open. It is up to you to walk in, to respond to my call, to find a new purpose, even through persistent suffering as you are experiencing now, and maybe forever. Our companionship is available to you and can continue all the time, is up to you to decide!" 
Results 
Therapy now goes on, and Gustav resumed his job and his university studies. He stopped using drugs and alcohol, at least temporarily. His behavior and emotions have become more stable. Even the relationship with his parents has improved. Now he is trying to resume his relationship with his girlfriend and to restore lost friendships. Knowing that he is a "borderline personality disturbance" person -a diagnosis that I keep to myself -I am not sure whether he will maintain this stability and therapy motivation. I really do not know for how long he will stay in this sound way of living, with this current emotional stability and his less turbulent behaviors giving him hope to go on. 
25 
Of one phenomenon I am sure: that using the logotherapy statements, appealing to freedom and responsibility, calling to face the meaning of truth and suffering with a new attitude, and the challenge to Gustav of changing himself through meaningful personal relations -I could at least help Gustav to decide to be conscious of himself, and sometimes authentic, in spite of great suffering, depression, and anxiety. Finally I could help him to firmly elaborate, within his deep spiritual person, that it is up to him to decide the purpose of his life and what he will do with his special and unique way of life and personality. 
Conclusion 
The logotherapeutic approach to the client with BPD may afford practitioners an excellent potential to deal with such a difficult syndrome and the opportunity to obtain, at least temporarily, positive results in its treatment. The main reason originates in the flexibility and humanistic comprehension of the unique and special way of the BPD patient's life. Trying accordingly to face the patient's emotional instability and unforeseen, unexpected behavior as a reality and as a challenge, the practitioner dares to appeal to the spiritual dimension to assume a new attitude, a free decision to reflect and be responsible, and for experiencing life-meaning, in spite of personality disturbance and persistent suffering. Also, this challenge is not only for the patient, but also for the therapist, who must unconditionally accept the patient's tendency to hostility, manipulation, bad successes and unexpected failures, abandoning treatment and regressing to a pre-therapy phase; and sometimes getting worse, potentially causing family hostility against the professional clinician. This flexible attitude required from the treating practitioner is also a model to the patient, who sometimes is desperately asking for such guidance unconsciously. 
ROBERTO RODRIGUES, M.D., Ph.D. [Ave lcarai 74 Cristal, Porto Alegre RS 90810-000, Brazil] is a Psychiatrist and Psychologist in Private Practice, Professor of Psychiatry at The Lutheran University of Brazil and Dip/ornate in Logotherapy. He is also President of the Viktor Frankl Association of Logotherapy, Curitaba, Brazil. 
26 
References 
1. 
Arieti, S. (1972). Handbook ofpsychiatry. Vol. I. NY: Basic Books. 

2. 
Crumbaugh, J. (1988). Everything to gain. A guide to self-fulfillment through logoanalysis. Berkeley, CA.: Institute of Logotherapy Press. 

3. 
Frankl, V. E. (1978). Fundamentos antropol6gicos da psicoterapia. 


R. Janeiro: Zahar. 
4. 
Frankl, V. E. (1996). Em busca de sentido. Um psic6logo num campo de concentrar;ao . Petr6polis: Vozes. 

5. 
Holmes, D. ( 1997). Psicologia dos transtornos mentais. Porto Alegre: Artmed. 


4
6. Kaplan, H., & Sadock, B. (2000). Tratado de psiquiatria. 3 Volumes. 8 edi<;:ao. Porto Alegre: Artmed. 
7. 
Lewis, M. (1999). Tratado de psiquiatria da lnfancia e adolescencia. Porto Alegre: Artmed. 

8. 
Lukas, E. ( 1986). Meaning in suffering. Berkeley, CA: Institute of Logotherapy Press. 

9. 
Rodrigues, R. (1991 ). Fundamentos da logoterapia. Petr6polis: Vozes. 

10. 
Rodrigues, R. (1999). Noodynamisms of value deficiency. Dallas: Logotherapy Diplomate Thesis. 

11. 
Sanchez Meca, D. (1984). Martin Buber. Fundamento existencial. Barcelona: Herder. 

12. 
Talbot, J., Hales, R., & Yudofski, S. (1998). Tratado de psiquiatria. Porto Alegre, Artes Medicas. 

13. 
Yalom, I. (1984). Psicoterapia existencial. Barcelona: Herder. 


27 
The International Forum for Logotherapy, 2004, 28-33. 
TREATMENT AND INTERVENTIONS FOR NARCISSISTIC PERSONALITY DISORDER 
Julius M. Rogina 
After the brief psychotherapy has been completed and the patient is "feeling better" the following thoughts and question arise: 
Your depression has lifted, your anxiety is 
tolerable, yet you complain about having 
feelings of unbearable emptiness and dislike 
for people. You talk about the need for 
admiration. You have shared how your friends 
admonish you that you behave in haughty and 
demanding ways. Would you be willing to 
explore these issues from the view of maladaptive ways of relating to 
yourself and others? These maladaptive ways of relating are called 
personality traits, features, or disorders. They are impaired patterns 
of self-sabotage. I am inviting you to engage in discovering some 
freedom to respond instead of just reacting to what is causing your 
pain. 
What is the prevalence of Narcissistic Personality Disorder (NPD)? Estimates of the prevalence of NPD range from 2% to 16% in the clinical 
16
population and are less than 1% in the general population.1 · p.7 
Logotherapeutic Formulation 
Persons diagnosed with NPD experience an ongoing and pervasive sense of "existential vacuum," or a sense of meaninglessness as formulated 
45
by Viktor E. Frankl.4' p.4 -4 In part, this is a by-product of self-absorption, which leads to experiences of existential vacuum that manifest in insensitivity to one's own needs as well as the needs and views of others. Thus, I propose a Logotherapeutic formulation for intervention with persons with NPD. 
Patients with NPD live like the Wizard of Oz. They like their wizardry and hide their real selves behind the curtain, unable to create intimate relationships. They are afraid of being discovered. Their compensatory behaviors are arrogant and haughty. They have created an illusion of entitlement and a malignant sense of specialness. Just like the Wizard of Oz, they are hiding from people and avoiding becoming known. As presented in the story written in the early 1900's by Frank Baurri2 the Wizard of Oz is viewed clinically by this writer as a compensatory narcissist. 

28 
Some persons with NPD can be extremely effective personalities but eventually problems arise.6· pa? Their increasing need for admiration and the exploitive nature of their relationships become irritating. The increasing sense of emptiness and deprivation in their relationships precipitates noogenic (spiritual) crises experienced as emptiness, sadness, loneliness, negativity, and isolation. 
To cope with these feelings of emptiness and loneliness and to assuage their insecurities, patients with NPD become preoccupied with establishing their power, appearance, status, prestige, and superiority.7· P-27 
The patients in this vicious NPD cycle expect everyone to recognize their entitlement and specialness and to meet their needs. Their illusion is that they are entitled to be served, that their own desires take precedence over those of others, and that they deserve special consideration in life. These beliefs reinforce the impenetrable defenses of resistance to examination of the existential vacuum. This impenetrable defense of resistance prevents them from openness for the specific meanings to be fulfilled, by clinging to maladaptive cognitive schemas, painful feelings of emptiness, and empty relationships. 
They are stuck in rigid ways of experiencing and interpreting themselves and the people around them. Patients with the NPD disturbances find it undesirable and unthinkable to love someone or something, to sacrifice personal specialness, or to experience a sense of deep empathy for others. They need guidance to see alternative ways of living their lives. 
When patients with NPD affirm an affiliation with an organized religion, or claim practices of some form of spiritual discipline, the maladaptive ways of relating continue. For them, God and everyone and everything else, even a daily practice of meditation and/or prayer, exist for one purpose: to feel better, to be loved, and to take care of them. Spiritual practices become another source for narcissistic supplies. Their basic spiritual deficits often manifest in a lack of awareness of grace and an incapacity for gratitude. They imagine God as an all-giving father. They perceive faith as magical entreaty.6· p.ss 
Logotherapy case conceptualization should include the following: 
(A) 
Gathering Relevant Historical Data. Which historical experiences contribute to presenting symptomatology of painful emotional intensity? Which historical experiences drain present meaning potentials? 

(B) 
Observing Compensatory Behaviors. Which current behaviors suggest avoidance of meaning potentials? What is the meaning of the patient's pain to himself/herself? Is the r.atient's personal conscience,the "voice of transcendence," 

· P-51 being listened to? 

(C) 
Presenting Problematic Issues or Behaviors. What is the patient presenting as the motivation for his/her desire to engage in psychotherapy? 

(D) 
Exploring Positive Beliefs about life in general. Life is meaningful to me when... and under all circumstances because ... then what. ..; my life offers demand quality for responsibility; I have freedom to choose among possible options... and decide about my goals. 

(E) 
Exploring Negative Beliefs about life in general. Life is meaningless because ... I behave this way because ... ; my behaviors are determined by my biology and I react instinctively to survive in whatever the situations are in my life. 


29 
Once the diagnostic impression is established, the Logotherapeutic Treatment Protocol should be initiated. 
Logotherapeutic Treatment Protocol 
1. 
Identifying domains of meaninglessness by conducting Logotherapeutic Existential Analysis of presenting frustrations and complaints (as stated above A through E). 

2. 
Educating the patient about noodynamics in general and his/her value deficiency in particular. 

3. 
Engaging the patient in skill training for empathic and compassionate living towards oneself and others. 

4. 
Modifying attitudes by expanding awareness about the needs of others; "relating to others as human beings to be loved and understood rather 


27
than things to be used and manipulated." 3· P
5. 
Guiding the patient to respond willingly to the meaning potentials of the moments as encountered in the demand quality of his/her life. 

6. 
Restructuring early experiences that created compensatory beliefs of specialness and generated lack of empathy for self and others. Focus on transforming these experiences with a meaningful perspective of uniqueness, explaining the difference between specialness and uniquness. 

7. 
Committing to the particular meanings of the moment and assisting the patient to accept the demand quality of life with responsibility, by using the Logotherapeutic Anchoring Technique. The assistance of the story of The Wizard of Oz 2 could be employed by addressing what is here at hand. 

8. 
Training Emotional Tolerance Skills to transcend maladaptive reactions of angry outbursts, alcohol or drug abuse, gambling, inappropriate sexual behaviors, and social isolation. The goal is to transcend grandiosity and in particular excessive seeking for resources of narcissistic supplies. Assist with restructuring the need for excessive admiration in order to continue structuring meaningful behaviors and goals. 


30 
The Case of Mr. Smith 
Mr. Smith is a 45 year old businessman with no children and a 15 yearlong marriage (the factual data in this case are disguised to protect confidentiality). 
He comes to treatment complaining of depression with anxiety and dissatisfaction with his marriage. He observed: 
It is terrible! She is never home. She does not spend time 
with me. I am such a great guy and there are many women 
who admire me. She does not have any idea about what a 
great guy I am. She puts me down. She does not 
acknowledge even a bit of all I have done for her. I want 
affection, but forget it! She isolates me. She tells me that I 
am arrogant and insensitive. 
Differential Diagnosis suggests that he not only meets criteria for Dysthymic Disorder and Anxiety Disorder NOS on Axis I, but his pre-morbid level of functioning, as assessed by MCMl-111, clinical interviews, and psychosocial assessment of personal history, reveals that he meets at least five criteria needed for Narcissistic Personality Disorder diagnosis on Axis II. 
There were no medical problems reported relevant for Axis Ill diagnostic concerns. When asked, the patient stated that he is in excellent physical health. His Axis IV is related to his isolative behaviors and moodiness. His level of functioning on Axis V is somewhere between 65 and 70. 
His haughty demand during the initial interview was "I need help with my depression. I need to feel better very soon. I hope you are trained to help me. My insurance carrier referred me to you. You are on the provider list." 
After my referring him to his primary care physician who initiated treatment for depression (Dysthymic Disorder) and anxiety with a small dose of antidepressant, the patient returned to continue psychological treatment with me within four weeks. His response to medication was positive as his sleep had improved and he felt less irritable. 
He was asked upon his return to psychotherapy: "are you willing to engage in psychotherapy and explore your maladaptive ways of relating to yourself and others and in particular to your wife?" His response was a strong, yes! 
The eight steps of Logotherapeutic Protocol for treating NPD were initiated. 
After 24 sessions of Logotherapeutic treatment and application of the protocol, the patient had a profoundly meaningful realization that prompted him to start engaging in his marriage. He committed himself to the selftranscended value system, as he said, "I will love her on her terms and generously. I have always tried to change her. I know I have to change myself. I do not like this change. I know that my behaviors have hurt her badly. I am not even aware of my particular destructive behaviors. All I know is that she is hurt and she does not trust me at this time." 
31 
The following story was shared with this patient: 
A man began to give large doses of cod-liver oil to his 
Doberman because he had been told that the stuff was good 
for dogs. Each day he would hold the head of the protesting 
dog between his knees, force its jaws open, and pour the 
liquid down its throat. 
One day the dog broke loose and spilled the oil on the floor. 
Then, to the man's great surprise, the dog returned to lick 
the oil from the floor and the spoon. That is when the man 
discovered that what the dog had been fighting was not the 
cod-liver oil but his method of administering it. 
Gradually, the narcissistic rigidity of his experiencing and interpreting the wife's behaviors gave way to empathy and desire to encounter her. "I never realized how needy and demanding I was. I did not know how beautiful and generous she is." 
As a result of treatment with logotherapy and antidepressant medication, Mr. Smith's symptoms have abated to a great degree. He is currently continuing on a smaller dose of antidepressant as monitored by his physician. The depression and anxiety appear to have been subsiding. The patient noted: "I still get hurt and depressed when I do not get what I want. It feels something like the world is falling in on me. But I am better able to act on what I believe is right and less on my painfully intense emotions. I am more able to listen to my defective emotions, soothe them, and not act on them." 
Mr. Smith continues attending emotional tolerance skills training and learning to love his spouse with empathic verbalizations and affirmations. He recognizes and notices at this time more readily his exploitive behaviors for narcissistic supplies. 
Conclusions 
The NPD Logotherapy Treatment Protocol provides a viable method for psychotherapy implications in general, and logotherapy as a specific mode of treatment in particular. 
The purpose of this article was to apply a theoretical framework of logotherapy in a particular treatment of NPD. The applied logotherapeutic protocol shows promise in this case. There is a need for further research to replicate its validity. 
Logotherapy protocol provides gradual healing from narcissistic injuries to encountering one-self and others through meaningful behaviors, away from grandiose narcissistic fantasies that create need for excessive admiration, haughty and demanding behaviors, and feelings of emptiness. 
The story of The Wizard of Oz, the Wizard being the compensatory narcissist, should be used as an illustration of the healing changes for the NPD. It was the Wizard himself who confessed after being discovered: "I 
32 
have fooled everyone so long that I thought I should never be found out. It was a great mistake my ever letting you into the Throne Room." Dorothy replied, "I think you are a very bad man." "Oh, no, my dear, I'm really a very good man; but I'm a very_ bad Wizard, 
162 173
I must admit. Yes, of course, I am tired of being such a humbug." 2· P· · 
The NPD patients gradually give up their maladaptive compensatory behaviors and give permission to themselves to explore a self-transcended value system of loving oneself and others. The Wizard of Oz gradually realized that giving up being a wizard behind the curtain did not mean the end of his life. It actually meant the beginning of a life of authenticity and new possibilities. 
JULIUS M. ROGINA, Ph.D. (427 Ridge Street, Suite A, Reno, Nevada 89501-1738, Telephone 775-324-2000, E-mail jmrogina@aol.com] is a Clinical Psychologist in Private Practice, Dip/ornate and Faculty Member of The Viktor Frankl Institute of Logotherapy. 
References 
1. American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders DSM-IV-TR (text revision), Washington DC. 
2. 
Baum, F. ( 1979). The wizard of Oz. NY: Ballantine Books. 

3. 
Fabry, J. (1980). The pursuit of meaning. San Francisco: Harper and Row. 

4. 
Frankl, V. (1969). The will to meaning. NY: Plum and Meridian Books by The New American Library. 

5. 
Frankl, V. (2000). Man's search forultimate meaning. Cambridge, MA: Perseus. 


6. Sperry, L. (2001 ). Spirituality in clinical practice: Incorporating the spiritual dimension in psychotherapy and counseling. Philadelphia, PA: Brunner-Routledge. 
7. Vaknin, S. (2003). Malignant self love: Narcissism revisited. Prague and Skopje: Narcissus Publications. 
33 
The International Forum for Logotherapy, 2004, 27, 34-38. 
COMBAT-RELATED PTSD AND LOGOTHERAPY 
Robin M. Gilmartin & Steven Southwick 
In accordance with DSM-IV, Posttraumatic Stress Disorder (PTSD) follows from traumatic events that have been experienced, witnessed, or confronted and which involve actual or threatened death or serious injury, or threat to the physical integrity of self or others. In addition, adults who develop PTSD must experience the trauma with a feeling of intense fear, helplessness, or horror, while children may express their distress in the form of disorganized or agitated behavior.1 Unfortunately, a high percentage of the world's population is exposed to one or more major traumas during their lifetime. Common traumas include natural disasters, war, domestic and criminal violence, child abuse, and accidents. Some traumas are more likely to cause PTSD than others. For example, the likelihood of developing PTSD in the United States is 45% for women who are raped, 65% for men who are raped, 30% for combat soldiers, and 2-10% for survivors of natural disasters.7'8 
The symptoms of PTSD are divided into three symptom clusters. The reexperiencing symptoms are characterized by recurrent and intrusive recollections of the event, recurrent distressing nightmares of the event, flashbacks, and intense psychological distress and physiological reactivity upon exposure to traumatic reminders. The avoidance symptoms include the persistent avoidance of thoughts, activities, people, and places reminiscent of the trauma, numbing of general responsiveness and restricted range of affect, and a sense of foreshortened future. The third symptom cluster involves the inability to modulate arousal with complaints of insomnia, anger, irritability, hypervigilance, exaggerated startle response, and difficulty concentrating. Additionally, many combat veterans report survivor guilt, depression, affect dysregulation, and an altered world view where fate is seen as uncontrollable and life as devoid of meaning. 
Chronic combat-related PTSD is difficult to treat. Therapeutic success rates generally have been modest to moderate. Currently accepted treatments include exposure therapies, cognitive processing therapies, psychodynamic psychotherapy, EMDR, hypnotherapy, and pharmacotherapy.4 These therapies have primarily focused on the alleviation of specific PTSD symptoms and symptoms of accompanying co-morbid psychiatric disorders. However, even when DSM symptoms respond to treatment, many veterans with PTSD are left feeling hopeless with profound existential questions related to the loss of meaning in life. 
In this report we describe the use of logotherapy for the treatment of a combat veteran suffering with chronic PTSD. We chose logotherapy because 
34 
it directly addresses the traumatized individual's struggles with several core issues related to free will and meaning. These include: a sense of foreshortened future, an external locus of control, guilt and survivor guilt, and existential loss of meaning. A focus on existential and spiritual issues also has been recommended by Hutzell et al. as part of a multimodal approach to treating PTSD. 6 
Logotherapy Case 
Jim, a 54-year-old Vietnam veteran who served as a medic in the Marines, struggled with chronic war-related PTSD. He joined a weekly meaning-focused Community Service (CS) group after completing a combination of treatments for PTSD -cognitive behavioral therapy (CBT), pharmacotherapy, skills training (relaxation, anger management, grounding techniques, etc), followed by exposure therapy. These treatments were moderately effective in reducing some symptoms while improving Jim's coping with other, persistent symptoms. Jim also learned he could manage without self-medicating with alcohol after years of heavy drinking to "numb out." Though his symptoms had improved somewhat, Jim still felt empty inside. As he put it: "My life doesn't seem so out of control and I can sleep and function better, but I still don't feel better." 
Now stable and sober, Jim was ready to join a CS group made up of other combat veterans with chronic PTSD. In the group, members collaboratively develop and implement community service projects that are meaningful to them. Projects tend to be generative, corrective, or redemptive. Personal experiences of suffering, guilt, and loss in war are the impetus for much of the group's work. 
Jim was continually haunted by the meaningless deaths he had witnessed, of two events in particular. First, the image of a bombed village, of children and elders he had once helped, now dead. The meaninglessness of this was exemplified for him in the undisturbed face of a dead child: "Her face wasn't burned or anything. She still looked so beautiful and young and hopeful, but she was dead and so were the rest of the children." The image seemed also emblematic of his own experience; though he looked "okay" on the outside, inside he felt dead. Since Vietnam, Jim felt a helplessness and despair and loss of meaning in life. 
A second traumatic loss involved the combat death of his best friend in Vietnam, which Jim had witnessed. Jim felt he had no right to live a full life with his friend dead. The question -"Why did I come home and he didn't?" could not be answered. His survivor guilt became more potent with age; while he had attained a mid-level corporate position by his late 30's ("going through the motions"), Jim was destitute and homeless by his late 40's. He frequently voiced disbelief at having "lived this long and for what?" 
Ever mindful of not letting others down, Jim quickly became active in a CS group project -planning a toy drive and holiday party for children in the local foster care system. Long anguished over his inability to protect children 
35 
in war, Jim now poured his energies into "making sure everything is right." His initial worry over every detail (as if the children's very lives depended on it!) eventually gave way to enjoyment in interacting with the kids. The simple acts of attending to the children -serving juice, helping them put batteries in toys, being the first adult to meet a new doll -brought him into the present and to current opportunities for meaning. 
Soon after joining the group, Jim learned that he was granted a pension from the government for chronic PTSD as a result of his military service. This was met with mixed feelings, on one hand, relief from financial worries, but on the other, guilt. Jim, like other veterans with survivor guilt, felt somehow it was "blood money." On top of having inexplicably survived while others didn't, he was now being paid for "making it home." Other veterans in the group helped Jim talk about his dilemma, and he seemed to awaken to the fact that he had choices. Instead of acting self-destructively, as he had so often in the past, Jim chose a different path. Prior to his death, Jim's friend had shared his dream of returning to college after the war. Jim now decided to set aside a portion of his disability pension to fund a partial college scholarship in his friend's name. 
Recently Jim's elderly mother has begun to fail. He and his mother are close. Jim has been surprised by his own response to facing his mother's death, which is imminent. Until now, Jim equated death with traumatic death, which he felt was devoid of all meaning. Through the group, he discovered meaningful responses to even the meaningless carnage of war. Jim has embraced what Frankl termed Tragic Optimism, optimism in the face of human suffering, guilt, and death, which enables one to transform tragedy into achievement. This has opened the way for him to experience death and dying in a different way. Jim is able to describe his mother's "full life" with all the objectivity of a storyteller and the subjectivity of a loving son. His feelings are poignant and new as he celebrates her life while preparing to lose her. 
Discussion 
We have identified four core existential issues that veterans with combatrelated PTSD often face and which conventional therapies alone do not adequately address. These include a severely skewed external locus of control, a foreshortened sense of future, guilt and survivor guilt, and loss of meaning. In the case presented, the meaning-focused treatment group combined action and reflection and provided a framework for Jim to address his existential symptoms of PTSD. While previous treatments succeeded in ameliorating other symptoms and in helping Jim find sobriety, he was stuck in the Tragic Triad of death, suffering, and guilt. A logotherapeutic approach was clearly indicated. 
Jim was initially "hooked into" the collective service work out of a sense of responsibility to help fellow veterans. Once hooked, responsibleness developed which challenged evidentially his fundamental skepticism that his choices and actions matter. In describing the children's faces as they opened 
36 
gifts, he later talked about experiencing something he rarely felt; the sure knowledge that what he did genuinely mattered. Through Socratic dialogue and group process, Jim explored disruptions in meaning, and, through the service work, rediscovered meanings, for example in responding to the children in the moment. 
While Jim accepts that he may be unable to prevent tragedies, he has begun to view himself less as a victim of circumstance. Although there is no explanation for the tragic loss of a friend, Jim managed to find meaning in his response to this fate. By initiating the scholarship, he transformed stagnating, and often destructive, survivor guilt into an animating guilt. Jim feels his survivor guilt contributed to prior alcohol abuse and believes that honoring his friend now helps to keep him sober. In addition, his sense of foreshortened future has now become a catalyst for his deciding on the legacy he wishes to leave. Jim's choice to initiate a scholarship in memory of his friend ensures that both their lives count! 
Conclusions 
We believe that meaning-related issues are a central and neglected aspect of PTSD research and treatment in combat veterans with PTSD. Rigorous research on the use of logotherapy as an adjunctive treatment for trauma-related existential loss of meaning is needed. Future treatment studies may operationalize particular logotherapeutic approaches thought to be well suited for male combat veterans, for example, models emphasizing collective action-oriented approaches. Instruments of meaning and pur~ose
39
and Existential Vacuum are valid and reliable for use in this research. 2·· · In our experience, logotherapy uniquely offers the combat veteran who struggles with existential issues, hope for healing through meaning. It also offers opportunities for important future investigation. 
ROBIN M. GILMARTIN, MSW, LCSW [VA Connecticut Healthcare, 555 Willard Ave., Newington, CT 06111, USA] is Director of the PTSD Residential Rehabilitation Program at the Newington, CT Veterans Hospital. She is Associate in Logotherapy. 
STEVEN SOUTHWICK, MD, is Deputy Director, Clinical Neuroscience Division of the National Center for PTSD, and Professor of Psychiatry, Yale University Medical School, New Haven, CT. He is Associate in Logotherapy. 
37 
References 
1. 
American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders, 4th edition (DSM IV). Washington, DC. 

2. 
Crumbaugh, J. (1977). The Seeking of Noetic Goals test (SONG): A complementary scale to the Purpose In Life test (PIL). Journal of Clinical Psychology, 33, 900-907. 

3. 
Crumbaugh, J., & Maholic, L. (1976). Purpose In Life test. Abilene, TX: Viktor Frankl Institute of Logotherapy. 

4. 
Foa, E., Keane, T., & Friedman, M., (Eds.). (2000). Effective treatments for PTSD. Practice guidelines from the international society for traumatic stress studies. NY: Guilford Press. 

5. 
Hutzel!, R. (1989). Life Purpose Questionnaire. Saratoga, CA: Institute of Logotherapy Press. 

6. 
Hutzel!, R., Halverson, S., Burke, T., Carpenter, B., Hecke, A., Wooldridge, H., Stanley, C., Chambers, T., & Hooper, R. (1997). A multimodal, second generation, posttraumatic stress disorder rehabilitation program. Journal of Traumatic Stress, 10, 109-116. 

7. 
Kessler, R., Sonnega, A., Bromet, E., Hughes, M., & Nelson, C. (1995). Posttraumatic stress disorder in the National Comorbidity Survey. Archives of General Psychiatry, 52, 1048-1060. 

8. 
Kulka, R., Schlenger, W., Fairbank, J., Hough, R., Jordan, B., Marmar, C., & Weiss, D. (1990). Trauma and the Viet Nam war generation: Report of the findings from the National Viet Nam Veterans' Readjustment Study. NY: Brunner/Maze!. 

9. 
Starck, P. (1985). The Meaning in Suffering Test. Berkeley, CA: Institute of Logotherapy Press. 


38 
The International Forum for Logotherapy, 2004, 27, 39-51. 
LOGOTHERAPY IN REHABILITATION WORK 
Manfred Hillmann 
The regional hospital at Meppen, in Northern Germany, has 418 beds and some 800 employees. In 1997, an interdisciplinary unit for early rehabilitation was established. 
In this unit, the strict demarcation between hospital treatment and rehabilitation was abolished. Patients with various illnesses and syndromes (neurological syndromes, brain-trauma, strokes, cerebral hemorrhage, post-operative conditions, conditions after oxygen deficiency, and inflammatory diseases) are treated at the earliest possible opportunity. There are two wards, one for patients who still need intensive care and one for patients whose health is more stable. Most of the patients are stroke victims. There are 45 beds and a team of 85 therapists -(medical staff, nurses, neuropsychologists, occupational therapists, physiotherapists, art-therapists, speech therapists, social-workers, and a logotherapist). The manifold health disorders require the involvement of different specialists and a variety of treatments. 
My employment as a logotherapist started with the idea of giving support to the families and relatives of patients with severe brain damage and comatose patients. From that involvement, the work was extended to particular patients for whom the application of the relaxation method of autogenic training and logotherapeutic counseling could be beneficial. 
Experience has shown that Viktor Frankl's logotherapy can be very aptly applied within such a setting. Logotherapy provides a human vision and a world-view, which yield fruitful insights into the suffering human and into the various ways to offer help. Given the variety of different patients and situations my experience indicates that the body of logotherapeutic knowledge offers deep insights and rich resources and is helpful to patients. Of course, some patients are more open and receptive than others are; but, even for those who are not, the logotherapeutic intervention never seems completely fruitless. The experience therefore is a very positive one and speaks for the quality of Frankl's teachings. In this article, I give a short description of my practical work in the clinic. 

39 
Logotherapy and Autogenic Training 
The tools I work with are three-fold: my own life experience, the concepts of Frankl's logotherapy, and the relaxation method of autogenic training. 
Autogenic training is a relaxation method that was developed by the German doctor Johannes Heinrich Schultz, who was well acquainted with Frankl's theories.6 Through a few well-chosen mental exercises, a profound state of relaxation can be achieved. It is simple in its structure and yields instant results, even if only partially applied. Autogenic training is scientifically well-researched and is an integral part of German medicine and psychotherapy. It is also one of the most popular relaxation methods in Germany and indeed is renowned worldwide. [For a more detailed description of this method see: Autogenic Training and Logotherapy in The International Forum for Logotherapy.5] 
In the clinic, I use this method with patients who suffer from nervousness, insomnia, anxiety, or pain. I also apply it as a preliminary stage for logotherapeutic counseling. The counseling works with much more concentration and fluency with application of relaxation. 
Logotherapy provides a wide range of therapeutic knowledge. Of immense help within a clinical setting are Frankl's insights about the suffering human being. Meaning is a strong healing force if it can be evoked in a patient. Frankl's meaning concept reaches further than the concept of positive thinking. The optimism, even in adversity, which is communicated through logotherapy triggers hope. 
Logotherapy surpasses narrow methodical concepts. The example of Frankl's own life serves as a role model and gives authenticity and substance to his teachings. The manifold therapeutic explanations and pointers are a rich source for counseling and crisis intervention. Frankl himself pointed out that the logotherapist must improvise in order to do justice to the individual patient. In a clinical setting, especially, the art of improvisation is demanded, and the possibility to do that successfully is inbuilt in logotherapy. It is the combination of "strategies on the one hand 
4 164
and on the other I-Thou relationships." · P 
The Patients and Their Sufferings 
The variety of illnesses means a variety of suffering experiences. It is obvious that each patient is unique, and, although there are common experiences, fundamentally, no one is to be compared with another. Each patient has his or her own background of personal life experiences, of personal development and skills, of attitudes and views of life, of psychological stability or instability, and of spiritual experiences or lack of them. It is therefore imperative to attend to the uniqueness of each patient 
40 
and to offer individualized help rather then enforce one method on all patients. 
Viktor Frankl's logotherapy is particularly helpful because it begins with an anthropological clarification, which includes a definition of Frankl's human vision and his worldview, before he develops any particular method for practical application. Logotherapy is very flexible in swinging between methods and a basic understanding of what is a human. For this reason it is possible to encompass all the different personalities and states of suffering one encounters in a clinical setting as described above. 
Some aspects of suffering apply to all. In the case of patients in general and of their relatives, there is shock, uncertainty, and disorientation. In the case of stroke patients, there is the experience that all of a sudden nothing is as it was before. Everyday stability has broken down and the future loses its positive outlook. Rather, it takes on the image of a desert -empty space and no resources to depend on. The existential vacuum becomes tangible and meaning seems a word devoid of all content. Fear and frustration creep in and hope seems nowhere in sight. There are different phases such as denial, depression, negotiation, and aggression. It is a crisis situation and is difficult and demanding. 
The logotherapeutic vision aims, of course, to help patients and relatives learn to cope with the situation and develop a positive, meaningful outlook on life, despite everything. It is important to keep up a vision but acknowledge at the same time that the slightest progress, change in attitude, or the slightest rising of hope is already something magnificent. The journey is arduous and cumbersome. Going forward and falling backward is a part of it. There are patients who absorb all proffered help and progress greatly. Others seem to come to a halt. And yet others make small progress. There is also a limitation to intervention as patients usually stay only between three and six weeks, though some stay for several months. Yet, experience shows that patients often can make use of logotherapy and autogenic training long after they have left the clinic. Information leaflets, book-recommendations, audiotapes, stories, memories of personal encounters, all of which the patients take home, are the basis for reconnecting and further growth. 
The Patients' Group 
The patients' group meets once a week and is attended by patients who are cognitively in a position to follow the subjects which are dealt with in the group. They are given information about the nature of their condition and are involved in a talk about how to deal as adequately as possible with their situation. The conversation is based on a variety of logotherapeutic themes 
41 
that are presented to the group. A few themes have proven relevant and helpful for the patients. I will mention some. 
The Human Being in Its Three Dimensions 
The simple distinction between the three dimensions, body, psyche, and spirit makes the patients aware that healing is not, and must not be, restricted to the focus on the body level alone. The psyche needs care as well, and the explanation of the spiritual dimension makes clear that one can also choose what to occupy the mind with. This explanation, and the conversation with the group and among the group members, as well as giving of graphic examples, broadens the previously narrowed focus. 
Three Pathways to Meaning 
Meaning is found on three pathways, through the creative, experiential, and attitudinal values. This is a most important differentiation, for usually a one-sided work ethic is dominant. Meaning is strongly linked with, and experienced in, work and functionality. But this is the area where currently, and often in the future, the patients are restricted. That the meaning of life can be dependent on different aspects is basically known to everyone but not lived. The idea that meaning can principally be fulfilled through hardship and restricted movement, as well as through suffering, makes patients think anew. 
The Copernican Turning Point 
The presentation of the Copernican turning point, that we ourselves can't ultimately make demands on life but that life demands answers from us, is also a powerful concept to help patients to arrive at a different attitude. "What was really needed was a fundamental change in our attitude towards life. We had to learn ourselves, and, furthermore, we had to teach the despairing men, that it did not really matter what we expected from life, but rather what life expected from us." 3' P·93 Patients are sometimes astonished that they never thought about this simple yet true idea. It is not the case that the presentation of such an idea turns around patients right away, but it clearly puzzles them and gives them reason to think. 
Evaluation of What is Lost at Present and What is Still Functional 
A suffering person is fixed on what is lost through the illness. For a stroke victim the legs, arms, or the face may be paralyzed, or eye-vision may be restricted. There is shock and emotional confusion on the psychical level. Thinking is overshadowed by a state of gloom. 
42 
In the group an evaluation is made on what is lost and what is still functional. In the process of this exercise of de-reflection most patients come to a more positive outlook. 
Three Possible Helping Factors 
In a crisis situation there are three principal helping factors, namely: the sympathy and understanding of other people, one's own meaning-orientation, and faith and trust in God. These hints give patients an idea of what areas to look for help, and it makes them also aware that in each area they can play a more active role. The sympathy and understanding of other people can be added to by the patient's acknowledging the attention and affection of others. Visitors like to come back if they find a patient who is able to smile and show gratitude for the visit. Searching for meaning-orientation is what the patients' group is about. The faith dimension needs special attention because in a modern society it is not spoken about openly. Often it has withdrawn into a private niche. 
It is by speaking sensibly about this latter area that patients become more open to speaking about their personal faith and prayer life. And often enough this is, in any case, the crucial point for keeping up hope and strength. Patients have to be aware that there is the help that comes from medicine, the help that comes from psychology, and the help that comes from spirituality. 
Evaluation of Attitudes towards Life 
The following is projected onto a screen and read out aloud: 
Life is an opportunity, benefit from it. 
Life is beauty, admire it. 
Life is bliss, taste it. 
Life is a dream, realize it. 
Life is a challenge, meet it. 
Life is a duty, complete it. 
Life is a game, play it. 
Life is a promise, fulfill it. 
Life is sorrow, overcome it. 
Life is a song, sing it. 
Life is a struggle, accept it. 
Life is a tragedy, confront it. 
Life is an adventure, dare it. 
Life is luck, make it. 
Life is precious, do not destroy it. 
Life is life, fight for it. 
(Mother Teresa) 
Each patient is asked to pick one phrase to which they feel near and is encouraged to talk about why he or she picked this particular phrase. It becomes obvious that every patient has his or 
43 
her own perspective, experience, and v1s1on. And by articulating these, each patient becomes aware that different standpoints are possible even within him or herself. The exercise leads also to the telling of personal stories that are beneficial for the other participants. It brings attitudinal values into awareness. 
Looking Back: A Crisis Already Lived Through 
In this exercise, patients look back into their own life histories in order to look for a crisis they lived through. By telling these stories, patients become aware that they have much more strength and creativity in them than of which they are usually aware. Realizing this gives encouragement for coping with the present situation. 
Stories 
Stories stimulate the imagination and are appealing on the emotional level. Therefore, patients are introduced to stories that carry a message that can be helpful in the coping process: 
Ben Sadak, a dour, gloomy man, was on his way through an oasis. He was a man so malicious of character that he no sooner saw something healthy and beautiful but he had to wreck it. At the edge of the oasis stood a young palm-tree in full bloom. This caught Ben Sadok's eye. Thereupon he grabbed a big stone and lobbed it on the crown of the young palm-tree. Then, with an evil chuckle, he continued on his way. 
The young palm shook and bent itself, in order to throw off the burden, but to no avail. The stone would not budge from the crown. 
At this the young tree dug deeper into the ground to have a firmer stand under its stony burden. Digging thus its roots so deep they reached the hidden water source of the oasis, and the stone was lifted so high that the crown reached above every shadow. Water from the depths and the blazing sun from above had turned the young palm into a majestic tree. 
Years later Ben Sadak returned to take delight in the tree he had crippled. He searched in vain. Then the loftiest palm lowered her crown, showing the stone, and said: "Ben Sadak, I have you to thank, your burden has given me all this strength." 
From this story one can draw a reflection on attitudinal values and seeing possibilities in crisis-situations. The hint that roots 
44 
have to dig deeper is also an important aspect to consider from this story. 
Role Models 
The autobiography of the actor Kirk Douglas, My Stroke of Luck -My New Life after a Stroke, 2 is suitable for presentation in the group as most everyone knows this actor and is interested in how Douglas deals with his experience in suffering a stroke. One sees how he was in despair and how he slowly recognized that the only way is to look forward, and to do that is to practice whatever one can in order to progress. Some quotations are given to the patients that they can read again and again. 
Very authentic role models can also be found in the patients' group itself. I listen attentively to what patients say in the group; and whenever I sense a good story behind a remark I inquire and encourage the particular patient to tell more. Very impressive, touching, and encouraging stories have been given. 
Humor 
Frankl described humor as a "weapon of the soul," and in paradoxical intention humor is the decisive force in overcoming the neurotic circle. And further on Frankl writes: "It is well known that humor, more than anything else in the human make-up, can afford an aloofness and an abilit¥: to rise above any situation, even if only for a few seconds." 3· p. 3 
Humor and joy are necessary elements in any demanding situation. Humor is catching and loosens the tensed up soul, freeing the mind for a more positive outlook. Jokes, funny stories, smiling, and joy are qualities which are encouraged wherever possible. 
The Individual Patient 
Besides the group, we offer individual counseling. The patients themselves can ask for it, or it may be recommended by the nursing or medical staff. What comes to light here, again, is the amazing variety of peoples' experiences and problems. The approach is, first of all, to listen attentively. Sometimes what really haunts a patient is mentioned only symbolically or as a passing remark. In all instances we consider whether autogenic training can be of help; and with many patients I start with such, which is then followed by a conversation or a more therapeutic dialogue. After the relaxation exercise, both the patient and I have found inner stillness and we are able to concentrate and reflect better. 
How often I will subsequently attend to a patient varies considerably. There can be the one single talk, which may bring clarification; or there might be more than a dozen visits. Several logotherapeutic themes come to the fore in a natural way. There 
45 
are some patients where a logotherapeutic instruction can be made a project. These are mostly patients who are acquainted with reflection about life themes through reading, self-help books, or simply through good literature. Others need to communicate on a more general level. One has to take into account that the patients are all in an early phase of dealing with their illness. Some patients are not ready for a constructive dialogue because they are still at a stage where denying or ignoring is important for them. The necessary time involved in movements of the soul has to be respected. There are patients for whom the purpose for the moment can only be to establish a good relationship, which is helpful to them, and to leave some material (texts, audio-tapes) with them to which they can turn at a later stage, even long after they are released from the hospital. 
Then again there are patients where logotherapeutic guidance is a substantial part of the whole treatment in the clinic. A middle-aged man was hit by a car and lost part of his leg. From the very beginning he had a positive outlook towards the future, a sound, basic trust in life. The reason why he was trying not to let himself down was actually his wife and his young daughters. He said that they, especially his wife, were taking the situation very seriously and that he gave them strength by not letting them down. This attitude was a good foundation for several logotherapeutic talks that followed. When introducing him simultaneously to the talks and autogenic training he was absolutely flabbergasted that the phantom pain he experienced vanished completely during the exercise. He was experiencing that the mind can influence the body. That again strengthened his optimism in dealing with his situation. 
Another patient, a young woman, was recovering from a suicide attempt. She suffered from insomnia, and nervousness, and was quite out of balance. In the conversation she spoke of her parents as dominating her and trying to plan her future. For this reason she worried all the time and couldn't sleep. On the basis of this information a fruitful logotherapeutic dialogue developed in which she learned how to establish a hierarchy among her values. Being nice to her parents ranked very high, but in the end, living a life-style that was important to her ranked even higher. She therefore became strong enough to ask her parents not to ring for a few days, and after that only at certain fixed times. Her quality of sleep improved considerably as did her outlook about her future. 
In the last few months there have been a few patients who awoke from a comatose state and were bewildered by the strange dreams they had experienced. In the dreams there was murdering and other strange behavior and as a result the patients felt guilty. Within two to three sessions these patients learned something 
46 
about the symbolic nature of dreams (although there can also be a confusion of images in dreams), and learned to interpret the dreams under the heading of meaningful messages. It was rather easy to calm the patients and help them understand that dreams are normally symbolic, and should not give rise to guilt feelings. 
Relatives 
Relatives of patients need also to be attended. For some of them the situation is just as traumatic as for the patients. It is our experience that in this crisis intervention, logotherapy is of particular help. One of the leading questions is "what is the next meaningful step?" Relatives easily lose their balance and try to overcome the emotional turmoil with ceaseless activity, which in turn sets them even more out of balance. The wish to care for their spouse, partner, son, daughter, or friend can cause them to sit many hours a day for weeks at their bedside without caring for their own personal needs. They can also become over-sensitive to the needs of the patient, which can, at times, lead to disagreements and a difficult relationship with the hospital staff. In such cases I approach the relatives and invest as much time as needed. This is often the first time that they get the chance to express themselves by describing the situation in detail. This alone has a balancing effect. 
During the conversation they can be outspoken about everything and can complain about whatever they think is going wrong. I make them realize that I wish to be an advocate for them, and that if necessary I keep what is entrusted to me confidential. I am able to function as a mediator between them, the medical staff, the nursing staff, and the therapists. I explain to them that I am interested in helping in every way, with the intention of following and pursuing whatever seems to be meaningful in the particular situation. Doing what is meaningful is a keyword in the whole counseling situation. 
In support of doing what is meaningful, I sometimes give them small texts to read, or, more often, I give them tapes from suitable lectures by Elisabeth Lukas.8 With one woman I listened to her and built up a therapeutic relationship. The phrase "I have to do what is meaningful" became the central motive for all her actions. But, she realized only months later that acting meaningfully also included care for herself. As strong as the idea of the meaningful is, the vision of possibilities is also strong. However, the possibility that her husband would recover was slight. After many weeks of no progress, the husband was released from the hospital into a nursing home. The wife was still intrigued with the meaningful and the possibilities. She talked to her husband. She did exercises with him. She tried hard to make him communicate. Now, more than a year later, her husband can sit upright, walk a bit, speak 
47 
clearly enough to be understood, and is able to eat on his own. This wife reminds me of the mother described in Christy Brown's autobiography, My Left Foot. 1 Despite the medical judgement Christy Brown's mother saw possibilities of growth and development and acted accordingly. 
For many relatives it is important to learn to distinguish between expectation and hope in the healing process. As long as people have an attitude of expectation, they are inwardly tensed up as they often have yet to realize that things do not always develop as they would expect. Hope, on the other hand, clearly expresses a strong wish that healing might occur. Hope motivates for action, but the inner psychical state is not as tense as in the state of expectation, which includes a demanding attitude. Hope is essential, and is a strong motivational factor. It gives a firm meaning orientation. Hope is the last to give up, as in the following story titled The Invincible: 
My drubbings, said fate in an interview, are tough, and my right is just as much to be feared as my left. Loyalty, faith, love, in short, [are] the toughest nuts I have sent to the canvas, and they were all counted out. There is only one whom I have not as yet been able to dispatch, for, as often as I deliver the knockout and satisfy myself that he lies there on the ground being counted out, just before the "nine" he is again on his feet. And who is this invincible one, the interviewer asks? Hope, was fate's reply.7 P·11 
The Role of Encouragement 
Therapeutic process depends on whether a patient is discouraged or encouraged. The question is how to best encourage a patient in order to foster the rehabilitation process. Encouragement is a skill that, in itself, needs reflection, because it is not easy to encourage a person who is deeply discouraged and frustrated by the course of events. Having a meaningful aim, e.g., regular training of body movements or speech in order to achieve improvement, and actually realizing it does not necessarily always happen, and often requires reflected encouragement. 
The reasons why patients are discouraged are manifold. It can be, for example, the inability to perceive meaning because of bodily disability or the lack of social support. It can be the shattering of one's expectation of life, or the inability to speak because of speech-impairment, or many other reasons. Encouragement has to be a concept in the forefront of the therapist's mind. 
An elderly man moved through the ward in his wheelchair. In his hand he held a biggish book of poems. Just a book, so no 
48 
one had as yet taken notice. I asked him about the book and he explained. I asked him about his favorite poem and he told me. asked him how often he read poems and he told me that he reads a few every day. I asked him if anyone else takes any interest and he replied that no one else does. I asked him to look up my favorite poem, and he was delighted to find it included in the book. I asked him to borrow the book for half an hour in order to make a copy of a particular poem that I wished to have. For the next few weeks I looked up the gentleman every time I was in the hospital; and we conversed about poems, as well as, of course, other matters. Often we spoke for just five minutes, enough to share poems and thoughts. The book became even more valuable to him. He received the messages of the poems more deeply. He felt encouraged. 
Another patient was a lady whose speaking ability was impeded because of a stroke. Training is still the most important thing in order to improve this deficiency. The brain can learn, but time is of the essence. It is even more difficult to speak to someone when you cannot really express yourself, and when you feel that the other becomes embarrassed or does not have the patience to wait long enough. Discouragement takes over very quickly; the level of one's self-worth diminishes; and meaning often takes flight. I took the woman aside and communicated with her in whatever way possible. First, I made her understand that I understood that she had speech impairment but not a thinking impairment. Then I highlighted the fact that she needed to continue practicing. I showed her a breathing exercise and offered her the argument that the meaning of the moment was that she herself has to take on a therapist's role now. Whereas other people are impatient, she herself could, perhaps, exercise more patience in formulating her words. The other person thereby learns to be more tolerant, and that experience is invaluable. Whereas the patient may be the one who puts demands on other people, at the same time she helps them to become better listeners. She felt encouraged. I practiced with her a few times and went back to her later to talk about her experiences. 
One can learn to become more sensitive to encouragement. Through just a remark which takes only seconds, or through ones that take a few minutes, proper listening to a patient can help enormously. Of course, encouraging is not what is meant by encouragement, but rather, what is received as encouragement. Words like "just look at the positive," "keep up your spirits," "don't worry", and the like, have an encouraging effect only if not spoken at all. 
Encouragement in combination with what is meaningful is very powerful because they are mutually conditional. 
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Autogenic Training and Logotherapy 
In addressing or solving conflicts between the emotional and rational spheres, I believe the application of autogenic training with patients to be very helpful. The trauma the patients experience leads to a considerable amount of confusion and conflict on the emotional and cognitive levels. Conversation then proves to be difficult and fruitless. In that case it has been found to be extremely helpful to do a relaxation exercise with patients. 
One particular individual with a stroke had made good progress in rehabilitation but still had much potential for further progress. For this reason the medical staff had in mind some follow-up rehabilitation treatment in a different clinic. But, upon several approaches, the patient refused and demanded instead to go home. Eventually the medical staff had to give in. I considered the disadvantages the patient would suffer from not accepting the offer and decided to approach this individual myself. The patient had been previously introduced to two autogenic training sessions and I began with another session. 
I made him lie down and went through the particular exercises with him. I asked him about the experience and he said that he found it difficult to relax because he had argued with the doctor. He explained what it was about and I asked him to lie down again in order to feel comfortable. I asked him to formulate why he wanted to go home and in the relaxed state he slowly became aware of his motives, which were his feeling uncomfortable in engaging with a new situation and with new people. Rather, the thought of finding calmness and security in his own home comforted him, which was only understandable. 
I then entered into a Socratic dialogue addressing the different motives and values involved. I asked him which, in principle, he favored following: a meaningful goal or emotional motives. Further questions involved thinking about opportunities given and opportunities rejected. How would he accept if he might not progress at home as much as he liked? Would guilt feelings creep in because he rejected further rehabilitation in a clinical setting? The state of relaxation allowed the patient to feel and think more freely; and, slowly, feelings and thoughts where put into a different order. The patient's perspective changed within 15 minutes, and he said that he would take the offer to attend the other clinic for three more weeks. I asked him to reflect on and strengthen his decision overnight, but he refused and remained with his decision to be transferred into the other clinic for further rehabilitation. The meaningful had succeeded over the secondary motives. 
Relaxation, as addressed with autogenic training, is an integral part of my work with patients. Because it has a moment of 
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intimacy and inner peace, it also fosters the relationship between therapist and patient. With this basis, logotherapeutic intervention becomes easier and more successful. 
Conclusion 
Work in the clinic is demanding as there are a great variety of tasks to tackle. Each patient is a new challenge. Although most patients suffer from a stroke, there is a great variety of other illnesses as well. Relatives need different kinds of support. And yet there are answers that can be given. Frankl writes: "Logotherapy... opens the dimension of the very humanness of man and draws upon the resources which are available in the humanitas of the homo patiens." In my understanding, it is because of the particular structure of Frankl's logotherapy that one rarely feels at a loss. The philosophical basis of logotherapy is a kind of key code from which strategies and methods can be creatively developed. It is the insight Frankl offers and the element of wisdom in logotherapy that broaden the field of action. Logotherapy is a good instrument to work with -that is my personal experience over the last few years. The interplay between logotherapeutic intervention and the relaxation method of autogenic training has proven to be fruitful, and the explanations and guidelines as outlined in logotherapy are appealing to patients. 
MANFRED HILLMANN, Dipl.Soz.Pad., BA (Phil.) [Lingener Strasse 61, 49716 Mappen, Germany; Web: www.logo-24.com, Email Manfred.Hillmann@gmx.de] works in a medical clinic and is a chair of a hospice group. He teaches logotherapy and autogenic training. He received a Dip/ornate in Logotherapy from The South German Institute of Logotherapy. 
References 
1. 
Brown, C. (1998). My left foot. London: Random House. 

2. 
Douglas, K. (2002). My stroke of luck. NY: Harper Collins. 

3. 
Frankl, V. (1985). Man's search for meaning. NY: Washington Square. 

4. 
Frankl, V. (1988). The will to meaning. NY: Meridian. 

5. 
Hillmann, M. (2002). Autogenic training and logotherapy. The International Forum for Logotherapy, 25, 73-82. 

6. 
Hoffmann, B. (1997). Handbuch des Autogenen Trainings (12th ed.). Munchen: Deutscher Taschenbuch Verlag. 

7. 
Hoffsummer, W. (2002). Kurzgeschichten 1. Mainz, Matthias-Grunewald-Verlag. 

8. 
Lukas, E. (1998). Lehrbuch der Logotherapie [Textbook of logotherapy]. Munchen: Profil Verlag. 


51 

The International Forum for Logotherapy, 2004, 27, 52-55. 
MEANINGFUL FRAMEWORK FOR GAINING INFORMED CONSENT TO EVALUATION/TREATMENT 
Eduardo & Maria Mendez Asin 
In the United Kingdom, the recent publication of the guidelines for gaining informed consent for evaluation/ treatment represents a significant milestone in the attempt to involve patients in their own care, and to provide a quality of care that is respectful of their rights and dignity in the face of suffering and pain. 1 To facilitate a meaningful dialogue between care providers and the recipients of care, the guidelines for valid informed consent require providers to observe the following principles: (a) explain the need for obtaining informed consent; (b} present relevant information in a clear and concise manner; (c) present sufficient information; (d} give a balanced view of options, expected treatment outcomes, benefits, and risks; (e) clearly state the eventual limitations or side-effects; (f) explain the responsibilities of the provider and the patient throughout the treatment process; and (g) allow sufficient time for reflection before and after making a decision. 
The current guidelines emphasize the fact that valid informed consent can be given by persons who have the capacity to give such consent adults with the ability to retain, understand, and form judgements on the basis of information presented to them, and who are able to weigh relevant facts and then respond in a comprehensible manner. While obtaining valid consent in some cases is not straight forward, good practice guidelines provide provisions for procedures in such instances, emphasizing involvement of patients in the decision making process to the best of their capabilities. 
As consent is valid only when it is given voluntarily, without pressure or undue influence, this places responsibility on the caregivers to gain consent during a careful, mutual sharing of information. It commands respect for the final decision resting with patients regarding their entitlement to make informed decisions freely, and in harmony with their own beliefs or value systems. Thus, care providers are advised to listen to their patients' individual needs in order to establish their priorities, and to find out about patients' beliefs, cultural assumptions, or other facts that 
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may have a bearing on the information that the patients need in order to reach a meaningfur decision. 
Recognizing Suffering During the Process 
The current guidelines for obtaining informed consent rest on two fundamental imperatives: (a) the recognition of patients' human rights and freedom to determine what evaluations/treatments they receive, and (b) an appreciation of the role of health care providers in alleviating human suffering.1 The first principle clearly applies to the process of obtaining informed consent, and the guidelines specify good practice principles. However, much less is clear from the guidelines about the ways in which patients' suffering affects their consent to evaluation/treatment, or the way in which health care professionals can deal with the patients' distress during the process of gaining informed consent. 
During the process of seeking consent, patients are affected by their illness, not only physically but also psychologically, thus potentially limiting their freedom, coloring their mood, and influencing their decision-making. Frequently, patients try to communicate hope. Yet, their suffering can be expressed verbally or non-verbally during seeking informed consent, and the caregiver can easily identify feelings of fear, confusion, or worries in relation to changes in their quality of life and future capabilities. Thus, patients' behavior and communication about their suffering can provide the clinician with relevant clues about patients' efforts to seek help, understanding, and caring, as they seek to make sense of what is happening to them, and search for a meaningful response to their circumstances. 
Meaning-Oriented Principles in Obtaining Consent 
Frankl's logotherapy principles have application in the practice of seeking consent for treating a person -even a person suffering from a physical ailment. This is because the patient who is suffering from an illness can still have the capacity to choose the attitude he or she has toward the illness. 2·3 
Ethically and legally, the caregiver can not engage in treatment before consent is gained. The process of gaining consent, however, by its very nature presents an opportunity to meet patients and to build a relationship with them. The provider can display caring, not only about fixing the problem but also a genuine interest in how the illness is affecting patients' lives. The practitioner can recognize a search for finding meaning in suffering, and in life; and build an atmosphere where patients are enabled to establish attitudes which are constructively meaningful in facing their illness.4 ·67 This interest is reflected in verbal and non-verbal communication which starts with an attitude from the care giver. 
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Practical Interventions in Gaining Consent 
In Frankl's logotherapy, one method that applies when communicating information which can be anxiety provoking about the illness is Paradoxical lntention. 2 The essence of this concept lies in the fact that directly intending what is feared -with a sense of humor tapping into the noetic dimension while not ignoring the seriousness of the circumstances -cancels out fear and avoidance. 2 ·6 
The role of the practitioner during gaining informed consent is not to reinforce patients' fears by avoiding their attitudes, but exactly the opposite. The task is to face the patients' attitudes and provide the basis for helping patients make sense of what is happening to them, and to help them to make decisions that will affect their lives. 
Modification of Attitudes can be used in situations where patients are assuming unhealthy attitudes towards their illness.2 These attitudes include nihilistic, fatalistic, self-defeating ideas or !)reoccupations that produce more unnecessary suffering in themselves.6 This requires first that practitioners not only explain the nature of illness and treatment options in clear and objective terms, but also that they listen to patients beliefs, goals, and values. This environment provides patients the opportunity to see their illness for what it is. It helps them to see that their illness is something they have, but they are not their illness. They are persons who, through their healthy core, can choose to take a stand toward their illness. Here, practitioners recognize that patients retain free choice in their attitudes: even though there is objective suffering, there is also a healthy core, which is separate from the illness. Through this intact and healthy area, patients are able to detach themselves and distance themselves from their illness, and to make conscious decisions concerning treatment. 
De-reflection can be used to help patients look to what still can be done, instead of seeing only what can not be achieved.2 This can be brought about in a gentle, questioning way, that provides the opportunity to think and to reflect on alternatives. By recognizing the uniqueness and strengths of patients and their circumstances, the practitioner can help patients become aware of their unique choices, freedoms, and responsibilities, rather than comparing themselves at all costs to others. 
Socratic Dialogue also is useful in intervening to reduce human suffering during the informed consent process. 6·7 This is the ability to communicate to patients with "what if" scenarios, or "as if' scenarios, through which different outcomes can be illustrated, allowing patients to accept the real implications of their illness and make decisions without exaggeration of their illness. 
Metaphors are also useful in getting specific messages across. A well known example is to explain that even though there are dark clouds in the sky, the sun is still behind and will come out after the storm; intending to explain that if the treatment is successful then the patient's true self will be able to express itself.5·7 
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Conclusion 
Logotherapy principles can be of help in seeking informed consent from patients, as the procedure in itself does not have to be just mere exercise of giving factual information, or assessing patients' capacity to give the consent. Rather, right from the start, the process of gaining consent can be a helpful and hopeful experience for patients. It can enable them to gain trust in their own capabilities, and exercise their freedoms in a responsible manner, even if they have found this challenging to do. By conducting informed consent communications in this manner, practitioners succeed in facing the formidable task of ameliorating at least one piece of unnecessary suffering -they combat their patients' fear of the unknown, and feeling of helplessness, which cloud the patients' sense of meaning and purpose in life. 
MARIA (UNGAR) MENDEZ ASIN, Ph.D., is a Dip/ornate in Logotherapy, Registered Psychologist in British Columbia, Canada, and Graduate Member of the British Psychological Association. 
EDUARDO MENDEZ ASIN, M.D., Ph.D., is Staff Grade Psychiatrist at the Fair Oak Clinic, St. James' Hospital [Locksway Road, Portsmouth, Hampshire PO4 8LD, United Kingdom; Tel. (+44) (0) 77 66 58 1789; Email: emendez@doctors.uk.org]. 
References 
1. Department of Health. (2002). Reference guide to consent for examination or treatment. London: The Stationary Office. (www.doh.gov.uk/consent). 
2. Frankl, V. E. (1988). The will to meaning: Foundations and applications of logotherapy. NY: Meridian. 
3. 
Frankl, V. E. (1997). Man's search for meaning. Touchstone Edition. NY: Simon & Schuster. 

4. 
Frankl, V. E. (2000). Recollections: Autobiography. Cambridge, Massachusetts: Perseus. 

5. 
Frankl, V. E. (1986). The doctor and the soul: From psychotherapy to logotherapy. Revised and Expanded Edition. NY: Vintage Books. 

6. 
Lukas, E. (1986). Meaning in suffering: Comfort in crisis through logotherapy. Berkeley, California: Institute of Logotherapy Press. 

7. 
Ungar, M. (2002). Logotherapy treatment protocol for major depressive disorder. The International Forum for Logotherapy, 25, 3-10. 


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ISSN 0190-3379 IFDDL 27(1)1-64(2004) 
The International Forum for 
LOGOTHERAPY 
Journal of Search for Meaning