SOURCE_DOCUMENTS/journal_027_1.txt

EDITORIAL  
Julius M. Rogina  1-2  
LOGOANAL YSIS: FOR TREATMENT OF MOOD DISORDER  
DUE TO MEDICAL CONDITION  
Rosemary Henrion  3-8  
THE CHRONIC PAIN PATIENT: HOW CAN LOGOTHERAPY HELP?  
Geoffrey T. Hutchinson  9-14  
LOGOTHERAPY AND MALE ADOLESCENTS WITH MENTAL  
RETARDATION/DEVELOPMENTAL DISABILITIES  
AND SEXUAL BEHAVIOR PROBLEMS  
Stefan E. Schulenberg & Elizabeth D. Kolivas  15-20  
BORDERLINE PERSONALITY DISTURBANCES AND  
LOGOTHERAPEUTIC TREATMENT APPROACH  
Roberto Rodrigues  21-27  
TREATMENT AND INTERVENTIONS  
FOR NARCISSISTIC PERSONALITY DISORDER  
Julius M. Rogina  28-33  
COMBAT-RELATED PTSD AND LOGOTHERAPY  
Robin M. Gilmartin & Steven Southwick  34-38  
LOGOTHERAPY IN REHABILITATION WORK  
Manfred Hillmann  39-51  
MEANINGFUL FRAMEWORK FOR GAINING INFORMED  
CONSENT TO EVALUATION/TREATMENT  
Eduardo & Maria Mendez Asin  52-55  
BOOK REVIEW  
Robert C. Barnes  56  
JAMES E. LANTZ, Ph.D., ACSW, AAP IN MEMORIAM  57-58  
RECENT PUBLICATIONS OF INTEREST TO LOGOTHERAPISTS  
Cindy Strege  59-62  
INFORMATION FOR AUTHORS  63  
MEMBERSHIP APPLICATION/RENEWAL  64  
Volume 27 Number 1 Spring 2004 


The International Forum for Logotherapy, 2004, 27, 65-76. 
INNER TRANSFORMATION IN EXISTENTIAL CRISES: RENACER GROUPS FOR BEREAVED PARENTS 
Alicia Schneider-Berti & Gustavo A. Berti 
Renacer (Rebirth) is the name of a mutual help group for parents who have gone through the experience of losing one or more children. It was created by the authors of this paper 6 months after the death of their 18-year-old son, 
23 557
Nicolas.1· • .4, ,, The first meeting took 
5thplace on December 1988 in Rio Cuarto, Argentina; and now there exist over 120 groups in all Argentina and growing numbers in Uruguay, Paraguay, Mexico, and Spain. 
We take a phenomenological approach in 't-'hich emphasis is placed on how we handle what has happened. This orientation (which was given to the group from its early inception) led automatically to a meaning-oriented perspective. 
The groups have no leaders. Meetings are conducted twice a month and are coordinated by two or three parents who rotate every meeting with no pre-planned topics. Prior to each meeting there is an informal reception (which may last up to half an hour) where first time parents are received, introduced to other parents, and asked in a caring manner: what their experience is, the name of the child or children, and the cause of death. The more veteran parents are asked to initiate each meeting in a pleasant and encouraging manner by relating some positive experience they have had. 
Many of the meetings have been recorded on videotape, and the material for this paper has been extracted from these tapes. As we were reviewing the tapes for material that would provide evidence for the human capacity for inner transformation following severe existential crises, the emergence of the spiritual dimension showed itself with such brilliance that it could not be ignored, thus earning its prominence in this paper. 
The Power of Transformation 
130 131
According to Elisabeth Lukas 9· P· -the power for transformation that lies in every human being is an under-utilized capacity. Lukas states that this capacity is an inherent part of every human being and that it has been described and richly utilized by all religions and religious myths since ancient times. Always something transforms into something else. There are concrete examples in everyday nature: the coal transformed into a fine diamond; the 
65 
worm which from a small, crawling existence breaks out of the cocoon and flies free with its newly discovered wings. 
As an integral part of a flowing, changing nature that is rich in shades and expressions, human beings also possess the capacity for transformation. Karl Jaspers, quoted by Elisabeth Lukas, tells us that "the tragic" is a most powerful force that is capable of unchaining existential commotions with a great power for transformation. This is true not only in the world around us but also in the depths of each human being, allowing individuals to transcend from horror and misery to the essence of things. This means that human beings are capable of not only changing the world around themselves but also of changing themselves. Individuals can emerge from the abyss of what they were to the heights of what they begin to discover, toward their essence, toward "being." Individuals can elevate above their physical and psychological conditions; they can go past their "worm self," beyond all previous experience. They can emerge free, seeing themselves for the first time with the clear eyes of their spirit, where conscience dwells; and they can start building from nothing. 
Early Stage of the Group -The Emotional Phase 
When parents first enter the Renacer group, the questions they ask can only be asked from their "worm self," that is from their psychological dimension: "Why me? Why my child? Is there a God?" Everything that was familiar suddenly has become alien; and existence, as they conceived it, has been shattered into pieces. 
From their "worm self' it is impossible to see beyond the narrow horizon that constituted their existence prior to their loss. Before the crisis, everything seemed well, and life was understood as something that could be planned and kept under control. Upon this conception rested their idea of security and support. Just as the worm cannot understand the physiological changes that start in its body foretelling the great metamorphosis that will take place, human beings, when confronted with this true existential commotion, struggle in the storm of emotions, unable to understand the ultimate meaning of this moment of pain and uncertainty. 
9 140 141
In her book "Psicoterapia en Dignidad" · P· -Elisabeth Lukas describes an investigation done by Dr. Dieter Frey, University of Kiel, Germany, on surgical patients following traumatic accidents, where he observed that those with delayed recovery were persons who: 
1 -continuously questioned whether they could have done anything 
to prevent the accident, 
2 -felt totally defenseless and dependent on outside help, and 
3 -perseverated on the unfairness of destiny. 
Concerning point 1, we observe that the parents who remain in the past, wondering about the things that could have been done or said to prevent the death of the child, do not progress on the road back to life. The loss becomes perpetual. Many years later, everything is the same as it was the first day; 
66 
and these parents tearfully relate, over and over, the tragic way in which their child died, with all the painful details. 
Regarding point 2, many parents feel defenseless and vulnerable after such a traumatic experience. Suddenly they realize that what they thought was under their control -their life and that of their children -was in fact beyond that possibility. They feel powerless, and they then feel victims of a capricious destiny or of a cruel and incomprehensible God. 
Considering point 3, we also see parents who, more than crying over the death of the child, center their energy on arguing with destiny: "Why him/her? Why in this manner? Why them when they have always been good and caring?" These are unanswerable questions; and parents stagnate in this stage for long periods of time, keeping open a wound that refuses to heal. 
In none of these cases does the acceptance of the irreversible take place, as a necessary first step on the road to recovery. These parents struggle amidst feelings of anger, guilt, hatred, revenge; they feel victimized; or they simply give up and move from sadness to long lasting depression. 
Trying Out the Butterfly Wings -Rediscovering Human Transcendence 
During the first few years, we had the idea that parents must go through a stage of catharsis, since catharsis appears spontaneously. We were unsure or afraid to interrupt parents when they were engaged in continuous lamenting. We expected that, once this stage was over, the parents would be more at peace with themselves and therefore ready to consider what the group had to offer. However, we soon realized that the opposite often seemed true. Parents who tended to dwell endlessly on painful details also tended to be unable to see the encouraging approach that the group lent primarily through attitude modulation. They remained anchored in the dimension of their emotions. 
When we began to work in a different manner, positive results appeared to be achieved much sooner. The newly arrived parents were able to see the wider horizon of values by elevating their view above their emotions. This new approach also encouraged the others in the group (many times even with only one previous meeting) to transcend themselves to help the others. 
In May 1994, we consulted Dr. Lukas on this point during a course that she conducted in the city of Mendoza, Argentina. She pointed out that when parents enter the group, we know why they are there. It is likely that they have told their experience several times. They attend the group because they do not want to live the way they have been living since the tragedy. 
If we wish to change a person's point of view, we must make 
accessible contents that demand of them and invite them to give a 
part of their self to the world. To make this clear, this is a level of 
communication very different from the simple level of wishing to 
understand. We do need to feel understood, but the fact that 
comprehension is rendered to us does not in itself liberate our inner 
67 
power for transformation. To understanding must be added a kind of 
139
aperture, an aperture of new dimensions of evolvement.9· P· 
We also note that, as Dr. Dieter Frey states, philosophical-existential confrontation with traumatic situations has a great influence on the recovery process. Logotherapy also tells us that while a person lingers in a meaning void their power for transformation is not activated. 
We say then that, when working with the group, we should not have a preconception that limits what the parent can achieve -even if it is their first time in the group; no matter either how soon after the death. The spiritual dimension is there, latent, waiting to be discovered. What is more, we are convinced that nothing is more painful for a parent than the possibility of meaninglessness in the death of their child. The spiritual dimension allows us to see beyond the grief; it enables us to contemplate not only this turbulent portion of the river, but also the origin and the calm end in the sea. 
The following example supports the above concepts, such as the importance of appeal to the human spiritual dimension, since the power for transformation is not activated until that higher level of consciousness is awakened. It can be a word, a look, an embrace, another suffering parent, or any little thing that may bring about the "click" and help produce the awakening of the spiritual dimension. 
A couple had lost a child through a particularly painful form of cancer that left them, especially the mother, immersed in a sea of disbelief and resentment. They were angry at life and at God for the suffering their child had gone through. Nevertheless, when a member of Renacer invited them to the group, they accepted the invitation since they realized they were drowning in their own grief and unable to come to terms with what life had presented them. They had other children, and they knew they had to go on living, but they did not know how. They started to attend our group meetings twice a month. Slowly they showed signs of recovery. But even though their life was changing for the better (they smiled easier, embraced back, helped new parents) there was something still that held them back. They confided in other parents that there was still underlying sadness whenever their child's memory came to mind; they were not able to remember him with joy, as so many other parents did, thinking of the wonderful moments they had together. It was not until more than a year later, while these parents were still active in the group, that we came across a paragraph by Viktor Frankl that, as soon as we read it, we hoped it would make a difference to them. It read: 
If a person would have realized completely the possibilities of value 
that are outlined in his depths, life should come to a halt, it should 
end. I think this is the reason why so many saints die young. If we 
consider the life of Luis de Gonzaga, of St. John Berchmans, of St. 
Teresa, or so many others, do we not get the obvious impression 
that these people had no more to realize here on Earth, as if they 
had realized everything that there was to realize, as if they had 
realized everything that was possible? And that many of these young 
68 
saints would have died with great suffering because in this 
endurance of pain and illness was the last task they needed to 
realize? 8· p.232 
The next time we saw them at a meeting, they confirmed that the short paragraph we had sent them made the difference. They were able to find meaning in their child's suffering. This showed that, though parents may be able to accept the death of a child and find meaning in their life, there is still a void to be filled; and the void is that of finding a higher purpose to the child's suffering in order to finally surrender the resistance and embrace life fully. 
From Self-Renunciation to Self-Transcendence 
As we stated above, at first we held the idea that the parents new to the group had to work through their feelings by narrating their experience without much interruption. However, at one point in one of our meetings, as a mother started to describe in excruciating detail the tortures her child suffered in the hands of her assassins, we firmly but kindly interrupted the mother, suggesting that she leave the painful past behind since it could not be changed. Since her child was no longer going through that terrible experience, why kill the child over and over again in her thoughts? 
In doing this, we were asking her to make the ultimate renunciation: to renounce the desperate suffering that goes beyond the natural grief for the death of the child -and this can only be done from our spiritual dimension. According to Elisabeth Lukas, 10· P· 132 we can only renounce something that is a part of our self by transcending to a higher value beyond our self. In other words, only appealing to the unconditional love a parent feels for their child makes the renunciation possible. 
A young couple traveled a substantial distance twice a month to come to our meetings since there was at that time no other group in their city or close by. They had lost the youngest of their three children. The father told in the meetings that he did not know what to do with the mother who frequently vented her feelings of despair and anger with no regard about anybody else, not even their two remaining children. We appealed to the love the mother must feel for those two children. The love was still there, beneath all that pain, if she allowed herself to rise above her grief and think of those around her. We said that even though we have the right to suffer, we are always responsible for the way in which we endure our grief. We can suffer with dignity or miserably -that is our choice to make, as Frankl has pointed out. Slowly but steadily, the mother was able to renounce her "victim role" and control her outbursts, especially in front of her children. We could see this change take place long before she felt ready to describe it in words. As her eyes grew gradually livelier, a timid, almost bashful smile began to soften the somber expression on her face. Her hands rested relaxed on her lap, her voice grew more serene, until she finally admitted feeling better, willing to take the long-awaited step toward acceptance and start over. The couple later became actively involved in forming a Renacer group in their hometown. 
69 
They also helped organize a workshop for persons who wanted to do more for other people -the group provided for needy children in their community. 
Timing -It is Never Too Soon nor Too Late 
During the wake of two children killed in a car accident on Christmas morning, we visited the parents, introducing ourselves as parents who had lost a young son as well. Some of the members of the family recognized us, because of the work we do in Renacer, and soon introduced us to the parents: "If anybody can help them, surely you both can" they said with some degree of relief. The mother squeezed our hands while crying and repeating over and over: "It's two of my children, two of them, what are we going to do?" 
We held her in our arms and told her we were aware of what she was going through. We knew we had to appeal to her spiritual dimension in order to get her out of the circle of continuous lamentation, so we told her about the meaning to be discovered in suffering, especially when we say good-bye to somebody as beautiful and important as a child. We knew, immediately, that these words had made a difference. We witnessed the emergence of the indomitable power of the human spirit as she grew attentive, assumed an erect posture, and stared directly into our eyes. Then, slowly, she dried her tears while absorbing every word we said. As we paused for a second, she said firmly and eagerly: "Tell me more, please, tell me more .... " 
She was no longer lamenting and crying desperately as she had been doing with everybody who had approached her that day with well intentioned phrases like: "It will be alright, you have other children, ... time ... resignation .... " This mother, in the midst of pain and incredulity, was debating with herself something she knew intuitively -from her spiritual dimension -that "there had to be something else." She raised her eyes above the horizon, sensing the butterfly that was to come. Our words corroborated her intuition. This would not have happened had we remained at the level of simple empathy and understanding. Fifteen days later, these parents were in the next group meeting. When the father spoke for the first time, he said: "I don't see the point of telling you how we feel since you all must know this very well, what I want to know is how do we find a way out of this ... how can we go on living .... " 
It was clear they did not wish to remain at the testimonial level. They knew how they felt. As soon as they saw so many others in that meeting, they also knew they were not alone in their tragedy. As the meeting progressed and they heard encouraging, loving testimonies, we could all see how their body postures changed from contracted, tense positions to more relaxed, easy breathing postures. Their shoulders relaxed until their words reflected our observations. From that moment on, their progress was sustained. They became aware of how well they felt every time they extended their hands to others as they assumed the role of helpers realizing the importance of becoming a "social referent" to others. 
70 
In a different case, several decades had passed since a couple had lost their child in one of the most tragic ways possible, the father inadvertently ran over the child with his vehicle. Their life became a nightmare of struggling amidst feelings of pain, guilt, anger, and depression. In their own words: " ... From that moment on, a deep feeling of guilt tortured us, happiness and joy were absent for many years in our home. Each member of the family parents and siblings -suffered in isolation; each one ruminated their own grief in silence, re-creating over and over the nightmare .... " 
Then, a member of Renacer gathered enough courage to talk to the father -the family had been in pain for such a long time that the member had serious concerns about taking this step. To this member's surprise, the invitation to attend a group meeting was accepted. 
We anticipated that these parents had plenty to cry, complain, and talk about at their first meeting. However, as they were warmly received by the other parents, they were given the chance to listen first to what others with more experience had to say. The meeting started -as we make a point in doing -in a positive tone. Emphasis was placed on some parents' accomplishments since the death of their children, including how well some of them felt when they transcended their own grief and decided to comfort somebody who had just lost their child. There was talk about experiencing joy in the little things in life. Hope was expressed as the room filled with loving thoughts and feelings. 
When these newly arrived parents were invited to talk, they were asked from the start to do so in such a way as to pull them out of that "dark night of the soul." They were not asked how they were feeling; rather, they were asked if they cared to comment about the discussion topics by telling them: "We have talked about meaning in suffering, do you think this could be possible for you?" First, they commented on the love that they felt as they entered the room and were embraced by the other parents. They remarked on the love they perceived in the different testimonies that had gone straight to the heart of these parents; especially the father who could not believe he was worthy of love and acceptance -all these people considered him worthy of the utmost respect and value as a suffering human being. Then the father talked about all the comforting words he and his family had heard. In a hopeful and relieved tone of voice he exclaimed: "Why didn't something like this exist when we lost our child? Things could have been so different!" 
In the next meeting, the father, with a tender smile on his face, undusted his harmonica that had been in a drawer since the death of their child. With accompanying clapping by all the parents present, he played a tune that was his child's favorite. In his own words: "Joy returned to our home and allowed the little child to transcend in warm and loving memories devoid now of the dark shadow of guilt." 
These parents never went through the catharsis stage. They were simply given the opportunity to activate the power for transformation latent for all those years. 
71 
Appeal to Give Their Best 
We have found that properly applied appeals to the power for transformation inherent in all human beings is a rapid and direct way to pull a grieving parent out of the circle of intense emotions following the death of a child, even after many years of a poor quality life in which meaning is yet to be found. In appealing to this capacity for transformation, we help the parent consider the possibility of meaning in suffering, encouraging them to take full responsibility for their life as well as the way in which they choose to live it. In this sense, when the parent enters the group for the first time they are told: "If you attend this group, sooner or later you will have to make a choice. Either Renacer is a place where you go to be comforted and consoled and receive help, or it is a place where you go to give something of your self to honor your child. If you choose the second option, then you have to answer the following question: "What can you give that is worthy of your child?" And the answer follows naturally: "Only your best, anything else would be of no value." 
Hence, from the first moment, we appeal to the responsibility the parent still has to their child, to those who still need the parent, and to life itself. We encourage the parent to transcend self and grief in a supreme act of love, to jump over the barrier of emotions, and to look to the wide horizon of values that exist to discover the meaning awaiting, the meaning that only that parent can realize. When done well, a feeling of fulfillment and purpose in a meaningful life is the result of this task. 
We consulted this point with Dr. Lukas in a mail exchange. She stated: "The idea of giving the newly arrived parents the opportunity to choose from the first moment is splendid, in the best sense of logotherapy." 
Forgiveness as an Option 
In Renacer we hold the concept that forgiveness is not a feeling but an option. If we wait to feel better before we forgive, we err the way. It is not until we forgive that we start feeling better. In other words, inner peace comes as a result of a choice made in spite of our emotions. It comes with the responsibility assumed when making that choice. It is the result of choosing a higher value. 
A father shared with us how he was able to forgive the young men who raced with their cars down a street and killed a whole group of persons waiting at a bus stop, one of them his teenage child: 
At first, I hated the young men whom I called "my child's assassins." 
Afterwards, I hated the parents who did not do a good job at raising 
them. Then I hated the justice system for being slow and uncaring, 
and the company that built the bus stop in that particular place. In 
this bottomless abyss of hatred, I hated myself for failing my child, 
since I was not able to protect them, and finally God for allowing this 
tragedy to happen. I realized however that this hatred was like a 
furnace that consumed all my strength since it needed to be fed 
72 
continuously, which in turn demanded of me to think over and over 
how justified my hatred was in order to add the needed fuel to keep it 
going. 
This was a vicious circle for this father. The invitation to attend a Renacer meeting reached this family, and the mother started to attend by herself. The father chose not to, saying to himself: "As the man of the family I have to endure this on my own, by myself, that much I owe to my child." 
A year later, this father was still isolated in this hermit-world he constructed for himself. Nevertheless, he was able to notice -from the spiritual dimension which never becomes ill -that his wife seemed better. Day after day, she appeared more calm and more serene. She even smiled! So, the father decided to investigate and attend one of the meetings. 
"Maybe there is another way .... " he said to himself. At first, what seemed to crack the shield he had built around him were the love and the respect with which he was received. He felt accepted, no questions asked, just genuine, loving interest pouring out to him because he was a father who had lost a child. When he was confronted with the choice of being consoled or giving something to honor his child, he realized -from his spiritual dimension -that it was not hatred his child deserved. He felt surprised when the following thought came to his mind: "What if one of the young men in the car was my own son? How would I feel?" 
From that moment on, he realized he felt much better, and he noticed how his life started changing for the better. He was surprised to find he still had plenty of love to give; that not all of it was gone with his child. His eyes grew softer. He showed genuine concern for others. But it was necessary to forgive first in order for the love bottled up inside him to flourish. 
We believe the advantage of a group is the many mirrors in which participants see themselves, or their particular experience, reflected. The above example was corroborated dramatically by a couple whose child was driving the car in which four young people were killed, among them two of their other children. It helped these parents to know that the father mentioned above was capable of forgiving the young men who ran over his child. They were able to exchange comforting ideas and embraces with him. Ultimately, these parents were able to forgive their own child and themselves. 
Both couples chose to resolve suffering through service, unleashing the power of the human spirit, changing their lives and themselves for the best. In their own words: "We were not bad people before, but certainly we are more compassionate and understanding than we ever were before." They became active helpers in the groups. They were ready to give an open, warm embrace to every new parent who arrived at the meetings, with a concerned smile and comforting arm around the parent's shoulder as the conversation began to flow. 
A great challenge was presented to the group, in its early stages, by a couple who attended a meeting for the first time. They had lost their only, long-awaited child through suicide. They had tried therapy, doctors, priests, 
73 
but no comfort had come. The mother especially was slipping more and more into depression that had her lying in bed for days, crying, complaining, answering in anger whenever anybody tried to approach her. They questioned themselves repeatedly: "Why didn't we realize what was happening? We should have done ... , or We should have tried .... " They could not forgive themselves. The father realized that this situation could not continue, so he desperately took the advice of a friend, who had attended some meetings of Renacer since the death of her own child. When these parents came through the door, their despair was obvious. They were warmly received, and comforting words were offered, but we realized they were not really listening. They kept talking, both at the same time, making it extremely difficult for the others in the group to reach them. 
As the meeting progressed and a warm feeling of love permeated the atmosphere, these parents began to dry their eyes. Though they did not seem to be listening much, their breathing grew easier, interrupted only by some soft sighing. There was nothing in particular that we said or did that made the difference, rather it seemed to be the presence and accompanying energy of the spirit. We have been witnesses many times to the emergence of the human spirit, to the presence, the eyes, the voice, and the touch. 
At the next meeting they tried to put into words what they had experienced. They said that as they left the prior meeting they felt "like they were floating on air," so much weight had been removed from their shoulders. The mother rested her open, right hand on her chest and with a serene voice said: "I have peace." It was in later meetings that they were actually able to fully understand the concept of choosing to forgive. 
We tell parents who have lost their children to suicide: "We may not like it, may not understand it, and are hurt deeply by it, but we owe it to our child to respect them and let him go with our blessing and love. We need to forgive them for leaving us and forgive ourselves for not being able to meet their every need." Now it is between them and their God, and it is up to us to give love in their name. 
In the words of Dr. Elisabeth Lukas: 
No human relationship could last without receiving from time to time 
the elixir of forgiveness. Understanding everything means forgiving 
everything. Comprehension means approaching the other from the 
spiritual dimension, expressing a benign judgment on their expres
sions and actions. Both the power of reconciliation and the power for 
transformation spring from a common longing for a "worthwhile 
existence," that is only valid if we can feel we are of value to 
141 142
something or somebody. Beyond lies the meaning void.9· P-
Phenomenology of the Emerging Human Spirit 
We recognize the emergence of the human spirit when a parent who has been sobbing desperately in a sea of self-pity becomes erect in posture, begins to look forward as if there is a hopeful horizon, and the eyes acquire a 
74 
new and brilliant gleam. In Gabriel Marcel's words: "I have eyes, but I am my intended look, I am my eye-glance." The parent's voice becomes strong and clearly understood. The entire facial expression changes and transmits a feeling of confident hope -the kind of hope that anticipates the best but is willing to accept what comes; the kind of hope that is willing to accept destiny in humility, allowing the events in life to be as they are, in freedom. 
This emergence of the human spirit is a presence that unveils the opening of Being into the truth; a presence that not only becomes visible but also senses the objective meaning-potential in suffering. This is the reason why Frankl could say that suffering has not only an ethical dignity but also metaphysical relevance, since it makes the human being lucid and the world transparent. 
This manifestation of the unveiling of the human spirit is of much importance for the helping person because the presence of the human spirit manifests itself phenomenologically by the changes noted above, usually prior to the parent verbalizing any changes. The sooner the helping person can become aware of this manifestation of the human spirit, the easier it is for the helping person to induce dereflection in the suffering being -because, as it so frequently happens with phenomena, it may be re-concealed so rapidly that it is missed, and the suffering person allowed to fall again into a hyper-reflection crisis. 
Conclusion 
In Renacer groups we share Frankl's idea on aiming high in our goals we have witnessed the heights human beings are capable of reaching once suffering is thought about as an important, unique opportunity for growth. We have seen parents rise above all possible adverse, painful circumstances to emerge stronger, more compassionate, open to life, and open to the needs of others. These parents take full responsibility for their lives and the ways they live them. They choose to resolve suffering through active service in the groups and in their communities. They not only transform themselves, but, in the process, they also affect other parents and the communities in which they live, becoming valuable social referents to others. They take all three roads to meaning as stated by Dr. Frankl, realizing creative, experiential, and attitudinal values as they enrich and dignify life with their existence, standing tall, accepting and embracing life as it is in all its pain and all its beauty. 
We believe there are several factors accounting for the unveiling of this capacity for inner transformation. Among these is the prospective, meaningoriented approach of the group. Another is the understanding of suffering as a human experience rather than a disease or illness amenable to be cured. Another is the inescapable presence of other suffering persons that not only discloses and facilitates but also promotes the "towards where" of human transcendence as Frankl has stated. Also, there is the fact that attitudinal values are contagious in a group of peers. Finally, and perhaps one of the 
75 
most important, is the intuitively acquired capacity of the more veteran peers to encourage dereflection by the suffering parents. 
Frankl and his followers are among the most adamant defenders of a holistic or spiritual approach to psychology, and they have argued consistently against reductionistic approaches to human existence in general and human suffering in particular. Indeed, based on our experience, we believe that what we see in our Renacer groups is the existential "how-being" of the emergence of the human spirit that precedes its declaration or even its subsequent action, and that this is what the more veteran parents have intuitively grasped. This has allowed them to be prepared to encourage and contribute to unleashing the inner transformation in their suffering peers. 
ALICIA SCHNEIDER-BERTI [San Lorenzo 1325, 5800 Rio Cuarto, Argentina; Telefax *54-358-4632175; e-mail gyaberti@arnet.com.ar] is VicePresident of the Foundation for Existential Crises and Professor of English at the lnstituo /anteriano La Merced, Rio Cuarto, Argentina. GUSTAVO A. BERTI, M.D., is a Dip/ornate of the American Board of Neurological Surgery, a member of the Argentinean College of Neurological Surgeons, and President of the Foundation for Existential Crises. 
References 
1. 
Berti, G., & Schneider-Berti, A. (1993). Life after the death of a child. Palliative Care Today, 2(3), 42-44. 

2. 
Berti, G., & Schneider-Berti, A. (1994). When your child dies: Logotherapy and self-help groups. Journal Des Viktor-Frankllnstituts, 2(1), 7-19. 

3. 
Berti, G., & Schneider-Berti, A. (1994). When an offspring dies: Logotherapy in bereavement groups. The International Forum for Logotherapy, 17, 65-69. 

4. 
Berti, G., & Schneider-Berti, A. (1996). La muerte de un hijo. Ayuda mutua en el proceso de duelo. Archivos Argentinos de Pediatria, 94, 323-333. 

5. 
Berti, G., & Schneider-Berti, A. (1996). Mutual help and logotherapy: From despair to logos. Journal Des Viktor-Frankl-/nstituts, 4(2), 2939. 

6. 
Berti, G., & Schneider-Berti, A. (1999). Mourning and logotherapy. Journal of the Viktor Frankl Foundation of South Africa, 4, 87-89. 

7. 
Berti, G., & Schneider-Berti, A. (1999). On the meaning of sacrifice and self-renunciation. Journal of the Viktor Frankl Foundation of South Africa, 4, 57-60. 

8. 
Frankl, V. (1990). Logoterapia y Analisis Existencia/. Barcelona: Herder. 

9. 
Lukas, E. (1995). Psicoterapia en dignidad. Buenos Aires: San Pablo. 

10. 
Lukas, E. (2000). Psicologia espiritual. Buenos Aires: San Pablo. 


76 
The International Forum for Logotherapy, 2004, 27, 77-79. 
PARENTAL DIVORCE AND PURPOSE IN LIFE OF ADOLESCENTS IN BANGLADESH 
Tania Rahman 
(ABSTRACT) The relationship between parental divorce and Purpose-in-Life (PIL} test scores was assessed for Bangladeshi adolescents, 43 each of divorced and intact families. It was found that adolescents of divorced families had significantly lower scores compared to intact families (PIL = 60.3 vs. 90.1; t(84) = 7.09, p < 0.001). The present finding suggests that a larger number of adolescents from divorced families may be in special need of logotherapy to help individuals counteract the tendency toward lower sense of meaning and purpose in this population. 
The family environment is the most basic and earliest social environment that children experience. The quality of that experience, and the relationships within the family, can have both direct and indirect effects on children's behaviors and competencies. It is reasonable to believe that family environment may have a relationship with children's adjustment in various life situations, including their sense of meaning 
and purpose in life. 
Psychologists attach great importance to the role of parents in determining personality characteristics of children. In divorced families, the literature has shown children are more likely to experience significant
10
psychological problems.4· The association between parental divorce and adjustment problems of children suggests that separation can have a direct and substantial influence on children and adolescents regardless of the circumstances responsible for the separation. 
It can be tentatively concluded from various studies that academic problems, low self-concept, and emotional stress, maladjustment, and social withdrawal increase in children from divorced families.6·7·8 Based on the above mentioned findings, it is hypothesized that Bangladeshi adolescents of divorced families will tend to have also low purpose in life compared to the adolescents of intact families. 
Method Subjects 
The study sample consisted of 86 adolescents of whom 43 were from divorced families and 43 from intact families. Divorced and intact families were roughly matched in terms of age, sex, socioeconomic status, and 

77 
education. Age of participants of this study ranged from 14 to 17 years. The samples were obtained from different schools and colleges of Dhaka city, Bangladesh. The samples were selected following purposive sampling technique. The samples of this study represent the lower-middle class of Dhaka city. 
Measuring instruments 
Purpose-in-Life (PIL) test:2 A Bengali version of the PIL scale was used in the present study. There was no time limit for completion. Subjects took about 10 minutes to complete the 20 PIL items of Part A. The PIL objective scores in Part A are the sums of the numerical values; scores below 92 indicate the lack of clear meaning and purpose in life. 
Data were collected after securing due permission from the authority of the selected college and school. The participating students were provided with appropriate information about this study. The PIL scale was administered in small groups. Precise information was given and pre-tests were performed. Proper care was taken so that the subjects could answer all the items correctly. The respondents were assured of confidentially of their individual information. 
Results 
The mean PIL score of the adolescents from divorced families (M = 60.3, SD = 14.6) was significantly lower than that from intact families (M =90.1, SD= 23.4); t(84) = 7.09, p < 0.001. 
Discussion 
The present research assessed the relationship of parental divorce to the sense of life-meaning in Bangladeshi adolescents. In this study, adolescents from divorced families had lower life-purpose than those from the intact families. 
Purposefulness in life is an indicator of good adjustment and a healthy personality.9 Research findings with other populations have shown that children's social development and adjustment are influenced by the parentchild relationships-1'3 
In Bangladesh, due to financial problems, adolescents from divorced lower-middle class families rarely live with either mothers or fathers. Most of the time, they go out of their houses for wage earning purposes. An adolescent often has a surface appearance of gay and carefree activity. Deep inside an adolescent suffers from many anxious thoughts and uncertainties undergoing a period of decision-making and problem-solving which is difficult. In addition to that, adolescents from divorced families, who are already experiencing their own developmental difficulties, acquire additional problems with separation of the parents. They become anxious, perhaps because they realize their parents were not perfect and were not certain about their own future. This situation may become an obstacle for the 
78 
adolescents to think of themselves in a positive way. They may feel inferior and less happy than adolescents in intact families, which may influence their poor adjustment pattern and less purposefulness in life compared to adolescents from intact families. The finding of this study is consistent with the findings elsewhere.5 
Divorce may be a factor for less purpose in life, but there are many other factors which may influence it at the same time, such as financial solvency, family structure, etc. The present finding, suggests that a larger number of adolescents from divorced families may be in special need of logotherapy to help individuals counteract the tendency toward lower sense of meaning and purpose in this population. 
TANIA RAHMAN, M.Sc., is Associate Professor of Psychology at the Institute of Social Welfare and Research [University of Dhaka, Dhaka University Campus, Dhaka 1205, Bangladesh, Email: zeaur@icddrb.org or Tasmina7@yahoo.com]. Her main interest is Social Psychology. 
References 
1. 
Bee, H. (1978). The developing child (2nd ed.). NY: Harper & Row. 

2. 
Crumbaugh, J. C. (1968). Cross-validation of Purpose-in-Life test based on Frankl's concepts. Journal of Individual Psychology, 24, 74-81. 

3. 
Douvan, E. N., & Adelson, N. (1966). The adolescent experience. NY: Wiley. 

4. 
Fulton, J. A. (1979). Parental reports of children's post-divorce adjustment. Journal of Social Issues, 35, 126-139. 

5. 
Dorpat, T. L., Jackson, J., & Ripley, H. S. (1965). Broken homes and attempted and completed suicide. Archives of General Psychiatry, 12, 213-216. 

6. 
Long, N., Slater, E., Forehand, R., & Fauber, R. (1988). Continued high or reduced interparental conflict following divorce. Journal of Consulting and Clinical Psychology, 56, 467-469. 

7. 
Forehand, R., Mccombs, A., Long, N., Brody, G. H., & Fauber, R. (1988). Early adolescent adjustment to recent parental divorce: The role of interparental conflict and adolescent sex as mediating variables. Journal of Consulting and Clinical Psychology, 56, 624627. 

8. 
Smith, E. T. (1990). Parental separation and adolescent's selfconflict An effort to solve the puzzle of separation effects. Journal of Marriage and Family, 52, 107-118. 

9. 
Sultana, Q. A. (1984). A study of some factors in adjustment patterns of adolescent boys and girls in Bangladesh. Bangladesh Journal of Psychology, 7, 72-81. 


10. Wallerstein, J. S., & Kelly, J.B. (1980). Surviving the break-up: How children actually cope with divorce. NY: Basic Books. 
79 
The International Forum for Logotherapy, 2004, 27, 80-83. 
EXPANDING THE TOPOGRAPHY: VARIATIONS ON FRANKL'S MOUNTAIN RANGE EXERCISE 
Stefan E. Schulenberg 
One of logotherapy's techniques is Frankl's Mountain Range Exercise (MRE). The MRE is a noninvasive method that can aid in building rapport with a client as well as revealing relevant clinical information. The MRE can be conducted in individual or group formats and in a variety of treatment settings (e.g., outpatient, inpatient, group home). The purpose of this article is to describe some variations of the traditional MRE. 
The Traditional Mountain Range Exercise (MRE) 
The concept of the MRE was introduced by Frankl and developed by ErnzenY It has become part of the Viktor Frankl lnstitute's educational curriculum.5 The MRE was described originally as a group exercise where each participant is given the chance to look over their life as they would look out over a mountain range, placing the people who have influenced them on the peaks (e.g., loved ones, authors).1 Participants use paper and colored pencils or markers to depict their mountain ranges graphically. Persons of influence are then "placed" on the peaks. People sometimes experience a sense of surprise as they remember people they may not have thought about in years. 1 The MRE reminds the client how others have contributed to their life. In so doing, it brings the client's underlying value system to the surface, and fosters an increased sense of awareness and a sense of gratitude.1 
The incorporation of maieutic questions is a useful adjunct to the MRE. For instance, areas that may be probed include: the values that the client has in common with the people "placed" on the mountain peaks, "surprises" experienced while participating in the exercise, and on whose mountain peaks the client would like to appear.5 
It may also be useful to document the number of positive influences "placed" on the peaks as well as to assess the depth of the relationship to the client. For instance, a client who places several friends, family members, and teachers among their positive influences may have a deeper reservoir to draw from in terms of values and guidance than a person who places only authors or musicians. 
Ernzen reported that the MRE has been used with psychiatric inpatients, meaningful living groups, and retreat groups. 1 Schulenberg reported on the 
80 
use of the MRE with adolescent males with mild to moderate mental retardation/developmental disabilities and sexual behavior problems in a high-management group home setting.4 The MRE was used successfully in group therapy to build rapport, improve attention and focus, and address important treatment issues (e.g., values clarification, patient disclosure of sexual offense histories).4 The following variations of the traditional MRE were developed with this latter population in mind (with exception of the computerized MRE) as a means of discussing abstract treatment issues in a concrete manner. However, their potential utility extends beyond this group. 
Variations on the Traditional MRE Peaks and Valleys 
It may be useful in some clinical circumstances to ask clients to place positive influences on mountain peaks and negative influences in valleys between the peaks. These influences could be relationships in the client's life, or they could be events that have had a strong effect. This variation of the MRE may provide additional useful clinical information. The key difference in this variation is that it highlights the positive aspects of a client's social support network while simultaneously revealing negative influences that may become targets for therapeutic intervention (e.g., a maladaptive response to a traumatic event). The idea is for a client to develop a more complete understanding of both positive and negative life-influences through graphical representation. 
Treatment Goals 
Another variation of the MRE is to focus not on the positive influences in a person's life, but on treatment goals. The procedures are similar to the traditional MRE except that the therapist prompts the client to label peaks with treatment objectives. Again, incorporation of maieutic questions is useful. Some areas that may be probed include: the values that would be actualized if the therapeutic goal is achieved, "surprise" goals that were included, and which goals seem most important. Clarifying values related to treatment goals may increase motivation or alternatively may demonstrate that the goal is not important to maintain. 
Life-Goals 
Another version involves instructing clients to place life-goals on the peaks (rather than specific treatment objectives). Here again, maieutic questions can clarify personally-meaningful values by probing: values that will be actualized, "surprises" that were included, and the most important of the life-goals. 
Computerizing the MRE 
Schulenberg discussed a rationale for clients to use the graphics features of stand-alone computers to develop MREs.3 Some therapy clients 
81 
may prefer the computerized modality. With the graphics features that are available for computers nowadays it is not complicated to develop computerized "drawings" of mountain ranges. The underlying principles of this version of the MRE remain the same as the traditional MRE. · 2·5 
Incorporating a Symbol of Client Progress 
In the life and treatment goal variations of the MRE, the client can be asked to draw himself or herself on each individual mountain as a means of representing progress toward the peak (at the middle of the mountain for being halfway, near the top of the mountain for near completion, etc.). This serves as a graphical representation of a client's perception of progress, and it can be used to stimulate discussion about progress. Concurrently, these latter variations afford opportunities to talk about what the client needs to do to maintain his or her position on each individual mountain (e.g., relapse prevention), as well as ways to continue the ascension toward objectives. 
This activity provides added opportunities to discuss how coping skills relate to a client's progress or areas that may be hindering a client's ability to ascend a particular mountain. This is related to a client's degree of insight. For instance, what factors are contributing to a client's treatment success? What factors are contributing toward a lack of treatment progress? Once the exercise has been completed, there is the opportunity to realistically discuss treatment to help ensure that the therapist and the client are on the same page. 
Conclusions and Future Directions 
As with the traditional MRE, maieutic dialogue is important. For example, once clients have depicted themselves climbing a mountain, they can be asked how they have climbed so high, how they can continue to keep climbing, and how they can avoid slipping and falling. It is a metaphorical means of revealing important clinical information that a client may use in time of need (e.g., social support), or it may reveal issues that require clinical intervention (e.g., as in the case of a client's maladaptive response to a traumatic event). Such discussions have implications for revising goals, motivating participation and gains, and assisting in relapse prevention. 
It is important that the effectiveness of the MREs be documented in the literature. What is their applicability and effectiveness with children, with adolescents, and with adults? What is their applicability and effectiveness with persons from different backgrounds? How effective are they with individuals, groups, couples, and families? Use of MREs in couples and family therapy has received particularly little attention in the published literature. Having a couple participate in an MRE activity focusing on life goals may facilitate useful discussion as to the similarity of the couple's life goals. Having a family complete an MRE during a family session may prompt useful discussion on important family values and may be a healthy bonding activity. The potential applications of the MREs are many, and 
82 
documentation of their clinical utility may be achieved through case studies or through their inclusion in clinical outcome studies. 
STEFAN E. SCHULENBERG, Ph.D. [sschulen@olemiss.edu] is an Assistant Professor in the Department of Psychology at The University of Mississippi, University, Mississippi 38677, USA. 
References 
1. Ernzen, F. I. (1990). Frankl's Mountain Range Exercise: A logotherapy activity for small groups. The International Forum for Logotherapy, 13, 133-134. 
2. Frankl, V. E. (1986). The doctor and the soul: From psychotherapy to logotherapy (Rev. ed.). NY: Vintage Books. 
3. 
Schulenberg, S. E. (2001, June). Computers and logotherapy: Using technology in clinical practice. Paper presented at the Thirteenth World Congress On Logotherapy, Dallas, TX. 

4. 
Schulenberg, S. E. (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. 

5. 
Welter, P. R. (1995). Logotherapy-lntermediate "A": Franklian psychology and logotherapy. The Viktor Frankl Institute of Logotherapy, Box 15211, Abilene, TX 79698-5211. 


83 
The International Forum for Logotherapy, 2004, 27, 84-91. 
TRANSCENDENTAL LOCUS OF CONTROL: IS IT AKIN TO NOODYNAMICS? A Hermeneutic-Phenomenological Inquiry 
Maria (Ungar) Mendez Asin, Eduardo Mendez Asin, & Julia Ungar 
Transcendental Locus of Control is a phenomenon which is not alien to logotherapists: Frankl's notion of self-transcendence refers to a mode of existence which focuses on a higher dimension.1·2·3 By acknowledging the capacity of the human being for self-transcendence, logotherapists recognize that the basic motivating force for our human existence is the Will to Meaning.8 
However, the notion of Transcendental Locus of Control does not have to be restricted in its meaningfulness to logotherapists. Rather, it can be conceptualized inductively and deductively from the interface between logotherapy and the evolution of psychological thought, with special attention to those highlights which stand as milestones in our evolving understanding of humanness: (a) Views on Human Nature; and (b) Motivation of Human Behavior. More specifically, we hypothesize that, in the light of a meaningoriented framework, the notion of Transcendental Locus of Control can be directly intuited as an extension of Rotter's original "Locus of Control" theory. 14 
In examining this premise, we rely on a hermeneutic-phenomenological inquiry. This qualitative research method serves not only to describe phenomena on the basis of information gained from pre-existing literature, but also to integrate the authors' own reflections with currently existing knowledge.15 
Views on Human Nature Brief Review of the Evolution of Psychological Thought 
According to a current textbook on the Foundations of Psychology, 10 ever since psychology was a fledgling science, its goal has been a better understanding of human behavior. Historically, the understanding of human nature (and human motivation) started with quantitative studies of overt reactions, and responses to environmental stimuli.10 Not infrequently the focus of these studies was physiological processes or neural mechanisms underlying the reactions. In general, early studies were most concerned: with homeostasis, or inner balance; with understanding environmental clues that elicit responses; and with learned behavioral responses. The focus of the studies was to understand physiological instincts and drives (such as hunger, thirst) with some discussion of neural mechanisms underlying them. 
A "second chapter" in the history of psychological thought started with 
84 
the advent of more sophisticated methodologies (among them not only quantitative, but also qualitative methodology) and the recognition of human needs, cognitions, and emotions. Physiological motives, drives, and instincts were recognized as very important. But aside from them, there began study of cognitive motivations (both conscious and unconscious) which are evident in such achievements as the understanding of the role of avoiding cognitive dissonance, ego defense mechanisms, and a range of interpersonal dynamics that modify the individual's response to the environment. 
Studies on learned helplessness, attribution, locus of control, and selfefficacy were crucial in fostering our understanding of personality traits and characteristics.10 However, qualitative analyses of affective motives, such as the need for affiliation and positive regard, helped to crystallize a more sophisticated view of the human person -a bio-psycho-social-being beyond elemental physiology and drives. 
Yet, a crucial dimension, the dimension of the spirit was still missing. Moreover, without it, how could one ever explain the complexity of human behavior and human motivation? 
Logotherapy's Contribution to the Evolution of Psychological Thought 
In a well-known illustration, Dr. Lukas demonstrated the way in which loqotherapy revolutionized psychology through its "dimensional ontology." 12· 
p fSo 
BODY SOUL 
t t 
old visible, 
invisible, distinction material 
immaterial
} 
( concretization) (abstraction) 
I \ 
completion
by psychology by logotherapy 
~ 
.:2.. 
~ ~ 
I \ 
t ~ 
SPIRIT 
t 
new determined free 
distinction (FATE) (FREEDOM)
} 

Lukas, E. (1995). Psychological Minsitry. p. 160 
85 
Dimensional ontology asserts that we not only have body (soma) and 
2 55
mind (psyche), but also we are spirit-beings (noos). 1· .4, , Noetically (in our 
5
spirit) we are in search for purpose and Reason for our lives.4· 
As apparent from Lukas' schematic, this new conceptualization complements traditional views of the human person, by leaving room for the "invisible," and "non-material" ("abstraction"). It allows us to move beyond
11 12
acknowledging concrete causation, to a search for reasons. · 
From Psycho-dynamics to Nao-dynamics 
The homeostasis principle that underlies the physiological and dynamic interpretation of human beings maintains that our behavior is basically directed toward: the gratification and satisfaction of our drives and instincts; reconciliation of the different aspects of our psyche (such as id, ego, and super-ego); self-preservation; and adaptation and adjustment to society. The homeostasis principle is directed toward the maintenance of our own biopsycho-social equilibrium.16 
Frankl _affirmed that in the dimension of .theJpiri~ what ~e need _is not homeostasis but what he called "noodynam1cs. · p. 5 That 1s, the kind of appropriate tension that holds us oriented toward concrete values to be actualized, toward the meaning of our personal existence to be fulfilled: 
What I call noodynamics is a field of tension whose poles are 
represented by us and the meanings that beckon us. Noodynamics 
structures our life like iron filings in a magnetic field. In contrast to 
psychodynamics, noodynamics leaves us the freedom to choose 
between fulfilling or declining the meaning that awaits us.5· p. 88 
Noodynamics creates a constant tension between who we "are" as human beings and who we can be if we follow an ideal. 16 Frankl termed this tension, "...a tension between existence and essence, or being and meaning." 7· P225 Meaning, he said, "...must always be one step ahead of being -only then can meaning fulfil its own meaning, namely to be the 
15
pacemaker of Being." 4' P· 
Motivation for Human Behavior Locus of Control 
From a strictly psychological perspective, Rotter demonstrated that the beliefs that individuals hold about how much they control situations can make a great difference with regard to how they cope.14 People with internal locus of control believe that control of their lives largely comes from their own efforts. Such persons experience less stress than those with an external locus of control, who believe that they are largely the victims of circumstance. These beliefs easily become self-fulfilling prophecies, since people with an internal locus of control are more likely to make an effort to influence their lives, whereas those with an external locus of control are more likely to take a passive stance towards their circumstances.10· p.4 52 
86 
The implications of internal vs. external locus of control and subse9iuent 
10 13
coping responses have been the topic of much research and debate. · · While initially there seemed a consensus among therapists for the need to "educate" those who have an external locus of control to develop an internal locus of control, this approach received criticism from groups emphasizing communal values, altruistic behavior, and a recognition that not all situations can be controlled (and that a degree of external locus of control in such 
10 18
situations can be a helpful coping mechanism).9· · 
This train of research led to a more recent conceptualization of locus of control as an adaptive and dynamic personality disposition, rather than a static trait. The term "Integrative Locus of Control" 19· P-35 suggests that adaptive coping requires the flexible combination of degrees of external and internal locus of control in response to situational demands.13·19 

~ 
External Internal Locus of Control Locus of Control 
Freedom and Fate 
23
To every life there are limitations. This is what is in our area of fate. 1· ·· 
p.92 
Frankl's legacy shows that "Everything can be taken away from us (what we have) except our spirit." 2· P-14 However, in our spirit is where we truly are, and we can be, and be even better than what we can appear to our own 
eyes! 1,2,s,s 
Thus, every life holds a possibility to find an area of freedom. Ultimately, 
268 
we can at least in our attitudes respond to what is in our area of fate. 1·· · 
Fate Freedom Demands Resources 

While we see that Rotter's notion of internal and external locus of control emphasizes self-awareness and development, logotherapy charts the course further. Logotherapy brings into the picture the possibility of self-distancing and the possibility of self-transcendence. 
87 

Interfacing Locus of Control Studies with Logotherapy Conceptualizing Transcendental Locus of Control 
Following the above line of reasoning, we posit that what makes the areas of fate and freedom overlap, and appear in context, is a coordinate system in which there are reference points. These reference points are universal values, which provide ~uideposts to "trans-subjective" meanings the aim of self-transcendence.4·5· ·7 
As we know from logophilosophy, our conscience is a "meaning-organ."
5 
· p.2 1 And it is our conscience that provides the "psychological-spiritual joint" 17· P 128 for intuiting person-, situation-, and time-specific meaning. ·7 

Search for Meaning 
In the context of logophilosophy, Transcendental Locus of Control is conceptualized as an awareness of meaning permeating the whole of life. As such, it provides a "backbone" (reason) for all our validly human efforts to perceive/think/feel/cope/act through a reference to a "Reason de Etre" -the higher dimension and Ultimate Meaning in our lives. 
88 
·················.............. Diment~:~fn~ltimate 

·•.....Transcendental L.bous of Control 
·····-. 
Implications of Transcendental Locus of Control 
Transcendental Locus of Control implies a reference point in the dimension of the Transcendent which makes our human strivings lasting, and worthwhile. Through the possibility to have internal and external loci of control we can see our life, our limitations, our potentials. However, rising beyond ourselves, through hearing the "voice of the transcendent," we have the capacity to respond according to our best ability, even if this response under extreme conditions is limited to the attitudinal response of our spirit. 
In logotherapy's presuppositions, meanings are not fabricated, only discovered.1'2 They are ends in themselves, and they all converge into higher meanings and Ultimate Meaning,8 which provides the coordinates for all of our physical, psychological, and spiritual aspirations. Meanings can not be given by one person to another, they have to be reached out to, and discovered. 
Frankl remarked that the aim of psychotherap¥ is to foster mental health while the aim of religion is to lead to salvation. Yet, inadvertently, good therapy can result in increased spiritual awareness and faith; and, vice versa, a spiritual awareness and faith can protect and even improve our mental 
45
health.3-P 
Transcendental Locus of Control implies that when physical, psychological, or social obstacles are removed, a natural and innate resurgence of the search for meaning can take place. However, it also emphasizes that even when physical/psychological/social obstacles cannot be fully removed, the search for meaning does not cease. 
Frankl remarked that the task of the therapist is similar to that of an optometrist: to help us to see clearly. As therapists, we are called upon to help to remove the obstacles from the path so that our patients are able to recognize that piece of the Transcendent that their human existence allows them to absorb. Our task is to point them toward the Transcendent, which, even amidst profound limitations, envelops each human being. 
89 
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, MD, Ph.D., is a 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]. 
JULIA UNGAR, M.Ed., is a Doctoral Student of Clinical Psychology, and Lecturer on Psychology at the University of Windsor, Windsor, Ontario, Canada. 
References 
1. 
Barnes, R. C. (1994). Viktor Frank/'s /ogotherapy. Unpublished manuscript, Hardin-Simmons University, Abilene, Tx. 

2. 
Barnes, R. C. (1994). Logotherapy and the human spirit. Unpublished manuscript, Hardin-Simmons University, Abilene, Tx. 


3. Frankl, V. E. (1967). Psychotherapy and existentialism. Selected papers on !ogotherapy. NY: Washington Square Press/Pocket Books. 
4. Frankl, V. E. (1972). Der wille zum sinn. Bern: Hans Huber Verlag. 
5. 
Frankl, V. E. (1975). Anthropo!ogische grundlagen der psychotherapie. Bern: Hans Huber Verlag. 

6. 
Frankl, V. E. (1986). The doctor and the soul: From psychotherapy to logotherapy (rev. & exp. ed.). NY: Vintage Books. 


7. 
Frankl, V. E. (1996). Zeiten der entscheidung. Freiburg: Herder/Spektrum. 

8. 
Frankl, V. E. (2000). Man's search for ultimate meaning. Cambridge, MA: Perseus Publishing. 

9. 
Frazier, L. D. (2002). Perception of control over health: Implications for sense of self in healthy and ill older adults. In S. P. Shohov (Ed.), Advances in psychological research, Vol. 10 (pp. 145-163). Huntington, NY: Nova Science Publishers, Inc. 

10. 
Hayes, N. (1994). Foundations of psychology: An introductory text. Walton-on-Thames, Surrey: Thomas Nelson & Sons. 

11. 
Long, J. (1986). Reasons versus causes as explanations of human behavior. The International Forum for Logotherapy, 9, 93-99. 

12. 
Lukas, E. (1995). Psychological ministry. Unpublished manuscript, translated from Psychologische Vorsorge by W. Schulte. 

13. 
O'Connor, D. B., & Shimizu, M. (2002). Sense of personal control, stress and coping style: A cross-cultural study. Stress and Health, 18, 173-183. 

14. 
Rotter, J. B. (1966). Generalized expectancies for internal vs. external control of reinforcement. Psychological Monographs, 80, (No. 1). 

15. 
Smith, D. G. (1993). Hermeneutic inquiry: The hermeneutic imagination and the pedagogic text. In E. C. Short (Ed.), Forms of Curriculum Inquiry, (pp. 187-210). Albany, NY: SUNY Press. 

16. 
Ungar, M. (1999). Viktor E. Frankl's meaning-oriented approach to counselling psychology. Unpublished dissertation, University of Alberta Library Catalogue, Edmonton, Alberta, Canada. 

17. 
Ungar, P. (2002). Questions on the borderline of psychiatry, psychology, and theology. Unpublished manuscript, Surrey, British Columbia, Canada. 

18. 
Wallston, B. S., Wallston, K. A., Kaplan, G. D., & Maides, S. A. (1976). Development and validation of the Health Locus of Control (HLC) scale. Journal of Consulting and Clinical Psychology, 44, 580585. 

19. 
Wilken, C. S., Walker, K., Sandberg, J. G., & Holcomb, C. A. (2002). A qualitative analysis of factors related to late life independence as related by the old-old and viewed through the concept of locus of control. Journal of Aging Studies, 16, 73-86. 


90 

91 
The International Forum for Logotherapy, 2004, 27, 92-97. 
EACH DAY IS A MINIATURE LIFETIME AGING AND MEANING 
Deborah Paden-Levy 
"As soon as you are born you are old enough to die." 5· P· 64 So said Jean-Paul Sartre. 
A person of 70 may be no closer to death than a young child. They may have different viewpoints of death, but both may enter death's kingdom at a moment's notice. Life has been envisioned as a process, and time envisioned as both a destroyer and a restorer. Unfortunately, advancing age is viewed in present Western society as more of a destroyer. Young people today mostly associate aging with disability and death.a Betty Freidan noted that the old are often caricatured as "sexless, demented, incontinent, toothless, and 
51
childish." 7· P· In Western culture, the physical sphere is over-valued; and yet old bodies fail. We treasure and bow down to Adonis and appearance; yet, attractiveness fades. "We are not taught that old spirits often shimmer with 
50
beauty." 7· P· 
Most of us have been given the gift of long life. The length of life has increased dramatically in the last century. In 1900, the average life expectancy was 47 years. In 2000, the life expectancy for men was 73 years and 80 years for women. However, after the Industrial Revolution, the aged came to be seen as useless because of their physical deterioration and their outdated skills.a And in our current production-oriented society, the elderly are viewed as obsolete, as "hollow" beings. Can't we better appreciate this gift of longer life? In ancient times, to live a long life was to nearly qualify as a philosopher.5 Even as the body declines with age, there is room for growth in the psyche and in the spirit. As Elisabeth Lukas stated, we have the "possibility of shaping our lives responsibly and filled with meaning, up to the last breath." 6· P·50 
For the developmental psychiatrist, Erik Erikson, the human comes into the world as an organism and dies a member of society. Living is viewed as a three-level process involving physical, psychological, and sociological change. Erikson depicts "living for society" in his theory of eight psychosocial crises corresponding to each stage of life.5 Living for something else, someone else, is critical. As Erikson said, "Once we have grasped this interlocking of human life stages, we understand that adult man is so constituted as to need to be needed lest he suffer the mental deformation of 
97
self-absorption, in which he becomes his own infant and pet." 5· P· This 
92 
corresponds to the logotherapeutic concept of self-transcendence -key through the entire lifespan. 
Erikson describes the last stage of life as reminisce/reconcile with the psychosocial crisis as integrity/despair. Healthy development in late life means accepting one's path of life regardless of outcome, realizing that no one eludes the limitations of life such as missed opportunities and encountering misfortunes. Erikson's healthy aged development is similar to logotherapy's concept of attitudinal values -accepting life and adversity with dignity. To Erikson, the aged accept their one and only life and have an affinity with humanity where self, others, and the universe are merged. G. Stanley Hall observed, "the function of competent old a~e is to sum up, keep perspective, draw lessons, particularly moral lessons." · P· 105 Teaching these lessons, contributing to descendents, can provide meaningful work for the later years. Elders teach the younger the value of time, connections, gratitude, responsibility, patience, endurance, civility. 
In logotherapy, old age is a special time to expand the spiritual dimension. As the body and mind slowly decline with age, the spirit can keep broadening if not prevented by illness. There are gifts of old age, if noticed and cultivated. These gifts, according to Elisabeth Lukas include: 
... strength of spirit based on a mature philosophy of life, a 
rich meaning orientation based on a lifelong search and 
struggle, a secure value structure built by personal 
experiences, and the memory of an abundant and unique 
life. These are the quiet blessings of the late years, 
unfortunately often lost in today's unhealthy attitudes toward 
old age_6, p.71-?a 
As humans encountering the elderly in our daily life, and as logotherapists, we must draw attention to their riches accumulated in the spiritual dimension and dereflect their attention from the physical decline. "Becoming an elder does not occur simply by living many years but more so by what we and fate fill us with over the years. It is never too late to deepen." 9· P·28 There can be a welcome shift from primarily "doing" to a state of "being," a contemplative time. From life experiences, elders can turn sorrow into wisdom into compassion. "As bodies grow frail, souls often grow strong and resilient." 7• P 216 Life then is our job, is our career, even through old age. 
Moving toward a state of "being" with age, later life can shift to an intuitive, unifying mode of thinking. This has caused speculation of a spiritual element in cognition in late life.2 Palovtzian and Ellison developed a measure of spirituality where spiritual well-being consists of two dimensions -a vertical one reaching to the heavens and a horizontal one stretching through ordinary life experiences.2 Certainly, ordinary experiences take on a richer meaning for the elderly; and a practical outlook changes to a transcendent perspective on self and life. Indeed, a study of the elderly has found enhanced emotional adjustment with a "being" orientation and greater mental illness with a "doing" orientation.11 
93 
While the losses of old age have been amply described and dreaded, the gains have remained concealed. According to some research, the stressfulness of old age is debatable. Recent studies have found that life events are no more stressful than in earlier life and do not necessarily mount up in a negative manner in old age. Many life events (such as loss of spouse, illness) produce less of a toll in old age because they are viewed as being "on time." 2 There can be a continuing participation in life as opposed to having a "roleless role." Elders continue to be involved in volunteer work and home improvements, have a renewed relationship with nature, pass down history, and give aid to grandchildren. Recent observations note the elderly as giving support and help rather than mostly receiving help. Research on these altruistic behaviors is just launching.2 
In past studies, the elderly were seen as passive in their coping skills with difficult life events. In more recent studies, the older are seen as active, seeking challenges, navigating their lives, and surmounting limits. Control over circumstances may become less imperative while inner control over meaning and viewpoint may become more significant. This inner control includes acceptance of the existing situation, gaining detachment, and maintaining a positive and optimistic attitude. 10 Achieving acceptance has been called "the last great gift of old age." 7 As there is more adversity to accept, there is more capacity to achieve acceptance. Attitudinal change, acceptance, and self-distancing sets the vigor and mettle of the human spirit against fate. "All of us want to do something noble before we die. It is a way to wrest some kind of victory from the defeat of death." 7· P-205 
The theory that elders disengage from life is being questioned as the old persist with their recreations and interpersonal relations. There is often an active selecting and molding of social connections. The core social ties ( close friends and family) remain stable, whereas more peripheral ties undergo trimming.8 As we grow older, we sift through our relationships and retain those which we value the most. We become more selective without diminishing the quality or satisfaction gained from our social network. 
Personality traits remain relatively stable with age, but what we do with our personalities and how we handle our innate nature can progress as we age. Since new, difficult challenges appear with aging, it makes sense that emotional learning continues throughout this stage of life. Instead of muted, inflexible, flat emotions with little enthusiasm being descriptive for the elderly, another viewpoint in recent years regards emotion as a dimension that is spared from the losses of age. We may manifest emotional gains as we age and encounter new experiences with increases in emotional refinement and competency.8 
In Qualls and Abeles' book,8 older couples have been reported to show more affection, experience more positive affect, more pleasure, and more emotional balance. The elderly have been found to arrange their environment to maximize positive emotion and minimize negative emotion. Age-related improvement in managing emotions along with increased emotional 
94 
competence has been found. In fact, older people experience lower rates of all psychiatric disorders than younger people do. 
Emotional development may be a lifelong process with certain aspects not reaching their pinnacle until late in life. Our emotional range can become more honed with age, with growth in compassion, understanding, poignancy, and with more depth, breadth, and complexity.8 Our physical resources weaken, while at the same time, the challenges that confront us increase and become harsher. Emotions then become more critical; this refinement of feelings allows older people to "grow up" rather than "grow down." ''The saddest thinq about old age isn't loss but the failure to grow from experience." 1,p 192 
Dependency is a significant hurdle for the aged. Dass notes that it can be also an opportunity to grow, to expand in attitude.4 Needing help can spur feelings of humiliation since self-sufficiency is such a high value in our society. However, we can transform the situation for ourselves and for those who help; there is a wisdom of dependency. By allowing ourselves to accept care, we allow those around us the opportunity to help -a basic need in humanity. If we resist or show bitterness over dependency, we create suffering, producing uncomfortable feelings for the helpers. Caretakers who help a dependent person whose hands and spirits are light and open can come away as if they have received a gift. Both parties can feel rewarded from having been in the exchange. This has been called a "sacred exchange of love and care." 4· P-94 With role changes, there are often surprising benefits and deep learning -the "paradox of misfortune." 4· P-95 
In ''Tuesdays with Morrie," Morrie Schwartz in old age chose to transform his disease-addled experiences and refused to be ashamed about his dependency. 
I'm an independent person, so my inclination was to fight all 
of this ... But then I figured, "Forget what the culture says." I 
began to enjoy my dependency. Now I enjoy when they turn 
me over on my side and rub cream on my behind so I don't 
get sores... I revel in it. I close my eyes and soak it up. It's 
like going back to being a child again. Someone to bathe 
you. Someone to lift you ... We all know how to be a child. It's 
inside all of us... The truth is, when our mothers held us, 
rocked us, stroked our heads -none of us ever got enough 
of that. 1· P-116 Do we choose to shake our fists at fate or do we mold our attitude in an unchangeable situation? "Courage is the price life exacts for granting peace." 
7, p.153 
As a discounted activity of elders, reminiscing has been dismissed as "living in the past." Yet, the later years of life can be a humanizing experience through reminiscence. There is often reinterpretation, new perspectives, increased sense of self, repairing old wounds, reframing painful memories all leading to an ultimate acceptance of life experiences. "The book of life 
95 
remains open. We still have the opportunity of finding treasure hidden in the pages of our years." 9· P49 Exploring memories can draw out new meaning to past experiences, making sense of the unexamined or unmined events of our lives. Our lives and selves then start to cohere. Ultimately, life review can provide clues as to the purpose of one's life. 
In logotherapy, the experiential dimension is an avenue to find meaning. With the elderly limited by physical decline, illness, and less active lives, reminiscence can be a conduit to the experiential realm. In our younger years, only peak moments gave us "experiential transcendence," but remembering in late life leads to that transcendence more readily and more frequently. Events evoked from the past evoke pleasure in the present. There can be a sensory quality of remembering, with time now to savor the past in the now. In fact, there have been studies demonstrating that reminiscence was associated with positive affect, increased life satisfaction, and adaptive coping even for those moving into nursing homes. 11 
Another logotherapy dimension to find meaning is the creative area. Memory is available to the elderly for their own creative expression and experience. Some see reminiscence as an art form. "Memory is a great artist. For every man and for every woman, it makes the recollection of his or her life a work of art." 11 · P-197 For reminiscing, the person's life need not be unusually exciting but instead "epiphanies of the ordinary." 11 · P-197 Remembering is "consciously reweaving the gorgeous tear-stained threads of your colorful life into a fresh tapestry of meaning." 9· P-97 Our own internal drama can be equated with liberation -liberation to assess our own past, to integrate it, to harvest the tastes, colors, textures, and uniqueness of our lives. 
Creating our life story has been considered a "sacred duty." 11 · P-201 This duty falls in the attitudinal realm and into the spiritual dimension of logotherapy. "Tolstoy said that the life of an ordinary man, if accurately captured, would be the best and most complex piece of literature ever written." 7· p.2os By turning the events of the past into meanings for the present, we dig up our lives again and become richer. If life's sufferings become part of our core, we remain defeated. However, we can unshackle ourselves by remembering and jump beyond our anguish to find dignity, new revelations, serenity, and gratitude. This digging is with a kind of artistry. As one older person eloquently described looking back: 
Things seem to fit together a little different... and it always 
gives me satisfaction... even if I think about bad memories, 
because now they fit. I see where they fit. .. but they didn't 
before. It's like... they had to be that way... for the whole 
thing to make sense. 11 ·p.2os-206 
This supports Erikson's final stage of development. In order to achieve integrity, a person needs to accept one's life as something that "had to be." The aged are our pioneers of attitudinal shifts especially through this vital introspection. Based on research, Kaufman found that life review is more important to many elderly than happiness and morale.11 So it is not the 
96 
pursuit of happiness that is crucial but the pursuit of meaning up to our last days. 
There can be "creative aging": we can evolve, we can grow in our later years. Shall we be explorers or retreaters as we age? Shall we be responsible commandeers of our lives or shall we be victims at the end? If not limited by cognitive impairment, we have the freedom to keep reaching for experiential and creative values. We can transform our older lives of dwindling physical activity to mining our memories for those values. And in our attitudes, there lies the deepest realm to show our freedom. Leonardo da Vinci said, "As a well spent day brings happy sleep, so life well used brings happy death." 3· pVIII 
DEBORAH PADEN-LEVY, MA, LPC [5939 Harry Hines, Suite 823, Dallas, Texas 75225 USA DebPLevy@aol.com] is a Licensed Professional Counselor working in the psychiatric practice of Manoochehr Khatami, M.D., in Dallas, Texas. 
References 
1. 
Alborn, M. (1997). Tuesdays with Morrie. NY: Doubleday. 

2. 
Birren, J., & Schaie, K. (1996). Handbook of the psychology of aging. San Diego, CA: Academic Press. 

3. 
Coleman, P. (1986). Aging and reminiscence processes. Chichester, England: John Wiley & Sons. 


4. Dass, R. (2000). Still here: Embracing aging, changing, and dying. NY: Riverhead Books. 
5. 
Esposito, J. (1987). The obsolete self. Berkeley, CA: University of California Press. 

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


7. Pipher, M. (1999). Another country: Navigating the emotional terrain of our elders. NY: Riverhead Books. 
8. Qualls, S., & Abeles, N. (2000). Psychology and the aging revolution. Washington, DC: American Psychological Association. 
9. Raines, R. (1997). A time to live: Seven tasks of creative aging. NY: Penguin Books. 
10. 
Schulz, R., & Ewen, R. (1988). Adult development and aging. NY: Macmillan Publishing. 

11. 
Sherman, E. (1991 ). Reminiscence and the self in old age. NY: Springer Publishing. 


97 
The International Forum for Logotherapy, 2004, 27, 98-105. 
LOGOTHERAPY AND ACCEPTANCE AND COMMITMENT THERAPY (ACT): AN INITIAL COMPARISON OF VALUES-CENTERED APPROACHES 
William Sharp, Stefan E. Schulenberg, Kelly G. Wilson, & Amy R. Murrell 
One of logotherapy's strengths lies in its openness to integration with other forms of psychotherapy. Grounded in what is most meaningful to clients, logotherapy is often described as humanistic/existential. However, it has elements that are consistent with other paradigms. The importance of an emphasis on meaning has not escaped other mental health movements. Meaning has become part of the positive psychology movement, 13 and is a part of the growing contextual-behavioral movement in psychology. 
The purpose of this paper is to compare and contrast logotherapy with a recent and expanding contextual-behavioral treatment called Acceptance and Commitment Therapy (ACT).12 ACT shares many elements common to logotherapy, including an emphasis on meaning and values. The focus of this paper is on the basic tenets of the two paradigms, underlying why ACT may be of interest to logotherapists. 
Values and Psychotherapy 
Values in psychotherapy are traditionally associated with an existentialhumanistic approach to counseling. Arising out of a general dissatisfaction with the dehumanization of psychotherapy which many argued accompanied a scientific understanding of human behavior, the existential-humanistic movement's primary focus has been to steer the course of therapy back onto the actual, immediate person. 3 Based on this focus, the general aim of the existential-humanistic movement has been to bring the phenomenological 
3
world of the client back into schools of psychotherapy. 1· 
With the search for meaning at its philosophical core, logotherapy has played a steadfast role in the existential-humanistic movement to rehumanize psychotherapy. As part of the "human rights" movement, logotherapy's main assignment has been to address what Viktor Frankl considered a basic human motivation: the search for meaning in life.7·9 By addressing questions regarding meaning and values, logotherapy emphasizes an area that had been largely dismissed as existing outside the realm of a scientific psychology. In doing so, logotherapy has helped to reexamine psychology's role in handling difficult questions often posed by clients regarding the nature and meaning of life.15 
98 
Conceived as an open system, one of Frankl's goals in developing logotherapy was to provide a way of thinking and a methodology that could be incorporated into other established schools of therapy.9 As an open system, logotherapy has helped to bridge the gap between a scientific orientation to human behavior and the existential-humanistic movement. Notably, values-centered interventions within the behavior therapy movement represent attempts to merge client values and behavior therapy procedures. One such behavior therapy model, ACT, emphasizes a robust connection to a basic scientific account of human behavior while maintaining a focus consistent with logotherapy's interest in values and meaning.18 As such, ACT can be conceptualized as a contextual-behavioral model that synthesizes behavioral science with some of the same central contents as logotherapeutic theory. This synthesis is evident in ACT and logotherapy's common conceptualization of psychological health and shared emphasis on values and meaning. 
The Mental-Hygiene Philosophy of Mental Health 
Logotherapist Edith Weisskopf-Joelson asserted that the psychological mainstream works primarily from a mental-hygiene philosophy of psychological health.7 This philosophy emphasizes the importance of being symptom free and happy in order to live a meaningful and fulfilling life. Viewed from this perspective, psychological suffering represents not only a symptom of maladjustment but also an antecedent for feelings of shame and guilt. A person who is suffering deals not only with the burden of being unhappy, but experiences unhappiness with being unhappy.7 Elaborating on themes consistent with a mental-hygiene philosophy, ACT asserts that much of the mental health community operates with an underlying assumption of healthy normality. This assumption rests on the notion that psychological health is the natural, homeostatic state for humans that is disturbed only during periods of psychological illness or distress.12 It is this assumption that is at the core of the traditional medical model of mental illness that dominates psychological treatment and research. 
Both logotherapy and ACT argue that the psychological mainstream has made little progress in explaining human suffering. Based on the assumption of healthy normality, the primary focus of clinical research has been on identifying illnesses that cause psychological distress and identifying their deviant etiology. 12'18 The result of this endeavor has been twofold: (a) the creation of a taxonomical system with high rates of co-morbidity and arguably little treatment utility,12 and (b) the establishment of a healthcare environment where psychological suffering is often associated with shame and guilt.7 While the avoidance of unhappiness is a common goal of helping professions, the psychological mainstream appears to focus squarely on the negative aspects of suffering by conceptualizing it as an anomaly that needs to be eradicated by science, while doing little to explain the pervasiveness of human suffering. Due to the relative ineffectiveness of the current system, 
99 
ACT and logotherapy present an alternative view of mental health that attempts to re-humanize our conceptualization of suffering. 
Suffering as a Basic Human Process 
In contrast to mainstream assumptions of healthy normality, the logotherapeutic view of psychological health is that suffering is an ineradicable part of life.6 As such, suffering is seen as a common element that accompanies almost every act of growth or change that occurs during one's life.9 Freedom from suffering is not a prerequisite for a fulfilling and meaningful life. Instead, logotherapy argues that it is possible to lead a meaningful and fulfilling life when faced with suffering. 
Approached in this manner, suffering can be viewed less negatively. Logotherapy proposes that unavoidable suffering provides the opportunity to demonstrate the bravery and creative powers inherent in confronting misery and unhappiness.9 From a logotherapy perspective, suffering can be viewed as an internal signal or motivational element to search for meaning in one's life. For example, logotherapy often differentiates among three types of suffering.9 The first type is suffering associated with an unchangeable fate, such as experiencing cancer. The second type is suffering that accompanies an emotionally painful experience, such as the death of a loved one or torture in a concentration camp. The third type of suffering arises out of a lack of meaning in one's life, such as the void that may accompany a life empty of purpose and goals. Frankl believed that this third type of suffering, existential vacuum, served a distinct purpose in the health of an individual, guarding against apathy by serving as a reminder of mental or physical inactivity or meaninglessness.9 
Paralleling logotherapy's normalization of human suffering, ACT provides a parsimonious alternative to the pathology-oriented medical model by conceptualizing suffering as arising from ordinary psychological
12 18 
processes. · Described by Hayes et al. as "the assumption of destructive 
12 412
normality," · P-ACT assumes that normal human psychological processes can lead to and exacerbate human suffering. More specifically, ACT proposes that an analysis of ordinary learning, focusing especially on the processes underling language, can explain a significant proportion of human suffering.1 From this perspective ACT holds that, in addition to the possibility of problematic learning histories or biological vulnerabilitt, the mere possession of language can generate suffering among humans.1 With this said, ACT does not discount pathological processes, such as brain injury and neurological abnormalities. Instead, the ACT model asserts that ordinary psychological processes involved in human lan~uage may intensify difficulties generated by aberrant biological processes. 8 
Approached from the assumption of destructive normality, the pervasiveness of human suffering can be directly related to the social-verbal environment. As noted by Hayes et al.,12 individuals are taught that it is important to feel happy and remember good events, while unpleasant 
100 
feelings or events should be forgotten. This is the cornerstone of Western culture's adoption of the assumption of healthy normality. As part of this culture, we internalize these beliefs and attempt to control our negative thoughts and feelings. But as noted by Frankl, human suffering is intimately intertwined with the human experience. The commonality of suffering, and the culturally propagated adherence to this "feel good" agenda, creates a context where "we fight not only the present circumstances, but also those 
6
that occur in our imagined future and remembered past." 18· P· 
Mainstream psychology tends to support this agenda. We are preoccupied with being happy while attempting to avoid events or thoughts that may lead to suffering. We suffer, and, we suffer that we suffer. In doing so, we compound our suffering. Due to the apparent cyclical and destructive nature of this avoidance of pain, ACT and logotherapy attempt to bring dignity back to suffering by focusing the course of treatment on finding meaning in spite of suffering. Although differing on the application of meaning in the therapeutic process, both treatment models represent alternatives to the more traditional, pathology-oriented therapies. 
The Meaning of Meaning· 
In the context of logotherapy, meaning typically refers to a reason or value that an individual has in his/her life.7 As noted by Tengan, Frankl used the term to represent "a purpose in the sense of an orientation towards a 
15 142
goal for which one devotes one's energies and time." ' P· As such, meaning is intimately linked to the future in that it provides individuals with a general aim or direction in life. Once armed with this direction (i.e., meaning), Frankl asserted that a person can endure any life situation, regardless of the suffering that the situation may hold.6 
Conceived in this manner, the meaning of meaning is broad in nature, allowing the specificity of meaning to vary from individual to individual.15 For example, one person may focus primarily on pursuing an advanced degree while another may devote effort mainly to a significant interpersonal relationship. People may also focus their energies on multiple meaningful goals. Although conceived in a very personal manner, the desire to find meaning in life is viewed as a universal motivation. This motivation, termed by Frankl the "will to meaning," is thought to represent a general desire to reach out beyond the self in order to find and fulfill a meaning or purpose in life that is shared throughout the human family. 7 The inability to pursue this motivation can lead to a host of psychological problems including aggression, addiction, and depression.7 
Values in the context of ACT are conceptualized as verbally constructed, global, desired life directions. As such, the general use of the term valuing is the theoretical equivalent to logotherapy's concept of meaning in that values 
• The heading for this section was previously used by Tengan ( 1999) in an exploration of the same subject. 
101 
intimate relations), (b) marriage/couples/intimate relations, (c) parenting, (d) friendship, (e) work, (f) education, (g) recreation, (h) spirituality, (i) citizenship, and U) physical self-care. Clients rate the importance of each of these domains on a 10-point Likert-type scale. On the second page of the instrument, clients are then instructed to make an estimate, using the same Likert-type scale, of how consistently they are working and living with those values over the past week. While the development of this scale is still in the experimental stages, the instrument has demonstrated good test-retest reliability, and validity data are currently being collected.8 
Once the client has completed the VLQ, their profile is assessed to determine if there are domains where the client feels a perceived loss of freedom to act and where that loss is generating suffering. The general strategy for this examination of scores is twofold. First, scores on the first page of the VLQ are examined to see if there are valued activities that could be used with what is termed "value-directed behavioral activation." Like exposure, behavioral activation represents a therapeutic tool that has successfully made the transition from laboratory science to clinical application. 18 In brief, behavioral activation traditionally involves the client engaging in pleasant activities to help increase the breadth of narrow and inflexible behavior patterns. Working from the ACT perspective, the dimension that directs behavioral activation is not how pleasant an activity is, but how meaningful the activity or event is to the individual. Stated more concisely by Wilson and Murrell, "this perspective generates what might be thought of as 'valued-events scheduling' in contrast to the pleasant-events scheduling in earlier forms of behavior therapy." 18· P· 16 Second, the client's profile on the second page is explored to determine if there are areas that the client values in life but is not living consistently. ACT then explores possible obstacles to valued activities and targets those obstacles with exposure and diffusion strategies.18 
Conclusions 
The current paper has examined similarities between logotherapy and ACT. In doing so, the authors have focused specifically on the approaches' common ideology regarding human suffering and similar emphasis on the incorporation of personal values into psychological interventions. This initial analysis is important for a number of reasons. First, this comparison has helped to highlight the relationship between lo~otherapy and the growing contemporary contextual-behavioral movement.1 In addition to its ubiquitous role in the positive psychology movement, logotherapy's impact extends beyond the humanistic/existential movement. Second, this paper has laid the foundation for future collaboration and comparisons between logotherapy and ACT. 
An area of particular interest is ACT's and logotherapy's use of meaning/value-centered questionnaires. As noted above, the ACT perspective is yielding a promising new measure (the Valued-Living 
103 
Questionnaire) which may have benefits in therapy once additional validation research has been performed. Logotherapy measures available for research use include the Purpose-in-Life (PIL) test,5 the Life Purpose Questionnaire (LPQ), 10 the Seeking Of Noetic Goals (SONG) test,4 and the Meaning in Suffering Test (MIST),14 to name a few. Psychometric research employing batteries of ACT and logotherapy measures should not only further establish the construct validity of these measures but also serve to add to the empirical knowledge base of these paradigms as well. 
There is also merit in looking at the application of therapeutic tools across paradigms. Logotherapy utilizes a variety of techniques. For instance, paradoxical intention is an important logotherapy intervention that is useful in working with some forms of anxiety.13 Paradoxical intention has long been useful to researchers and clinicians outside of the logotherapy paradigm.2 Similarly, given the close parallels between logotherapy and ACT, logotherapists may find use of validated techniques derived under the ACT paradigm. These authors hope that this paper sparks a dialogue that will enable both perspectives to more effectively alleviate suffering by sharing useful therapeutic techniques and assessment instruments. 
WILLIAM SHARP, M.A. [wsharp@olemiss.edu] and AMY R. MURRELL, M.A., are graduate students in the doctoral program in Clinical Psychology at The University of Mississippi where DRS. STEFAN E. SCHULENBERG and KELLY G. WILSON are Assistant Professors in the Department of Psychology. 
References 
1. 
Arbuckle, D. S. (1975). Counseling and psychotherapy: An existential-humanistic view. Boston: Allyn & Bacon. 

2. 
Ascher, L. M. (1981 ). Application of paradoxical intention by other schools of therapy. The International Forum for Logotherapy, 4, 5255. 

3. 
Corsini, R. J., & Wedding, D. (2000). Current psychotherapies. Itasca, Ill: F. E. Peacock. 

4. 
Crumbaugh, J. C. (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. 

5. 
Crumbaugh, J.C., & Maholick, L. T. (1964). An experimental study in existentialism: The psychometric approach to Frankl's concept of noogenic neurosis. Journal of Clinical Psychology, 20, 200-207. 

6. 
Frankl, V. E. (1986). The doctor and the soul: From psychotherapy to logotherapy. NY: Alfred A. Knopf. 

7. 
Frankl, V. E. (1992). Man's search for meaning: An introduction to logotherapy. NY: Washington Square Press. 

8. 
Groom, J.M., Wilson, K. G., & Roberts, M. (2003, May). Examination of the psychometric properties of the Valued Living Questionnaire 


104 
{VLQ}: A tool for Acceptance and Commitment Therapy (ACT). 
Paper presented at the meeting of the Association for Behavior Analysis, San Francisco, CA. 
9. Guttmann, D. (1996). Logotherapy for the helping professional: Meaningful social work. NY: Springer. 
10. 
Hablas, R., & Hutzel!, R. R. (1982). The Life Purpose Questionnaire: An alternative to the Purpose-in-Life test for geriatric, neuropsychiatric patients. In S. A. Wawrytko (Ed.), Analecta Frankliana (1980) (pp. 211-215). Berkeley, CA: Logotherapy Press. 

11. 
Hayes, S. C., & Gregg, J. (2001). Functional contextualism and the self. In C. Muran {Ed.), Self-relations in the psychotherapy process (pp. 291-307). DC: American Psychological Association. 


12. Hayes, S. C., Strosahl, K., & Wilson, K. G. (1999). Acceptance and Commitment Therapy: A contextual approach to cognition and emotion in psychotherapy. NY: Guilford. 
13. 
Schulenberg, S. E. (2003). Empirical research and logotherapy. Psychological Reports, 93, 307-319. 

14. 
Starck, P. (1983). Patients' perceptions of the meaning of suffering. The International Forum for Logotherapy, 6, 110-116. 


15. Tengan, A. (1999). Search for meaning as the basic human motivation: A critical examination of Viktor Emil Frank/'s logotherapeutic concept of man. Germany: Peter Lang. 
16. 
Wilson, K. G. (2002). Valued Living Questionnaire working manual v. 11-13-02. Available from the author at Department of Psychology, University of Mississippi, University, MS. 

17. 
Wilson, K. G., & Groom, J. (2002). The Valued Living Questionnaire. Available from the first author at Department of Psychology, University of Mississippi, University, MS. 

18. 
Wilson, K. G., & Murrell, A. R. (in press). Values-centered interventions: Setting a course for behavioral treatment. In Hayes, S. C., Follette, V. M., & Linehan, M. (Eds.) The new behavioral therapies: Expanding the cognitive behavioral tradition. NY: Guilford. 



105 
The International Forum for Logotherapy, 2004, 27, 106-109. 
QUEST FOR MEANING IN THE EVENTS OF 9-11 
Arlen Salthouse 
The horror of the calamitous events of September 11th 2001 was felt, not only on the scene in Manhattan, Washington, D.C., and Somerset County, Pennsylvania, but also across the continent and around the globe; as almost instantaneously, televised images brought the unfolding devastation into homes, schools, and business places. The initial reaction of many was utter disbelief. Then, as reality set in, the effect was to shatter innocence, complacency, and a sense of security. Even more intense reactions were experienced by those who were there and directly affected, as well as families and friends, rescue workers, and others whose lives were personally touched in one way or another. Is it possible to find meaning in the face of such wanton death and destruction? While on the one hand, the catastrophic events of 9-11 resist the very possibility of meaning, on the other hand such disaster causes people to embark on a quest for meaning. 
While remaining sensitive to those for whom the losses and subsequent experiences of 9-11 have been so overwhelming that they cannot yet imagine any possibility of meaning in the situation, we also realize that the tragic events themselves cry out for meaning. This is consistent with logotherapy's contention that meaning is not essentially a subjective self
30 31
expression, but contains a certain amount of objectiveness.3· P· -Likewise, it rings true to the most basic assumption of logotherapy, that there is unconditional meaning potential in every circumstance, including the most 
tragic.4 · pAO The generous response by persons from all walks of life, indeed the nation and world at large -in the form of financial contributions, blood 
donations, and volunteerism -became a vehicle for discovering and expressing meaning. For some Americans it was in the rethinking of values and dedication to ideals, hitherto taken for granted, that meaning was found. 
For many, meaning was realized in the self-transcendent, sacrificial, even heroic manner in which they responded to the tragedy. Many courageous sacrifices of individuals, who put themselves at risk and assisted others away from harm, are well known. Some will be memorialized in stone and bronze; others will never be known publicly. Nonetheless, to quote Dr. Frankl: "Jede Tat ist ihr eigenes Denkmal" ("Every deed is its own monument").3· P· 111 In the face of overwhelming disaster, otherwise ordinary people -firefighters, police and rescue workers, chaplains and counselors, 

106 
as well as office workers, merchants, business executives and employees, maintenance staff, laborers, and visitors -called forth from the depths of the human spirit, courage they never knew they possessed, and found meaning in so doing. Logotherapy refers to this as the defiant power of the human spirit. Dr. Elisabeth Lukas explains: "Everyone has a 'power of the spirit (to) defy' at his disposal, which enables him to turn an unalterable suffering into a human achievement, yes, to transform it into an inner triumph." 6· P-89 This was demonstrated many times over in the valiant acts of those who put their own safety aside. Notable among these were the courageous passengers on United flight 93. Confronted by the stark reality of their inevitable fate -the fact that they were doomed to perish -they refused to submit to that fate. Instead, they chose to exercise their freedom by resisting the highjackers. 
In another situation, a young woman, Tina Hanson, with a long-term arthritic condition, was trapped on the 68th floor of the World Trade Center. Unable to use her 75-pound motorized wheelchair to escape, she was nevertheless determined to get out: "No matter what I had to do, even if it meant scooting down the stairs on my butt, I would have done it." Fortunately, that was unnecessary, for two strangers, Michael Benfante and John Cerqueira, picked her up, put her in an evacuation chair, and carried her down all 68 flights to safety. An article about her states: "Hansen was a testimony to willpower before Sept. 11. But on that Tuesday morning, the strength that allowed a well-traveled, well-educated, so-called 'disabled' New Yorker to live an ordinary and full life, only got stronger." 1· P-95 
In these, as in numerous other instances, the attitudinal response to the disaster of 9-11 was coupled with or translated into meaningful deeds. For rescue workers it was a matter of searching through rubble to recover 450 bodies. A firefighter/EMT from a neighboring state who went to assist in the early days after the disaster made this emotional observation: 
My fellow EMTs and Firefighters from NYFD were so tired 
and the sadness on their faces was absolutely gut wrenching 
-overwhelming. THEY were so thankful, they hugged and 
thanked us for being there, and I remember feeling bad 
because I wanted to be there because that is what we do, 
and I didn't want them to think they had to thank us.... I felt 
so guilty for leaving because so many of the firefighters and 
EMTs couldn't leave -or had no home -or just lost a co
worker/loved one, and I got to go home to a warm bed, hot 
shower, and a full family. (S. Krajkovich, personal 
communication, 10/4/2002) 
For construction workers it was clearing 1.8 million tons of debris over 261 days at the World Trade Center site. Brian Lyons, a construction engineer whose brother was lost in the destruction, described his experience supervising ground zero clean-up while searching for his brother, by saying he "never had a job that was more fulfilling." 2 · P 171 
107 
Together with the discovery of meaning in attitudes and ideals, as well as creative deeds, the avenue of loving and compassionate relationships was also productive of meaning. In fact, in many instances the three avenues were intertwined. For the families of those who perished, the quest for meaning was evident in the way families turned to each other, forging or renewing bonds. Sometimes survivors participating in group therapy sessions were drawn together, as one of their number remarked: "We just
11
desperately needed each other." 7· P· Eileen Simon and her children, whose husband and father perished in 9-11, eventually became part of two support groups, the members of which formed " ... such close bonds that (she} would 
319
consider them (her) best friends." 2· P 
Other times the meaning, and indeed the heroism, of the moment was simply a matter of coping with everyday life and chores without the help of a spouse or parent. For one widow, Grace Godshalk, it was instigating a drive to build a memorial for the victims from her county. Lisa Beamer, whose husband Todd led the charge against the terrorists on flight 93, wrote a book Let's Roll! She tells how she faced her personal loss and sadness with courage and strength. She designated a portion of the proceeds to benefit children who lost a parent on 11 September, as well as others in need. Kirsten Saracini, 14-year-old daughter of the captain of the United plane that crashed into the South Tower, expressed her feelings, and the meaning she found, in a school essay: "Has something horrible ever happened to you, but then something good occurs later on, as if God was saying, 'I haven't forgotten about you'?". 
A similar sentiment was expressed by a nun who worked as a volunteer counselor at St. Paul's Chapel across from the disaster site in Manhattan. From her faith perspective she said she believed God was able to bring good out of the tragedy. Her compassionate volunteer work among the rescue workers, like that of so many others, was certainly a meaningful vehicle for making that happen. (S. Wolf, personal communication, 10/23/2002) 
Reflecting on the disaster of 9-11 , a clergyman explains that in the face of evil "Redemption is always possible, for ourselves and others." He goes on to say that while faith has no final answers to human suffering ... 
it offers something better. Faith allows us to transcend 
suffering by forging the deepest bonds of love and 
compassion. It governs our best and most healing response 
to evil and death. The suffering and loss of life on September 
11 and the heroic response to it created not just despair, but 
also friendship, love, and finally new strength for new life, 
between colleagues in the rescue effort, between spouses, 
between parents and children -new life that, because it is 
achieved by those who know in their bones about weakness 
45
and mortality, is stronger than death.7· P 
These expressions parallel and substantiate Frankl's contention that "If there is meaning, it is unconditional meaning, and neither suffering nor dying 
108 
can detract from it." Furthermore, "The unconditional faith in unconditional 
meaning may turn the complete failure into a heroic triumph." 5· P·156 
In summary, while the tragic events of 9-11 initially seem to contradict what we understand as meaning, nevertheless they cry out for meaning. That meaning is found in the many positive human responses to the tragedy -in the heroic deeds and the unsung acts of selflessness, in the overcoming of sadness, despair, anger, and fear. It is found in the courage, sacrifices, and demonstrations of love and compassion. It is found in the rethinking of and rededication to positive values and ideals. Indeed, meaning -and thus the human spirit -is found to triumph even in the midst of this most tragic circumstance! 
ARLEN SAL THOUSE, Ph.D. [2761 Arrowhead Drive, Langhorne, Pennsylvania, 19053, USA] is retired from parish ministry as Pastor Emeritus, as well as from counseling practice. He is an Associate in Logotherapy and former member of the International Board of Directors of The Viktor Frankl Institute of Logotherapy. 
References 
1. Baker, S. (2002, Sept.-Oct.). A hero among us. Arthritis Today, 16(5), 96. 
2. Brill, S. (2003). After: How America confronted the September 12 era. NY: Simon & Schuster. 
3. 
Frankl, V. E. (1967). Psychotherapy and existentialism. NY: Washington Square Books. 

4. 
Frankl, V. E. (1978). The unheard cry for meaning. NY: Simon & Schuster. 

5. 
Frankl, V. E. (1988). The will to meaning. NY: New American Library. 

6. 
Lukas, E. (2000). Logotherapy textbook. Toronto: Liberty Press. 

7. 
Smith, R. (2002, Sept. 8). Philadelphia Inquirer. Special Issue. 


109 
The International Forum forLogotherapy, 2004, 27, 110-116. 
MEANING IN HEAL TH CARE DIRECTIVES 
William M. Harris 
Modern medicine has lengthened life considerably. Life expectancy in Colonial America was less than 50 years. Today a newborn baby can expect an average of nearly 80 years of future life. People now are able to survive diseases and conditions that used to cause death. Now the same formerly lethal situations may lead to a few days or weeks of discomfort followed by many years of life and opportunity. 

Yet the ability of medical care to extend life has led also to the extension of suffering. Chronic illnesses have tended to become more common in modern life precisely because people now live long enough to get them. Debilitating arthritis and senile dementia were relatively uncommon a century ago because the people who got these conditions did not live as long as they do today. Children who were born with Cerebral Palsy or Down's Syndrome rarely survived to adulthood, but now they usually do. One of the reasons for the rise in cancer is that people now live long enough to get this condition. 
Medicine Becomes Health Care Technology 
Beginning especially in the middle of the 19th century, medicine began to be increasingly based on science and technology. Today we think of John Wesley as a theologian and preacher whose efforts at reform led to the Methodist Church. Yet, in Colonial America he was better known as the author of a little book, A Primitive Physic. At one point this book was second only to the Bible as the most widely owned book in America. No one thought it strange that a preacher should write a guidebook on household remedies because the line between ministry and medicine was less clear than today. Few 18th century citizens would trust a physician who had no theological training. The clergy, often the most educated persons in a community, were rarely ignorant of the prevailing medical practices. Today few clergy know much about medical technology, and theological training is not considered essential to the training of a physician. This separation of religious practice from medical practice has tended to remove spirituality from medicine. 
The move to high technology has led medicine to see humans as fantastically complex machines, subject only to the laws of chemistry and physics. Frankl's protest against reductionism is more than just a protest against psychology's tendency to see behavior as merely defense mechanisms. It is a protest against the tendency to see human beings as nothing but organized chemicals in a biomechanical machine. 
110 
Protesting the Reductionism of Health Care Technology 
The American pubic has been staging its own protest against the reduction of humans to mere biomechanics. Hardly a day goes by that I don't hear someone say, "I don't want to live on machines." 
The origins of this public protest are many. Patients resent long waits in the doctor's office for appointments. People have rejected the notion that the physician always knows best. Now they insist that they have access to their own medical information and be able to participate in making the medical decisions that affect their bodies. Families are much more proactive in seeking various opinions before making medical decisions. But by far, the most important motivator of this public outcry comes from the publicity given to some extreme situations of life and death decisions. 
The first to get national publicity was the case of Karen Ann Quinlan. This young woman became comatose on April 15, 1975. She was placed on a respirator because her breathing was impaired. Later it was determined that she was in a "persistent vegetative state" in which the lower brain has some function while the higher cortex is basically devoid of electrical activity. 
Her physicians argued that it was unethical to remove her from a respirator since it would cause her death. Her parents argued that it was cruel to keep her alive when she had no chance for a normal life. They went to court in New Jersey in a much-publicized case. There the Supreme Court of New Jersey ruled in 1976 that her parents had a legal right to remove the ventilator that was sustaining her. Part of the court's reasoning was that the patient's (and her parents') right to privacy in this instance had priority over the state's interest in the preservation of life. The court further ruled that the use of a respirator when it had no curative function was not ordinary medical treatment, but amounted to extraordinary treatment "in the context of the forced sustaining by cardiorespiratory processes of an irreversibly doomed patient." In effect, the court said that medical technology is natural when it is curative but inhumane when the persistently vegetative patient cannot improve. 
Karen Ann Quinlan's parents were not the first to raise such issues. But their experience was a turning point because of the publicity given to the case. She was removed from the respirator and, to the surprise of everyone, she lived until 1985 in a nursing home where she died from pneumonia. 
There were several other situations that contributed to a concern on the part of the American people about the use of high tech medical interventions. The legal case of Nancy Cruzan was one of many that galvanized public opinion that something had to be done about "living on machines." 
Some folks in academic medicine are working now to re-humanize medicine by offering training in such fields as medical ethics and complementary therapy. Although not specifically motivated by Frankl, I see them saying something very similar to Frankl. They are trying to move medicine beyond the mindset that refused to recognize the validity of anything but technology. 
111 
The Development of Health Care Directives 
Congress enacted the Patient Self Determination Act of 1990. Several states had already responded to the public groundswell of interest in allowing people to specify how they wanted to be treated when they were unable to speak for themselves. But the Patient Self Determination Act gave a national impetus to this movement. 
The Patient Self Determination Act requires all health maintenance organizations, hospitals, and nursing homes to ask whether an incoming patient has a health care directive. If a patient has such a document, the organization is required to make a good faith effort to get a copy and place it in the patient's chart. If a patient does not have a health care directive, the organization is required to provide an opportunity for the patient to make an informed decision about making one. Hospitals are further mandated to have a plan for outreach into their communities to increase public understanding of health care directives. 
Every state passed enabling legislation; and starting no later than December 1991, every hospital and nursing home in the nation began to use these documents. Many people, especially older persons, began to express interest in health care directives. Hospitals developed a variety of plans for implementing the law. Many simply had admission clerks note whether the person had an advance directive. The counseling for health care directives was often given over to social workers, but some hospitals designated nurses or others to help patients with these issues. 
The hospital where I work decided that the chaplains should take the lead in providing this service for patients and families. The reason for this was that health care directives express moral and spiritual values in a concrete way. The concern was that some people have difficulty expressing their deepest convictions concretely. So, I have been working with patients, families, and community seminars regarding health care directives since the early 1990s. 
Each state has its own approach to health care directives. Yet, in general they boil down to one of two types of documents. "Living Wills" have various names. They are sometimes just called an Advance Health Care Directive. This is a written request that a person be treated in a certain way when that person is no longer able to communicate. It does provide clear and convincing proof of what a person wanted in the way of medical treatment when that person becomes severely incapacitated. However, it is not a legally binding document. This is because it is essentially a request. To make this point, I often turn to someone in the room and ask for $100. After they get over the shock, I explain that I can ask but it is no guarantee that my request will be fulfilled. There can be many legitimate reasons that a "Living Will" may not be honored. 
The other general category of advance directive has some legal teeth in that it can be enforced in a court of law. This is a Power of Attorney for Health Care. This document specifies a person or persons who have the 
112 
authority to speak for the incapacitated person in matters relating to medical treatment. 
One of the first observations to be made about these documents is that, while they are legal documents, their completion is not primarily a legal matter. I believe the most important thing that can come from the completion of an advance directive is to build greater communication within a family. The first matter of communication is what the person believes about the use of sophisticated medical technology to prolong life. More importantly, it is communication about fundamental ideals of life. What is needed to have a meaningful life? What values, whether religious, philosophical, economic, or otherwise, should be used to make life and death decisions? 
These are fundamental questions that every family should discuss. Yet many people have never articulated them for themselves, let alone discussed them with others who are dear to them. I have observed that some elderly people experience a kind of existential loneliness from the fact that they want to discuss these issues but find that their children change the subject whenever it is brought up. With a little help, these people can view a health care directive as leverage to get their children and other family members to discuss a serious topic that they have long wanted to consider. I have come to the point that I tell families that this discussion is far more important than whatever document may come out of it. I tell them that this discussion is worthwhile even if a written document never becomes the resulting product. 
Unfortunately, most people approach the subject of advance directives from an attitude of fear. "I don't want to be kept alive by machines." "When you're brain dead, they shouldn't keep your body suffering just so they can get the money." "I'm not afraid of dying, but I'm afraid of prolonged suffering." "I've heard that they break your ribs when they are trying to get your heart started, and I don't want that." "If you're living on a machine, you're completely helpless. That's not really living." I hear such comments frequently. They represent a fear and suspicion of modern medicine. 
Fear may be a very powerful reason for making end-of-life decisions, but it gives no particular satisfaction or peace. It does not enhance family communication or help survivors reach acceptance in the months and years after death has occurred. As someone trained in logotherapy, I assume that finding a meaningful basis for end-of-life decisions is more effective than deciding out of fear. 
We Should Emphasize the Interpersonal 
Often I see people who have made a health care directive in which they have asked for certain things to happen. The family and/or the doctor do not know their wishes. Then they are disappointed when their wishes are not followed. Even worse is when the wishes are known but the family does not want to honor them. There can be a fundamental breakdown in family relationships because some family members refuse to follow what they already know is the expressed wish of the patient. All too often, I am called 
113 
upon to referee family fights over the patient's wishes because the doctor and the nurses are afraid to deal with the family miscommunication or unresolved tensions. 
After more than 3000 cases with which I have been involved, I have made a few observations. Some of these have already been mentioned. Most people approach making health care directives out of fear and distrust of high tech medicine. Many people do not see the value of involving their family in the process unless this value is pointed out to them. Most people have unrealistic expectations of how much a health care directive can do and how rigidly they are enforced. 
Early on the chaplains in our department decided that the process of discussion and decision making was more important than the actual document that might be written. I have had many interventions that were considered very successful in which nothing was actually put on paper, but the patient and the family were happy with what they considered a satisfactory outcome. 
Most of the studies done of health care directives have focused on the cost savings for the institution. Much of the literature has also considered the legal quality and impact of these documents written without the aid of attorneys. From my experience, other criteria are much more useful in evaluating advance health care directives. 
The criteria that I emphasize in making a health care directive are: 
. 
the impact of the decision on the family dynamics, 

. 
whether the communication with the physician is enhanced, 

. 
the conscious connection of the patient's value system to the decisions made, 

. 
the degree to which the process is meaningful to the patient and family, 

. 
and whether the process helps the surviving family with coming to a better resolution after the patient's death. 


How Logotherapy Can Enhance Advance Directives 
I offer some of the following subjective observations of how the search for meaning can enhance the use of health care directives in a hospital setting. My comments should be seen more as hypotheses worthy of testing than as conclusions on which to rely. 
Many people see control of their destiny as something that is meaningful. One of the ways that I have been able to get people to move away from the fear mode of decision making is to frame the issue as one of limited control over what happens to them. It is unethical to suggest that this document gives them absolute control over what happens, but it does give people a chance to have a meaningful voice over how they are treated. This suggestion by itself has had the effect of lowering patient anxiety. It goes a long way toward helping a patient reframe their perspective of medical technology. Patients can change their perspective of modern medicine from 
114 
one of fate to a useful resource that is at their disposal. For many people this sense of being in charge of their destiny is the greatest source of meaning. It is similar to Frankl's experience with his Nazi tormentors when he thought that they could take his book, his heat, his food, and even his life, but they could not take his freedom unless he gave it to them. 
Whenever possible I try to do health care directive counseling in the presence of family. This is aimed toward increasing the level of family understanding and improving family communication. Meaning is found in relationships. Meaning can be enhanced by improved relationships. The potential nearness of death can be an impediment to family closeness. While some families draw closer as the end of life nears, others use the stress of the moment to dredge up old sources of conflict. Family conflicts take on a new intensity that unfortunately results in painful fights. These animosities may lead to further fights over funeral and inheritance that can divide families permanently. Often it is the apparent meaninglessness of death that leads family members to do destructive things in their relationships. Yet nearly all of the time, older people and people with life threatening conditions want their family members to "get along" and to resolve family conflicts. 
The process of discussing a health care directive can be the opportunity to resolve or at least ameliorate family conflicts. A logotherapist has a unique perspective here. There is an opportunity for meaning in at least two ways. 
The discussion of the values often helps family members to see the possibility of meaning in some very painful events. When they find this meaning, they are much less likely to act in destructive ways. The very act of discussing the meaning of the situation tends to suggest to people that they have hope in a situation that they have formerly seen as only hopeless. Religious people may do this quite naturally, but those who see themselves as religionless or even hostile to religion often see this sort of talk as futile. I have often seen the discussion of a health care directive become the opportunity to discuss how meaning can be found in what has been seen as an otherwise hopeless situation. Folks hostile to "religious talk" can find a small comfort zone talking about the meaning of what is happening. It only takes a small nudge to get the discussion of values started. When family can focus on the possibility of finding meaning in a life and death situation, the discussion and the hope that these discussions engender can reduce the family conflict. 
In other words, the discussion of the values inherent in a health care directive can be the opportunity to discover meaning for those family members who otherwise refuse to talk about the possibility of death. The discovery of meaning can reduce denial by family members and reduce family conflict. This is the first opportunity for meaningful growth for a family. 
The second form of meaning in this situation is a subjective benefit to the patient. The reduction of family conflict is nearly always meaningful for the patient. I have had many patients, especially older women, who say that the 
115 
reduction of family conflict is one of the most important values to them. This is especially true when the family has a long history of feuding and conflict. 
One of the significant opportunities for dying persons to find meaning is to leave a lasting legacy. The desire to be remembered is a powerful source of meaning. I have observed many people who want a health care directive to serve this function. For a few people, this is an opportunity to express to grandchildren what they believe about life, death, and ultimate values. These folks cannot satisfy this desire for meaning using a fill-in-the-blanks form that is so often used to make health care directives. They must write their own personal document in order to find this source of meaning. Ironically, such personal documents may run a higher risk of being ignored by busy physicians, especially if they a very long. As a clergy person, I have always found special joy in helping those few people who see the health care directive as an opportunity to leave a legacy of values and meaning. 
Some people express the same desire for a legacy through their desire to have their organs and tissues transplanted to others in need. It is rare that the person thinks that such donation will enable them to "go on living" through another. More frequently, it is their wish that something good can come out of the end of their life that will continue on after them. 
The desire for leaving a legacy through a health care directive is expressed more frequently for financial reasons. People usually want to have their assets pass on to people and causes they deeply love rather than to the hospital or doctor they merely appreciate. Realizing that modern health care (especially in the United States) is expensive, they want limitation of aggressive care at the end of their lives so that they can leave assets to others. For some people the leaving of a financial legacy is a powerful source of meaning during their last days. 
One case of the meaningfulness of a financial legacy that stands out in my memory was the grandfather that wanted a health care directive to save money for his granddaughter. Some family members thought that silly since they considered the granddaughter to be wasting her life. However, the granddaughter, who had been dragged reluctantly into the health care discussion, saw the love of her grandfather in the process. She knew that her grandfather decided against aggressive medical care so that the granddaughter could have the money. This was so meaningful for the young woman that she took the money and invested it into a college education. 
The logotherapeutic perspective sees the making of a health care directive as an opportunity to find and enhance meaning in a situation that many see as meaningless. When meaning is found in the process, hope is found and despair is reduced. 
WILLIAM M. HARRIS, D.Min. [1303 South John Avenue, Springfield, Missouri 65804-0632 USA; ka0dgk2003@yahoo.com] works full time as a Chaplain at Cox Health Systems in Springfield, Missouri. He is a Dip/ornate in logotherapy. 
116 
The International Forum for Logotherapy, 2004, 27, 117-119. 
DOSTOEVSKY, SOCRATES, FRANKL: OF WHAT DO YOU SPEAK FROM A PRISON CELL? 
Carol Miller & George Schultze 
This poem was inspired by the question in Viktor Frankl -Recollections: An Autobiography "What would Socrates and Frankl have discussed if they shared the same prison cell?" 
Charges, verdicts, sentences, crimes, and punishments, scaffold, hemlock, crematorium, militarism, tzarism, nazism: all crucibles of suffering toward Transcendence. 
Confinement in coldness compelled them to question the essence of existence in its boldness. 
Choices and circumstances had compelling consequences. No exit but death faced each one 
yet 3, p.56 
an examined life was about to become 
357 487
because they thought 1· p.2 ; · P intimations of immortality: legacy, destiny, eternity as one. 
Ultimate questions loomed in the dark with eclipses from the start. What is death? What is life? What is birth? What is it all? 
117 
Fyodor, Socrates, Viktor locked together in a cell: labor camp and death camp 
1
to ponder 6· p.4 desolation and consolation 3· P 60 "I to die and you to live" in the spirit of wonder. 
75
"I am more than a piano key" 4· P-echoed from the depths and heights in their humanity and divinity solitary and solidarity as prisoners yet internally free. 
Shackled in chains they argued to and fro struggling for significance by creative synthesis: decreasing physical eyesight and increasing philosophical insight, orthodoxy and revolutionary, character and conduct, bitter and better, church and state, vice and virtue, good and evil, 2· P-178 swine and saint. 
Poet, philosopher, physician 
9
were they, 3· p.4 even gadflies per se, summoning peoples and lands, seas and histories, moving constitutions and institutions, renouncing oppression, 
announcing liberty in order to be 
57
responsible for self 5· P-and responsive to society. 
14
Awe -the nature of human ontology 5· P-through the prism of prison to reprieve, of what goodness, beauty, truth, and justice did they see? 
118 
This perennial ideal leads us to question the relevance of these philosophical reflections. Attitudes, aptitudes, attributes they used reaching masses of people who were destitute. 
Their message was unique yet universal. Peoples of Russia, Greece, and Austria relate as geographical compass and moral compass what do these connections make? 
"Since Auschwitz, we know what humanity is capable of. Since Hiroshima/Nagasaki we know what is at stake." 2 · P· 179 
Peoples on this one planet divided into six worlds: awaken to humanity in its coldness, in its boldness, in its heights, in its depths, in its cries for justice and peace. 
References 
1. 
Frank, J. (2002). Dostoevsky: The mantle of the prophet. Princeton, NJ: Princeton University Press. 

2. 
Frankl, V. (1984). Man's search for meaning. NY: Washington Square Press. 

3. 
Jowett, B. (Ed.) (1942). Plato. NY: Black Publishers. 

4. 
Kaufman, W. (1963). Existentialism from Dostoevsky to Sartre. NY: Meridian Press. 

5. 
Scanlon, J. (2002). Dostoevsky: The thinker. Ithaca, NY: Cornell University Press. 

6. 
Vaudon, J. (1990). Last days of the Gulag? National Geographic, 177(3), 40-49. 

7. 
Wordsworth, W. (1886). Ode to intimations of immorality. In Works of William Wordsworth. NY: T. Y. Cromwell. 


119 
The International Forum for Logotherapy, 2004, 27, 120-121. 
SUSAN E. SHAUB -IN MEMORIAM 
Written by -Allison Lansky (daughter) 
Susan E. Shaub, M.A., Associate in Logotherapy, died April 14, 2004. Susan served on the Board of Directors of the Viktor Frankl Institute of Logotherapy for many years. Shortly after her return from the Fourteenth World Congress on Logotherapy in Dallas, Texas (June, 2003), she was diagnosed with endometrial cancer (September, 2003) and subsequently underwent a series of surgeries and rounds of chemotherapy, which were unsuccessful in curing her illness. 
Susan earned her Bachelor's degree in Psychology from Rutgers University and completed her Master's degree in Psychology at Seton Hall. Dr. Viktor Frankl had become Susan's hero from the moment she opened "Man's Search for Meaning." He continued to mentor her through his many writings as she evolved in her psychotherapeutic treatment of emotionally, spiritually, and psychologically suffering people. Susan was the founder of the Center for Anxiety Therapy in Bayonne, New Jersey. For more than 10 years she specialized in treating patients suffering from a range of anxiety and panic disorders utilizing the principles of logotherapy, including paradoxical intention. In her career she treated thousands of people with these and other issues of human suffering. The main components of her approach included laughter, education, compassion, and meaning discovery. Susan presented a workshop at the Twelfth World Congress on Logotherapy (1999) entitled "Paradoxical Intention: Mobilizing the Spiritual Dimension in the Art of Self Defense -A Guided Approach to the Use of Paradoxical Intention for Sufferers of Panic Disorder, with or without Agoraphobia." 
Susan's most recent work during the past four years included treating people dealing with meaning crises in the workplace. She acquired a large clientele who looked to her to identify a specific series of symptoms which were diagnosed as Post Traumatic Stress Disorder as a result of being harassed in the workplace. This evolving project was particularly meaningful for the clients who gave testimony at her memorial service. They spoke of how she saved their lives with her ongoing support, both in private and group counseling. Many of her clients --suffering in their private lives from being bullied in the workplace --found their only retreat and comfort within the walls of Susan's office. While being guided by her individually, they also listened to the words of others enduring similar experiences and symptoms in group sessions. Her pioneering contribution inspired collaboration in respective communities to work towards eradication of this problem, which brought attention to the problem within the New Jersey legal system; consequently, people are still being compensated for their psychological and somatic injuries. 
120 
As a result of her work in the area of workplace bullying, Susan founded the Institute for Dignity in the Workplace. She presented another paper at the Thirteenth World Congress on Logotherapy (June, 2001) entitled "Meaning Crises in the Workplace: Understanding, Helping, and Healing the Terrorized, Dehumanized, and Traumatized Survivors of Workplace Abuse." At this Congress she received The Statue of Responsibility Award for Distinguished Leadership from the Viktor Frankl Institute of Logotherapy. During a Plenary Session at the most recent Congress (2003) she was joined by three of her clients. Susan and her participants spoke movingly about "Psychological Terrorism in the Workplace." 
Susan was a beautiful, brilliant person, an exceptional diagnostician, and someone who deeply cared for human beings. She is survived by her brother, Michael Newburg, her daughters Allison Lansky and Liana Clementz, and her three grandchildren, Joshua, Zachary, and Briana. She felt very strongly about the fundamental importance of education as well as generosity. In Susan's memory, her daughter Allison has established the "Susan E. Shaub Logotherapy Scholarship Fund" with the hope that even one person who might not otherwise be able to afford a portion of their education in logotherapy will be able to bring compassionate care to others. If you are interested in making a contribution in her honor or are interested in utilizing the scholarship funds, please contact Allison using the information below. 
SUSAN E. SHAUB 
Allison Lansky 
803 Spruce Hills Drive 
Glen Gardner, New Jersey 08826 USA 
Email -MyMantraChant@aol.com 
(908) 537-0803 home 
(908) 500-4088 cell 
121 
The International Forum for Logotherapy, 2004, 27, 122-125. 
RECENT PUBLICATIONS OF INTEREST TO LOGOTHERAPISTS 
Cindy Strege 
Halama, P. [Institute of Experimental Psychology, Slovak Academy of Sciences, Dubravska cesta 9, 813 64 Bratislava, Slovak Republic]. (2000). 
Dimensions of life meaning as factors of coping. Studia Psychologica, 42(4), 339-350. 
--Examines the relationship of meaning in life and the preference of coping strategies in late adolescence. Three dimensions of meaning were measured including intensity (level an individual perceives that his/her life has purpose), breadth (number of sources or values in one's life), and depth (level of selftranscendence of meaning in life). 
Honkasalo, M. L. [Department of Cultural Anthropology, PB 59, 00014 University of Helsinki, Finland]. (2000). Chronic pain as a posture towards the world. Scandinavian Journal of Psychology, 41, 197-208. 
--The author used a phenomenological approach and case examples to describe chronic pain and to illustrate the meaning of chronic pain in three patients. Pain was described in relation to the issues of meanings in the world and life in general. 
Kallenberg, K. [Orebro Medical Centre Hospital, kallenberg@profide.se]. (2000). Spiritual and existential issues in palliative care. Illness, Crisis & Loss, 8(2), 120-130. 
--The article discussed spirituality, view of life, and sense of coherence in palliative care. The author described a person's view of life as a meaninggiving system. Recommendations for caregivers were provided to help cope with existential problems. 
Langer, N. [School of Graduate Social Service, Fordham University, USA]. (2000). The importance of spirituality in later life. Gerontology and Geriatrics Education, 20(3), 41-50. 
--The assessment and enhancement of spirituality in older adults were discussed. Spirituality was conceptualized in terms of purpose, meaning, and life themes. 
122 
Lantz, J. [Ohio State University, College of Social Work, 1947 College Road, Columbus, Ohio, 43210 USA], & Gregoire, T. (2000). Existential psychotherapy with couples facing breast cancer: A twenty year report. 
Contemporary Family Therapy, 22(3), 315-327. 
--Described an existential approach to couples therapy with couples facing breast cancer. The PIL Test was used, and results suggested that this was an effective treatment strategy. 
Lantz, J. [Ohio State University, College of Social Work, 1947 College Road, Columbus, Ohio, 43210 USA], & Gregoire, T. (2000). Existential psychotherapy with Vietnam veteran couples: A twenty-five year report. 
Contemporary Family Therapy, 22(1), 19-37. 
--Provided a descriptive clinical study of existential psychotherapy with 53 Vietnam combat veteran couples treated by the main author. Treatment included elements of holding, telling, mastering, and honoring the combat trauma pain. All couples were reported to have made good progress based on self-report and two clinical measures of marital adjustment. 
Lantz, J. [Ohio State University, College of Social Work, 1947 College Road, Columbus, Ohio, 43210 USA]. (2000). Phenomenological reflection and time in Viktor Frankl's existential psychotherapy. Journal of Phenomenological Psychology, 31(2), 220-231. 
--The author described Viktor Frankl's existential psychotherapy in terms of phenomenological reflection. Case material was used to illustrate this approach and its relationship with time. Frankl's therapeutic approach was described as helping clients to "notice," "actualize," and "honor" the meanings and meaning potentials in life. 
Maltsberger, J. T. (Ed.). [38 Fuller Street, Brookline, Massachusetts 02146 USA]. (2000). Mansur Zaskar: A man almost bored to death. Suicide and Life-Threatening Behavior, 30(1 ), 83-90. 
--A case study of a man struggling with boredom and lack of meaning. Three case conceptualizations were presented including one describing noogenic neuroses. 
McColl, M. A. [School of Rehabilitation Therapy, Queen's University, Kingston, Ontario, Canada, K7L 3N6], Bickenbach, J., Johnston, J., Nishihama, S., Schumaker, M., Smith, K., Smith, M., & Yealland, B. (2000). 
Changes in spiritual beliefs after traumatic disability. Archives of Physical Medicine and Rehabilitation, 81(6), 817-823. 
--The researchers interviewed 16 patients after discharge from a rehabilitation program for a spinal cord or brain injury. A sense of purpose in life that was not present before the onset of the injury was reported. 
123 
Minehan, J. A., Newcomb, M. D. [Box 951563, 1282A Franz Hall, UCLA Psychology Department, Los Angeles, California 90095-1563 USA], & Galaif, 
E. R. (2000). Predictors of adolescent drug use: Cognitive abilities, coping strategies, and purpose in life. Journal of Child and Adolescent Substance Abuse, 10(2), 33-52. 
--Examined the role of purpose in life (used Revised PIL Test) among adolescents as a predictor of drug use. Found that high purpose in life predicted less alcohol use; and existential confusion predicted more illicit drug use. Concluded that educational programs should encourage a feeling of purpose in life as a deterrent to drug use for adolescents. 
Mountain, D. A. [Specialist Registrar in Psychiatry, Royal Edinburgh Hospital, Scotland], & Muir, W. J. (2000). Spiritual well-being in psychiatric patients. Irish Journal of Psychological Medicine, 17(4), 123-127. 
--This study surveyed patients with psychiatric disorders, chronic medical conditions, and patients visiting their general practitioner. Psychiatric patients scored lower on the Existential Well-Being subscale of the Spiritual WellBeing Scale and expressed lower life satisfaction and purpose. 
Norberg, A. [Umea University and University of Goteborg, Sweden), Ekman, I., & Ehnfors, M. (2000). The meaning of living with severe chronic heart failure as narrated by elderly people. Scandinavian Journal of Caring Sciences, 14(2). 
--Using a phenomenological hermeneutic approach, the meaning of elderly patients' experiences of living with chronic heart failure was studied. 
Plante, T. G. [Psychology Department, Santa Clara University, Santa Clara, California 95053-0333 USA], Yancey, S., Sherman, A., & Guertin, M. (2000). 
The association between strength of religious faith and psychological functioning. Pastoral Psychology, 48(5), 405-412. 
--Examined the relationship between religious faith and psychological functioning in college students. Strength of religious faith was significantly associated with experiencing life-meaning. Themes that emerged were "feeling imprisoned in illness" and "feeling free despite illness." 
Rhoades, D. R. [1208 Bush River Road, C-11, Columbia, South Carolina 29210 USA], & McFarland, K. F. (2000). Purpose in life and selfactualization in agency-supported caregivers. Community Mental Health Journal, 36(5), 513-521. 
--Utilizing the PIL Test, the researchers examined the experiences of paid caregivers for seriously mentally ill individuals. The caregivers in the study possessed a high purpose in life compared to norms for the PIL. 
124 
Robak, R. W. [Psychology Department, Pace University, 861 Bedford Road, Pleasantville, New York 10570 USA], & Griffin, P. W. (2000). Purpose in life: What is its relationship to happiness, depression, and grieving? 
North American Journal of Psychology, 2(1), 113-120. --This article described the relationships between purpose in life (PIL Test), happiness, depression, and grieving among college students. 
Sarvimaki, A. [Research Director, Kuntokallio Center for Gerontological Training and Research, Helsinki, Finland]. (2000). Quality of life in old age described as a sense of well-being, meaning, and value. Journal of Advanced Nursing, 32(4), 1025-. 
--Examined quality of life in a group of 300 elderly participants aged 75 and older. Quality of life was defined as a sense of well-being, meaning, and value. The study presented a model of quality of life and provided results that give preliminary support to the model. 
Seeber, J. J. [Center for Aging, Religion, and Spirituality, USA]. (2000). 
Meaning in long-term care settings: Victor Frankl's contribution to gerontology. Journal of Religious Gerontology, 11, 141-157. --The author applied logotherapy concepts to aging and also provided a list of potential sources of meaning for elderly persons in long-term care. 
Showalter, S. M. [Graduate School of Psychology at Fuller Theological Seminary, 180 North Oakland Avenue, Pasadena, California 91101 USA], & Wagener, L. M. (2000). Adolescents' meaning in life: A replication of DeVogler and Ebersole (1983). Psychological Reports, 87(1), 115-126. 
--Meaning in life characteristics and categories (based on essay responses) among adolescents in a Christian setting were compared with findings from a previous study of non-Christian adolescents. 
Smith, B. W. [Department of Psychology, Arizona State University, Tempe, Arizona USA], & Zautra, A. J. (2000). Purpose in life and coping with knee-replacement surgery. The Occupational Therapy Journal of Research, 20, 96-99. 
--Found that a sense of purpose in life was related to recovery from kneereplacement surgery. Suggested that occupational therapy may promote recovery by increasing an individual's sense of meaning and purpose. 
Taylor, S. E. [Department of Psychology, University of California, 405 Hilgard Avenue, Los Angeles, California 90024-1563 USA], Kemeny, M. E., Reed, G. M., Bower, J. E., & Gruenewald, T. L. (2000). Psychological resources, positive illusions, and health. American Psychologist, 55(1), 99-109. 
--The researchers examined the role of optimism, control, and meaning on the physical health of men infected with HIV, and found that the ability to find meaning in the experience was associated with a less rapid course of illness. 
125 
ISSN 0190-3379 IFODL 27(2)65-128(2004) 
The International Forum for 
LOGOTHERAPY 
Journal of Search for Meaning