Volume 13. Number 2 Fall 1990 CONTENTS A Logotherapy and Cognitive Therapy Center in Dallas · 83 M. Khatami, D. Doke, and R. Boyer Overcoming the "Tragic Triad" 89 Elisabeth Lukas Who Am I? A Journey of Self-Discovery 97 Phyllis p. Ward A Case History in Existential Analysis Psychotherapy 101 Alfried Langle Meaning for the Developmentally Handicapped 107 Dave Hingsburger A Logotherapeutic Doctor-Patient Relationship 112 Lola G6mez de Perez Uderzo Logotherapy and the Vietnam Veteran 115 Jim Lantz and Richard Greenlee Meaning and the Older Unemployed Worker 119 John C. Rife An Experimental Investigation of Viktor Frankl's Theory of Meaningfulness of Life 125 A.A.Sappington, J. Bryant, and C. Oden Meaning in Drug Treatment 131 Kevin W. Olive Frankl's Mountain Range Exercise 133 Florence I. Ernzen Book Review 135 Logotherapy on Hysteria Elisabeth Lukas Hysteria is among the great challenges to the therapist. Unfortunately it has become a pejorative term. In Freud's time its symptomatology was reported widely; much less so later, and at present it is experiencing a comeback. Hysteria sufferers are fascinated by negatives and resist anything positive. This means that for the patient a cure is not necessarily the goal of therapy. Often patients participate in therapy until the goal is in sight, and then suddenly start subverting the goal. The therapist may help the patient resolve numerous problems but when the therapist says, "Now we don't need any appointments for a while, you are able to be on your own," hysterics tend to respond, "If you don't give me an appointment soon I'll have a relapse." Instead of being glad of having retained stability, they are willing to sacrifice it in order to retain the therapist's attention. Rather than thanking the therapist, hysterics are inclined to use blackmail to continue therapy. Frankl lists three characteristics of hysteria patients: •Lack of authenticity. Hysterics lack authentic inner experiences such as genuine joy, genuine love, genuine grief. Everything is a stage setting, even their sickness is part of that setting. As a result, they crave experiences of any kind. Even negative experiences are better than none. •Pathological egoism (narcissism). Hysterics crave attention at any price, even if it ultimately hurts them. They constantly draw attention to themselves and punish others who neglect to pay adequate attention to them. •Manipulative thinking/behavior. Their behavior is calculated to meet their own desires. They are rarely interested in a matter per se, but have ulterior motives. A basic characteristic of hysteria is that sufferers do not self-transcend. Instead, they demand the attention of others at any price, even if that is totally unrealistic. Hysterics usually use their symptoms to manipulate others into behaving contrary to their own convictions. This meets the patients' needs but is also the cause for their extreme unpopularity. People tend to avoid them and as a result hysterics feel isolated and unhappy. To draw attention and sympathy from others, they may even harm themselves. The ultimate result is a vicious circle -they receive less and less sympathy while they continually "up the ante." The basis for hysteria is not only the patients' character disposition, but also their childhood experiences. Usually these patients were either neglected or overindulged as children. Both have the same result. Neglected children have to sacrifice much while they are small; they no longer want to do that once they grow up. Overindulged children, on the other hand, never lea ·rn to make sacrifices, so they remain ignorant in this aspect, even as adults. This explains why hysteria was so widespread in Freud's time -there were many neglected children. It also explains why hysteria is making a comeback today -there are many overindulged children. Attitude Modification The treatment of hysteria requires a re-education of the total person. Patients must be motivated by the therapist to give up their hysterical behavior. This is possible only through a number of attitude modifications. Attitude modification aims at changing a person's negative attitude into a positive, in circumstances that are either unchangeable or can be changed only through a different attitude. Or the circumstances present meaning possibilities that have gone unnoticed. Every attitude modification aims at a healthier, better, ethically more valuable or more positive attitude. The attitude "I can't do anything right, I'm a total failure" is unhealthy. A healthy attitude opposes anything destructive, derogative, and paralyzing, it offers a strong protection against psychological illnesses, and fosters a strong ability to bear suffering in crisis situations. A positive attitude is in harmony with one's own conscience. Two examples: A mother suffered for many years from anorexis and poor eating habits. When she was finally cured, she was not satisfied that her eating habits were normalized. She worried that her small daughter might develop the same symptoms. Because it was risky to burden the daughter with her mother's negative expectations, an attitude modification was conducted with her mother. She was advised: "Don't keep observing your daughter for symptoms. That could only interfere with her healthy development. Rather, work on yourself so one day you can say to yourself: I don't mind her following my example." The mother was deeply impressed by the thought that even now she could be an example for her daughter. It motivated her to give up her exaggerated anxiety about her daughter. She reconsidered her own behavior as well and began to change in a positive direction. The second example concerns an elderly woman who was to go to a special clinic for a minor operation. Two years previously her husband died in the same clinic after severe suffering. Because of this painful association she refused to go to that clinic -the only one in that area equipped to perform her operation. It was gently suggested that a return to the place where she parted from her husband might present an opportunity to come to terms with the parting. It might lead to a feeling of thankfulness that she had been able to be with her beloved partner to the very end -to be at his side in his hour of greatest need. The clinic could be seen as a symbol of her love for him, a place she could enter with confidence and a clear conscience. After this discussion the woman no longer resisted going to the clinic. Small Sacrifices Logotherapy can help hysterics by motivating them to develop a willingness to make small sacrifices. Of course they will do it only if they know what for. This "what for" will have to be explained to them because the way to great meaning contents in life is through small sacrifices. The unintended side effect of great meaning contents is "happiness." Conversely, acquiring small immediate gratifications is incompatible with making small sacrifices, and as a result great meanings remained unfulfilled and the unavoidable side effect is unhappiness. A person, for example, who wants to study medicine, must make a series of small sacrifices, such as preparing for an exam instead of enjoying an evening or weekend. But this person can realize a great meaning content through these sacrifices by becoming a physician holding a responsible and important position. If this student does not want to make these small sacrifices but seeks immediate gratification in dancing, skiing, and other pleasurable activities, the great meaning content of a professional career evaporates and may eventually lead to a humdrum, disliked job. Heart Neurosis Sometimes hysteria takes the form of a heart neurosis. Every time the family is happy and celebrating, mother develops a heart condition. The celebration is spoiled, everyone is concerned about her, and happiness is gone. The display of the heart condition brings immediate gratification to the mother because she is the center of attention. The long-term consequences, however, lead to unhappiness. The children will leave the home earlier, the husband may file for divorce. Ultimately the woman's health may actually be affected and she becomes progressively bitter and lonely. Therapy should aim at uncovering this threatening catastrophe, not by way of reproach but out of genuine concern for the patient. Somehow the therapist should signal to the patient: "I like you but not your hysteria." To differentiate between what a person is and what a person has is important in logotherapy. What does the mother, in the heart-neurosis example, have? A few hours of enforced attention from her family; and even that she is likely to lose. But what is she? A sick woman. Nobody likes to be with her because everybody is afraid of the next hysterical outburst. She will be like that to the end of her days if she does not change her attitude radically. Even after her death she will be remembered as the woman who was shunned -being is forever, even if it is a being-in-the -past. Therapy must focus on the person the woman could be a beloved wife and mother, visited gladly by every family member because she makes people feel good. Is that perhaps what she wants at the bottom of her heart? If this should be the case, the logotherapist can show her the way. But it requires giving up her melodramatics, being prepared to take the back seat once in a while, and allowing others to enjoy themselves. The way leads from having to being. Treating hysteria The hysteric's talent for melodrama can be utilized in a positive way. The therapist can describe a new role and challenge the patient to play-act this character. In the case of the woman with the heart neurosis, the role of a selfless lovable mother might be tried. One might argue: what good is it if she only plays a better character; it is not genuine. This is not the case with hyseria because here transition between the conscious and unconscious, between the genuine and false, are fluid. In fact, one of the greatest dangers with hysteria patients is that they identify so strongly with their initial, faked, unhealthy character that they cannot shake it off even when they want to. It is as if hysterics have no textbook for enacting a positive character, and it is up to the therapist to provide one. The symptoms may take on a life of their own. In our example it is possible that the mother actually develops heartarhythmia, whether she wants it or not. If for hysteria 9 sufferers the transitions between the unconscious and conscious are so fluid, why shouldn't they be able to identify with a positive role, when in the long run it gains so much more attention than the negative one? At some point the patient must be made aware of this possibility. It is, however, not the therapist's job to play along with the hysterics' melodramatics. They love long-term therapy because it provides them with what they need: they are the center of attention with an understanding listener. If they have alienated the rest of the world, the therapist may be the last person who cares to listen. In exchange, they pay not only with money but with stories, whatever the therapist wants to hear -from terrible childhood experiences to wild dreams or sexual fantasies. But that does not solve any problems. If the therapist determines that the therapeutic arguments are not taken seriously, and the patient refuses to play a positive role or declines to make a meaningful sacrifice for the sake of realizing genuine values, or uses therapy as substitute for meaning, the therapist must end the treatment. Therapists cannot help all persons but must not harm them either. Playing along with hysterical behavior is harmful. Today, sociogenic factors support this playing along. Hysterics are tempted to fill their leisure time by undergoing therapy, on the other hand jobless therapists are only too willing to provide this "leisure activity." This results in people being harmed by therapy and therapy sinking into disrepute. It has been my experience that, with some regularity, one week before my vacation several of my patients have "attacks" and are at "death's door." This is supposed to give me the message: "How dare you go on vacation and be unavailable to me?" They want me to know that, if I must go on vacation, at least I should go with a heavy heart and a bad conscience. Certainly, persons suffering from hysteria are emotionally handicapped; they can, however, still be responsible for their actions. That is exactly what they have to learn, even if it is a slow and difficult process. ELISABETH LUKAS, Ph.D. is director of the South German Institute of Logotherapy in FOrstenfeldbruck, Germany. 1 0 Multiple Personality Disorder and Logotherapy R.R. Hutzel!, T. Gonzalez-Forestier, and M. Eggert Jerkins Multiple Personality Disorder (MPD) is much less rare than previously believed by mental health professionals. Logotherapists are finding themselves working with persons with MPD. Following a presentation on MPD at the World Congress of Logotherapy Vll,4 six members of the audience reported work with MPD clients. Successful treatment of MPD is long, complicated, and requires the various personalities to come to a working agreement for internal cooperation.9, 11 This agreement is one of the difficult aspects. A logotherapy technique, the Values Awareness Technique (VAT)6 has proved useful. A recent publication7 describes successful treatment with the VAT of two patients with two personalities each. This article describes a more complicated case of a patient with eight alters. At the time of this writing, the patient has not completed therapy, but sufficient work has been done to illustrate use of the VAT. Overview of the Disorder MPD is a dissociative disorder, 1 a disturbance in identity, memory, or consciousness. MPD is diagnosed when two or more distinct personalities (or personality states) exist and recurrently are in full control of an individual. Each personality has its own relatively enduring pattern of perceiving, relating, and thinking. Most persons with MPD are not correctly diagnosed initially. They average around seven years (and three or more misdiagnoses) for a correct diagnosis. So, typical cases have a history of much failed previous treatment. Many psychiatric and somatic symptoms coexist with MPD, such as depression, severe headaches, mood swings, suicidality, insomnia, amnesia, nightmares, sexual dysfunction, conversion symptons, fugue episodes, phobias, panic attacks, depersonalization, substance abuse, somatization, self-mutilation, eating disorders, and unresponsive periods. Many symptoms can lead astray any diagnostician not keenly alert to the possiblity of MPD. 1 1 A notable clue to MPD is that the patient often exhibits obvious changes, including fluctuating symptoms, changing appearance, and poorly modulated affect states. In roughly one-third of the patients, clinicians suspect MPD only after having observed periods of marked change in the patient's appearance and behavior. MPD patients may admit to time distortions or time losses, lasting a few minutes to several hours. They may report discovering unfamiliar belongings or "waking up" in settings without knowing how they arrived. They report others telling them of actions they are unaware of having taken. But in only about one-fifth of the cases do the patients report awareness or suspicion of alter personalities. Often time distortions are attributed to alcohol/drug usage. Because severe brain disorders (e.g., tumors) also can produce time distortions, many medical practitioners conduct extensive brain evaluations before, during, and even after a correct diagnosis of MPD. MPD patients usually have more than one alter. Although some patients have many alters, the majority have fewer than ten. The number of alters revealed at diagnosis typically is much smaller than the number detected during therapy. Chris Sizemore (Eve, of The Three Faces of Eve) actually had 22 personalities rather than the three her therapists initially believed. Alters vary widely. A child alter seems the most common type. Others include: different ages, possessing continuous awareness, protector, and persecutor (including mutilations and attempts to kill other alters). Half the cases have at least one alter of the opposite gender, and some have alters of a different race. In most cases, one or more of the alters are angry, depressed, suicidal, substance abusing, sexually promiscuous, or combinations. Different alters of the same individual may have different responses to a single stimulus. One study found that 74% of the persons with MPD reported somatic symptoms, such as headaches, were specific to certain alters. 10 They found 46% reported different responses across alters to medications; 39%, different responses to the same foods; 35%, different responses to alcohol. Twenty-six percent reported allergies differing across alters. Changes in dominant handedness were observed in 37% of the patients. The initial development of an alter usually follows childhood traumas, typically sexual and/or physical abuse. It 12 has been suggested that dissociation is a spontaneous selfhypnotic primitive defense reflex to protect oneself when traumatized. 2 Usually, alters have different proper names, with a specific reason for each name. Some alters have functional names (e.g., Trouble) or go unnamed. Parents and children of MPD patients are likely to have psychiatric problems. Most frequent for parents are alcoholism/substance abuse, schizophrenia, and major depression. One study reports that 40% of the children of MPD patients have psychiatric diagnoses.3 Another study suggests that an average of 1.5 first-degree relatives of MPD patients are diagnosed with MPD, and an additional 2.0 firstdegree relatives are suspected of having MPO. 12 Therapy for MPD is similar to other intense, insightoriented psychotherapies, except that the patient's personality initially is un-unified.8 A major element of the psychotherapy typically is abreaction (i.e., the reliving, desensitization, and reframing of dissociated trauma). Hypnosis often is used. The goal of therapy is integration, an agreement for cooperation within the system of personalities. Fusion is achieved whenever possible -combining all separate personalities into a unified whole. Therapy preceding integration might be seen as group therapy with the various personalities of a single individual. Pharmaceuticals may be useful to therapy when they can help alleviate the coinciding distress and physical symptoms, but the core symptoms of MPD are not known to respond to drugs. Case History The patient was a middle-aged, never-married male who had been hospitalized because of depression, self-neglect, and a suicidal gesture. He had worked as a clerk for many years. He reported physical abuse by his stepmother and showed a special interest in the wellbeing of children, as they reminded him of his own unfulfilled needs for affection during childhood. He had periods of memory lapses. After first eliminating possible medical explanations for the patient's symptoms, assessment and treatment were directed toward MPD. The patient agreed to hypnosis, and proved to be remarkably suggestible. During the first few months of therapy, several personality alters acknowledged their presence. When each alter made its appearance, it was distrustful of therapy, including fear that the therapist would try to eliminate it. Often the defensive attitude included selfrighteousness, demands that "things will be done my way," raw anger, and occasional threats of violence. On at least four occasions the vows, threats and selfharm gestures made by various alters led to the patient's return to acute-care wards and even to a legal commitment for three months. As each alter was given feedback about the patient's condition and the alter's role, the alter became less righteous, more cooperative and concerned about the patient's treatment outcome, sometimes making statements to the effect that helping the patient "is what I am here for." The patient's history was pieced together largely from statements made by him and his alters. He had received physical, sexual, and emotional abuse, primarily from his stepmother. He was locked in a small basement closet for hours after being severely beaten by her, his puppy was kicked to death in front of him, and he was abused by an uncle. His stepmother was an alcoholic who eventually died from her drinking, and also experienced periods of dissociation apparently unrelated to her drinking. The patient began to show signs of dissociation during grade school in the form of marked daydreaming. Between ages 5 to 1O he developed an alter that allowed him to escape the pain of physical abuse. Another alter developed at age 1O and exhibited curiosity about his stepmother's promiscuity. At the time of this writing eight alters had made their presence known, six male and two female. All but one reported proper names. The different alters, identified here by letters for confidentiality, are briefly described below. The alters change over time and become more moderate. The descriptions below are based on their initial presentations: (A) A sensitive, colorful, effeminate male; (B) An extroverted, confident, fun-loving male who disappears when pain is experienced; (C) A matter-of-fact, observant male who carried memories of various abuses; often takes the role of helping the therapist understand the patient; (D) A raging, fist-shaking, initially mute young male who occasionally reveals a very painful, sensitive side; his role seems to be seeking vengeance and scaring off the stepmother; (E) A dramatic, strong-willed, gregarious female with exaggerated feminine mannerisms, apparently the 1 4 result of attempts at gaining closeness and communication with the stepmother through the expression of feminine qualities; (F) A "go-for-the-gusto", motorcycle-and leather-loving young male who seems to embody a sporting enjoyment of life; (G) A calm and reasoned female who apparently has the role of providing insight and judgment; (H) An angry, hurting male who stores memories and pain related to perceived physical deformities. One of the challenges the therapists faced during months of intense therapy was conflict between the patient's desire for relief from his painful memories of abuse and his resistance to attempts at therapeutic abreaction. Still, the patient made progress during the two years of therapy (two or three sessions per week). On numerous occasions he made significant gains in overcoming the grip of his memories of victimization. As therapy progressed, conflicts emerged among the alters and added to the patient's resistance to even discuss integration. Thus, the logotherapy approach was suggested because it had proven useful in previous treatment of persons with MPD. At this writing, the patient is not cured and, as will be seen, the logotherapy is not yet completed for all eight personalities. The patient shows partial integration in the form of cooperation among his still separate personalities much of the time. The Values Awareness Technique (VAT) The VAT provides a practical application of Frankl's !ogophilosophy. It was developed as a method for helping individuals clarify the creative, experiential, and attitudinal values they find personally meaningful. It has been outlined in several publications and is available in complete workbook form as well, 6 so it won't be described in great detail here. The small amount of validational work completed to date supports the validity of the VAT.5 The VAT includes a series of paper-and-pencil exercises each following a three-step format: • Expanding Conscious Awareness, • Stimulating Creative Imagination, and • Projecting Personal Values. The first step allows the person (or personality) to move away from daily patterns and view life from other perspectives. The person searches for meaningful aspects that may get overlooked in every-day living. The person responds to questions for which many responses are possible and chooses an answer that is personally meaningful. During the second step of the VAT, the person is asked to think of all the possible reasons why the response might be meaningful to anyone at all. That is, the subject considers many possible values that could underlie the response. At step three the person selects up to three values listed in step two that particularly "fit" the individual's way of thinking at step one. Thus, at the second and third steps of the exercise, the patients project values, found to be personally meaningful, onto responses that they have already selected as important. The first exercise is followed by others, each incorporating the same three-step process: Expanding Conscious Awareness, followed by Stimulating Creative Imagination, followed by Projecting Personal Values. The creative values (things that we do, such as from jobs) are easiest to clarify, and thus are done first. Experiential values (things that we have experienced, such as from our five senses) come second. The most difficult to clarify, the attitudinal values (things that we believe, such as things for which we take an unpopular stance), are left until last. The completion of the VAT takes several therapy sessions and may include homework. Productive discussions usually result from the responses. Most people clarify more than 100 values, many of which are repeats across different exercises. To finish the VAT, the repeated values are rankordered from most repeated to least repeated so that a values hierarchy is formed for the subject. Values listed only once probably have less meaning to the individual and are disregarded at this point. Use of VAT in Case Example To foster cooperation among MPD personalities and demonstrate reasons for them to agree to integrate, each personality completes the VAT separately. To begin, we asked the host personality to read and complete the MPGs workbook. 6 Unfortunately, one of the child alters hid the materials and then destroyed the forms. So we later conducted the VAT in one-to-one therapy sessions. First, values were clarified for the host personality. Those values that appeared to be essentially the same were consolidated into core values selected by the host. Next, a female alter E was eager to complete the VAT. We followed the same course as with the host. Then we contacted both the host and the alter to determine common values that were listed as different words -when possible, we sought a single word to describe common values. Then, we continued the same process with the fun-loving child alter F, followed by the adult male alter 8. Other alters were unwilling to participate at that point. For the host and alters who have participated to date, the values are presented in Table 1. These lists of meaningful values were reviewed separately with each participating alter to determine: a) similarities across alters; b) areas in which acceptance of values held by one alter might be of benefit to another alter; and c) areas for possible discussion where any dissonance in values might exist. The assumption underlying this procedure is that basic core values of the alters have similarities because the alters originated via dissociation from the same basic original personality. Alters usually see themselves as vastly distinct from one another and express surprise to learn they may have substantial similarities in their underlying values despite obvious differences in how they actualize those values. How this process fosters agreement for cooperation can be demonstrated by a specific example taken from the work with the host and the female alter E. The host did not want to be associated in any way with E -because of the femininity and the attention-seeking behavior. E considered the host so lacking in interesting aspects as to be beneath consideration. Indeed, the host and E showed dissimilarities at the Expanding Conscious Awareness step of the VAT. The host, when asked about creative values through job interests, chose jobs that permitted solitude and anonymity -park ranger, conservationist. E focused upon jobs that required being the center of attention--model, talk show hostess. It was only at the underlying value level that we saw similarities. Both, for example, found Beauty to be one of their creative values. E actualized the Beauty value by decorating the patient's room in an unusual and attention-seeking manner. The host commented negatively upon the decorating. When we recognized that both held not only Beauty but also Outdoors as creative values, it became easy to convince them that they could both live with the decorating if it reflected beautiful outdoors and nature themes. Not only could they both enjoy actualization of Beauty through decoration of the room in an outdoors, natural motif, but also they could agree to work together on the project. Acceptance of values held by other alters was illustrated when E realized that Freedom would make it easier for her to actualize the value of Individuality she regarded highly. Freedom had not surfaced as a value for E, but had surfaced for the host and other alters. Certain values were not shared, but the alters came to realize that there need not be dissonance when a value was not shared. E, for example, valued Pastime highly, whereas the host did not. However, upon consideration, the host realized that Pastime was not incompatible with any of his values. Thus, although the host did not seek Pastime activities, he realized that he did not need to have a strong sense of opposition to such activities. The VAT helped the alters recognize that there were more similarities between them than they had realized. Also, it helped each to become more aware of the others' qualities. Each initially tended to view other alters in a unipolar sense, attributing a very narrow band of distinct qualities to each alter. Following completion of the VAT, each was surprised at how many dimensions there were to each of the others. Some of the alters had viewed themselves in a narrow sense, and were surprised to find many dimensions in themselves reflected by the many values that each clarified. As each alter gained increased understanding of the others, each became more tolerant of the others. Discussion In the case example, the VAT was used specifically to foster agreement between the personalities to promote cooperation and integration. Convincing the personalities to cooperate and to consider integration is a difficult component of therapy for MPD. The resistance of MPD patients to cooperation appears to stem in part from their belief in separateness and difference between the personalities. However, use of the VAT is based upon the hypothesis that it is only at the surface level (the level of actualization of underlying values) that the personalities differ substantially. Because the personalities are derived from one original personality, it is likely that each of the parts takes some similar values from the common, original value pool. A drawback to the use of the VAT with complicated cases of MPD is that the technique can take several sessions per personality to complete. With many alters, the hours required for completion of the VAT rise quickly. In the case example, approximately five hours per personality were required to complete the VAT. And so far we have not been successful in having alters in complicated cases complete the VAT exercises as independent homework. Yet, with hundreds of hours already invested in the more complicated cases, the hours required to complete VAT's may seem reasonable, relatively speaking, if the results are productive for the therapy. In our case example, not all the alters agreed to participate in the VAT or other aspects of the therapy. Those that did agree to participate appeared more cooperative and tolerant of the others upon completion of the VAT. The patient reached a plateau at which both the VAT and other formal psychotherapy were halted. The personalities have not been fused. If the patient's condition deteriorates, it is likely that continuation of the VAT and of other psychotherapy will be suggested. At present, the patient is better integrated than when he started therapy, yet he has considerable therapy ahead of him if he is to eventually become well integrated or fused. Our case example shows the VAT as one therapy component of MPD. A previous publication7 demonstrates successful use of the VAT in therapy. For our complicated case presented here, to reach a successful fusion will likely take another several years of therapy. Table 1. Values of Four Personalities XX = one of the top 6 value categories chosen by Subject X = a final value category chosen by Subject (X)= a value that was surfaced but fit under a different category when the values were combined and a final category (title) was selected. Value Host E F B Adventure XX Beauty XX XX ( X ) Communication X Control X Emotional Health X X Enjoyment (X) X X Excitement (X) ( X) XX X Fitting In XX X X X Freedom XX X XX Friendship XX XX Helping (X) ( X) (X) xx Honesty X X Imagination X X Individuality (X) xx xx xx Improving Things X xx Knowledge xx X Nostalgia X X Observation/Alertness - X X Outdoors xx X X xx Pastime xx ( X) People ( X) xx (X) Physical Health X ( X) X xx Recognition xx X X Relaxation ( X) X xx Responsibility X Self-Esteem X X X Sensible X Sensual X X X Spiritual X Survival (X) X (X) (X) Valuable xx X Variety X X X X ROBERT R. HUTZELL, Ph.D. is a clinical psychologist and a Dip/ornate in Logotherapy. TOMAS GONZALEZ-FOREST/ER, Ph.D., is a clinical psychologist. MARY EGGERT JERKINS, Ph.D. is a counseling psychologist. All three are on the staff at the VA Medical Center and in private practice of psychology in Knoxville, IA. REFERENCES: 1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. (3rd Ed. Rev.) (DSM-III-R)( 1987) 2. Bliss, E.L. "A Symptom Profile of Patients with Multiple Personalities, Including MMPI Profiles," Journal of Nervous and Mental Disease, 172, 1984. 3. Coons, P.M., E. Bowman and V. Milstein, "Multiple Personality Disorder: A Clinical Investigation of 50 Cases," Journal of Nervous and Mental Disease, 176, 1988. 4. Hutzell, R.R. "The Use of a Logotherapy Technique in Multiple Personality Disorder: A Case Report," presented at the World Congress of Logotherapy VII, Kansas City, MO,1989. 5. __. "Projections Into Self-Reports," In J.C. 20 Crumbaugh, J.R. Graca, R.R.Huzell, M.F. Whidden, and E.C. Cooper (Eds.), A Primer of Projective Techniques of Psychological Assessment. San Diego, Libra, 1990. 6. __ and M. Eggert, A Workbook to Increase Your Meaningful and Purposeful Goals. Berkeley, Institute of Logotherapy Press, 1989. 7. __ and M. Jerkins, "The Use of a Logotherapy Technique in the Treatment of MPD," Dissociation: Progress in the Dissociative Disorders, 3, 1990. 8. Kluft, R.P. "An Update on Multiple Personality Disorder," Hospital and Community Psychiatry, 38, 1987. 9. Putnam, F.W. Diagnosis and Treatment of Multiple Personality Disorder. New York, Guilford Press, 1989. 10. __, J. Guroff, E. Silberman, L. Barban and R. Post, "The Clinical Phenomenology of MPD: Review of 100 Recent Cases," Journal of Clinical Psychiatry, 47, 1986. 11. Ross, C.A. Multiple Personality Disorder: Diagnosis, Clinical Features, and Treatment. NY, John Wiley and Sons, 1989. 12. __, G. Norton and K.K. Wozney, "Multiple Personality Disorder: An Analysis of 236 Cases," Canadian Journal of Psychiatry,34, 1989. Meaning in Women's Lives Mary Alice Nicholson Frankl4,5,6 sees responsibility as a key to meaning. Yet, for many women responsibility presents a conflict. The root of this conflict lies in their early development when their identity is imbued with a pervasive responsibility to others, while male children are reinforced more for autonomy.2,7 Reasoning from logotherapeutic principles, a compelling feminine focus on others that subverts the development of personal autonomy is a formidable block to the discovery of meaning. Women's growth toward autonomy is confounded also by their submissive role prescribed by society. This places women at risk of interpreting life "in terms of the taskmaster[society) who has assigned it to them," instead from spiritually fulfilling P-114 values of personal conscience. 6, Passive acceptance of social roles stifle their humanity and destine women to experience existential vacuum, even existential neurosis.9 For both women and men, sociological effects on psychological maturation may challenge meaning strivings, although challenges may differ according to gender. Women may underemphasize the responsibility for autonomy; men, responsibility for self-transcendence. Thus, in researching the paths to meaning we need to focus upon women and men serparately. Because the issue has been neglected in psychological study, I conducted research on paths to meaning taken specifically by women. Inspired by many women successful in experiencing meaningful lives, I developed several questions: What developmental processes facilitate women's later striving for meaning? What life processes do women seek to aid their meaning discoveries? How do women cope with the tension between autonomy and self-transcendence in their developmental experiences? How do women overcome societal values to arrive at personal meaning? My research does not provide definite answers to these questions but it does yield information that may provide useful steps toward answers. From a literature review, 10 the following variables were hypothesized to be related to experiences of self-transcendence (via intimacy) and autonomy: •Family experiences of intimacy and autonomy. •Locus of control. Expectancy that rewards in life are the result of one's own behavior, or of external sources. •Social support. •Personal moral judgment of right and wrong. •Educational and occupational levels. Method More than 200 women, ages 29 to 56, volunteered to participate, 168 completed the assessment. The subjects resided in a 10-county urban and rural mid western area and were socio-economically representative of that population. The assessments (Table 1) took from,1 to 1 1/2 hours. Thirty-five participants either failed or did not complete reliability tests to measure moral judgment; moral judgment was therefore deleted as a variable in the final data analysis. Data were analyzed and interpreted through a stepwise multiple linear regression statistical procedure. The procedure ranked the research predictors according to the strength of their unique associations with the criterion, (PIL scores) and reflected the cumulative influence the predictors had on different levels of meaning (i.e. which individual research variables were most important as predictors of meaning). Research Variables and Measurement Instruments Predictors: 1.Family Experiences of The Family of Origin Scale8 Intimacy and Autonomy 2. Locus of Control The Adult Nowicki-Strickland Internal-External Control Scale11 3.Social Support The Inventory of Socially Supportive Behaviors1 4.Moral Judgment The Defining Issues Test 12 5.Education & Occupational The Personal Information Report Levels (unpublished assessment form developed by the author) Criterion: Meaning in Life The Purpose-in-Life (PIL) Test 3 Results After Moral Judgment was dropped, the multiple correlation between the rest of the predictors and meaning in women's lives was .53 (B_=.28, {L<.05, tL=168). Scores on the measure of Locus of Control and the measure of Family Experiences and Intimacy and Autonomy accounted for 18% and 8%, respectively, of unique variance in responses on the Meaning-in-Life measure, while Social Support scores added only 1% of unique variance to the regression equation {Q__<.05). Education and Occupational Levels accounted for 1% of variance and were not statistically significant. These results suggest that an internal Locus of Control and positive childhood Experiences of Intimacy and Autonomy are both associated with women's meaning in life, while the receipt of Social Support yields minor influence on meaning. Statistical control of intercorrelations among all predictors indicated that the statistically significant simple correlations of Education (c=.22) and Occupation ([=.30) Levels with meaning scores occurred mainly through their shared relationships with other more important predictors. Discussion The present study supports the hypothesis that experiences of intimacy and autonomy in childhood in conjunction with an adult internal locus of control and adequate social support are related to meaning in women's lives. The results are also in accord with Frankl4 that the acceptance of responsibility for one's fate is essential to the discovery of meaning, particularly when one transcends the self through trust and empathy of authentic human intimacy. For women with meaningful lives, an internal locus of control may help to successfully integrate feminine responsibility to others with responsibilty for self. Early developmental experiences of intimacy and autonomy may be key factors in this process. Many women with life-meaning may have been prepared by their families of origin to resist societal pressures to remain passive and dependent. Thus women who as children were reinforced by their caregivers for selfsufficiency, as well as for caring for others, may more easily achieve fulfillment as adults. The results agree with Frankl 6 that psychological processes are directly associated with meaning. This accounts for the implication that higher education and occupation levels influence meaning indirectly, i.e. through association with the 24 capacity for autonomy and intimacy. It seems likely that women predisposed and motivated to strive for meaning choose higher education levels and occupations which provide greater personal freedom and responsibility. Future research would benefit from the study of noetic processes in families and of the influence of moral judgment on women's meaning striving. Perhaps the most interesting question the present research generates, however, pertains to paths to meaning for women who experience inadequate intimacy and autonomy in their families of origin. MARY ALICE NICHOLSON, Ph.D., is a psychotherapist in the Hean/and Personal Growth Center in Kansas City, Missouri. REFERENCES 1. Barrera, M., I. Sandler, and T. Ramsay. "Preliminary Development of a Scale of Social Support." American Journal of Community Psychology, 9, 1981. 2. Chodorow, N. "Family Structure and Feminine Personality," in Women, Culture and Society, M. Rosaldo and L. Lamphere, Eds. Stanford University Press, 1974. 3. Crumbaugh J. and M. Maholick. "Manual of Instructions for the Purpose in Life Test." Munster, Indiana, Psychometric Affiliates, 1981. 4. Frankl, V. Psychotherapy and Existentialism. New York, Washington Square Press, 1967. 5. ___. The Will to Meaning. New York, New American Library, 1969. 6. ___. Man's Search for Meaning. New York, Simon and Schuster, 1984. 7. Gilligan, C. In a Different Voice. Cambridge, Harvard University Press, 1982. 8. Hovestadt, A., W. Anderson, F. Piercy, S. Cochran, and M. Fine. "A Family of Original Scale." Journal of Marital and Family Therapy, 3, 1985. 9. Maddi, S. "The Existential Neurosis." Journal of Abnormal Psychology, 72, 311-235, 1967. 10. Nicholson, M. "Psychological and Demographic Correlates of Meaning and Purpose in Women's Lives." Dissertation Abstracts lnternational,48,2821 A. 11.Novicki, S. and M. Duke. "A Locus of Control Scale for College as well as Non-College Students." Journal of Personality Assessment, 38, 136-137, 1974. 12. Rest, J. "Manual for the Defining Issues Test: An Objective Test of Moral Judgment Development." Univ. of Minnesota). Logotherapy and the Disabled: A Case Study Martha K. Stavros The search for meaning is an important challenge for patients in acute rehabilitation. Medical science has developed to the point where the effects of chronic disease and major traumas do not lead to death in many cases as they once did. Millions of patients who would have died of complications of spinal-cord injury or head trauma survive, often under difficult circumstances. Professionals are aware of the stress that grows out of the discrepancy between the promise of life after the onset of terrible physical problems and the apparent value of such an existence. The frustration of patients who ask why they have been left to live out a life that is limited in so many ways is matched by the knowledge of medical staff that survival is not the same as having a productive life. Solutions are difficult to find. The increased cost of medical care and the reduction of staff make it difficult to do more than chart and medicate the patients' depression. Logotherapy can be the tool professionals have been groping for, to relieve the darkness of their patients' lives. The following is a report of results in a difficult case. The logotherapeutic approach changed the life of one man dramatically and quickly. A Threatening Disease In November of 1989 Bill, 65, was moved by ambulance from a small hospital to a high-tech university setting because within two days he had progressively weakened until he lost all motor control and reflexes below his chin. The hospital diagnosed Guillain-Barre Syndrome, a rare disorder that attacks the peripheral nerves of the body. Its extreme manifestation is complete paralysis. The cause is unknown, but its swift and devastating onset is frightening and sometimes life threatening. Bill began his hospital stay on a rota-bed, to avoid dangerous accumulations of mucus or pressure sores. His sheets were pulled tight to avoid creases, and bony prominences were routinely massaged to increase blood circulation. He was completely dependent, needing assistance for bowel and bladder function, oral hygiene, eating, and scratching skin that itched from dryness. He had never in his adult life experienced physical dependence, and now he needed help to blow his nose or wipe away unwelcome tears. In the early days of the hospitalization much energy was spent to save Bill's life. His survival brought encouragement to him, his family, and his treatment team. The euphoria was shortlived, however. Nerve-conduction studies revealed that despite the use of powerful steroids, which sometimes result in swift changes for Guillian-Barre patients, he was going to have to fight for every inch of recovery. The long-term prognosis was not good. The tough man who had felt self-sufficient and able to take care of others began deteriorating under the assault of this strange new enemy. In January 1990 he slipped into a deep depression. Anti-depressant drugs were prescribed so that his emotional state would not interfere with the grueling therapies required. The decisions to use medication did not come easily because drugs sometimes dull cognition and support lethargy. Nevertheless, the slow progress in relearning elementary movements and still needing someone for every human act was tearing at the patient's courage and resilience. The Logotherapy Approach The social worker assigned to Bill had many years of training in adjustment to disability but the recent addition of logotherapy skills offered the treating team an option to drug therapy. A comfortable therapeutic alliance had been established between Bill and the therapist but the patient was disappointed in himself for being depressed and he kept repeating his determination to do better. Logotherapy concepts often are most easily introduced by the story of Viktor Frankl's suffering in concentration camps. Bill was moved by the enormity of Frankl's challenges, but his initial reaction was to view his own depression as a sign of weakness. He could not read Man's Search of Meaning because his attention span was reduced by his depression. But he listened to the recounting of the book, and he heard Frankl's challenge to each person to uncover his or her own unique values as a guide to choosing a response to circumstances, no matter how difficult. By responding to Socratic questioning, Bill slowly began to uncover the root values that supported the meaning of his previously happy life. He talked about the times he had felt fulfilled, happy, successful. The nature of such a discussion was not familiar to him but it opened a new avenue that might help. Bill named several times and achievements that had been important to him. There was a distinctly different sound in his voice, however, when he stated that having had five good children was remarkable in this day and age. "Furthermore," he added quietly, "they are all Mennonites." The stillness following this announcement underscored its place in Bill's value system. The process had uncovered the center spot from which he had drawn the energy for his life. The practice of his religion and the fathering of five good children were the hallmarks of this suffering man's existence. But he was anguished by shame that his faith was being so sorely tried and by sadness that he could no longer do anything for his beloved family. In the course of the Socratic dialogue Bill was asked: "If life were thought of as a long and dark road, who held the torches to show you the way?" He was clearly embarrassed, not so much by the question as by the ready answer he had. He cited the help he had gotten from his wife, his dad, his minister. However, his hesitancy suggested another answer too personal, too special, too deep to spill out carelessly in front of someone who might not understand. A long and thoughtful silence ensued. Finally, lauding his accomplishments in having raised five children who had selected to cherish his own rich faith, the social worker pressed again. "Who helped you do this? Who provided direction when things were not easy or clear?" There could be no doubt that this information was not easily shared. Valued very personally, it needed to be held in the same esteem that Bill had for it. He asked for assurance. In fact, he elicited a promise that the therapist would not laugh when he talked about his torch-bearer. "My leader any time when things got hard...any time at all. .. was Jesus Christ", he whispered almost inaudibly. Jesus as model and teacher was obviously intrinsic to Bill. He was hurting in body as well as in spirit. Now, for the first time since his ordeal began he had dereflected from his suffering. Stepping away from his focus on the hellish circumstances of his disease, he was in a position to choose how he would respond. Next, Bill was asked to imagine that Jesus was sitting in a chair near his bed, and describe his person. "He is a big man, dark curly hair, suntanned skin, quiet." "What would Jesus say to you now, under your present circumstances? What would he who has known you all your life, known your fine children, known your commitment to the Mennonite faith -what would he have to say about this suffering?" The question hung in the air for only a moment. Bill knew what his role model might say. He spoke the words with confidence, as though he had known them all his life. Jesus' message was personal and clear. He told Bill that he, Jesus, had suffered, too. That his own patience with the pain of his crucifixion could stand as a model for Bill. In fact, Jesus suggested that although Bill couldn't do much for his family physically and financially, he could model how to respond to life's blows when they would inevitably come. After the "conversation" with his internalized role model there was a visible difference in the sick man's face. He was clear about what he valued, and now he had found a means of putting it back into his life. To make this discovery concrete, the social worker encouraged him to dictate a letter to his children. This is what he dictated: My dear children: I have never been much on writing letters. But today, from my hospital bed, I want to share some thoughts with you. A great depression came over me when I realized I was paralyzed, that I could not do anything for myself. Before I was sick I thought I could handle a depression about anything that came upon me. I believed God walked with me. In my hospital bed, however, I couldn't remember that. All I could think of is being paralyzed for the rest of my life. This was my tear. I want to tell you about this because I know life will sometimes be rough to you, too. You will need someone to help you. God comes to you through people. For me it has been your mother. She never left my side during all I have been through. Another was a social worker. She told me what I knew in my heart and couldn't quite get to the surface by myself. She helped me remember what I am telling you right now. There is always a way. God lives within each of us. We need the help of others. God will speak to you through someone if you ask and trust. I want to b~ that someone for you. My own suffering has been turned around because I'm looking at it as an opportunity to model for you the way to get through rough times. I know you will suffer, and I hate to see it, but when you do you can remember what I am saying here. As your dad I am asking you to remember me, and when you suffer try to trust that God has people around who will lift you up under any circumstances so you can again see the light shining through. My own suffering isn't done yet. I don't know how it will end. But I know this: it has gotten easier because I have turned it into an opportunity to show you the way. I will not give time to negative thoughts. I am determined to be as patient as possible and I will hold to my beliefs, no matter what things look like. That is all I can do for you now. I can't work and do physical things for you, but I can do this. As your father I am trying to be your model. Having decided to look at things in this way, my suffering is changed. In some way that is hard to explain, I am happy. I love your mother. I love each of you. The value of Bill's change was not merely having found a new frame of reference from which to view his suffering, but that he had found a new direction for his life that was consistent with what he valued most. He changed immediately. He became light, content, cooperative. The therapists couldn't work him hard enough. He laughed at the jokes told by other patients and told a few himself. He seemed almost happy under his dire circumstances, and even when the news of his progress was less than optimal, he remained undaunted. In fact, on one level, Bill's story doesn't end well. He has not recovered enough function to feed himself. The medical center discharged him to a nursing home. His slow progress didn't merit the costs required to do long-range inpatient therapy. He is now in his own home, confined to a power wheelchair, and must have help to get in and out of bed. On another level, however, Bill's story has a wonderful ending. His story is told at professional conferences to staff who need the encouragement it brings. Bill is a peer counselor of unparalleled dimension. In the nursing home he helped other patients struggling with depression. He and his recreational therapist arranged for a re-enactment of his wedding on occasion of his 40th wedding anniversary, and 200 guests came. Twenty handicapped residents from the nursing home performed as bridal attendants. The local newspaper covered the event with a full page of pictures. Bill has maintained his joy and purpose. He brings immense pleasure to other patients he visits. What he does for the staff with whom he works is influencing the lives of hundreds of people they serve. After presenting his case at a nursing conference, dozens of invitations followed. Truly, we search for meaning. Whether it is in the hospital bed where patients face questions of their pupose, or in the staff room where professionals question the goals of their labor, there is a need for a procedure to find meaning. Bill's story demonstrates that logotherapy is a tool to help those who suffer from disabling diseases and for those who serve them. The latest report about Bill came from his daughter in December 1990. She wrote: "My father has made tremendous strides as he remains in outpatient therapy. To the amazement of the medical professionals he can now stand on his own and even takes a few steps in a walker. All medical tests say standing should be impossible for him. Today I phoned my parents and to my surprise Dad answered and was able to hold the phone to his ear. He's beating the odds. I'm to be married in the spring, his only daughter. He's working toward walking me down the aisle. We both know he'll stand tall to give me away. My father's faith is strong and his spirit joyous. I seldom hear him complain, and it's never about his illness that so devastated him and our family. He continues to fight for the use of his limbs to return. Even from the seat of my father's wheelchair he stands tall." MARTHA K. STAVROS, ACSW, BCD, is a clincal social worker at the Department of Social Work, University of Michigan Medical Center, Ann Harbor, Michigan. 3 1 Social Conscience in Logotherapy Robert F. Massey Frankl values conscience as a distinctively human faculty. He sees it as the intuitive capacity to grasp the uniqueness of a situation and to decipher a "unique necessity. 1 ,P-19 He views conscience from the perspective of a self-transcendent individual. Social conscience is new to logotherapeutic thinking. This article explores the rationale for including social conscience in logotherapeutic thinking. Frankl links conscience with love.2 For the individual, both are intuitive capacities. They deal with uniqueness (love with the uniqueness of the beloved, conscience with the uniqueness of the meaning of a situation). It is helpful in an investigation of social conscience to remember that both love and conscience require self-transcendence and are nonreductionistic. Self-transcendence connotes that we are questioned by life, that we are called to be responsible in fulfilling meaning. Frankl's metaphor of advocating a Statue of Responsibility for the West Coast of the United States underscores that understanding the oneness of humanity advances the search for meaning. Personal Conscience Frankl4 notes that drives and instincts do not dictate what humans will do. Nor do traditions and conventional values constrain human behavior as decidedly they once did. For some people this results in an existential vacuum of guiding values and prompts them to submit to conformism or totalitarianism. Others, out of fear of confronting an existential vacuum, may engage in centrifugal leisure -a "flight from the self."2-P-97 Authenticity and responsibility to unique meanings sometimes require that we disregard standards of a superego and follow the "premoral understanding of meaning,"3,p 34 which flows from conscience. The ought of conscience requires centripetal leisure and provides an irreducible basis for human freedom to be responsible. 2 Frankl 1 contends that conscience requires the foundation of a sound philosophy. He asserts that the values on which individual conscience relies cannot be taught but need to be lived. Fulfilling values is an active process involving becoming, productive growth, and self-identity. 32 Social Conscience Frankl's emphasis on dimensional ontology, selftranscendence, and transsubjectivity provides the seeds for a holistic understanding of the relationship between persons and social structures. He refers to "the four basically different layers (or 'dimensions') of ... [human existence]: physical, ... psychic, . . . social field of force, and . . .mode of existence. 1,PP-176-177 He highlights the noetic dimension and underplays the social.8 A fully holistic theory attends to all four. Human existence is anchored in social processes. An adequate explanation must not "overarch . . it."2, p.26 Conscience is not a physical process and has been discussed mostly from the psychological and noological viewpoints. To speak of social conscience, we must also discover how conscience is related to the societal field. Dimensional ontology indicates that a unity incorporates and does not abrogate parts. Social conscience involves both societal processes and unique persons who grasp the unique meanings of situations. Individual conscience frequently has a social reference because it considers the consequences of personal actions on others. Social conscience connotes more than this. It concerns the ways in which unique individuals interrelate with each other so they contribute to and are influenced by a mutual morality. This process respects the uniqueness of individuals and also recognizes that they participate in and are governed by social structures. Persons and the social structures they cocreate form a unity. This union is not explained by the component phenomena and does not exist without them, but occurs as personal and social phenomena interconnect. This interconnection on the level of meaning occurs through self-transcendence. Humans can engage in selftranscendence because they can think abstractly. 5 Se Iftranscendence can happen with significant others and through considering relevant public opinion. Viable social structures either provide means to satisfy the fundamental sociophysiological needs, or they need to be reconstructed so they facilitate social cooperation. Participants in viable social structures share common interests, can meaningfully identify with the attitudes and roles of others, and find societal patterns useful in adapting to the environment. Viewing conscience as "reflective moral conscience"9, P92 anticipates Frankl's emphasis on conscience as dependent on selftranscendence and underscores the interconnection between 33 persons and social structures. "Control by the community over its members provides indeed the material from which reflective moral conscience builds its own situation, but cannot exist as a situation until the moral consciousness of the individual constructs it. "9,P84 Frankl3 distinguishes between individual superego and conscience. We can follow this line of reasoning on the group level. When interactions conform to autocratic power or peer pressure, particularly when they lead to destructiveness, they adhere to a superego.? But when interactions respect and protect the enhancement of life, including consciousness and responsible choosoperative. the ing, human social potential conscience is for The Context of Conscience Frankl cautions against reductionism and sociologism. Reductionism results from exclusive reliance on psychodynamic explanations for human behaviors. Sociologism or reification of human processes stems from the claim that social structures determine human behaviors. Actually, persons and social structures interconnect. Persons cocreate the social systems which interlink, organize, and regulate them. We can avoid reifying social structures by remembering that in "a system, the sum of the parts is more powerful, but not other than the [interdependent! members."6,p.3o Frankl2,p,60 acknowledges that we view reality through a perspective, and he decries regarding a perspective as the full reality of a phenomenon. From an expanded perspective, we can view "phenomena [such as selfesteem, search for meaning, conscience! in a context."2,P40 of social structures cocreated by self-transcending processes which modulate human behaviors. In the context of interactions between specific persons and particular social structures, individuals can act on experiential, creative, and attitudinal values in relation to social structures. Valuing occurs in the context of interconnectedness of persons and social structures. Individuals do not exist in isolation. Through socialization they learn how to communicate and interact in patterns of group structure which evolve as the participants influence each other. These patterns become institutionalized. "The construction and modification of social institutions is possible because persons can take the attitude of the other and consquently understand, communicate with, and cooperate with others in creative and meaningful ways."7,P109 When social conscience is actualized in institutions, favorable conditions develop for constructive human living. In these cases institutions promote the increase of self-esteem through fulfillment ot creative, experiential, and attitudinal values as persons discover unique meanings. When social conscience is lacking or suppressed by social structures, the free search for unique meanings is thwarted and institutions debase self-esteem or make it dependent on authoritarian or conformist dictates. Then a search for community, based on responsible freedom, calls for a new vision of social conscience, lived out by persons courageous enough to struggle for their own self-actualiztion in a life-affirming community. Logotherapy reaches the height of social-explanatory power by exploring the depth of the social processes which support the self, increase self-esteem, encourage the search for meaning, and protect social conscience. ROBERT F. MASSEY, Ph.D., is professor of psychology at St. Peter's College, N.J. He is a licensed psychologist and marriage counselor and an approved supervisor with AAMFT. This article records ideas presented at the Seventh World Congress of Logotherapy, Kansas City, June 1989. REFERENCES: 1.Frankl, V.E. The Doctor and the Soul. NY, Vintage Books, 1955. 2. __.The Will to Meaning. NY, New American Library, 1969. 3. __ .The Unconscious God. NY, Simon and Schuster, 1 9 7 5. 4. __. The Unheard Cry for Meaning. NY, Simon and Schuster, 1978. 5. Goldstein, K. Human Nature: In the Light of Psychopathology. NY, Schocken, 1940. 6. Massey, R.F. "What/Who is the Family System?" The American Journal of Family Therapy 14(1 ), 1986. 7. __ . "Transactional Analysis and the Social Psychology of Power." Transactional Analysis Journal 17, 1987. 8. __ . "A Critique of Logotherapy as a Personality Theory. International Forum for Logotherapy 11 (2), 1988. 9. Mead, G.H. Selected Writings. Indianapolis, Bobbs-Merrill, 1964. NOTE: The editors of the International Forum for Logotherapy welcome readers opinions on social conscience, a term not mentioned by Dr. Frankl explicitly, and individual conscience and self-transcendence which play an important part in logotherapy. 35 Alcoholics Anonymous as Group Logotherapy Robert M. Holmes Human beings were born to ask why they were born. It is our (luest for meaning that makes us human. The absence of meaning dooms us either to the slow death of neurosis or the instant death of suicide. This is the underlying philosophy of Frankt's logotherapy. He emphasizes the individuality of each person's unique opportunity to live life and face death for him-or herself. It is therefore the discovery of meaning that psychotherapy would do well to direct more attention to. No group in our society provides a better laboratory for logotherapeutic goals than Alcoholics Anonymous. In AA, the quest for meaning is not an expUcit aim but is seen basic to the alcoholics' need and central to the AA's therapeutic program. It functions independently of Frankl or other psychiatric traditions (in fact, even without psychiatrically oriented leadership) but operates with the very presuppositions which are also basic to logotherapy. AA is essentially a "group logotherapy experience," designed to meet a broad sprectrum of human problems. The four basic concepts of Frankl's view of the human being also happen to be fundamental in AA's therapeutic program. They are: a dimensional view of human nature; existential frustration; freedom; and responsibility. A Dimensional View of the Human Being The human person is seen in terms of dimensions rather than layers or compartments and, to be understood fully, must be viewed in all these dimensions simultaneously: the psychic, the somatic, and the noetic. The noetic dimension is uniquely human, it is the "spiritual" nature, without a necessarily religious connotation. But ample room is left for the development of clients' views about the nature of God and the bearing of their theological convictions. The noetic is the dimension where we are not limited by physical or psychological forces, but where we are tree to choose -at least our attitudes. The primacy of the noetic. dimension is the avenue to wholeness and fundamental in Frankl's view of human nature. Many participants in AA know from experience that the problems of alcoholism cannot be met through psychiatric help alone. Alcoholics have a psychological structure and history, and a set of biological needs and problems, but their noetic dimension must not be overlooked or rejected. To be really understood, alcoholics must 36 be viewed in all their dimensions. Many alcoholics have long histories of futile attempts to deal with their drinking problems independently. In this sense, AA is profoundly existential in its approach because it focuses upon persons with drinking problems as they "ex-ist." Emphasis is not on general causes and symptoms of alcoholism, but on the experience of the specific alcoholic. The extent to which the AA program encourages alcoholics to become aware of their total existence is daring in its depth and often painful in its intensity. The original fellowship of AA was founded on the insight that one's drinking problem could not be separated from the total combination of the person's relationships to others, to the self, and to life. Herein lies the import of steps tour and five of the Twelve Steps of AA: 4 ... [to make] a searching and tearless moral inventory of ourselves. 5 ... (to continue] to make personal inventory and when we were wrong promptly admit it. Through experience rather then clinical training, AA has discovered that alcoholics must not be dealt with as bundles of symptoms or pawns of drives, but as persons who must be met as total selves and must come to see themselves this way. They must emerge spiritually above their psychophysical condition. 2 The success of AA, like that of logotherapy, is dependent on the noetic dimension. Though both programs refuse to spell out God's nature in any specific terms, the reality of God and our spiritual nature are basic assumptions of both. They are concerned with the healing of the soul, leaving the saving of the soul to religion. But AA is unapologetic about the centrality of the "God" concept. Six of its twelve steps make specific reference to God. Repeatedly, in the handbook of AA the word "God" is followed by the modifying phrase, "as we understand [the concept]."Yet while AA does not press for an "objective" conceptualization of God, it speaks of its program as a "spiritual awakening."1 Existential Frustration Frankl's vast clinical experience led him to formulate the concepts of "existential frustration" and "existential vacuum." The former refers to the frustration of one's will to meaning, and existential vacuum refers to that condition of emptiness that exists when all meaning seems lost or undiscovered. Frankl maintains that existential frustration, far from being pathological, is the most human of all phenomena. 3, p83ff Although the causes of alcoholism can hardly be reduced simply to existential frustration, it plays a crucial role. Many 37 psychologists and sociologists speak of boredom as one of the factors in our growing alcohol problem. People are unequipped to use their increasing leisure time healthfully. Frankl sees the existential vacuum, too, as manifesting itself in the condition of boredom. Even when all apparent needs are satisfied, there is a fundamental need that is not met on a psychic or somatic level.3 He speaks of victims of "Sunday neuroses"4 , P-124 who get drunk to flee from their spiritual horror of emptiness. Boredom, in the deepest sense, means not just lack of something to do, but lack of a real sense of purpose or meaning. Alcohol is one of the most prevalent escapes from this intolerable state. This would explain why alcoholics are often rich, popular, highly skilled, and sometimes extremely gifted people. But possessions and abilities are secondary to the meanings one finds in these endowments. If meaning is lost, no amount of wellbeing will provide a satisfying life. The slow death of alcoholism is selected as an apparent alternative to suicide (although suicide is often chosen as the easier course). Alcoholics can be helped, not by making them see the dangers of their drinking or by increasing their already intolerable sense of guilt for their gross misuse of life, but by meeting them at the point of their sense of meaninglessness -their existential vacuum. Without using the technical terminology, this is precisely what AA does, in two ways: First, by providing experiences of being accepted in which the alcoholics' worth as persons is confirmed, regardless of their alcoholism. And second, by providing them with a sense of purpose that arises not in spite of their alcoholism but out of the very fact of it! Affirmation of Personal Worth. To Frankl, this is crucial to all good therapy. In his encounters with patients he makes frequent reference to the value of their past contributions to life or their potential for the future. His stress upon the supreme importance of "attitudinal values" is aimed at helping patients achieve or retrieve a sense of personal integrity and importance by making them see their unique opportunities. If one can create little (thus possessing few "creative values"), and one's sphere of experiences is limited (thus providing few "experiential values"), patients have a unique and almost limitless field of "attitudinal values" which arise out of the manner in which they face and deal with a particular situation. The alcoholics' abiding need is for an experience of acceptance of such genuineness that it can move them beyond the stultifying restrictions of social rejection and self-rejection. Accordingly, the most fundamental characteristic of the atmosphere of AA is maximum acceptance. It provides a context where the individual is a person again in his or her own right. Frankl would maintain that this 38 provision for a sense of personal worth is essential in genuine therapy. Discovery of Purpose. According to Frankl, no life is purposeless and every life can find purpose, no matter what its history.s Older citizens or terminal patients can choose to look upon death as a fitting climax to a meaningful life, or their response to the fact of death can itself become an event of ultimate meaning perhaps the highest meaning a mortal can achieve. Alcoholism, like death, is an inescapable fact. Alcoholics cannot look hopefully to the day when they will not be alcoholics. They can only confront this fact, accept it, and decide how they are going to deal with it. AA suggests that the most significant meaning one can ever achieve may arise directly out of the fact of their alcoholism. When alcoholics testify to their own experience, they discover that it is of value to others. Thus the culminating step of the program asks them to be on call at any hour and willing to travel any distance to be at the side of an alcoholic who has taken the initiative to call for help. The realization that, as alcoholics, there are functions they can perform better than anyone else (even a psychiatrist or pastor) provides the ultimate satisfaction of their existential frustration. Frankl is fond of paraphrasing Nietzsche: "Those who have a 'why' to live can endure almost every 'how."'4,P106 Freedom Frankl rejects seeing the human being as victim of determinism. We are free to make choices, to take positions, say "yes" or "no" to life. We are free even if we do not understand ultimate meaning, and even if we pretend not to be free. Alcoholics who have alternatively encountered sympathy and rejection, come into AA where they find neither. The judgment under which they have lived -that they are "hopelessly drunk" -is contradicted by AA's affirmation that although they are "drunks" they are not in the least hopeless. The AA program is based on the assumption that people, no matter how depressing their past, are free to choose -to accept or reject a positive future, step by step, one day, one hour at a time. To make the admission called for in the "first step" (one's powerlessness over alcohol) is to make a decision of the greatest import. It launches the alcoholics on a program that enables them to accept their situation and to use their freedom creatively within the limits of that situation. They are free to acknowledge that they are not free to drink, and are free to abide by the self-imposed restriction of abstinence. Step three states: "We made a decision to turn our will and our lives over to the care of God as we understand 39 him." Indeed, each of the twelve steps is accepted only by personal decision. Frankl would applaud this insistence on the recognition of each person's freedom. Responsibility Freedom and responsibility imply each other. According to Frankl, in the same way that therapy frees patients from much that has encumbered them, it must educate them to a sense of responsibility. Though we may not be responsible for everything that happens to us, we are inevitably responsible for what we do about what happens to us. We may not be responsible for our symptoms, but we are responsible for our attitude toward our symptoms. There may be limits to the extent we can alter our situation, but we are under obligation to realize values and discover meaning in our lives, no matter what the circumstances. Frankl's phrase "education for responsibility" is a particularly apt description of the AA program. The education begins when the alcoholic first dials AA's number or attends the first closed meeting. Of course, alcoholism is always the result of a complex of factors which spread the total responsibility far beyond the alcoholic. But it is no help for alcoholics to dwell on that fact. Recovery comes through the difficult but releasing process of selfacceptance, the vital core of which is acceptance of personal responsibility. Each of the Twelve Steps presupposes the alcoholics' capacity to respond. This response-ability includes acceptance of one's condition, the confession of one's willful wrongdoing and tendencies to evade responsibility, and a sense of obligation to apply one's own experience to the needs of others. The focus is upon responding creatively in the present moment in such a way that meaning is discovered not apart from or in spite of the circumstances of life, but out of their very warp and woof. Group Therapy AA procedures are are to be compared to Frankl's philosophy rather than his clinical methods. Group therapy, undertaken in the manner of AA's rejuvenated Oxford Movement, could pay large spiritual dividends. AA dramatizes the possibilities of implementing the logotherapy philosophy in concrete "growth group" situations under relatively unskilled but devoted leadership. The potential of such groups is large, with the participants discussing their own failures and their own existential vacuum. Personal discoveries may be made in the discipline of "telling one's own story" from the standpoint of one's search for meaning among the unavoidable facts of life. Personal insights may result from a reexamination of selected readings in the light of Frankl's focus on meaning. With a logotherapeutic orientation, executed in the pattern of the informal quasi-class-meeting structure of AA, the groups become laboratories in which the participants can forge ahead with new freedom and vitality in their essential quest for life, liberty, and the pursuit of meaning. ROBERT M. HOLMES, Th.D. is a retired chaplain and associate professor of Christian Thought, Rocky Mountain College, BIiiings, Montana. The above article in an edited version of Dr. Holmes' article with the same title in Pastoral Psychology, 1970, 21, pp. 30-36. REFERENCES: 1. Alcoholics Anonymous. AA Publishing Company,1954. 2. Frankl, V.E. Man's Search for Meaning. NY, Washington Square Press, 1985. 3., ___. "On Logotherapy and Existential Analysis," American Journal of Psychoanalysis, 18(1), 1958. 4., ___. The Will to Meaning. NY, The World Publishing Company, 1969. 5.. ___. Psychotherapy and Existentialism. NY, Washington Square Press, 1967. "Stress Management" for Teachers Bianca z. Hirsch Teachers often are frustrated in their efforts to make life meaningful for their students and themselves because many decisions are made for them. Examples are having to deal with large classes, mainstreaming special-education children, or incorporating new teaching methods and materials. Getting rid of all tension and stress is not the goal. A certain amount of stress is healthy to initiate action and motivate the individual. Frankl proposed that "in contrast to the homeostasis theory...man not only does not primarily care for tension reduction -he even needs tension. Therefore he is in search of tension. Today, however, he does not find enough tension; that is why he sometimes creates tension."1,P-94 Although too much tension may be incapacitating, a "sound amount of tension is necessary -the kind of tension that is established between a human being...and a meaning he has to fulfill."1,P-95 Without a meaning to fulfill or an obligation to meet, life often becomes meaningless and a noogenic neurosis may develop. Consequently, individuals seek self-induced tension by climbing mountains, winning games, or participating in sports. Living in stressful situations can be detrimental to efficient functioning. Popular articles speak of "stress management." I believe this term to be a misnomer. Stress is not a manageable item. We can manage aspects that contribute to stress, such as time schedules, work toad, priorities, attitudes, and motivation. Classroom teachers experience many of these, causing tense moments and stressful situations. Time Frame. Teachers have to operate within time frames. They have to provide educational programs to meet the needs of thirty or more students within a certain period. Some students work at a slower pace and need more time to read a passage and discuss it, while others read more quickly and need to have challenging work after completing their assignments. When the bell rings, the material scheduled for classroom presentation has to be completed because homework must be concommittant to the material covered in class. Work Load. In a teaching/learning situation, current events impact many lessons. To create a meaningful learning environment, the teacher cannot merely read from a textbook. To be meaningful, the students have to be able to apply the material to every-day situations. This takes time, energy, preparation. To teach history in high school or social studies in elementary school, the abstract concepts have to be incorporated into current events. Additionally, teachers have to become involved in day-to-day operations of the school, assume responsibilities for yard duty, extra-curricular activities, and such tasks as displaying student work and having students enter contests. Each of these activities adds to the teacher's work load. Priorities. Teachers have priority choices as to when and how material is presented and what type of instruction and implementation will enhance learning. Without clear objectives, priorities, and goals, too many areas may be touched upon and none studied in depth. This may lead to tension. Attitude. The teacher's positive attitude will improve teaching and also serve as example for students. How often do we see teachers teach subject matter rather than children? How often do we hear students complain that the material covered in class is not relevant to their lives? How often do students graduate without being properly prepared for employment or even an idea of what they want to do with their lives? Too often school is only a place to spend time until they reach 16, or simply a place to meet friends. A lack of positive attitude toward learning or the students can be a source of stress. Motivation. Teachers motivated to reach their students and to present material meaningfully spend untold extra hours in preparation. Motivated students work on projects far beyond the material presented in class. These extra-curricula activities may be meaningful, self-transcending, even enjoyable, but nevertheless may produce stress . To manage these various aspects and to provide a visual framework for action, a modification of Khatami's logochart is helpful. 2 I have presented it in special-education teachers' workshops to help them plan their time and programs. The chart demonstrates that choices can be made, priorities set, work loads controlled, and attitudes and motivations channeled to reduce stress. Example Let us assume that a teacher feels overwhelmed by having to meet with parents after school and write an individualized education program (IEP), in which she has to set up learning objectives and academic goals that have to be met by the end of the year. 43 LOGOCHART FOR SETTING REALISTIC GOALS Problem: Write an IEP on John. I (the teacher) have to review the material John has learned and what I hope he will learn next year. Planning this should take about 3 hours. Questions Automatic Self Authentic Self 1 ask myself (Usual behavior) (What I expect of me) Attitude: What do Complain. What a Complete the forms I think about this? hassle! A waste of and have a productive time to meet with meeting with parents parents and write this in detail in their presence Meaning: What is It's the law and I have This is the law but it my purpose/goal? to do this annually gives me a chance to in the presence of meet with the parents the parents and talk about John's progress and special needs Behavior/ Procrastinate I prepare and plan each Response: What item to be discussed and do I do about this? help them see what they can do to help John at home to improve his skills Once a teacher identifies what needs to be done, reasonable goals can be set and thus a stress-provoking situation can be reduced. In this manner teachers can plan their work in such a way that it meets the legal requirements and also incorporates the goals for individual students. Example of another problem: What about the teacher who is threatened with termination because of budget cuts? The "authentic self' responses may be as follows: Time Frame. Layoffs occur at the end of the school year. This allows time to update the curriculum vitae, prepare material to interviews, and apply for summer jobs and new employment. Work Loads. Value clarifications and commitment to curren job need to be explored, under the subject: what is my attitude toward the present and what do I expect of myself? Priorities. To complete this year efficiently and to plan fa next year as much as possible. Attitude ( v'Vhat do I think about this?). Is teaching really what I want to do? What is my purpose/goal? Is my commitment primarily to students? Or am I teaching because I like time off for family and travel? Can I use my talents more effectively in another type of employment? Under the threat of layoffs, finishing the school year may be difficult. A high level of performance to meet the needs of children may be stressful. Being authentic and clarifying personal values may enable the teacher to transcend personal feelings. Motivation (what do I do about this?). The teacher has a choice. Joining other teachers as a representative or as a member of a professional organization may enable individuals to harness their energies in a productive manner, for example 1) make a presentation to the legislature, the Board of Education, or the superintendent, and offer feasible suggestions for budget cuts; 2) incorporate clear and precise information into classroom teaching so that students will understand the issues. It is the intent of this article to identify components of stressful situations and indicate how these components can be charted, using the logochart, to clarify necessary actions and to "manage" stress. BIANCA z. HIRSCH, Ph.D. is president of the Viktor Frankl Institute of Logotherapy, California, a school psychologist of the San Francisco Unified School District, and on the clinical faculty of the University of California Medical School, Division of Behavioral and Developmental Pediatrics. REFERENCES: 1. Frankl, V.E. The Unheard Cry for Meaning. New York, Simon and Schuster, 1987. 2. Khatami, M. Logochart Workbook for Meaningful Living. Saratoga, California, Institute of Therapy Press, 1989. Lessons from Two Children Harald Mori This article reports my encounter with two children, both victims of cancer, who taught me how human beings are able to grow beyond their sufferings. Manfred Manfred was eight-and-a-half when I met him at the children's clinic of the University of Vienna. He suffered from pain in his thigh bone. The diagnosis was neuroblastoma, a cancerous tumor on the sympathetic nerve in the last phase. The prognosis was extremely poor. Our friendship began at the time of his first surgery which removed cancerous tissues from his abdomen. Then came chemotherapy and X-ray treatments causing exhaustion, insomnia, and constant nausea. Frequent medication, daily blood tests, and various other manipulations of his tortured body caused additional stress. For these reasons a Hickman catheter was inserted into his main vein to retain access to his blood circulation. Under these conditions we met and built up trust, especially through my being with him and my compassion for the way he was mastering his suffering. He increasingly responded to my efforts and talked to me about his pain and about himself and his home. I taught him to play chess, which became a meaningful activity for him. He showed interest in my experiences in the outside world. This severely sick child was able to bear his fate, to find an attitude to make the best of his possible choices. He showed no despair although he saw children die in the next room. He spoke of death, not with me but with a friend with whom he wanted -and thus was able -to play. During a high fever, caused by blood poisoning, he got up until his strength left him, and responded to questions until his voice failed and he could communicate only by movements of his eyes. He demonstrated what logotherapy calls self-distancing and self-transcendence. We adults need to realize and to learn from the incredible abilities of a child. Manfred rarely spoke to me about his illness, but when he did it was without selfpity and without attempts to arouse pity, but fully trusting his ability to regain health. I promised to take him, after his release from the hospital, to the technical museum and to visit him at the farm of his parents, 60 kilometers from Vienna. These expectations testify to Manfred's capacity for self-distancing because he was able to imagine what he would do when he was well again. He made plans and visualized new possibilities. His ability to self-transcend can be seen from the following incident: During one of Manfred's frequent periods of severe nausea I told him about a little Irish setter whose mother had died shortly after its birth. A friend of mine, a veterinarian, had taken it in and nursed it around the clock, not knowing if she could save it. Manfred listened to the story of the little sick dog with intense interest, the story of another living creature fighting for its life. Manfred's nausea disappeared, he transcended his own suffering, and showed continued interest in the fate of the dog, feeling that he, too, could be nursed back to health. It may seem questionable that an animal can serve as a model, but I believe that children who like animals have phenomenological access to pets. At one time medication caused Manfred to lose almost all his hearing, and one of his kidneys had to be removed. When I saw him in the summer of 1987, after I had been on a month's vacation, I was sorry to hear him say that he needed a hearing aid because he could not hear me. But he did not dwell on this problem. Rather, with the unconditional joy of a child, he turned to the presents he had received for his ninth birthday. That summer he received a bone marrow transplant and had to remain for five weeks in a sterilized room, suffering the pain of frequent bone marrow punctures, no contact with others, and having difficulties in learning to hear again -all this Manfred experienced and survived. Of course he went through periods of depression, but he used the defiant power of his spirit to give us adults a shining example of how suffering can be mastered. At Christmas Manfred was sent home, greatly improved and with an uncertain prognosis. I saw him when he came to the hospital for infusion of red blood cells and platelets. At present he attends school, participating in all activities except sports. Playing chess is a meangful hobby. He is well liked by his classmates and teachers -not because he was sick but because he defied his suffering and held his own among his classmates. More than two years after onset of his sickness he leads a lite no different from his friends. His will to life, his capacity for self-distancing and self-transcendence has played a significant role in his recovery. It was fascinating to see how a nine-year-old can find positive attitudes in a negative situation and try his best. Nurses of the hospital have passed on to me Manfred's much appreciated words when he wanted to phone me: "Over there, I have a friend!" Anna In the summer of 1985, six-year-old Anna complained about a sore throat, a week later her parents noticed blood in her saliva. The lymph nodes in the throat area were swollen. The diagnosis was lymphoblastic leukemia -a cancer leading to death within four months, if untreated. Her treatment was similar to Manfred's: strong Xrays and medications, and frequent bone marrow punctures. In November 1985 the cancer went into remission, with a 70% chance it would be lasting. Therapy with X-rays and medication continued for two years. In October 1987 the feared recurrence occurred and she was sent to the hospital where I worked, for a bone marrow transplant. Before her illness, Anna had a pleasant childhood, went horseback riding, learned ballet dancing, and enjoyed going to school. She continued these activities during her remission. She was a good student and had a lovable personality. In January 1988 she was prepared for the bone marrow transplant . For 37 days she was kept isolated in a sterile room with only the staff and her closest relatives allowed in, and then only in sterile clothing, gloves, operating cap and mask. The treatment in these surroundings meant great physical and psychological stress, pain, and nausea. She knew that the previous treatment had failed. I admired the girl who showed self-control, rare even among adults. Her personality was stable, her outlook positive. Her mother once told me: "Anna comforts us all, me and the family. She gives us more hope than we can give her. She is incredibly strong." Indeed, Anna's will to regain health was unconquerable. "I know I have cancer," she said, "But I also know I shall get well. I still have so much to do." Once I asked Anna how she felt in her isolated room, and she answered: "Yes, I've been here a long time, but other children have it much worse." This from a child who hardly was able to sleep and could see her mother only hidden by an operating mask -I could hardly imagine anyone worse off. What an achievement for a child to spontaneously express such thoughts! Her mind was on her future. "I want to get going," she told me. "I want to be promoted to the next class, not repeat my grade. I don't want to be left behind." When I asked her how she was doing with her sickness, she answered (and these are her words): "Every person has to go through a test in life, some harder, some easier, some last longer, some shorter. I've passed the test." When she finally was permitted to leave the hospital, I helped her clean her room. I asked her what we should do with the Mickey Mouse magazine. She said: "We'll leave it here and write on it: For the next child." Who can still say that children mostly think of themselves? On the day of liberation she realized experiential values for the next child. She immediately went back to school, and remained one of the best students. She had studied in the hospital, and was further ahead in school work than her healthy classmates. She resumed her riding and swimming lessons. When she went to ballet school one could see the tube of the Hickman catheter under her tights. She knew how to bear her check-ups, follow-up treatments and complications. But her trust in the future, her hope, her will to live, her will to meaning remained unbroken. She continued to live at the brink of death. The count of her white blood cells never rose to more than one-tenth of normal. During the last days in August we sat in the hospital garden, talked, and played together. Two weeks later Anna left her tortured body. As Viktor Frankl expressed it in his yet untranslated book, Homo Patiens. "Where all words would be too little, every word is too much." HARALD MORI is a medical student at the University of Vienna and assistant to Dr. Frankl in his University lectures. 49 Self-Transcendence in Marital Therapy Jim Lantz and Karen Harper Almost 60% of all marriages in the United States end in divorce.9 Approximately three of every five children will experience parents divorcing before they turn eighteen. 2,9, 1o The divorce rate has climbed rapidly in the 1980's and there is no evidence that this trend will be changing i11 the near future.2,7.9.10 One reason for this high divorce rate is that we are formally and informally taught inadequate philosophies about marital life, and as a result are ill-equipped to make marriage succeed. 1,2,6,7.a,9. 10 This article outlines two inadequate yet prevalent marital philosophies, and an alternative. healthy and more useful philosophy of marriage based upon Frankl's3 .4, 5 concept of selftranscendence. Awareness of these different marital philosophies may be useful to therapists who wish to help troubled marriages. The Narcissistic Marriage In the narcissistic marriage both partners get married so that the other will take care of him or her, and meet all needs. Both members feel a sense of entitlement. Each feels as the center of the universe, around whom everything should revolve. Neither desires to give to the other, and when such giving occurs, it is a form of manipulation to promote more effective taking. In no way does it resemble true giving for the sake of the other. 1,6 Some narcissistic marital couples use anger and assault as a way of controlling the other. 1 Threats, rage, and physical attack are used to "force" the other to "give" and take care of their own needs. Or they use depression, sadness and a show of apparent weakness to "trick" the other member into meeting these needs by pretending to be inadequate and/or "sick." 1 Whatever the method, the marriage fails to provide either partner with an enjoyable, meaningful, and satisfactory experience of human intimacy.1,6 The Social-Exchange Marriages In the social-exchange marriage, the partners believe that marriage is a social contract in which both members should "give and get" at an equal rate of exchange. It is an equilibrium model in which no more is given than received and no more received than given.6 The partners seek a "balance" of giving and getting that is "fair" and "equal."1,6 There are two major problems with the socialexchange model. The first can be called the procrastination problem. 1,6 Both members of the marriage are willing to give as much as they receive but each wants the other to "start first." As a result neither gives anything. Each waits for the other to give first. This can last a long time as both "wait it out."1,6 Such marriages can last for 30 or more years while both practice their procrastination skills. 1 The second problem with the social-exchange marriage is the "accounting" problern. 1,6 Both members put a great deal of time and energy into "measuring" and "counting" how much they and their partner have been giving.6, 10 In this kind of marriage, anxiety and obsessive-compulsive symptoms rush in to fill the existential vacuum which results from the effort that the couple puts into counting rather than loving. 1-6 The Self-Transcendent Marriage The healthy marriage is a self-transcendent marriage. 1,6,7 Awareness and discovery of a sense of meaning in marital life occurs reactive to the selftranscendent relationship with the other.3,4,s,s This relationship is neither narcissistic nor a form of social exchange. It is a connection with the partner resulting in a feeling of communion.3,5 ,8 This self-transcending concern for the partner paradoxically results in a more meaningful and strengthened sense of self.1,3A.5,6 Andrews1 points out that the successful marriage is one in which both partners consistently attempt to help the other "win" in both life and marriage. In Frankl's3 terms, this is self-transcendence. This concern for helping the other "win" is very different than the focus upon "winning over" the partner in narcissistic marriages or the focus on "having a tie" in social-exchange marriages. 5 l Helping Couples Change From a logotherapy point of view, helping couples change may be most effective when it is done in premarital therapy.6.7, 10 Logotherapeutic activities such as Socratic questioning, 5,7 therapist reflection on interactional patterns, and provocative comments7,8 can be used to help the couple develop awareness about the kinds of relationship problems they may have in the future. In ongoing marital therapy, the same treatment can be used to help the couple identify and make use of the selftranscendent "marital meanings of the moment" that occur during the time of the therapy.1,6.7,8,9 JIM LANTZ and KAREN HARPER are faculty members at The Ohio State University College of Social Work and logotherapists at The Worthington Marital Therapy Institute. REFERENCES: 1. Andrews, E. The Emotionally Disturbed Family. New York, Jason Aronsen, 1974. 2. Brothers, B. "Breaking Even." Voices, 22(2), 1986. 3. Frankl, V. Man's Search for Meaning. New York, Simon and Schuster, 1959. 4. __. The Will to Meaning. New York, New American Library, 1969. 5. _______. The Unconscious God. New York, Simon and Schuster, 1975. 6. Lantz, J. Family and Marital Therapy. New York, Appleton-Century-Crofts, 1978. 7. . An Introduction to Clinical Social Work Practice. Springfield, Charles C. Thomas, 1987. 8. _____. "Franklian Family Therapy." International Forum for Logotherapy, 10(1), 1987. 9. Nichols, W. Marital Therapy. New York, Guilford Publications, 1988. 10. Zuk, G. Process and Practice in Family Therapy. New York, Human Sciences Press, 1986. Assisting Caregivers of Alzheimer's Victims Joseph Graca and Dale Archer In July, 1988, the VA Medical Center in Knoxville, Iowa, opened an Alzheimer's Day Care Center (ADCC) for Veterans with Alzheimer's Disease or related disorders. It also provides respite relief for the caregivers, monthly support groups, and monthly home visits by a nurse and a psychologist. The ADCC emphasizes the application of logotherapy principles for Alzheimer's victims and caregivers. Overview of Alzheimer's Disease Alzheimer's Disease is a type of dementia. Dementia is an acquired persistent impairment of intelligence. At least three of the following areas are impaired:language, memory, visuospatial skills, personality/emotions, and cognition. 1 While numerous diseases can produce dementia, an estimated 50 to 75 percent are of the Alzheimer's type. 6 A conservative estimate is that more than one million persons in the United States suffer from this disease. The number of cases is growing rapidly due to the aging of the overall U.S. population. Significant advances have been made in our understanding the disease but there is presently neither a cure nor effective treatment for delaying the disease. It begins with difficulties in memory , and inevitably results in a profound loss of cognitive functioning and the inability to provide for one's daily needs such as eating and toileting. Difficulties in memory include lower ability to learn new information, decline in abstract reasoning, and errors in social judgment. Problems with naming objects is often the first sign of language impairment. Visuospatial functioning also is affected, resulting in difficulties with such tasks as driving. Interest in one's personal hygiene often declines. There may be a loss of social graces and social interests. In the early stages, victims may be acutely aware that something is wrong with their mental functioning, and often become apathetic, irritable, distrustful, or accusatory, with bouts of sadness and grief. In the middle stages of Alzheimer's Disease, memory for past as well as recent events becomes impaired. The victims may no longer remember the names of family members nor significant events in their lives such as vacations, marriages, or deaths. They have difficulties comprehending what others say and expressing their own thoughts. They are unable to concentrate and to initiate purposeful behavior. Their difficulty in daily living increases. They may no longer recognize faces. Personality functioning regresses and they may have outbursts of anger and poor impulse control. Apathy and hostility may become more pronounced. In the final stages of the disease, language and memory functioning decreases profoundly. The victims need total assistance with activities of daily living. They become unresponsibe to their surroundings except to direct stimuli. Death usually results from a fall or systemic illnesses such as pneumonia. The course of the disease from the early stages of memory loss to death can take anywhere from two to 15 years. In the early stages, caregivers witness the psychological and emotional death of the loved one. As the disease progresses, they watch the patient die before their eyes. In essence, they are forced into a grieving process often long before death occurs. The Caregiver's Plight Caring tor a loved one with Alzheimer's Disease is a stressful experience. Caregivers are affected physiologically, psychologically, and noetically by the stress of caring. Primary stressors for caregiver and victim include the erosion of financial resources, loss of emotional support within and outside the family, loss of independence, and social isolation. The Alzheimer victims' dependency on the caregiver becomes a constant source of stress. Both are often in emotional turmoil as they experience bewilderment, frustration, guilt, depression, and anxiety.5 As the patient's needs for assistance and supervision increases, caregivers often feel pressured to quit any outside work and social activities. The mounting stress often has a profound impact upon the caregiver's own feelings of self-worth and sense of meaning and purpose in life. The caregiver role can dominate their entire life and thus become the only source of meaning. Caregiving becomes the standard to judge their selfworth. In essence they live to care for their loved one. If the caregivers do not receive assistance from family, friends, or social services, the stress of caregiving can result in their physical or emotional breakdown. This results in the placement of the Alzheimer victim in a nursing home or other structured settings because the caregiver is no longer able to meet the needs of the patient. Once the patient is placed, caregivers often experience an existential vacuum because their primary source of meaning is no longer available. Contrary to many health-care workers' views, caregivers may continue to experience frustration, guilt, and depression long after the loved one has been placed in a nursing home.7 One of the most effective approaches in reducing caregiver stress is to involve them in a support group. 7 Such groups provide recognition that someone cares, a forum for problem solving, and a resource for information on financial, legal and medical issues.5 Other sources of help are day-care services, and brief inpatient hospitalizations to provide respite from the caregiver role. Individual counseling can also be effective in alleviating depression, guilt, and anxiety while teaching the caregiver effective stress management techniques. 5 Application of Logotherapy Application of logotherapy principles are helpful in understanding the effects of the Alzheimer's Disease process upon victims and caregivers. We have applied these principles in three areas: •Discovery of meaning in tragedy. One of the basic tenants of logotherapy is that "life can be meaningful. ..through the stand we take toward a fate we no longer can change."2 Alzheimer's Disease is a terminal illness. In its early stages, both caregivers and victim are acutely aware of the disease's course. They witl often struggle with feelings of hope and despair. It is essential in the early stages, that the patient take a stand toward the disease process. But caregivers are also victims of this process and should develop a meaningful stand toward it. With support and understanding, the Alzheimer victim and the caregiver can take a stand of acceptance without false hope and without overwhelming despair. As one caregiver said in our support group, "It's like he is dying before my eyes. It isn't easy for me, but it is a labor of love. God has forced me to look at what is really meaningful in my life." •Maintenance of life meaning. It is essential that caregivers maintain other sources of life meaning. They must experience values outside the caregiver role. The importance of maintaining a parallel value system versus a pyramidal value system, clearly applies. 4 As Levinson pointed out,3 many American women find meaning primarily within the marriage relationship, and often rely on few extraneous sources of meaning. This task of finding outside meaning represents a challenge for them, yet is congruent with the concept that caregivers must take care of themselves to effectively care for the loved one. Otherwise they also become victims of the disease process. Many times caregivers tend to neglect vocations, friendships, social interests, and hobbies. It is important for them to maintain these contacts and interests as a relief from stress and as sources of meaning. These sources of meaning may come from social support services such as day care and support groups as well as from family and friends. As one caregiver, who still had a part-time outside job, said, "I don't make any money on my job when I add up the cost of my paying someone to care for my husband. But at least I can meet people and feel I am appreciated for what I do." Also, drawing from other sources of meaning becomes crucial once the Alzheimer victim is placed in a structured setting and the caregiver is faced with loss of meaning provided by the caregiver role. Removing this role can lead to an existential vacuum. •Self-transcendence. Logotherapy can assist caregivers by motivating them to transcend their current situation by helping others. Some professionals find it difficult to accept that caregivers who are experiencing significant stress and behavioral problems with their loved one, can also find the time and strength to reach out and help other caregivers. Our clinical observation is that transcending one's situation in reaching out to help other caregivers is one of the most effective approaches in assisting caregivers. Our support-group members often comment that they feel uplifted whenever they help one another. One woman caring for her husband in the advanced stages of the disease said, "I feel satisfaction when I can help someone cope with a problem. My suffering taught me a lot about Alzheimer's Disease. Things you don't read in the books but are important to know." Caregivers as well as the Alzheimer victims are faced with a profound noetic challenge. Caregivers who are able to confront the challenge are better able to maintain self-esteem, manage caregiver stress, and continue to experience a sense of meaning and purpose in life. JOSEPH GRACA, Ph.D., is a clinical psychologist at the VA Medical Center, Knoxville, Iowa. DALE ARCHER, Ph.D., is a former psychology Intern at Knoxville and presently is a clinical psychologist at St. Mary•s Medical Center, Evansville, Indiana. REFERENCES: 1. Cummings, J. and D. Benson. Dementia: A Clinical Approach. Boston, Butterworths, 1983. 2. Frankl, V. Psychotherapy and Existentialism. New York, Simon and Schuster, 1967. 3. Levinson, J. "Existential Vacuum in Grieving Widows." The International Forum for Logotherapy, 12(2), 1989. 4. Lukas, E. Meaningful Living. New York, Grove Press, 1984. 5. Mace, N. and P. Rabins. The 36-Hour Day. Baltimore, The John Hopkins University Press, 1981. 6. Martin, R.L. "Update on Dementia of the Alzheimer's Type". Hospital and Community Psychiatry, 40(6), 1989. 7. Zarit, S., N. Orr, and J. Zarit. The Hidden Victims of Alzheimer's Disease: Families under Stress. New York, New York University Press, 1985. The International Forum for LOGOTHERAPY Journal of Search for Meaning