"KEY WORDS" AS A GUARANTEE AGAINST THE IMPOSITION OF VALUES BY THE THERAPIST Elisabeth Lukas  1  
ADAPTIVE MODEL OF THE ADDICTIVE PROCESS Mitchell Young & George E. Rice  8  
RAISON D'ETRE IN RECOVERY: SOBRIETY, SERVICE AND SENSE OF PURPOSE Bill Asenjo  17  
PSYCHOMETRIC PROPERTIES OF THE PURPOSE IN LIFE TEST WITH A SAMPLE OF SUBSTANCE ABUSERS Jodie L Waisberg and Meyer W. Starr  22  
LOGOTHERAPY IN TODAY'S MANAGED CARE CLIMATE Ann Graber Westermann with Helen Gennari  27  
THE SURVIVAL OF LOGOTHERAPY Ingeborg van Pelt  30  
MEANING IN LIFE AND ADJUSTMENT AMONGST EARLY ADOLESCENTS IN HONG KONG Daniel T. L Shek  36  
INTEGRATING LOGOTHERAPY INTO A COURSE IN ETHICS Eileen E. Morrison  44 I.. 
TOWARDS AN INTEGRATIVE MODEL OF MEANING-CENTERED COUNSELlNG AND THERAPY Paul T. P. Wong  48  
BOOK REVIEW  57  
RECENT PUBLICATIONS OF INTEREST TO LOGOTHERAPISTS  58  
STEPHENS. KALMAR~ A TRIBUTE  63  
Volume 22. Number 1 Spring 1999 


The International Forum for Logotherapy, 1999, 22, 1-7. 
"KEY WORDS" AS A GUARANTEE AGAINST THE IMPOSITION OF VALUES BY THE THERAPIST 
Elisabeth Lukas 
As a therapeutic approach that provides meaning and value-oriented accompaniment in all aspects of life, logotherapy is not only applied to anxiety syndromes, affective disturbances, addictions, sexual aberrations, and personality and behavior disturbances. It can also support young people in their search for themselves or their efforts to reach maturity, or help the elderly to look back on their lives and prepare for departure. It can guide lovers and family members through conflicts, and help working people as well as the unemployed to cope with the demands placed on them, whether too great or too little. It can even raise up those who are bent under their cares and resentments, and lead people who have lost their spiritual home back to their ideal roots. 
Logotherapy can do all of this; yet its only medium is language. If we disregard its content for the moment, it is a therapeutic/pedagogical/ philosophical/pastoral dialogue form. The critical examination of patients' statements does not mean that the therapist gives a lecture. Logotherapy takes the form of a dialogue, an exchange of ideas that entwines itself around the patient's statements in a joint effort to reach a consensual understanding of a piece of truth. It aims at helping patients better understand the meaning opportunities that await them in the world. For this purpose, the therapist introduces ideas, helps to think through possible consequences, and stimulates the patient spiritually. 
The danger exists however that the therapist could make judgments on what is right and wrong in the lives of the patients and impose the therapist's own value standards on them. Frankl has often stated that the external imposition of values on patients would totally contradict his intentions. 
Looking for "Cues" 
If we assume the conscience is a sort of "meaning organ", then it is comparable to a prompter, giving us "cues" to tell us in which directions we should take actions in order to seize the opportunities for the meanings demanded from us. Each situation demands that we apply a certain value standard. But the values against which this standard is calibrated are anchored in such a deep layer of our being that we can do nothing but follow them unless we wish to risk being untrue to ourselves. 
In light of these considerations, an optimal success through therapy would mean that the patients reach the stage where they could do nothing (or wish nothing) but follow their conscience, whose standards are based on their innermost value standards. Whenever we work with people, especially with persons who are suffering emotionally, it is important to listen for a cue, a key word that will unlock the chamber where the hidden cares are kept. When the key word opens the door, then the values shine through, and the voice of their conscience whispers more audibly. This allows the therapist to adapt arguments to prompt the patients to correct their behavior and attitudes that are in line with their own convictions. The logotherapist has to listen for signals from the deepest (or "highest") level of the patients; to listen to what the spiritual person is saying. 
The Problem of Ambivalence 
Ambivalence means liking and disliking contrary possibilities. Patients do not formulate a clear yes or no in their hearts. The resulting long-term inner state is extremely unpleasant, since all activities undertaken in this connection are overshadowed by a lack of a clear sense of purpose, so that energy is blocked. 
Here is an example: an acquaintance offers Marie, a young woman in Sicily a job in a pizzeria in Munich. She is a widow with a small child, and has no work in Sicily. If she does not accept the job, she will pass up the chance to earn an adequate income and offer her child better opportunities. If she goes to Munich, she will have to leave the child with relatives and live on her own in a foreign city where she does not speak the language. Both alternatives seem bleak. Finally she heeds the urgings of her acquaintance and moves to Munich, where she sits and cries all day. If she had decided to stay in Sicily, she would have reproached herself for turning down a good source of income. Unhappiness is inevitable in either case. 
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How is therapeutic help possible? It is not permissible for the therapist to make value judgments that point in one direction or the other -at least not until the therapist has decoded which of the alternatives "barely tips the scales" in favor of meaning for the patient. Who tells the therapist?--the patients themselves. 
I asked Maria: "What actually caused you to choose the pizzeria in Munich?" Her answer: "In Sicily there is severe unemployment. I would like to have enough money so my son can receive the best possible education to find good work later." I then asked what she could do for her son if she were to return to Sicily. She: "Not much. Apart from my presence, I couldn't offer him much." "But isn't your presence something very precious for the child, too?" She: "Yes, of course, but it can be replaced, because my son is very close to his grandparents, aunts, and cousins," 
From this dialogue we can gather that there is a nuance that tips the scale in favor of Munich. Maria sees a good education for her son as more valuable than her motherly presence, which she even calls "replaceable." After careful listening to Maria, I reinforced this tiny hint of the greater value of one alternative so she could make a more unequivocal affirmation of her decision. I surmise: "So you believe that your son will suffer little and profit greatly in the long term through your absence because you are earning money. And you think that this combination of suffering little and profiting greatly can only be reached through your great suffering here in Munich?" Maria reflected and agreed. "Why aren't you proud of yourself then instead of crying?" I challenged her. "Why don't you say to yourself every day in the pizzeria when you are peeling potatoes and vegetables; "I'm doing this for you, my son!". Later, when you are learning vocabulary lists in your rented room, why don't you say again, "I'm doing this for you!". Later still, when you pick up your salary from the bank, say, "This is for your future, my son. Earned through your mother's efforts... " 
Almost any mother will breathe more easily on hearing such words. Maria saw that she was on the right path. Here, "right" refers to her own convictions and not to mine. Ambivalence can be resolved only through intensive discernment of every tiny nuance, every small hint of "moreness" that speaks in favor of one alternative over the other in terms of values. Do the child's future opportunities outweigh the mother's present fears? Yes, they do -the clear yes has been regained by Maria herself. 
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The Problem of Non-acceptance 
Some people react to every challenge of fate primarily with a rebellion that sooner or later hardens into an attitude of stubborn refusal. Those who are mired in a state of stubborn protest can be moved to adopt an attitude of flexible acceptance only if they abandon their perspective of personal deprivation and turn to a viewpoint that is receptive of values. In such cases, the therapist must intensify the perception of people who constantly protest and refuse to accept something -but the therapist also has to make sure that no externally imposed values are pushed into the field of perception. This again demands that we cautiously grope our way in the direction of the signals sent out by the patients 
An example: Carla was separated from her parents as a child during the chaotic period after the war. She lived in a convent children's home until her mother was found. Her father had been killed in the war. At the age of 30, Carla attempted to join a religious order but was not accepted. Her wish was dismissed as a passing whim or a spiteful reaction following an unhappy love affair. 
Carla was deeply insulted by this rejection and would not get over it. She felt that the religious order had failed to recognize her religious motivation, and had chased her away like a stray dog. She was frozen in silent protest. 
During our conversations, I took up this lack of recognition of her motivation. "What would you honestly say you were looking for in the convent?" I asked. "Security," she answered simply. "You are bitter because you did not get what you were looking for?" I persisted. "Does that surprise you?" she retorted. "Well," I answered, "actually you got security, but years earlier, as a child. Back then, when you were suddenly alone in the world, a convent gave you shelter. Who knows what would have become of you? The convent also searched for your mother. So you would be within your rights to say: 'What I was looking for in the convent at the age of 30 was granted to me a child. The fact that I was once in a convent, and secure, can never be taken away, not even by a Mother Superior.'" Carla laughed. "That is a liberating thought!" she called out, "Of course one could also look at it that way!" And she added a little archly, "Perhaps being sheltered in a convent twice would have been too much of a good thing, what do you think?". I had no trouble agreeing with her. 
The following example is more tragic. Michael was in a coma for five days after a motorcycle accident. Thereafter, he was seriously disabled many bodily movements were no longer possible. The work to regain movement cost him unimaginable efforts for microscopic progress. He 
4 
was desperate. What is more, he had an irrational grudge against his parents who had bought him the motorcycle. It had been second-hand, and Michael was obsessed with the notion that the brakes would have worked better on a new motorcycle -if his parents had been less interested in saving money. This was his way of compensating for his own share of the blame because according to the police report Michael had been speeding on a bad road. 
It was understandable that Michael did not wish to accept his situation. On the other hand, it would remain unendurable if he did not achieve final acceptance, and in fact he harbored a desire to die. All of his hopes were gone. For many hours I merely listened to his aggressive complaints. I was waiting for something, but I did not know what. One afternoon it came. It was a memory of a plan in the past to attend a climbing course. Shortly before his accident he had obtained brochures from several schools in the Alps that offered such courses. I leafed through them with him. Sitting in his wheelchair, he could hardly hold them steady. The photographs of mountain climbers daringly scaling treacherous cliff faces set his cheeks aglow. Fantastic!" he murmured to himself, "Awesome!". That was my cue. "Oh yes," I agreed, "Mountain climbers master great challenges. But that is nothing compared to what you are up against. The rock that you are climbing step by step in physiotherapy 1s higher than the highest mountain in the world. No one has reached that peak before you, because no one has been in exactly the same situation. The steep walls before you seem insurmountable. No steps, no handholds in sight. But have the courage to climb anyway! You wanted to learn to climb -now you have a chance as never before to master a great climbing challenge! Prove to yourself that you won't surrender. Fight your desire to quit, carry the flag to the top and plant it on the peak of your triumph over weakness and infirmity." The young man closed the brochure in his hand and pressed it to his chest. "That's a way I could imagine giving myself another chance," he whispered to himself, "but will I make it?" I got up and bent over to him. "You are climbing with an invisible rope which holds you up, I'm sure of that." With these words I left him to his inner images. 
Since then Michael has been on the road to improvement. He no longer mentions the wish to die and has come to terms with his parents. He manages his daily exercises with relentless energy. And he always keeps a brochure from a climbing school in his room. He has become one of the most admirable "climbers" I know. 
In both the above cases, people moved forward from frozen attitudes of protest to more flexible postures of acceptance. It was not the power of persuasion that made this possible. I did not impose the value 
5 
Judgment on Carla to see the convent as a place where security can be found, or the enthusiasm for mountain climbing as an act of Michael proving himself. I read these from the patients' own statements and used them to heal spiritual wounds. I injected them with that which, in logos terms, was already in them. 
The Problem of Indifference 
Among the least promising therapeutic undertakings is working with people who are walled in by indifference. Whatever the approach taken, they do not respond spiritually because a hard shell of ignorance or even brutality surrounds the soft core of their inner being. They established this shell to protect them in earlier phases of their lives, and it remains with them. But how can they get rid of it? There seems to be hardly any effective remedy. Those who ignore their fellow human beings, lose their sense of awe, or break all rules of decency, increasingly exclude themselves from human society and then need an even thicker shell. Soon they don't have contact with their inner selves, let alone with others. The gentle stirrings of the spirit are left to waste away in a "value vacuum" If we are fortunate, however, the shell has cracks in which the deep human longing for a meaningful existence gathers. By driving a wedge in at these places, we can occasionally chip away a piece of the shell and create space for new sensitivity to develop. 
Julia, a rather obese patient, complained incessantly. Her crisis had been triggered by a company excursion, during which she had quarreled with her supervisor. Because her colleagues had taken his side, she had lost her temper and threatened to file suit for slander. As a consequence she was dismissed after ten years of loyal employment, or so she claimed. 
I asked her to describe the excursion in detail. The program had been planned by the supervisor: a bus trip, a walk up to a recently renovated castle on a hill, lunch at the castle, chamber music in the concert hall of the castle, a walk down the hill to the bus for the return journey. A pleasant program. "Very pleasant!" said the patient scornfully. "We had to trudge all the way up the stupid hill. How can anyone think up such a stupid trip? The route was stupid, the supervisor was stupid." "Did everyone on the trip think that?" "No", she screamed in my face. "The others hopped from stone to stone like young deer while the sweat was pouring into my eyes and my blouse was clinging to me. I could hardly get my breath. It was pure torture!" "For you!" I said emphatically. "Yes, for me " "For you, and not for the others." I repeated. Julia was silent tor the first time. "Could it be your obesity that caused your problems?" "And what if it did" she grumbled in a more moderate tone. "I'm just too 
6 
stupid to control my eating. I've tried all kinds of ways and have never stuck with it. I just can't." 
The cat was out of the bag. "You're angry about your past inability to lose weight", I said, summing up the situation. "And that makes you malicious. The route is stupid. The supervisor who planned it is stupid. You yourself are stupid in your eyes. And getting fired is the most stupid thing of all. Anger makes you ignorant. You ignored the fresh forest air, the beauty of the castle, the concert, and the friendly organizers. You were too busy fending off your real problem." I got out paper and a pencil. "Now correct what is not right in your soul and in your thoughts. Write down: 'The route to the castle was inspiring. My supervisor chose it with wise foresight. I myself am a nice woman with all kinds of talents. The only bothersome thing is my obesity. However, I have a new opportunity to fight it. My dismissal is a chance to change my eating habits. I will use the time I now have on my hands to go on a diet. After this I will look for a new job and nothing in my life is stupid anymore.' "You want me to write that?" she asked in astonishment. But she did as I told her and took the page home. And the result?--Unfortunately, not a slim person; but nevertheless something positive came of it. When she began her next job she wrote her former supervisor a letter of apology and sent me a copy. In it she wrote, " ... you planned a wonderful excursion with a completely suitable route. It was my fault that I couldn't jump like a young deer. Forgive me." Now, in a certain sense the patient did manage to jump in the end, namely over her own shadow and over her emotional defenses. 
It is hard to help people who ignore and trample on all that is valuable in their surroundings. If it is at all possible, then it is so only through persistent questioning of their justifications for demolishing their "Will to meaning". 
ELISABETH LUKAS, Ph.D. [Geschwister Scholl Platz 6, D-82256 Furstenfeldbruck, Germany] is Director of the South German Institute of Logotherapy and teaches logotherapy at the University of Munich. 
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The International Forum for Logotherapy, 1999, 22, 8-16. 
ADAPTIVE MODEL OF THE ADDICTIVE PROCESS 
Mitchell Young & George E. Rice 
The disease model of addiction has long been the predominate paradigm used in addiction treatment centers. This model supports the notion that addiction is a result of the addictive qualities of a particular substance. The role of emotional pain and suffering is often overlooked in an attempt to just stop drug or alcohol use. The present paper explores the adaptive model of addiction as opposed to the disease model and discusses the role of pain and suffering in addiction development and recovery. 
Disease Model vs. Adaptive Model of Addiction 
The adaptive model of addiction, as put forth by Alexander, suggests three major differences between the disease model and adaptive model. 1 ·2 These differences center around the role of choice in addictive acting-out and, perhaps more important, emphasize the role of choice in recovery and healing. 
Sickness or Maladaptive Choice 
The disease model assumes that people are sick. In traditional treatment centers patients are told that they are not responsible for their alcoholism; they have a "disease" like having pneumonia, chicken pox, or tuberculosis. Many health professionals defend this aspect of the disease concept by saying that this allows alcoholics to displace responsibility for the shambles of their lives and regain at least a minimum of self-respect. 
The adaptive model of addiction builds upon the premise that addicts are not sick but rather are responding to the limits of their abilities, perceptions, and environment.1·2 They are held responsible for choices that are maladaptive and have serious consequences. The adaptive model posits that the addict has failed to become an integrated adult; has failed in becoming a part of the community; lacks selfreliance, social competence, and acceptance. The addictive acting-out is 

8 
seen as an alternative adaptation (albeit maladaptive) and attempt to find meaning, purpose, and presence in the community with the aid of alcohol, drugs, or some other addictive behavior. 
Problem or Symptom 
A major difference between the two models is related to cause and effect. The disease model sees the addicts' problems as caused by the addictive properties of their drug of choice, while in the adaptive model the addictive acting-out is seen as a result of problems, mainly lack of integration into the social fabric, leading to social ostracism, despair, mental disintegration, and perhaps even suicide. 1·2 
A common metaphor used to demonstrate the difference between the two models is that of an iceberg. Only the tip is visible above the water and represents addictive behaviors of which there may be several. Traditionally, treatment centers have focused on the visible portion of the addictive process, ignoring issues below the surface The adaptive model's focus concerns the major portion of the iceberg below the line, representing lack of integration and other problems the addict experiences before access to addictive substances. 
Before substance use, addicts display an inability to use and benefit from their emotions. They are unable to experience and show empathy for others. They are emotionally constricted, unable to experience the full range of human emotions. This emotional dysfunction precludes their being able to construct a viable support system. Inept social skills and low self-esteem are also below the surface, causing feelings of shame and embarrassment. As the at-risk youth reaches adolescence, mobility increases and they become readily able to access alcohol and other drugs. The first experience of intoxication from alcohol, or the first "high" from marijuana or other drugs, provides a profound sense of well-being. It is this experience of well-being that attracts further use. The false sense of well-being is euphoric; this is the "high" being sought in repeated use. Of course, repeated use of alcohol and drugs begets chemical changes in the body and increased tolerance calling for greater quantities and eventual addiction. 
Powerlessness or Lack of Integration 
Another area of difference between the two models concerns control and exposure. The disease model postulates that addicts are out of control, powerless, unable to employ willpower or control their fate. But anyone who has worked with addicts can verify that active addicts have tremendous willpower and resources, tenaciousness, creativity, and ability to be successful in obtaining what is needed to feed their 
9 
addiction. The adaptive model states that lack of integration, lack of meaning and purpose, and social ineptness provide the risk factors, and the addictive behavior is merely a tool for a substitute meaning. 
Psychological Antecedents to Addiction 
Shedler and Block provide hard data to support the adaptive model. 10 Their study began with subjects three and four years old and followed them to age 18. These subjects were assessed on a wide range of psychological measures at ages 3, 4, 5, 7, 11, 14, and 18. Those subjects who at age 1 8 were frequent drug users (marijuana, alcohol, and other drugs) were clearly maladjusted as children. They were unable to form relationships, were insecure, showed signs of emotional distress, were emotionally labile, stubborn, uncooperative, likely to withdraw, and had low self-efficacy. Bowlby,3 too, found that anxious and avoidant infants and children continued to exhibit negative characteristics until adulthood. Troubled and dysfunctional children maintained or increased in maladaptive behavior. At age 18, frequent users were hostile, emotionally withdrawn, alienated from meaningful relationships, and unable to invest in productive activity; which typically means they were unlikely to find meaning and purpose in life. Also of note were findings that mothers of frequent users were cold, hostile, not responsive. critical, rejecting, and tending to shame their children. 
Emotional Numbing in Addiction 
Emotional numbing, another ubiquitous characteristic of adult addicts, starts in early childhood; and by adolescence the regulation of affect is a serious problem3• 7 0 Alcoholics and drug addicts use substances to escape emotional pain, not to "get high." Most relapses are caused by emotional stress, often anger, but relapses can also be caused by strong positive emotions. Addicts have forfeited the ability to respond to emotional cues, and are buffeted about by their emotional selves without understanding why they respond with addictive actingout. They often have "an inability to identify and verbalize feelings, an intolerance or incapacity for anxiety and depression, [and] an inability to 
"8 540
modulate feelings... 0 Emotionally healthy individuals use their emotions to guide them in decision-making. When the emotional system is dysfunctional, people lose their sense of direction and become confused and dispirited, opening the door to addicted behavior. 
Alexithymia is the inability to benefit from one's emotions. Flores views this as leading to the somatization of affective responses. 5 The person experiences sensations, such as physical pain, not feelings. "Such painful affective states call attention to the uncomfortableness 
10 
rather than to the ·story behind the feelings.' Such individuals are marked by their striking inability to articulate their most painful, bothersome, and important feelings. "5· P-191 This process is translated into somatic complaints and creates a sense of isolation, alienation, and craving, leading to addictive acting-out in order to medicate such uneasiness and to regain a sense of empowerment. 
Emotional numbing and alexithymia create a sense of isolation and prevent the development of intimate bonds. Addicts are loners, their addiction 1s their primary concern. They abuse those closest to them Addicts do not trust others; they are concerned that others will let them down. This is often caused by the addicts' unrealistic expectations. Alexithymic individuals blame others for their suffering, helplessness, and sense of confusion. Until addicts learn to identify, accept, and functionally deal with emotions, they are likely to continue addictive acting-out, 
Suffering and Addiction 
It is often stated that addicts will not begin recovery until they "hit bottom." The loss of a family, loss of a job, or a tragic accident caused by substance use may perforate the emotional numbness and defensive network. It is with the acknowledgment of the addiction problem that !ogotherapy may begin to be beneficial 
It 1s a tenet of logotherapy that meaning can be found in life not 
only through acting or experiencing values but also through 
suffering. That is why life never ceases to have and retain a 
meaning to the very last moment... what matters then, is the 
stand he [the addict] takes in his predicament.6 P-37 One of the most important predictors of long-term recovery is the addict' s ability to manage the tension inherent in intrapersonal and interpersonal interaction. 
The fact remains that the tension between being and meaning is 
ineradicable in man. It is inherent in being human, and therefore 
indispensable to mental well-being. 6· P-25 In his view, a lack of tension is as dangerous a threat to mental health as is too much tension. 
Tension is not something to be avoided indiscriminately. Man 
does not need homeostasis at any cost, but rather a sound 
amount of tension such as that which is aroused by the de
mand quality inherent in the meaning of human existence.6 • P 35 Recovering addicts realize that freedom is more than "freedom from" the addictive cycle; "freedom from" begets "freedom to" a commitment to reactivate the emotional system. This is most often accomplished by 
11 
· normalizing emotional pain and creating a new understanding of the role 
of suffering. 
This task is addressed at AA meetings in an understated and 
unconscious manner. Members of AA share their pain, suffering, trials, 
and tribulations. Newer members see that they can engage, 
acknowledge, and own their suffering with positive results. This creates 
a "kinship of common suffering." 5· P·246 This process reacquaints the 
addicts with the need for others, to have someone who will bear 
witness to their suffering. The outcome is often a new meaning for the 
suffering that has been experienced as a result of addictive acting-out. 
Suffering becomes an accepted part of the recovering addict's new self. 
Several sources maintain that the task of psychotherapy is to 
exchange neurotic suffering for real suffering. This is certainly true for 
addicts. They have been enmeshed in neurotic suffering brought about 
by the addictive process and addictive acting-out. To achieve and 
maintain long-term recovery it is necessary to engage real suffering; 
that is, to gain an understanding of the depth of the addiction. 
Addiction begins when one understands that some substance or 
process will lessen one's pain, offering a temporary refuge from 
suffering. The attempted escape from suffering brings neurotic 
suffering 
Evil, in all its forms, is created and perpetuated by our flight 
from suffering. In order to escape from the unacknowledged 
pain of childhood rejection, for example, we dismiss, condemn, 
or attack anyone or anything, which threatens to remind us of 
this wound. In turning toward our pain we deprive these ugly 
mechanisms and subpersonalities of the energy they need to 
survive. 4· P·26 
When addicts attempt to escape suffering through addictive acting-out, 
they are on a course doomed to failure. 
Empathy and Addiction 
When one loses the capacity for emotion, one losses the capacity for empathy and compassion. Interpersonal relationships are then characterized by form not substance; role play replaces genuineness; anger and defensiveness replace spontaneous self-disclosure. Colgrave states it well: "Our capacity for empathy is a consequence of our capacity to acknowledge and suffer our own wounds. Inasmuch as we deny a pain within ourselves, we are likely to be too defended from it to feel a similar wound in another. "4· p. 143 Many addicts in treatment acknowledge their awareness of being emotionally numb; they experience situations in which they know they should feel something for 
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another but do not. This tends to increase the gulf between them and others and increases addictive acting-out. It is the fear of our buried wounds, "fear of their being touched and perhaps painfully awoken into consciousness by another's actions" which keeps us defended against closeness with others.4• P 57 When we suffer our wounds, embrace them if you will, we are able to embrace another's wounds also. It is this process of empathy that gives recovering addicts access to others, and the possibility of close supportive relationships. Many addicts, well into recovery, are amazed with the new realization of how much they need other people in order to maintain their recovery. 
Support for Recovery Through Logotherapy 
Logotherapy's tenets may be the most effective re-orientation to insure long-term recovery. Addicts must learn that there are inescapable experiences and consequences for human beings; that emotional pain and suffering is part of the human experience. Through paradoxical intention, addicts are encouraged to experience their deep fear of emotion and suffering, freeing them of their catastrophic anticipatory anxiety of emotional pain. 
Addiction treatment centers need to encourage addicts to embrace their despair and emotional pain in a group setting. In this manner, persons experiencing or observing pain come to understand that it is through the experience of despair that they gain true hope. The presence of others also creates a sense of belonging and mutuality, helping the recovering addicts fit into the social fabric. 
Greenburg and Safran offer detailed support for Frankl' s insistence upon the discovery of meaning and acceptance of suffering. 7 They have shown the necessity of accepting and experiencing suffering if positive therapeutic change is to occur. Three aspects of their work show the inherent efficacy of logotherapy: 1) the importance of arousing affect, 
2) acknowledging emotion, and 3) discovery of meaning through emotional experience. 
Importance of arousing affect 
The cathartic experience of emotional expression, by itself, is incomplete therapeutically. Intense emotional expression is the vehicle to hidden information or new cognitions. "Lasting change comes about because people almost reflexively give meaning to their experience." 7· 
0 198 
The discovery of meaning through emotional experience provides the opportunity to synthesize the new material into a cognitive structure built around abstinence, non-addictive acting-out, or other more functional concepts. 
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Acknowledging emotion 
Many addicts believe that they cannot survive experiencing their emotions. As alexthymics they have little or no understanding of their emotional system, having worked for years to subdue it. When addicts do experience their emotional pain the results often are feelings of integrity and vitality, as if a burden has been lifted. This may be their first experience of the meaning of hope. 
This is what Greenburg and Safran call knowledge by acquaintance rather than knowledge by description. Knowledge by acquaintance is direct experience; knowledge by description is knowledge about something without the experience. To fully experience one's repressed pain and suffer one's suffering is a process of discovery and creation. Addicts discover what it means to feel, and they discover that they can survive the feelings without the expected catastrophe. 
When one faces the pain, however, certain feelings and 
meanings emerge that had been previously avoided. Accepting 
these feelings as truly occurring tends to deepen individuals' 
awareness of what is occurring, and informs them of what they 
want, are missing, or wish for; that is, the feelings are 
information... 1· P· 7 9 3 To begin to feel one's emotions, no matter how difficult, is the way to overcome alexithymia. The experience is paradoxical--that which has so long been feared offers salvation and new meaning. 
Discovery of meaning through emotional experience 
The emotional experience works in tandem with cognition to discover meaning. Meaning is not created by a search, but emerges from the experience itself. The emotional expression reveals new cognitive information that requires the formation of new concepts and discovery of meaning. This emotional/cognitive blend accounts for the strong "absolute sense of integrity that is experienced, and it is therefore remembered as a truly trustworthy experience ... it means that the trueness of an experience is such that it cannot be removed. "9 • P· 733 This accounts for the fact that many addicts, when they have a deep emotional experience in the therapeutic session, emerge with feelings of JOY, hope, and renewal--the sense of integrity is complete. Many mental health professionals have witnessed the beatific look of those who have Just experienced repressed sadness or grief. These individuals have been cut off from their past and their emotions, and both have re-emerged during the therapeutic session, hence feelings of integration. 
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Meaningful events are a blend of emotion and cognition. Most persons can remember exactly what they were doing when they first heard that President Kennedy had been shot, or the space shuttle Challenger blew up. The emotion imprints the cognition in an indelible manner. Memorable experiences are memorable because of their emotional impact. For those who are alexithymic, life becomes a dreary monotonic landscape without memorable markers. 
Summary 
An adaptive model of addiction offers a congruent understanding of the process of addiction development, behavior, and recovery. Such a model also accounts for the various addictive behaviors, not limiting addiction to "drug abuse." Addicts' maladaptive choices are symptoms of their attempts to adjust to the psychological antecedents carried from early childhood. The emotional distress of childhood culminates in a serious and painful sense of self in late adolescence. At this time, the young adult attempts to avoid this emotional malaise with addictive selfmedication. The resultant emotional numbing (alexithymia) precludes development of awareness of meaning. The use of logotherapy offers the addict the cognitive material to assimilate and integrate the disowned emotional self. The experience of emotion provides the schematics necessary to reformulate cognitive structures with a sense of meaning and purpose. Frankl's view, that of affirming meaning in suffering, prescribes the manner in which human beings, addicted or not, can maintain a sense of integrity. If addicts have any chance of long-term recovery, they must find meaning and purpose within their emotional selves. 
15 
MITCHELL YOUNG, Ph.D. [Educational Leadership & Counseling, Northeast Louisiana University, Monroe, Louisiana 71209] is currently Assistant Professor in the Department of Educational Leadership and Counseling at Northeast Louisiana University. He has numerous presentations and publications in the areas of shame, attachment, and addiction. 
GEORGE E. RICE, Ph.D. is currently Professor in the Department of Educational Leadership and Counseling at Northeast Louisiana University, and Professor, Louisiana Consortium, at Gambling State University, Louisiana Tech University, and Northeast Louisiana University. 
References 
1. 
Alexander, B. K. (1987). The disease and adaptive models of addiction: A framework evaluation. Journal of Drug Issues, 17, 47-66. 

2. 
Alexander, B. K. (1990). The empirical and theoretical basis for an adaptive model of addiction. Journal of Drug Issues, 20, 3765. 

3. 
Bowlby, J. (1977). The making and breaking of affectional bonds British Journal of Psychiatry, 130, 201-210. Colgrave, S. (1988). By way of pain. Rochester, VT: Park Street Press 


5. Flores, P. J. (1988). Group psychotherapy with addicted populations. NY: Haworth. 
6. 
Frankl, V. E. (1967). Psychotherapy and existentialism. NY: Washington Square Press. 

7. 
Greenburg, L. S., & Safran, J. D. (1987). Emotions in psychotherapy. NY: Guilford. 

8. 
Khantzian, E. J. (1982). Psychopathology, psychodynamics, & alcoholism. In M. E. Pattison & E. Kaufman (Eds.), Encyclopedia of alcoholism (pp. 581-587), 

9. 
Kuzuhara, D. K. (1982). Despair and three meanings of hope In 


S. A. Wawrytko (Ed.), Analecta Frankliana: The proceedings of the first world congress of logotherapy (pp. 129-136). 
10. Shedler, J., & Block, J. (1990). Adolescent drug use and psychological health. American Psychologist, 45(5), 612-630. 
16 
The International Forum for Logotherapy, 1999, 22, 1 7-21 
RAISON D'ETRE IN RECOVERY: SOBRIETY, SERVICE AND SENSE OF PURPOSE 
Bill Asenjo 
(ABSTRACT) This study surveyed members of Alcoholics Anonymous concerning the extent of their 1i1volvement in AA service work The purpose was to investigate the relationship between involvement in AA service and a sense of meami1g in life during abstinence. The Purpose in Life (PIL) test was administered to 8Ei members of AA. Members who were active 1r1 AA service showed greater sense of purpose in life. 
Parallels  between  Frankl' s  
thought  and  the  program  of  
Alcoholics  Anonymous  have  been  
discussed in the literature for more  
than  25  years."' ·,u  Certainly  
Frankl' s  premise,  that  to  be  fully  
human  one  must  be  directed  
toward something other than  one 
self,  resonates  with  the  principle  
advanced in AA's preamble  which  
1s  read  before  each  AA  meeting,  
reminding  members  that  their  
primary  purpose  is  to  stay  sober  
and  to  help  others  recover  from  
alcoholism.  
Frankl  considered  the  lack  
of  meaning  in  life --existential  vacuum  to  be  a  major  factor  in  
recovery from alcoholism:  
even though I do not consider alcoholism  as  being caused (at  

least not exclusively) by the existential vacuum, filling up this vacuum may well be of primordial therapeutic value--nay, a prerequisite for therapeutic success, and in any event a decisive component in the rehabilitation of the chronic 
alcoholic. p.x 
17 
Logotherapy attempts to remedy the sense of meaninglessness by focusing an individual on a means of fulfilling a raison d'etre, a reason for being. 8 This approach parallels AA 's position, AA 's Twelfth Step, "carrying the message... is our principal aim and the main reason for our existence."3· P-7 39 
Self-transcendence, a principal feature of logotherapy, is a commitment to significant others and important causes. 9 For recovering alcoholics, this can be accomplished through 12th step work whether the alcoholic has been involved in AA for months or years: "Even the newest of newcomers finds undreamed rewards as he tries to help his brother alcoholic, the one who is even blinder than 
he."2,p.109 
Alcoholics helping other alcoholics remains a primary purpose of AA. As Madsen observed: "Twelfth-stepping gives a sense of purpose and serves as a constant reminder to the alcoholic of where he's been." 11-P-782 
Although AA typically helps alcoholics stop drinking, or remain 
sober, through supportive conversations it is more than that: There are many opportunities for those of us who feel unable to speak at meetings or who are so situated that we cannot do much face-to-face Twelfth Step work. We can be the ones who take on the unspectacular but important tasks that make good Twelfth Step work possible, perhaps arranging for the coffee and cake after the meetings, where so many skeptical, suspicious newcomers have found confidence and comfort in the laughter and talk. "2 · P-710 
The study presented below investigated the hypothesis that AA members who were active in AA service would experience a greater sense of purpose in life. To this end, a survey of 85 AA members who attended meetings at a single setting in Florida, was conducted. 
Method Participants 
Male and female participants ranged in age from 20 to 78; they included Caucasians, Hispanics, and Afro-Americans. The length of time participants had remained alcohol-free ranged from several weeks to nearly 20 years. 
18 
Procedure 
Those attending AA meetings were invited to partIcIpate in this study by completing the Purpose-in-Life (PIL) test. Participants also were asked to stipulate the degree to which they were active in AA work. 
Results 
With two exceptions, every AA member who was invited to participate did so. Of the 85 participants, 20 had less than one year alcohol-free; 4 7 had been abstinent for 1 to 10 years; and 18 had been free of alcohol for 10 or more years. PIL scores ranged from 77 to 140. 
Statistical analyses were implemented in order to examine the relationship between involvement in AA service activity and PIL scores. Results supported the hypothesis that activity in AA service was significantly related to meaning in life. The mean PIL score for members who reported to be not active in AA work was 88.9 (N = 14; SD = 3.6). Mean PIL score for members who reported to be occasionally active was 108.0 (N = 28; SD = 8.8). Mean PIL score for members who reported to be active was 113.1 (N = 43; SD = 3.8). 
[All comparisons were statistically significant. Statistical data, ANOVA summary tables, and Tukey HSD post hoc results are available upon request from the author.] 
Discussion 
As the results demonstrated, PIL scores reflected the level of activity in AA service work. The results are in keeping with other researchers who have observed that as "Successful AA members become more actively involved in the organization... If differences in adjustment are observed, they favor the more active members. " 7· P·54 
Those who are familiar with AA have more than likely come in contact with the individual who assumes that just not drinking is sufficient. But those researching AA recognize that simply not drinking does not necessarily represent an enduring change in drinking behavior. Unless there is intentional, volitional cooperation, lasting behavior change is not possible. 6 Ultimately, beyond attempting to insure their sobriety, the suggestion that AA members carry the message to other suffering individuals makes use of the human 
19 
quality of self-transcendence and supplies a meaningful experience of achievement.4 
Frankl posited that each individual possesses an innate Will to Meaning. Some AA members have been able to maintain a meaningful, alcohol-free life by virtue of AA service. However, as in any organization, some members are more active than others; many members of AA also participate in community service, civic groups, and volunteer activities outside of Alcoholics Anonymous. AA's cofounder, Bill Wilson, recognized the limits of restricting oneself to AA: 
Each of us in turn--that is, the member who gets the most out of the program--spends a very large amount of time on Twelfth Step work in the early years. However, sooner or later most of us are presented with other obligations--to family, friends, and country. As you will remember, the Twelfth Step also refers to "practicing these principles in all our affairs." I just know you are expected, at some point, to do more than carry the message of AA to other alcoholics. In AA we aim not only for sobriety--we try again to become citizens of the world that we rejected, and of the world that once rejected us. This is the ultimate demonstration toward which Twelfth Step work is the first but not the final step. 1 · P·21 
AA service--far from an end in itself--is for some alcoholics a good beginning to the realization of a meaningful and purposeful alcoholfree existence. However, in order to acquire a better understanding of the activities by which recovering alcoholics are able to realize a meaningful life without alcohol, it is important to investigate the nature and extent of these commitments. Perhaps then we will better comprehend the ways in which former alcoholics are able to "become citizens of the world." 
BILL ASENJO [714 5th Avenue, Iowa City, Iowa 52245 USA] is a post-comprehensive examination (ABD) doctoral candidate and Certified Rehabilitation Counselor (CRC) in the Rehabilitation Counselor Education Program at the University of Iowa. 
20 
References 
1. Alcoholics Anonymous. (1967). As Bill sees it: The AA ;•.•ay ut life... selected writings of AA 's co-founder. N'{· Al'~ /:ur!cJ Services. 
2. Alcoholics Anonymous. (1988). Twelve steps anci tvvt"!vf traditions (40th printing). NY: AA World Services 
3. Alcoholics Anonymous. (1989). Alcoholics Anonymou.'o r.·untc'-' of age: A brief history of AA (15th printing). NY: P../'\ 'Norll1 Services. 
4. Brown, H. P. (1993). Tools for the logotherapist: A twel,:e step spiritual inventory. lnternatt0na! Forum for Logotherapv 7D. 77-88. 
5. Crumbaugh, J., Wood, W. M., & Wood, W. C. , 1 Ci80) Logotherapy: New help for problem drinkers. Chicago: r•JE:i,:;cnHall. 
6. 
DiClemente, C. (1993). Alcoholics Anonymous and the structure of change. In B. McCrady & W. Miller (Eds.), Research on Alcoholics Anonymous: Opportunities and alternatives (pp. 70-98). New Brunswick, NJ: Rutgers Center on Airnr1ol1sni Studies. 

7. 
Emrick, C., Tonigan. J., Montgomery, H., & Little, l ( 199J). Alcoholics Anonymous: What is currently known. In f3 McCrady & W. Miller (Eds.), Research on A!colw!ics Anonymous: Opportunities and alternatives (pp. 41-78\. New Brunswick, NJ: Rutgers Center on Alcoholism Studies. 

8. 
Frankl, V. (1967). Psychotherapy and existentialism: Selected papers on logotherapy. NY: Washington Square Pn~ss. 

9. 
Frankl, V. (1969). The will to meaning: Foundations and applications of logotherapy. NY: New American Library. 


10. Holmes, R. (1991). Alcoholics Anonymous as woup logotherapy. International Forum for Logotherapy, 74, 3t541. 
11. Madsen, N. (1974). The American alcoholic. Springfir,lcJ, !l .. Charles C. Thomas. 
21 
The International Forum for Logotherapy, 1999, 22, 22-26. 
PSYCHOMETRIC PROPERTIES OF THE PURPOSE IN LIFE TEST WITH A SAMPLE OF SUBSTANCE ABUSERS 
Jodie L. Waisberg and Meyer W. Starr 
(ABSTRACT) The Purpose in Life (PIL) test has proven useful in several studies of alcoholism and drug addiction. The present article summarizes information on psychometric properties of the test with a sample of substance abusers. Results of an inter-item reliability assessment and factor analysis are presented, along with findings on the relationship of the PIL to the Beck Depression Inventory (BDIJ. Two clearly interpretable factors emerge: 1 J Life is meaningful, and 2) Daily life is interesting. The standardized item alpha (. 91) indicated high internal consistency of the test items. Only three items had low item-total correlations in the inter-item reliability assessment and did not load on either of the two factors. A 17-item version of the PIL, 
with these three items omitted, may be more applicable to the general population than the 20-item test. Analyses support the position that the constructs of depression and lack of purpose in life are overlapping but different. 
The Purpose in Life (PIU test was developed by Crumbaugh and Maholick to measure Frankl's construct of purpose or meaning in life. 4 It was proven useful in several studies of alcoholism and drug addiction. Newcomb and Harlow9 used it to explore the role of purpose in life in the development of substance abuse problems, while others used it in studies of alcoholics who were undergoing treatment. 3• 7 Research with the PIL indicates that alcoholics have a lower sense of purpose in life than do nonalcoholics, and that their sense of life purpose increases significantly during treatment for their addiction.2 ·3 .7· 12 
22 
Although the PIL has been employed with substance abusers, its psychometric properties with this population have not been well documented. The present paper, which is based on part of a dissertation study of substance abusers undergoing inpatient treatment, summarizes information on this topic . 17 A more detailed version of this paper, which includes a more complete description of the statistical analyses, is available from the authors. 
Procedure 
The PIL and the Beck Depression Inventory (BDI) 7 were administered to the 146 participants at the beginning of their treatment programs as part of a larger test battery employed in the study. An inter-item reliability assessment was performed to determine the internal consistency of the items. The relationship between purpose in life and depression was explored through calculating the correlation coefficient between PIL and B01 scores and plotting PIL vs. B01 scores on a scatter plot. A factor analysis was performed to determine the factor structure of the PIL with this substance-abusing sample, and to compare it with factor structures obtained in similar analyses with other populations. 
Results and Discussion 
The reliability assessment of the PIL yielded a high internal consistency (standardized item alpha = .91). 
A previous study, using a slightly revised version of the PIL, found a high positive correlation between purpose in life and happiness, and a high negative correlation between purpose in life and meaninglessness.6 They found a correlation of -.57 (p < .001) between purpose in life and suicidality. The present authors found a correlation between BDI and PIL scores of -.70 (p < .0001 ); this indicates shared variance of about 50%, which is in the range predicted by assuming depression and lack of purpose in life are overlapping but different. The shape of the plot of PIL scores versus 801 scores supported this interpretation as well. In the middle range (mild-moderate and moderate-severe depression) PIL scores were quite predictable from 801 scores, while in the two outside ranges (nondepressed and extremely depressed) B01 scores were less predictive of PIL scores. This is not surprising in the nondepressed range, because the PIL score should represent more than just the absence of depression. The findings in the extremely depressed range were more difficult to interpret; perhaps 801 scores in this range represent much the same state of mind. In any case, while PIL scores are likely constrained by level of depression, purpose in life is not just the inverse of depression. 
23 
The factor analysis yielded five unrotated factors. All items except items 14 and 1 5 loaded on the first factor. Item 14 assesses the participants' beliefs regarding freedom/determinism in making choices; item 1 5 assesses the participants' degree of fear and preparedness for death. These two items also had the lowest item-total correlations in the inter-item reliability assessment. Item 7, which taps the activity/passivity dimension of participants' retirement plans, also had a low item-total correlation in the reliability assessment and barely made the cut-off on the first factor. 
Table 1 
Rotated Factor Pattern of PIL Items (Two-Factor Solution) 
Factor 1  Factor 2  
1  feeling of enthusiasm  .170  .684  
2  excitement in life  .042  .802  
3  clarity of goals in life  .462  .410  
4  meaningfulness of life  .592  .421  
5  newness of each day  .194  .799  
6  would choose more lives  .724  .286  
7  activity level of retirement plans  .269  .391  
8  achievement of life goals  .745  .231  
9  fullness of life  .497  .528  
10  worthwhileness of life  .743  .182  
1 1  reason for existing  .768  . 161  
12  meaningfulness of world  .740  .242  
13  level of responsibility  .577  .108  
14  freedom/determinism  .181  .120  
1 5  preparedness for death  .194  .224  
16  thoughts of suicide  .569  .209  
17  ability to find meaning  .536  .390  
18  locus of control over life  .340  .519  
19  pleasure of daily tasks  .371  .686  
20  goals and life purpose  .677  .423  
Sum of Squared Loadings  5.448  3.968  

Note. Underlining indicates which items had significant loadings on each factor. twelve items on Factor 1 and six items on Factor 2. 
24 
The first two rotated factors were easily interpreted, while the remaining three factors yielded no non-redundant information. Thus, two factors were retained. These two factors accounted for 4 7 % of the variance. The factors can be summarized as: (1) Life is meaningful, and 
(2) Daily life is interesting (see Table 1). Omitting items 7, 14, and 1 5 improves the test for the following reasons: the retirement question may not be particularly relevant to the central construct, especially for young people, and the other two items may be too abstract for general use with less educated populations. 

A previously published factor analytic study of the PIL with a university population yielded a two-factor solution very similar to the present one. 8 A study of Chinese high school students produced a 2factor and a 5-factor solution with some similarity to those found in the present study. 10 Interestingly, items 14 and 15 had low item-total correlations for the Chinese high school sample, but not for the university sample. This supports the notion that the concepts may be too abstract for many people with less than a college education, such as the high school student research participants and the majority of our substance-abusing research participants. Item 7 (retirement) had low loadings in the high school study, as well as in ours, suggesting that retirement plans may not be closely related to a sense of life purpose. 
The present study adds to past validity research and to past reliability findings on the PIL. Future research should investigate further whether the 17-item version presented in this paper would be more applicable to the general population than the original 20-item test. The PIL appears to be a useful measure with a variety of populations, including substance abusers. A lack of purpose in life appears to be an element in the development of substance abuse problems, and an increased sense of purpose in life appears to be concomitant with behavioral changes in the areas of drinking, family relations, and employment. 5 In helping us to study this subjective aspect of human experience in a relatively objective way, the PIL may prove to be a very valuable instrument for monitoring treatment process and outcome. 
JODIE L. WAISBERG, Ph.D. [797 Princess Street, Suite 201, Kingston, Ontario, K7L 1 G 1, Canada] based the present article on part of the doctoral dissertation conducted at the University of Windsor. 
MEYER W. STARR, Ph.D. was Associate Professor at the University of Windsor and a member of the dissertation committee. 
25 
This research was supported by a National Health Research and Development Program grant from Health and Welfare Canada. 
References 
1. 
Beck, A., Steer, R., & Garbin, M. (1988). Psychometric properties of the Beck Depression Inventory: Twenty-five years later. Clinical Psychology Review, 8, 7 7-1 00. 

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

3. 
Crumbaugh, J., & Carr, G. (1979). Treatment of alcoholics with logotherapy. The International Journal of the Addictions, 14, 847853. 

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

5. 
Crumbaugh, J., Wood, W. M., & Wood, W. C. (1980). Logotherapy: New help for problem drinkers. Chicago: Nelson-Hall. 

6. 
Harlow, L., Newcomb, M., & Bentler, P. (1987). Purpose in life test assessment using latent variable methods. British Journal of Clinical Psychology, 26, 235-236. 

7. 
Jacobson, G., Ritter, D., & Meuller, L. (1977). Purpose in life and personal values among adult alcoholics. Journal of Clinical Psychology, 33, 314-31 6. 

8. 
Molcar, C., & Steumpfig, D. (1988). Effects of world view on purpose in life. The Journal of Psychology, 122, 365-371. 

9. 
Newcomb, M., & Harlow, L. (1986). Life events and substance use among adolescents: Mediating effects of perceived loss of control and meaninglessness in life. Journal of Personality and Social Psychology, 51, 564-577. 

10. 
Shek, D. (1988). Reliability and factorial structure of the Chinese version of the purpose in life questionnaire. Journal of Clinical Psychology, 44, 384-391. 

11. 
Waisberg, J. ( 1 992). Purpose in life, depression, and outcome of treatment for alcohol dependence. (Doctoral dissertation, University of Windsor, 1990). Dissertation Abstracts International, 52, 610161028. 

12. 
Waisberg, J., & Porter, J. (1992). Purpose in life and outcome of treatment for alcohol dependence. British Journal of Clinical Psychology, 33, 49-63. 


26 
The International Forum for Logotherapy, 1999, 22, 27-29. 
LOGOTHERAPY IN TODAY'S MANAGED CARE CLIMATE 
Ann Graber Westermann with Helen Gennari 
With the advent of "managed care" in the U.S., health care givers in the mental health field are scrambling to find more effective, shorter term, therapeutic approaches. To better understand the dilemma facing us, and the role logotherapy could play in today's managed care climate, I sought out and interviewed Helen Gennari, LCSW, who is familiar with all sides of the problem" 
Mrs. Gennari has gathered a wealth of experience during 38 years in the health care field. As a former member of a religious order that operates a large health care system in Missouri, she has held various administrative positions before becoming a clinician. Recently she has been instrumental in setting up a regional office for a managed care organization. While serving as a case manager there, she has gained a better understanding of the problems encountered by the managed care organization. She also has maintained a private practice. Her ongoing challenge as a therapist is to meet the needs of clients who have a limited number of sessions available through their managed care company. 
Helen: Many of us are frustrated because we are trying to work in a new framework with old tools. The traditional ways in which we were trained 
27 
to do psychotherapy are not always easily applicable to the short-time frame available to us now. Currently we are trying to use therapies in a framework for which they were not designed. We are looking for better, more effective methods to accomplish our tasks. 
Ann: With the emphasis in therapy today being on effective short-term care, a remark by Donald Tweedie, Ph.D.,2 · P-147 comes to mind. He cites a survey of the session frequency of patients seen in Dr. Frankl's clinic 
during  a two-year period  as  slightly less than eight.  Also noted is the  
remarkable  effectiveness  of  logotherapy.  Are  you  also  seeing  
logotherapy as that 'more effective method?'  

Helen: Yes! I think, logotherapy can provide an important part of the answer to the managed care dilemma in mental health. Logotherapy is particularly well suited to fit into the current climate of reaching therapeutic goals. The preferred treatment modality today is brief therapy. 1 If we look at some of the basic principles of solution-focused brief therapy alongside logotherapy, you will see similarities. The major points of brief therapy are: 
.It is situation-oriented .Focus is on client strengths rather than on pathology .Goal setting is done by the client, not the therapist .Responsibility for change rests with the client; it's not therapistdependent .Belief is maintained that all environments, even the most bleak, contain resources 
.Interviewing questions are designed to focus on imagining the future when the problem is solved; the kind of questioning that enables the birth of a latent idea 
These tenets are also inherent in Viktor Frankl's logotherapy. However, logotherapy, with its meaning-seeking motivation--its spiritually-based psychotherapy--can help clients find their noetic goals and build a meaning-filled future. Wouldn't this be far more productive than just acquiring coping skills? And it could probably be accomplished in a shorter period of time, thus reducing the frustrations of all parties. 
Ann: You mean that logotherapy could actually be beneficial to all three: client, managed care organization, and therapist. 
Helen: Yes, especially the last. As therapists, we want to assist our 
28 
clients to discover their own solutions to existing problems. We also want to accomplish this within their available insurance coverage so they can afford the treatment they need. 
Ann: I can see that you have looked at the problem from everyone's angle. 
Helen: Indeed I have. That's why I think the time is ripe for logotherapy. You have to make the merits of Franklian psychology and logotherapy widely known. You, who are trained in logotherapy, need to put your heads together to show us, who are on the front lines, how to apply logotherapy in today's climate of care giving. 
Ann: How do you foresee logotherapy fitting into managed care in the future? 
Helen: I would like to point out to you that "managed care" could well be the mechanism through which logotherapy becomes widely used-even if for economic reasons alone. Furthermore, logotherapy's holistic approach of taking body, mind, and the human spirit into consideration in healing is highly acceptable today. That may not have been the case in decades past. Logotherapy could well become the primary treatment modality, where applicable, in the near future. 
ANN GRABER WESTERMANN, M.DIV. [512 Pare Forest Trail, St. Charles, Missouri 66303 USA] is a Dip/ornate in logotherapy and active as a Pastoral Counselor. Ann has initiated Distance Learning in logotherapy for the V,ktor Frankl Institute of Logotherapy (E-mail: LTDistlLrng@A OL. com). 
HELEN GENNARI, LCSW, St. Louis, Missouri, is a Licensed Clinical Social Worker with 38 years of experience in health care. She is a Psychotherapist in private practice, has worked in managed care, and is currently working in an Employee Assistance Program. 
References 
1. 
DeJong, P., & Miller, S. (1995). How to interview for client strengths. Social Work, 40, 729-736. 

2. 
Tweedie, 0., Jr. (1979). In J. Fabry, R. Bulka, & W. Sahakian (Eds.) Logotherapy in Action. NY: Jason Aronson. 


29 
The International Forum for Logotherapy, 1999, 22, 30-35. 
THE SURVIVAL OF LOGOTHERAPY 
Ingeborg van Pelt 
attended the 1997 World Congress of Logotherapy, and was stirred by Viktor Frankl' s message: will logotherapy survive? I left the conference with concerns, and with the determination to focus on repeatedly mentioned issues: where 1s a school of logotherapy; why does logotherapy have such a hard time becoming accepted as an important method of psychotherapy? 
Viktor Frankl, a neurologist, who had communicated closely with Sigmund Freud then Alfred Adler (also neurologists), departed from their medical approach. He challenged their pathology-based theories of cause and effect, and introduced his philosophically based view of individual uniqueness and wholeness, individual selfdetermination, and striving for transcendence. He insisted that the human being was more than body and emotion (psyche), driven and determined by abnormal dysfunctions and forces. Instead he claimed that we are human because of our third dimension, the human spirit. With the introduction of this third self-determining factor, he left behind the medical model of cause and effect, to which medicine had adhered since Descartes. While Freud's introduction of psychopathology evoked excitement in academic circles. Frankl's new concept found less acceptance. Freud's approach to therapy led to victimization of the human being, to insecurity and anxiety, and finally, to fear of seeking help from the "shrinks" 1n psychiatry. In contrast, Frankl' s focus on the healthy human spirit with the potential for self-healing and transcendence rekindled courage, selfdetermination, responsibility, and hope in those who sought his help. 
30 
Logophilosophy Is Applicable to All Areas of Human Life 
As a philosophy, logotherapy emphasizes the human dimension as 
a resource of health. Its hypothesis: claims the uniqueness and self-determination of each individual; encourages healthy tensions awareness of opportunities to be taken, rather than stopping at a mental state of equilibrium; claims that the defiant power of the human spint can enable us to overcome obstacles in our lives and leave traumatic events without permanent harm; 
emphasizes  the  importance  of tapping  the  human  
conscience  (responsibleness)  and  activating  
responsibility;  

fosters self-evaluation: looking from strength to areas in need of improvement. 
This philosophy is not new, but it has been overpowered by this century's dysfunction-oriented psychologies. If vigorously marketed, however, logotherapy could permeate "education and management theory, ... theory of culture, psychology (motivational psychology, developmental psychology), sociology, and history. ·P 23
"1 
The Dilemma of Logotherapy 
While Frankl's meaning-oriented philosophy has influenced millions of people, predominantly through his book Man's Search for Meaning, logotherapy still finds little acceptance in research-oriented academic circles, The reason, I believe, is that logotherapists have focused so much on meaning, which is difficult to document scientifically. With it, the emphasis has been taken off the spiritual/human dimension of strength. Thus, the tri-dimensional ontology has not been kept front and center--a place it deserves in Franklian logotherapy. 
For example, in 1994 there was a heated debate between German and Austrian logotherapists about the interpretation of the meaning concepts, stimulated by an article of Alfried Langle: Sinn-Glaube oder Sinn-Gespur (Faith in Meaning or Awareness of Meaning), The debate focused on differentiating between ontological and existential meaning in logotherapy. Perhaps this is an important subject to discuss. However, at this point of struggle for recognition it does not 
31 
help promote logotherapy among psychologists who are already skeptical of logotherapy and see it as a religious philosophy. 
Our basic message of logotherapy is the uniqueness of the individual because of the third dimension, the human spirit. We logotherapists try to reach this dimension through the Socratic dialogue. It is the recognition of inner strength which enables patients to leave the past behind, to distance themselves from bodily and emotional pain, to re-direct their energy toward a new goal and toward love for others. It is regrettable that the mainstream psychologies are still stuck with being primarily concerned with pathology: blaming the client's dilemma on the negative impacts of the past, on faulty behavior, or on unhealthy circumstances. 
This beckons us to come forward with a spirit-centered psychology, which will lead unquestionably to "meaning." We have to let our worldv1ew become known in popular journals and advertise the values that we place in the third dimension: responsibility, compassion/love, creativity, and the ability for attitudinal change even under most difficult circumstances. That we can be convincing in this regard shows the acceptance of Frankl' s concept of the human spirit in the recent textbook of Alan Ivey. I quote: 
Van Pelt argues persuasively that the healthy human spirit is 
important to psychological and physiological well-being. 
Moreover, she points out that if broad human issues are 
considered from the philosophical framework ot logotherapy, 
new dimensions for mental and physical health, and even 
world peace, can be the result.4 · P· 388 But it is Frankl himself who states: Man lives in three dimensions: the somatic, the mental, and the spiritual. The spiritual dimension cannot be ignored, for it is what makes us human.....psychotherapy which not only recognizes man's spirit, but actually starts from it may be termed logotherapy. In this connection logos is intended to signify "the spiritual" and, beyond that, "the meaning." 3· 0·''' Neither Irvin Yalom nor Alan Ivey mentioned the tri-dimensional 
ontology, although logotherapy is referred to several times. Is it fair to say that we logotherap1sts might have to blame ourselves for it? Do we have to blame ourselves perhaps as well that some traditional psychologists perceive logotherapy as operating without a personality construct? Again, our emphasis on "meaning" works here against us. 
32 
Logotherapy has such a specific Menschenbild--the image of the human being--with his/her innate values, and the capacity for transcendence, that it surpasses the perception of personality by psychoanalysts or behaviorists. 
Furthermore, logotherapy needs to stand on its own feet! As long as we perceive logotherapy as an "adjunct" to traditional psychotherapies we undermine the credibility of its uniqueness. In addition, individuals who are eager to become logotherapists are deprived of the firsthand experience of logophilosophy. Instead, they are undergoing initially extensive training in traditional psychology which then has to be unlearned, or at least vastly modified--in the USA in a 15-hour introductory course, three 30-hour intermediate courses, and a 50-hour supervised practicum or an equivalent research demonstration project. 
Spirituality and Healing in Medicine--The Future of Logotherapy 
In the USA we are witnessing a paradigm shift in Medicine. While the practice of medicine has been dominated by the western "scientific" method for many years, awareness is emerging that ancient healing practices can no longer be ignored, and they need to be invited back into the medical arena. For example, the Massachusetts Medical School has established a mindfulness meditation and Yoga program as a healing tool, which is successfully used and propagated by its founder, Jon Kabat-Zinn. 5 Harvard Medical School, through the initiative of Herbert Benson (author of The Relaxation Response), gives two yearly symposia on "Spirituality and Healing in Medicine." 
I attended its first symposium in Boston in December 1995, and was excited to hear Benson remark: "This is a milestone event in Medicine from the two-legged stool to the three-legged stool--body, mind, and spirit." Here was Frankl's tri-dimensional ontology' The main focus of the symposium, however, was spirituality in the context of faith and prayer, much in contrast to Frankl's logotherapy. 
The public today is attracted to books like Healing Words: The Power of Prayer and the Practice of Medicine2 by Internist, Larry Dossey, (former co-chair of the National Institute of Health's Panel on Mind/Body Interventions for the Office of Complementary and Alternative Medicine). Medical professionals are studying the beneficial effects of prayer and healing, and are working on scientific 
33 
proof. I see here the opportunity for logotherapy to become the bridge between traditional "scientific" medicine/psychology and faith-healing. Our concept of the defiant power of the mind (the human spirit-the self-healing capacity of a person) will perhaps be more acceptable to a medical scientist than accepting healing through prayer. 
The Viktor Frankl School of Spirit-Centered Meaning-Oriented Psychology/Therapy 
support the founding of an independent school of logotherapy that teaches all aspects of the Franklian philosophy and logotherapeutic methods under one roof. If logotherapy wants to become the psychology of the future, logotherapists have to speak with ONE voice. 
Definition of terms 
One will have to come to terms with questions of spirituality and healing, particularly in regard to new developments in medicine which allow the discussion, study, and practice of prayer. Perhaps the definition of the human spirit has to be re-examined together with the concept of meaning and ultimate meaning. One might even have to define more precisely the "mind," the "psyche." How do we define the "soul"? What is meant by transcendence in logotherapeutic terms? 
Scientific research 
At the 1997 World Congress of Logotherapy a group of logotherapists discussed the importance of scientific research in order to gain acceptance in academic communities. The same concern has been voiced by German logotherapists (see editorials in Logotherapie & Existenzanalyse, 2/95-1 /96 by Jurgen-Peter Arimond). 
There is already much evidence that positive thought, goals, and meaningful living have a positive effect on healing and health. What needs to be better established is a quantitative measure of this effect on the neurotransmitter modulator system (one needs to evaluate the scientifically accepted placebo effect in a positive not negative way). And where could this be accomplished better than in a logotherapy school that focuses on strength and hope rather than on pathology? Of course, this will not be easy. 
34 
The Complexity of training 
Frankl was a philosopher, humanist, scientist. He was deeply rooted in the Judaic tradition and faith. If we want his vision and commitment to a better world to survive, we will have to establish a school of logotherapeutic living. Perhaps we will have to gather first the pupils of Frankl--philosophers at heart, religious advisors, therapists, teachers, friends--and brainstorm together about curriculum, departmental involvement (religion, anthropology, sociology, psychology/psychiatry), and teaching staff. I envision tremendous potential and an enthusiasm, which would reach all areas of life. With time, a new school could have the hoped-for influence on other faculties, including medicine. It might inspire higher education to teach and study global responsibility, freedom, and meaning in life. It might even influence the worldview in general. 
INGEBORG VAN PELT, MD [302 Amherst Road, Pelham, Massachusetts 01002 USA: e-mail = IVANPELT@AMHERST.EDU] is a Diplomate in logotherapy, a physician at the University Health Services in Amherst, MA, and the director of the Headache Clinic. 
References 
1. 
Bockman, W. (1990). The International Forum for Logotherapy, 13, 22-23. 

2. 
Dossey, L. (1997). Healing words: The power of prayer and the practice of medicine. Harper Mass Market Paperbacks. 


3. 
Frankl, V. E. (1965). The doctor and the soul: From psychotherapy to logotherapy. NY: Vintage Books. 

4. 
Ivey, A., Ivey, M., & Simek-Morgan. L. (1996). Counseling and psychotherapy: A multicultural perspective. Boston, Allyn & Bacon. 

5. 
Kabat-Zinn, J. (1990). Full catastrophe living: Using the wisdom of your body and mind to face stress, pain, and Illness. NY: Dell Publishing Group 


35 
The International Forum for Logotherapy, 1999, 22, 36-43. 
MEANING IN LIFE AND ADJUSTMENT AMONGST EARLY ADOLESCENTS IN HONG KONG 
Daniel T. L. Shek 
(ABSTRACT) The responses of 378 adolescents to the Chinese 
version of the Purpose-In-Life (P!L) Test and other tools assessing 
their psychological we/I-being and perceptions of parenting behavior on two occasions were examined. Regarding the link between meaning in life and we/I-being, it was found that those who had lower PIL scores had: (a) higher levels of psychiatric morbidity and hopelessness and (b) lower levels of life satisfaction and self-esteem. Results further revealed that the association between perceived parenting behavior and adolescent we/I-being was stronger in adolescents with a lower sense of purpose in life than in those with a higher level of purpose--suggesting that a higher sense of purpose in life provides a buffer against the impact of negative parenting behavior on adolescent we/I-being. 
According to Frankl, when an existential vacuum 1s present and a person fails to extract meaning in life, he or she is faced with existential frustration, which is characterized by the feeling of boredom.4 Although the presence of existential vacuum does not necessarily lead to noogenic neuroses, mental problems can come in to fill the vacuum.5 While the assessment of existential vacuum had been accomplished by Frankl with clinical measures, the Purpose-In-Life (PIL) Test was constructed to quantify the existential concept of meaning and purpose in life, which is operationally defined as the "ontological significance of life from the view of the experiencing individual. "1· P 201 The PIL has been used in different contexts and it has been translated into different languages.3· 11 

36 
Although there are research findings supporting the thesis that there is an intimate link between meaning in life and psychological 
13 15
well-being, 11 · · there are several limitations of the existing literature. First, since most of the available studies are cross-sectional in nature, the causal relationship between purpose 1n life and psychological wellbeing cannot be adequately examined. Second, there has been, to date, no systematic study of the link between the two in early adolescents. In the Piagetian framework, it was proposed that the cognitive system of adolescents changes during adolescence where they begin to show interest in ideological concerns such as meaning of life.8 It would be important theoretically to know how such ideological concerns and quest for life-meaning relate to adolescent psychological well-being. Finally, there has been no systematic research examining how the influence of a stressor (such as lack of parental responsiveness and concern) on adolescent psychological well-being is affected by purpose in life. If a higher sense of purpose in life is related to a lower level of psychiatric morbidity and a higher sense of subjective well-being, then it is reasonable to conjecture that a higher sense of life purpose would protect oneself from the negative impact of psychosocial stressors--those who have a higher sense of life purpose would find it easier to make sense and accept psychosocial stress and live positively under a stressful condition. With specific reference to parenting behavior, while there are research findings showing that negative parenting behavior is related to poor adolescent well-being in the Chinese context,9 it is not clear whether purpose in life would moderate the impact of parenting style on adolescent adjustment. 
The present paper reports empirical evidence on the relationship between intensity of meaning in life (as indexed by the PIU and psychological well-being in a sample of early adolescents in Hong Kong. Specifically, the following research questions were addressed: 
• 
What are the relationships between meaning in life and different indicators of well-being (including psychiatric morbidity, hopelessness, life satisfaction, and self-esteem) in Chinese adolescents? 

• 
Does purpose in life moderate the relationship between parenting behavior and adolescent psychological well-being? 


37 
Method 
Subjects and Procedures 
The subJects (N = 378) were early adolescents recruited through multi-stage cluster sampling. Details of the sampling and subject recruitment procedures were published previously. 16 Each participant completed an Adolescent Questionnaire (containing the measures described below) twice in their home, with an interval of one year. A trained research assistant was present throughout the administration session at Time 1 and Time 2. The median age of the participants was 1 3 at Time 1 . 
Instruments 
The intensity of life-meaning was measured by the Chinese version of the PIL. Other scales used in the present study included: 
1
. The Chinese version of the 30-item General Health Questionnaire (GHOJ--measures current non-psychotic disturbances. 10 Higher scores suggest higher levels of psychiatric symptoms. 

2. 
Chinese Hopelessness Scale (HOPEL}--measures the sense of hope in a person. 14 Higher scores suggest higher levels of hopelessness. 

3. 
Life Satisfaction Scale (LIFE)--measures an individual's global Judgment of his/her life. 2 ·12 Higher scores suggest higher levels of life satisfaction. 

4. 
Chinese Self-Esteem Scale (ESTEEM)--assesses the self-esteem of an individual. 11 Higher scores suggest higher levels of selfesteem. 

5. 
Paternal Parenting Style Scale (PPS)--measures an adolescent's perception of the specific parenting style of the father. 7·'17 

6. 
Maternal Parenting Style Scale (MPS)--measures an adolescent's 


17
perception of the specific parenting style of the mother. 7· 
The first four of the above instruments can be regarded as measures of well-being; the last two are tools assessing an adolescent's perception of the specific parenting behavior. 
If purpose in life influences psychological well-being, Pl L scores at Time 1 would be negatively correlated with GHQ and HOPEL at Time 2 whereas PIL scores at Time 1 would be positively correlated with LIFE and ESTEEM scores at Time 2. If purpose in life protects a person's well-being from the negative influence generated from parenting style, it would be expected that the links between PPS and 
38 
MPS and measures of well-being would be higher 1n those with a lower sense of purpose in life than in those with a higher sense of life meaning. 
Results 
The correlations between meaning in life and measures of wellbeing are presented in Table 1. The concurrent correlations at Time 1 and Time 2 showed that the PIL scores were positively correlated with LIFE and ESTEEM, and there were significant negative correlations between meaning in life and GHQ and HOPEL. Similar patterns were found for the longitudinal correlations (i.e., correlations between Time 1 PIL scores and Time 2 measures of psychological well-being). 
Table 1: Correlations between PIL and Measures of Well-Being 
Measures Pearson r 
Time 1 Pl L scores with: Time 1 GHQ Time 1 HOPEL Time 1 LIFE Time 1 ESTEEM 
Time 2 PIL scores with: Time 2 GHQ Time 2 HOPEL Time 2 LIFE Time 2 ESTEEM 
Time 1 PIL scores with: Time 2 GHQ Time 2 HOPEL Time 2 LIFE Time 2 ESTEEM 
-.48* -.64* "54* .62* 
-.50* -.68* .52* .66* 
-.34* -.48* .37* A2* 
Note.  PIL:  Purpose  in  Life  Questionnaire.  GHQ:  General  Health  
Questionnaire.  HOPEL:  Hopelessness  Scale.  LIFE:  Life  Satisfaction  
Scale. ESTEEM: Self-Esteem Scale.  * p < .0001  

39 
In order to examine the influence of purpose in life on the relationship between parenting style and adolescent psychological well-being, the participants were divided into the High Purpose Group (PIL scores above the Time 1 mean of the sample) and Low Purpose Group (PIL scores on or below the Time 1 mean of the sample). The findings presented in Table 2 revealed that the magnitudes of the correlation coefficients 1n the High Purpose Group were generally lower than those of the Low Purpose Group. It was also found that while all the correlations in the Low Purpose Group were significant (except MPS vs. GHQ), only the correlation between PPS and GHQ was significant in the High Purpose Group. 
Table 2: Correlations between Parenting Style at Time 1 and Measures of Psychological Well-Being at Time 2 Under the "High" Purpose and "Low" Purpose Conditions 
Measures GHQ HOPEL LIFE ESTEEM 
High Purpose Group PPS MPS  -. 1 9 * -.01 ns  -. 12ns -.08ns  .07ns .06ns  .13ns .05ns  
Low Purpose Group PPS MPS  -. 18* -.09ns  -.21** -. 17*  .24** .15*  .22* * .15*  

Nore. GHQ. General Health Questionnaire. HOPEL: Hopelessness Scale. LIFE: Life Satisfaction Scale. ESTEEM: Self-Esteem Scale. PPS: Paternal Parenting Style Scale. MPS: Maternal Parenting Scale. 
***= p < .001 **= p < .01 *= p < .05 ns= non-significant 
40 
Discussion 
Concerning the link between purpose in life and well-being, it was found that a higher sense of purpose in life was associated with lower levels of psychiatric symptoms and hopelessness and higher levels of life satisfaction and self-esteem at Time 1 and Time 2. Such findings are generally in line with the previous cross-sectional data 
13 15
that there 1s a link between purpose in life and mental health. 11 · · Furthermore, the present findings showed that a higher level of life purpose at Time 1 was predictive of lower levels of psychiatric symptoms and hopelessness and higher levels of life satisfaction and self-esteem at Time 2. These findings support the proposal that life purpose is a precursor of psychological well-being. Since no systematic research has been conducted to examine the link between purpose in life and adolescent psychological well-being over time, the present findings can be regarded as pioneering. In addition, in view of the virtual non-existence of published materials on the Purpose-In-Life Test among early adolescents in the Chinese culture, 6 the present paper can be regarded as a contribution to that literature. 
With respect to the influence of purpose in life on the relationship between parenting style and adolescent psychological well-being, the findings showed that the correlations between the PIL scores and measures of psychological well-being in the High Purpose Group were generally lower than those in the Low Purpose Group. This finding suggests that purpose in life might serve as a buffer or coping resource reducing the negative impact of poor parenting style on the psychological well-being of adolescents. Theoretically speaking, the present findings suggest that the role of purpose in life in adolescent development should be thoroughly addressed in models of adolescent development. Practically speaking, the present findings suggest that primary prevention programs which aim at cultivating and enhancing purpose in life in adolescents could help adolescents deal with psychosocial stress. 
41 
DANIEL T. L. SHEK [Department of Social Work, The Chinese University of Hong Kong, Shat,n, Hong Kong] is at the Department of Social Work of the Chinese University of Hong Kong. This work was financially supported by the Research Grants Council of the UGC (Grant CUHK155/94H) and the Madam Tan Jen Chiu Fund. The author wishes to thank Chan Lai-kwan for her assistance in collecting the data. 
References 
1. 
Crumbaugh, J. C., & Maholick, L. T. (1964). An experimental study in existentialism: The psychometric approach to Frankl's concept of noogenic neurosis. Journal of Clinical Psychology, 20, 200-207. 

2. 
Diener, E., Emmons, R. A., Larsen, R. J., & Griffin, S. (1985). The Satisfaction with Life Scale. Journal of Personality Assessment, 49, 71-75. 

3. 
Dyck, M. J. (1987). Assessing logotherapeutic constructs: Conceptual and psychometric status of the Purpose in Life and Seeking of Noetic Goals Tests. Clinical Psychology Review, 7, 439-447. 

4. 
Frankl, V. E. (1955). The doctor and the soul. NY: Knopf. 

5. 
Frankl, V. E. (1967). Psychotherapy and existentialism: Selected papers on logotherapy. NY: Simon and Schuster. 

6. 
Ho, D.Y.F., Spinks, J. A., & Yeung, C. S. H. (Eds.) (1989). 


Chmese patterns of behavior: A sourcebook of psychological and psychiatric studies. NY: Praeger. 
7. Lamborn, S. D., Mounts, N. S., Steinberg, L., & Dornbusch, S. 
M. (1991). Patterns ot competence and adjustment among adolescents from authoritative, authoritarian, indulgent, and neglectful families. Child Development, 62, 1049-1065. 
8. 
Phillips, J. L. (1981 ). Piaget's theory: A primer. San Francisco: Freeman. 

9. 
Shek, D. T. L. (1989a). Perception of parental treatment styles and psychological well-being in a sample of Chinese secondary school students. Journal of Genetic Psychology, 150, 403415. 

10. 
Shek, D. T. L. (1989b). Validity of the Chinese version of the General Health Questionnaire. Journal of Clinical Psychology, 45, 890-897. 

11. 
Shek, D. T. L. (1992a). Meaning in life and psychological wellbeing. An empirical study using the Chinese version of the Purpose in Life Questionnaire. Journal of Genetic Psychology, 153, 185-200. 

12. 
Shek, D. T. L. (1992b). "Actual-ideal" discrepancies in the representation of self and significant-others and psychological well-being in Chinese adolescents. The International Journal of Psychology, 27, 229. 


42 
13_ Shek. D. T. L. (1993a). The Chinese Purpose-in-Life Test and psychological well-being in Chinese college students. International Forum for logotherapy, 16, 35-42. 
14. 
Shek, D. T. L. (1993b). Measurement of pessimism in Chinese adolescents: The Chinese Hopelessness Scale. Social Behavior and Personality, 21, 107-119. 

15. 
Shek, D. T. L. (1994). Meaning in life and adjustment amongst midlife parents in Hong Kong. The International Forum for logo therapy, 17, 102-107. 

16. 
Shek, D. T. L. (1995). The relation of family environment to adolescent psychological well-being, school adjustment and problem behavior: What can we learn from the Chinese culture? 


International Journal of Adolescent Medicine and Health, 8, 
199-218. 
17. Shek, D. T. L., Lee, T. Y., Ngai, N. P., Law, W. 0., & Chan, L. 
K. (1995). Assessment of perceived parenting styles, parentadolescent conflict, and family functioning in Chinese adolescents in Hong Kong. Hong Kong Journal of Social Work, 29, 74-76. 
43 
The International Forum for Logotherapy, 1999, 22, 44-41. 
INTEGRATING LOGOTHERAPY INTO A COURSE IN ETHICS 
Eileen E. Morrison 
The need for a foundation In personal and professional ethics is critical in today's health-care system with its over-emphasis on the business side of the field. The following article illustrates how well Frankl's work applies to the teaching of such ethics. 
The article describes how I integrate the principles of logotherapy into a graduate course in ethics for health-care managers. It explains how I use the techniques of dereflection and Socratic dialogue. It also describes an assignment I make to foster self-distancing and self-transcendence. 
Integrating Theory into the Ethics Course 
The purpose of the 10-week summer course in ethics is to offer graduate students in health-care management the opportunity to formulate their own foundation in ethical theory and practice.. The students are working health-care professionals with a variety of backgrounds including counseling, information technology, nursing, occupational therapy, clinic management, and assisted living center management. This diverse group contributes insights to the learning process that stimulate lively discussions. Issues explored in the course include duty to clients, duty to the organization, and duty to the community as well as staffing and bioethics issues. 
As a foundation, I first present theories and principles of personal and societal ethics. Theorists included in the personal ethics area are Buber, Kohlberg, and Frankl. 
To integrate Frankl's work, I begin by giving an overview of his history and how his orientation to humankind is different from his 
44 
predecessors. I discuss his view of the multidimensional nature of humankind, emphasizing our spiritual dimension. In the process, students are asked to give examples of the effects of spirit and healing that they have seen. I present the three pillars of logotherapy, being careful to have the students identify connections to healthcare. We then discuss Frankl's definition of conscience as it relates to these foundational premises. Again, a discussion is used to elucidate the application of Frankl' s theory to the students' experiences in health-care. 
Additionally, we discuss problems that result from existential vacuum and the search for meaning; and the impact of these problems on today's health-care system. The business side of student thinking is evident as they relate the costs of treating alcohol, drugs, sex, and violence used to fill the existential void. They readily understand the negative impacts of lack of meaning as they realize they will be called upon to treat those impacts on the individual and on the community. 
Application of Logotherapy Techniques 
Hyperreflection to Dereflection 
Graduate students who enroll in this ethics course tend to use hyperreflection as a way of dealing with their ever-changing environment. They focus on increasing productivity and making a profit. While these areas are important to the business of health-care, hyperreflection on the "bottom line" sometimes leads the students to think that they cannot afford to be concerned about the ethical issues of patient treatment. To them, being ethical is not cost effective. 
I use logotherapeutic techniques to encourage students to change their focus of thinking from solely organizational survival to their duty to their patients and to society. Storytelling is used to assist students to dereflect from finances and consider the viewpoint of the customer in the health-care business. For example, I ask students to imagine themselves as patients. We talk about having to be naked in front of total strangers, having to tell things "you wouldn't tell your mama," and experiencing private touching and even pain in the name of diagnosis. Students recall their own pos1t1ve and negative experiences, emphasizing how they felt. We then discuss how the patients would like to be treated as human beings in this situation and the responsibilities of the manager to assure that treatment. 
The students become aware that, ironically, hyperreflection on the financial aspects of health-care may actually cause them to lose 
45 
money. If they are not attending to the humanness of the customer, they may lose business. While never losing sight of the fact that they are in a business, they do begin to see how the view of health-care held by the community at large conditions them both positively and negatively_ 
Using Socratic Questions 
Using Socratic questions has long been a technique in college teaching. However, in its current usage, this is often applied in adversarial ways and creates more fear than learning. By careful use of Socratic questions, I can encourage greater introspection and allow students to formulate their own answers. These questions can lead to a true dialogue and promote actual change in thinking. This change in thinking is vital if you want learning to be applied in the work setting rather than just regurgitated on tests. 
Socratic questions are developed to address specific topics in the course. For example, in discussing the ethics of patient consent, I ask: If you had an adult patient in the ER with a blood alcoho I of 1 . 7, what do you believe is your personal duty regarding informed consent? Why? What if the patient clearly does not understand the procedure that is being done, has he/she consented to it? What then is your duty to this human being? Why? 
With the wide variety of topics presented in this course, the Socratic questions I can use are almost limitless. The main things to remember are (a) to ask questions that guide and not confront, and 
(b) to allow the students time to think. 
Finding Meanings and Opportunity for Self-Transcendence 
Class discussions, dialogue, cases, storytelling, reading, reflection, and other directed learning activities make for an interesting and lively ethics class. However, these techniques do not always allow the student time for true introspection and reflection. Therefore, I have created a way to foster self-distancing and selftranscendence through the final product in the course. All students are asked to create a creed--a statement of their ethics as a leader in health-care. This creed must be suitable for framing (in fact, some students have actually posted this in their offices). 
The support for the creed is prepared by creating an ethics treatise. In this writing, students are instructed to apply what they have learned in the course, through professional and personal experience, and from outside readings. Students are encouraged to 
46 
read Frankl' s original work and to apply his theory. They are guided through this process of finding meaning by several questions: 
What is your real duty to your community and how does this 
influence your ethics? 
What is your real duty to your organization and how does this 
influence your ethics? 
How will you use your creed to make your workplace more 
ethical? 
Students are encouraged to use first person and to think about 
how they can transcend what currently exists to create a more 
ethically sensitive environment. While no page length is specified, 
students prepare work that averages 20-30 pages. One of my 
students produced a scholarly work that exceeded 100 pages and 
demonstrated great depth of thinking. 
The students have reported on feedback sessions and written 
evaluations that this introspective exercise is a difficult assignment. 
They have to think about what they have learned in class and how it 
applies to thern. They must find meaning in the teaching. They tell 
me it is much easier to write a research paper than to think in this 
way. They report finding themselves thinking about ethics in their 
cars, at meetings, and even while watching the news. Creating their 
ethics treatise and personal creed clearly fosters self-transcendence. 
Conclusions 
Frankl's work and the techniques of logotherapy need to be a part of the teaching tools at all levels. They can have a strong connection to the teaching of ethics for the management side of health-care. Of particular value in my experience is the opportunity provided for introspection and application through the developing of an ethics creed and supporting documentation. This experience has assisted my students to find meaning and purpose in their careers and in making ethically mature decisions that benefit the clients, the organizations, and themselves. 
EILEEN E. MORRISON, M.Ph., Ed.D., L.P.C. [University of Mary, Hardin-Baylor, UMHB Station, Belton, Texas 76513-2599 USA] is founding professor of Health Services Management at University of Mary. 
47 

The International Forum for Logotherapy, 1999, 22, 48-56. 
Towards an Integrative Model of Meaning-Centered Counseling and Therapy 
Paul T. P. Wong 
Existential therapy in general, and logotherapy in particular, has been generally regarded as a philosophical approach rather than a separate school of counseling. There is the possibilitv that !ogotherapv rnay go the way of Gestalt therapy --disappearing cis a distinct therapy after its basic concepts have been absorbed by eclectic therapists and other theoretical rnodBls. However, logotherapy may enjoy a brighter future when its basic concepts form the core of a meaning-centered integrative model rather than remaining peripheral to other models. This paper provides a blueprint for such an integrative model. 
The last two decades have witnessed a movement towards technical eclecticism and theoreticai integration,4 because of an increasing awareness of the limitations of working within a single theoretical orientation. Moreover, multicultural counseling spec1f1cally requires that therapists possess a wide range of concepts and skills." MCCT, being broad and flexible, offers the 
48 
best opportunity for integrating spiritual and multicultural issues within an existential conceptual framework. 
Unlike Freud and Adler, Viktor Frankl never purposefully set out to formulate a formal theory. Logotherapy is Viktor Frankl -who he was and what he stood for. His genius was his ability to influence millions of people through his extraordinary life, profound insights, and prolific publications. His classic work, Man's Search for Meaning, 2 has been translated into more than 22 languages and remains influential around the world. Very few people remain unchanged after reading his work or being exposed to his ideas. 
Now that he is no longer with us, there is greater need to further develop his ideas and build upon his foundation. MCCT represents an attempt to expand and systematize Dr. Frankl' s concepts into a distinct, integrative model of counseling and therapy. 
Basic Assumptions and Propositions of MCCT This section identifies the theoretical orientations that have influenced the major assumptions of MCCT. These sources are listed in parentheses. Please note that existential therapy is used as a generic term for logotherapy and existential analysis as well as other approaches to humanistic/existential therapy.3 
1. Human beings are bio-psycho-social-spiritual beings with conflicting needs and existential concerns. (Adlerian, Jungian, Freudian, Existential) 
2, Human beings have two overarching motivations: (a) to survive, and (b) to discover a meaning and purpose for survival. Individuals cannot long endure adversities and suffering without a reason for living. (Behavioral, Adlerian, Existential) 
3. Human beings are meaning-making and meaning-seeking creatures. They are motivated to make sense of the world and discover meaning for their existence and actions. They live in a world of meanings. Their perceptions of events often affect them more than the events themselves. (Freudian, Jungian, Adlerian, Cognitive, Existential) 
4.. Human beings are predisposed by their genes and shaped by their development and life experiences, but their 
49 
thoughts and actions are not determined by biology and the 
environment because of their inherent capacity to choose. 
(Freudian, Adlerian, Cognitive-behavioral, Existential) 
5. 
Human beings can influence and can be influenced by their family, society, and culture. There is an inherent interdependence between individuals and the group. Their relationship with others can be a source of meaning as well as distress. (Adlerian, Jungian, Family systems, Crosscultural, Existential) 

6. 
Human beings are capable of transcending biological, environmental, and historical influences. They have the freedom and responsibility to choose their own futures; they are the authors of their own life stories. (Existential, Behavioral, Reality therapy, Person-centered, Narrative, Ex1stent1al) 


7 Human beings are capable of construing their own experiences and attaching unique meanings to each situation. (Adlerian, Jungian, Cognitive, Existential) 
8. 
The human condition necessarily involves experiences of stress, anxiety, fear, guilt, shame, meaninglessness, despair, frustration, and fear of death; but people can live fulfilling lives in spite of suffering, anxiety, and distress. (Existential) 

9. 
Cognitions (i.e., beliefs, schemas, and attitudes) are important determinants of emotions and behaviors. (Adlerian, Cognitive-behavioral, Existential) 


1 0. Human beings are capable of being good and bad, rational and irrational. Choosing among these conflicting forces is a life-long struggle. (Jungian, Rational-Emotive, Existential) 
11. 
Human beings are capable of change and personal growth through learning. (Jungian, Adlerian, Cognitive-behavioral, Existential). 

1
2. Human beings are capable of spiritual experiences and higher levels of consciousness. (Jungian, Transpersonal, Ex1stentialL 


50 
Key Concepts of MCCT 
1. 
The quest for meaning and purpose is a primary motivation. (Adlerian, Existential) 

2. 
Causal and existential attributions reflect the cognitive need for meaning. (Cognitive, Existential) 

3. 
Responsibility and choice are essential to mental health. (Adlerian, Existential) 

4. 
Cognitive schemas are a means of organizing life experiences and, as such, have considerable influence on how we process information and make decisions. (Cognitive-behavioral, Adlenan, Existential) 

5. 
Dysfunctional beliefs and distorted schemas can lead to psychological problems. (Cognitive-behavior, Existential) 

6. 
Significant life tasks are necessary for meaningful living. (Adlerian, Existential) 

7. 
Reinforcement and validation are needed to sustain goalstriving and endow life with some measures of fulfillment. (Adlerian, Behavioral, Existential) 

8. 
Self-transcendence is essential to mental health and personal development. (Jungian, Adlerian, Existential) 

9. 
Life review contributes to personal development. (Adlerian, Narrative, Existential) 

1
0. The stress and coping process is important to aid in the understanding of personal difficulties. (Cognitive-behavioral, Existential) 

11. 
Existential coping and spiritual coping are important aspects of adaptation. (Cognitive-behavioral, Existential) 

1
2. Coping resources and coping skills are needed for successful adaptation. (Cognitive-behavioral, Existential) 

1
3. Realistic and optimistic stress appraisal is important to successful adaptation. (Cognitive-behavior, Existential) 

14. 
Acculturation is an integral part of adaptation. (Cognitivebehavioral , Cross-cultural, Existential) 

15. 
Effective problem solving includes both preventive and reactive components. (Cognitive-behavioral, Existential) 

1
6. Perspective taking provides new understandings. (Cognitivebehavioral, Existential) 

1
7. Authentic living means being true to one's values and ideals. ( Ex1stenti al) 


57 
1 
8. Authentic living requires courage to take risks and endure suffering. (Existential) 

1 
9. Therapy involves a genuine encounter between two human beings. (Gestalt, Existential) 


20. 
Therapy involves a journey of personal transformation. (Gestalt, Existential) 

21. 
The therapist serves as a coach and a mentor. (Adlerian, Cognitive-behavioral, Existential) 


22.Achieving integration or integrity is a sign of personal growth and mental health. (Jungian, Existential) 
Therapeutic Goals of MCCT 
1. 
To encourage clients to explore what is missing in their lives and discover what they really want. (Person-centered, Existential) 

2. 
To challenge clients to examine their values and priorities and discover what is worth living and dying for. (Adlerian, Existential) 

3. 
To work with clients in reviewing their past and assessing their strengths and weaknesses in order to develop realistic and meaningful goals. (Adlerian, Existential) 

4. 
To empower clients to grow towards openness, integration, and fulfillment of potential. (Person-centered, Jungian, Existential) 

5. 
To challenge clients to replace dysfunctional attitudes and distorted schemas with more adaptive ones. (Cognitivebehavioral, Existential) 

6. 
To confront clients with their self-defeating strategies and Achilles' heels. (Cognitive-behavioral, Existential) 


7 To challenge clients to develop a greater awareness and a deeper understanding of themselves and their life situations. (Person-centered, Existential) 
8. 
To help clients develop more effective ways of coping with the demands of life and achieve meaningful life goals. (Cognitivebehavioral, Reality therapy, Existential) 

9. 
To help clients develop new patterns of relating. (Adlerian, Family systems, Existential) 

1
0. To help clients become more aware of their own ethnic/cultural identity in order to develop a more integrated self-concept. (Cross-cultural, Cognitive-behavioral, Existential) 


52 
11.To help clients become more aware of their own unresolved issues and conflicts. (Freudian, Existential) 
12. To help clients rewrite life stories in which they overcome their obstacles and become the kind of persons they really want to be. (Narrative, Existential) 
The Therapeutic Relationship of MCCT 
The relationship between therapist and client is complex and operates at several levels. 
1. 
At the social level, it is the meeting of two strangers learning to know each other in a safe, supportive environment. 

2. 
At the existential level, it is the encounter between two human beings on equal footing and the transaction between two private worlds. 

3. 
At the professional level, it is a therapist-client relationship with unequal power, because the therapist possesses certain expertise needed by the client. 

4. 
At the functional level, it is a mentor-protege relationship, in which the therapist encourages and helps the client to succeed. 

5. 
At the symbolic level, it is like two travelers on a difficult journey struggling together and helping each other to reach the same destination. 


Therapeutic Interventions of MCCT 
1. 
Providing encouragement, validation, and inspiration. (Adlerian, Existential) 

2. 
Reflecting feelings and meanings. (Person-centered, Existential) 

3. 
Assessing sources of personal meaning. (Existential) 

4. 
Exploring ways of finding meaning and purpose. (Existential) 

5. 
Clarifying levels of construed meaning. (Cognitive, Family systems, Existential) 


53 
6 Clarifying values and beliefs. (Adlerian, Cognitive-behavioral, Ex1stential i 
7. 
Confrontation. (Cognitive-behavioral, Existential) 

8. 
Magic questions. (Adlerian, Solution-focused, Existential) 

9. 
Life review. (Adlerian, Narrative, Existential) 

1
0. Story-making. (Narrative, Existential) 

11. 
Paradoxical interventions. (Adlerian, Cognitive-behavioral, Existential) 

1
2. Dereflection. (Cognitive, Existential) 

1
3. Day dreaming, imagination, and fast-forwarding. (Cognitive, 


Existential) 14.Journaling and letter writing. (Cognitive, Narrative, Existential) 
1
5. Using symbols and metaphors. (Jungian, Existential) 

1
6. Dream analysis. (Jungian, Existential) 

1
7. Transference and countertransference. (Psychoanalysis) 

1
8. Using drawings and charts. (Jungian, Cognitive-behavioral, Ex1stent1al) 

1
9. Exploring new possibilities and limits. (Cognitive-behavioral, Existential) 

20. 
Working on personal projects. (Cognitive-behavioral, Existential) 

21. 
Directive and didactic methods. (Cognitive-behavioral , Reality therapy, Existential) 


22.Modeling, reinforcement, and skill training. (Cognitivebehavioral) 
23. 
Refram1ng, cognitive restructuring, and perspective taking. (Cognitive-behavioral, Existential) 

24. 
Socratic dialogue and challenging dysfunctional beliefs. (Cognitive-behavioral, Existential) 

25. 
Role play and imagery. (Cognitive-behavior, Existential) 

26. 
Problem-solving and coping skills training. (Cognitivebehavioral) 

2
7. Stress-inoculation and rehearsal. (Cognitive-behavioral) 

28. 
Focusing on here and now feelings and sensations. (Gestalt, Experiential) 


29.Joining the family, family mapping, and setting boundaries. (Family systems) 
54 
30. Using family and ethno-cultural resources. (Cross-cultural, Family systems) 
Conclusion 
I have presented, in broad strokes, an integrative model of MCCT. Although MCCT appears to be technically eclectic, it is actually an integrative metatheory, because MCCT spells out hidden assumptions and synthesizes different theoretical models and interventions into a coherent model. 
The integrative perspective has increasingly become the therapeutic stance of choice.4 I have taken up the challenge of developing an integrative model, with meaning playing a central role. I believe that logotherapy is likely to have a greater impact on the therapeutic community when it becomes the core of a broader and constantly evolving integrative model, 
PAUL T. P. WONG, Ph.D. [Trinity Western University, 7600 Glover Road, Langley, British Columbia V2Y 1Y1, Canada] is Professor and Director of the Graduate Program in Counseling Psychology at Trinity Western University. 
55 
References 
1. 
Corey, G. (1996). Theory and practice of counseling and psychotherapy (5th ed.). Pacific Grove, CA: Brooks/Cole Publishing Company. 

2. 
Frankl, V. (1963), Man's search for meaning. Boston, MA: Beacon. 

3. 
May, R., & Yalom, I. (1995). Existential psychotherapy. In R. 


J. Corsini & D. Wedding (Eds.), Current psychotherapies (5th ed.) (pp. 262-292). Itasca, IL: F. E. Peacock. 
4. 
Norcross, J. C., & Newman, C. F. ( 1 992). Psychotherapy integration: Setting the context. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration (pp. 3-45). NY: Basic Books. 

5. 
Sue, D. W., Ivey, A., & Pederson, P. (1996). A theory of mult1cultural counseling. Pacific Grove, CA: Brooks/Cole Publishing Company. 

6. 
Wong, P. T. P. (1997). Meaning-centered counseling: A cognitive-behavioral approach to logotherapy. The International Forum for Logotherapy, 20, 85-94. 

7. 
Wong, P. T. P. ( 1 998). Meaning-centred counseling. In P. T. P. Wong & P Fry (Eds.), The quest for human meaning: A handbook ol psycholog1cal research and clinical applications. 


IVlahwah, NJ: Lawrence Erlbaum Associates, Inc., Publishers. 
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The International Forum for 
LOGOTHERAPY 
Journal of Search for Meaning