Viktor Frankl
... to realize values, even if only attitudinal values. Frankl does not claim to have an answer for the client's meaning to life. Meaning must be found but it cannot be given. Logotherapy is an optimistic approach to life for it teaches that there are no tragic or negative aspects which cannot be the stand one takes to them be translated into a positive accomplishment (Meyer, Moore & Viljoen, 1997). 3. LINK BETWEEN LOGOTHERAPY AND PSYCHOPATHOLOGY 3.1 Existential Vacuum In order to understand the link between logotherapy and psychopathology or more specifically depression, Frankl’s concept of noögenic neurosis and existential vacuum needs to be explored: The striving after meaning can, of course, be frustrated, and this frustration can lead to noögenic neurosis, what others might call spiritual or existential neurosis. People today seem more than ever to be experiencing their lives as empty, meaningless, purposeless, aimless, adrift, and so on, and seem to be responding to these experiences with unusual behaviors that hurt themselves, others, society, or all three. One of Frankl’s favorite metaphors is the existential vacuum. If meaning is what we desire, then meaninglessness is a hole, an emptiness, in our lives. Whenever you have a vacuum, of course, things rush in to fill it. Frankl suggests that one of the most conspicuous signs of existential vacuum in our society is boredom. He points out how often people, when they finally have the time to do what they want, don’t seem to want to do anything! People go into a tailspin when they retire; students get drunk every weekend; society submerges itself in passive entertainment every evening. Frankl (1963) calls it the "Sunday neurosis.” So individual’s attempt to fill this existential vacuums with “stuff” that, because it provides some satisfaction, one hopes will provide ultimate satisfaction as well: one might try to fill one’s lives with pleasure, eating beyond all necessity, having promiscuous sex, living “the high life;” or one might seek power, especially the power represented by monetary success; or one might fill their lives with “busy-ness,” conformity, conventionality; or might fill the vacuum with anger and hatred and spend the days attempting to destroy what one thinks is hurting him/herself. Individuals might also fill their lives with certain neurotic “vicious cycles,” such as obsession with germs and cleanliness, or fear-driven obsession with a phobic object. The defining quality of these vicious cycles is that, whatever one does, it is never enough (Frankl, 1963). These attitudes (Filling our lives with “stuff”) lead to nihilism that is that response to life that says that being has no meaning. A nihilist is one who considers that life is meaningless. Man has freedom in spite of his instincts, inherited disposition, and environment. Certainly man has instincts, but these instincts do not have him. One can accept or reject his instincts. Regarding heredity, Frankl talks about twins, one of which was a cunning criminal and the other a cunning criminologist. Both were born with cunning, but each used it differently. As for environment, it does not make the man, but everything depends on what man makes of it: on his attitude toward it (Pytell, 2000). 3.2 Logotherapy and psychopathology 3.2.1 Anxiety neuroses Anxiety neuroses are seen as founded on existential anxiety -- "the sting of conscience." (1963, p. 179) The individual, not understanding that his anxiety is due to his sense of unfulfilled responsibility and a lack of meaning, takes that anxiety and focuses it upon some problematic detail of life. The hypochondriac, for example, focuses his anxiety on some horrible disease; the phobic focuses on some object that has caused him concern in the past; the agoraphobic sees her anxiety as coming from the world outside her door; the patient with stage fright or speech anxiety focuses on the stage or the podium. The anxiety neurotic thus makes sense of his or her discomfort with life (Kroon, 1997). Frankl notes, that "Sometimes, but not always, it (the neurosis) serves to tyrannize a member of the family or is used to justify oneself to others or to the self..." (1963, p. 181) but warns that this is, as others have noted as well, secondary to the deeper issues (Rogina, 2000). 3.2.1.1 Treatment Rogina (2000) proposes a logotherapeutic protocol for treating anxiety disorder which includes five steps of meaning centered treatment intervention. The logotherapy principles are sometimes implicit and sometimes explicit within each step (Rogina, 2002). 3.2.1.2.1 Step 1 – Name the worry In the first stage the logotherapist assists the patient to name and verbalize specific worries. The patient should not stay in generalized or vague worry feelings. The patient names one specific worry which becomes the focus of treatment. 3.2.1.2.2 Step 2 – Emptying the worry In this stage the therapist provides training and instructions in relaxation, cognitive skills and other resources to accomplish somatic calm and centeredness 3.2.1.2.3 Step 3 – Noetic Anchoring In this stage the therapist assist the patient in finding uniqueness, and the focus is on the modification of the client’s attitudes towards the disorder and the meaning in life. By the end of this stage the patient should have began his cognitive search for something meaningful in his/her life. 3.2.1.2.4 Step 4 – Opening up willingness for meaningful behaviour The aim of this stage is for the patient to initiate self appraisal and begin to reflect on his/her own life. This reflection would assist the patient in opening up to the idea that he/she can have something meaningful which s/he can work towards. In this stage the therapist can also use dereflection and paradoxical intention as appropriate. 3.2.1.2.4.1 Paradoxical Intention It is commonly observed that anxiety often produces precisely what the patient fears. Frankl calls this anticipatory anxiety. For instance, in cases of insomnia, the patient reports that she has trouble going to sleep. The fear of not going to sleep only adds to the difficulty of trying to go to sleep. Many sexual problems may be traced back to the forced intention of attaining the goal of sexual intercourse: as in the male seeking to prove his potency or the female her ability to experience orgasm. It seems that anticipatory anxiety causes precisely what the patient fears (Coetzer, 1997). It is upon this fact that Logotherapist bases the technique known as "paradoxical intention." For instance, when a phobic patient is afraid that something will happen to him, the Logotherapist encourages him to intend for precisely what he fears. For example, Frankl tells the story of a young physician who sweated excessively when in the presence of his chief. At other time, he was not bothered by excessive sweating. The patient was advised to resolve deliberately to show the chief just how much he really could sweat. He was to say to himself, "I only sweated out a liter before, but now I'm going to pour out at least 10 liters." Through this paradoxical intention, he was able to free himself of his excess sweating. The treatment consists not only in a reversal of the patient's attitude toward his phobia but also that it is carried out in a humorous way if possible (Coetzer, 1997). 3.2.1.2.4.2 Dereflection A second technique is called dereflection. Frankl believes that many problems stem from an overemphasis on oneself. By shifting attention away from oneself and onto others, problems often disappear. If, for example, a person feels anxious getting up on stage, using dereflection, that person should attempt to concentrate on the audiences satisfaction with his talk without appraising own performance. Concerns over anxiety disappear. Frankl insists that, in today's world, there is far too much emphasis on self reflection. Since Freud, we have been encouraged to look into ourselves, to dig out our deepest motivations. Frankl even refers to this tendency as our "collective obsessive neurosis." (1963, p. 95) Focusing on ourselves this way actually serves to turn us away from meaning (Hutchinson, 2002). 3.2.1.2.5 Step 5 – Learning to live meaningfully with normal anxieties In this final stage the patient develops meaningful tasks and attention on part of the patient is paid towards meaning potentials. In other words attention is paid towards looking at every opportunity as a potential for finding meaning. 3.2.2 Obsessive-compulsive disorder Obsessive-compulsive disorder works in a similar fashion. The obsessive-compulsive person is lacking the sense of completion that most people have. Most of us are satisfied with near certainty about, for example, a simple task like locking one's door at night; the obsessive-compulsive requires a perfect certainty that is, ultimately, unattainable. Because perfection in all things is, even for the obsessive-compulsive, an impossibility, he or she focuses attention on some domain in life that has caused difficulties in the past (Hutchinson, 2002). 3.2.2.1 Treatment. The logotherapist should attempt to help the patient to relax and not fight the tendencies to repeat thoughts and actions. Further, the patient needs to come to recognize his temperamental inclinations towards perfection as fate and learn to accept at least a small degree of uncertainty. But ultimately, the obsessive-compulsive, and the anxiety neurotic as well, must find meaning. "As soon as life's fullness of meaning is rediscovered, the neurotic anxiety... no longer has anything to fasten on." (1963, p. 182) People with OCD often feel like slaves to their disorder and often feel like they have little control over their symptoms. Therefore, OCD sufferers need to be challenged to accept their disorder with dignity and courage, and yet to take a stand against their symptoms by living a meaningful life. Frankl refers to this as attitudinal values, which can be the highest or ultimate way a human being can find meaning (Lukas, 1986). 3.2.2.1.1 Craziness and Humour One of the core components of OCD is that people afflicted with this disorder often fear they are “crazy.” They believe that their obsessions will make them dangerous or immoral, and that they will act out on these thoughts. OCD sufferers are not aware that many people who do not have OCD also have many random, nonsensical thoughts, and yet are able to live productive lives. Logotherapists may wish to present OCD clients with a list of “intrusive thoughts” gathered from a community sample of people who do not present for therapy to show them that their thoughts are not that abnormal (Millon & Davis, 1996).Once this fear is reduced, logotherapists can continue helping OCD clients change their attitudes towards the disorder. The goal is to have the OCD client develop a relaxed attitude towards his or her symptoms. This can include using humour to ridicule the symptoms, and to help the client ultimately laugh at him or herself. This use of humour will assist the OCD clients in creatively distancing themselves from their symptoms (Hutchinson, 2002). 3.2.2.1.1 Paradoxical Intentions To gain some control over their symptoms the OCD patients can make use of paradoxical intentions (refer to 3.2.1.2.4.1, p.7), to face the “fateful event” that is causing them so much anxiety (Hutchinson, 2002). 3.2.2.1.1 Dereflection (Refer to 3.2.1.2.4.2, p.7) It is all too tempting for people with OCD to want to fight their obsessions, often by engaging in an extensive analysis of what these thoughts may really mean. Unfortunately the more the person gets involved with the obsessions. The more the obsessions may persist and perhaps intensify (Hutchinson, 2002). For OCD sufferers, dereflection can help them decenter their obsessions as they fulfill meaningful tasks. As the person with OCD begins to accept the obsessions as part of fate and becomes involved in life tasks, the symptoms may begin to remit. The OCD client even may learn to ignore the obsessions as he or she focuses on concrete goals. As these goals are fulfilled, OCD clients may feel happier, and overall decrease in the symptoms connected with the disorder is experienced (Hutchinson, 2002). 3.2.3 Schizophrenia Schizophrenia is also understood by Frankl as rooted in a physiological dysfunction, in this case one which leads to the person experiencing himself as an object rather than a subject (Tsuang & Winokur, 1996). Most of people, when they have thoughts, recognize them as coming from within their own minds. They "own" them, as modern jargon puts it. The schizophrenic, for reasons still not understood, is forced to take a passive perspective on those thoughts, and perceives them as voices. And he may watch himself and distrust himself -- which he experiences passively, as being watched and persecuted. Frankl believes that this passivity is rooted in an exaggerated tendency to self-observation. It is as if there were a separation of the self as viewer and the self as viewed. The viewing self, devoid of content, seems barely real, while the viewed self seems alien (Boeree, 1997). 3.2.3.1 Treatment Although logotherapy was not designed to deal with severe psychoses, Frankl nevertheless feels that it can help: By teaching the schizophrenic to ignore the voices and stop the constant self-observation, while simultaneously leading him or her towards meaningful activity, the therapist may be able to short-circuit the vicious cycle (Boeree, 1997). 3.2.4 Depression 3.2.4.1 What is Major depression? Major depressive disorder is one in a group of conditions called mood disorders. Mood disorders are categorized by type of mood (low or elevated) and by severity. Major depression is the disorder characterized by severe, low mood. Although there is a very specific clinical definition for this type of depression, depression comes in many forms, E.g. Bipolar mood, where episode of depression may alternate with periods of elevated moods. Another type would be dysthymia, which is condition where severe depression may be superimposed on a long, even life-long, pattern of mild low mood. Other types of depression are postpartum depression (If a major depressive episode occurs in a woman within a month of delivering a baby) and seasonal affective disorder where depression occurs according to a seasonal pattern (Tsuang & Winokur, 1996). The key feature of any depression is a change in mood, usually experienced as low mood, but it may be felt as irritability, as a lack of pleasure or interest in pleasurable activities (anhedonia), or a loss of energy. Usually, in major depression, the mood change is considered distinct and severe and lasts for a significant period (at least two weeks) (American Psychiatry Association, 1994). A clear biological cause has not been determined, but major depression probably involves changes in the transmission of chemical messengers (neurotransmitters) in certain regions of the brain. There may also be hormonal changes (for example, the steroid or thyroid hormones). Environmental causes, such as early losses (the death of a parent, for instance) or stressful events, have an impact, too. An episode of depression may well be triggered by a stressful life event, but in many cases, it is not possible to identify a precipitating event (Potter, Rudofer & Manji, 1991). Major depressive episodes are quite common. They can occur at any age and about twice as many women are affected as men. There is also a genetic link, with an increased incidence of depression and drinking in the family members of people who have suffered major depression (Potter, Rudofer & Manji, 1991). 3.2.4.1.1 Symptoms According to the American Psychiatry Association (1994) a depressed person may notice a change in weight or appetite (either an increase or decrease) and a change in sleep pattern (insomnia or sleeping more than usual). He or she may feel tired, with no energy for work or play and it may be quite noticeable to others. The person can actually appear slowed down. Or, friends and family may notice agitation and restlessness. Depression can also affect an individual's ability to concentrate. Perhaps the most painful and most dangerous aspect of this illness is an unshakable feeling of worthlessness and guilt. One may feel guilty about a specific life experience. There may be a global feeling of this without clear content. Small burdens or obstacles may appear impossible to manage. If pain and self-criticism become great enough, it can lead to feelings of hopelessness, self-destructive behaviour, thoughts of death and suicide. The vast majority of people who suffer severe depression do not attempt or commit suicide, but they are at increased risk. People with major depression quite commonly have distorted thinking; for example, they are likely to be pessimistic out of proportion with the reality of their situation. Sometimes, thinking becomes frankly psychotic, that is, the person has a gross impairment in the ability to recognize reality. They may develop delusions (false beliefs) or hallucinations (false perceptions). According to the American Psychiatry Association (1994) symptoms of major depression include: • Distinctly depressed or irritable mood • Loss of interest or pleasure • Weight/appetite decreased or increased • Increased or decreased sleep • Appearing slowed or agitated • Fatigue and loss of energy • Feeling worthless or guilty • Poor concentration • Thoughts of death, suicide attempts or plans 3.2.4.1.2 Diagnosis A primary care physician or a mental health professional usually can make a diagnosis on the basis of history. Major depression is diagnosed when a person has at least five out of the nine symptoms listed above lasting at least two weeks. It is, however, less important to decide whether it is major or minor, and more helpful simply to recognize that some form of mood disorder is present. There is a great deal of overlap with other common mood disorders, such as dysthymic disorder and bipolar disorder (Millon & Davis, 1996) 3.2.4.1.3 Expected Duration Episodes of major depression last on average four to eight months, but they can last for any length of time. Symptoms may vary in intensity during an episode. Left untreated, it can become chronic. Treatment can and often does considerably shorten an episode's duration and severity (American Psychiatry Association, 1994). 3.2.4.2 Conventional Treatment of major depression A combination of psychotherapy and medication is most helpful. The most commonly prescribed antidepressants are in the group known as selective serotonin reuptake inhibitors (SSRIs). They are fairly easy to take and relatively safe compared to previous generations of antidepressants (Byrum, Ahearn & Krishhnan, 1999). No medication is without side effects. SSRIs are known to cause problems with sexual functioning, some nausea, and an increase of anxiety in the early stages of treatment and apathy in the long run. Concerns about the increased risk of suicide have been overblown, but a very small number of patients taking these medications (as with all antidepressants) may feel worse rather than better as a result of taking the medication (Byrum, Ahearn & Krishhnan, 1999). The older classes of antidepressants, tricyclic antidepressants and monoamine inhibitors, are still in use and can be very effective for those who have not responded to other treatments (Byrum, Ahearn & Krishhnan, 1999). A number of psychotherapeutic techniques may be helpful depending on a number of factors, including possible precipitating events, the availability of family and other social support, and personal preference. Education about depression and support is always called for. Cognitive behavioural therapy is designed to examine and help correct faulty, self-critical thought patterns. Psychodynamic, insight-oriented or interpersonal psychotherapy can help a person sort out conflicts in important relationships or explore the history behind the symptoms (Keller, 2000). In some situations, the controversial, but clearly effective electroconvulsive therapy (ECT) can be a life-saving option. While anesthetized and carefully monitored, a seizure is induced with an electrical impulse. Medication is given before the procedure to prevent any outward signs of convulsions. Improvement is seen gradually over a period of days to weeks. Contrary to what is popularly believed about ECT, it is the quickest and most effective treatment for the most severe forms of depression, and the risks compare favourably with other antidepressant treatments (Miller, 1994). 3.2.4.3 Logotherapy and Depression Frankl (1963) sees depression, as founded in a "vital low," i.e. a diminishment of physical energy. On the psychological level, he relates depression to the feelings of inadequacy we feel when we are confronted by tasks that are beyond our capacities, physical or mental. On the spiritual level, Frankl views depression as "tension between what the person is and what he ought to be." (1988, p. 202) The depressive patient exaggerates this gap between the self in the present and ideal in the future, thereby creating the sense that there is no future to live for. The ever-present gap between what is and what should be becomes a "gaping abyss." (1988, p. 202) The demand to be the ideal self is not only an irrational belief, but is based upon a narcissistic desire rather than response to a value. A human being may experience being pushed by his instincts and drives, but values always exercise a pull leaving the person with a choice to respond for his values (Merbis, 2002). For example, someone may be pushed or urged to use another person to reduce tension created by aggressive instincts, but the person may also chose to love another human being. In fact Frankl (1985b) maintained only to the extent that sex becomes integrated as a physical expression of love is it really a rewarding experience. A value does not urge, demand or push as psych-physiological needs, drives and instincts do, and therefore values are rooted in spiritual or existential dimensions, not the somatic or and psychosocial dimensions . Therefore Depression may reflect an existential or spiritual struggle (Merbis, 2002). Unfortunately, science has yet to ascertain the importance of existential dimension in the cause and treatment of depression. It can only be established that people with depression struggle with the meaning of life (Crumbaugh, 1968). The existential issues come forth from the lack of awareness as to what is valuable and meaningful in life, and thereby the person fails to vitally engage with life and others. This is what Fankl called, an existential vacuum (refer to 3.1, pp 5). Another aspect of depression is that humans respond to the fact that they have depression, and in some cases the response is marked by negatively biased thoughts. In fact Frankl (1988) points out that a patient may falsely believe that he/herself is causing the depression and can become frustrated, guilty, and self-depreciatory adding a secondary depression. 3.2.4.4 Logotherapy and the treatment of unipolar/major depression Depressive patients may be willing to struggle with the question whether life is meaningful, but it may eventually lead to apathy if the actualization of creative, experiential and attitudinal values (refer to 2.2.3, pp.5) continue to be frustrated by circumstances and, most significantly, by their own way of thinking and behaving (Merbis, 2002). According to Frankl, this may lead to noogenic neurosis (3.1, pp.5). The point that Frankl makes is that everyone is responsible themselves for discovering and actualizing meaning in their lives, and the task of the logotherapist is to challenge and encourage the person to continue to wrestle with difficult questions and actualize values by performing deeds (Frankl, 1997). Ungar (2002) proposes 3 phases in which the logotherapist can assist the depressed in discovering and actualising meaning in their lives 3.2.4.4.1 Diagnostic Phase The diagnostic phase as the name suggests is where the logotherapist would diagnose different symptoms of the client’s, e.g. suicidal thoughts, low self esteem, self blame, etc. from a careful clinical interview. By making the symptoms objective, therapist aid in client’s self-distancing, and assuming a stand towards these symptoms. Here the task is to see the symptoms for what they are, as the sign of the depressive illness, nothing more and nothing less. Only by taking the depressive illness seriously and objectively will clients learn how to take its symptoms “lightly” (Frankl, 1988). 3.2.4.4.2 Therapy Phase According to Ungar (2000) therapy, in general, starts with attention to the safety of the patient. Suicidal thoughts, which can increase in frequency, have to be monitored. Patients need to be asked directly about them: “Do you have thoughts of harming yourself?” Frankl claimed that questioning the patient is important in monitoring the patients’ progress. This technique and its importance is illustrated by a real life example in an address by Victor Frankl to the Evolution of Psychotherapy Conference in Hamburg (1994). In this address Frankl claimed that from 1928 to 1938 he worked with William Burner who was the Director of a center for people who suffer from depression. Frankl said that he learned something there that I was able to use when he became Director of the Suicide Pavilion at the Steinhof, a psychiatric hospital in Vienna. During his four years at the hospital approximately 12,000 suicidal patients were put under his charge. As the Director it was his responsibility to determine whether or not a patient was ready for discharge, a decision which carried tremendous responsibility. Out of this experience he says he developed a series of questions which allowed him to assess the condition of a patient in only five minutes. During a face to face interview Frankl would ask the patient, "Do you know that it is time for your release?" He would say, "Yes." Frankl would then ask, "What do we do next? Should we keep you here?" In almost every case the patient would say, "No." Then Frankl would ask, "Are you truly free from all intention to commit suicide?" To this he would respond, "I have no more intentions of committing suicide. You can let me go home." But Frankl had to make sure that the patient was not dissimulating, so immediately after his response, that he had no intention of killing himself, Frankl would ask, "Why not?" Next, one of two things would happen. The first type would sink into the chair, unable to respond or to look Frankl in the eye. With a toneless voice he might repeat himself saying, "No, no, doctor...I am not going to commit suicide." This sort of response indicated that the patient was in very serious danger of suicide. In contrast, a patient who immediately stated that he had a duty, (e.g., "I am needed at work." or "My religion forbids suicide."), some meaning to fulfil, (e.g., "My family is counting on me."), he was safe to release from care. He would not kill himself because he had a "why." As Nietzsche has said, whoever has a "why" will in almost every situation find a "how." (Frankl, 1994). Another technique which can be utilised by the logotherapist in this phase is paradoxical intention (refer to 3.2.1.2.4.1, p.7), which operates under the general assumption that “things get better when you try to make them worse” (O’Connell, 1983, p.12). Here the client is given a rationale for the reason the behaviour is being encouraged (Bergman, 1982). For example, if the depressed is determined to lie in bed 20 hours a day with minimal social interaction, then the logotherapist would encourage the patient to lie in bed for 23 hours a day with no social interaction at all. The patient would struggle with these rules and wit...