Therapeutic Alliance Part 2: Meaning and Viktor Frankl’s Logotherapy

Episode CME activity objectives:

In the context of a therapeutic alliance, apply the information given in this episode to help draw out meaning in others.

Identify who Viktor Frankl was and how his work and legacy have shaped how we understand and utilize meaning in psychiatry.

Define psychic determinism.

Recognize that meaning is idiosyncratic and unique to each individual.

Recognize the multitude of ways people can find meaning in their lives and the various ways they can express and convey this.

Summarize the various studies listed in this episode that have shown how meaning and the creation of meaning can have a positive impact.

David Puder, M.D. has no conflicts of interest to report.  

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In this week’s episode of the podcast, I’m going to be emphasizing the meaning that I, as a therapist, can help draw out of other people’s experience through a therapeutic alliance.

David Puder, M.D., Kristen Bishop, Brooke Haubenstricker, Mikyla Cho

In the celebrated book Man’s Search for Meaning, author Viktor Frankl wrote about his intimate and horrific Holocaust experience. He found that meaning often came from the prisoners’ small choices—to maintain belief in human dignity in the midst of being tortured and starved and bravely face these hardships together.

“The way in which a man accepts his fate and all the suffering it entails, the way in which he takes up his cross, gives him ample opportunity—even under the most difficult circumstances—to add a deeper meaning to his life. It may remain brave, dignified and unselfish. Or in the bitter fight for self-preservation he may forget his human dignity and become no more than an animal.” - Viktor Frankl

“We who lived in concentration camps can remember the men who walked through the huts comforting others, giving away their last piece of bread. They may have been few in number, but they offer sufficient proof that everything can be taken from a man but one thing: the last of the human freedoms—to choose one’s attitude in any given set of circumstances, to choose one’s own way.” - Viktor Frankl

Frankl argued that the ultimate human drive is the “will to meaning,” which could be described as the meaning to be found in the present and in the future. For example, I have had patients who are suicidal, yet they would not kill themselves, despite part of them desiring death, because they would not get to see their grandkids grow up. The meaning of the future moments and being able to help their grandkids in some small way empowers them to keep going to treatment.

People’s meaning keeps them going, even when other drives, like sex or desire for power, are completely gone. In this way, Frankl noted, “Focus on the future, that is on the meaning to be fulfilled by the patient in his future…I speak of a will to meaning in contrast to the pleasure principle (or, as we could speak also term it, the will to pleasure) on which Freudian psychoanalysis is centered, as well as in contrast to the will to power on which Adlerian psychology, using the term ‘striving for superiority,’ is focused.”

This idea led to the beginning of a new type of therapy—logotherapy.

Helping a patient find meaning

Being unable to find personal meaning in our lives can lead to depression, hopelessness, anxiety, and suicidality. As a physician, I see this often, and I try to help my patients find meaning in their lives. However, the approach I have learned from Dr. Tarr (my mentor), and from my studies, is different than the normal approach of just asking people, “What is your purpose?” or, “What is your vision for the future?” The technique I use is based on another principle called “psychic determinism,” which means that everything has meaning. There is nothing that a person says, no flash of emotion, no change in body posture that is meaningless.

When you believe this, you view the patients’ words differently. The meaning may not be readily apparent; it may be expressed in primary process mentations and have an unconscious-type meaning like dreams, which may be difficult to understand. Suffice to know at this point that the mindset we have when we approach people is that everything they say has meaning; every sequence of thoughts that they say is deep and valuable.

We start from small moments of meaning that are coming from their words, their body language, their microexpressions, your experience of them in the moment, and we take those small moments of meaningfulness and start to verbalize what we find meaningful. Listening to our patients and helping them to understand the hidden meaning in their lives, even in the midst of work or difficult times, can help them withstand trauma, stress, and hardships.

No rambling is random

Sometimes patients will talk for awhile, changing subjects rapidly, and we may think it is random, but it isn’t. Even when schizophrenic patients talk, there is meaning behind what they’re saying. When we allow for free association, we can derive a sense of meaning from the commonalities in topics that come up.

For example, a patient might be talking about how they are angry at their significant other, then immediately report that when they were young their mother would often yell at their father, and their father would cower in his room in silence. How is their current anger related to how they felt as a child watching this drama? How might the two be linked? What about the microexpression of disgust that flashed as they reported both topics.  

As you look deeper, the meaning becomes more evident. In this particular situation, the disgust or revulsion they experience recollecting their father’s cowardice magnified the disgust they felt toward their significant other. Understanding the link and the uncovered meaning helped them tolerate the intensity of that negative feeling, and helped them develop new meanings about their current and past experiences.

Even hallucinations and delusions generated by some mental illnesses have meaning. When I’ve given patients antipsychotics and they’ve adapted to the medicine, we explored their hallucinations and they were able to see why they wanted to believe in an alternate reality—it gave them a sense of power or control, or related to a deep underlying fear in some way. As we developed meaning in their real lives, they felt more comfortable in their actual reality.

When we sincerely believe that everything the patients say has meaning, the patients themselves feel meaningful. Ascribing meaning enhances the patient’s esteem tremendously and makes them feel safe enough to continue to freely associate. Incredible progress can be made with patients in this way.

To get people to free associate, you need to reduce the shame enough to get people to feel safe enough to be able to share their uncensored thoughts and feelings.

Empathize with the meaning

“Men are not moved by events but by their interpretations.” - Stoic Epictetus

Relationships can allow for deeper understanding and meaning to develop in life. To strengthen our relationship with our patients, we must understand what they’re saying and then empathize with that meaning.

We often think in the context of our own lives, and as therapists or physicians we need to allow people to be the experts of their own lives. A word or phrase may mean something completely different to our patients than it does to us, so we must ask the patients to help us understand their interpretations and the meanings they assign to the events they’ve experienced. It is important that the patient communicates their meanings and that assumptions aren’t made. Misunderstandings can cause feelings of isolation, leading to strains or ruptures in the relationship. If this happens, try to reconnect, as this conveys respect.

Try to deeply connect with the patient emotionally through empathy and listening. Listen to what is said, what is not said, and what makes the patient defensive. We can listen to the rhythm, the sound, their vocal cadence, and watch their face for emotional cues.

Even if we believe the patient isn’t entitled to the emotions they are experiencing, we have to search for the meaning they’ve assigned to their pain. That meaning is what we can empathize with, no matter the circumstance. When we empathize, we can join them in their distress or enjoyment, and we can develop a deeper therapeutic alliance that is patient-centered and emotion-centered.  

“To feel with a patient and share distress and hopelessness and mistrust of the future, is therapy. You are an observer in taking history, but you’re a participant as a therapist. To share together, is therapy.” - Dr. Tarr

Meaning develops emotional endurance

People who have chronic pain who believe they are enduring it for a deeper meaning report feeling far less physical pain compared to those who do not report a deeper meaning. Even in birthing units, women report the highest amount of pain, but also often the highest amount of satisfaction. The child being born gives meaning to the pain, and this meaning is so powerful that some women choose to endure the pain instead of accepting medication.

Help patients find meaning in their symptoms. Most symptoms are adaptive, even eating disorders, cutting, and other harmful behaviors. These things have helped people cope with the realities of their lives in some way. We don’t want them to judge their symptoms, but we want them to identify what the meaning behind them.

To really connect with a patient, we must convey to them through our words and actions that they mean something to us, and that we empathize with the meanings they’ve assigned to their lives.

Here are a few phrases I like to use that convey to the patient that I want to connect with them:

“What we are talking about together is meaningful.”

“We want to make sure we are understanding each other.”

“I think I know what you mean. Please tell me if ______ is what you meant. I want to make sure I am understanding you and that we are in tune with each other.”

“If you feel I misunderstood you, please tell me right away so we can clear it up as soon as possible.”

“We will know together, find out together…”

“Could you give an example, elaborate on that, I want to be sure I understand what you are sharing with me.”

“I can understand in part how that interaction would make you feel that way.”

Logotherapy, created by Viktor Frankl, helps patients understand and develop meaning in their lives.

Viktor Frankl’s book not only chronicles how the principles of logotherapy helped Frankl survive the Holocaust, it also recounts his observations of how others used meaning to retain their human dignity during times of great suffering. So what is this “logotherapy” that helped people survive?

Essentially, logotherapy is a meaning-centered approach to psychotherapy. Frankl first published his ideas on logotherapy in 1938, and it is now known as the “Third Viennese School of Psychotherapy.”

The Viktor Frankl Institute lists the three principles that are the basis for logotherapy:

Freedom of will

Will to meaning

Meaning in life

The core tenants can also be elaborated in another way, as done by the Viktor Frankl Institute of Logotherapy in Texas:

Life has meaning in all circumstances, even the most miserable ones.

Our main motivation for living is our will to find meaning in life.

We have freedom to find meaning in what we do, and what we experience, or at least in the stand we take when faced with a situation of unchangeable suffering.

Frankl noted that there are a variety of ways in which we can find meaning, such as by our actions, our experiences, our relationships, and our attitude toward suffering. Indeed, logotherapy has been utilized to help treat a variety of psychiatric illnesses, such as anxiety, depression, obsessive-compulsive disorder, and even schizophrenia. Currently, there are several logotherapy institutes around the world in Africa, Asia, Europe, and North America that focus on educating the public about logotherapy and applying it to find meaning in people’s lives.

Here are some studies about logotherapy:

One study (May, 2010) found psychological safety and psychological meaningfulness was significantly related to engagement in work. 73% of the variance in engagement in work was able to be explained, with 62% coming from meaningfulness and 42% coming from psychological safety.

One study (Mahdizadeh, 2016) of patients after heart surgery found that those receiving logotherapy had improvement in mood. Additionally, this study found that logotherapy did not change the physical capabilities of the patient post surgery. However in the patients who had little to no symptom relief and continued limitation of functions post-op, it still showed an improvement in mood 6 months after the study was completed.

Another study (Robatmili, 2014) had the logotherapy group work on describing what was meaningful, setting goals, and then had the group facilitate each other moving towards their goals. In this treatment group, the “meaning of life” scores increased and depression scores decreased. Discovering and pursuing meaning is facilitated by helping through the following steps: (a) establishing the therapeutic relationship; (b) increasing insight regarding identity, values, and goals; (c) reframing meaninglessness and depression; (d) discovering meaning within the meaninglessness and depression; and (e) pursuing the fulfillment of meaning.

Once you have some positive attributes, you find other positive attributes—like a snowball effect of developing positive meaning in life. One study (Zhang, 2018) showed this after surveying 1,000 elderly people in Hong Kong. There was a higher level of meaning associated with happiness, health status, and decreased healthcare utilization.

Another study (Mahdizadeh, 2016) showed that when educational interventions based on the main concepts of logothearpy were made, it lead to an improvement of the patient’s quality of life after CABG surgery in persons over the age of 35 (specifically, scores in QOL were improved psychologically).

In one study (Mosalanejad, 2013), an infertile experimental group that used logotherapy showed significant decreased psychological stress scores.

One case review (Southwick, 2006) looked at adding a meaning-based intervention into the treatment of chronic combat-related PTSD showed positive enhancement of outcome when combine with traditional therapies and medications.

A study of women with breast cancer (Mohabbat-Bahar, 2014) showed logotherapy to be helpful at reducing anxiety.  

I also discussed a study (Thomas, 2014) regarding how structured sessions helped cancer patients improve their sense of meaning in life.  

A qualitative interview study on nursing home residents (Drageset, 2017) found that meaning could be found in physical and mental well-being, belonging and recognition, personally treasured activities, and spiritual closeness and connectedness.  This present study also showed a link between well-being of patients’ hope for an improved state of health and are in accordance with previous studies showing significant associations between meaning, hope and well-being among older people in nursing homes.

Finally, a study (Leveen, 2017) explored how poetry can be used to increase a sense of meaning in physicians caring for patients.    

Conclusion:

By focusing on what is said by our patients and those we care about and by believing that everything that is said has meaning, we can increase our connectedness with them.  We can also slowly find the deeper sources of meaning and purpose which can help make sense of suffering and physical and emotional pain.