Psychotherapy , , Practice, Training Copyright 2008 by the American Psychological 2008, Vol. 45, No. 4, 447–463 0033-3204/08/$12.00 DOI: 10.1037/a0014331

LOGOTHERAPY FOR CLINICAL PRACTICE

STEFAN E. SCHULENBERG ROBERT R. HUTZELL University of Mississippi, Oxford Knoxville, Iowa CARRIE NASSIF JULIUS M. ROGINA Fort Hays State University Diocese of Nevada is based on the - Frankl’s most popular book, Man’s Search for focused existential of Viktor Meaning (Frankl, 2006; originally published in E. Frankl (1905–1997). Numerous men- English in 1959 as From Death-Camp to Exis- tentialism), written over a 9-day period shortly tal professionals have been in- after his concentration camp liberation during spired by his most popular book, Man’s World War II (Hutzell, 2006; Klingberg, 2001). Search for Meaning; however, many The book contains a narrative of concentration are unfamiliar with the depth of camp and outlines some of the basic Frankl’s work. The purpose of this arti- elements of logotherapy. A sense of personal cle is to discuss the tenets of logoth- life-meaning is critical to logotherapy, and Man’s Search for Meaning is a prime example of how erapy, including fundamental , people may reduce despair in severe circum- applicability and techniques, roles of stances by incorporating personal meaning the therapist, and assessment tools and through attitudes, experiences, and . new research findings. Logotherapy can Man’s Search for Meaning was written in 1945, readily be integrated with techniques yet it was still rated as one of the top 10 books to make a difference in the lives of American readers that professionals fre- as recently as the 1990s (Library of Congress, quently use, and thus it has much to 1991). Russ Newman, American Psychological As- offer mental health professionals re- sociation Executive Director for Practice, noted it to gardless of their theoretical orientation. be of particular relevance to after the terrorist attacks of September 11, 2001 (Newman, Keywords: meaning, purpose in life, 2002). The newest U.S. edition of the book (2006) indicates that there are more than 12 million copies logotherapy, , positive in print. Despite its continued relevance, many men- tal health professionals are not familiar with the depth of Frankl’s work. Logotherapy is based on the existential con- Frankl is credited with writing over 30 books. cepts of Viennese and Many were published originally in German, but Viktor E. Frankl (1905–1997). Frankl chose the there have been into at least 32 lan- term logotherapy—based on the Greek word guages. He published over 700 articles. An abbre- “” as “meaning”—because his perspective viated version of Frankl’s vita was published by J. I. emphasizes the unique capacity of beings Levinson in 2001 (Levinson, 2001). For more in- to perceive meaning. Many have been inspired by formation about Frankl’s life and how it influenced the formulation of logotherapy, such as his youth in , correspondence with Freud and Adler, ex- Stefan E. Schulenberg, Department of Psychology, Univer- periences in concentration camps during World sity of Mississippi; Robert R. Hutzell, Knoxville, IA; Carrie War II, and his personal and professional develop- Nassif, Fort Hays State University; Julius M. Rogina, Diocese of Nevada. ment thereafter, the interested reader is referred to Correspondence regarding this article should be addressed to Frankl (1997b), Gould (1993), and Klingberg Stefan E. Schulenberg, PhD, Department of Psychology, Uni- (2001). The purpose of the current article is to versity of Mississipi, Oxford, MS 38677. E-mail: sschulen@ present various aspects of logotherapy, including olemiss.edu major tenets, applicability and judicious use of the

447 Schulenberg, Hutzell, Nassif, and Rogina approach, therapist strategies, assessment-related is- itive health outcomes (Seeman, Dubin, & Seeman, sues, and new research support and remaining 2003). The field of psychology has shown increased . Our intent is to provide an in-depth, yet interest of late not only in but also in concise, orientation to logotherapy compiled from resilience and positive mental health (e.g., Emmons often difficult-to-find publications (e.g., out-of-print & McCullough, 2004; Keyes & Haidt, 2003; Lopez sources), incorporating recently translated texts and & Snyder, 2003; Snyder & Lopez, 2002). Logoth- current and forthcoming empirical findings. This erapy has long emphasized the importance of mean- article represents an update as to logotherapy’s cur- ing, faith, , humor, and many other adaptive rent status in the , with emphasis on constructs that have become a part of positive psy- logotherapy’s utility and accessibility to a broad chology; thus there is increasing support for the audience. utility of logotherapy concepts to researchers and clinicians. Frankl and other logotherapists have Meaning and Well-Being done much clinical work in these areas, and this existing work can readily be incorporated into positive A major that logotherapy has something psychology, as well as other, specific . to offer mental health professionals across various Logotherapy is often regarded as a humanistic– theoretical orientations has to do with the influence existential of , but it has much in of the meaning on human health and be- common with other paradigms. Indeed, McMul- havior. There is a growing basis for the relationship lin (2000) noted that “logotherapy is one of the between a sense of meaning and psychological and precursors to cognitive ” (p. 31), and in physical well-being (Melton & Schulenberg, 2008; describing innovative techniques used in cogni- Reker, 1994; Ryff, 2000; Ryff & Singer, 1998a, tive restructuring therapy (specifically perceptual 1998b; Savolaine & Granello, 2002; Spiegel & shifting), he outlined many techniques that are Fawzy, 2002; Zika & Chamberlain, 1992). For ex- consistent with those practiced by logotherapists. ample, meaning may contribute to an array of areas Particularly relevant examples of perceptual related to wellness, including awareness of social shifting described by McMullin include bridging support, sense of and values, health- techniques, with the “Hierarchy of Values promoting behaviors ( to follow Bridges” exercise being a prime illustration of through), and inoculation (Ryff & Singer, how clients’ personally meaningful values hier- 1998b; Savolaine & Granello, 2002). Moreover, in archy may be used to shift from old, maladaptive a recent review of the literature, Melton and Schu- beliefs into new, more adaptive beliefs.1 Simi- lenberg (2008) noted that meaning is associated larly, the creative, active, and strengths-focused with a range of outcomes, such as stable and aspects of logotherapy have parallels with con- less psychological distress, more proactive and so- structive , such as solution-focused or ciable , and favorable attitudes toward life narrative-focused therapies (Combs & Freedman, and the . Meaning has clear significance to the . The concepts emphasized in 1994; Furman & Ahola, 1994), in the encourage- logotherapy are of interest to mental health profes- ment of a more positive outlook in relation to life sionals striving to find ways to help their clients circumstances. help themselves and are compatible with a variety Frankl saw logotherapy, with its emphasis on of existing theoretical orientations and the contem- the meaning-dimension of human beings (often porary movement. termed the spiritual dimension in the broad sense of the word) as an addition to other therapies (Frankl, 1985, 1986, 1988, 2006), with the goal Relationship to Other Therapies and of enhancing techniques as opposed to replacing Positive Psychology them. Simply put, logotherapy is intended to be Several sources indicate that spirituality (in the collaborative (Fabry, 1981; Kovacs, 1999), and it general sense of meaning, values, and purpose, as is has been explored in relation to a number of emphasized in logotherapy) is becoming increas- ingly relevant in modern and medi- 1 Logotherapy techniques are described in a subsequent cine (see DuBois, 2007, Mahoney, 2000, and section of this article. For additional information regarding Savolaine & Granello, 2002), and there is increas- perceptual shifting and relevant examples, the reader is re- ing evidence that spirituality is associated with pos- ferred to McMullin (2000).

448 Logotherapy for Clinical Practice specific forms of therapy over the years, with Frankl held the position that opportunities to rational emotive behavior therapy (Hutchinson & respond—in action, , or — Chapman, 2005) and and commit- exist throughout an individual’s life, and when ment therapy (Sharp, Schulenberg, Wilson, & the chosen response is consistent with the indi- Murrell, 2004; Sharp, Wilson, & Schulenberg, vidual’s personal values hierarchy, the individual 2004) being recent examples. Training in logoth- experiences the longed-for sense of life meaning. erapy may benefit clinicians from a variety of Frankl held that each individual’s perspectives, given its congruence with many dif- meaning incorporates reaching out to an overall ferent methods. order to the universe, to other human beings, and to other animals. Responses inconsistent with Fundamental Tenets one’s personal life meaning do still have objec- tive impact; however, they do not provide the The fundamental tenets of logotherapy have individual a sense of life meaning. Oftentimes, been documented by Frankl in a number of individuals are objectively successful according English-language texts. Available books include to what others (e.g., peer groups, com- the most recent edition of Man’s Search for panies, and cultural ideals) might find important, Meaning (Frankl, 2006) and the recent but they lack a sense of life meaning, leaving a of On the Theory and Therapy of Mental Disor- of labeled existential vacuum. ders: An Introduction to Logotherapy and Exis- tential Analysis (Frankl, 2004). Additional Applicability to Mental Health Problems English-language texts include The Doctor and the : From Psychotherapy to Logotherapy In practice, logotherapy has application at each (Frankl, 1986), The to Meaning: Founda- of the dimensions of the human being (the tri- tions and Applications of Logotherapy (Frankl, dimensional ontology). Physiologically, logoth- 1988), The Unheard Cry for Meaning (Frankl, erapy is recognized for its efficacy in the reduc- 1985), and Man’s Search for Ultimate Meaning tion of despair in unavoidable . (Frankl, 1997a). Psychologically, Frankl developed useful tech- Described in the aforementioned texts, one niques, notably and dere- construct central to logotherapy is referred to as flection, especially for problems originating in the tri-dimensional ontology—the conceptualiza- anticipatory . From the spiritual sphere, tion of human beings along three overlapping many people experience meaninglessness at dimensions: physical, psychological, and spiri- some point that is characterized by existential tual (i.e., noological, meaning oriented). It is vacuum (Frankl, 2006; Hutzell, 1990; Sahakian commonly understood that human beings often & Sahakian, 1972). As such, individuals may feel respond with conditioned or automatic reactions bored or apathetic, as if they are “just going (such as self-statements, behaviors, and emo- through the motions” of their lives (Frankl, 2006; tions) in the first two dimensions and that other Hutzell, 1990). It is this feeling of emptiness that animals also function in the first two dimensions. can motivate people to respond to their circum- The third dimension is emphasized in logoth- stances, and it is their awareness of their personal erapy as distinguishing human beings from other life meaning that can guide them in an objective animals. However, human beings do not have to direction that they experience as full or satisfy- function in the third dimension (i.e., can behave ing. However, left unchecked, the feeling of emp- in conditioned and automatic ways). Functioning tiness may lead to disturbances from a lack of in the third dimension often demands a percep- actualization of personal life meaning or from tual shift away from the typical conditioned ad- conflicts of personally meaningful values (Frankl, herence to peer group expectancies or mass ad- 2006; Hutzell, 1990; Sahakian & Sahakian, vertising, for instance. 1972). In addition to the tri-dimensional ontology, When the existential vacuum leads to distur- logotherapy’s basic tenets assert that (a) human bances, the most common problems that are pre- life has meaning, (b) human beings long to ex- dicted to fill the existential vacuum are violations perience their own sense of personal life mean- of social norms, distress symptoms, and ing, and (c) human beings have the potential to physiological/psychological . Frankl experience life meaning under all circumstances. labeled these the mass neurotic triad and spoke

449 Schulenberg, Hutzell, Nassif, and Rogina of them as aggression, , and arises. In other words, are there situations in (Frankl, 2006; Hutzell, 1990). Although each of which logotherapy should not be used? There is these problems can originate also from the phys- little in the logotherapy literature on this subject iological and psychological dimensions, when the because logotherapists do not tend to think in symptoms originate from a sense of meaningless- these terms. Logotherapists consider that each ness, they can then be treated with therapy de- human being has internal resources, or strengths, signed to work particularly with discovering that may be applied in any given situation. Logo- personal life meaning. The idea that meaningless- therapists work with clients on helping them to ness is associated with alcohol (and other identify and access these internal resources. use) is well supported in the literature (Marsh, However, there are situations that arise that sig- Smith, Piek, & Saunders, 2003). The parallels nificantly inhibit the ability of clients to identify between logotherapy and the spiritual elements of and access their internal resources. For example, Alcoholics Anonymous have been discussed while the potential utility of logotherapy with (Holmes, 1991; Koster, 1991), and logotherapy psychoses was noted previously, in extreme cases has been applied in the treatment of alcohol prob- in which individuals are experiencing severe psy- lems (Crumbaugh, 1980, 1981; Crumbaugh, chotic states and reality testing is poor because of Wood, & Wood, 1980; Henrion, 2002; Hutzell, active hallucinations, delusional , or both, 1984). symptoms must be managed via other methods In addition to drug and alcohol problems, logo- (e.g., medication) prior to application of logoth- therapy has been useful with depression, anxiety, erapeutic principles. However, even in such and psychoses, as well as despair associated with cases, logotherapy may be useful with friends and incurable illnesses (see Fabry, 1994; Frankl, who are struggling in terms of how they 2004; Lukas, 2000; Lukas & Hirsch, 2002). can assist their loved one. Moreover, in the above Logotherapy has applicability in a growing num- instance, once symptoms are brought under con- ber of areas, such as rehabilitation (Ososkie & trol via other treatment, logotherapy is applicable Holzbauer, 2004; Starck, 1982, 2003), mental with regard to helping clients understand and retardation/developmental disabilities work accept their diagnoses, work with mental health (Hingsburger, 1989, 1990; Schulenberg, 2003a, professionals, and adhere to their treatment pro- 2003c), pastoral psychology (Graber, 2003; grams in spite of the fact that the logotherapy is Leslie, 1965; Welter, 1987), aging (Kimble, not expected to “cure” the . Thus, rather 2000), and relationship counseling than thinking in terms of contraindications, logo- (Crumbaugh & Henrion, 2004; Lantz, 1993; therapists typically think in terms of judicious use Winters, 2002), and daily life/work-related issues of the approach, working in collaboration with (Crumbaugh, 1973; Pattakos, 2004). other strategies as necessary, to maximize the Recent World Congresses on Logotherapy chances of a positive treatment outcome on have included colloquiums on incorporating the one hand and, on the other hand, to minimize logotherapy into the treatment of specific diag- the despair that can be associated with situations in noses of the Diagnostic and Statistical Manual of which a positive outcome (cure) is not possible. Mental Disorders (4th ed., text rev.; DSM–IV– TR; American Psychiatric Association, 2000). Logotherapeutic Strategies These protocols are subsequently published in The International Forum for Logotherapy. Exam- The roles of the therapist. The roles of the ples of recent papers have included applications therapist in logotherapy include regarding clients with mood disorders (Henrion, 2004; Ungar, as fellow human beings, emphasizing their 2002), anxiety disorders (Rogina, 2002), and per- uniqueness, teaching that they have some free- sonality disorders (Rodrigues, 2004; Rogina, dom to respond to their situations or problems, 2004; Rogina & Quilitch, 2006). and demonstrating to clients various techniques and how they may be applied to their situations or Judicious Use of the Approach problems. When clients assert that they have no freedom to respond, the therapist helps them to When applications of a particular theory or search for their remaining freedom, plus encour- technique are discussed, the question of when the ages them to take responsibility to respond to that theory or technique is contraindicated often freedom through behaviors, experiences, or atti-

450 Logotherapy for Clinical Practice tude changes in ways that they find meaningful tudes are shifted away from overfocus on the and adaptive. symptoms and shifted toward awareness of re- In regarding clients as equal human beings, maining options that are in keeping with what the therapists a high standard by including not individual perceives as his or her personal life only their clients’ physiological and psychologi- meaning, in spite of the symptoms. Attitudes are cal dimensions but also their spiritual dimen- not forced upon clients (unless in severe cases sions, in which responsibility, morality, and per- such as ); rather, in the process of working sonal life meaning are possible. Modernizing a with clients, a logotherapist facilitates the devel- quote of the German poet Goethe, Frankl (1967) opment of adaptive attitudes that are derived said, “If we take man as he is, we make him from each client’s perceived personal life mean- worse; if we take him as he ought to be, we help ing (or personally meaningful values hierarchy). him become it” (p. 12; see also Fabry, 1981). The What are available in response to a par- logotherapist, Joseph Fabry, paraphrased it this ticular situation or problem? What directions are way: “As long as we treat human beings as ani- most meaningful to a client? The third step in- mals that can be trained, and machines that can volves symptom reduction, which often occurs be manipulated, we make them into animals and automatically following successful completion of machines. If we make them aware of the re- modification of attitudes. At other times, specific sources of their human spirit we help them lift techniques for symptom reduction are incorpo- themselves into their true humanness” (Fabry, rated (e.g., skills, self-efficacy tech- 1981, p. 11). In other words, logotherapists afford niques). Once symptom separation has been clients the dignity of expecting them to be capa- achieved, and more adaptive attitudes have been ble as human beings in spite of the limitations of discovered, clients sense that options are avail- their current situation or problem. able, and symptoms become more manageable. In logotherapy, the client is active and partic- The final step involves maintenance of mental ipatory, retaining responsibility to alter maladap- health through and facilitation tive patterns and to actualize personal life mean- of continued awareness of personal life meaning ings (Lukas, 1979/1995). The therapist assists the and the resultant purpose or goals in life. client in facilitating this process. The client is Well-known therapeutic techniques. Logoth- encouraged to recognize the freedom he or she erapy has yielded several specific, well-known has and to implement that freedom in order to therapeutic techniques. They focus on heighten- take the away from the problem or symp- ing peoples’ awareness of their personal life tom and, instead, to move in a less problematic, meaning (i.e., their personally meaningful values and more personally meaningful, direction. The hierarchy), facilitating goal development, living is one of equality and responsibly, and making adaptive choices consis- offering opportunities to clients rather than one of tent with personal life meaning (Hutzell, 1990). superiority and “fixing” clients. As such, the ther- Attitude modification, particularly facilitated apist helps clients to clarify and work toward through Socratic dialogue (Fabry, 1994; Gutt- actions, experiences, and attitudes in which cli- mann, 1996; Hutzell, 1990; Lukas, 1979/1995; ents experience personal life meaning. The ther- Lukas & Hirsch, 2002), is the most often used apist insists that choices are always available, logotherapy technique. Socratic dialogue is a even if they are limited to choices among atti- technique whereby a therapist asks questions of tudes (Lukas, 1979/1995). clients to facilitate internal exploration to dis- Phases of logotherapy. When logotherapy is cover personal life meanings, to explore how conducted, oftentimes a series of four phases, or these may be actualized, and to foster recognition steps, are followed (see Fabry, 1994, and Lukas, that choices toward these ends are always avail- 1979/1995). The first step involves differentiation able. In the case of working with a client who of clients from their symptoms. Clients are more feels faced with an insurmountable problem for than clusters of symptoms, and in logotherapy it which there is no solution, a logotherapist may is imperative that they not overidentify with a ask about responses to similar problems in the given diagnosis. They remain human beings with past, seeking clues from the client as to person- the ability to overcome obstacles and experience ally meaningful attitude modifications that may personal life meaning. The second step involves have been used successfully to reduce the despair attitude modification about the symptoms. Atti- of the unchangeable problem. For the client, such

451 Schulenberg, Hutzell, Nassif, and Rogina discussion prompts the rediscovery of a person- working with sexual dysfunction (reorienting the ally meaningful hierarchy of values, thought pro- focus of an individual toward the pleasure of cesses, and that may be brought to one’s partner instead of one’s own physiological bear on the current situation. In addition to atti- success), and it has been argued that the influen- tude modification, well-known logotherapeutic tial work of W. H. Masters and V. E. Johnson in techniques that have been developed include par- relation to sexual problems validates Frankl’s adoxical intention, dereflection, and logoanalysis. approach in this area (Frankl, 1952, 1975; Saha- Paradoxical intention is a technique that be- kian & Sahakian, 1972). Use of dereflection has havior therapists have empirically validated, that grown over the years such that it is used to help Frankl developed independently in the 1920s clients respond to a variety of mental health dif- (Ascher, 1989; Fabry, 1982; Frankl, 1975; Lukas, ficulties when too much focus is placed on symp- 1986), and that was first published in 1939 toms to the detriment of client strengths. (Frankl, 1939, 1975, 1978/1979). It has been use- Another logotherapeutic technique, logoanaly- ful in cases involving recursive anxiety, such as sis (developed by Crumbaugh, 1973), is applied agoraphobia and public speaking anxiety (Ascher to persons experiencing a lack of sense of per- & Schotte, 1999; Schotte, Ascher, & Cools, sonal life meaning (initially experienced as bore- 1989; see also Schulenberg, 2003a). Components dom or apathy but with the potential to evolve of classical paradoxical intention, when con- into violations of social norms, distress symp- ducted by logotherapists, have been described toms, and physiological and psychological addic- (Fabry, 1982; Frankl, 1975, 1985; Hutzell, 1990; tions). Logoanalysis offers a systematic process Lukas, 1982, 1986; Yoder, 1994) and include (a) of mental and written exercises to help individu- a nonmanipulative therapist–client partnership, als set a life direction and subsequent achievable (b) ruling out of biological etiology, (c) educating goals based on their personal life meaning. The clients about paradoxical intention with regard to process lends itself well to self-help (Crumbaugh, what it is and how it works, (d) tailoring the 1973; Hutzell & Eggert, 1989; Hutzell & Jerkins, technique to the individual’s presenting com- 1995) and small-group formats (Hutzell, 1983, plaints, (e) participating in the fear state, while (f) 2002) and has yielded a variety of therapeutic simultaneously incorporating humor to counter- exercises. For example, the Meaning in Life act anxiety. (In logotherapy, the spiritual Evaluation scale (MILE; Crumbaugh & Hen- dimension—in this case through the use of rion, 2004; Henrion, 2001) was designed to humor—is utilized to facilitate self- to heighten an individual’s sense of personal life allow attitude change and then behavior change.) meaning through awareness of their hierarchy Dereflection (Frankl, 1975, 1985, 1988, 2004; of personally meaningful values, by prompting Hutzell, 1990; Lukas, 1986, 2000), as reported by individuals to select from among 20 different Frankl, appeared in the 1940s (in German), with values via a paired-comparisons approach. Ex- the first English-language appearance in 1952 amples of values incorporated in the MILE (Frankl, 1952, 1975). It is known that, in some include friendship, acceptance, health, and so cases, people focus on the possibility of a prob- forth. Of the 20 different values, the 5 highest lem or a symptom with such intensity that they ranked by the paired-comparisons process are create anticipatory anxiety that actually makes then emphasized to foster meaningful goal set- the problem or symptom worse (Frankl, 2006; ting. The MILE facilitates active thinking and Hutzell, 1990; Sahakian & Sahakian, 1972). The prioritizing of values, as well as recognition as point of dereflection is to reorient a client’s at- to whether energy is being focused on the pur- tention away from the preoccupying problem or suits that are most meaningful in relation to the symptom and refocus the instead onto participant’s values hierarchy. related, highly motivating areas of personal life Lesser-known logotherapy techniques. Many meaning (Frankl, 2006; Hutzell, 1990). The re- other applications and techniques of logotherapy sulting effect is typically a reduction of the an- have been developed that are not as widely known ticipatory anxiety associated with the symptom or as those described above. These techniques include problem in question and thus a reduction in the the Mountain Range Exercise (Ernzen, 1990; Schu- symptom or problem itself (Frankl, 2006; Hut- lenberg, 2003c, 2004b), the Movies Exercise (Schu- zell, 1990; Sahakian & Sahakian, 1972). Dere- lenberg, 2003b; Welter, 1995), the Family Shoebox flection is often a technique of when (Lantz, 1993), use of stories and metaphors

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(Moore, 1998; Schulenberg, 2003b; Welter, 1995), In the Family Shoebox Game (Lantz, 1993), and a variety of additional, assorted exercises de- the therapist presents a family with a shoebox, signed to clarify values and enhance meaning. tape, scissors, and magazines; the task is to ad- The initial idea for the Mountain Range Exer- here magazine pictures to the shoebox to repre- cise was noted by Frankl (see The Doctor and the sent family values and meanings. The outside of Soul, Frankl, 1986), and developed as an activity the box is used for values and meanings that are by Ernzen (1990). A mountain range is drawn, presented to people outside of the immediate and the person completing the exercise places family, while the inside of the box is used for people of importance to him or her (such as values and meanings of particular importance to friends or family members, authors, musicians, the members of the immediate family. Lantz and the like) on the various peaks. Participants (1993) argued that such tasks help in two are asked what they share in common with the primary ways: first, it gives family members a individuals on their peaks, as well as whose clear task that requires communication about val- mountains they would like to be a part of. The ues and meanings that are important to the family activity assists individuals in identifying posi- experience, and second, it provides the family tives in their lives, as well as in values clarifica- therapist with a means of observing family inter- tion. The activity is useful in either individual or action patterns that may help or hinder a family’s group therapeutic settings and has been used with search for meaning and direction. An underlying a variety of and treatment contexts, premise of Lantz’s (1993) applications of logo- such as people with alcohol-related problems, therapy to family therapy is that increased knowl- psychiatric inpatients, and meaningful living edge of family values and meaning can serve to groups (Ernzen, 1990). It has also been used with stimulate healthy family interaction patterns, adolescent male sex offenders with mental retar- which can, in cyclical fashion, further guide fam- dation (or developmental disabilities) and sexual ily members toward an increased sense of values behavior problems as a means of building rapport and meaning and direction for the family as a and discussing important treatment issues, such whole. as values and sexual offense (Schulen- Logotherapists often use stories and metaphors berg, 2003c, 2004b). Variations on the traditional as one means of facilitating attitudinal change Mountain Range Exercise have also been pro- (Moore, 1998; Schulenberg, 2003b; Welter, posed. Pattakos (2004) suggested adapting the 1995). Frankl’s own life experiences in the con- Mountain Range Exercise to the work environ- centration camps and his attitudinal stance to- ment to clarify values and find meaning in em- ward adversity (Frankl, 2006; Klingberg, 2001) ployment via those people who have influenced a serve as one remarkable example. However, the particular individual’s professional development. logotherapeutic literature is replete with stories There are two components to the Movies Ex- and metaphors that function as illustrations for ercise (Schulenberg, 2003b; Welter, 1995), both how one may adaptively deal with adversity. of which focus on facilitating awareness of per- Some of these stories are real-life examples of the sonal life meaning. The first component prompts experiences of logotherapists. For instance, in a an individual to develop a movie of his or her life, case of irreversible physical loss, as was re- on the past up to the present time. The counted by Long (1995), Klingberg (2001), and second component is a movie from the present Levinson (2002), a well-known logotherapist, into the future. These creative activities afford Jerry Long, was a teenaged baseball player whose opportunities to develop various movie aspects. pitching had the attention of the professional (Who will be in them? What actor or actors will leagues. Then he broke his neck and became the lead roles? What are the movies’ titles? physically dependent on others for his most basic What kind of budgets will be available? What activities of daily living. While he recognized will the movies be about, and what genre will that his potential for an athletic career had van- typify each film?) These various aspects are dis- ished, he also came to realize that much freedom cussed in terms of the participant’s personally remained in other areas in which he could actu- meaningful values hierarchy, , alize personal life meaning. He took responsibil- interpersonal relationships, and key experiences ity for implementing that freedom: graduated in order to help clarify the participant’s sense of from high school, went on to college, and even- personal life meaning. tually earned his in

453 Schulenberg, Hutzell, Nassif, and Rogina and became a practicing logotherapist. He was in some instances exceeding .90 (Melton & Schu- able to lead a fulfilling life in spite of quadriple- lenberg, 2008). gia. He often summed up succinctly his inspiring The Purpose in Life (PIL) is the earliest credo for life: “I broke my neck; it didn’t break and most widely studied of the well-known logo- me.” He took responsibility to do what he could, therapy psychometric instruments (Crumbaugh & within the freedom that he had, to establish and Maholick, 1964, 1969) and is the primary logo- maintain an attitude to pursue a personal life therapy measure of the degree to which an indi- meaning, in spite of his physical condition. Cli- vidual experiences a sense of personal life mean- ents learn from such stories that regardless of ing. The PIL has been psychometrically reviewed one’s circumstances, a proactive attitudinal in a number of sources (e.g., Crumbaugh & Hen- stance toward adversity may be chosen. rion, 1988; Hutzell, 1987a, 1988; Melton & A number of additional exercises to increase Schulenberg, 2008; Reker, 2000; Schulenberg, awareness of personal life meaning and to moti- 2004a). With regard to , the PIL, as is vate people toward the actualization of their po- expected, correlates positively with constructs tentials have been described by Fabry (1988), such as happiness, emotional stability, and extro- Mendez (2004), Pattakos (2004), and Crumbaugh version, and negatively with constructs such as and Henrion (2004). One example contained in proneness, anxiety, and depression Fabry’s text is the Value Auction, in which indi- viduals are invited to consider various values that (Hutzell, 1988, 1989; Melton & Schulenberg, are auctioned off and how much they wish to 2007, 2008; Robak & Griffin, 2000; Schulenberg, “bid” on them from their limited pool of “funds.” 2004a). Such correlations are consistent with Another example is the Self-Appraisal Exercise, logotherapy conceptualizations and research in which people are encouraged to participate in studies that demonstrate the relationship between answering questions such as those relating to meaning and well-being (Melton & Schulenberg, descriptions of themselves, whom they and others 2008; Schulenberg, 2004a). wish themselves to be, and their views as to their The Life Purpose Questionnaire (LPQ; Hablas potentials. Such exercises prompt reflection on & Hutzell, 1982; Hutzell, 1989) is another mea- the consistencies between the individual’s inter- sure of the degree to which an individual expe- nal and external behaviors and their sense of riences a sense of personal life meaning, but it personal life meaning. Mendez (2004) addition- was designed for use with specialized popula- ally outlined a number of less well-known tech- tions, such as geriatric neuropsychiatric inpa- niques applied by logotherapists (e.g., Logo- tients, for whom the PIL proves impractical drama, Life Review and Life Preview, Guided (Hablas & Hutzell, 1982), and the LPQ is some- Discovery of Meaning Potentials, the Logoan- times the measure of choice over the PIL because chor, and Appealing Techniques). Finally, Pat- it uses a simple dichotomous-choice format, in takos’ (2004) exercises are geared toward per- contrast to the PIL’s more Likert-type sonal life meaning in the workplace, while response format (Hablas & Hutzell, 1982; Hut- Crumbaugh and Henrion’s (2004) activities re- zell, 1989). The LPQ is the second most fre- late to enhancing personal life meaning in in- quently studied of the logotherapy measures. Va- terpersonal relationships. lidity support is evident via moderate-to-high correlations with the PIL and scores that - strate statistically significant improvement in pro- Psychometric Assessment of the grams that incorporated a life purpose component Meaning Construct (Burnette, Swan, Robinson, Lester, & Little, A variety of logotherapy tools have been intro- 2003; Kish & Moody, 1989; Melton & Schulen- duced over the years to quantify and study the berg, 2008; Schulenberg, 2004a). meaning construct. The best known of these are the The Seeking of Noetic Goals (SONG) test Purpose in Life test, the Life Purpose Question- (Crumbaugh, 1977a, 1977b) was developed to naire, and the Seeking of Noetic Goals test. There is assess motivation to find meaning. There is much ample evidence for the internal consistency of the less empirical data available in the published global scores generated by these measures, with literature on its psychometric properties (Hutzell, coefficient alphas often reported in the .80s, and 1987b; Schulenberg, 2004a).

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Empirical Support and Future from a factor analytic standpoint, as in the case of Research Needs the development of psychometrically alter- native forms of the measure. In a new study using Frankl was well aware of the emphasis placed samples of undergraduate students, Schulenberg on empirical scrutiny, and he encouraged re- and Melton (in press) took the 20 items of the PIL searchers to investigate logotherapy (Fabry, and demonstrated how is of assis- 1978/1979). Many studies have appeared with a tance in the assessment of the meaning construct, focus on the logotherapy , meaning in in this instance, in providing preliminary support general, and meaning-related constructs. Schul- for a replicable two-factor model of the PIL, as enberg (2003a) described research progress with well as a psychometrically viable short form that direct relevance for logotherapy, including such may be useful for future research. In addition to areas as paradoxical intention and assessment, as this study, other recent factor analytic studies well as positive psychology constructs such as have been completed (e.g., Schulenberg & , humor, hope, and (all of which are Gohm, in press; Schulenberg, Gohm, & Ander- central to logotherapy). son, 2006); however, such studies require repli- For a recent and comprehensive source of em- cation. Samples should be drawn from increas- pirical articles relevant to logotherapy, the reader ingly diverse populations (in each of the is referred to Batthyany and Guttmann’s (2006) previously mentioned studies, samples were pri- annotated bibliography, which is an important marily female, Caucasian undergraduates), as step in the advancement of the scientific study of factor structure may vary by . logotherapy because of its collection of abstracts Isolating and examining logotherapy tenets. on general theory, techniques, , While there is growing research assessing various and test construction and validation. It documents aspects of logotherapy, more research is needed how far the empirical study of logotherapy has in isolating and testing specific logotherapy pos- come, and it is clear that meaning-related re- tulates using increasingly stringent research de- search continues to advance. However, while em- signs. As one example of such, Melton and Schu- pirical studies continue to be conducted, research lenberg (2007) conducted a study examining needs remain a priority. Research is one means Frankl’s oft-noted postulate that boredom is one that may facilitate the continued evolution of outcome of meaninglessness. Melton and Schul- logotherapy into the mainstream of the mental enberg (2007) found support for the association health field (DuBois, 2007; Guttmann, 1996; of the two constructs via a statistically significant Hutzell, 2000; Schulenberg, 2003a). Areas of negative correlation between the PIL and the particular importance include expanding the psy- Boredom Proneness Scale (BPS; Farmer & Sund- chometric properties of logotherapy assessment berg, 1986) with a sample of psychology under- tools, isolating and studying specific logotherapy graduate students. In this case, PIL scores tenets, conducting studies of logotherapy’s utility (greater meaning) were associated with lower in relation to specific mental health diagnoses, BPS scores (less boredom proneness). However, and empirically examining logotherapy’s rele- the study was correlational in nature, and state- vance to clinical/disaster psychology, diverse ments with regard to causation could not be populations, and . made. Since Frankl’s postulate indicates a causal Logotherapy measures: Expanding the psycho- path, that is, boredom results from meaningless- metric foundation. One area to target for future ness, stronger research designs are necessary to research is that of continuing to expand the psy- further delineate the relationship (Melton & chometric properties of various logotherapy mea- Schulenberg, 2007). For example, one idea posed sures with different populations and under differ- by the authors is whether an experimental group ent contexts (Guttmann, 1996; Melton & writing about meaningful experiences will report Schulenberg, 2008). Procedures such as explor- less boredom and greater meaning than would a atory and confirmatory factor analyses may have control group writing about more neutral topics. particular relevance for logotherapy measures In addition to further studying the aforemen- and the meaning construct in general as assessed tioned relationship, empirical studies should be by these instruments (Melton & Schulenberg, designed to target other logotherapeutic postu- 2008; Reker, 2000; Reker & Chamberlain, 2000). lates that have been put forth over the years. For example, the PIL continues to be of interest Researchers should also continue to investigate

455 Schulenberg, Hutzell, Nassif, and Rogina the meaning construct and related postulates in mental health symptoms and greater meaning). different , because how meaning is de- The study offered support for the importance of fined, and the pathways to a sense of life mean- meaning to individuals with serious mental ill- ing, may differ cross-culturally (Savolaine & ness, particularly via its relationship to empow- Granello, 2002; Schulenberg, 2003a). erment. These results suggest future research di- Logotherapy’s relevance to mental health rections, such as investigating the degree to problems: Serious mental illness as case in point. which meaning-related interventions directly re- Earlier in this article the incorporation of logoth- sult in increases in empowerment. In addition, it erapy into the treatment protocols for various supports the rationale that meaning is a construct DSM–IV–TR diagnoses was noted. Outcome of much significance to those with serious mental studies integrating logotherapy with other treat- illness and should be considered in mental health ment approaches to better document its effective- evaluations and interventions. ness are needed as follow-up. People with a va- Clinical/disaster psychology. Clinical/ riety of forms of mental illness may benefit from disaster psychology is a rapidly growing field, in logotherapy, given its focus on the motivational which mental health professionals are taught how effects of personal life meaning; empowerment to to readily assist individuals directly affected by be positive, hopeful, and proactive (in life and in disasters. Often a community approach is taken, treatment); and encouragement to recognize the in which clinicians respond to traumatic events in choices that may be made in spite of unchange- the field (e.g., the terrorist attacks of September able circumstances. Given the emphasis on client 11, 2001; Hurricane Katrina). Clinicians may attributes and abilities, logotherapy may be par- work with individuals in the immediate aftermath ticularly helpful in developing diagnostic formu- of a disaster or in an ongoing therapeutic capacity lations, communicating diagnostic to in an office setting. They work with a wide vari- clients (Winters & Schulenberg, 2006), and ad- ety of disaster-related presenting complaints, dressing questions as to how people may adap- such as those that may meet formal DSM–IV–TR tively respond when facing mental illness. De- criteria for or Posttrau- spite their difficulties, clients can still have “a matic Stress Disorder (PTSD). , a meaning for existence, a There is a wealth of literature on the topic of place in life, a worthwhile cause” (Crumbaugh, logotherapy’s utility in assisting people with 1973, p. ix). adapting to and overcoming traumatic experi- These concepts have become increasingly im- ences, and Frankl’s own life experiences in the portant in the mental health literature. One recent concentration camps during World War II offers example has to do with empowerment and indi- added support for logotherapy’s relevance in an viduals with serious mental illness, for whom array of disaster situations, such as natural disas- empowerment refers to attempts to free individ- ters (Halpern & Tramontin, 2007; Schulenberg, uals from the grip of their symptoms as well as 2003a) and refugee mental health,2 in which in- enhancing their ability to be proactive and for dividuals may be displaced from their countries whom serious mental illness refers to disorders of origin for a variety of , including per- such as , , secution on the basis of sex, racial or ethnic and major depression (Strack, 2008; Strack, Deal, background, or spiritual beliefs. Refugees must & Schulenberg, 2007). There is an indication that not only deal with the traumas associated with individuals with serious mental illness perceive their displacement, but they must also deal with recovery from their disorder in terms of areas postmigration stressors as well (i.e., stressors as- directly relevant to logotherapy, such as meaning, sociated with moving from one country to an- self-determination, and hope (Strack, 2008). In other under duress). Halpern and Tramontin logotherapy terms they can still be “Somebody” (2007) noted that Frankl’s perspective advocates despite their symptoms (Crumbaugh, 1973, p. ix). for the ability of disaster survivors to learn how In a new study of meaning and empowerment to triumph over suffering, assisting individuals in individuals with serious mental illness, Strack directly affected by disasters to not only discover (2008) found through a serious of regression analyses that empowerment is dependent on meaning in life and psychiatric symptoms (those 2 See Reyes and Jacobs (2006) for a primer on issues in reporting greater empowerment reported fewer refugee mental health.

456 Logotherapy for Clinical Practice meaning in the events but also serve as a means activities to groups of individuals receiving ser- of facilitating posttraumatic growth. vices? If so, how effective would such interven- As a follow-up to the previous section refer- tions be? While these and other questions await encing serious mental illness, one area to inves- the attention of researchers, what is known is tigate systematically is logotherapy’s usefulness that the meaning construct holds much promise as an adjunctive treatment approach with individ- in terms of applicability to different types of uals with Acute Stress Disorder or PTSD. There trauma responses and conditions, and logoth- is logotherapy literature available on these topics, erapy is one specific means of facilitating the although primarily related to PTSD. For instance, discovery of meaning. Gilmartin and Southwick (2004) and Southwick, Logotherapy and diversity. The number of Gilmartin, McDonough, and Morrissey (2006) logotherapy established worldwide noted a rationale for logotherapy’s application to exemplifies the fact that cross-cultural applica- combat-related PTSD, describing multiple case tions and implications are integral to the ap- studies. Schiraldi (2000) noted logotherapy and proach (see the Appendix for further informa- the relevance of the meaning construct to indi- tion). Because of logotherapy’s emphasis on viduals with PTSD, listing several exercises to values clarification within a given person, it af- identify and enhance meaning. There is a strong fords mental health professionals opportunities to rationale for considering logotherapy in relation consider the unique cultural context of the indi- to traumatic experiences and specific diagnoses vidual. However, while there is much cross- such as PTSD; however, much of the literature cultural, or international, literature published, available is either conceptual or based on case there is little research or descriptive information studies. Systematic outcome studies are war- available on logotherapy and multicultural issues ranted to better delineate the aspects of logoth- in the United States. A notable exception is Corey erapy that are of particular relevance in treating (2005), who discusses multicultural issues in ex- people who have experienced traumatic events. istential therapy and mentions logotherapy For example, for those diagnosed with a disorder specifically. such as PTSD, would enhancement of meaning Logotherapy is one means of empowerment. It result in a better prognosis? To what measurable helps people to facilitate identity development extent does logotherapy enhance client through the recognition and clarification of val- resilience? ues, and it galvanizes people to find ways to deal In addition, are there certain elements of logo- with adversity. For these reasons, logotherapy therapy that could be incorporated into the Psy- should be studied empirically in relation to diver- chological First Aid (PFA) training of mental sity issues, such as racial and ethnic identity health professionals who respond to disasters? formation, and acculturative stress, PFA is a fundamental aspect of the training of racism and discrimination, and mental health disaster responders (Schulenberg et al., 2008). The tenets of PFA include fostering a or gender identity development, each of which sense of hope and focusing on may influence an individual’s functioning in sub- (being proactive), self-reliance, and strengths.3 tle to profound ways (Hunter & Lewis-Coles, Dereflection may be a particularly useful tech- 2004; Paniagua, 2005; Schneider, 2008; Strack, nique in this respect. Finally, while logotherapy Dunaway, & Schulenberg, 2008). Logotherapy may be integrated with PFA training that is of- may assist individuals in determining how much fered to mental health professionals, it would be importance they wish to place on their diversity interesting to study whether certain aspects of and how to deal with individuals and a larger logotherapy should be included in PFA training whose values may differ markedly from that is offered to paraprofessionals, such as di- their own. Logotherapy inspires people toward saster responders of the American Red Cross, as discovering their individuality, their uniqueness, PFA training tends to teach basic skills that can and how to feel comfortable within themselves be applied by mental health professionals and paraprofessionals alike. For instance, under the 3 See Schulenberg et al. (2008) for a review of the PFA supervision of mental health professionals, could literature and a discussion of the roles of psychologists in paraprofessionals at an American Red Cross shel- clinical/disaster psychology, specifically, natural disaster ter be trained to administer meaning-enhancing response.

457 Schulenberg, Hutzell, Nassif, and Rogina and within the larger world in which they live. As comes, and logotherapy is particularly attractive, a meaning-based approach, logotherapy may given its ability to work in collaboration with prove to be one means of stimulating people to other approaches. Frankl synthesized the thinking respond adaptively to stressors and find a positive of others and added his experiences (both with voice in the face of oppression. human beings and as a human being) to develop With respect to women, , and feminist logotherapy. As a result, logotherapy has much in therapies, logotherapy also has a wide range of common with other of psychotherapy. applicability. However, these topics are rarely Thus, therapists may find that logotherapy fits discussed in the logotherapy literature. Feminist with their existing ideas and work. Furthermore, therapies have traditionally focused on empow- because of Frankl’s emphasis on human experi- erment and of meaning, as well as ence in general and spirituality in specific, his how aspects such as oppression and marginaliza- ideas ring true to many clients. tion clients (Brown, 2008). The egalitarian In addition to describing logotherapy and its partnership of client and therapist within feminist applications, we sought to present examples of therapies is similar to the structure of the thera- well-known logotherapy techniques that clini- peutic relationship within logotherapy. Brown cians may find useful and to denote lesser-known (2008) is one of the few authors who specifically examples in the logotherapy literature. Measures mentions Frankl and the relevance of Man’s to assess meaning have been developed within Search for Meaning with respect to these issues. the logotherapy paradigm and were summarized Psychoneuroimmunology. Another research with regard to their psychometric properties. Fi- area in which logotherapy has applicability is nally, research progress was discussed, along psychoneuroimmunology, which is a field that with the for expanding the psychometric encompasses many disciplines (psychology, psy- properties of logotherapy measures and advanc- chiatry, immunology, endocrinology, and neurol- ing the study of logotherapy in relation to specific ogy) in order to better understand health and mental health diagnoses and diverse populations, disease processes (Ader, 2007; Goodkin & Vis- as well as growing fields such as clinical/disaster ser, 2000). The relationship between sense of life psychology and psychoneuroimmunology. meaning and well-being was noted previously The Appendix includes a brief discussion of (e.g., Melton & Schulenberg, 2008; Ryff, 2000; logotherapy research, educational, and training Ryff & Singer, 1998a, 1998b; Savolaine & resources. While one may learn about the theo- Granello, 2002). With regard to physical well- retical, descriptive, and empirical underpinnings being specifically, some have noted that meaning of logotherapy through such outlets, and how may be of special importance in prognoses with various techniques are applied, each therapist– illnesses such as cancer (Spiegel & Fawzy, client pairing forms a unique dyad with its own 2002). By implication, logotherapy has relevance unique challenges. When asked what he to the field of psychoneuroimmunology theoreti- would give to clinicians interested in logoth- cally, anecdotally, and empirically. However, the erapy, J. C. Crumbaugh encouraged them to uti- need for additional research on the sense of per- lize dereflection to help individuals focus on suc- sonal life meaning in relation to health and dis- cesses (toward the positives), to find what will ease processes remains (Ryff, 2000). As studies work in a specific situation (Schulenberg & Hen- in the field of psychoneuroimmunology continue rion, 2005). For logotherapy to be conducted to proliferate, logotherapy as a meaning-based successfully, clinicians must not only study logo- therapy could become an increasingly important therapy and work to apply it clinically, they must part of the empirical dialogue. learn to live logotherapy as well; and each day, each moment, presents new opportunities to live Conclusions meaningfully—this is the essence of logotherapy. A central theme of this article is the idea that References meaning-centered interventions such as logoth- erapy are of prime importance to the human con- ADER, R. (Ed.). (2007). Psychoneuroimmunology (4th ed., vols. I and II). Boston: Elsevier Academic Press. dition, with applicability to an array of presenting American Psychiatric Association. (2000). Diagnostic mental health complaints. The presence of mean- and statistical manual of mental disorders (4th ed., text ing is associated with a range of positive out- rev.). Washington, DC: Author.

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Appendix

Research, Training, and Educational Resources in Logotherapy

To enhance the study of logotherapy, a web- basic foundation for principles of logotherapy), based logotherapy research discussion group has intermediate (focusing on applications of logoth- been established by the scientific board of the erapy, such as attitudinal change), and advanced Viktor Frankl Institute of Vienna (http:// (focusing on Franklian theory and therapy of logotherapy.univie.ac.at/e/news_platform.html). mental disorders) courses to reach Associate Cer- In addition to facilitating discussion, the website tification. In addition, through advanced super- includes an annotated list of meaning-related vised study, qualified mental health professionals measures of interest to researchers. may achieve Diplomate Clinician or Educator/ There are logotherapy organizations world- Administrator Certification. The institute’s logo- wide, and these often offer training and educa- therapy curriculum is available for purchase for tion; a good place to start looking for these is the educational use in the form of a set of CDs (Rice, Logotherapy Vienna website at http:// Graber, Pitts, Rogina, & Sjolie, 2005). The U.S. logotherapy.univie.ac.at/. The website lists over institute also conducts a bi-annual world congress 50 and institutes in 24 countries on logotherapy, which provides a forum for the (DuBois, 2007). In the United States, training is exchange of information, research, and practical offered through the Viktor Frankl Institute of applications. Finally, The International Forum Logotherapy, which currently headquarters out of for Logotherapy, published since 1978, is a peer- Texas and maintains a website at http:// reviewed journal that specifically focuses on the www.logotherapyinstitute.org/. Training in the theoretical, descriptive, and empirical aspects of United States includes introductory (providing a logotherapy.

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