The Meaning of Logotherapy in Psychiatry and Psychotherapy

Presented by: Dr. Cvijeta Pahljina (1943 – 2022), Psychiatrist, at The Future of Logotherapy Congress, Vienna, 2016.

Translated by: Maria Marshall, Ottawa Institute of Logotherapy, 2023.

Recorded by: Yulianna Sagdieva, Director of the Institute for Logotherapy in Central Asia, 2016.

Published with permission from: Barbara Pahljina (daughter of the presenter).

In 1982, the Croatian translation of “Yes to Life In Spite of Everything” was published. In this book, Frankl expressed the view that the essence of a human being is spirit. Frankl stated that human beings always “stand on the ground with their forehead raised toward the sky.” This means that we are oriented toward values.  In this book, he gives a poignant illustration of the human potential for choosing between what is good and what is evil. As a psychiatrist and philosopher, he acknowledged the givens of life. His idea is that the spiritual dimension is an active and dynamic resource that finds expression through our being.

In this presentation, I would like to address the topic of what logotherapy means to the psychiatrist and the psychotherapist and what it means concretely, in my life. As a therapist, I want to work with to build trust and mobilize people’s inner strength with a vision to counteract despair and to break the chain of aggression. I want to work toward mobilizing the community in a sense of the ethos that “the world is not healthy, but healable” (Frankl) and that with small steps we can reach our goals and make progress. In this quest, everything is related and intertwined: values, conscience, freedom, responsibility, meaning, what we hold as worthwhile. I want to illustrate how I translate this into practice.

First, I want to talk about the question of who comes into psychiatric practice, and what kind of people I would be likely to meet? It is people with anxieties, people with psychoses, somatic complaints, addictions, dementia, or people who show symptoms of the ills of society. The emphasis here and the key point is that they are not patients, but people. I use individual or group psychotherapy with a logotherapy orientation to treat them.

The most important guideline is that we heal not only with medications and psychotherapeutic methods, but most importantly, with our own person. In the first place, psychiatrists and psychotherapists should love the people who come to seek their help. They should make them feel welcome. When one feels this love, one radiates it. Everything else that I feel or think should be put away, while I am ready to listen to the clients when they come. Clients expect that whatever they bring to me can be handled. Ideally, that we can handle everything together. One needs emotional stability for this kind of work. Inner calm. Trust that there is a solution. That client already has an intuition for the solution.

What we can offer is our time, care, and the best of ourselves. They entrust us their burdens and we seek to understand these from their position and as we look for solutions. We must be able to grasp life from their point of view, and live life with them.

People are not chemical test tubes in which many elements can be mixed and the wanted results will crystallize. They are not animals on which experiments can be done. There are biological causes that can be influenced with psychopharmacology. There are disturbances in the neurotransmitters of the nervous system. There are psychological causes that are exogenic and can be influenced by psychotherapy. But the person as a spiritual being needs the presence of another person who can understand their pain and look for meaningful solutions. Someone who believes in them that they can find a meaningful solution. Someone who helps them and believes in them. Someone who can differentiate fate from the area of freedom and in the free area acknowledge accomplishments. People develop trust in psychiatrists who welcome them, want to help them, and support them.  Trust is essential for further advancement.

As I mentioned earlier, in psychiatric practice, we face a whole palette of difficulties. What can one expect from logotherapy in all these cases. What meaning does the logotherapeutic approach bring? What is specific about it?

We are familiar with the imago hominis [image of the human being] of Frankl, the schema of freedom or fate. This applies to all the cases. As do the concepts of meaning, self-distancing and self-transcendence. Methods, such as modification of attitudes, de-reflection and paradoxical intention can be used. What is always different is the uniqueness of the person and the uniqueness of their situation. The Psychiatric creed: The person never loses their dignity. This is very specific to logotherapy and differentiates it from other psychotherapeutic orientations.

Individual Intervention

First example: A 45-year-old man, locksmith, married, father or two children, ages 14 and 7 years old. The dilemma is whether to orient him toward reality and to insist on it or not. Diagnosis: schizophrenia. First dialogue after he is discharged home, using the Socratic Dialogue.

Psychiatrist: “You say you have seen the Virgin Mary in the middle of the night?”

He: “Yes, she stood over a burning bush in my garden and said to me that I need to run to a priest who lives 25 kilometers away from my house and there I will receive a rosary. I ran, the priest received me, and he gave me a rosary.”

Me: “How did you end up in psychiatric care?”

He: “I did not want to go home, and I was scared because people were following me for a week on the street and photographed me. I don’t know why. Then, the priest had the idea to phone 911 and an ambulance was sent out, so they took me to the hospital.”

Me: “So, If the priest had not phoned 911, would that have been better or not?”

He: “I am grateful to the priest because at that time he saved me from this horrible anxiety.”

Me: “You were in the hospital for three months and you have been at home now 14 days. What is happening with the anxiety?”

He: “Everything is quiet now and no one is following me.”

Me: “What do you think now, were these real people who were following you, or it was part of the illness?”

He: “In the hospital the doctors explained to me that the hallucinations were psychotic, and I had paranoid delusions, and they gave me medication after which the thoughts went away.”

Me: “Can you accept that these thoughts were part of an illness?”

He: “Yes.”

Me: “How about the Virgin Mary and the rosary?”

He: “I did not see her after that. She was so kind and compassionate. I will never forget that. I think that it was the real Virgin Mary and not my illness.”

At home he had specific antipsychotic medications and in two years he had two additional episodes with paranoid delusions and hallucinations. He regained a good stability in his relationship and regularly came to appointments once a month. Since the illness affected his cognitive functioning, he couldn’t continue to work. Currently, he lives at home, and his wife works. They have a family with two children. This works out well with the children. They have a small farm where he is active. His father-in-law also had schizophrenia and he is making sure that he takes his medications as he should. A few years later, I had another Socratic dialogue with him to shed more light on his values that are his guiding principles.

Me: “How do you think about your life, are you satisfied with it, or would you have wanted it to be something different?”

He: “Thanks God, I am healthy. I have a good family. Despite the diagnosis I feel good, I would not want to change anything.”

Me: […There is an affirmation of his life as worthwhile despite the illness. This is an example of the defiant power of the human spirit. He is thankful for his life despite the illness.]

Me: “You received treatment. Looking back, could this treatment have some meaning?”

He: “I could not help the anxieties I was experiencing. That was beyond me. But after the treatment I am at home, my wife is working, and I can help my family more than before.”

Me: […He understands the difference between fate and freedom. I noticed that he developed mild Parkinson’s symptoms because of the medications. However, he insisted that despite the hospitalization, the medications, the Parkinson’s symptoms, his life was worthwhile and good as it was. He said this out of love for his wife, for his children, for his father-in-law whom he is helping. And he was grateful. Even a client with schizophrenia is capable of self-transcendence. He could experience meaning despite his illness.]

Question for the practitioner:

Should a psychiatrist question the client’s beliefs?

Here psychiatrists are questioned in their humanity. The client was convinced that the apparition of the Virgin Mary was real. The main point for psychiatrists to consider is that every person is more than their illness and they are capable of self-transcendence despite difficulties.

Second example: A 28-year-old hairdresser, a lady who was brought to see me by her mother after having been hospitalized at a psychiatric hospital. They were shocked when they the diagnosis of hebephrenic schizophrenia was communicated to them.  Her mother was a director of a bank. She was diagnosed with terminal cancer, and she was given only a few months to live. She wanted me to follow-up the treatment of her daughter. The daughter was beset by anxieties, she showed disorganized speech and abnormal speech content. She experienced hallucinations with depressive and manic mood. The father died in an accident when she was 3 years old. The older sister was a doctor who worked nearby. The mother wanted to leave the house to the daughter after her death. She hoped that with some psychiatric help, her functioning could improve to the point that the eldest daughter could care for her. After the death the mother, the client came to my office, and in a suspiring clear voice she said: “When I was a little girl, I asked Jesus to send me an illness so I can save the world. I have been in the hospital for a long time.” She begged me to say the “Our Father” together. We joined hands and we prayed the “Our Father” together. It was unexpected. Then, she sank into her confused speech. Sometime later, she met someone at the hospital who had schizophrenia for ten years. He lived with his parents. They went for walks together. Two times a week they baked pancakes together. He loved her despite her illness.

Questions for the practitioner:

What are the boundaries between mystical and spiritual experiences and psychotic illness? Was the early experience with Jesus an early childhood symptom of schizophrenia that was not diagnosed at that time? How should a psychiatrist react in such a situation?

Although the psychiatrist may not want to question something that the client holds so dear, the psychiatrist must ask about the implications of the experience because it is clearly something very significant. She showed the willingness to “save the world” through her illness. That was her attitude towards her illness. At that point one can stop questioning this religious experience any further.

Third example: A 45-year-old woman, divorced, who has a daughter and two grandchildren 5 and 7-years-old. She lives alone in an apartment in a  small city. Her diagnose was Schizoaffective psychosis. [This is a mixed psychoses with manic-depressive episodes and schizophrenia.] She was a policewoman. When she was 27, she saw the opportunity to steal money, which she reportedly did. There were internal investigations. The whole year of investigations left her very exhausted. She was married with a policeman from the same police station, and they had a 2-year-old daughter. The man had an affair with another woman and left her. She decided to move with her daughter to another town where she continued to work as a police officer. She had an emotional and financial crisis. A short time after, she started to experience obsessional ideas that she was being followed. She imagined that the police were going to storm her house and that she would end up in prison. In remission when she felt better, we had this conversation.

Me: “If you had the chance now, would you steal or not?”

She: “Of course not.”

Me: “What can you do now to get out of this problem?

She: “I am still in a financial crisis, I cannot acknowledge the investigation, I could not live with the ridicule of my colleagues.”

Me: “What else can you do then? This is in the area of fate now because it happened in the past. What can you do now to make this good again? When you cannot make it up to the right person, can one make it up to someone else? Can you think of something?”

She: “I am thinking about visiting an old man who lives alone and helping him.” 

After her release, she visited this old man and took care of him. She readily assumed this task out of her free will. With time, they became good friends and he sometimes helped to watch her daughter while she had some other work to do. She got a new job in a new place, working as saleslady at a kiosk. For seven years she was in good remission. Then, the old man died, and her grief precipitated a depressive episode. Although medications and psychotherapy helped, she had to be admitted to the hospital because of the depression. She wanted to commit suicide and took an overdose. Her 15-year-old daughter was there with her. In the next couple of years, she had depressive and manic episodes, and she was between lighter depression and suicides attempts and lighter manic episodes. She saw me regularly. Five years ago, her mother passed away. Her father developed Alzheimer’s disease died in a nursing home. Her sister developed depression and committed suicide. She lived through these difficult experiences. She grieved for her sister. Currently, she is in a stable condition, and she lives in her home. Next door to her lives her daughter. She is divorced and has two children. She goes for walks with them from time to time and she has a cat that she loves. She reads the newspaper, she writes cards, and writes poems. The symptoms of depression are the hardest. The suicidal thoughts ease up when she thinks about her grandchildren and her cat.

Questions for the practitioner: 

How can the client deal with the responsibility of a past crime?

One needs to evaluate what it is that she was doing at that time and how her actions are different now from those actions, since she is doing something good for the community. She developed a new attitude toward life because of her grandchildren and this change was not easy to make because of her health condition. It was a self-transcendental choice. She could find meaning and she found the steps to make life livable.

Can it be that guilt feelings are still leading to conflicts?

In this case one should find ways to restore her balance. For a practicing Catholic, seeking out spiritual guidance, reconciliation, and making amends can be considered. From the psychiatric point of view, it is important to emphasize connections with people, such as social workers, family, organizations, to remain active in society. The key is to do something from the heart and to live for someone. “Often it is through the ruins, that one can see the stars” (Frankl).

These were three different people with seemingly similar diagnosis, but as we said, unique persons in unique situations.

Group Intervention

In psychiatric treatment, we need to take into consideration the manifestations of dysfunctions in society. As we mentioned earlier, the premise is that “society is not healthy, but healable” (Frankl). For example, in Croatia, a significant proportion of young people live alone and avoid making commitments. This stems from not being mature enough to face adult responsibilities and seeking refuge in isolation from society. Then at the age of forty, realizing that opportunities have been missed and the time for establishing a family is faint, they develop depression and require mental health care. We can treat these people in de-reflection groups where everyone shares the same problem. There is a similarity between the experience of these people and the fairy-tale of the “Sleeping Beauty.” We can use this story to animate a discussion where everyone plays a role.

[For those of you who are not familiar with this fairy tale, it is about a 15-year-old girl who lives sheltered in her parents’ castle until one day wanders into a remote room of the castle where she accidentally pricks her finger and falls to asleep for one hundred years. A thick bush of thorns surrounds the castle. A young prince hears about the story of a princess asleep there and cuts though the bushes that turn into roses. She kisses the princess who wakes up from her sleep and the two live happily ever after.]

The knight who saves the princess comes through the thorns of the bushes surrounding the castle and all the bushes turn into roses. This illustrates that with hard work and goal orientation, the obstacles in life can fall away.

It is difficult to change society but when we do not shy away from our freedom and responsibility, we can creatively use our resources and the results can be very interesting: Volunteering, reading, hikes. The psychiatrist can lead these groups and help individuals in the groups to set meaningful goals.

In conclusion, “What is the meaning of logotherapy for the practitioner?”  We can answer this question by recognizing the spiritual dimension of the person and their unconditional dignity. It is a privilege in life to be able to help to someone.