“We have to do the best we can. This is our sacred human responsibility.”
(Albert Einstein)
Abstract:
Agency is often understood as the capacity to be in charge of our actions and decisions. It presupposes conscious awareness, and insight into the nature and consequence of our actions and decisions. However, it is not always taken for granted that we possess agency, nor is it always encouraged to have agency in clinical practice. After considering a dictionary definition of agency, its understanding in clinical settings, research findings, which indicate an evolving understanding of agency, the presenter explores two clinical examples, one in which the sense of agency is suppressed, and one is which a sense of agency is enhanced, to highlight key points for facilitating agency from a meaning-centered point of view. In this context, the Principled Model of the Freedom of Will (PMFW) is presented, and the concept of Meaning-centered Agency is introduced. The principles of Viktor Frankl’s Logotherapy and Existential Analysis (LTEA) are highlighted as fostering meaning-centered agency, the cornerstone of psychotherapy with dignity.
Key Points:
Dictionary Definition of Agency, Clinical Understanding of Agency, Research and Evolving Understanding of Agency, Perspectives on Agency, Two Examples, Key Points to Facilitating Agency, The Principled Model of the Freedom of Will, Meaning-Centered Interventions, Agency with Capacity, Agency with Limited or Diminished Capacity, Medical Ministry, Meaning-Centered Agency, Psychiatry with a Humane Disposition, Evidence-base, New Vistas.
Introduction:
The topic of agency brings into focus a fact that many of us take for granted, namely that we as human beings are in charge of and own our actions and decisions. However, the mere fact that this topic deserves attention is because in some contexts our sense of agency is questioned or ignored. This may well be the case in a clinical setting or in everyday life situations wherever we enter into a relationship with our surroundings. —Are we mere spectators, actors at the mercy of our desires, urges, needs and wishes, reacting to what we receive, and acting according to what is expected of us, or are we capable of actively shaping our surroundings, and even molding ourselves? The answers to these questions will vary according to our view of the person, the view of the human being, which influences what we think a human being is, and what a person is capable of being, and becoming.
Agency—A Dictionary Definition:
According to the English dictionary, “…agent is something or someone that is capable of producing an effect.” (Merriam-Webster, 2024). An agent is also called an actor. The word agent is derived from the Latin word” agere” which means to set in motion, drive forward, to do” and from the Greek “ágein” “to lead, to carry off” (Merriam-Webster, 2024). In legal terms, an agent can be acting on behalf of themselves, or on the behalf of someone else. Agents are given decision-making capacity (Merriam-Webster, 2024).
Agency in Clinical Practice:
In the clinical setting, agency is often formulated in terms of capacity. Capacity is a legal term that refers to a determination consciousness and the ability to have insight into the nature and consequences of one’s actions and decisions. Capacity is required for informed consent and for making informed decisions. It means that one is able to make their own decisions and execute necessary functions without help. It is “…the ability to use and understand information to make a decision, and communicate any decision made” (NHS, 2024).
Agency presupposes capacity but goes beyond the concept of capacity. The author would like to think of it as the ability to choose one’s actions and make one’s decisions according to one’s beliefs and values in a purposeful manner.
Psychologists and psychotherapists have defined agency as “…the sense of control that you feel in life, capacity to influence your own thoughts and behavior, and have faith in your ability to handle a wide range of tasks and situations” (PPCFL, 2024); or as “…a sense of control over our actions and consequences” (Moore, 2016).
Agency may be defined as “…your ability to set goals, monitor your progress and evaluate the outcome,” and colloquially equated with “…cutting through the noise, finding balance and advocating for yourself, in other words, taking responsibility for your life” (Napper and Rao, 2019). Simply put, it is “…the ability to achieve a goal” (McGill, 2024).
Research on Agency:
Research on agency and self-efficacy grew out of Alberta Bandura’s Social Cognitive Theory which started in the 1960s and was formulated in 1986 (LaMorte, 2022). His leading research on confidence and self-efficacy found that agency is aided by intentionality, forethought, self-reflectiveness, and self-reflection (McGill, 20204).
For a long time, agency has been recognized as a “crucial component in psychotherapy,” (Parsons, 2005; Wahlström & Seilonen, 2018). Today, although there is wide diversity amongst therapists on the issue of what constitutes agency and autonomy, fostering and developing personal agency is embraced as “…both a key aim and effective means of therapeutic change” in existential therapy, as practiced by its main proponents, van Deurzen, Cooper, Langle, McWilliams, Spinelli and Yalom (Stanovskaya, 2014).
Research indicates that there is an association between sense of agency and the quality of dialogues (Parsons, 2005). According to Alfred Langle, there is an association between “…the ability to say “yes” to one’s subjective reality, feelings, uniqueness and distinctiveness, and agentive presence in others and in the world” and positive therapeutic outcomes (Stanovskaya, 2014b). Th absence of relationality, causal attribution, intentionality, historicity and reflexivity—the absence of a sense of agency- or the presence of these traits—the presence of a sense of agency, have been identified as hallmarks of the core processes of effective psychotherapeutic interventions (Wahlström & Seilonen, 2018). Fostering autonomy, relatedness and competency have been hailed as the “future of humanistic psychology” (McArthur & Cooper, 2017).
Evolving Understanding of Agency:
According to Martin and his colleagues (2009), while there has been plenty of research exploring the concept of agency, little attention was given to assumptions about what a person with agency is. This leaves open the question of what the source of agency is, and what motivates a person. In line with this argument, the presenter believes that the difference in understanding of agency and how to foster it has to do with the view of the person which underlies each orientation to psychotherapy, whether that is laid clear or obscurely influencing the adopted method of practice, and what therapists consider to be the motivating factor or factors influencing human behavior.
In the history of psychotherapy, different schools had different ideas about the nature of the human person, and these ideas had a direct impact on understanding what motivates human beings to act. Without going too much into detail about centuries of debate about reductionistic views of the person that necessitated the re-humanization of psychotherapy, we may consider two well-known clinical examples that allow us to consider some key differences between a person as the victim of their circumstances, or an active agent of their destiny, granted that of them are conscious, and capable of having insight into the nature and consequences of their choices, actions, and decisions.
In 1959, when Frankl’s well-known book, “Man’s Seach for Meaning” was first translated into English, the Preface was written by Gordon Allport, who in 1960 proposed an “Open system in personality theory” (Allport, 1960). This system was heuristic in that it allowed for the personality to change and evolve –to be in a state of becoming–as opposed to rigid categories (Allport, 1960). Allport stressed that Frankl’s theory of motivation departed from the traditional homeostasis principle. By proposing a holistic view of the person in a state of tension between what is and what out to be, Viktor Frankl’s Logotherapy and Existential Analysis, according to Allport, ushered in a new era of re-humanization of psychotherapy, a most significant moment in the history of psychology (Allport, 1960; Frankl, 2000).
The contribution of this research article is to offer some points of agency from the perspective of Viktor E. Frankl’s Logotherapy and Existential Analysis, also known as meaning-centered therapy (Frankl, 2014b). The psychoanalytic perspective is included to discern and clarify insights about the nature of agency and how to enable it in contemporary practice. To accomplish this objective, two examples of a psychotherapeutic approach with patients will be presented: one from a psychoanalytic and one from a logotherapeutic perspective. Implications and treatment outcomes will be analyzed with respect to agency.
Example Recorded by Dr. Kurt Eissler:
There is a case study that appears in a textbook of psychoanalysis which was written by Dr. Kurt Eissler in 1955, entitled “The Psychiatrist and the Dying Patient.” It details the treatment of a 45-year-old female patient, suffering from cancer, all the way through attempted surgical interventions to the terminal stage and her death. This case was known to Dr. Edith Weisskopf-Joelson, and to Dr. Viktor Frankl, who mentioned it in “Man’s Search for Ultimate Meaning” (Frankl, 2000:112).
The original report by Dr. Eissler gives us the following account: A few weeks before this patient died, she was increasingly concerned about the meaning of her life. “The patient was doomed, and she knew it,” stated the therapist (Page 156). Since “…the patient apparently had no depression in the clinical meaning of the term,” (Page 194) “…assistance was given by extensive intellectualization” (Page 192). Her condition was likened to Alcestys, wife of Admentus, King of Thessalay in Greek mythology, who offered her life as a sacrifice in exchange for the recovery of her husband from a potentially deadly disease (p. 186). Her “narcissistic tendencies” were discussed in relation to the assertion that she was the only suitable caretaker for her children (Page 162). Amidst these conversations, the patient increasingly questioned the meaning of her life, stating that “…she could bear any suffering if she saw meaning” (Page 190). She voiced the observation that her life seemed “full of meaning in the first stage of her life,” while she was still healthy, and she was “…important for her children and fulfilled a function,” and “void of meaning” since she was diagnosed with cancer and had to be hospitalized. (Page 190). The doctor in charge responded to this observation by remarking that this lady was making “…a gross mistake” (Page 190). She was comparing the first stage of her life with the second stage and making unwarranted conclusions, when the fact was that both of these stages were devoid of meaning. “Her life—like life in general—had been futile and without meaning even before the onset of her disease.” (Eissler, 1955: 190). The only difference between the past and present, remarked the doctor in a well-meaning way, was that “…at that time you could attribute meaning to your life whereas now you are incapable of doing so” (p. 191). To this the patient reacted with a moment of silence, “confusion,” “she claimed not to understand me,” and after some time, started to cry (Page 191). No follow-up questions were asked. The doctor “…expected that she would come back to the argument, but she never did.” Therefore, Eissler concluded that the therapeutic intervention must have somehow reduced her wish to commit suicide. “As a matter of fact, the patient did not commit suicide but acted right to the end in keeping with the standards of her past; that is to say, lived up to the requirements of the reality.” (Page 191). Toward the end stages, she required medical interventions, for which the doctor provided morphine to ease her pain. She was grateful, but since this interview, “She never again mentioned feelings of thankfulness.” (P. 191). The doctor traveled abroad, and he entrusted the care of this lady to a more junior colleague. Upon his return, he found out that the patient had passed away. He enquired about the circumstances of her death from his colleague who said that the patient refrained from emotional expressions, accepted her fate in a stoic kind of way, and passed away without raising questions about the meaningfulness of her life. In her record it was noted that, toward the end of her life she, she wanted to be released to see her family, but this request was refused, and she was told that she was a “patient” and she “had to co-operate more.” (Page 194). In the last few days, she was “…confused because of heavy sedation, speaking about work she had to do and appointments she had to keep” and thus” …she died suddenly on the twenty-fifth day of her hospitalization” (Page 194).
Example Recorded by Dr. Viktor Frankl:
A strikingly similar, and yet, very dissimilar perspective on agency and its significance was presented in Frankl’s lectures about the psychotherapeutic treatment of Ms. Kotek, an eighty-one-year-old lady, who, like the previous patient, suffered from a terminal case of cancer, specifically from “…metastasized carcinoma and knew that she would soon die” (Frankl, 2024: 26). She was aware that her condition was incurable, and she was reflecting on the meaning of her life. In this instance, the therapist helped her to reflect on the beauty and goodness that she experienced in her life before she had been diagnosed. The doctor upheld these meaningful memories and deeds as something that no one and nobody on the face of the earth could remove and snatch away from this lady: “No one can erase the kindness that you have encountered in your life…what you have achieved and what you have gained” (Page 27). He exclaimed: “Ecce Homo!” (Page 27). –An exemplary human being, who makes the best of even her last weeks, giving the audience an example of a courageous human being who bore her suffering bravely. “And tell, me,” asked the therapist, “what do you think, can anyone undo such achievements?” “No, no one can,” replied this patient. “They remain,” confirmed the therapist. “Certainly, they remain,” agreed the patient. To which the therapist concluded: “You see, you haven’t just achieved all sorts of things in your life, you have also made the best of your life and your suffering. And because of that, you have become a role model for our patients in this department. I congratulate your fellow patients on the fact that they can take you as their example.” (Page 28). And to the spontaneous applause of the audience, this lady left the lecture hall. The therapist recorded that she died a week later, but “…she was no longer depressed.” (Page 29) “Earlier, she was depressed, weighed down by the feeling that she had led a useless life.” (Page 29). The conversation had shown her that “…life, and her life as well, had a meaning until the very last breath” (Page 28).
In the original recording we find that the last words of this patient were: “My life is a monument, so Professor Frankl said to the whole audience, to all the students in the lecture hall. My life was not in vain” (Frankl,1967: 98). She died peacefully, but not disconnected. In the therapist’s words, she went to the grave “like Job,” with “her granary full” and with a sense of consolation and contentment that her life had not been in vain (Page 98).
Examination of the Two Perspectives:
Both examples have been recorded, and both case examples are here for us today as reminders of two very different approaches to the ill person, their lives, their experiences, their wishes, desires, and their suffering. The first approach sought to appease the patient by telling her not to occupy herself with questions of meaning. By this act, the therapist guided her reflections away from what was meaningful and valuable in her life, what was worthwhile, memorable, and wonderful. This act reduced her sense of agency by snatching from her the opportunity to reconcile herself with her past and present situation. The patient manifested sadness, and despondency, until she seemingly accepted her fate and resigned herself to her condition. She remained collected but distanced from the doctor who treated her. Ironically the doctor was away while she passed on and contact with her family was forbidden. Although this patient’s self-report is not available to us, we can assume that she had to master courage to face her condition on her own terms and assume agency over a limited scope of her affairs. She achieved this despite the doctor’s absence.
The second example encouraged and assisted the patient to address existential questions that arose during time of suffering. The therapist involved her in a lively dialogue about her experience which helped her to see her life as a whole and evoked her sense of agency, as one who was fortunate to receive from, and to give something to, the world. This patient was helped to connect her past with the present and to see an opportunity in her present situation to still be someone to look up to: she demonstrated a courageous attitude in the face of death. She was led to see that, despite her illness, and exactly because of it, she had a unique role to fulfill, which she accepted wholeheartedly. Although her self-report is limited, we can infer that she died with a sense of mission, duty, and with composure—a sense of agency beyond her condition.
There is a qualitative difference between having to assume agency in the face of a terminal illness and being supported and affirmed in doing so. In the first case, one’s support system was literally made absent, and redundant. In the second case, even if a support system was initially felt as absent, a circle of care was created around the patient for the sake of preserving her legacy. We owe it to Dr. Eissler and Dr. Frankl to have these two examples today to attempt to learn more about fostering agency.
Value-blindness vs. Value-discernment:
The psychoanalytic framework is largely concerned with dynamisms of the body and the mind (physis and psyche). Within this scope, questions of existence are reduced to the level of drives and instincts. The patient’s allusion to taking care of her children is explained as a narcissistic desire. Her existential questions are interpreted as arising from the death instinct, which is handled through intellectualization. In the end, the dogmatic adherence to reductionistic tendencies results in value-blindness, the ignorance of the uniqueness and singularity of this person and her experience, as well as the denial of a part of her authentic desire for finding meaning in suffering.
Frankl’s meaning-oriented approach, on the other hand, makes the existential question of whether there is meaning in suffering and in the face of death, the focal point of intervention. Rather than interpreting it as arising from the realm of drives and instincts, Frankl recognizes this question springing from the essence of the person, as an impulse for the will to meaning–a life fully lived and thus fulfilled to the last breath. This awareness is kindled by value-discernment, the pinpointing of values, whether creative, experiential or attitudinal (Frankl, 2014; Marshall & Marshall, 2016).
Value-discernment is present in the way the Frankl pinpoints something that the patient “has been good for” and is still “good for.” The therapist emphasizes Ms. Kotek’s value, the truth, beauty and goodness that she encountered, and she gave in her life; the example that she is for those who can witness her life. Eissler did not specifically emphasize this in the case of his patient. He was concerned about “undue transference and counter-transference reactions” and “expressed concern and feelings about her plight in a way not offered previously in the psychotherapeutic situation” (Eissler, 19555:196). He later remarked that while “the physical side of therapy is replaceable, …the psychiatrist essentially is not” and there are no excuses to take up any commitments that would take him or her away from the bedside of the dying patient (Eissler, 1955:197):
“In these moments the psychiatrist, who has lent himself during the terminal phase as a frame into which the patient has projected his loves and hatreds and the aggregate of all the actors who played a role on the stage of his life, becomes irreplaceable. The separation between external reality and internal reality crumbles, and the psychiatrist is no longer an object of transference; that which serves in the treatment of the living as a tool to help the patient back to life becomes here an end in itself; without purpose beyond” (Eissler, 1955:197).
Resignation vs. Encounter:
The outcome in the first example is resignation–a discrepancy between the wavelength of patient and therapist, and in the second case it is consonance and resonance–a harmony between patient and therapist. According to Frankl, “…only when we have been able to inoculate ourselves against radical determinism and reductionism, only then can we be in the position to uphold the humanity of the patient and to be AWE of the ‘Homo patiens,’ the suffering human being” (Frankl, 1951). Beholding the patient and upholding what they are, what is dear to them, precious to them and what is worthwhile and meaningful in their lives is a key to imbuing them with a sense of value and a sense of purposeful agency.
Keys to Fostering Agency in Clinical Practice:
We can now summarize a few key points that are required for re-humanizing psychotherapy through a holistic view of the human person and emphasize what a difference these points mean in terms of what a therapist can accomplish when they are value-discerning, and able to recognize, and uphold, and encourage the agency of person, as opposed to ignore aspects of the person and part of their deepest aspirations:
- Moving from the view of an object, a “broken down machine,” to a “person:”
Considering a person in their totality, as a body, mind and spirit entity allows to acknowledge a human being’s will, and fundamental will to meaning. This is the key to agency. It allows to recognize and to mobilize the spiritual capacities of a person, such as their ability for self-distancing and self-transcendence (Frankl, 2014). According to Frankl’s psychiatric and psychological creed, a person can be disturbed, but not destroyed. Even behind the façade of the most serious illness, whether physical or psychological, the dimension of the spirit is still there. It may be masked, it may temporarily be blocked or inaccessible, but it is there, waiting to be able to express itself. This is a fundamental thesis about the value and dignity of every life and every person (Frankl, 1994:86, 96).
“Just as life remains potentially meaningful under any conditions, even those which are most miserable, so too does the value of each and every person stay with him or her, and it does so because it is based on the values that he or she has realized in the past, and is not contingent on the usefulness that he or she may not retain in the present” (Frankl, 1984:150-151).
Therefore, upholding WHAT a person is, is the first and crucial element of agency.
- Moving from Fate to Freedom:
Considering the body and mind that may be affected by illness or disease still leaves an intact area from which a person’s will to meaning springs. Will is a formidable force that springs innately from the essence of the person and cannot be imposed, deceived, tricked, manipulated, or commanded. In their dimension of spirit, every person retains the elements of will, hope and love, which escape every attempt of demand or imposition. According to Frankl, will is naturally activated in the direction of meaning, or Reason, which is a motivating force that cannot be reduced to the level of instincts or drives.
A person may be conditioned by their environment, illness, or past, but not determined by them. In their spirit, they can choose to distance themselves from their illness and choose their position toward adversities. What a human being may have to face may be unavoidable, but the how they face this situation and what they bring out of it is still possible to maintain an area of freedom over. Or as Frankl said, we may not be free from conditions but free to –dream, create, act, and choose the way we suffer and die.
“For what matters is to bear witness to the uniquely human potential at its best, which is to transform a personal tragedy into a triumph; to turn one’s predicament into an achievement” (Frankl, 2014b:105).
Therefore, WHERE a person maintains freedom, is the second crucial element of agency.
- Moving from no choice to horizons of meaning:
The area of freedom in the spirit leaves an area that allows a person to move toward the actualization of values. Whether through actions, creation, encountering others, or making the best of suffering through a courageous standpoint, the area of freedom opens a door to a human being’s ability to respond to life calling them, addressing them, personally, in their own, unique situations, by their name. As Frankl said, the question is not what we can expect from life but what life expects from us (Frankl, 2014b). In this Copernican revolution lies life’s call, a vocation, is to what one is free to choose to respond. And this is where a person who, through their conscience perceives and receives that life is addressing them, “per-sonare” –that the voice of the Transcendent sounds through, is no longer alone, disjointed, or disconnected, but is free to “re-sonate,” to respond and to actualize the meaning potentials waiting for him or her until the last breath. As Frankl encouraged his fellow prisoners,
“We are all comrades and fellow human beings, and there is no such thing as Übermensch, or super-human [as proposed by Nietzsche], as we think of it in terms of any superiority arising from any qualities, as in the dynamics of the spirit we are all the same, except for some who live along higher levels of consciousness, like the prophets, but to this we are all called to in life—to live to the fullest and according to the highest principles available to humankind” (Frankl, 2014b:77-80).
Therefore, TO WHAT a person responds to, and the MANNER in which they respond, is the third, crucial element of agency.
- Moving from Giving Meaning to Discovering Meaning:
In the Ten Thesis of the Person, Frankl asserted that the person is essentially self-directed:
“The person, the self…cannot be derived from the id, from the drive, not only dynamically, but also genetically: the concept of ego drives is to be rejected altogether as contradictory in itself. However, the person him or herself is also indeed unconscious: And precisely there, where the spiritual is rooted, –precisely in its source ground the person is not only facultatively, but obligatorily unconscious. In its origin, in its essence, the spirit is unreflective and insofar just pure and unconscious act. So, we have to distinguish very precisely between the libidinal unconscious, which is all that psychoanalysis had to deal with, and the spiritual unconscious. But to this, to the unconscious spirituality, also belongs unconscious faith, unconscious religiosity—as an unconscious, indeed not seldom repressed relation of human beings to transcendence” (Frankl, 1951; 1972; 2024).
When asked if he considered his theories pessimistic or optimistic, Viktor Frankl responded by saying that instead of these dichotomies, he considered logotherapy to be “activistic” (Vesely-Frankl, 2024). Activistic in a sense that logotherapy translates into action that what existential analysis highlights as authentically human. Frankl believed that people are neither inherently good nor bad but have the capacity to make decisions. Human beings have the capacity to decide who they want to be in the next moment (Vesely-Frankl, 2024).
Frankl affirmed:
“…Our aim must be to help our patient to achieve the highest possible activation of his life, to lead him, so to speak, from the state of a “patiens” to that of an “agens.” With this in view must not only lead him to experience his existence as a constant effort to actualize values. We must also show him that the task he is responsible for is always a specific task. It is specific in a twin sense: one, that the task varies from person to person—in accord with the uniqueness of the person. Two, that it changes from hour to hour, in accord with the singularity of every situation” (Frankl, 1980: 54-55).
“But if the patient should object that he or she does not know the meaning of his or her life, that the unique potentialities of his or her existence are not apparent to him or her, then we can only reply his or her primary task is just this: to find his or her way to his or her own proper task, to advance toward the uniqueness and singularity of his or her own meaning in life” (Frankl, 1980:56).
Therefore, the fourth key of fostering agency is to refrain from the imposition of values, and giving meaning, but rather, helping clients to decipher and discover meaning that is waiting for them.
The Principled Model of the Freedom of Will:
Based on Frankl’s assertion that “…human beings are not fully conditioned and determined but they determine themselves whether to give in to these conditions or to stand up to them. In other words, human beings are self-determined (Frankl, 2014:122) and “…the intrinsic fact that being human always relates to and points to something other than itself—better to say, something or someone…Truly, self-transcendence is the essence of human existence” (Frankl, 2000:138), Marshall and Marshall (2024: 119) presented a neuro-psychological model, entirely compatible with both Frankl’s theses and modern neuroscience findings.
This model shows that through a process of reflection, human beings can make a decision about which values to live for (slow process related to cortical brain activity associated with reasoning). These values are then coded and stored in conceptual memory, regulated by the cortico-limbo-diencephalic system to guide everyday decisions (fast process involving limbic structures associated with emotions).
As the model illustrates, during a process of reflection, and value-discernment, individuals can be helped to gain insight into their values and guiding principles. They can affirm whether they wish to live by these values or choose other values in harmony with universal values. Thus, they can modify their responses and with Frankl’s words, “…to the extent the person is manifested and actualizes him or herself in the values they live…,” choose which values they want to act on and bring into the world throughout their lives (Marshall, & Marshall, 2024).
Meaning-centered Interventions:
The principles and methods of Viktor E. Frankl’s Logotherapy and Existential Analysis are based on universal principles of respect for the dignity of the person. His system represents the first complete system in the history of psychotherapy (Frankl, 2000b); complete because of laying open the model of the person as a body-mind and spirit entity, and thereby rendering the person open to a world of relationships with the self, others, and the Transcendent—propelled by the will to meaning.
According to Fabry, self-discovery, helping clients realize their uniqueness, choices, ability to respond and responsibility, ability for self-distancing and self-transcendence are optimal guidelines for fostering a sense of meaning life (Fabry, 2021). These capacities of the person presuppose a sense of agency and promote it. Thus, we may conclude that a sense of agency enhances a sense of meaning in life and vice versa, meaning in life imbues us with a sense of agency.
Agency with Capacity:
Considering agency as the ability to choose one’s actions and make one’s decisions according to one’s beliefs and values in a purposeful manner, we can examine the implications of agency even in high-stakes situations. One such example is when exceptionally courageous people in history chose to defend their moral stance even at the cost of their lives.
In 1535, Saint Thomas More, Lord Chancelor to King Henry VIIIth, was granted one last visit by his daughter, Margaret. On this occasion, Meg, as Saint Thomas affectionately called her, begged him to renounce his statement condemning the King’s actions as immoral and change his position, at least superficially, to save his life, while knowing and believing the opposite in his heart. St. Thomas declined. He replied that what we do matters. The way we live and the legacy we leave behind matters: “Our choices matter, especially when we hold ourselves in our hands.” His well-known last words on the platform were: “I die as the King’s good servant, but God’s first” (The British Library, 2016).
Agency with Limited or Diminished Capacity:
The discipline of psychiatry and psychotherapy is concerned with treating individuals with severe conditions in which, oftentimes, patients have limited or reduced capacity due to illness. There are special considerations that need to be observed in such situations.
On July 27, 1890, Vincent Van Gogh left his room at the Auberge Ravoux located in the French village of Auvers-sur-Oise and went to the nearby fields. He was in the grip of a clinically severe depressive episode. In his letter to his brother, Theo, on July 10, 1890, he stated: “…My life, is attacked at the very root, my step also faltering” (Van Gogh Museum Amsterdam, 2024).
On the 23rd of July, he followed up this thought with the remark, “…I’d perhaps like to write to you about many things, but the desire has passed to such degree, then I sense the pointlessness of it” (Van Gogh Museum, Amsterdam, 2024). He felt that he was unable to continue his work, and he was failing in many ways, even though by that point his artwork started to receive some attention. This was not the first time that Van Gogh had experienced depressive episodes, sometimes with psychotic features.
Between the 31 of May 1889 and 6th of June 1890, he spent one year in the mental hospital in Saint-Remy-de-Provance (Van Gogh Museum Amsterdam, 2024). During this time, he completed some of his most beautiful paintings, such as the Starry Night (1889), and Almond Blossoms (1890), as a present for the nursery of his newborn nephew, Vincent, named after him—a sign of hope (Van Gogh Museum Amsterdam, 2024). While at the mental hospital, he was given space, and he painted, “…despite everything” (Van Gogh Museum Amsterdam, 2024). Since his release, however, his mental state began to fluctuate.
An unfinished letter that was found on him on July 27th, addressed to Theo, read: “…Ah well, I risk my life for my own work and my reason has half foundered in it. But what can you do?” On July 29th, he died in his room from an apparently self-inflicted gunshot wound, sustained 30 hours earlier (Arenberg et al., 2020). At the time, Vincent was under the care of Dr. Gachet, whom he saw on May 20th. Van Gogh described him as “…rather eccentric.” This doctor offered him no medical treatment but encouraged him to continue to paint (Van Gogh Museum Amsterdam, 2024).
Caveat About Diminished Capacity with Impact on the Sense of Agency:
There are conditions in which a sense of agency is reduced due to lack of, or diminished capacity. At the hospital in Saint-Remy, Dr. Peyron, Van Gogh’s physician, concluded that he suffered from a form of epilepsy. That was the only formal diagnosis Van Gogh ever received (Van Gogh Museum Amsterdam, 2024).
Severe depressive episodes, psychotic conditions, schizophrenia, dementia are among those medical illnesses that have complex biochemical, psychological and social correlates. The primary focus of intervention in such cases should be medical, with an understanding that the spirit of the person is still intact, but its expression hindered by disease (Frankl, 1985).
Medical Ministry:
“Medical Ministry” is the domain under which Frankl described the primacy of pharmacological and medical interventions that should result in lifting or ameliorating the symptoms of the disease, which leads to gradually recovering as sense of agency (Frankl, 2004; 1980). Patients are advised to be patient with themselves until the treatment takes effect and to be, according to their capacity, knowledgeable about their condition, the treatment proposed, and its possible side effects, advantages and disadvantages. A sense of agency is supported by creating a safe space and environment in which they can have a quality of life, with attention to meeting their physical, psychological, social, and spiritual needs (Frankl, 2004; 1980; 1935).
Accepting vulnerability, one can still point to what is intact, true, good, and beautiful in and around the person; what they have accomplished well and what possible life-affirming choices they have. The will to meaning and the defiant power of the human spirit are allies in this quest. Agency is fostered indirectly, and springs forth from re-gaining a sense of trust, hope, purpose, meaning, and direction in life. As capacity increases, existential analysis can be used to support the will to meaning and logotherapeutic methods can be used to find meaning (Marshall & Marshall, 2024).
As for how important it is for the even the most severely ill patients to be respected and to feel valued and included, Frankl was one of the first psychiatrists who as early as in 1935, organized a special celebration of Yom Kippur at the psychiatry ward for the Jewish patients he was treating:
“…Some patients with hallucinations spoke to themselves and their lost gaze spread without a precise objective in the room. Then, the Rabbi approached them, for— “to serve human beings is also to serve God” –and started to talk to them in German. With emphasis, he explained to them what has been sung in sacred language, capturing in this way the attention of his listeners. This is what he did for an hour and the following day for six more hours. Soon, he realized what a sick soul needs: to be snatched out of the delusional world, to conquer once again their attention…keep the patients occupied. A lot of sensitivity, adaptation, patience, and capacity for encounter were needed for this task. But Rabbi Fischer managed to do it” (Frankl, 1935:7).
To be looking at the other with eyes of care and tenderness requires seeing them in their complex reality—not myopically, using monovision, but stereoscopically: as they are, as they can be, and ought to be. As in the words of Pope Francis, loving others requires “…a leap of the heart,” that reaches from the “I” to the “Thou,” to create bonds of sharing and communion (Pope Francis, 2021; Buber, 2008).
The aim of Logotherapy and Existential Analysis is to enable people to use their agency to the maximum to actualize truth, beauty and goodness, aspects of meaning and value in their lives.
Meaning-Centered Agency:
Meaning-centered agency is a conscious and conscientious decision to actualize the value that stands in relation to us and beckons us, the actualization of the meaning of the moment (Frankl, 2014). In light of the fundamental principles of Viktor E. Frankl’s Logotherapy and Existential Analysis, meaning-centered agency is the purposeful actualization values in harmony with universal human values. Universal human values affirm the dignity of the person and the unconditional meaningfulness of life (Marshall & Marshall, 2024).
The facilitation of meaning-centered agency is through pointing to avenues and possibilities through which a person has lived and can still respond to life. Thus, to point to what a person is and what they accomplished that no one could take away from them. It refers to a re-humanized way of practicing in which “psychiatry with a humane disposition” is welcomed (Frankl in Batthyány, 2024).
Psychiatry with a Humane Disposition:
Viktor Frankl’s Logotherapy and Existential Analysis is a trailblazer of hope for guiding patients or clients toward a holistic view of themselves and others, and therefore, encouraging and supporting them in their agency as persons with dignity regardless and beyond their circumstances. Edith Weisskopf-Joelson and Frankl agreed that in the last analysis, a therapist should aim to imbue their patient’s life with a sense of wonder instead of taking away meaning, a sense of purpose and direction (Frankl, 2000). Psychiatry and psychotherapy with a humane disposition means honoring and embracing the aspirations, dreams and utmost will of every person to live a meaningful life, filed with creative, experiential and attitudinal values (Frankl, 2014).
In Frankl’s Logotherapy and Existential Analysis, patients and doctors work collaboratively to “co-form disease outcomes” by awakening, noticing, honoring the “trans-morbid noetic” –spiritual resources–of the patient, through which stabilized patients can take a distance from their symptoms, and at least to some extent, influence the manifestation of the symptoms through the attitude taken toward them (Batthyány, 2024:11). They can also accept, to the extent possible, “…a self-chosen and responsible stance toward their own illness” which in turn “…affects the course of the disease itself “(Batthány, 2024: 11).
“We have to bring the patient to the place where he does not try to “pull himself together,” on the contrary: to where he allows the depression to issue out and around himself insofar as it is possible—that he take sit precisely to be endogenous, in a word that he objectifies it, and as such, distances himself from t—and this is possible in light to moderate cases. Whether one person ceteris paribus distances himself rom his endogenous depression while another allows himself to succumb to the depression rests not upon the endogenous depression itself, but rather upon the spiritual person; for the person is aways at work, always exerting some effect, always co-forming disease outcomes” (Frankl, 1985:62)
Such approach is not possible without a wholistic view of the person as body, mind, and spirit entity. And while we may tend to take it for granted that modern psychiatry, psychology and counselling have embraced Frankl’s anthropological view of the person, today, at least we can at least hope that we can make strides towards incorporating this model into contemporary clinical practice to improve the experience, the outcomes, and the effectiveness of interventions.
Evidence-Base:
In 1950, Dr. Weisskopf-Joelson remarked, “…it almost seems as if Dr. Frankl does not quite fit into APA Division 29 Psychotherapy Division, but that psychotherapy should be such that Dr. Frankl would fit into it” (Weisskopf-Joelson Archives, Undated).
Since then, the evidence base of logotherapy regarding the validation of its theoretical concepts and methods has been compelling (Batthyány and Guttmann, 2006; Batthyány, 2021). Today, Viktor Frankl’s Logotherapy and Existential Analysis is accepted as a valid, evidence-based method of treatment in the field of psychiatry and psychotherapy (Breitbart, 2016; Batthyány, 2024; Marshall & Marshall, 2024).
Perspectives Point to New Vistas:
The history of psychotherapy influenced our understanding of what is meant by agency. Viktor Frankl’s Logotherapy and Existential Analysis offers a holistic model of the person in which agency goes beyond self-reflection and includes self-discovery, the capacity for self-distancing and self-transcendence.
Self-distancing is the ability to step away from ourselves, observe a phenomenon–or even ourselves and our illness– from the outside to be able to choose a response toward it. Self-transcendence “is the essence of existence,” meaning that the noetic (spiritual dimension) of the person is attracted to values that must be discovered and actualized in the world (Frankl, 1988:50). The manifestation of this existential dynamics is the will to meaning, “…which cannot be demanded, commanded, or ordered. One cannot will to will. And if the meaning is to be elicited, meaning has to be elucidated.” (Frankl, 2014: 27). The will to meaning is a life force that propels us toward making free and responsible decisions.
Eventually, we all face unavoidable suffering. At such times, what really matters becomes even more crystallized, and how a person chooses to respond to their predicament is even more relevant.
As responsible and conscientious actors, if we played our part well, then there is no need for applause, it is just a well-deserved grace, for we can have the inner reassurance, the wisdom of the heart, that our life has an unconditional value. However, if we want to foster people’s agency, then, with the words of Goethe, we “…must take people not as they are but as they can be” to help them become the best version of themselves (Frankl, 2014b). Borrowing a metaphor from Frankl:
“…If it is true that people in life are like actors on the stage, then let’s remember that the actor—blinded by the limelight—does not see the audience or the auditorium, but a large black hole. They never see “before whom” they are performing. And is it not the same for the average person? He too—blinded by the light of everyday life—does not see “before whom” he or she bears the responsibility for his or her existence (as an actor bears his or her role). He cannot see before…And still there are always people who think that precisely in the spot where we see “nothing,” precisely there sits the Great Spectator who steadfastly watches us. These people are the people who call out to us, “Watch out, you’re on stage and the curtain is up!” (Frankl, 2024:124).
Existential dialectics are co-existing opposites and realities that seem to be contradictory. That is why, initially, there seems to be an incompatibility between the logotherapeutic and other approaches:
“Seen from a unidimensional, or two-dimensional perspective, existential dialectics create obstacles and misconceptions about human nature and existence. Seen from a three-dimensional vantage point, existential dialectics expand our vision horizontally and vertically to a view in which apparent opposites can be reconciled and approached in a constructive manner” (Marshall, & Marshall, 2024:165).
Dialectics help us to understand perspectives and to rise above them. Ascertaining the reality of fate, we can transcend to, and act–in and through–an area of freedom. Accepting vulnerability, we can transcend to and act—in and through–an area that remains intact. Acknowledging pleasure or power orientation, we can transcend to meaning-orientation. Realizing a character, we can strive toward an evolving personality. Conscious of immanence, we can strive for transcendence.
Conclusion:
In the health care setting, fostering agency requires the noetic dimension to be allowed to remain in charge. Therapists accomplish their duty by enabling to forge ahead through collaboration and co-creation of a pathway through which the biological, social and psychological correlates of illness can be treated or managed, always in the service of meaning—a joint project of discerning a value that stands in relation to the person.
When a patient is temporarily not able to name this meaning, or see it clearly, the therapist’s duty is to maintain unconditional belief its existence (Frankl, 1985). In such instances, therapists should refrain from traditional forms of therapy requiring introspection and self-analysis, as these could increase feelings of guilt and self-depreciation and increase the likelihood of suicidal ideation (Frankl, 1985). They should instead, unconditionally uphold the human dimension, and foster the resources of the spirit (Frankl, 1985, Batthyány, 2024).
Logotherapy can stretch our thinking beyond the confines of conventional forms of psychotherapy. Perhaps, at such times the following lines from the poem “What It Is” by Eric Fried (2013) may help us to ponder this topic beyond the confines of this presentation.
“It’s nonsense, says reason.
It is what it is, says love.
It is calamity, says calculation.
It is nothing but pain, says fear.
It is hopeless, says insight.
It is what it is, says love.
It is ludicrous, says pride.
It is foolish, says caution.
It is impossible, says experience.
It is what it is, says love.”
This last line, love, may be of most relevance when we want to summon our agency and, through the defiant power of the human spirit, say “Yes” to life, despite everything” with every fiber of our being (Frankl, 2019). Also, when we recognize, embrace, and uphold the value of the other as a person, despite their condition, and beyond their condition, to help them to respond to their challenges in a meaningful way.
For at the end, “only goodness shall count” (Rabbi Leo Baeck, 1945, cited in Frankl, 2014b:175). –And psychotherapy still has long ways to go.
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