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Logotherapy and Existential Analysis for Moral Injury validated by Science

The December 2022 issue of the Scientific American features an article by Elisabeth Svoboda on Moral Injury: “Moral Injury is an Invisible Epidemic that Affects Millions.” The article defines Moral Injury as a “specific trauma that arises when people face situations that deeply violate their conscience or threaten their core values.” It presents recent examples from the health care setting, where ethically challenging dilemmas are part of the everyday scenario.

Scientific American, December 2022

The article reviews literature that first identified Moral Injury in the military setting, to its working definition for everyday life and clinical practice. It provides several examples that require a therapeutic approach that goes beyond traditional cognitive behavioral therapy (CBT), since the distress is genuine and not the product of distorted thinking. The article asserts that Moral Injury is different from Post Traumatic Stress Disorder (PTSD). It does not respond well to conventional trauma treatments, and it requires a more “spiritual approach” that considers the whole of the person.

Proposed models for the treatment of Moral Injury share the emphasis on the search for meaning to overcome its effects. The article reflects on the role of Viktor Frankl’s Logotherapy and Existential Analysis (LTEA) for the management of Moral Injury. This approach “bolsters a clients’ sense of purpose.” It validates the reality of values transgressions, and helps to find meaning in line with core values as guiding principles. LTEA can be applied alone, or as a complement to other treatment modalities currently employed in the treatment of Moral Injury.

The book, “Logotherapy and Existential Analysis for the Management of Moral Injury,” by Edward Marshall and Maria Marshall, published through the Ottawa Institute of Logotherapy in 2021, reviews the history of the conceptualization of Moral Injury, the development of tools for its assessment, and a review of the treatment modalities proposed for its management. In developing the case for the application of LTEA, the book reviews the evidence base of LTEA, and provides practically relevant principles and methods based on LTEA that can be useful for clinicians when treating individuals affected by Moral Injury.

Logotherapy and Existential Analysis for Moral Injury
Ottawa Institute of Logotherapy, 2021

On March 31, 2022, Professor Edward Marshall offered a workshop with over 120 participants on the application of Logotherapy and Existential Analysis for the management of Moral Injury at the Royal Ottawa Mental Health Centre, Canadian Centre of Excellence on PTSD.

Awareness of Moral Injury is increasing as examples locally, and globally amount. Validation for the use of LTEA as an evidence-based method for addressing the symptoms arising from moral injury is a welcome sign that the scientific community embraces LTEA to offer a purposeful and meaningful contribution to the treatment of moral injury, one that puts humanity at the forefront of responding to suffering arising from values transgressions. 

On March 23-24, 2023, Professor Edward Marshall is offering a two-day workshop at the Royal Ottawa Mental Health Centre that will focus specifically on the methods and applications of Viktor Frankl’s Logotherapy and Existential Analysis. This event is tailored toward health professionals and students who would like to deepen their knowledge and understanding of the uses of this modality in their clinical practice. Registration Page.

photo of pathway surrounded by fir trees

The Road Less Traveled: Reflection on the Dictum that One Becomes the Value that one Actualizes; One Becomes the Cause that one Makes One’s Own

Maria Marshall, PhD, RP

“Two roads diverged in the wood, and I-I took the one less traveled by, and that has made all the difference”

(Robert Frost)

In “The Will to Meaning,” we find a paragraph where Frankl reports that he has been asked by some of his students about conscience. Specifically, about how Hitler ended up the way he was? He replied that “Hitler would have never become what he did unless he had supressed within himself the voice o conscience.” (Frankl, 2014b:46). He went on to say that “…only an erroneous conscience will demand a person to commit suicide, homicide, or genocide” (Frankl, 2014b:46).

Frankl understood human beings as entities who want to shape their lives in a meaningful way(Lukas, 2000). He made it clear that “Logotherapy is a life-affirming stance” (Frankl, 2014b:46). In the same paragraph, he explained that “…No logotherapist can pretend they know the value and know what makes sense and what does not” (Frankl, 2014: 46). No therapist can impose their values on others. But what they can do is to refer people back to their own conscience to show what is of value and what is meaningful or not.

There is a description of what conscience is in Elisabeth Lukas and Heidi Schőnfeld’s (2019) book entitled “Meaning-centered Psychotherapy.” Conscience has been denoted as the meaning organ, a resource of the human spirit, a specifically human phenomenon, whose function is to intuit, and discern what is meaningful. Meaning is present in a value that stands in relation to a person. In Frankl’s definition, meaning is objective and not subjective (Frankl, 1994). It is subjective only to the extent that it is person, and situation specific. It is an objective reality through which a human being is called every moment and in every instance.

We can be either consciously or unconsciously in search for meaning. The actualization of the value that we intuit is the most meaningful in a particular situation, brings it into the reality, makes it appear in a concrete and visible form this value that we “make our own.” This is the case with creative values, when we put into the word something that was not there before. We literally, co-create. It is evidenced in the case of experiential values, were we take something from the world in relationships with nature, or persons.  Attitudinal values represent our inner stand through the defiant power of the human spirit. Meaning is thus actualized in the context of a relationship between a person and a value, in that a person reaches out to a value that he or she intuits, recognizes, and acknowledges as the meaning of the moment.

Conscience has intuitive, aesthetic, and creative capacities. Intuitive refers to the capacity to anticipate outcomes and points to what really matters, a “vision,” of what ought to be. Aesthetics refers to what seems in harmony and flow freely, what “should be.” Creative refers to possibilities, what “could be.” The three aspects of conscience encompass the realms of Intuition (Ethical Conscience); Inspiration (Aesthetic Conscience) and Justice (Moral conscience).  These aspects correspond to the aspects of meaning as Truth, Beauty, and Goodness (Marshall & Marshall, 2022). Not every possibility that we can think of or can think of is equally meaningful. In general, what is meaningful to us in a particular moment is what is tailored to our context, our abilities, possibilities, and responsibilities (Batthyány, 2021).

Furthermore, the values that we choose to actualize need to conform to the aspects of meaning: they need to be true, good, and beautiful. At least, we need to aim for the actualization of the best possible alternative in a situation. The best is what reduces the suffering in the world as much as possible, and at least, does not harm the other and does not harm the person. The value that we actualize needs to conform to the “Laws of the Universe” and to the laws of universal values, to be meaningful. Universal values consider the dignity and uniqueness of each person, the value of each life, the dignity of the person. The meaning of the moment must be in harmony with “Ultimate Meaning” (Frankl, 2000). There needs to be a connection and a relationship between the here and now and the eternal, and when this connection is lost, alienation is inevitable (Marshall & Marshall, 2022).

When conscience is ignored, supressed, or repressed, when its voice is not brought to consciousness, or pushed back to the unconscious, one’s actions will not be meaningful. Most likely, they will not be in line with universal values and thus, not in line with harmony in the universe, not in line, in deep spiritual terms, with the “Will of God.”

This can happen when conscience is not formed to conform to the laws of the universe, when the spiritual muscles atrophy, and when a person chooses to turn away from the call to bring out the best that they can, are able to, and are called to, in the world.

The consequence of this alienation is objectification. The person will see their objectives in treating others as means to ends. They can even consider them as replaceable, their value depending on their utility for one’s own self-imposed goals.  However, at the root of their actions will be a motivation by primitive instincts and fear, science Basic Trust, a belief in life’s ultimate meaningfulness and value, is compromised.

As the will to meaning remains unheard and frustrated, one may reach to power to enforce one’s ways. Violence, aggression, the blatant disregard for human rights and freedoms, mass murder, can happen when the other is alienated to the point of being objectified, and denigrated to the level of the less than human as one projects one’s own faulty image of the person onto others to justify one’s erroneous and mistaken actions.

When reflection to hear the voice of conscience to discern value is not heard, the loud screams of violence take over. Worse yet, a calculated and cold mastermind can spread suffering and destruction in the world, foreshadowing his or her own demise.

Frankl distinguished between subjective meanings, based on feelings, and objective meaning, that are actualized in the world (Frankl, 1968). He referred to rat experiments that were conducted in California, whereby brain regions of rats were stimulated with LSD, giving them the sensation of instant satisfaction, orgasm, and elation. The rats habituated to the drug very quickly and pressed the lever with increasing frequency, to the point that they cared only for the feeling and rejected actual sexual partners and real food. Frankl explained, that when one resorts to subjective meaning, one by-passes real meaning possibilities in the store because they seek for meaning within themselves, and neglect objective meaning that is waiting as potential to be fulfilled in the world.  Once we have actualized the potentiality, we rescued it into the past, where no one can take it away. But the other way it is true: what we did not actualize is lost forever. Within this realm lies our responsibility. No one can always actualize every meaning possibility, but that is part of human reality, of fallibility and vulnerability and does not hinder the actualization of objective meaning, exactly in the face of transitoriness, fallibility, and vulnerability. We have to aim not to pass by transitory potentialities, for once we actualize them, we have rescued them forever (Frankl, 1968).

Only what is meaningful will remain in the world. Only what was courageously suffered, the guilt that was overcome, the consolation that was given, the unavoidable suffering courageously faced, the goodness shared. What is meaningless will remain meaningless and return to meaninglessness, into nothingness, into non-existence.

The basis of existence is self-transcendence (Frankl, 2014a, 2014, 2019). Human beings reach to a value, reach toward a cause to make their own and a person to love, or a difficult situation to handle. Through actualizing creative, experiential or attitudinal values is that they actualize meaning. One of the characteristics of human beings is the ability to make decisions and to be able to reflect on their values and the consequences of their actions. Thus, human beings are free, within their potential freedom as a finite, vulnerable and fallible human being, to “create themselves:” to shape themselves, mold themselves, to re-form themselves. They can make the choice to break an unhealthy habit and to shift from habitual or dysfunctional ways into a new direction. When one embraces meaning, one may travel the path “less travelled.” In other words, it may not be the most convenient, obvious, or easy path. However, one takes this road considering its promise: to conforms to the person in the image and likeness of that which was intended form the beginning—a self-transcendent and meaningful life that shows response-ability, responsiveness, and responsibility toward the self, toward others, toward the environment, toward the world, and the Transcendent.

What one has become, one has become through one’s choices. When one actualizes a wrong possibility, they become that what they chose. A person ordering the murder and killing of others becomes a murderer. A person who steals things from others becomes a thief. A person that does teel the truth becomes a liar, and so on. But they are still a person with the possibility to let meaning imbue their being and per-sonat, sound through their being in the world (Lukas & Schőnfeld, 2021).

The person is conditioned, but not determined. The person retains his or her value. To the last breath, one can bring meaning into the world a flood one’s life with meaning. But for that to happen, one needs to alter course, change heart. Have an honest conversation with oneself in the light of what the rules of the universe demand, what universal human values point to, what one is asked to do. One does not, one can not and one should not invent meaning and create it, because ultimately that is not the truth. It is a self-deception to think that one is leading a meaningful life if one created and fabricated meaning oneself without consulting one’s conscience and acknowledged the truth.

Meaning can not be invented, created, or fabricated. That is where the mistake lies. Conscience is creative because it can help us actualize a value that was intended in the circumstances in ways that it is possible for us to accomplish with our resources that are given and available.

The voice of conscience can be awakened by being present and being with. It cannot be done in isolation, talking to ourselves. It is not just a monologue to oneself, it needs to be in a dialogue with what is meant in an honest encounter in the light of truth, beauty, and goodness.

Quite frankly, “Life is not something, it is the opportunity for something,” Frankl affirmed (Frankl, 2019:50 quoting Hebbel, a German poet 1813-1863).

In a lighthearted way, he remarked, “…I am quite convinced that God knows when someone has made a confusion of Him with oneself…” (Frankl, 1994:284).

References:

Batthyány, A. (2021). La superación de la indiferencia. Overcoming Indifference. Herder & Herder.

Frankl, V. E. (1994). Logotherapie und Existenzanayse. Texte aus sechs Jahrzehnten. München : Quintessenz.

Frankl, V. E. (1968). Subjective and objective meaning. Viktor Frankl Institute Vienna: Videoclip Archives.

Frankl, V. E. (2000). Man’s search for Ultimate Meaning. New York, NY: Perseus.

Frankl, V. E. (2014). Man’s search for meaning. Boston, MA: Beacon Press.

Frankl, V. E. (2014b). The will to meaning. Foundations and Applications of Logotherapy. New York, NY: Penguin/Random House.

Frankl, V. E. (2019). Yes to life in spite of everything. Boston, MA: Beacon Press.

Frost, R. (1993). The road not taken and other poems. Dover Publications.

Lukas, E. (2000). Logotherapy textbook. Toronto: Liberty Press.

Lukas, E. & Schőnfeld, H. (2021). Meaning-centered Psychotherapy.  Bamberg: Elisabeth Lukas Archives.

Marshall, M. & Marshall, E. (2022). Viktor E. Frankl’s Logotherapy and Existential Analysis: Theory and Practice. Ottawa: Ottawa Institute of Logotherapy. Peck, S. M. (2002). The road less traveled. New York, NY: Simon and Schuster.

Logotherapy and Existential Analysis for Moral Injury

Logotherapy and Existential Analysis for the Management of Moral Injury

New Book by Edward and Maria Marshall (2021)

Logotherapy and Existential Analysis for Moral Injury

The COVID-19 pandemic brought Moral Injury (MI) to the forefront of clinical attention and research. This multi-dimensional syndrome has been first described in the military context and is now understood to affect people in other occupations such as health care, business, education, law enforcement, the legal profession, disaster relief, international aid, social justice, as well as other areas of social and occupational functioning. Moral injury occurs when deeply held beliefs, ethical and moral principles have been trespassed. The violation of universal values and personal principles can be committed by oneself or by others. Witnessing potentially morally injurious events gives rise to guilt, shame, remorse, anger, disgust, feelings of betrayal, spiritual struggles and disorientation, loss of meaning, and despair. The secondary symptoms of moral injury may include anxiety, depression, and post traumatic stress. The symptoms of moral injury can vary in intensity and can present from mild to severe, seriously impairing functioning. Moral injury is not considered a mental illness but a syndrome that warrants clinical attention.


Employing a phenomenological hermeneutic method of systematically reviewing pertinent texts, the present study explores the lived experience of moral injury in relation to assessment and treatment methods currently available. Conceptually, research indicates that self care, moral resilience, and social support are linked with factors such as resiliency, post-traumatic growth, and self-transcendence. These factors are correlated with meaning, a key factor in wellness following existential frustration and distress. Thus, a holistic body, mind and spirit approach to the assessment and response to moral injury is warranted.


Viktor E. Frankl’s Logotherapy and Existential Analysis (LTEA) is an evidence-based meaning-centered approach to psychotherapy and counselling that has been successfully applied in the treatment of conditions involving existential issues. The present research examines the contribution of LTEA to the conceptual understanding of moral injury and to its related symptomatology. It details the application of LTEA principles and structured meaning-centered interventions in responding to moral injury. The applications are illustrated with examples that help to position this method into a holistic framework promoting re-connection, renewal, and health.