1818THTH ANNUAL ANNUAL CONFERENCE CONFERENCE OF OF JAPANESEJAPANESEASSOCIATION ASSOCIATION OF CLINICAL OF CLINICAL THANATOLOTHANATOLOGY GY

Logotherapy, Logotherapy, Meaning Meaning

Therapy, & Therapy, & SpiritualitySpirituality©Paul T. P. Wong

OverviewOverview

The role of meaning in spiritual care The role of meaning in spiritual care for cancer patientsfor cancer patients

Dr. Frankl’s Logotherapy & his Dr. Frankl’s Logotherapy & his concept of spiritualityconcept of spirituality

Wong’s Meaning Therapy in tapping Wong’s Meaning Therapy in tapping into the human capacity for meaning into the human capacity for meaning makingmaking

Breitbart’s Meaning-Breitbart’s Meaning-Centered Group Therapy for Centered Group Therapy for

Cancer PatientsCancer Patients Session 1 – Concepts of meaning and sources Session 1 – Concepts of meaning and sources

of meaning of meaning Session 2 – Cancer and meaningSession 2 – Cancer and meaning Session 3 – Meaning and historical context of Session 3 – Meaning and historical context of

lifelife Session 4 – Storytelling, life projectSession 4 – Storytelling, life project Session 5 – Limitations and finiteness of lifeSession 5 – Limitations and finiteness of life Session 6 – Responsibility, creativity, deedsSession 6 – Responsibility, creativity, deeds Session 7 – Experience, nature, art, humorSession 7 – Experience, nature, art, humor Session 8 – Termination, goodbyes, hopes for Session 8 – Termination, goodbyes, hopes for

the futurethe future

Itami’s Meaningful Living Itami’s Meaningful Living Therapy with Cancer Therapy with Cancer

PatientsPatientsReynolds (1989) - The basic principles for the patient of Reynolds (1989) - The basic principles for the patient of

M.L.T. are:M.L.T. are:1.1. To take major responsibility in the fight against the To take major responsibility in the fight against the

disease.disease.2.2. To live a life devoted to fulfilling daily goals.To live a life devoted to fulfilling daily goals.3.3. To be helpful to others.To be helpful to others.4.4. To undergo training in coping with the anxiety associated To undergo training in coping with the anxiety associated

with illness and the fear of death.with illness and the fear of death.5.5. To contend with death naturally and constructively by To contend with death naturally and constructively by

accepting the principle that everyone inevitably dies.accepting the principle that everyone inevitably dies.6.6. To avoid being a "sick person" even though ill.To avoid being a "sick person" even though ill.7.7. To live out the remainder of life positively, undefeated by To live out the remainder of life positively, undefeated by

the disease.the disease.

Katsutaro Nagata Katsutaro Nagata WHO professor, WHO professor,

psychosomatic psychosomatic medicine and medicine and psychopharmacology psychopharmacology

Logotherapy Logotherapy approach to pain & approach to pain & illnessillness

Logotherapy as Logotherapy as effective treatment effective treatment for chronic painfor chronic pain

Dimensions of Suffering Dimensions of Suffering (Mak, 2007)(Mak, 2007)

Physical Physical – physical symptoms & pain– physical symptoms & pain

Psychological Psychological – helplessness, – helplessness, hopelessness, & uncertaintyhopelessness, & uncertainty

Social Social – isolation & relational conflict– isolation & relational conflict

Spiritual Spiritual – lack of meaning in life– lack of meaning in life

The Good DeathThe Good Death

A comfortable & pain-free deathA comfortable & pain-free death A harmonious deathA harmonious death A meaningful deathA meaningful death A hopeful deathA hopeful death A peaceful deathA peaceful death

Aspects of SpiritualityAspects of Spirituality Pertain to ultimate meaning and purposePertain to ultimate meaning and purpose Discover a sense of meaning, calling, & Discover a sense of meaning, calling, &

significancesignificance Involve certain spiritual practicesInvolve certain spiritual practices May involve a set of religious beliefs & ritualsMay involve a set of religious beliefs & rituals Believe in a Higher Being and a spiritual Believe in a Higher Being and a spiritual

realityreality Experience sacred momentsExperience sacred moments Cultivate a transcendental connectionCultivate a transcendental connection Seek spiritual direction & formationSeek spiritual direction & formation

An Instrument Approach to An Instrument Approach to Spiritual Care:Spiritual Care:

(Based on what you say and do with (Based on what you say and do with patients)patients)

Addressing patients’ spiritual needsAddressing patients’ spiritual needs

Addressing patients’ existential needsAddressing patients’ existential needs

Taking a spiritual history of patientsTaking a spiritual history of patients

Incorporating appropriate spiritual practicesIncorporating appropriate spiritual practices

Involving chaplains and spiritual leadersInvolving chaplains and spiritual leaders

Involving the appropriate faith communityInvolving the appropriate faith community

A Transformative Approach A Transformative Approach to Spiritual Care:to Spiritual Care:

(Based on what you say and do with patients)(Based on what you say and do with patients)

The healing The healing silencesilence – listening to the inner voice – listening to the inner voice

The healing The healing touchtouch – touching the heart & soul – touching the heart & soul

The healing The healing connectionconnection – establishing an I-You – establishing an I-You relationshiprelationship

The healing The healing presencepresence – providing a caring, – providing a caring, compassionate presencecompassionate presence

The healing The healing processprocess – nurturing spiritual growth – nurturing spiritual growth

Coping with Death Coping with Death AnxietyAnxiety

Elizabeth Kubler-Ross’s (1969) five stages of copingElizabeth Kubler-Ross’s (1969) five stages of coping

DenialDenial – – Death avoidance and extreme sports Death avoidance and extreme sports

AngerAnger – Aggression, violence and terrorism – Aggression, violence and terrorism

BargainingBargaining – Doing good deeds or worshipping – Doing good deeds or worshipping godsgods

DepressionDepression – Disengagement and isolation – Disengagement and isolation

AcceptanceAcceptance –Engagement in life –Engagement in life

Three Types of Death Three Types of Death AcceptanceAcceptance

(Wong, Reker, & Gesser, 1994)(Wong, Reker, & Gesser, 1994)

1.1. NeutralNeutral - - facing death rationally facing death rationally as an inevitable end of every lifeas an inevitable end of every life

2.2. ApproachApproach - - accepting death as a accepting death as a gateway to a better afterlifegateway to a better afterlife

3.3. EscapeEscape - - choosing death as a choosing death as a better alternative to a painful better alternative to a painful existenceexistence

Positive Death Positive Death AcceptanceAcceptance

““Death Acceptance is the only antidote to Death Death Acceptance is the only antidote to Death Anxiety.”Anxiety.”

Acceptance of one’s life as worthwhileAcceptance of one’s life as worthwhile Readiness to let go things of this worldReadiness to let go things of this world Recognition of the spiritual connection Recognition of the spiritual connection

with a transcendental realitywith a transcendental reality Hope in sharing spiritual life with loved Hope in sharing spiritual life with loved

ones for all eternityones for all eternity

Pathways to Death Pathways to Death AcceptanceAcceptance

Life review (Wong, 1995) Life review (Wong, 1995) Self-acceptance (Wong, 1998) Self-acceptance (Wong, 1998) Religious/spiritual beliefs (Wong, 1998) Religious/spiritual beliefs (Wong, 1998) Embracing one’s own life Embracing one’s own life Death education Death education

To contemplate our death is to To contemplate our death is to contemplate our life that leads to contemplate our life that leads to death.death.

Coping with Death Coping with Death AnxietyAnxiety

The Japanese PerspectiveThe Japanese Perspective Naikan Therapy Naikan Therapy – focuses on inner – focuses on inner

looking & self-cultivation; life review of looking & self-cultivation; life review of one’s relationship with a significant one’s relationship with a significant other, resulting in a more realistic other, resulting in a more realistic sense of self & relationshipssense of self & relationships

Morita Therapy Morita Therapy – learning to accept – learning to accept & live with negative emotions without & live with negative emotions without judgment, focuses on taking control of judgment, focuses on taking control of own behaviour in spite of how one feelsown behaviour in spite of how one feels

The Life-Death The Life-Death ConnectionConnection

““To solve the problem of death, one To solve the problem of death, one must first solve the problem of life, must first solve the problem of life, living life” (Dennis Yoshikawa) living life” (Dennis Yoshikawa)

““To be prepared for death is to be To be prepared for death is to be prepared for living; to die well is to prepared for living; to die well is to live well” (Konosuke Matsushita)live well” (Konosuke Matsushita)

“ “ Living well and dying Living well and dying well involve enhancing well involve enhancing

one’s sense of self, one’s one’s sense of self, one’s relationships with relationships with others, and one’s others, and one’s

understanding of the understanding of the transcendent, the transcendent, the

spiritual, the spiritual, the supernatural….”supernatural….”

(Kuhl, 2002)(Kuhl, 2002)

Living and Dying well Living and Dying well through Meaning & through Meaning &

SpiritualitySpirituality• Human beings are born with the innate need for Human beings are born with the innate need for

meaning & spirituality.meaning & spirituality.

• Finding meaning and purpose can make a big Finding meaning and purpose can make a big difference in how we live & how we die. difference in how we live & how we die.

• The psychology of meaning management helps The psychology of meaning management helps deepen our spirituality and existential deepen our spirituality and existential understanding.understanding.

• Meaning management helps construct an Meaning management helps construct an effective psychological and spiritual model. effective psychological and spiritual model.

• Meaning management motivates us to embrace Meaning management motivates us to embrace & assume responsibility for our personal lives. & assume responsibility for our personal lives.

Viktor Frankl & Viktor Frankl & the Medical Ministrythe Medical Ministry

Logotherapy is adjunct to Logotherapy is adjunct to medical treatments.medical treatments.

Healing needs to occur at the Healing needs to occur at the spiritual level.spiritual level.

Needs to address questions of Needs to address questions of suffering and deathsuffering and death

Meaning can be found in the Meaning can be found in the most horrible situations.most horrible situations.

Needs to awaken the defiant Needs to awaken the defiant human spirithuman spirit

For more information, visit For more information, visit www.meaning.cawww.meaning.ca

Logotherapy literally means therapy through meaning.

It is a spiritually-oriented approach towards psychotherapy.

Existential analysis is needed to make the clients aware of their spirituality and capacity for meaning.

“Inasmuch as logotherapy makes him aware of the hidden logos of his existence, it is an analytical process” (Frankl, 1984, p. 125).

What is Logotherapy?

Many people seek healing of inner emptiness because of a felt sense of existential vacuum.

Frankl believed that existential vacuum may lead to both the tragic triad and neurotic triad. Meaning therapy is uniquely suitable to address these mental health issues.

Existential Vacuum

The Tragic Triad

The Neurotic Triad

Freedom of will: Not only freedom from some negative condition but also freedom to something rewarding.

Will to meaning: Striving to find a meaning in one’s life is the primary motivational force.

Meaning of life: One can always discover meaning in life regardless of life’s circumstances.

The Basic Tenets of Logotherapy

Freedom & Freedom & ResponsibilityResponsibility

Logotherapy emphasizes the responsible Logotherapy emphasizes the responsible & meaningful use of freedom. & meaningful use of freedom.

Human existence can only be Human existence can only be understood in terms of responsibility.understood in terms of responsibility.

The will to meaning is based on a sense The will to meaning is based on a sense of responsibility.of responsibility.

Responsibleness means meeting the Responsibleness means meeting the demand quality of every situation. demand quality of every situation.

The Will to MeaningThe Will to Meaning

It is the primary motivation for living.It is the primary motivation for living.

Everyone needs to find the true Everyone needs to find the true meaning of one’s own life. meaning of one’s own life.

Will to meaning is essential for resilience and well-being to the extent that it means one’s capacity to live in spite of pain & suffering (similar to the will to live, “sei no yokubo”, in Meaningful Life Therapy)

Meaning of LifeMeaning of Life Life has meaning under all circumstances. Life has meaning under all circumstances.

It is our responsibility to respond to life’s It is our responsibility to respond to life’s demands.demands.

Each person must discover the meaning Each person must discover the meaning potential of each situation.potential of each situation.

The ultimate meaning lies in its pursuit.The ultimate meaning lies in its pursuit.

The situational meaning can be The situational meaning can be experienced through three avenues of experienced through three avenues of value.value.

Creative value: giving something to the world through creative works.

Experiential value: receiving something from the world through appreciation and gratitude.

Attitudinal value: taking a heroic stand towards suffering and fate.

Three Basic Pathways to Meaning

Schematic Representation of Human Dimensions

Spiritual

PSYCHOLOGICAL

Biological

Psychosomatic

Noetic

PERSONHOOD

Sociocultural Context

Awareness of theSpiritual Realm

Capacity to KnowGod

Encounter with theTranscendent

Perception

Learning &Meaning

HigherCognitive

Social Processes

PhysicalHealthBiologicalDrives

BiochemicalProcesses

Will toMeaning

MoralUnderstanding

SpiritualBeliefs and Values

PositiveAttitudes inSuffering

Emotional States

Stress Reaction

Physical Pain

Sensation

Noetic DimensionNoetic Dimension The dimension of the human spiritThe dimension of the human spirit

It is the healthy core or “medicine chest” It is the healthy core or “medicine chest” of logotherapy.of logotherapy.

It contains uniquely human attributes, It contains uniquely human attributes, such as: will to meaning, ideals, such as: will to meaning, ideals, creativity, faith, love, conscience, self-creativity, faith, love, conscience, self-detachment, self-transcendence, humor, detachment, self-transcendence, humor, goal-striving, and taking on goal-striving, and taking on commitments & responsibilities.commitments & responsibilities.

It evolves from logotherapy and cognitive behavioral therapy.

It is part of the third wave of psychotherapy which involves powerful new concepts such as acceptance, commitment, meaning-making, and re-storying.

What is Meaning Therapy?

Integrative/holistic Existential/spiritual Relational Positively oriented Multicultural Narrative Psycho-educational

The Defining Characteristics of

Meaning Therapy

Meaning Therapy is Meaning Therapy is IntegrativeIntegrative

Existential meaning – Logotherapy & Existential Therapy

Cognitive meaning – Cognitive-Behavioural Therapy 

Narrative meaning – Narrative Therapy Positive meaning – Positive Psychotherapy Cultural meaning – Cross-cultural &

Indigenous Therapy

Meaning is all we need.

Relationship is all we have.

It is difficult to implement effective interventions when either one of the above conditions is missing.

The Motto of Meaning Therapy

Who we are is more important than what we say.

Rogers’ three pre-conditions need to be the personal characteristics of counsellors.

Personal wholeness of the therapist is important.

The messenger is the message.

The therapist is the therapy.

The counsellor brings a healing presence.

The counsellor models meaningful living.

The counsellor practices counselling by osmosis.

The Therapeutic Presence

Building rapport and trust is essential to effective therapy.

Authentic and caring relationships has more healing power than therapeutic alliance.

Accepting resistance and negative reaction as part of the healing process.

The ground rule of respect and caring applied to both the therapist and the client.

Recognize that each individual is both unique and similar.

Healing through Relationship

At the social level, two strangers get to know each other in a trusting and non-judgmental environment.

At the existential level, two human beings share their common humanity.

At the professional level, the therapist is responsible for achieving desirable therapeutic goals.

Therapy involves the reciprocal influence between the therapist and the client.

Different Levels of Relating

To awaken the client’s sense of responsibility and meaning.

To achieve a deeper understanding of the problem from a larger perspective.

To help the client discover their true identity and place in the world.

To help the client pursue what really matters in life.

Therapeutic Goals

To grow and develop the client’s full potential.

To make life better for self and others. To transform a victim’s journey into a

hero’s adventure. To discover meaning and hope in

boundary situations. To learn principles and skills to achieve

positive outcomes and transform negative outcomes through meaning.

Therapeutic Goals Cont’d

Responsibility questions Choice questions Trajectory questions Quest questions Eight enduring existential

questions Magic questions Diagnostic questions

The Art of Questioning

1. Who am I?2. How and where do I find happiness?3. What should I do with my life?4. How can I avoid making the wrong choices

in the major areas of my life?5. Where do I belong?6. What is the point of all my striving?7. What will happen to me after I die?8. What would make my life more meaningful

and significant?

Eight Enduring Existential Questions

The four treasures of Meaning Therapy:

Purpose – the motivational componentUnderstanding – the cognitive component

Responsible action – the behavioral component

Enjoyment – the affective component

The PURE Principles

Accept and confront the reality -- the reality principle.

Believe that life is worth living – the faith principle.

Commit to goals and actions – the action principle.

Discover the meaning and significance of self and situations – the Aha! principle.

Evaluate the above – the self-regulation principle.

The ABCDE Strategy

Accepting what cannot be changed.

Accepting reality, limitations, loss, trauma, existential givens.

Acceptance does not mean giving up or resignation.

Confronting one’s worst fears with courage and tragic optimism.

Transcending and transforming the tragedy.

Acceptance

Cognitive acceptance Emotional acceptance Realistic acceptance Integrative acceptance Existential acceptance Transcendental acceptance Transformative acceptance

Levels of Acceptance

Affirming one’s ideals and core values.Believing in the intrinsic value and meaning of lifeBelieving in an Ultimate Rescuer or Higher PowerBelieving in the eventual triumph of good & justice

Belief

Moving forward and carrying out one’s responsibility with determinationDoing what needs to be done regardless of feelings or circumstancesStriving to fulfill one’s responsibility no matter whatEnduring hardship and pain for a worthy causePracticing the PURE principlePursuing realistic goalsRe-authoring one’s life story

Commitment

Learning something new about the self and life.

Digging deeper, exploring farther, and searching higher.

Discovering one’s hidden courage and strength.

Discovering the power of faith and spiritual resources.

Grasping the complexities of life and people.

Discovery

Savoring small successes or re-assessing one’s progress.Feeling relief that the worst is over.Savoring the moments of small success.Reflecting and reviewing one’s life.Receiving feedback from others.Conducting assessments and making adjustments.

Evaluation

SOURCES OF MEANING

1. Achievement

2. Acceptance

3. Transcendence

4. Intimacy

5. Relationship

6. Religion

7. Fairness

8. Positive emotions

According to Wong (1998), there are 8 sources of meaning and the good life.

1. It is deeply felt – It touches your emotions in a deep and lasting way. More than a fleeting feeling, it reaches your innermost being.

2. It is deeply processed – It involves deeper layers of meaning beyond the factual and superficial.

3. It is enlightening – It provides a solution to some puzzling problems or leads to some new discovery.

4. It is transforming – It enriches your life, changes your life’s direction or restores a sense of purpose and passion to your life.

Definition of a Meaningful Moment

The Meaning MindsetThe Meaning Mindset

1.1. Life has intrinsic meaning and value.Life has intrinsic meaning and value.

2.2. My ultimate purpose is self-transcendence.My ultimate purpose is self-transcendence.

3.3. I can live at a deeper level by detecting the I can live at a deeper level by detecting the meaning & significance of any situation.meaning & significance of any situation.

4.4. I can live at a higher plane by serving a higher I can live at a higher plane by serving a higher purpose & being attuned to the transcendental purpose & being attuned to the transcendental realm.realm.

5.5. I can live fully by integrating by my I can live fully by integrating by my potentialities with my vulnerabilities moment by potentialities with my vulnerabilities moment by moment.moment.

1. I can find something meaningful or significant in everyday events. 1 2 3 4 5

2. There is a reason for everything that happens to me. 1 2 3 4 5

3. There is no ultimate meaning and purpose in life. 1 2 3 4 5

4. There is no point in searching for meaning in life. 1 2 3 4 5

5. No matter how painful the situation, life is still worth living. 1 2 3 4 5

6. The meaning of life is to “eat, drink and be happy”. 1 2 3 4 5

7. What really matters to me is to pursue a higher purpose or calling regardless of personal cost. 1 2 3 4 5

8. I would rather be a happy pig than a sad saint. 1 2 3 4 5

9. I am willing to sacrifice personal interests for the greater good. 1 2 3 4 5

10.Personal happiness and success are more important to me than achieving inner goodness and moral excellence. 1 2 3 4 5

Life Orientation ScaleLife Orientation Scale

Meaning-mindset

Meaningful moments

PURE Framework

Sources of meaning

Frankl’s 3 basic tenets and values of meaning

Recovery: Bouncing back and returning to normal functioning.

Invulnerability: Remaining relatively unscathed by the adversity or trauma.

Post-traumatic Growth: Bouncing back and becoming stronger.

Patterns of Resilience

Four Life Trajectories

Acceptance of the worst.

Affirmation of the value and meaning of life.

Self-transcendence (altruism).

Faith in God and others.

Courage to face adversity.

Elements of Tragic Optimism

ConclusionConclusion Meaning is a key component in spiritual Meaning is a key component in spiritual

care for cancer patients. care for cancer patients.

Logotherapy focuses on the Logotherapy focuses on the responsibility to discover & fulfill the responsibility to discover & fulfill the will to meaning through self-will to meaning through self-transcendence & authentic living. transcendence & authentic living.

Meaning therapy is integrative. It Meaning therapy is integrative. It focuses on the human capacity for focuses on the human capacity for meaning-seeking & meaning-making. meaning-seeking & meaning-making.