Depression and Logotherapy
by Michael Priv
The theorist and theory I have chosen to discuss is Viktor Frankl and Logotherapy. Logotherapy is based on the assumption that a person is motivated by “an inner pull to find meaning in life” (Viktor Frankl Institute of Logotherapy). The tenets of logotherapy are that life has meaning in all situations, even in miserable or unenjoyable ones, a person’s motivation to live is based on wanting to find meaning in life, everyone has the freedom to find this meaning in what they do and in their experiences, or in their outlook and the position they take when faced with a situation of “unchangeable suffering” (Viktor Frankl Insitute of Logotherapy). A problem faced by many in this day and age is the issue of depression, which is often thought of as a mood disorder. Depression manifests itself through a low or sad mood or outlook that lasts longer than two weeks at a time (Bartha, 2). My project will look at depression through a lens of Logotherapy and attempt to find new ways in which to view and treat the disease. According to the tenets of Logotherapy, depression could be viewed as an absences of meaning in one’s life. A possible way to treat depression using Logotherapy might be to work with a patient to encourage them to understand and explore the sources of meaning in their day to day lives, and how they themselves have meaning as an individual. Since Logotherapy focuses on the problem of existential angst, I will examine frameworks to best understand this angst, who develops it, and which unique life factors hold a person at risk for developing existential angst. I will then use the tenets of Logotherapy to discover how the loss of meaning in one’s life causes existential angst, and how this may lead to depression, and other mental health disorders.
            The basic premise of Logotherapy is that in the absence or meaning, an individual suffers mentally and spiritually.  That suffering, that angst, can contribute to demise of the individual. The most significant illustration of Logotherapy affecting the very survival of a person, the ultimate in existential angst, is Frankl's own experiences in concentration camps. Frankl wrote, “This was the lesson I had to learn in three years spent in Auschwitz and Dachau: other things being equal, those apt to survive the camps were those oriented toward the future - toward a task, or a person, waiting for them in the future, toward a meaning to be fulfilled by them in the future." Millions of people with and without purpose died in those camps, but per Frankl, the survivors had one trait in common: they had a meaning for their life and their future. That meaning was not necessarily sublime and esoteric. The meaning could be mundane and highly subjective. These people created the meaning that made sense to them. That point alone makes Logotherapy therapy possible.
Logotherapy was also the result of Frankl's own ideas and research, not all of which are the results of his imprisonment in German death camps, and not all of it is as significant as the meaning of life. In Logotherapy, life is composed of a multitude of lesser situations and experiences that could have a meaning or, at least, finding the meaning for various circumstances or experiences, or even the everyday mundane tasks, by the patient can be effective in relieving mental illness in that patient.
            According to Frankl, life’s meanings can be discovered in three different ways:
By working or accomplishing some task
By experiencing something fully or loving somebody
By the attitude that one adopts toward unavoidable suffering
Working and accomplishing tasks are processes. They have duration. They do not occur instantaneously. Same can be said about experiencing something fully or loving somebody. The attitude one adopts toward anything is no different in that regard. They all require judgement and follow through (the component of time), or, more fundamentally, the freedom of choice and a sense of having power over something and being able to control something, i.e. responsibility.
Thus, the common denominators of these three ways to find life’s meaning are the freedom of choice and the assumption of responsibility—a possible definition of Existentialism: “In simpler terms, existentialism is a philosophy concerned with finding self and the meaning of life through free will, choice, and personal responsibility. The belief is that people are searching to find out who and what they are throughout life as they make choices based on their experiences, beliefs, and outlook.” (All About Philosophy, http://www.allaboutphilosophy.org/existentialism.htm). Within the framework of Logotherapy, these three ways are used to successfully treat and even cure depression, addictions, PTSD, phobias and schizophrenia.
In performing work, creating something, getting something done, first one had to make a decision to do it and see it from inception all the way through to completion. A task done signifies, fundamentally, the fact of having exercised one’s freedom of choice and being responsible for the task itself, for the process of its accomplishment and for the final result.
Experiencing something fully or loving somebody is again based, most elementally, on freedom of choice and a sense of responsibility. The experience could be pleasant or unpleasant. In fact, the experience could be suffering, but the fact that it was experienced fully signifies the freedom of choice and assuming responsibility in regards to that experience.      
Frankl believed that suffering is a part of life, and that man’s ultimate freedom is his ability to choose how to respond to any set of given circumstances, even the most painful ones. Epictetus held that “Men are not moved by events but by their interpretations.” Thus, meaning can be found in suffering, which holds obvious therapeutic value and expands the application of Logotherapy.
Therefore, I am advancing a premise that freedom of choice and the sense of responsibility are the key factors in mental health of an individual. The loss or perceived loss of the freedom of choice and a sense of responsibility (ability to control) causes depression and a host of other mental ills. Logotherapy works by being effective in restoring the freedom of choice and the sense of responsibility. Taking responsibility in human experience translates into assuming power and taking control. Thus, responsibility is impossible without the freedom of choice.
In the process of proving this thesis I analyzed the techniques and methods of Logotherapy.
The three main techniques of logotherapy are:
Dereflection: Dereflection is used when a person is overly self-absorbed on an issue or attainment of a goal. By redirecting the attention, or dereflecting the attention away from the self, the person can become more complete by thinking about others rather than themselves.
Being self-absorbed, a person is less attuned to the environment, which impedes his judgement, reduces his freedom of choice and makes any real responsibility impossible. In that regard, the concept of “help” could be therapeutic as it gives meaning to “cooperation.”
Cooperation, the expression of one’s freedom of choice and responsibility in helping another or others, is of extreme importance in mental well-being. Ashley Montagu states in her The Direction of Human Development “The biological basis of cooperation, in short, has its origins in the same sources as social behavior, namely, in the process of reproduction. Social, cooperative behavior is the continuation and development of the maternal-offspring relationship; it is therefore as old as life itself, and in spite of recent appearances to the contrary the movement of evolution has, in man, been increasingly directed toward the fuller development of cooperative behavior. Cooperative behavior has great survival value. When social behavior is not cooperative it is diseased behavior. The dominant principle which informs all behavior which is biologically healthy is love. Love, social behavior, cooperation, and security mean very much the same thing. Without love the other three cannot exist.”
The workability of the Redirection method is based on the concept that social behavior, cooperation and security cannot exist without love. Redirection is the method of restoring the subject’s love toward their environment and people in it by putting attention on that environment and people. Thus we have the reason this method works: it restores or improves social behavior, cooperation and the sense of security. Having love and cooperation as a part of one’s life is vitally important factor in mental health. Any method of restoring the sense of loving somebody and being loved, as well as being a part of a cooperating effort, help, would go along way towards curing or alleviating mental afflictions.   
The premise that mental health is rooted in one’s freedom of choice and the sense of responsibility does not contradict the thesis presented in the above paragraph, which puts love and cooperation at the top of the list for mental health. A case can be made that responsibility is not possible without love, as one’s perception of their ability to control the unloved or hated thing would be insufficient to affect any real responsibility. Lack of love also suppresses the freedom of choice. As an example, a person who dislikes cats is unlikely to pick a cat as a pet, the freedom of choice here being impaired by one’s dislike.  Arguably, all these terms describe the same phenomenon from two different angles.  
In his Article 5 Innovative Applications of Logotherapy for Military-Related PTSD paper based on a program presented at the 2012 ACA Conference, San Francisco, CA, March 21, Aaron Smith stated, “Dereflection has been used in a variety of different ways when counseling veterans with PTSD. Perhaps the most common application of Dereflection in treating veterans with PTSD is outlined in the Connecticut in-patient veteran’s hospital’s use, wherefore they implemented mandatory community service to get the clients to think more towards helping others than reflecting on their own situations (Southwick et al., 2006). Dereflection can be used to eliminate the Anticipatory Anxiety related to working towards wellness. Another potential application of Dereflection in treating military-related PTSD is in combating what Frankl calls the, ‘collective neuroses’ wherefore we all look inside ourselves and miss the potential lessons we can learn through facing our traumatic experiences head-on.”  
Facing the traumatic experience head-on is also the subject of the Paradoxical Intention method, used to help people with anxiety or phobias, people incapacitated by fear.
Paradoxical intention: Paradoxical intention involves asking for the thing we fear the most. By using humor and ridicule, the subject can wish for the thing they fear the most, thus removing the fear from their intention and relieving the anxious symptoms associated with it.
Paradoxical Intention is an intervention that uses encouragement and praise to prescribe the same problematic behavior that the individual wants to change. For example, if the subject is experiencing insomnia then they will be asked to stay awake or if a patient is depressed, they will be advised to really wallow in sadness and avoid any pleasant situations. Paradoxical intention is a method that offers quick and lasting results amongst a range of cases (Shoham-Salomon & Rosenthal, Paradoxical Interventions: A Meta Analysis, 1987).
These fears can be genuinely terrifying, such as the military PTSD cases, described by Aron Smith in Article 5, where after active service in a war zone, veterans would be terrified to leave the safety of their home in fear of IEDs. The insurgencies in Iraq and Afghanistan cleverly hide IEDs in everything from road-kill carcasses to potholes and debris, all of which are things veterans encounter at home in a safe environment. Paradoxical Intention would prescribe the victims of military-related PTSD to confront their fears of travel through challenging them to leave the safety of their homes and travel the roads by car or truck. Every time they make it to their destination and return home safely without getting blown up by an IED, their anxiety and reluctance to driving should decrease. “This premise is based in the reality principle for which the individual assesses how realistic particular expectations are, which according to Structure Theory, is considered the main function of the Ego (Freud, 1938). Once the phenomenological belief that they will encounter an IED is put to the test and fails, the individual readjusts his or her expectations in subsequent situations.” (A.J. Smith, Article 5, 2012) 
Thus, paradoxical intention empowers the subject by restoring their freedom of choice and the ability to exercise control (responsibility) over the object of their fear.
Socratic dialogue: Socratic dialogue is a technique in which the logotherapist uses the person's own words as a method of self-discovery. By listening intently to what the person says, the therapist can point out specific patterns of words, or word solutions to the client, and let the client see new meaning in them. This process allows a person to realize that the answer lies within and is just waiting to be discovered.
The Socratic Dialogue is a way of engaging the person in a discussion that allows that person to discover what he or she already knows. The client has already formed these ideas, either preconsciously, unconsciously, or through the spiritual realm of the unconscious. The therapist does not presume to know the right solution for the patient.  Frankl wrote: "It is not necessary, however, to enter into sophisticated debate with the patients.  Logos is deeper than logic."  
Maieutic Questions force a person to formulate concepts through a logical sequence of questions. One way in which Socratic or Maieutic Dialogue is begun in Logotherapy is by asking what Dr. Elisabeth Lukas (2015) calls a two-legged question.  A two legged question has one leg in the patient’s problem area and the other leg in the their area of freedom.  A famous example from Dr. Lukas is, "Why stand among the flowers and water the weeds?"  This same principle is illustrated in another famous quote by Dr. Jerry Long, who was paralyzed from the neck down, when he said, "I broke my neck, it did not break me,"
Per Aron Smith, some examples of particularly effective Socratic questions to ask veterans with military-related PTSD are, “What is life asking of you at this time, even in all your suffering?” as well as, “How do you find courage?” These questions probe the subject’s reality, but they are anchored in the intended ends, which would be the realization that life is calling them to act in a meaningful and intentional fashion. Once the client begins deriving meaning and purpose for his or her current and past existences, he or she becomes empowered as an autocrat, capable of accepting the existential responsibility to live towards meaning and purpose.
To summarize, the suggested premise that at the root of depression, PTSD and other mental disorders is the true or perceived impairment of one’s freedom of choice over and the ability to control something. Logotherapy addresses these issues.
Dereflection improves one’s freedom of choice and the ability to control (take responsibility for) by diverting a person’s attention away from themselves and out to the environment and other people, stressing the points of help and cooperation—and love, a necessary component to the sense of security and mental well-being.
Paradoxical intention restores one’s freedom of choice and a sense of responsibility by having a person face their fears and come out a triumphant winner over them.
Socratic dialog is effective in restoring one’s freedom of choice and the ability to control things in two ways: (1) it presupposes that the patient and only the patient knows the answers and now it is only a matter of formulating them. The therapist does not evaluate or give the answers, it is really the subject who is coaxed to give the answers. That is significant in restoring one’s confidence and abilities in any area; (2) through working out and formulating the answers, the subject gets the intended realizations, aimed to improve their freedom of choice and the sense of responsibility.         



References
Bartha, C. (2013). Depression : An information guide CAMH, Centre for Addiction and Mental Health.
Institute of Logotherapy, V. (n.d.). Viktor Frankl Institute of Logotherapy. Retrieved April 24, 2016, from http://www.logotherapyinstitute.org/About_Logotherapy.html
Victor E. Frankle, (1959) Man’s Search for Meaning, Hodder & Stoughton
Smith, A.J. (2013). Logotherapy to treat substance abuse as a result of military-related PTSD. Journal of Military and Government Counseling, 1(1), 61-74.
All About Philosophy, http://www.allaboutphilosophy.org/existentialism.htm
M. F. Ashley Montagu, (1955), The Direction of Human Development, Biological and Social Bases
William G. Sharp, Kelly G. Wilson, Stefan E. Schulenberg. (2004) Use of Paradoxical Intention in the Context of Acceptance and Commitment Therapy. Psychological Reports 95:3, 946-948
Aaron Smith, (2012) Article 5 Innovative Applications of Logotherapy for Military-Related PTSD, ACA Conference, San Francisco, CA
Shoham-Salomon & Rosenthal, (1987), Paradoxical Interventions: a Meta Analysis
A. A. Brill, Sigmund Freud, (1938), The Basic Writings of Sigmund Freud
Elisabeth Lukas, (2015), Logotherapie und Depression