META-CLINICAL PROBLEMS

More and more, a psychiatrist is approached today by patients who confront him with human problems rather than neurotic symptoms. Some of the people who nowadays call on a psychiatrist would have seen a pastor, priest or rabbi in former days. Now they often refuse to be handed over to a clergyman and instead confront the doctor with questions such as, "What is the meaning of my life?"

A LOGODRAMA

I should like to cite the following instance: Once, the mother of a boy who had died at the age of eleven years was admitted to my hospital department after a suicide attempt. Dr. Kurt Kocourek invited her to join a therapeutic group, and it happened that I stepped into the room where he was conducting a psychodrama. She was telling her story. At the death of her boy she was left alone with another, older son, who was crippled, suffering from the effects of infantile paralysis. The poor boy had to be moved around in a wheelchair. His mother, however, rebelled against her fate. But when she tried to commit suicide together with him, it was the crippled son who prevented her from doing so; he liked living! For him, life had remained meaningful. Why was it not so for his mother? How could her life still have a meaning? And how could we help her to become aware of it?

Improvising, I participated in the discussion, and questioned another woman in the group. I asked her how old she was and she answered, "Thirty." I replied, "No, you are not thirty but instead eighty and lying on your deathbed. And now you are looking back on your life, a life which was childless but full of financial success and social prestige." And then I invited her to imagine what she would feel in this situation. "What will you think of it? What will you say to yourself?" Let me quote what she actually said from a tape which was recorded during that session. "Oh, I married a millionaire, I had an easy life full of wealth, and I lived it up! I flirted with men; I teased them! But now I am eighty; I have no children of my own. Looking back as an old woman, I cannot see what all that was for; actually, I must say, my life was a failure!"

I then invited the mother of the handicapped son to imagine herself similarly looking back over her life. Let us listen to what she had to say as recorded on the tape: "I wished to have children and this wish has been granted to me; one boy died; the other, however, the crippled one, would have been sent to an institution if I had not taken over his care. Though he is crippled and helpless, heisafterallmyboy.AndsoIhavemadea fuller life possible for him; I have made a better human being out of my son." At this moment, there was an outburst of tears and, crying, she continued: "As for myself, I can look back peacefully on my life; for I can say my life was full of meaning, and I have tried hard to fulfill it; I have done my best—I have done the best for my son. My life was no failure!" Viewing her life as if from her deathbed, she had suddenly been able to see a meaning in it, a meaning which even included all of her sufferings. By the same token, however, it had become clear as well that a life of short duration, like that, for example, of her dead boy, could be so rich in joy and love that it could contain more meaning than a life lasting eighty years.

After a while I proceeded to another question, this time addressing myself to the whole group. The question was whether an ape which was being used to develop poliomyelitis serum, and for this reason punctured again and again, would ever be able to grasp the meaning of its suffering. Unanimously, the group replied that of course it would not; with its limited intelligence, it could not enter into the world of man, i.e., the only world in which the meaning of its suffering would be understandable. Then I pushed forward with the following question: "And what about man? Are you sure that the human world is a terminal point in the evolution of the cosmos? Is it not conceivable that there is still another dimension, a world beyond man's world; a world in which the question of an ultimate meaning of human suffering would find an answer?"

THE SUPER-MEANING

This ultimate meaning necessarily exceeds and surpasses the finite intellectual capacities of man; in logotherapy, we speak in this context of a super-meaning. What is demanded of man is not, as some existential philosophers teach, to endure the meaninglessness of life, but rather to bear his incapacity to grasp its unconditional meaningful-ness in rational terms. Logos is deeper than logic.

A psychiatrist who goes beyond the concept of the super-meaning will sooner or later be embarrassed by his patients, just as I was when my daughter at about six years of age asked me the question, "Why do we speak of the good Lord?" Whereupon I said, "Some weeks ago, you were suffering from measles, and then the good Lord sent you full recovery." However, the little girl was not content; she retorted, "Well, but please, Daddy, do not forget: in the first place, he had sent me the measles."

However, when a patient stands on the firm ground of religious belief, there can be no objection to making use of the therapeutic effect of his religious convictions and thereby drawing upon his spiritual resources. In order to do so, the psychiatrist may put himself in the place of the patient. That is exactly what I did once, for instance, when a rabbi from Eastern Europe turned to me and told me his story. He had lost his first wife and their six children in the concentration camp of Auschwitz where they were gassed, and now it turned out that his second wife was sterile. I observed that procreation is not the only meaning of life, for then life in itself would become meaningless, and something which in itself is meaningless cannot be rendered meaningful merely by its perpetuation. However, the rabbi evaluated his plight as an orthodox Jew in terms of despair that there was no son of his own who would ever say Kad-dish for him after his death.

But I would not give up. I made a last attempt to help him by inquiring whether he did not hope to see his children again in Heaven. However, my question was followed by an outburst of tears, and now the true reason for his despair came to the fore: he explained that his children, since they died as innocent martyrs, were thus found worthy of the highest place in Heaven, but as for himself he could not expect, as an old, sinful man, to be assigned the same place. I did not give up but retorted, "Is it not con­ceivable, Rabbi, that precisely this was the meaning of your surviving your children: that you may be purified through these years of suffering, so that finally you, too, though not innocent like your children, may become worthy of joining them in Heaven? Is it not written in the Psalms that God preserves all your tears? So perhaps none of your sufferings were in vain." For the first time in many years he found relief from his suffering through the new point of view which I was able to open up to him.

LIFE'S TRANSITORINESS

Those things which seem to take meaning away from human life include not only suffering but dying as well. I never tire of saying that the only really transitory aspects of life are the potentialities; but as soon as they are actualized, they are rendered realities at that very moment; they are saved and delivered into the past, wherein they are rescued and preserved from transitoriness. For, in the past, nothing is irretrievably lost but everything irrevocably stored.

Thus, the transitoriness of our existence in no way makes it meaningless. But it does constitute our responsibleness; for everything hinges upon our realizing the essentially transitory possibilities. Man constantly makes his choice concerning the mass of present potentialities; which of these will be condemned to nonbeing and which will be actualized? Which choice will be made an actuality once and forever, an immortal "footprint in the sands of time"? At any moment, man must decide, for better or for worse, what will be the monument of his existence.

Usually, to be sure, man considers only the stubble field of transitoriness and overlooks the full granaries of the past, wherein he had salvaged once and for all his deeds, his joys and also his sufferings. Nothing can be undone, and nothing can be done away with. I should say having been is the surest kind of being.

Logotherapy, keeping in mind the essential transitoriness of human existence, is not pessimistic but rather activistic. To express this point figuratively we might say: The pessimist resembles a man who observes with fear and sadness that his wall calendar, from which he daily tears a sheet, grows thinner with each passing day. On the other hand, the person who attacks the problems of life actively is like a man who removes each successive leaf from his calendar and files it neatly and carefully away with its predecessors, after first having jotted down a few diary notes on the back. He can reflect with pride and joy on all the richness set down in these notes, on all the life he has already lived to the fullest. What will it matter to him if he notices that he is growing old? Has he any reason to envy the young people whom he sees, or wax nostalgic over his own lost youth? What reasons has he to envy a young person? For the possibilities that a young person has, the future which is in store for him? "No, thank you," he will think. "Instead of possibilities, I have realities in my past, not only the reality of work done and of love loved, but of sufferings bravely suffered. These sufferings are even the things of which I am most proud, though these are things which cannot inspire envy."

LOGOTHERAPY AS A TECHNIQUE

A realistic fear, like the fear of death, cannot be tranquilized away by its psychodynamic interpretation; on the other hand, a neurotic fear, such as agoraphobia, cannot be cured by philosophical understanding. However, logotherapy has developed a special technique to handle such cases, too. To understand what is going on whenever this technique is used, we take as a starting point a condition which is frequently observed in neurotic individuals, namely, anticipatory anxiety. It is characteristic of this fear that it produces precisely that of which the patient is afraid. An individual, for example, who is afraid of blushing when he enters a large room and faces many people will actually be more prone to blush under these circumstances. In this context, one might amend the saying "The wish is father to the thought" to "The fear is mother of the event."

Ironically enough, in the same way that fear brings to pass what one is afraid of, likewise a forced intention makes impossible what one forcibly wishes. This excessive intention, or "hyper-intention," as I call it, can be observed particularly in cases of sexual neurosis. The more a man tries to demonstrate his sexual potency or a woman her ability to experience orgasm, the less they are able to succeed. Pleasure is, and must remain, a side- effect or by-product, and is destroyed and spoiled to the degree to which it is made a goal in itself.

In addition to excessive intention as described above, excessive attention, or "hyper-reflection," as it is called in logotherapy, may also be pathogenic (that is, lead to sickness). The following clinical report will indicate what I mean: A young woman came to me complaining of being frigid. The case history showed that in her childhood she had been sexually abused by her father. However, it had not been this traumatic experience in itself which had eventuated in her sexual neurosis, as could easily be evidenced. For it turned out that, through reading popular psychoanalytic literature, the patient had lived constantly with the fearful expectation of the toll which her traumatic experience would someday take. This anticipatory anxiety resulted both in excessive intention to confirm her feminin­ ity and excessive attention centered upon herself rather than upon her partner. This was enough to incapacitate the patient for the peak experience of sexual pleasure, since the orgasm was made an object of intention, and an object of attention as well, instead of remaining an unintended effect of unreflected dedication and surrender to the partner. After undergoing short-term logotherapy, the patient's excessive attention and intention of her ability to experience orgasm had been "dereflected," to introduce another logo-therapeutic term. When her attention was refocused toward the proper object, i.e., the partner, orgasm established itself spontaneously.

Logotherapy bases its technique called "paradoxical intention" on the twofold fact that fear brings about that which one is afraid of, and that hyper-intention makes impossible what one wishes. In German I described paradoxical intention as early as 1939. In this approach the phobic patient is invited to intend, even if only for a moment, precisely that which he fears.

Let me recall a case. A young physician consulted me because of his fear of perspiring. Whenever he expected an outbreak of perspiration, this anticipatory anxiety was enough to precipitate excessive sweating. In order to cut this circle formation I advised the patient, in the event that sweating should recur, to resolve deliberately to show people how much he could sweat. A week later he returned to report that whenever he met anyone who triggered his anticipatory anxiety, he said to himself, "I only sweated out a quart before, but now I'm going to pour at least ten quarts!" The result was that, after suffering from his phobia for four years, he was able, after a single session, to free himself permanently of it within one week.

The reader will note that this procedure consists of a reversal of the patient's attitude, inasmuch as his fear is replaced by a paradoxical wish. By this treatment, the wind is taken out of the sails of the anxiety.

Such a procedure, however, must make use of the specifically human capacity for self- detachment inherent in a sense of humor. This basic capacity to detach one from oneself is actualized whenever the logotherapeutic technique called paradoxical intention is applied. At the same time, the patient is enabled to put himself at a distance from his own neurosis. A statement consistent with this is found in Gordon W. Allport's book, The Individual and His Religion: "The neurotic who learns to laugh at himself may be on the way to self- management, perhaps to cure."

A few more case reports may serve to clarify this method further. The following patient was a bookkeeper who had been treated by many doctors and in several clinics without any therapeutic success. When he was admitted to my hospital department, he was in extreme despair, confessing that he was close to suicide. For some years, he had suffered from a writer's cramp which had recently become so severe that he was in danger of losing his job. Therefore, only immediate short-term therapy could alleviate the situation. In starting treatment, Dr. Eva Kozdera recommended to the patient that he do just the opposite of what he usually had done; namely, instead of trying to write as neatly and legibly as possible, to write with the worst possible scrawl. He was advised to say to himself, "Now I will show people what a good scribbler I am!" And at the moment in which he deliberately tried to scribble, he was unable to do so. "I tried to scrawl but simply could not do it," he said the next day. Within forty-eight hours the patient was in this way freed from his writer's cramp, and remained free for the observation period after he had been treated. He is a happy man again and fully able to work.

A similar case, dealing, however, with speaking rather than writing, was related to me by a colleague in the Laryngological Department of the Vienna Poliklinik Hospital. It was the most severe case of stuttering he had come across in his many years of practice. Never in his life, as far as the stutterer could remember, had he been free from his speech trouble, even for a moment, except once. This happened when he was twelve years old and had hooked a ride on a streetcar. When caught by the conductor, he thought that the only way to escape would be to elicit his sympathy, and so he tried to demonstrate that he was just a poor stuttering boy. At that moment, when he tried to stutter, he was unable to do it. Without meaning to, he had practiced paradoxical intention, though not for therapeutic purposes.

However, this presentation should not leave the impression that paradoxical intention is effective only in mono- symptomatic cases. By means of this logotherapeutic technique, my staff at the Vienna Poliklinik Hospital has succeeded in bringing relief even in obsessive-compulsive neuroses of a most severe degree and duration. I refer, for instance, to a woman sixty-five years of age who had suffered for sixty years from a washing compulsion. Dr. Eva Kozdera started logotherapeutic treatment by means of paradoxical intention, and two months later the patient was able to lead a normal life. Before admission to the Neurological Department of the Vienna Poliklinik Hospital, she had confessed, "Life was hell for me." Handi­ capped by her compulsion and bacteriophobic obsession, she finally remained in bed all day unable to do any housework. It would not be accurate to say that she is now completely free of symptoms, for an obsession may come to her mind. However, she is able to "joke about it," as she says; in short, to apply paradoxical intention.

Paradoxical intention can also be applied in cases of sleep disturbance. The fear of sleeplessness results in a hyper-intention to fall asleep, which, in turn, incapacitates the patient to do so. To overcome this particular fear, I usually advise the patient not to try to sleep but rather to try to do just the opposite, that is, to stay awake as long as possible. In other words, the hyper-intention to fall asleep, arising from the anticipatory anxiety of not being able to do so, must be replaced by the paradoxical intention not to fall asleep, which soon will be followed by sleep.

Paradoxical intention is no panacea. Yet it lends itself as a useful tool in treating obsessive-compulsive and phobic conditions, especially in cases with underlying anticipatory anxiety. Moreover, it is a short-term therapeutic device. However, one should not conclude that such a short-term therapy necessarily results in only temporary therapeutic effects. One of "the more common illusions of Freudian orthodoxy," to quote the late Emil A. Gutheil, "is that the durability of results corresponds to the length of therapy." In my files there is, for instance, the case report of a patient to whom paradoxical intention was administered more than twenty years ago; the therapeutic effect proved to be, nevertheless, a permanent one.

One of the most remarkable facts is that paradoxical intention is effective regardless of the etiological basis of the case concerned. This confirms a statement once made by Edith Weisskopf-Joelson: "Although traditional psychotherapy has insisted that therapeutic practices have to be based on findings on etiology, it is possible that certain factors might cause neuroses during early childhood and that entirely different factors might relieve neuroses during adulthood."

As for the actual causation of neuroses, apart from constitutional elements, whether somatic or psychic in nature, such feedback mechanisms as anticipatory anxiety seem to be a major pathogenic factor. A given symptom is responded to by a phobia, the phobia triggers the symptom, and the symptom, in turn, reinforces the phobia. A similar chain of events, however, can be observed in obsessive-compulsive cases in which the patient fights the ideas which haunt him. Thereby, however, he increases their power to disturb him, since pressure precipitates counterpressure. Again the symptom is reinforced! On the other hand, as soon as the patient stops fighting his obsessions and instead tries to ridicule them by dealing with them in an ironical way—by applying paradoxical intention—the vicious circle is cut, the symptom diminishes and finally atrophies. In the fortunate case where there is no existential vacuum which invites and elicits the symptom, the patient will not only succeed in ridiculing his neurotic fear but finally will succeed in completely ignoring it.

As we see, anticipatory anxiety has to be counteracted by paradoxical intention; hyper- intention as well as hyper-reflection have to be counteracted by dereflection; dereflec-tion, however, ultimately is not possible except by the patient's orientation toward his specific vocation and mission in life.

It is not the neurotic's self-concern, whether pity or contempt, which breaks the circle formation; the cue to cure is self- transcendence!

THE COLLECTIVE NEUROSIS

Every age has its own collective neurosis, and every age needs its own psychotherapy to cope with it. The existential vacuum which is the mass neurosis of the present time can be described as a private and personal form of nihilism; for nihilism can be defined as the contention that being has no meaning. As for psychotherapy, however, it will never be able to cope with this state of affairs on a mass scale if it does not keep itself free from the impact and influence of the contemporary trends of a nihilistic philosophy; otherwise it represents a symptom of the mass neurosis rather than its possible cure. Psychotherapy would not only reflect a nihilistic philosophy but also, even though unwillingly and unwittingly, transmit to the patient what is actually a caricature rather than a true picture of man.

First of all, there is a danger inherent in the teaching of man's "nothingbutness," the theory that man is nothing but the result of biological, psychological and sociological conditions, or the product of heredity and environment. Such a view of man makes a neurotic believe what he is prone to believe anyway, namely, that he is the pawn and victim of outer influences or inner circumstances. This neurotic fatalism is fostered and strengthened by a psychotherapy which denies that man is free.

To be sure, a human being is a finite thing, and his freedom is restricted. It is not freedom from conditions, but it is freedom to take a stand toward the conditions. As I once put it: "As a professor in two fields, neurology and psychiatry, I am fully aware of the extent to which man is subject to biological, psychological and sociological conditions. But in addition to being a professor in two fields I am a survivor of four camps—concentration camps, that is— and as such I also bear witness to the unexpected extent to which man is capable of defying and braving even the worst conditions conceivable.

CRITIQUE OF PAN-DETERMINISM

Psychoanalysis has often been blamed for its so-called pan-sexualism. I, for one, doubt whether this reproach has ever been legitimate. However, there is something which seems to me to be an even more erroneous and dangerous assumption, namely, that which I call "pan- determinism." By that I mean the view of man which disregards his capacity to take a stand toward any conditions whatsoever. Man is not fully conditioned and determined but rather determines himself whether he gives in to conditions or stands up to them. In other words, man is ultimately self- determining. Man does not simply exist but always decides what his existence will be, what he will become in the next moment.

By the same token, every human being has the freedom to change at any instant. Therefore, we can predict his future only within the large framework of a statistical survey referring to a whole group; the individual personality, however, remains essentially unpredictable. The basis for any predictions would be represented by biological, psychological or sociological conditions. Yet one of the main features of human existence is the capacity to rise above such conditions, to grow beyond them. Man is capable of changing the world for the better if possible, and of changing himself for the better if necessary.

Let me cite the case of Dr. J. He was the only man I ever encountered in my whole life whom I would dare to call a Mephistophelean being, a satanic figure. At that time he was generally called "the mass murderer of Steinhof" (the large mental hospital in Vienna). When the Nazis started their euthanasia program, he held all the strings in his hands and was so fanatic in the job assigned to him that he tried not to let one single psychotic individual escape the gas chamber. After the war, when I came back to Vienna, I asked what had happened to Dr. J. "He had been imprisoned by the Russians in one of the isolation cells of Steinhof," they told me. "The next day, however, the door of his cell stood open and Dr. J. was never seen again."

Later I was convinced that, like others, he had with the help of his comrades made his way to South America. More recently, however, I was consulted by a former Austrian diplomat who had been imprisoned behind the Iron Curtain for many years, first in Siberia and then in the famous Lubianka prison in Moscow. While I was examining him neurologically, he suddenly asked me whether I happened to know Dr. J. After my affirmative reply he continued: "I made his acquaintance in Lubianka. There he died, at about the age of forty, from cancer of the urinary bladder. Before he died, however, he showed himself to be the best comrade you can imagine! He gave consolation to everybody. He lived up to the highest conceivable moral standard. He was the best friend I ever met during my long years in prison!"

This is the story of Dr. J., "the mass murderer of Steinhof." How can we dare to predict the behavior of man? We may predict the movements of a machine, of an automaton; more than this, we may even try to predict the mechanisms or "dynamisms" of the human psyche as well. But man is more than psyche.

Freedom, however, is not the last word. Freedom is only part of the story and half of the truth. Freedom is but the negative aspect of the whole phenomenon whose positive aspect is responsibleness. In fact, freedom is in danger of degenerating into mere arbitrariness unless it is lived in terms of responsibleness. That is why / recommend that the Statue of Liberty on the East Coast be supplemented by a Statue of Responsibility on the West Coast.

THE PSYCHIATRIC CREDO

There is nothing conceivable which would so condition a man as to leave him without the slightest freedom. Therefore, a residue of freedom, however limited it may be, is left to man in neurotic and even psychotic cases. Indeed, the innermost core of the patient's personality is not even touched by a psychosis.

An incurably psychotic individual may lose his usefulness but yet retain the dignity of a human being. This is my psychiatric credo. Without it I should not think it worthwhile to be a psychiatrist. For whose sake? Just for the sake of a damaged brain machine which cannot be repaired? If the patient were not definitely more, euthanasia would be justified.

PSYCHIATRY REHUMANIZED

For too long a time—for half a century, in fact—psychiatry tried to interpret the human mind merely as a mechanism, and consequently the therapy of mental disease merely in terms of a technique. I believe this dream has been dreamt out. What now begins to loom on the horizon are not the sketches of a psychologized medicine but rather those of a humanized psychiatry.

A doctor, however, who would still interpret his own role mainly as that of a technician would confess that he sees in his patient nothing more than a machine, instead of seeing the human being behind the diseasel

A human being is not one thing among others; things determine each other, but man is ultimately self-determining. What he becomes—within the limits of endowment and environment—he has made out of himself. In the concentration camps, for example, in this living laboratory and on this testing ground, we watched and witnessed some of our comrades behave like swine while others behaved like saints. Man has both potentialities within himself; which one is actualized depends on decisions but not on conditions.

Our generation is realistic, for we have come to know man as he really is. After all, man is that being who invented the gas chambers of Auschwitz; however, he is also that being who entered those gas chambers upright, with the Lord's Prayer or the Shema Yisrael on his lips.