Abstract
Experiencing illness, in its physical or mental expressions, raises radical questions concerning the sense or non-sense of a subject’s existence: Does life still have meaning and purpose when it is marked by suffering? How can feelings of meaninglessness and despair be avoided or prevented? These are questions that both those providing care and those receiving are compelled to face in their daily encounter with the vulnerability and precariousness of the human condition. Viktor Frankl’s existential analysis and logotherapy represents an attempt to restore the inner spiritual resources of the homo patiens, with a view to turning limit situations into challenges and opportunities for personal growth. This chapter focuses on the nature of Frankl’s meaning-oriented psychotherapy as a kind of ‘medical care of the soul’ (ärtzliche Seelsorge): an ethics-based practice originally developed as a ‘value-based psychotherapy’ (wertende Psychotherapie) which intentionally seeks to foster responsibility as an ‘ethical formal value’. A prime example of its application in clinical contexts is meaning-centred group therapy conducted with cancer patients; clinical experience and research proves that investing in meaning and values acts as a psychological protective factor and a therapeutic resource in coping with illness.
A man without ethics is a wild beast loosed upon this world.
Albert Camus
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Keywords
The physician and philosopher Karl Jaspers (1919, 1932) defined limit situations (Grenzsituationen) as circumstances that place individual existences at risk of being ‘shipwrecked’. Illness is an example of a limit situation; it makes subjects suddenly feel at the mercy of fate, as the core certainties undergirding their sense of existential security begin to falter. Yet the experience of many patients shows that, precisely in such situations, the quest for meaning intensifies, helping those who suffer to be resilient and even to undergo personal growth, despite their unfavourable circumstances. This need for meaningfulness is a protection factor of incalculable value that should be fostered and guided as part of care work.Footnote 1
Stories of Illness and Meaning-Making Processes
Illness proves to us most starkly that a person is first and foremost a body and yet, at the same time, is never reducible to this body. Each experience of illness is accompanied by a meaning attribution process that modifies how it is perceived by the subject and how it impacts their existence as a whole. As human beings, we are all ‘simultaneously material and metaphoric beings’ (Charon, 2006, p. 86), hence all events at the physical level are instantly pervaded by cultural preunderstandings (Quaranta & Ricca, 2012) and bear emotional, existential and spiritual implications that cannot be overlooked when listening to a patient (Good, 1993). Each ill person’s body is itself a story, in that it interprets what is happening to it in light of its own past history, and at the same time, it is a project, in that—based on what is happening to it—it embodies a peculiar way of being-in-the-world (Heidegger, 1927; Binswanger, 1965). All changes enacted or undergone at the bodily level (growth, aging, chronic illness, disability, etc.) necessarily entail a restructuring of personal identity and existential project.
Nevertheless, it is not only events that determine what we are but also the story that we weave from these events. Indeed, an event (Geschehnis) and our lived experience of it (Erlebnis) are inseparable from one another (Straus, 2011), given that all happenings are immediately perceived by those experiencing them as bearing a certain meaning. The occurrence of an undesired or traumatic event can cause a ‘biographical disruption’ (Bury, 1982), a hiatus in our life story with the power to challenge our self-perceptions and shake our most deeply held convictions. Serious illness, from this perspective, is a key event that forces patients to radically question the meaning of their very existence. The impact of experiencing illness on patients’ quality of life (Glaser & Strauss, 1975) is shaped in great part by how the patients themselves subjectively perceive—but above all by how they process—the related events (Toombs, 1993).
Thus, meaning-making plays a key role in determining the effect of critical situations and stressful events on the lives of individuals, directly impacting the well-being of patients and their families. Crystal L. Park, at the University of Connecticut, proposed a theoretical model of meaning-making with two dimensions: global meaning and situational meaning (Park & Folkman, 1997; Park, 2010). Global meaning comprises three factors: beliefs and convictions; ideals and aspirations and sense of self and purpose. Each of these aspects is directly related to a person’s well-being and psychophysical health. Global meaning in particular ‘plays an essential role in how individuals deal with situations of crisis or serious illness, influencing their adjustment and, some research suggests, even their survival’ (Park, 2013, p. 41). Situational meaning, on the other hand, is the meaning that individuals attribute to what they are experiencing at a given point of their lives: their personal way of representing and reacting to events. Such attributions of meaning are largely determined by a person’s cultural background and life story, but also by the contingent resources (whether relational, affective, religious, etc.) available to them at this juncture.
A perceived discrepancy between the meaning of a particular situation (as actually experienced) and our overall framework of reference (what we believe and aim for) generates a tension, which may be resolved by means of assimilation (modifying the meaning of a concrete situation) or accommodation (changing ourselves and our framework of reference). This twofold effort to process experience demands a change of perspective and, in some cases, a significant degree of self-transformation. Experiencing serious illness, whether chronic or terminal, can turn a person’s life upside down, because it represents ‘an alteration of one’s relationship with the world’ (Costa & Cesana, 2019, p. 89) that generates imbalances and a profound sense of psychological suffering; nevertheless, it can also be an opportunity to revisit one’s storytelling, with a view to developing a story about oneself that encompasses the illness experience as a further stage of growth and development.
Narrative meaning-making is the process concerning ‘the existential dimension underlying coping and adjustment’ (Hartog et al., 2017, p. 4); its aim is to support existential change and the corresponding ‘narrative reconstruction’ process. An illness may said to have been dealt with from an existential point of view ‘to the extent to which the life event is integrated in the life narrative, given a new meaning and becoming a part of someone’s identity’ (ibid., p. 8). In the face of an experience that undermines their worldview and life view, patients must rise to the challenge of generating a new narrative; this presupposes the adoption of a fresh outlook on events and sometimes even a demanding process of reinterpreting their life stories (e.g. Bruzzone, 2018).
Searching for Meaning and Responsibility: The Legacy of Viktor Frankl
In the field of psychology, the question of meaning has traditionally been viewed as an ambiguous and non-scientific factor because it is difficult to objectivize (Armezzani, 2002). But excluding meaning is too great a sacrifice to be made on the altar of ‘scientificity’; if psychology can tell us nothing about the inner life (psyché) and its meaning (logos), it betrays its very essence and purpose. Humanistic-existential, constructivist and phenomenological approaches have contributed to rehabilitating the dimension of meaning as one of the keys to understanding experience and human behaviour.
The first-time meaning was introduced into experimental psychology as a variable was probably when Crumbaugh and Maholick (1964) published an instrument for measuring the meaningfulness of an individual’s existence: the Purpose in Life (PIL) test. The authors had been students of the Austrian psychiatrist Viktor E. Frankl, the well-known concentration camp survivor, who had based his logotherapy and existential analysis on the principle of ‘will to meaning’ (Wille zum Sinn) that is the basic strive of the human spirit to find meaning and purpose in concrete day-to-day situations (Bruzzone, 2007, 2012). Frankl, who today is viewed as the forerunner of existential and positive psychology, had observed that feelings of meaninglessness cause suffering, and existential frustration can even spring up in a ‘noogenic neurosis’ (Frankl, 2010a); from this fact, he deduced the need for a form of therapy centred ‘on life’s meaning as well as man’s search for this meaning’ (ibid., p. 51).Footnote 2 His theory informed a subsequent line of empirical research on the theme of personal quest for meaning across different life contexts (Wong & Fry, 1998; Batthyany & Guttmann, 2005; Batthyany & Ruzzo-Netzer, 2014; Thir & Batthyany, 2016).
Frankl had personally experienced the survival value of the inclination to seek meaning as a deportee to Nazi concentration camps during World War II (Frankl, 2006)Footnote 3; in this, he pre-empted to some extent later theories on resilience and post-traumatic growth (Calhoun & Tedeschi, 2006).
In one of his first talks after his release from the camps, in 1946, Frankl used the title Trotzdem Ja zum Leben sagen for the first time to express this concept; it is possible to go on loving life despite all, on condition that life holds a meaning for us that makes it worth living.Footnote 4 But the ‘meaning’ spoken of by Frankl is not so much a purely intellectual notion (such as a plausible explanation for what is happening to us), but rather a primarily ethical matter: meaning as a goal, a purpose to be fulfilled, a good reason for resisting and even for suffering. Meaning, therefore, must be identified, pursued and achieved; it presupposes that any healthy existence will be underpinned by a tension between being and ought (Frankl, 1967, pp. 67 ff.), that is: an ethical tension. For this reason, the dimension of logos (meaning), to which the human person is naturally drawn, is never purely a question of self-actualization or self-expression (ibid., p. 71) but rather a universe of trans-subjective goals and values.
Meaning, correctly understood, is unique and singular, always arising in an unrepeatable manner that is given ad personam and ad situationem, and yet at the same time it is not created or constructed by the subject. In Frankl’s view, perceiving meaning is more akin to the Gestalt intuition of a form; it is similar to what Wolfgang Köhler (1925) labelled an ‘Aha!’ experience, whereby a subject reorganizes his or her perceptual field based on an insight, or to the ability to grasp a situation’s inherent demands, which Köhler himself (1938) called ‘requiredness’. Meaning, therefore, is the link between our conscience and the transcendence’s appeal; it is the possibility, hidden in every situation, to respond to life and shape ourselves.
The concept of meaning-centred psychotherapy sprang from the young Dr. Frankl’s dissatisfaction with developments in depth psychology . His ‘third Viennese School of psychotherapy’ (after Freudian psychoanalysis and Adlerian individual psychology) positioned itself as a height psychology , founded on the spiritual (or noetic) dimension of human nature. While the earlier approaches had characterized neurotic ways of being as limited awareness and freedom on the part of the self, logotherapy and existential analysis were informed by the anthropological assumption that ‘being-myself means being-conscious and being-responsible’ (Frankl, 2000, p. 115).Footnote 5 Remaining faithful to Adler’s insight that it is more important to focus on the purpose of a behaviour than on its cause, Frankl sought to comprehend the deepest need underpinning human conduct, the demand for meaning. He thus supplemented the psychodynamic perspective with a noodynamic interpretive lens that recognized moral tension as a ‘primordial, wholly authentic aspiration to moral value’ (ibid., p. 117). This rediscovery of the spiritual nature of human beingsFootnote 6 brought ethics into focus in the field of psychotherapy—and medical care more generally—as a typical aspect of human existence.
Indeed, our spiritual existence is intrinsically intentional, insofar as it is directed towards a world of objects and other subjects. It follows that ‘the spiritual being actualizes himself through being-oriented (Bei-Sein) to someone or something, and this quality of the spiritual being represents its most peculiar potential, its specific primordial capacity’ (Frankl, 1959, p. 673). This explains why Frankl insistently claimed that the core qualities of human existence are self-detachment and self-transcendence ; the former consists of the ability to look at ourselves from a distance; the latter is expressed through the ability to devote to something other than ourselves: a person to love, a task to complete, a calling to follow. Being conscious of meaning thus implies being conscious of a possibility that is waiting to be fulfilled; reawakening it implies making a person responsible, and when persons become aware of their own responsibility this ‘somehow forces them to make their own judgments on the ground of this responsibility’ (Frankl, 2000, p. 119).
While it is up to patients to live according to this responsibility in their everyday lives, it is the therapist’s duty to present them with it and to rescue them from the fatalism that is often associated with life’s limit situations. This was why Frankl, following Rudolf Allers, liked to define psychotherapy as an ‘education in recognizing responsibility’ (ibid, p. 130). In this perspective, it can be interpreted ‘as a means for an ethical purpose’ (ibid. p. 143). The ethical purpose, in this case, is to shape one’s existence according to meaningfulness and coherence. Life, thus, is a task that we mould by our choices: ‘every decision is a self-determination and self-determination is a self-configuration’ (Frankl, 1984, p. 143).
Alfried Längle (2005) has identified a four-step method, by which each patient can be helped to assume responsibility of his or her own being and becoming, in relation to objective meaning and values:
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To recognize the situation: Facts and constraints, as well as degrees of indetermination and chance (self-detachment).
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To evaluate possibilities according to one’s hierarchy of values (self-transcendence).
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To choose the best and more significant option (freedom).
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To implement and fulfil the decision made (responsibility).
By this process involving intellect, feeling, will and action, the suffering man is allowed to take a position towards the conditions imposed.
The ethical nature of psychotherapeutic intervention raises a deontological question: is it possible for psychotherapists to address values? In engaging, as they are obliged to do, with their patients’ individual worldviews (Weltanschauungen), therapists are faced with a dilemma: ‘On the one hand, the need for and the presupposition of values; on the other hand, the moral impossibility of any form of imposition’ (Frankl, 2000, p. 144). The only way to resolve the issue is to recognize responsibility as a ‘formal ethical value that constitutes the indispensable condition for all other judgements’ (ibid.). The therapist’s task, therefore, is to guide patients to the threshold of making a decision and, at that juncture, to leave them in charge. Deciding to whom and for what to be responsible is the patient’s prerogative only. Yet a therapeutic process that induces patients to ask themselves this question is a good therapy, in that it leads them to seek good and saves them from the risk of losing their autonomy, which is always inherent in situations of suffering.
And so, it happens that the condition of being ill, despite interfering with patients’ most fundamental needs, paradoxically makes them conscious of a more intimate and irreducible demand: finding a purpose in life, despite everything. Frankl’s triple route represented by the creative, experiential and attitudinal values encompasses the various means by which life may be endowed with meaning: through creating and producing something, or through enjoying something or someone, or through transforming oneself in relation to a destiny that cannot be changed. The last-mentioned possibility offers extraordinary scope for resilience and post-traumatic growth to those who are afflicted by incurable and fatal health conditions. Indeed, the dynamics of responsibility saves them from victimhood and allows them to recover ‘authorship’ with respect to their own life story. Sometimes ill persons are not victims of their fate but of the story they have spun about it (Hillman, 1998); their existence is no longer free, but determined and entirely taken over by a dominant theme (Binswanger, 1958). Logotherapy and existential analysis set out to prevent this danger and to restore the dignity and, insofar as possible, the authenticity of the suffering man.
Experiences of Meaning-Oriented Psychotherapy with Cancer Patients
Over 40 years have passed since the setting up, in 1977, of the Department of Psychiatry and Behavioral Science at the Memorial Sloan Kettering Cancer Centre, a research institute on New York City’s Upper East Side, since 1945 to the present day a centre of excellence in the treatment and psychological support of cancer patients and their families. Its Meaning-Centred Psychotherapy programs, led by Dr. William Breitbart and his team, were originally inspired by the above-outlined ideas of Viktor Frankl (1988, 1997) as well as by group psychotherapy techniques implemented by the American psychiatrist Irvin Yalom (Yalom & Greaves, 1977; Yalom, 1980).
The Sloan Kettering’s existential approach to individual and group psychotherapy (Breitbart & Poppito, 2014a, b) seems to be particularly effective at fostering coping skills (Lazarus & Folkman, 1984; Park & Folkman, 1997) in patients who suffer from chronic and terminal disease. This kind of psycho-spiritual therapeutic intervention, centred on the patients’ search for meaning, has been proved to have relevant influence in oncology and palliative care (Greenstein & Breitbart, 2000; Noguchi et al., 2006; Mangione, 2013; Rosenfeld et al., 2017).
Breitbart’s key insight was that, although clinical observation had long picked up on the importance of a sense of meaningfulness throughout the entire course of an illness, most of the available scientific evidence concerned types of treatment that were more focused on symptoms reduction (especially anxiety and depression). Hence the need to empirically investigate the role of searching for meaning in the illness stories of cancer patients, as well as the psychological support strategies that might be implemented to facilitate this quest. Following in the tradition of certain pioneering studies (Zuehlke & Watkins, 1975; Lazer, 1984), Breitbart and his staff initiated an intensive therapeutic and research program, with the aim of developing a meaning-centred method targeting individuals and groups. Their studies on the effectiveness of these interventions (Breitbart et al., 2010, 2012) have been widely acknowledged internationally as having significantly contributed to the development of psycho-oncology.
Group therapy appears to be particularly appropriate for cancer patients, perhaps due to the nature of the process through which meaning is sought, which entails the exercise of doubt, Socratic dialogue and shared reflection. The intervention format is basically quite simple:
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Presentation of the philosophical theory of existential meaning on which the therapy is based.
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Experiential exercises and homework.
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Group discussion with feedback from the therapist.
The patients are invited to read selected passages from Man’s Search for Meaning (Frankl, 2006) starting from the first session. The notion of meaning invoked is similar to that outlined by Reker and Wong (1988, p. 221), namely ‘the cognizance of order, coherence and purpose in one’s existence, the pursuit and attainment of worthwhile goals, and an accompanying sense of fulfilment’.
The aims of the therapeutic work may therefore be summarized as follows:
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Exploring, based on autobiographical retrospection, the sources of meaning in one’s life.
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Becoming aware of one’s personal way of interpreting and facing suffering.
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Identifying meaningful existential goals and consolidating one’s capacity to adopt a constructive attitude towards life, despite illness.
Individual and group meaning-centred psychotherapy is therefore a kind of existential intervention, whose aim is to reaffirm the ethical responsibility of the patients towards their personal condition; life can be lived passively, like an imposed fate, or actively assumed as a challenge to make what is still possible and—above all—an opportunity to become a better person. This (although implicit) reference to the good is what allows us to address it as an ethics-based care practice.
In Italy, LAEOn (Logotherapy and Existential Analysis in Oncology) groups have been introduced by Dr. Luciana Murru at the Clinical Psychology Unit of the National Cancer Institute in Milan, a treatment centre originally set up in 1928. Their aim is to help patients to manage the psychological issues stemming from their illness, and also (and especially) to foster in them the paradoxical growth process that they can attain to the extent that they effectively integrate the illness in their life stories, without writing it off as meaningless.
The program consists of a preliminary individual session and five group sessions held weekly for about 2 h. Each encounter is divided into three parts: explaining the theory underpinning Frankl’s principles for seeking meaning, individual exercises, sharing and final feedback from the therapist. Between sessions, participants are invited to complete homework assignments.
These include, among others:
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reflecting on their personal lifeline and the sources of meaning they have experienced;
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identifying resilience mentors in people who are role models for them in terms of how they have handled difficult situations;
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seeking out personal resources (values, experiences, competences) that have remained healthy despite their disease;
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sharing life lessons learned from the experience of being ill;
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and imagining their future lives and formulating plans and goals.
These elicitation techniques, together with the well-known power of groups to unite and encourage, have been shown to reduce participants’ sense of loneliness and loss of control over their lives and to foster positive aspects (self-awareness, initiative, inner strength, deeper relationships, greater appreciation of the small things in life, confidence in the future).
The literature on post-traumatic growth (Tedeschi et al., 1998; Prati & Pierantoni, 2006) suggests that experiencing illness can stimulate positive changes in patients’ self-perceptions, interpersonal relationships and existential priorities. Empirical evidence shows that personal growth following cancer is experienced by 50–90% of patients (Stanton et al., 2006). A study conducted on a sample of 39 patients who took part in LAEOn groups between November 2008 and February 2010 (Murru et al., 2013) and, later, extended to 65 patients until May 2013 (Murru et al., 2014) confirmed the effectiveness of meaning-centred group therapy in enhancing participants’ psychological well-being and quality of life, accompanied by a decreasing of symptoms of depression and anxiety, as measured by a battery of research tools.Footnote 7 Above all, those showing at the beginning low meaning fulfilment and high search for meaning (usually associated to distress situations) moved towards high meaning fulfilment and low search for meaning. These gains apparently were stronger after 18 months. This means that probably this kind of intervention needs a longer time to achieve deeper change. Some of them died before that date. Nevertheless, they died struggling to preserve their dignity and to find a way of leading a life worth living, despite their destiny. Which is probably the highest ethical purpose of human existence: turning evil into good, somehow, and facing the transitoriness of human condition without succumbing to nihilism and despair.
Conclusions
Illness often represents a disruption of patients’ life course. The extent to which being ill can destabilize their existence depends on whether or not they are able to integrate this experience into their life stories. Indeed, illness threatens to undermine a person’s sense of meaning, seriously interfering with their desires and existential projects. When cancer or terminal patients are taken into care, it is crucial to attend to their meaning-making processes and to help them deal with their suffering in such a way that their existence can continue to be meaningful for them in spite of everything.
Individual and group existential psychotherapy projects conducted with cancer patients in different countries have shown that guiding patients to explore the existential dimensions of their illness and to seek purpose in their lives can enhance their psychological well-being and help them to combat existential frustration and sense of meaninglessness, while also helping to prevent the onset of anxiety or depression syndromes.
The Austrian psychiatrist Viktor Frankl was a forerunner in the field of meaning-centred therapy; he was the first to develop a theory of motivation focused on the will to meaning and the characteristically human capacity to find meaning in life even in apparently desperate situations. His proposal for a ‘medical care of the soul’ (Frankl, 2010b) is rooted in an understanding of humans as spiritual beings oriented towards the fulfilment of purposes and values. From this anthropological standpoint, it is possible to redefine the boundaries of care as ethics-based, in that caring for patient’s demands engaging with their individual frameworks of meaning and hierarchy of values, and helping them, not only to cope with their illnesses but above all to appreciate life up to their very last breath.
Notes
- 1.
The issue of sense and non-sense in wounded existences also directly concerns healthcare practitioners, given that they are continuously in contact with suffering and the questions that stem from it. For them too, searching for meaning is a primary need: it is precisely in the face of an unavoidable destiny (and the limits of one’s power to change it) that the most radical questions pose themselves (Natoli, 1986). Hence, healthcare professionals’ initial and continuing education should recognize, make explicit, and explore this demand for meaning, thereby helping them to cultivate a reflexive attitude and emotional competence as core components of their professional ethics (for further details cf. Bruzzone & Musi, 2007; Bruzzone, 2014, 2020; Bruzzone & Zannini, 2021).
- 2.
Logo-therapy (from lógos, meaning) literally means “healing through meaning” (Frankl, 2010a, p. 125).
- 3.
Frankl was deported with his family in 1942, initially to the “model ghetto” of Theresienstadt, in Bohemia. In October 1944, he was transferred with his first wife, Tilly, to Auschwitz-Birkenau, where he fortunately passed Dr. Mengele’s strict selection process, and after a few days way sent on to Bavaria, first to Türkheim and later to Kaufering III (a subcamp of Dachau), where he remained until the liberation of April 1945. The Viennese psychiatrist lost his father, mother, brother and first wife, as well as a large number of friends in the concentration camps. After his return to Vienna, he was appointed Head of Neurology and Psychiatry at the General Hospital, a position that he held until 1970. His first books Ärztliche Seelsorge and Ein Psycholog erlebt das Konzentrationslager were first published in 1946. The last one, which was first translated into English on the initiative of Gordon W. Allport in 1959 under the title From Death-Camp to Existentialism, subsequently became a bestseller under the alternative title of Man’s Search for Meaning (1963) with millions of copies sold. This brought Frankl international fame and he was awarded a total of 27 honoris causa degrees over the remainder of his lifetime. He died on 2 September 1997.
- 4.
This book has recently been translated into English under the title Yes to Life: In Spite of Everything (Frankl, 2020).
- 5.
The collected writings of the young Viktor Frankl, published between 1923 and 1942, were first recollected in Italian under the editorship of Prof. Eugenio Fizzotti, and only subsequently in German and other languages. In this paper, I cite from that first edition (translations to English my own).
- 6.
Frankl’s anthropological outlook was primarily informed by Max Scheler’s phenomenology, to the extent of defining his logotherapy as “the result of an application of Max Scheler’s concepts to psychotherapy” (Frankl, 1988, p. 10). The relationship between phenomenology and logotherapy can’t be analysed here, however (for further details see Bruzzone, 2007; about Scheler’s notion of ‘spirit’, see Lehmann & Klempe, 2015). Frankl was also significantly influenced by the existential analysis of Martin Heidegger and Ludwig Binswanger, with whom he kept up a constant dialogue and long-term friendship (the correspondence between Frankl and Binswanger is reconstructed and commented in Bruzzone, 2007, pp. 61–94).
- 7.
Purpose in Life Questionnaire (PIL), Seeking of Noetic Goals Test (SONG), Sense of Coherence Scale (SOC), Mental Adjustment to Cancer—reduced version (Mini-MAC), Hospital Anxiety and Depression Scale (HADS), Psychological Well-Being Scale (PWB).
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Bruzzone, D. (2021). Meaning-Oriented Counselling and Psychotherapy as an Ethics-Based Care Practice: Logotherapy and Existential Analysis with Cancer Patients. In: Knizek, B.L., Klempe, S.H. (eds) Foundation of Ethics-Based Practices. Annals of Theoretical Psychology, vol 18. Springer, Cham. https://doi.org/10.1007/978-3-030-83666-5_7
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