J o u r n a l of Religion and Health, Vol. 30, No. 2, S u m m e r 1991
Franklian Treatment With Vietnam Veteran Couples J I M LANTZ ABS T R AC T : In this article, the F r a n k l i a n t r e a t m e n t method of existential reflection is described as it can be used in m a r i t a l therapy with V i e t n a m veterans. The author also provides information about t r e a t m e n t results with twenty-three Vietnam veteran couples from 1974 to 1987.
The primary task of the therapist in Franklian treatment is to help the client discover, rediscover, and/or create a sense of meaning in life. 1 In this paper I outline a Franklian approach to marital treatment that I believe can be very helpful to the Vietnam veteran and the veteran's spouse. I started using this Franklian approach in my private practice with Vietnam veteran couples because of my belief that the existential concepts of Viktor Frankl, 2 which had been found effective with death camp survivors, might be equally helpful to other survivors of terror such as the Vietnam veteran and the veteran's spouse. I first started treating Vietnam veteran couples in my private practice in 1974 in response to a veteran's request that I see him and his wife privately because he did not view the staff at the local mental health system as capable of protecting his records and confidentiality. He did not trust "government agencies" and wished to be seen in a private practice setting where "it's just you and me and my wife." This initial Vietnam veteran couple later referred other veteran couples who also referred Vietnam veteran couples to me over the years. Between 1974 and 1987 I worked with twenty-three Vietnam veteran couples in my private practice. Since 1987 I have agreed to work with five other Vietnam veteran couples, but this work is not included here as I have yet to terminate treatment with some of them and have not yet completed the two-year follow-up with the veteran couples who have terminated t r e a t m e n t since 1987. Information about the twenty-three Vietnam veteran couples seen between 1974 and 1987 is summarized in Table 1. J i m Lantz, Ph.D., is a faculty m e m b e r at The Ohio State University College of Social Work, and Director of the Worthington Marital Therapy Institute. 131
9 1991 Institutes of Religionand Health
69 1 84 93 58 3 46 108 1 94 82 4 61 124 98 43 1 79 43 26 53 87 93
Hrs of Srv M M M F M M M M M F M M F M M M M M M F M M M
Sex of Vet M, F , I M M, F , I M, F , I M, F , I M,I M, F, I, Md M, F, I, Md M M, F, I, Md M, F , I M,I M, F , I M, F , I M, F , I , H M, F , I , H M M, F , I , H M, F, I, Md M, F , I M, F , I , H M, F , I , Md M, F , I
Type of Srv I, M, F, H or Md
Individual Therapy Marital Therapy Family Treatment Hospital Admission (short term) Medications utilized during t r e a t m e n t Dropped out of t r e a t m e n t against professional advice Service
KEY
1974-77 1974 1975-78 1975-79 1976-77 1976 1977-79 1978-83 1979 1979-83 1980-84 1980 1981-82 1981-86 1981-85 1982-83 1982 1982-86 1983-84 1984-85 1985-87 1985-87 1985-87
1 *2 3 4 5 *6 7 8 *9 10 11 "12 13 14 15 16 "17 18 19 20 21 22 23
= = = = = = =
Yrs of Service
Client Number
I M F H Md * Srv
1
W
H W A B C D
= = = = = =
118 No 117 114 118 No 119 113 No 117 119 No 113 118 124 122 No 121 118 124 116 117 119
119 Data 123 117 123 Data 118 116 Data 126 120 Data 118 115 124 118 Data 115 119 124 117 118 123
PIL: Termination H W
Husband Wife Things are worse No improvement Some improvement Considerable improvement
84 92 No Data 64 99 99 76 88 104 76 84 94 108 97 103 No Data 95 84 101 107 71 92 93 106 78 94 86 107 95 110 No Data 104 110 96 107 113 94 98 104 74 103 89 97
H
PIL at Intake 118 116 No Data 124 118 122 121 116 118 No Data 118 116 126 114 No Data 124 128 112 116 No Data 119 121 114 112 122 115 117 113 No Data 126 116 114 113 124 118 112 112 118 113 115 118
PIL: 1 yr Followup H W 121 No 118 120 116 No 113 115 No 118 114 No 113 114 112 122 No 119 116 121 118 116 113
118 Data 120 118 121 Data 113 115 Data 124 118 Data 116 113 120 114 Data 114 118 118 115 117 119
PIL: 2 yrs. Followup H W
I n f o r m a t i o n P r o f i l e o f a b o u t 23 V i e t n a m V e t e r a n C o u p l e s T r e a t e d b e t w e e n 1974 a n d 1987
TABLE
D C No Data D D D D D D A A D D D D No Data D D D D A A D D D D C C D C No Data D D D D C D D D D C D D
Client's View of Service
Jim Lantz
133
When I first started working with Vietnam couples, my understanding of their t r e a t m e n t needs was based primarily upon my initial knowledge of Viktor Frankl's logotherapy treatment with concentration camp survivors ~ which I had gleaned through reading and by attending one workshop with Dr. Frankl. When I first was working with Vietnam veteran couples (1974), I also discovered and read some of the initial work published by Lifton 4 and Shatan2 It appeared to me that Frankl, Lifton, and Shatan were saying very similar things from somewhat different theoretical positions. It seemed to me that both Lifton and Shatan were confirming Frankl's earlier discovery that a person's painful reactions to terror and horror can be transformed through the person's discovery and realization of self-transcendent meaning opportunities embedded in the survivor's memory of terror. 7 1 felt that Lifton's and Shatan's descriptions of Vietnam veteran self-help groups were excellent examples of Frankl's concept of meaning awareness through self-transcendence 8 and that these self-help groups also illustrated Frankl's belief that it is important to help the victim of terror turn survivor's guilt into survivor's responsibility. 9
The denial and repression of terror Both denial and repression are common coping methods used by many victims of terror. '~ These two coping methods have both a positive and a negative side. On the positive side, they keep us from directly experiencing the pain of terror. On the negative side, they also keep us from discovering or experiencing the meaning potentials that are always connected to and embedded in the experience of terror. In such a Franklian understanding of repression, denial, and terror, even the terror of a Nazi death camp includes meaning potentials to be realized and discovered on a conscious level of awareness.ll This Franklian understanding of repression, denial, and terror is illustrated in Figure 1. Figure 1 shows that terror that has been repressed or denied also includes meaning potentials pulled into the unconscious through the denial and/or repression of terror22 From this Franklian point of view, helping the Vietnam veteran recover the awareness of terror can also help the veteran recover meaning potentials embedded in the memory of terror23 From such a point of view, flashbacks and intrusive memories can be understood as a method the Vietnam veteran uses to start a search for meaning potentials embedded in the memory of terror. ~4 The recovery of meaning potentials embedded in terror is an extremely painful process for the Vietnam veteran, the veteran's spouse, and even for the therapist2 ~ On the other hand, the recovery of meaning potentials to consciousness can trigger extremely powerful and positive treatment results. ~ This is especially true when memories and meaning potentials are recovered
134
Journal of Religion and Health
FIGURE 1
REPRESSED
Repressed Meaning Potentials Hidden in Terror
TERROR
"with" the spouse in conjoint treatment. '7 The recovery of terror to consciousness without a connected recovery of meaning potentials is extremely dangerous and non-productive, and simply rehearses the person's feelings of terror. is The process of helping clients recover meaning potentials to consciousness is labeled as Socratic questioning by Dr. FrankW and is called "existential reflection" by some of his followers. 2~
Existential reflection When using existential reflection in conjoint marital therapy, the therapist uses questions, comments, clarification, empathy, interpretations, and sincere personal interest to help the client couple get in touch with meanings and meaning potentials embedded in the couple's meaning unconsciousY 1 Existential reflection in Franklian treatment appears to be similar to the circular questioning methods of the Milan Systemic Group and has also been described as somewhat similar to the Zen koanY In the Milan approach, the
J i m Lantz
135
therapist uses questions to introduce new information into the client system, so that resistance is bypassed. In Franklian intervention, on the other hand, existential reflection is used to help the client system make new meaning connections that enhance meaning awareness. 23
Pacing and safety Helping the Vietnam veteran couple recover to conscious awareness meaning potentials that are embedded in the memory of terror is not an easy or safe treatment process. The couple will resist such existential reflection until they are sure that the therapist can safely and empathically help them manage the material that emerges in this treatment approach. The couple will insist that existential reflection not "go too fast" so that they do not get "overwhelmed" by the emerging memories of terror. At times, short-term inpatient hospitalization at a safe and adequate treatment facility can assist in the process of existential reflection; and, at times, medication prescribed by a psychiatrist who does not confuse post-traumatic stress syndrome with either schizophrenia or a character disorder problem can be a helpful adjunct to treatment. The Vietnam veteran couple will simply not be willing to engage in existential reflection unless they feel sure that the therapist truly believes in the potential for meaning discovery embedded in the veteran's repressed memories of terror and that the therapist will not "run away" at the sound of "incoming terror."
A case illustration of existential reflection Bob served in combat in Vietnam during 1966 and 1967. He returned home, married Mary, and finished college in 1971. Bob's son, Bob Jr., was born in 1970. Bob reported that he had "no problems" adjusting to civilian life after returning home from Vietnam. After being home for fifteen years, Bob started having flashbacks and intrusive memories about his time in Vietnam. He had "strange partial memories" at night. Bob was afraid to talk to Mary about these experiences. He reported that he "did not want to remember more" and that he did not want to tell Mary what he had remembered because "she might leave me." Bob and Mary were seen in marital treatment in 1983 and in 1984. During this period, existential reflection helped the couple discover and remember that Bob had killed a young Viet Cong soldier whom Bob believed to be "about the same age as my son." Bob and Mary learned that Bob Jr.'s thirteenth birthday triggered Bob Sr.'s flashbacks and intrusive memories. The couple were eventually able to use this "horrible memory" as a basis for self-transcendence and meaning discovery through improved parenting
136
Journal of Religion and Health
with Bob Jr. and through volunteering at a youth activity center for underprivileged children. A very moving moment in treatment came when Bob and Mary gave a funeral "in honor" of the young Viet Cong soldier. In this ceremony the couple "bonded" with their newly discovered meanings and self-transcendent activities "in honor" of the dead young soldier. Bob reported that "telling Mary my memories" in marital treatment and seeing that "she didn't leave me" was a "profound relief." Bob reports that he now feels "more married than ever."
What I have learned From 1974 to the present, my basic approach to Franklian treatment with Vietnam veteran couples has not changed a great deal. Although I now frequently use other intervention methods, such as network intervention to increase meaning opportunities in the Vietnam veteran couple's environment and social skills training to help the couple improve communication and learn to make better use of meaning opportunities that do exist in the social environment, existential reflection still seems to me to be the most useful, important, and primary curative factor. ~4 In Table 1 the reader can notice that I saw 23 Vietnam veteran couples in Franklian marital treatment from 1974 to 1987. Of the twenty-three couples, five couples dropped out of treatment between the first and fifth treatment session, and I was not able to get systematic treatment or follow-up data on them. In my opinion I lost these five dropout couples because I moved too fast and "overwhelmed" them before we had a good treatment relationship. The other eighteen couples did stay in treatment. Table 1 shows the Purpose in Life Test scores for both members of the Vietn a m veteran couple at intake, at termination, at the one-year follow-up and at the two-year follow-up evaluation. The Purpose in Life (PIL) Test is a psychometric test developed by Crumbaugh and Maholick 25 which measures the client's sense of meaning in life or the client's experience of an existential or meaning vacuum. A score of 112 or above is a good indication that the subject has discovered and is experiencing a sense of meaning in life. A score of 92 or less is a good indication that the subject is experiencing an existential or meaning vacuum. A score of 93 to 111 is considered a good indication that the subject is in danger of experiencing an existential or meaning vacuum. The lowest possible score on the PIL test is 20, and the highest possible score is 140. The reader will notice that the eighteen couples who stayed in treatment showed excellent improvement in meaning awareness at termination and in follow-up evaluations, as this meaning awareness is measured by an increase in PIL test scores. In my opinion Franklian treatment with Vietnam veteran couples is not particularly helpful on a short-term basis. Table 1 shows that almost all of
J i m Lantz
137
the eighteen veteran couples stayed in treatment for over two years and that most of them received over sixty hours of treatment. In my opinion all of these couples decided to work on life directional change rather than simple symptom control. Although Dr. Frankl ~ would probably disagree, in my opinion such a directional change is "generally" not achieved in short-term treatment. In my experience Franktian marital treatment does not mean that the couple should "always" be seen together in a conjoint interview. Column 5 in Table 1 shows that individual, marital, and family interviews were used with almost all of the eighteen Vietnam veteran couples that stayed in treatment. The reader is asked to notice that starting in 1983 (that is, with clients 15, 16, 18, and 21) I started using short-term inpatient hospitalization to facilitate existential reflection in a few selected instances. I started using hospitalization after I had developed a good working relationship with an excellent private psychiatric hospital in Worthington, Ohio, and a good working relationship with the director of its short-term emergency unit. Clients 7, 8, 10, 19, and 22 found medication to be helpful in "facilitating" existential reflection. None of these clients were given major tranquilizers by my consulting psychiatrist, who is very able to tell the difference between schizophrenia and post-traumatic stress disorder. Three of the five medication clients went on anti-depression medication, and all five medication clients were "carefully" provided with minor tranquilizers on a "short-term" basis to overcome sleep disturbance problems. All eighteen couples (36 clients) reported that there had been either some improvement or considerable improvement at termination.
Countertransference From a Franklian point of view, the occurrence of countertransference feelings when working with victims of terror is a good sign that the therapist is aliveY Not to have painful and uncomfortable feelings in reaction to the "stories" of Vietnam veterans during the process of existential reflection is, in my opinion, a good indication that the therapist has a character disorder, or it is an indication that the therapist is also repressing an experience of terror. I believe that Frankl, Lifton, and Shatan would probably agree with this point. Occasionally the therapist will not feel pain in reacting to a veteran's story of terror because the story is not true and the veteran is telling the story to "test" the therapist. In my opinion the therapist's beginning "inside pain" in reaction to content manifestations of terror during the treatment sessions is a good indication that the couple are starting to recover meaning potentials to awareness in the memories of terror. If the therapist disrupts the process of "remembering" terror to handle his or her inside, countertransference pain, the therapist will also be disrupting the couple's search for meaning. The
138
Journal of Religion and Health
therapist's ability to tolerate and transform inside pain into empathy for the Vietnam veteran couple is a good sign that the therapist is well on the way to doing a good job of helping the couple discover meaning and meaning potentials for the future in the "Vietnam past. ''2s
References 1. Frankl, V., "Logos and Existence in Psychotherapy," American J. Psychotherapy, 1953, 7, 1, 8-15. 2. _ _ , The Doctor and the Soul. New York, Alfred Knopf, 1965. 3. _ _ , "From Psychotherapy to Logotherapy," Pastoral Psychology, 1955, 7, 2, 56-60. 4. Lifton, R., Home from the War. New York, Simon and Schuster, 1973. 5. Shatan, C., "The Grief of Soldiers: Vietnam Combat Veterans' Self Help Movement," Amer. J. Orthopsychiatry, 1973, 43, 4, 640-653. 6. Frankl, V., From Death Camp to Existentialism. Boston, Beacon Press, 1959. 7. _ _ , The Unconscious God. New York, Simon and Schuster, 1978. 8. _ _ , The Will To Meaning. New York, New American Library, 1969. 9. ., "On Logotherapy and Existential Analysis," Amer. J. Psychoanalysis, 1957, 18, 1, 28-37. 10. Lindy, J., Vietnam: A Casebook. New York, Brunner/Mazel, 1988. 11. Frankl, V., "Group Psychotherapeutic Experiences in a Concentration Camp," Group Psychotherapy, 1954, 7, 2, 81-99. 12. Lantz, J., "Family Logotherapy," Contemporary Family Therapy, 1986, 8, 3, 124-135. 13. ., "The Use of Frankl's Concepts in Family Therapy," J. Independent Social Work, 1987, 2, 2, 65-80. 14. Williams, C., "The Mental Foxhole: The Vietnam Veteran's Search for Meaning," Amer. J. Orthopsychiatry, 1983, 53, 1, 4-17. 15. Lantz, J., Family and Marital Therapy. New York, Appleton-Century-Crofts, 1978. 16. Frankl, V., The Unheard Cry for Meaning. New York, Simon and Schuster, 1979. 17. Lantz, J., "Existential Reflection in Marital Therapy with Vietnam Veterans," J. Couples Therapy, in press. 18. Lantz, J., and Greenlee, R., "Logotherapy and the Vietnam Veteran," International Forum for Logotherapy, in press. 19. Frankl, V., "Basic Concepts of Logotherapy," J. Existential Psychiatry, 1962, 3, 3, 111-118. 20. Lantz, J., and Lantz, J., "Meaning, Tragedy and Logotherapy with the Elderly," J. Religion and Aging, 1989, 5, 1, 43-51. 21. Lantz, J., and Harper, K., "Anomic Depression and the Migrating Family," Contemporary Family Therapy, 1990, 12, 2, 153-163. 22. Lantz, J., "Family Logotherapy with an Ovel~veight Family," Contemporary Family Therapy, 1989, 11, 4, 287-297. 23. Lantz, J., and Harper, K., "Network Intervention, Existential Depression and the Relocated Appalachian Family," Contemporary Family Therapy, 1989, 11, 3, 213-223. 24. Lantz, J., and Pegram, M., "Casework and the Restoration of Meaning," Social Casework, 1989, 70, 8, 549-555. 25. Crumbaugh, J., and Maholick, L., "An Experimental Study in Existentialism: The Psychometric Approach to Frankl's Concept of Noogenic Neurosis," J. Clinical Psychology, 1964, 20, 4, 200-207. 26. Frankl, V., "Determinism and Humanism," Humanitas, 1971, 7, 1, 23-36. 27. Lantz, J., "Logotherapy and the Person of the Therapist," International Forum for Logotherapy, 1986, 9, 1, 29-32. 28. Lantz, J., and Greenlee, R., "Existential Social Work with Vietnam Veterans," J. Independent Social Work, in press.
Franklian Treatment With Vietnam Veteran Couples J I M LANTZ ABS T R AC T : In this article, the F r a n k l i a n t r e a t m e n t method of existential reflection is described as it can be used in m a r i t a l therapy with V i e t n a m veterans. The author also provides information about t r e a t m e n t results with twenty-three Vietnam veteran couples from 1974 to 1987.
The primary task of the therapist in Franklian treatment is to help the client discover, rediscover, and/or create a sense of meaning in life. 1 In this paper I outline a Franklian approach to marital treatment that I believe can be very helpful to the Vietnam veteran and the veteran's spouse. I started using this Franklian approach in my private practice with Vietnam veteran couples because of my belief that the existential concepts of Viktor Frankl, 2 which had been found effective with death camp survivors, might be equally helpful to other survivors of terror such as the Vietnam veteran and the veteran's spouse. I first started treating Vietnam veteran couples in my private practice in 1974 in response to a veteran's request that I see him and his wife privately because he did not view the staff at the local mental health system as capable of protecting his records and confidentiality. He did not trust "government agencies" and wished to be seen in a private practice setting where "it's just you and me and my wife." This initial Vietnam veteran couple later referred other veteran couples who also referred Vietnam veteran couples to me over the years. Between 1974 and 1987 I worked with twenty-three Vietnam veteran couples in my private practice. Since 1987 I have agreed to work with five other Vietnam veteran couples, but this work is not included here as I have yet to terminate treatment with some of them and have not yet completed the two-year follow-up with the veteran couples who have terminated t r e a t m e n t since 1987. Information about the twenty-three Vietnam veteran couples seen between 1974 and 1987 is summarized in Table 1. J i m Lantz, Ph.D., is a faculty m e m b e r at The Ohio State University College of Social Work, and Director of the Worthington Marital Therapy Institute. 131
9 1991 Institutes of Religionand Health
69 1 84 93 58 3 46 108 1 94 82 4 61 124 98 43 1 79 43 26 53 87 93
Hrs of Srv M M M F M M M M M F M M F M M M M M M F M M M
Sex of Vet M, F , I M M, F , I M, F , I M, F , I M,I M, F, I, Md M, F, I, Md M M, F, I, Md M, F , I M,I M, F , I M, F , I M, F , I , H M, F , I , H M M, F , I , H M, F, I, Md M, F , I M, F , I , H M, F , I , Md M, F , I
Type of Srv I, M, F, H or Md
Individual Therapy Marital Therapy Family Treatment Hospital Admission (short term) Medications utilized during t r e a t m e n t Dropped out of t r e a t m e n t against professional advice Service
KEY
1974-77 1974 1975-78 1975-79 1976-77 1976 1977-79 1978-83 1979 1979-83 1980-84 1980 1981-82 1981-86 1981-85 1982-83 1982 1982-86 1983-84 1984-85 1985-87 1985-87 1985-87
1 *2 3 4 5 *6 7 8 *9 10 11 "12 13 14 15 16 "17 18 19 20 21 22 23
= = = = = = =
Yrs of Service
Client Number
I M F H Md * Srv
1
W
H W A B C D
= = = = = =
118 No 117 114 118 No 119 113 No 117 119 No 113 118 124 122 No 121 118 124 116 117 119
119 Data 123 117 123 Data 118 116 Data 126 120 Data 118 115 124 118 Data 115 119 124 117 118 123
PIL: Termination H W
Husband Wife Things are worse No improvement Some improvement Considerable improvement
84 92 No Data 64 99 99 76 88 104 76 84 94 108 97 103 No Data 95 84 101 107 71 92 93 106 78 94 86 107 95 110 No Data 104 110 96 107 113 94 98 104 74 103 89 97
H
PIL at Intake 118 116 No Data 124 118 122 121 116 118 No Data 118 116 126 114 No Data 124 128 112 116 No Data 119 121 114 112 122 115 117 113 No Data 126 116 114 113 124 118 112 112 118 113 115 118
PIL: 1 yr Followup H W 121 No 118 120 116 No 113 115 No 118 114 No 113 114 112 122 No 119 116 121 118 116 113
118 Data 120 118 121 Data 113 115 Data 124 118 Data 116 113 120 114 Data 114 118 118 115 117 119
PIL: 2 yrs. Followup H W
I n f o r m a t i o n P r o f i l e o f a b o u t 23 V i e t n a m V e t e r a n C o u p l e s T r e a t e d b e t w e e n 1974 a n d 1987
TABLE
D C No Data D D D D D D A A D D D D No Data D D D D A A D D D D C C D C No Data D D D D C D D D D C D D
Client's View of Service
Jim Lantz
133
When I first started working with Vietnam couples, my understanding of their t r e a t m e n t needs was based primarily upon my initial knowledge of Viktor Frankl's logotherapy treatment with concentration camp survivors ~ which I had gleaned through reading and by attending one workshop with Dr. Frankl. When I first was working with Vietnam veteran couples (1974), I also discovered and read some of the initial work published by Lifton 4 and Shatan2 It appeared to me that Frankl, Lifton, and Shatan were saying very similar things from somewhat different theoretical positions. It seemed to me that both Lifton and Shatan were confirming Frankl's earlier discovery that a person's painful reactions to terror and horror can be transformed through the person's discovery and realization of self-transcendent meaning opportunities embedded in the survivor's memory of terror. 7 1 felt that Lifton's and Shatan's descriptions of Vietnam veteran self-help groups were excellent examples of Frankl's concept of meaning awareness through self-transcendence 8 and that these self-help groups also illustrated Frankl's belief that it is important to help the victim of terror turn survivor's guilt into survivor's responsibility. 9
The denial and repression of terror Both denial and repression are common coping methods used by many victims of terror. '~ These two coping methods have both a positive and a negative side. On the positive side, they keep us from directly experiencing the pain of terror. On the negative side, they also keep us from discovering or experiencing the meaning potentials that are always connected to and embedded in the experience of terror. In such a Franklian understanding of repression, denial, and terror, even the terror of a Nazi death camp includes meaning potentials to be realized and discovered on a conscious level of awareness.ll This Franklian understanding of repression, denial, and terror is illustrated in Figure 1. Figure 1 shows that terror that has been repressed or denied also includes meaning potentials pulled into the unconscious through the denial and/or repression of terror22 From this Franklian point of view, helping the Vietnam veteran recover the awareness of terror can also help the veteran recover meaning potentials embedded in the memory of terror23 From such a point of view, flashbacks and intrusive memories can be understood as a method the Vietnam veteran uses to start a search for meaning potentials embedded in the memory of terror. ~4 The recovery of meaning potentials embedded in terror is an extremely painful process for the Vietnam veteran, the veteran's spouse, and even for the therapist2 ~ On the other hand, the recovery of meaning potentials to consciousness can trigger extremely powerful and positive treatment results. ~ This is especially true when memories and meaning potentials are recovered
134
Journal of Religion and Health
FIGURE 1
REPRESSED
Repressed Meaning Potentials Hidden in Terror
TERROR
"with" the spouse in conjoint treatment. '7 The recovery of terror to consciousness without a connected recovery of meaning potentials is extremely dangerous and non-productive, and simply rehearses the person's feelings of terror. is The process of helping clients recover meaning potentials to consciousness is labeled as Socratic questioning by Dr. FrankW and is called "existential reflection" by some of his followers. 2~
Existential reflection When using existential reflection in conjoint marital therapy, the therapist uses questions, comments, clarification, empathy, interpretations, and sincere personal interest to help the client couple get in touch with meanings and meaning potentials embedded in the couple's meaning unconsciousY 1 Existential reflection in Franklian treatment appears to be similar to the circular questioning methods of the Milan Systemic Group and has also been described as somewhat similar to the Zen koanY In the Milan approach, the
J i m Lantz
135
therapist uses questions to introduce new information into the client system, so that resistance is bypassed. In Franklian intervention, on the other hand, existential reflection is used to help the client system make new meaning connections that enhance meaning awareness. 23
Pacing and safety Helping the Vietnam veteran couple recover to conscious awareness meaning potentials that are embedded in the memory of terror is not an easy or safe treatment process. The couple will resist such existential reflection until they are sure that the therapist can safely and empathically help them manage the material that emerges in this treatment approach. The couple will insist that existential reflection not "go too fast" so that they do not get "overwhelmed" by the emerging memories of terror. At times, short-term inpatient hospitalization at a safe and adequate treatment facility can assist in the process of existential reflection; and, at times, medication prescribed by a psychiatrist who does not confuse post-traumatic stress syndrome with either schizophrenia or a character disorder problem can be a helpful adjunct to treatment. The Vietnam veteran couple will simply not be willing to engage in existential reflection unless they feel sure that the therapist truly believes in the potential for meaning discovery embedded in the veteran's repressed memories of terror and that the therapist will not "run away" at the sound of "incoming terror."
A case illustration of existential reflection Bob served in combat in Vietnam during 1966 and 1967. He returned home, married Mary, and finished college in 1971. Bob's son, Bob Jr., was born in 1970. Bob reported that he had "no problems" adjusting to civilian life after returning home from Vietnam. After being home for fifteen years, Bob started having flashbacks and intrusive memories about his time in Vietnam. He had "strange partial memories" at night. Bob was afraid to talk to Mary about these experiences. He reported that he "did not want to remember more" and that he did not want to tell Mary what he had remembered because "she might leave me." Bob and Mary were seen in marital treatment in 1983 and in 1984. During this period, existential reflection helped the couple discover and remember that Bob had killed a young Viet Cong soldier whom Bob believed to be "about the same age as my son." Bob and Mary learned that Bob Jr.'s thirteenth birthday triggered Bob Sr.'s flashbacks and intrusive memories. The couple were eventually able to use this "horrible memory" as a basis for self-transcendence and meaning discovery through improved parenting
136
Journal of Religion and Health
with Bob Jr. and through volunteering at a youth activity center for underprivileged children. A very moving moment in treatment came when Bob and Mary gave a funeral "in honor" of the young Viet Cong soldier. In this ceremony the couple "bonded" with their newly discovered meanings and self-transcendent activities "in honor" of the dead young soldier. Bob reported that "telling Mary my memories" in marital treatment and seeing that "she didn't leave me" was a "profound relief." Bob reports that he now feels "more married than ever."
What I have learned From 1974 to the present, my basic approach to Franklian treatment with Vietnam veteran couples has not changed a great deal. Although I now frequently use other intervention methods, such as network intervention to increase meaning opportunities in the Vietnam veteran couple's environment and social skills training to help the couple improve communication and learn to make better use of meaning opportunities that do exist in the social environment, existential reflection still seems to me to be the most useful, important, and primary curative factor. ~4 In Table 1 the reader can notice that I saw 23 Vietnam veteran couples in Franklian marital treatment from 1974 to 1987. Of the twenty-three couples, five couples dropped out of treatment between the first and fifth treatment session, and I was not able to get systematic treatment or follow-up data on them. In my opinion I lost these five dropout couples because I moved too fast and "overwhelmed" them before we had a good treatment relationship. The other eighteen couples did stay in treatment. Table 1 shows the Purpose in Life Test scores for both members of the Vietn a m veteran couple at intake, at termination, at the one-year follow-up and at the two-year follow-up evaluation. The Purpose in Life (PIL) Test is a psychometric test developed by Crumbaugh and Maholick 25 which measures the client's sense of meaning in life or the client's experience of an existential or meaning vacuum. A score of 112 or above is a good indication that the subject has discovered and is experiencing a sense of meaning in life. A score of 92 or less is a good indication that the subject is experiencing an existential or meaning vacuum. A score of 93 to 111 is considered a good indication that the subject is in danger of experiencing an existential or meaning vacuum. The lowest possible score on the PIL test is 20, and the highest possible score is 140. The reader will notice that the eighteen couples who stayed in treatment showed excellent improvement in meaning awareness at termination and in follow-up evaluations, as this meaning awareness is measured by an increase in PIL test scores. In my opinion Franklian treatment with Vietnam veteran couples is not particularly helpful on a short-term basis. Table 1 shows that almost all of
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the eighteen veteran couples stayed in treatment for over two years and that most of them received over sixty hours of treatment. In my opinion all of these couples decided to work on life directional change rather than simple symptom control. Although Dr. Frankl ~ would probably disagree, in my opinion such a directional change is "generally" not achieved in short-term treatment. In my experience Franktian marital treatment does not mean that the couple should "always" be seen together in a conjoint interview. Column 5 in Table 1 shows that individual, marital, and family interviews were used with almost all of the eighteen Vietnam veteran couples that stayed in treatment. The reader is asked to notice that starting in 1983 (that is, with clients 15, 16, 18, and 21) I started using short-term inpatient hospitalization to facilitate existential reflection in a few selected instances. I started using hospitalization after I had developed a good working relationship with an excellent private psychiatric hospital in Worthington, Ohio, and a good working relationship with the director of its short-term emergency unit. Clients 7, 8, 10, 19, and 22 found medication to be helpful in "facilitating" existential reflection. None of these clients were given major tranquilizers by my consulting psychiatrist, who is very able to tell the difference between schizophrenia and post-traumatic stress disorder. Three of the five medication clients went on anti-depression medication, and all five medication clients were "carefully" provided with minor tranquilizers on a "short-term" basis to overcome sleep disturbance problems. All eighteen couples (36 clients) reported that there had been either some improvement or considerable improvement at termination.
Countertransference From a Franklian point of view, the occurrence of countertransference feelings when working with victims of terror is a good sign that the therapist is aliveY Not to have painful and uncomfortable feelings in reaction to the "stories" of Vietnam veterans during the process of existential reflection is, in my opinion, a good indication that the therapist has a character disorder, or it is an indication that the therapist is also repressing an experience of terror. I believe that Frankl, Lifton, and Shatan would probably agree with this point. Occasionally the therapist will not feel pain in reacting to a veteran's story of terror because the story is not true and the veteran is telling the story to "test" the therapist. In my opinion the therapist's beginning "inside pain" in reaction to content manifestations of terror during the treatment sessions is a good indication that the couple are starting to recover meaning potentials to awareness in the memories of terror. If the therapist disrupts the process of "remembering" terror to handle his or her inside, countertransference pain, the therapist will also be disrupting the couple's search for meaning. The
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therapist's ability to tolerate and transform inside pain into empathy for the Vietnam veteran couple is a good sign that the therapist is well on the way to doing a good job of helping the couple discover meaning and meaning potentials for the future in the "Vietnam past. ''2s
References 1. Frankl, V., "Logos and Existence in Psychotherapy," American J. Psychotherapy, 1953, 7, 1, 8-15. 2. _ _ , The Doctor and the Soul. New York, Alfred Knopf, 1965. 3. _ _ , "From Psychotherapy to Logotherapy," Pastoral Psychology, 1955, 7, 2, 56-60. 4. Lifton, R., Home from the War. New York, Simon and Schuster, 1973. 5. Shatan, C., "The Grief of Soldiers: Vietnam Combat Veterans' Self Help Movement," Amer. J. Orthopsychiatry, 1973, 43, 4, 640-653. 6. Frankl, V., From Death Camp to Existentialism. Boston, Beacon Press, 1959. 7. _ _ , The Unconscious God. New York, Simon and Schuster, 1978. 8. _ _ , The Will To Meaning. New York, New American Library, 1969. 9. ., "On Logotherapy and Existential Analysis," Amer. J. Psychoanalysis, 1957, 18, 1, 28-37. 10. Lindy, J., Vietnam: A Casebook. New York, Brunner/Mazel, 1988. 11. Frankl, V., "Group Psychotherapeutic Experiences in a Concentration Camp," Group Psychotherapy, 1954, 7, 2, 81-99. 12. Lantz, J., "Family Logotherapy," Contemporary Family Therapy, 1986, 8, 3, 124-135. 13. ., "The Use of Frankl's Concepts in Family Therapy," J. Independent Social Work, 1987, 2, 2, 65-80. 14. Williams, C., "The Mental Foxhole: The Vietnam Veteran's Search for Meaning," Amer. J. Orthopsychiatry, 1983, 53, 1, 4-17. 15. Lantz, J., Family and Marital Therapy. New York, Appleton-Century-Crofts, 1978. 16. Frankl, V., The Unheard Cry for Meaning. New York, Simon and Schuster, 1979. 17. Lantz, J., "Existential Reflection in Marital Therapy with Vietnam Veterans," J. Couples Therapy, in press. 18. Lantz, J., and Greenlee, R., "Logotherapy and the Vietnam Veteran," International Forum for Logotherapy, in press. 19. Frankl, V., "Basic Concepts of Logotherapy," J. Existential Psychiatry, 1962, 3, 3, 111-118. 20. Lantz, J., and Lantz, J., "Meaning, Tragedy and Logotherapy with the Elderly," J. Religion and Aging, 1989, 5, 1, 43-51. 21. Lantz, J., and Harper, K., "Anomic Depression and the Migrating Family," Contemporary Family Therapy, 1990, 12, 2, 153-163. 22. Lantz, J., "Family Logotherapy with an Ovel~veight Family," Contemporary Family Therapy, 1989, 11, 4, 287-297. 23. Lantz, J., and Harper, K., "Network Intervention, Existential Depression and the Relocated Appalachian Family," Contemporary Family Therapy, 1989, 11, 3, 213-223. 24. Lantz, J., and Pegram, M., "Casework and the Restoration of Meaning," Social Casework, 1989, 70, 8, 549-555. 25. Crumbaugh, J., and Maholick, L., "An Experimental Study in Existentialism: The Psychometric Approach to Frankl's Concept of Noogenic Neurosis," J. Clinical Psychology, 1964, 20, 4, 200-207. 26. Frankl, V., "Determinism and Humanism," Humanitas, 1971, 7, 1, 23-36. 27. Lantz, J., "Logotherapy and the Person of the Therapist," International Forum for Logotherapy, 1986, 9, 1, 29-32. 28. Lantz, J., and Greenlee, R., "Existential Social Work with Vietnam Veterans," J. Independent Social Work, in press.
