Suffering and Meaning in Life – Frankl, Maslow and Freud

There are not many books that purport to provide a measured response to the worst human tragedy of all time, as well as the meaning of life. The classic text, “Man’s Search for Meaning”, by Viktor Frankl, responds to this, but also provides a fascinating insight into a historical window of psychotherapy, what it could have been, and what it still can be.

The text comprises three parts. The first is astounding enough in its premise, as the account of a concentration camp prisoner during the Holocaust, who was also a psychiatrist. The account is strangely muted as well as graphic, alternating between humble recognition that there existed many other accounts that replicated the data, together with stark descriptions of suffering and unrelenting morbidity. Early on in the account, he describes how survival depended on striking bargains with, and even potentially becoming, one of the “Capos” – a “ruling class” of prisoners who had extra benefits, including a reduced risk of execution. Given the nature of what was necessary in order to protect oneself and one’s friends, he grimly notes “it is not the best of us that survived.”

The firsthand account is understandably harrowing. He notes in particular the number of people who succumbed to their situation, with the first casualty being their will to live. It was those whose philosophy failed, who would be least likely to survive.

The text also appropriately describes one of the most fundamental horrors of the Holocaust – how ordinary people were transformed into dispassionate murderers. He recalled a guard idly pointing prisoners in different directions as they walked past him, only later to realise the fate of those directed to the other side of the camp.

However, the author’s mission is not merely to demonise. He makes considerable effort to point out the humanity, however rare, that was occasionally present in his oppressors. The account, amidst the loss (the author’s wife, and most of his family, were lost in the tragedy) and struggles (he describes treating the sick and dying whilst himself suffering from typhoid fever, aware that his utility was a fundamental component of his own survival), gradually is increasingly marked with moments of beauty. He describes one point, when he provided a group psychotherapeutic intervention in the camp, which itself arose as a direct result of his trauma. A primary insight he attained, was that in the presence of abject suffering, there was an unparalleled potential for personal growth. The school of therapy he championed was named “Logotherapy”. I would not be disappointed if you hadn’t heard of it – I hadn’t either.

“We must never forget that we may also find meaning in life even when confronted with a hopeless situation, when facing a fate that cannot be changed…There are situations in which one is cut off from the opportunity to do one’s work or enjoy one’s life; but what can never be ruled out is the unavoidability of suffering. In accepting this challenge to suffer bravely, life has a meaning up to the last moment, and it retains this meaning literally to the end.”

It is in the second and third parts of the book, where logotherapy takes centre stage, following the undeniable personal and observed experiences that precede. He describes logotherapy as a dialogue with the intent making sense of a patient’s current experiences. As with many second wave psychotherapies, it arose as a rejoinder to deterministic developmental theory – he provides the example of the psychotherapy of an government official who had learned from his prior therapist that he sought repeatedly to seek authoritarian paternal figures in a re-experiencing of his adolescence, whereas Frankl’s approach was to recognise that the patient’s current dissatisfaction with life was simply due to being in the wrong career. There are interesting – and somewhat unsatisfying – perspectives, such as the management of panic attacks. In modern psychotherapy (following the teachings of cognitive behavioural therapy), panic attacks are understood as a response to an external trigger leading to the sympathetic nervous system being unnecessarily activated, and thus understanding the triggers and using supportive techniques (such as breathing techniques) help to reduce panic attacks. Frankl espouses logotherapy’s solution to the panic attack as one of encouraging the individual to attempt to pre-emptively provoke the panic attack prior to the offending trigger, thus nullifying the anticipatory anxiety. It’s a reasonably sensible trick, except I struggle to understand what that has to do with logotherapy. It also does not seem terribly reliable to myself. He does, fortunately, also recognise the inconsistency of this approach. The third part, written in 1980s, must have occurred following awareness of the early days of cognitive behavioural therapy, or perhaps might have been written in spite of it.

Maslow’s Hierarchy (published in 1943, whilst Frankl was still interred) is still cited today, in universities and journal clubs, as a foundation psychological theory. It describes the idea of a hierarchy of human needs – with physiological needs and safety being basic requirements that must be fulfilled, working one’s way to the elements that are at the top of the pyramid and are the “highest level” elements – issues of self-esteem and self-actualisation. You probably might have seen brightly coloured pictures of a triangle or pyramid, with “Self-actualisation” capping the top of the pyramid, either in a psychologist’s office or floating around the Internet. The history of this triangle is quite remarkable. Few are aware that Maslow was a proponent of what was called “gestalt therapy”  (named for “gestalt” as being a holistic therapy)- which, like logotherapy, emerged as a humanistic response against Freudian psychodynamic theory. Even fewer are aware that, for all of the apparent face validity of Maslow’s famous triangle, it has and always has had no actual evidence base beyond anecdotes- a major issue with gestalt theory as a whole. Many claim the same lack of evidence for many features of psychodynamic therapy, which I concede is accurate. It is one of those situations where both the prevailing therapy of the time (psychodynamic) and its opponent (gestalt) shared more similarities than either would care to admit to.

The issue, is that Maslow’s theory was formulated as a defense against the implications of the unconscious in the world of psychodynamic theory – that which has had far more opponents rather than champions. C.S. Lewis was a prominent author against it, and the academic conflict inspired a book, play and movie, pitting Christian moral responsibility against Freudian atheistic determinism. Logotherapy was written at about the same time. Both Gestalt and Logotherapy arose as a defense against the idea that we are primitive apes being driven by unconscious drives. It’s interesting how, in this circumstance at least, the enemy of my enemy is not my friend. It is also interesting to me to consider how these battlegrounds have since faded, with few being aware that the conflicts ever existed.

However, there remain some ideas which have somehow remained, like Maslow’s famous triangle. A construct several have championed, which was created by an antagonistic school of psychotherapy, without evidence. “Man’s Search for Meaning” stands as a considerable antithesis (to use the word correctly) against Maslow’s hierarchy. It suggests that a state of physiological debilitation, in itself, can lead to a potential for self-actualisation. Critics who state that Maslow’s hierarchy is not supposed to indicate an order for motivation are gently encouraged to read the original paper. There are profound insights from this idea of conversion of suffering into triumph, not least of which are the implications for patients with post traumatic stress disorder. Maslow’s ideas are used to explain why people with PTSD are unable to progress, as the state of vulnerability reduces one’s capacity for personal growth. Logotherapy suggests the opposite.

It also brings back to a more reflective, perhaps more scholarly time before pharmacotherapy meant that psychiatry became seen as a primarily pharmacological intervention, as patients are nowadays no longer booked for assessments but rather for “medication reviews”. Logotherapy dealt with no less than the meaning of life, by the simple doctrine that one generates meaning from one’s experiences. Which, I find striking. When was the last time any of us thought that the purpose of visiting the psychiatrist was to find meaning in life?

And yet, to be honest, I still find it unconvincing. It is an aesthetically beautiful and important concept to find meaning in suffering, but I feel it swings the pendulum too far to consider that suffering is essential.

To be fair, Frankl himself directly states this himself, but not in too convincing a fashion.

“But let me make it perfectly clear that in no way is suffering necessary to find meaning. I only insist that meaning is possible even in spite of suffering–provided, certainly, that the suffering is unavoidable. If it were avoidable, however, the meaningful thing to do would be to remove its cause, be it psychological, biological or political…”

Within that alone, a logical fallacy is obvious. If suffering generates meaning, but that suffering can be avoided, what does that say about the validity of any meaning obtained?

This is never discussed, although it lurks in the sidelines of the book like an inconvenient critic. A critical tragedy in the book is that Frankl struggled to remain alive out of a sense of hope for being reunited with his wife. However, unbeknownst to himself, his wife had perished early in his incarceration. Yet he considers that, even he were to be aware of the loss of his wife, this would not have significantly impacted his own search for meaning. My sense of sympathy for his situation prevents me from agreeing with him.

The text builds from his experiences to introduce the concepts of logotherapy. Out of the three fundamental tenets of logotherapy, is that meaning is identified in response to suffering (the other two being, in summary, achievement and love). This certainly makes sense in its position in psychotherapeutic history, but he also noted  its difficulty in application with specific psychiatric difficulties, such as depression – unless a challenge of meaning is present. It therefore strikes me as an important issue to be kept in mind, to fill out my formulation of patients. I have had several patients coming to me concerned that their perceived failures in life have been due to undiagnosed AD/HD. How many of them had a pathological philosophy towards their concept of meaning?

I’ve once seen written, and so far have been unable to find the original author, a perhaps more concise and balanced summation of the above conflicts. “All human beings strive for security and significance.” I suspect this to be truest, although it necessarily does not conflict with Frankl’s profound insights.

I have waxed lyrical on a classic text, no doubt one that many readers are already intimately aware of, and more familiar with. And I write this seated in my own supposedly modern clinic, between hearing the trials and traumas of patients. This invites reflection. We have three voices to consider – the Freudian, where we are driven by an unconscious shaped by adolescent experiences. Maslow, where we overcome trauma in order to achieve ultimate goals of dignity and identity. Frankl, where we find meaning in the suffering itself. All three of these voices, with powerful ideas, and yet remarkably…absent.

What struck me most about this text is that, after over a decade of being a psychodynamic psychotherapy supervisor, authoring several publications and hearing hundreds of lectures in the field, I had never heard of logotherapy before its chance discovery. I work with and supervise therapists on a daily basis, yet these ideas are rare to encounter in the field itself. There has been much written on what constitutes “Christian” therapy, and it is difficult to solidify, walking that tightrope between recognising the value of faith whilst avoiding the ethical quandaries (not to mention mandatory notifications) of evangelising to vulnerable individuals. Amidst all these questions of meaning, is the harsh reality of what I see – that so many patients are brought to our attention, with the idea that there is no meaning, only pathology to diagnose. Try medications, teach breathing exercises, and watch as the suffering continues, maybe diminishes, more frequently denudes. In a role that is supposed to be about healing, how is one supposed to heal, without determining meaning?

It reminds me that an attitude of humility is paramount in my field, to remember that there is always something more to learn. More people, in my field and outside of it, need to read this text. The question of finding meaning in suffering is not new – I submit the entirety of Job and Ecclesiastes for excellent consideration of this field. However, the challenge of needing to keep it in our minds remains non-instinctive. Pain is something to avoid, that’s why it’s called pain. This text reminds us that we may not need to spend our lives avoiding it.

To live is to suffer. What we do with that suffering, is up to us.