Current Issue
Volume 10 Number 3
 Recent Volume(s)
Volume 10 Number 2 2010
Volume 10 Number 1 2010
Volume 9 Number 2, 2009
Volume 9 Number 1, 2009
Volume 8 Number 2, 2008
Volume 8 Number 1, 2008
Volume 7 Number 2, 2007
Volume 7 Number 1, 2007
Volume 6 Number 2, 2006
Volume 6 Number 1, 2006
Volume 5 Number 2, 2005
Volume 5 Number 1, 2005
Volume 4 Number 2, 2004
Volume 4 Number 1, 2004
Volume 3 Number 2, 2003
Volume 3 Number 1, 2003
Volume 2 Number 2, 2002
Volume 2 Number 1, 2002
Volume 1 Number 2 , 2001
Volume 1, Number 1, 2001


Volume 8, Number 2



Health care professionals must provide care to those who are suffering. Frankl's theory about "will to meaning" describes man's primary motivation to make sense of life's experiences and to find purpose in it. The author believes this theory provides the underpinnings of a clinical approach by which to guide patients through their sufferings, and she recommends a three-step process to facilitate discovery of meaning and purpose: assessing the meaning of life in the suffering experience; validating the strength of the human spirit; and, last, freeing the human spirit. She suggests psychometric tests and various therapeutic techniques to be used and illustrates them, using actual patient situations.

Suffering is a universal experience, yet the search for meaning in an individual's unique suffering is a lonely one. In a therapeutic relationship, a caring health professional can guide the patient through unavoidable suffering, and this relationship can be a powerful tool for healing. In this paper I offer guidelines to assist the health professional to integrate care of the human spirit into traditional practice. These guidelines are based on my belief that the professional has a duty and a responsibility to help patients in their search for meaning and purpose in suffering. I present a theoretical framework for strengthening the human spirit during suffering and outline practical applications to facilitate the discovery of meaning and purpose in clinical situations, using examples from my own experience.

Theoretical Framework
Victor E. Frankl1-3 first provided a theoretical framework for care of the human spirit, which has been expanded by Cassell4,5 and others. In a synthesis of Frankl's writings, I6 have termed this body of knowledge "meaning psychology" and declared it to be a rich resource for clinical practice. Frankl believed that striving to find meaning in all life experiences, including suffering, provides humankind with its primary motivation. This "will to meaning" can be contrasted with Freud's "will to pleasure" and Adler's "will to power." Frankl conceived the human as a unity having four dimensions: biologic; psychologic; sociologic; and spiritual or noetic. An appreciation of the "spiritual dimension," which focuses upon matters of ultimate concern, is essential if the caregiver is to understand human suffering and individual responses of coping.

For some people, their spiritual nature has a religious dimension; for others, it does not. The human spirit searches for goals that have personal meaning and enhance life. When called upon to deal with life's challenges, the spirit's defiant power is activated in a tenacious determination: it responds with irresistible inner stirrings including the urge to live, to be free, to understand, to enjoy, to create, to connect and to transcend.1,7 The urge to transcend or focus on things outside the self for a greater cause brings a sense of unity and oneness with nature, and with God or humankind, or both. Malaise of the human spirit can be recognized as existential frustration, the state of searching for meaning, and as existential vacuum, the state of sensing that life has lost its meaning. The theory has two important postulates: (1) it does not matter what we expect from life but rather what life expects from us1 and (2) everything can be taken from a man but one thing - the last of the human freedoms - to choose one's attitudes in any given circumstances, to choose one's own way.1

Although no one can determine meaning for someone else, health care professionals can help patients to discover their own meaning. Meaning can be found in three categories: creative; experiential; and attitudinal.1,7 Creative meaning can be sought in such individual accomplishments as one's occupation, rearing a family or writing a book. Experiential meaning can be found in such experiences as witnessing a beautiful sunset, giving and receiving love or being a part of a close-knit group. Attitudinal meaning consists of adopting a positive attitude toward a fate that cannot be changed. We have the freedom to choose how we will react and what stance we will adopt. This type of meaning may require a reassessment and a change in values. The essence of the concept of freedom is our power and willingness to change our attitude. We are free to choose our own attitude, but then we must be responsible for the outcomes. If we choose to be bitter and resentful following a tragic accident, we also assume responsibility for stress to loved ones, perhaps alienation of friends and family and the subsequent failure to find new potential in life.

The work of Cassell4,5 has expanded our knowledge and understanding of the nature and causes of suffering. In his view, suffering is the state of severe distress associated with events that threaten the individual's intactness. The whole-person ("personhood") concept includes personality and character, the person's past and life experiences, family identity, cultural background, roles, relations with others, political aspects of our being, the body, our secret life, perceived future and a transcendent or spiritual dimension. Suffering may arise from any of these aspects and all should be considered in the caregiver's attempts to alleviate suffering. Oreopoulos8 viewed suffering as an opportunity for individual development, forging personality and refining character. He emphasized caring and urged medicine to abandon the Cartesian duality of body and soul and return to caring for the whole person.

Practical Applications: Facilitating the Discovery of Meaning and Purpose
I have found a three-step process useful in activating the human spirit to find meaning in spite of suffering. These steps are: (1) assessing the meaning of life in suffering experiences; (2) validating the strength of the human spirit; and (3) freeing the human spirit.

Assessing the Meaning of Life

Assessment consists of eliciting information about the suffering experience and discovering the meaning it holds for the patient. There are two ways of making the assessment: by direct questioning and by psychometric testing. Cassell4 concluded that the only way to know whether suffering is present is to ask the sufferer. Yet most practitioners do not introduce such questions into their assessment. I have found the following questions helpful in assessing the presence and degree of suffering.

A 29-year-old quadriplegic man has had multiple complications and several hospitalizations: "Kenny, I've read your chart of this hospitalization and of your previous hospitalizations. You've been through quite a bit of suffering, haven't you? Can you tell me what it's like?... Can you help me understand what it's like to be in your place?... What was the worst of it for you?... What kind of things helped when you were suffering?... On a scale from 1 to 10, with 10 being the most suffering imaginable, how would you rate your suffering?... Have you learned anything from this suffering?... Has any good come out of this suffering?... How does your family fit into this picture of suffering?"

Several psychometric tests are available to elicit information about the patient's perception of suffering.

Crumbaugh and Maholick's9 Purpose in Life (PIL) test is an attitudinal scale constructed from the orientation of logotherapy. They have demonstrated both construct and criterion validity using norm groups and psychiatric patients.10 Construct validity refers to the investigation of psychologic qualities, traits or factors measured by a test. (Criterion validity is a statistical correlation between a set of scores or some other predictor of an external measure or criterion.) Crumbaugh11 reported the split-half (odd-even) reliability to be 0.92. (Split-half [odd-even] reliability is a technique used to ascertain the degree to which a test reliably measures a given phenomenon and is internally consistent. Each paper is calculated with two scores: odd items and even items. A Pearson product-moment score is calculated between the two sets of scores. A score of 1.00 is a perfect correlation.) The PIL test consists of three parts. The first section, part A, which has 20 scaled items, is the only portion that is objectively scored. Parts B and C are sentence-completion and paragraph-composition exercises; the responses are interpreted clinically. These authors established norms and percentile equivalents based on 1151 cases. Possible scores range from 20 to 140 (mean 102, standard deviation 19.0). Scores of 113 or above suggest the presence of definite purpose and meaning while scores of 91 or below suggest lack of clear meaning. The middle range of 92 through 112 represents uncertain definition.

The Seeking of Noetic Goals Test (SONG) is a complementary attitude scale developed by Crumbaugh12 to measure the strength of the individual's motivation to find meaning in life. One would expect the SONG scores to be high in a person who was seeking meaning and purpose in life, and low in those who either had found meaning or were not motivated to do so. Its originator has demonstrated construct validity and, in the PIL-SONG combination, has found a correlation from -0.27 to -0.52. The split-half reliability of the SONG was found to be 0.83.13 Like the PIL test, the SONG test consists of 20 items with answer choices from one to seven and with possible scores ranging from 20 to 140 (mean 79, standard deviation 14).

Other tests of interest are Elizabeth Lukas' Logo Test,14 which measures the existential vacuum and Starck's Meaning in Suffering Test (MIST) 15 These tests and their accompanying manuals are available from the Institute of Logotherapy, Office of Publications and Education, P0 Box 156, Berkeley, CA 94704-0156, USA.

Validating the Strength of the Human Spirit

The dynamic power of the human spirit may be activated by adversity. Assisting the patient to get in touch with the human spirit can mobilize the forces of healing. Suggestions for evoking such feelings are: Tell me about the things in your life of which you are most proud. Were you ever at a point you thought you couldn't make it? What caused you to keep trying? What do you have to live for?

Another useful technique is the Socratic dialogue or reflective questioning; even hypothetical questions may stimulate the human spirit to choose a new attitude.

A therapist was counselling a dysfunctional family and their 12-year-old child, who had cerebral palsy and who seemed to be causing much tension and stress. The therapist looked around the group of mother, father and siblings and asked the child, "If you could, which of your family members would you give your cerebral palsy to so you could be free of it?" Quickly, the mother spoke up, "I would take it," but the therapist persisted in asking the child to make a decision. One by one, the child went around the room thinking about how each family member would deal with the suffering he knew so well. Finally he said, "I would keep it myself because I can deal with it better than any of my family. "Now he was seen as strong, the only family member who could handle this heavy burden; and as benevolent to bear it instead of giving it to another This technique stimulated an attitude change in all family members, including the patient.

Freeing the Human Spirit

From birth, each of us has a unique spirit; when free and unfettered, it guides our choices and actions in life. However, the human spirit can become constrained, intimidated or abused. It can become blocked, stymied or crushed. When health professionals encounter such states, they have a duty to provide the proper spiritual comfort or call in other professionals to help, or both.

Story telling, use of fables or metaphors and use of parables help to free the human spirit. For example, in trying to help a patient get in touch with her core, the therapist asked her to describe the kind of child she had been and to relate a story from her childhood. The patient told this story:

My mother told me that when I was 2 years old and we were at a large family picnic in my grandmother's backyard, I got an old broom and started sweeping the area around the picnic table. My mother said to my father "Look, she is stirring up dirt around the food. Go and stop her" My father jokingly replied, "No, I'm not going to try to do that and embarrass myself in front of all these people," meaning that I was strong willed and would put up a protest if told to stop.

The therapist then used the story to reinforce this patient's strong determination, which was part of her inner core.

Also we can help to free the human spirit by asking the patient to categorize a situation into fate or freedom. Some things are past and cannot be changed, or genetic or one's luck. These things may be classed as "fate." Other issues are yet to be decided, and hence one is free to choose. In the case of child abuse, the injury is categorized as fate, but the individual is free to make many decisions in response to it.

Miller16 described the suffering of childhood and the resulting narcissistic disturbance. The individual cannot rationalize away this suffering and can heal only by allowing feelings of the painful childhood experience to come into consciousness. For survival, the growing child may need to present a false self - to be what the loved object wants and needs from the child. Thus, the true self (human spirit) is hidden to the developing child or adult. Without adequate therapy, this pattern may be repeated in succeeding generations as the child, now a parent, finds a new love object, another child, to meet the unmet longings. I worked as a co-therapist with a group of women who were survivors of incest. Using Miller's approach, the therapists guided the patients to get in touch with their locked-up feelings of anger, disappointment, sadness and hurt. Building upon this achievement, the therapist would use Socratic dialogue to help the patient categorize events into fate and freedom, for example:

Therapist: Your suffering has been great. Remember we said that all experiences can be divided into two categories -fate or freedom. Your abuse was a fate you could not control. Do you have any freedom -any options?

Patient: Yes, I am free to choose if I will have a relationship with my mother now. Perhaps she was abused too. She is old and sick now. I have a choice of deciding if I will forgive her l am also free to break the cycle with my own children.

Here, the patient's human spirit had been evoked and she is responding by recognizing decisions she is free to make. She sees that she is responsible for her future.

The human spirit also needs to be re-energized. When a person is physically tired or emotionally drained, the human spirit will be at a low ebb. Thus, arranging physical and emotional rest will help to free and restore the spirit

Health professionals can assist suffering patients by attending to the needs of the spirit. The human being seeks meaning and purpose in life, including meaning and purpose in suffering experiences. Meaning is unique to each individual and must be discovered; it cannot be given by another person. By using a process of assessing meaning, validating the strength of the human spirit and freeing the person to make choices, health professionals can guide patients through suffering experiences.


* Frankl VE: Man's Search for Meaning: an Introduction to Logotherapy, Beacon Pr, New York, 1959
* Idem: The Unheard Coy for Meaning, Simon & Schuster, New York, 1978
* Idem: The defiant power of the human spirit: a message of meaning in a chaotic world (audiotape), Institute of Logotherapy, Berkeley, Calif, 1979
* Cassell EJ: The nature of suffering and the goals of medicine. N Engl J Med 1982; 306: 639-645
* Idem: The Nature of Suffering, Oxford U Pr, New York, 1991
* Starck PL: Logotherapy comes of age: birth of a theory. Int Forum Logotherapy 1985; 8: 71-75
* James M, James J: Psychology and the Human Spirit, Dutton Publ, New York, 1991
* Oreopoulos LG: The meaning of suffering. Humane Med 1985; 1: 82-85
* Crumbaugh JC, Maholick LT: Purpose in Life Test, Psychometric Affiliates, Munster, Ind, 1976
* Idem: Manual of Instructions for the Purpose in Life Test, Psychometric Affiliates, Munster, Ind, 1969
* Crumbaugh JC: Cross-validation of purpose in life test based on Frankl's concepts. J lndivid Psychol 1968; 24: 74-81
* Idem: The Seeking of Neotic Goals Test, Psychometric Affiliates, Munster, Ind, 1977
* Idem: Manual of Instructions for the Seeking of Noetic Goals Test, Psychometric Affiliates, Munster, Ind, 1977
* Lukas E: Logo Test, Clinical demonstration at Logotherapy Certification Seminar, San Francisco, Calif, Institute of Logotherapy, Berkeley, Calif, 1984
* Starck PL: Guidelines - Meaning in Suffering Test, The Institute of Logotherapy, Berkeley, Calif, 1984
* Miller A: The Drama of the Gifted Child, Basic, New York, 1981

Dean and professor, School of Nursing, University of Texas, Health Science Center at Houston, Houston, Tex.

Correspondence to: Professor Patricia L. Starck, School of Nursing, University of Texas, Health Science Center at Houston, 1100 Holcombe Blvd., Houston, TX 77030, USA