The Role of Viktor Frankls Logotherapy
In Teaching Narrative Medicine
I teach narrative medicine1 on the undergraduate level at a small state college in New Yorks Hudson River Valley, about 2 hours north of New York City. We have a small, but growing pre-med program, so about half of my students are pre-health majors and the rest English majors. My course fulfills two General Education requirements, Humanities and Writing Intensive, so many students choose the course because it kills two birds with one stone, not because they are interested in the interdisciplinary nature of narrative medicine. However, I have found that these students, as well as the vast majority of my students, respond to Viktor Frankls logotherapy2; in fact, many of the English majors express annoyance that Frankl is not taught in our required Literary Criticism course. This paper examines combining logotherapy with the literary theory of narratology3, or the study of the structure of narrative, as the primary critical approach of my undergraduate Narrative Medicine course.
I will begin my paper with a definition, not of logotherapy, but with the term psychology, the study of the psyche. Today we equate psyche with mind, but being a literature professor, I prefer the original Greek connotation of soul. This is a concept that seems to make non-logotherapists, physicians and literature professors alike, somewhat nervous, even uncomfortable, a state that Frankl would consider most promising (Will 45). I think that Frankl would welcome a discussion of the soul at a conference such as this. Even if the soul is no longer a part of psychoanalysis, and rarely a part of literature courses, to ignore the patients soul (and the practitioners soul or the teachers soul) is to risk overlooking, even oppressing, a part of the narrative being examined, which seems to me to negate the purpose of narrative medicine. For Frankl, meaning was frequently associated with spirituality or religion, the domain of the soul (The Doctor and the Soul). These human endeavors and creations most closely connected with the soul are what created meaning for many of his patients and seemed to be the most significant in his own life, even during his existence in the Nazi concentration camps (Mans 87-90). However, the souls meaning seems to be frequently overlooked by medical care practitioners, a notable exception being Abraham Verghese. In My Own Country: A Doctors Story Verghese acknowledges that particularly when a cure is impossible, healing must incorporate more than physical treatments: without a cure for AIDS, he realizes that my job was to minister to the patients soul, his psyche . . . (272). Verghese begins to practice what Frankl in The Doctor and the Soul: From Psychotherapy to Logotherapy calls medical ministry (283).
I first wish to discuss an example of an oversight of the spiritual meaning in a patients story, an oversight that would not occur if logotherapy, or at least medical ministry, were more commonly practiced; then I will give several examples of how incorporating logotherapy into the analysis of literature allows me, not only to examine patients perspectives (Kottow and Kottow), but also to discuss the role of spirituality and religious beliefs in medical settings. A patients story, any narrative in fact, is an inherently rich source of information, revealing far more than mere facts, revealing the patients beliefs, paradigms, moral codes, spirituality, and even unconscious thoughts. Likewise, interpretation of such a story is equally complex, and made particularly challenging if the person hearing the story is not the patients narratee.
I need to explain a few narratological terms here to ensure that everyone understands my vocabulary. The narrator is the person telling the story; if the patient is telling her own story, she is the narrator, but if the doctor is re-telling the patients story, then the doctor is the narrator. The narratee is the person to whom the narrator is telling the story; the narrator expects the narratee to understand her language, syntax, references, nuances, and allusions. The difference between the real audience and the narratee could probably explain many if not most of medical lawsuits. The focalizer is the person through whose eyes we see the action, the events, the characters. If the narrator is telling the story in first person, then the narrator is the focalizer. But if the narration is in third person, then the focalizer could be any character and could change from character to character. For example, Harry Potter is the focalizer for much of the series, so far at least, but there are a few instances when someone else is the focalizer. The patient is always the focalizer of her own story, and when the physician is re-telling the story, the patient should always remain the focalizer of the story.
The importance of the narratee is critical in understanding the following narrative ethics case consult reported at the 1997 American Society for Bioethics and Humanities at Baltimore, Maryland. I teach this case consult in my course under the title Wandering in the Wilderness to give my students a hint as to how they should interprete it. The narrator of the case consult was the biomedical ethicist of the hospital where the patient had been receiving chemotherapy. The focalizer, the patient, was a deeply religious woman and expected her narratee, originally her oncologist, to understand the religious nature of her comments; however, her real audience, both her oncologist and the biomedical ethicist, either were not religious or ignored the religious possibilities of the patients story. The oncologist requested the biomedical ethicist to participate because she thought that the patient was requesting physician-assisted suicide, illegal in that state. And the ethicist had presented this case to the audience at this particular panel as an example of using narrative ethics in a case consult involving physician-assisted suicide. However, because I recognized the master narrative the patient was referring to, my interpretation was radically different, and incidentally the correct one. In other words, unlike the oncologist and the medical ethicist, I could and did become the patients narratee.
The patient was in the final stages of terminal breast cancer; she had accepted her prognosis, but during an appointment with her oncologist, she said that she felt trapped by her cancer, referring to the Exodus story of the Israelites being enslaved in Egypt. She said that she was wandering in the wilderness and looked to her physician for deliverance into the Promised Land. The oncologist, who was the patients audience but not the patients narratee, either did not recognize the master narrative found in Exodus, or did not comprehend the spiritual significance of the patient choosing this narrative. In logotherapy terms, the significance of this narrative is the meaning that the patient had found in her dying (Frankl, Will, 150). Instead, the oncologist interpreted this remark as a request for physical deliverance, for physician-assisted suicide, and contacted the hospitals biomedical ethicist. He also was not athe patients narratee, and thus misinterpreted the patients request. So did almost everyone at this panel, as the discussion following his presentation focused on the legal ramifications of physician-assisted suicide or on the racial issues (the patient was African-American, but neither the oncologist nor the biomedical ethicist was). When I asked the ethicist if he had followed the story behind the patients request, if he or the oncologist had considered the ramifications of the Exodus story, he appeared confused. Neither he nor the oncologist had thought about the master narrative behind the patients words, although he at least was familiar with the story of Exodus. But neither had considered the patients linguistic choice of bondage and deliverance in terms of religion, not racism. By overlooking the master narrative of the Exodus story, specifically the story of the Jews wandering in the wilderness, both the oncologist and the ethicist had failed to become narratees; they had failed to hear the entire narrative, and thus had misinterpreted the patients request.
Choosing the metaphor of slavery or bondage might reflect the patients concern with racial identity. And dying of cancer certainly involves loss of control and the potential of crippling, enslaving pain. The image of the Promised Land as a symbol for release from bondage or slavery, as well as for life after death, is a popular one in the African-American community. However, this metaphor is grounded in the biblical story of Exodus, and it is in this master narrative that the patient and the patients narratee find meaning. Reading the patients narrative as an allegory of this master narrative is difficult, and the oncologists reading that the patient saw her in the role of God, and thus the deliverer of death, is not unreasonable, but does not consider the entire master narrative from the book of Exodus. The story of Exodus is more than a miraculous release from physical bondage and suffering into the Promised Land; it is also the spiritual release of the soul from its earthly confines after a period of purification so that it is now capable of experiencing eternal union with God.
Chapter 16 of Exodus describes the Hebrews wandering in the wilderness for forty years following their successful escape from Egypt. This part of the story encapsulates the patients meaning of her suffering and explains her request. This forty years of wandering between the bondage of Egypt, ones physical existence or what C. S. Lewis calls the Shadowlands, and Canaan or Heaven allegorically represents the process of dying, which the patient was experiencing. Moses and his people were lost in the wilderness, neither enslaved nor totally free; however, they were not abandoned, unlike the patient. God had provided succor: at the journeys beginning, even before the Hebrews had crossed the Red Sea, the Lord led them by day in a pillar of a cloud . . . and by night a pillar of fire (Exodus 13:21). Later, however, when they had escaped from the Egyptians, the Hebrews began to complain (16:2-3). It seems that journeys to the Promise Land are not without the usual travel-associated hassles, including in this case an extended layover in an uninhabitable wilderness that makes Atlantas Hartsfield Airport look like an oasis. However, the Lord provided for the Hebrews, sending quails every evening and manna every morning (16:13-15).
God provides for the Hebrews, but what is equally important to understand the patients meaning, what Frankl also repeatedly refers to (Mans), is that the Lord expects humans to obey his will. For example, the manna is to be gathered each morning, every man according to his eating (16:18). No one is allowed to take more than is needed or to take from others; furthermore, because the seventh day is reserved for rest, no manna is provided for this day, and so, the people are told to collect double portions on the sixth day. Those who disobey are obliged to fast for a day. Including this part of the Exodus story provides the necessary context for the narratee to understand the patients meaning behind her request. Humans must have faith that God will provide for their needs. And this cancer patient did have faith. She accepted that the dying process would be long and painful, and that she requires assistance, not assistance to die, not a short cut through the wilderness, but assistance to alleviate her suffering. In other words, she was requesting manna from heaven, hospice care or palliative care. In fact, when the biomedical ethicist finally suggested hospice care to the patient, she immediately accepted it.
This narrative ethics case consult, Wandering in the Wilderness, is one of the assignments in my Narrative Medicine course, usually discussed in the third week of class following the introduction of the basics of narratology and logotherapy. Although I do incorporate other literary critical approaches, such as feminism or deconstruction depending on the work of literature being discussed, most of the class discussion involves a combination of narratology and logotherarpy. In the first week I introduce the basic concepts of narratology that the class will need, and then I give a brief biography of Frankl before the class watches Ruth Yorkin Drazens documentary The Choice Is Yours, a copy of which was provided free of charge for classroom instruction purposes by the American Board of Internal Medicine (ABIM) Foundation. Class time constraints limit discussion following the film, though I give have a ten to fifteen minute reflective writing assignment following the ABIMs guidelines, asking the students to describe what gives meaning to their lives. They write two to three paragraphs describing what is important to them, and what were the most important considerations when choosing their intended major or career, medicine and teaching being the most common career choices of the students in this course. The students then read the first half of Frankls Mans Search for Meaning, his holocaust memoir titled Experiences in a Concentration Camp.
We then discuss a variety of literary texts using a combination of narratology and logotherapy, much as in my previous discussion of Wandering in the Wilderness: poems by William Blake, Emily Dickinson, and W. H. Auden, Henry Fieldings Journal of a Voyage to Lisbon, J. K. Rowlings Harry Potter and the Sorcerers Stone, Nathaniel Hawthornes Rappaccinis Daughter, Oliver Sackss A Leg To Stand On, C. S. Lewiss A Grief Observed, Kafkas The Metamorphosis, Mark Twains The Mysterious Stranger. Each of these texts is the subject of class discussion and at least one writing assignment.
The current trend in teaching narrative medicine as well as in medical training in general seems to be placing primary consideration on self-reflective writing (Talen; Charon Form), a type of journal writing long popular in college composition courses. However, self-reflective writing4, particularly for students, can easily degrade into egotism or even self-pitying tirades (Frankl, Will, 38). I have recently attended several conference sessions where panelists describe a medical schools or a hospitals program in self-reflection in which the student participants complain more about themselves, about how difficult their lives are. Most statements begin with I:statements such as I am so tired all the time!; I cant learn everything!; I dont have time to eat, sleep, watch TV! greatly outnumber the non-egotistical variants, such as I feel Im not giving the patients the best care because Im so tired all the time! or I think I should be helping patients more, but the system wont let me! The inherent danger in self-reflective writing is that the writer is also the focalizer, and thus never moves away from the self. As in Hawthornes The Birth-Mark or Rappaccinis Daughter, what is best for the focalizer, the physician or the medical student, takes precedence over what is best for the patient. In Hawthornes stories, the medical practitioners arrogance not only prevents healing, but also precipitates disaster. Logotherapy lessens the focalizers ego by re-focusing the narrators attention away from self-centeredness to self-fulfillment, from ones ego to ones responsibility. The first part of Frankls Mans Search for Meaning, his holocaust memoir, is logotherapy in action, written in a style so subtle and so poetic that the reader finishes the holocaust memoir the first time before realizing that the memoir has become a logotherapy textbook essay.
This memoir, initially to be published anonymously, dramatically explains the
essence of logotherapy, that life holds a potential meaning under any
conditions, even the most miserable ones (16), even in the prolonged,
degrading, inhumane Nazi camps. This memoir vividly re-creates Frankls
experience, but does not dwell upon his day-to-day humiliations and sufferings.
Frankl does not take us through his experiences in chronological order, nor
does he begin by revealing the meaning he found in his experiences. He draws
the reader into his experiences by using first-person plural and not second
person as he does in Mans more clinical second section, Logotherapy
in a Nutshell. In other words, Frankls creation of a clear focalizer
that includes the reader ensures that this reader, no matter what age or background,
will become his narratee. The reader becomes a participant in his memoir, at
least in his psychoanalytical exploration of his work-camp experiences. Furthermore,
by beginning in media res Frankl does not allow his reader to perceive himself
or herself as the other, as someone who not being Jewish or gypsy or insane
(22) can never be placed in a similar, unthinkable situation. However, what
is unthinkable to us is always possible because there is always someone else
capable of thinking it.
Although Frankl does occasionally describe daily life in the work camps, he spends little time on daily life, partly to create the blurring of time created by ones loss of a future (91-92) and partly to reproduce the intense apathy felt by the camps inmates. If one does not care about ones surroundings, and one has virtually no control over them, then one does not notice the details; one has fewer individual memories. Instead, Frankl selects specific vignettes to relate, each one a lesson in logotherapy, although the reader does not notice this on the first reading. By acknowledging the existence of fate, Frankl notes, one acknowledges the freedom and power of ones choices, limited and insignificant though they may seem (85-87).
Frankl teaches us logotherapy by example and by turning us, the readers, into his narratees. He first invites us to imagine what our choices would be in certain unimaginable situations, implicitly and without our realizing what the narrator is doing, at least not on the first reading of the memoir. Frankls first story (22-23) poses the question of how far one would go to ensure not to be transferred to another camp, which almost always meant the gas chamber. He uses this story to introduce the degradation of the inmates from men to mere numbers, the beginning of the camps dehumanizing process. But Frankls overt purpose, the moral of the story, is that survivors soon lost all scruples in / their fight for existence; they were prepared to use every means, honest and otherwise, even brutal force, theft, and betrayal of their friends, in order to save themselves. We who have come back . . . we know: the best of us did not return (24). Frankl not only negates his moral superiority, but also forces us to question ours. His admission asks of us what our choices would be and thus, forces us to acknowledge that we have choices, that even when we are most powerless, we still have choices, a lesson in logotherapy also found in the other assigned readings in my course.
A later story describes one of the few cooks who doled out portions equally, never favoring a friend. Frankl, remembering this encounter as one of only two pleasurable moments at a particular work camp (67), then explicitly draws our attention to his refusal to judge those prisoners who put their own people above everyone else (68), again forcing us to consider what we would do in a life or death situation. But fighting for survival is only one possible choice, and sometimes even this choice involves other decisions. Frankl would not accept William Ernest Henleys assertive conclusion to his poem Invictus: I am the master of my fate; / I am the captain of my soul. (However, one could apply logotherapy to a reading of this poem so that the speaker is asserting his freedom to choose how he responds to what fate has dictated to him.) Frankl relives enough examples so that the narratee, the reader by this point, accepts that in certain situations, at certain times, ones future depends only upon the happenstance of fate, chance, and is totally outside ones control. Therefore, the narratee must focus only on how to respond to whatever fate delivers.
After recounting several instances when his life was saved by chance, where fate had passed me in many different forms (75), Frankl retells the Persian fable, Death in Teheran. A servant, following a brief encounter with Death, convinces his master to loan him his fastest horse so that he can flee to Teheran to escape Death. The master agrees, but shortly afterwards encounters Death himself. He asks Death why he had threatened the servant. Death responds that he had only expressed surprise in meeting the servant there at his masters house, as he was expecting to meet him that evening in Teheran. In other words, attempting to cheat Fate only brings Fate closer, as the narrator of Mark Twains The Mysterious Stranger discovers, although Twain complicates this version of the story by personifying fate as Satan.
Frankl does not envision a universe as bleak or as meaningless as does Twains narrator. Frankl believes in an existence beyond the physical (Mans 115), the Shadowlands. Life, though tragically short, filled with suffering and pain, has meaning, a glimpse of what Lewis describes as Sehnsucht. Frankl does not use this term, but he describes the will to meaning as a refuge from the harsh reality of his life as a prisoner, a refuge consisting of either memories of the past or intense appreciation of art and nature (59). Those prisoners who found meaning, even if meaning was only in how they accepted their suffering, survived, while those who allowed
themselves to be trapped in an unattainable past or in a present without spiritual meaning, lost hope and died.
Literature provides the opportunity to be the someone who thinks the unthinkable.
Or as Lewiss words, literature heals the wound, without undermining
the privilege, of individuality (149). Most of my reading list would fit
Lewiss description of literature because of the way it is written. For
example, Kafkas creation of a third-person narrator with Gregor Samsa
as the focalizer in The Metamorphosis denies the reader the luxury
of remaining the outsider, the one who will never become a victim. As with Frankls
Mans Search for Meaning, Kafkas reader must become the narratee,
someone who is no longer in control, one who could wake up any morning, if not
a bug, then perhaps crippled, incapacitated. Kafka demands that we participate,
at least vicariously in the daily degradations, privations, hardships, and brutalities
of such an abnormal situation.
Logotherapy also has a place for the regeneration of the spirit as a necessary component of healing, of life in general for the patient and the healer. As Frankl points out, human existence has three components: the body, the mind, and the spirit or soul (Doctor x). While medicine does cure or at least successfully treat most diseases of the body and the mind, true healing must also include the spirit. Rejuvenation of ones spirit is what one once did on vacation; now one works at improving ones golf game, or spends vast sums of money at an amusement park where one is dropped thirteen floors in a elevator or spun around in a centrifuge clearly labeled as potentially hazardous, only to exit through a gift shop where one spends yet more money on souvenirs of said thrilling experience. For those unfamiliar with Americas favorite vacation destination, Ive just described the Twilight Zones Tower of Terror ride at MGM Studios and Mission Space at Epcot, both part of Walt Disney World. Now, much as I love all things Disney, I find I require a day or two of rest following a vacation at Disney World. I have learned the necessity of spiritual relaxation on vacation, to sit on the beach or by a mountain stream and watch nature, to take leisurely walks. My spirit, my soul, needs regeneration, renewal, as much as my body needs fun. The souls renewal, similar to Lewiss Sehnsucht, seems to require a connection with nature; Verghese describes his routine of wrapping his arms around a giant oak tree to forge a spiritual connection to his patients, his community, and to the earth, a connection that rejuvenated him (299). As Frankl notes, the wholeness, the health of ones inner spiritual life is more significant, more empowering than ones physical state (Mans 53).
For more and more of us, especially students as Frankl predicted (Will 44-48, 85-88), the meaning of life becomes more than money, an expensive house, a prestigious career, or a promotion (Frankl, Mans, 128-130). Life is making new friends, spending time with family, discovering connections with others, with nature, with God. These experiences are part of Frankls logotherapy: drawing upon the spiritual resources of the patient allows for healing from within even when a cure is impossible (Will 140). Frankl understood that living is more than existing, that life creates a story of multiple meanings. Words are all most of us have to express these meanings, but words are only the outward, superficial expression of our temporal, incomplete earthly existence, our Shadowlands. Logos is the beginning of something deeper, richer, the unquantifiable complexity of thought and spirit combined.
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