My aim in this article is threefold: to adumbrate Viktor Frankl’s nosology, his diagnostic of mental illness/disorder, paying particular attention to his morphology of melancholy (depression), to emphasise the originality and importance of Frankl’s philosophico-psychological approach, and to urge/commend it to practitioners and mental health professionals. I shall do this with reference to Frankl’s 1956 book, Theorie und Therapie der Neurosen, which came out in the English edition of 2004, entitled On the Theory and Therapy of Mental Disorders: An Introduction to Logotherapy and Existential Analysis. My hope is to contribute a number of articles on this subject on the interface between psychiatry and clinical psychology on the one hand and philosophy and anthropology on the other hand but delineating and exploring both from a Franklian logotherapeutic perspective. This preliminary paper lays the template for further reflection and research.
According to Frankl, a perceived lack of meaning in suffering (aetiology) may lead to a noogenic depression (classification). This is so because we flourish (understood in the Aristotelian sense of eudaimonia, misleadingly translated as ‘happiness’) when our will to meaning is not thwarted (ontology). Frankl’s theory of mental disorders is based on his philosophical anthropology (metapsychology). We know that for Frankl a human being is a multilayered unity comprising three dimensions (dimensional ontology): the somatic, which is the bodily/biological (here we need to mention the influence of heredity and constitutional factors grounded in the person’s endocrine and neurological functions), the mental, which is the level of psychological processes and the noetic (or spiritual) component. We may thus distinguish between a somatic depression (which would be an endogenous disorder), a psychological depression, the level at which mental disorders are manifested and a noogenic depression. In this final one – where Frankl is unique among psychiatrists – though the spirit can never be sick (Frankl’s ‘psychiatric credo’) it may be blocked or frustrated culminating in a noogenic disorder; this will interact with the somatic and psychological dimensions. So when we ask the question: what is the meaning of melancholy?, the logotherapeutic/Franklian answer is that it is precisely at the level of meaning – and the perceived lack of it – that we must look to if we are to help or heal the suffering and acting person. A major depression (biologically caused) may, however, affect the person’s spirit and it is thus imperative that the whole person be treated in their biopsychospiritual and social unity/reality. So we have three types of disorders: somatogenic (if the cause is biological), psychogenic (if the cause is mental) and noogenic (if the cause is spiritual).
The logotherapeutic injunction is to find meaning – creatively, experientially or attitudinally – drawing on the human person’s capacity for humour and self-transcendence in a therapy/existential analysis which will incorporate Socratic dialogue, attitude modification/modulation and de-reflection primarily if we are dealing with a noogenic or psychogenic depression. If it is a somatogenic one then a course of prescribed drugs through psychiatric and pharmacological intervention is advisable because such endogenous psychoses, which would include the bipolar disorders along with schizophrenia, have a biological basis in the brain. The DSM would call such an endogenous depression a ‘major depressive disorder with melancholic features’. Logotherapy and existential analysis would here operate at the level of a supplemental therapy, where pockets of freedom and responsibility, of values and meaning, of hope and humour and conscience may be reached and realised leading to attitudinal change. Understood thus, and even when a pharmacological treatment is prescribed, logotherapy can be utilised to prevent secondary depression arising from psychogenic or noological causes or prevent suicide and it can also console logotherapeutically (healing through meaning). Needless to say, if the depression is triggered by ‘blows of fate’ (a reactive depression) then logotherapy and existential analysis are essential on the path to healing. Not all crises or cries for help are pathogenic or neurotic; a person may be in existential distress and not have a mental disease. An existential crisis or crisis of conscience may precipitate a noogenic neurosis, which will have a spiritual cause. Frankl resisted the tendency to medicalise problems and our profession. In terms of treatment we may distinguish, so, between phenomenology (the description of the symptomatology) and the aetiology (the genesis or cause of the ‘disorder’). We would also have to emphasise that there are no purely somatogenic, psychogenic or noogenic illnesses but, rather, only mixed/borderline cases in which one of the above aspects achieves more attention that the other aspects.
Frankl is unique in containing within his theoretical and therapeutic model an understanding of noogenic neurosis, the treatment modalities involved, and the philosophic-anthropological perspective of the human subject as a unified-wholistic essence (psychosomatic and spiritual unity), despite the differences in the constituent parts. The noetic cannot be neurotic. Psychotic illness, by contrast, may (but need not be) triggered by psychological events (such as extreme stress); these remain primarily somatogenic. These illnesses may be shaped by many variables but there is a person behind the psychotic symptoms who possesses some residual freedom. Logotherapy engages with this person at this spiritual dimension where alone truth and reason and recovery reside. An endogenous depression, as we have said, will involve drug therapy to treat the symptoms and logotherapy to enable the patient/person to adopt adaptive attitudes towards their sickness and to prevent secondary depression. Even psychosis has a meaning for the person – the meaning is discovered not given by the patient himself; there is an uninjured humanity beyond the injury (the ‘defiant power of the human spirit’). The human being is constituted existentially by the spirit, by freedom and responsibility and these are mobilised in the course of a logotherapeutic/existential analytic course of treatment exploration. The psychotic person still retains his dignity even if he doesn’t retain his utility; the homo patiens is higher than the homo faber, Frankl contests (Frankl, 2004, p. 66). His humane perspective on mental health is evident everywhere.
For Frankl there is the ‘triad of failure’, which are three insufficiencies from which patients suffer: an inability to work (self-reproaches and admonitions here are common and when people tell them ‘to pull themselves together and get out there and work or go for a walk’ this has the opposite desired effect), to feel pleasure (it’s a kind of vegetative depression) and to suffer (no meaning is sensed in the suffering and suicidal ideation or intention may require hospitalisation) (see ibid., p. 69). Socratic dialogue and de-reflection will help the patient deal with their conflicts and complexes and gradually and perhaps painfully move from pessimism (mood swings where the logic is one of ‘either/or’) to a ‘tragic optimism’ (a case of ‘both/and’), which is the realism of (existential not just logical) understanding. It is the place of hope. As Proverbs acknowledges: ‘Hope deferred makes the heart sick’ (13: 12). Meaning is not in the ‘that’ of suffering but in its ‘how’ (see ibid., p. 89). In summary: not all existential crises are pathological; many are part and parcel of the maturational process. Noogenic neuroses are those that arise when existential frustration is dealt with in a maladaptive manner (when the spiritual character of the crisis is ignored or repressed). Symptoms may include depression, anxiety, aggression, addiction, and so on. Frankl avoids the two extremes/pitfalls of psychologism (which denies the spiritual dimension) and spiritualism (which sees the spiritual as the only dimension).
Logotherapy is a specific and special (one is tempted to say) therapy of and for noogenic neuroses in particular as each one of us (and not just our patients) struggles ‘for the most meaningful fulfilment of personal existence’ (ibid., p. 173) possible. As the philosopher-physician Paracelsus reminds us: illness arises from nature, but its cure comes only from the spirit.
STEPHEN J. COSTELLO, B.A., M.A., Ph.D., Diplomate in Logotherapy [email@example.com], is a philosopher, existential analyst and Director of the Irish Viktor Frankl Institute of Logotherapy and Existential Analysis [www.logotherapyireland.com]. He is the author of The Irish Soul: In Dialogue, The Pale Criminal: Psychoanalytic Perspectives, 18 Reasons Why Mothers Hate Their Babies: A Philosophy of Childhood, Hermeneutics and the Psychoanalysis of Religion and of the forthcoming The Ethics of Happiness: An Existential Analysis, and What Are Friends For?: Insights from the Great Philosophers. He is a member of the Viktor Frankl Institute of Logotherapy and the Irish Philosophical Society. He holds a black belt in Aikido and is a senior student of Wing Tsun Kung Fu.
- Frankl, V. (2004). On the Theory and Therapy of Mental Disorders: An Introduction to Logotherapy and Existential Analysis. New York and Hove: Brunner-Routledge.