Suffering Suffering
Freedom to choose Freedom to choose
Freedom to choose
Freedom to choose
for satisfaction. From a total of 3,521 areas, 13 categories of meaning were identified: (1) altruism, (2) animals/nature, (3) family, (4) finan-cial security, (5) friends/acquaintances, (6) health, (7) hedonism, (8) home/garden, (9) leisure time, (10) occupation/work, (11) partnership, (12) psychological well-being, and (13) spirituality/religion. This study also revealed areas of meaning predominant in each age group, which for youth was friends; young adulthood, partnership; middle adult-hood, work; retirement, health, and altruism; and advanced age, spiri-tuality/religion and animals/nature.
Fjelland, Barron, and Foxall (2008) conducted a review of 12 instru-ments to measure (1) search for meaning and (2) meaning in illness. A detailed review of this analysis will help the future researcher select the appropriate instrument.
Nursing Research
Health professionals from various disciplines have contributed to research in the significance of meaning and purpose. Prior to the 1970s, much of the research was in the domain of psychology/ psychiatry professionals and related to mental health views. Starck (1979) developed and tested a nursing intervention model for a population of individuals in the community with permanent spinal cord injury.
Starck, Ulrich, & Duffy (2009) reported that the most intense suffering was reported by hospitalized psychiatric patients as compared with hospitalized patients with either a medical-surgical or high risk prenatal diagnosis.
In the 1980s and '90s, Steeves and Kahn (1987), Kahn and Steeves (1995), and Steeves (1992, 1996) studied the concept of suffering in various populations including hospice patients and their families and patients undergoing bone marrow transplantations. Steeves, Kahn, and Benoliel (1990) studied how nurses experience and react to a per-son’s suffering. During this same time period, Starck (1992) studied suffering in a nursing home.
Other nursing researchers (Coward, 1991, 1994, 1995, 1996, 1998;
Coward & Dickerson, 2003; Coward & Kahn, 2004, 2005; Coward &
Lewis, 1993; Coward & Reed, 1996) have studied meaning and PIL in a healthy population as well as patients with breast cancer, AIDS, and at the end-of-life. Coward emphasizes self-transcendence, combining the work of Frankl and others in helping patients overcome spiritual disequilibrium.
Since the turn of the century, research in the role of meaning in health care has greatly expanded—internationally as well as across
disciplines. Patient conditions where the role of meaning has been explored include myocardial infarction (MI), cancer, rheumatoid arthritis, addictions, bereavement, battered women, and HIV-positive individuals.
There are several more recent studies addressing life meaning and purpose for populations with chronic diseases. In a 5-year longitudi-nal study of patients with MI, Baldacchino (2011) documented that by finding meaning in the illness experiences and by clarifying values and PIL, MI patients were motivated to make lifestyle change, particu-larly in the immediate aftermath of their MI. However, by the third year onward, compliance with lifestyle modification was inconsistent (Baldacchino, 2010). In a study with 156 patients diagnosed with rheu-matoid arthritis, Verduin et al. (2008) documented the independent contribution of life purpose to the mental health component of qual-ity of life. In the exploration of the relationship between spiritualqual-ity, PIL, and well-being in HIV-positive people, Litwinczuk and Groh (2007) found a significant relationship between spirituality and PIL in 46 HIV-positive men and women. The researchers recommended the design of nursing interventions to help HIV-positive people redefine themselves and find meaning in life.
There are several studies of life meaning and purpose with cancer patients. For instance, in longitudinal work with more than 500 cancer survivors, Jim and Anderson (2007) found that loss of life meaning contributed to poor social and physical functioning. In other research where investigators accepted the premise that many newly diagnosed cancer patients experience existential distress, Lee (2008) and Lee, Cohen, Edgar, Laizner, and Gagnon (2006) studied a meaning-making intervention, using a Lifeline exercise. The Lifeline exercise engaged participants in marking important life events in the past, and noting plans to achieve important life goals in the future. Use of the Lifeline exercise resulted in improved self-esteem, optimism, and self-efficacy in this randomized controlled trial.
Life meaning and purpose has also been studied in populations with addictive disorders. In research on Hungarian men and women, meaning in life as measured with the PIL test differentiated nonsmok-ers from daily smoknonsmok-ers. Life meaning had a significant negative impact on smoking intensity for females (Thege, Bachner, Martos, & Kushnir, 2009). In another study of cocaine abusers in treatment, PIL signifi-cantly predicted relapse to cocaine and to alcohol use, as well as the number of days of use, 6 months after treatment (Martin, MacKinnon, Johnson, & Rohsenow, 2011). Martin et al. (2011) suggest that increas-ing one’s sense of PIL may be an important component of treatment for cocaine-addicted patients.
Korean researchers (Kang & Kim, 2011) recently reported a study of life purpose and resilience in a group of 110 battered women. Greater life purpose was positively associated with higher resilience, measured as self-efficacy, communication efficiency, and optimism. Findings led the researchers to conclude that practitioners can help battered women to clarify their values and meaning in life and thereby improve their resilience.
Meaning and PIL play a significant role in health outcomes for a broad range of patients. The most often used measure is the PIL test, which was introduced more than 4 decades ago (Crumbaugh, 1968).
Nurse researchers are now positioned to develop and test meaning- making interventions, such as the Lifeline exercise (Lee, 2008;
Lee et al., 2006) described above. The move to intervention research to examine change in life purpose and health outcomes for people with chronic illness can easily be accommodated with guidance from the theory of meaning.
USE OF THE THEORY IN NURSING PRACTICE
Fabry (1980) has described logotherapy as “guiding people toward understanding themselves as they are and could be and their place in the totality of living” (p. xiii). When contrasted with traditional psy-chotherapy, it is less retrospective and introspective (Frankl, 1984).
Other comparisons between psychotherapy and logotherapy are found in Table 5.1.
TAbLE 5.1
Contrast of Psychotherapy and Logotherapy
Psychotherapy Logotherapy
Depth psychology Height psychology
Sees life in terms of problems Sees life in terms of solutions
Focuses on obstacles Focuses on goals
Is reductionistic Is holistic
Emphasis on uncovering Emphasis on discovering
Analytical style Uniqueness and improvisational style
Psychiatrist listens Logotherapist talks
The goal of logotherapy is to help persons separate themselves from their symptoms, to tap into the resources of their noetic dimension, and to arouse the dynamic power of the human spirit. Helping another find meaning may be described as promoting an unfolding of what is already there. It is helping the other discover his or her values and facilitating awareness of subconscious beliefs and commitments.
Frankl does not advocate techniques in a routine procedural sense but rather encourages creativity based on the situation at hand.
Frankl (1969) has described three logotherapeutic approaches. These approaches are dereflection, paradoxical intention, and Socratic dialogue. Both dereflection and paradoxical intention “rest on two essential qualities of human existence, namely, man’s capacities of self-transcendence and self-detachment” (Frankl, 1969, p. 99).
Dereflection
Dereflection is the act of de-emphasizing or ceasing to focus on a trou-blesome phenomenon, issue, or problem; it is putting this issue aside.
Dereflection strengthens the capacity for self-transcendence.
Obsessions are recognized as hyper reflection or excess atten-tion, described as the “compulsion to self-observation” (Frankl, 1973, p. 253). The urge for better sexual performance is an example. “Sexual performance or experience is strangled to the extent to which it is made either an object of attention or an objective of intention” (Frankl, 1969, p. 101).
Complaining is an example of hyper reflection, as an excessive amount of attention is given to the self. Dereflection helps the person stop fighting an anxiety, a neurosis, or a psychosis, and spares the per-son the reinforcement of additional suffering. If a perper-son is depressed, dereflection can help achieve distance between the person and the depression, “to see himself—not as a person who is depressed but—
as a full human being who has depressions with the capacity to find meaning despite the depressions” (Fabry, 1991, p. 136).
Paradoxical Intention
Paradoxical intention is intentionally acting the opposite to one’s desired ends, thereby confronting one’s fears and anxieties.
Paradoxical intention strengthens the capacity for self-distancing.
By distancing from the triggers of problems, these triggers become
ineffective. Paradoxical intention is helpful in dealing with the prob-lem of anticipatory anxiety. The object of the person’s fear is fear itself.
The underlying dynamic is apprehension about the potential effects of the anxiety attacks. And, of course, the fear of the fear increases the fear, producing precisely what the person is afraid of. The person is caught in a restricting cycle. The aim of therapy is to break the cycle, to interfere with the feedback mechanism. In logotherapy, one is asked to replace fear with a paradoxical wish, to wish for the very thing one fears. By this treatment, Frankl said, “the wind is taken out of the sails of the anxiety” (1984, p. 147).
This approach makes use of the specific human capacity for self-detachment. For example, in sleep disturbances when a person worries that he or she will not be able to get to sleep and focuses on trying to go to sleep, sleep will not come. The fear of sleeplessness results in the hyperintention to fall asleep, which inevitably leads to sleeplessness.
Paradoxical intention advises the person not to try to sleep, but rather to try to do the opposite, stay awake as long as possible. The person who has been trying to stay awake wakes up to find that he or she has been asleep.
Paradoxical intention can be used to change unwanted behavior pat-terns. This does not depend upon understanding how and why the behavior started. It simply breaks the cycle of fear. Ascher and Schotte (1999) demonstrated that individuals with public speaking phobia complicated by recursive anxiety—for example, fear of loss of bladder control, vomiting, and so on—showed greater improvement when par-adoxical intention was included in treatment.
Based on the finding that 55% of patients with a psychiatric disor-der who presented in the emergency department were diagnosed with conversion disorders, Ataoglu, Ozcetin, Icmeli, and Ozbulut (2003) conducted a study and concluded that paradoxical intention therapy provided greater improvement than diazepam therapy.
Socratic Dialogue
Socratic dialogue is a conversation of questions and answers, probing deeply into existential issues such as one’s values. It is rhetorical debate to trigger a change in attitude, behavior, or both. Socratic dialogue is self-discovery discourse and seeks to get rid of masks that have been put on to please or to be accepted. The therapist poses questions so that patients become aware of their unconscious decisions, their repressed hopes, and their unadmitted self-knowledge. In Socratic dialogue, experiences of the past are explored as well as fantasies for the future
to modulate attitude (Fabry, 1980). Socratic dialogue requires impro-visation and intuition and asks probing questions like the following:
● Was there a time when life had meaning?
● Who do you know who leads a meaningful life? What keeps you from living like this person?
● Who are the people who need you?
● Tell me about an experience that made you see things differently.
● Tell me something you said you couldn’t do but you did it.
As an example, Lukas (1984) working with a patient who strongly valued physical ability and who had undergone a leg amputation, asked the question, “Does the value of human existence depend on the use of two legs?” (p. 47).
Fabry (1991) proposed five guideposts to probe areas of meaning.
These are discovery, choice, uniqueness, responsibility, and self-transcendence. He also identified a number of creative methods and exercises to illustrate choice, where family members act out the role of others in the way they wish the others had responded. The flashlight technique can be useful in self-discovery and in aggressive discussion.
The facilitator shines the flashlight on the partner who says some-thing offensive to the other, indicating that the person must rephrase what has been said without hostility or sarcasm, thus helping reshape attitudes and behaviors. Fabry (1991) also has guidelines for groups, wherein the Socratic dialogue becomes a multilogue.
A family who was experiencing problems thought to be caused by one child who had a physical condition requiring most of the moth-er’s attention, making her less available to her other children and to her husband, sought logotherapy. The therapist asked the “identified patient” this question in the presence of the entire family—“If you could give your condition to anyone else in the family, who would you give it to?” The mother quickly spoke and said, “I would take it.”
The therapist specified that the child was the one to answer the ques-tion. After looking at each member of his family, the child responded,
“I would keep it myself because I think I am the best one to handle it.”
This attitude changed the family dynamic; the child was seen as a hero and not a burden to others.
Other Practices Using Logotherapy
Pearce (2005), a parish nurse, declared that Frankl was a forerunner to integrative medicine and holistic nursing, contrasting this with today’s
fragmented system of healers specializing in healing only a part of the whole. Patients with a complex interaction of physical, psychologi-cal, and spiritual suffering often find their way to logotherapy after being disappointed with the existing health care system. Logotherapy provides tools to tap into inner resources to emerge as a stronger and more joyous self.
Winters and Schulenberg (2006) pointed out that diagnosis is a necessary evil in practice. Diagnosis is inherently reductionistic and focuses on defeats. To address this problem, the authors developed a holistic, logotherapeutic model of diagnosis. The diagnostic process is a bio-psychosocial-spiritual one and incorporates an assessment of one’s inner strength. For example, the provider might include a positive history of emotional balance and a history of making it through previous difficult times as noetic resources. Logotherapy is aimed at empowering the patient by emphasizing choice, responsi-bility, and hope.
More recent practice applications of meaning theory, both patient-related and provider-patient-related, have been developed. Wong (2010) pres-ents an interesting approach to meaning therapy including the PURE strategy (purpose, understanding, responsible action, and evalua-tion) and the ABCDE strategy (accept, believe, commit, discover, and evaluate).
The central ideas of the theory of meaning are proving useful for a range of life-altering illnesses and significant life time points. For instance, there is perhaps no greater challenge than finding mean-ing when confrontmean-ing end-of-life. There is a growmean-ing recognition that symptoms of psychological distress and existential concerns are ever more prevalent and problematic than pain and other physical concerns when facing imminent death (Breitbart, Gibson, Poppito, & Berg, 2004).
Finding meaning in the traumatic experience of cardiac disease is used by psychotherapists to help patients reconstruct basic assumptions about self and others and to re-establish predictability in their lives (Sheikh & Marotta, 2008). A meaning-centered intervention has been used in treating veterans with chronic combat related posttraumatic stress disorder (Southwick, Gilmartin, McDonough, & Morrissey, 2006).
Not only do patients benefit from a sense of meaning and life pur-pose, care providers also benefit. Taubman-Ben-Ari and Weintroub (2008) studied physicians and nurses frequently exposed to termi-nally ill children in Israel. A higher level of exposure to patient death, higher optimism and professional self-esteem, and lower secondary traumatization (being close to someone who experienced trauma), predicted the sense of meaning in life. Fillion and colleagues have
studied nurses who work in a palliative care setting. They designed a meaning-centered intervention consisting of group therapy in four sessions plus a closing session (Fillion, Dupuis, Tremblay, De Grace,
& Breitbart, 2006). In the intervention, enhancing meaning in pallia-tive care, the focus of each session was (1) search for and sources of meaning, (2) historical perspective and sense of accomplishment as creative values, (3) meaning and suffering through attitudinal change, and (4) affective experiences and humor in experiential values. Each session consisted of didactic content, exercises, and group discussion, plus home assignments. In a follow-up study, the researchers sought to ameliorate stress and improve job satisfaction and quality of life for nurses working in palliative care. The four-session meaning-centered intervention was conducted (Fillion et al., 2009) using a wait list design.
Outcome measures included personal and job-related measures. Even though spiritual and emotional quality of life remained unchanged, nurses who received the intervention reported greater job benefits associated with working in the palliative care setting.
CONCLUSION
The theory of meaning can be a useful guide in research and practice.
The theory focuses on discovering meaning when facing life challenges that threaten one’s purpose in relation to unique circumstances. Nurse researchers and practitioners can draw on the theory to understand ordi-nary life stresses, as well as life-changing events and human suffering.
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6
Theory of Self-Transcendence
Pamela G. Reed
A
central focus of nursing is facilitating well-being and understand-ing the capacity for well-beunderstand-ing in the context of difficult health-related experiences. The nursing Theory of Self-Transcendence was created from a developmental perspective of human–environment processes of health. The word developmental is used in the theory to emphasize inherent change processes that are ongoing, innovative, and context-related while still acknowledging inevitable changes that may be viewed as random, decremental, or mechanistic. Self-transcendence theory originated from an interest in understanding developmental processes of later adulthood as integral to mental health and well-being. Although the role of development had long been an accepted perspective in work with children and adolescents, little attention was given to its significance for adults and especially older adults. The theory is now applied to individuals across the life span.PURPOSE OF THE THEORY AND HOW IT WAS DEVELOPED The purpose of the theory of self-transcendence is to provide a framework for inquiry and practice regarding the promotion of well-being in the midst of difficult life situations, particularly where individuals and families are facing loss or life-limiting ill-ness. According to the intermodern philosophy of nursing science (Reed, 2011), theories are open systems of knowledge development that incorporate various ways of knowing including empirical and practice-based sources. Knowledge from research and practice is organized into theories for creative applications with people who need nursing care. Research and practice using self-transcendence