What is Dissaffection?

Introduction

The term disaffectation was coined by noted French psychoanalyst Joyce McDougall as a strictly psychoanalytic term for alexithymia, a neurological condition characterised by severe lack of emotional awareness.

Background

McDougall felt that alexithymia had become too strongly classified as a neuroanatomical defect and concretised as an intractable illness leaving little room for a purely psychoanalytic explanation for this phenomenon.

In coining the term McDougall hoped to indicate the behaviour of people who had experienced overwhelming emotion that threatened to attack their sense of integrity and identity. Such individuals, unable to repress the ideas linked to emotional pain and equally unable to project these feelings delusively onto representations of other people, simply ejected them from consciousness by “pulverizing all trace of feeling, so that an experience which has caused emotional flooding is not recognized as such and therefore cannot be contemplated”. They were not suffering from an inability to experience or express emotion, but from “an inability to contain and reflect over an excess of affective experience.”

‘Disaffectation’ conveys a deliberate double meaning. The Latin prefix dis-, indicates separation or loss and suggests, metaphorically, that certain people are psychologically separated from their emotions and may have “lost” the capacity to be in touch with interior psychic reality. Also included in this prefix is the secondary meaning from the Greek dys- with its implication of illness.

According to Professor of Psychiatry of the University of Toronto, Graeme Taylor, this psychoanalytic conceptualisation departs from older, less applicable theories which emphasized the role of unconscious neurotic conflicts, and instead facilitates a psychoanalytic model of physical illness and disease based on the operation of primitive pre-neurotic pathology that has failed to achieve psychic representation. Henry Krystal Professor of Psychiatry at Michigan State University agreed, adding that it is useful to separate the consideration of psychotherapy for the “disaffected” individual from that of the classical psychosomatic neuroses. To Krystal this consideration is important because “since these patients may develop serious, even occasionally fatal exacerbations of illness during psychotherapy, treating them with psychotherapy for psychosomatic illness is not indicated”. This distinction has allowed the field of psychoanalysis to contribute constructively to the field of psychosomatic medicine.

What is the Diathesis-Stress Model?

Introduction

The diathesis-stress model, also known as the vulnerability-stress model, is a psychological theory that attempts to explain a disorder, or its trajectory, as the result of an interaction between a predispositional vulnerability, the diathesis, and a stress caused by life experiences. The term diathesis derives from the Greek term (διάθεσις) for a predisposition, or sensibility. A diathesis can take the form of genetic, psychological, biological, or situational factors. A large range of differences exists among individuals’ vulnerabilities to the development of a disorder.

The diathesis, or predisposition, interacts with the individual’s subsequent stress response. Stress is a life event or series of events that disrupts a person’s psychological equilibrium and may catalyse the development of a disorder. Thus the diathesis-stress model serves to explore how biological or genetic traits (diatheses) interact with environmental influences (stressors) to produce disorders such as depression, anxiety, or schizophrenia. The diathesis-stress model asserts that if the combination of the predisposition and the stress exceeds a threshold, the person will develop a disorder. The use of the term diathesis in medicine and in the specialty of psychiatry dates back to the 1800s; however, the diathesis-stress model was not introduced and used to describe the development of psychopathology until it was applied to explaining schizophrenia in the 1960s by Paul Meehl.

The diathesis-stress model is used in many fields of psychology, specifically for studying the development of psychopathology. It is useful for the purposes of understanding the interplay of nature and nurture in the susceptibility to psychological disorders throughout the lifespan. Diathesis-stress models can also assist in determining who will develop a disorder and who will not. For example, in the context of depression, the diathesis-stress model can help explain why Person A may become depressed while Person B does not, even when exposed to the same stressors. More recently, the diathesis-stress model has been used to explain why some individuals are more at risk for developing a disorder than others. For example, children who have a family history of depression are generally more vulnerable to developing a depressive disorder themselves. A child who has a family history of depression and who has been exposed to a particular stressor, such as exclusion or rejection by his or her peers, would be more likely to develop depression than a child with a family history of depression that has an otherwise positive social network of peers. The diathesis-stress model has also served as useful in explaining other poor (but non-clinical) developmental outcomes.

Protective factors, such as positive social networks or high self-esteem, can counteract the effects of stressors and prevent or curb the effects of disorder. Many psychological disorders have a window of vulnerability, during which time an individual is more likely to develop disorder than others. Diathesis-stress models are often conceptualised as multi-causal developmental models, which propose that multiple risk factors over the course of development interact with stressors and protective factors contributing to normal development or psychopathology. The differential susceptibility hypothesis is a recent theory that has stemmed from the diathesis-stress model.

Diathesis

The term diathesis is synonymous with vulnerability, and variants such as “vulnerability-stress” are common within psychology. A vulnerability makes it more or less likely that an individual will succumb to the development of psychopathology if a certain stress is encountered. Diatheses are considered inherent within the individual and are typically conceptualised as being stable, but not unchangeable, over the lifespan. They are also often considered latent (i.e. dormant), because they are harder to recognise unless provoked by stressors.

Diatheses are understood to include genetic, biological, physiological, cognitive, and personality-related factors. Some examples of diatheses include genetic factors, such as abnormalities in some genes or variations in multiple genes that interact to increase vulnerability. Other diatheses include early life experiences such as the loss of a parent, or high neuroticism. Diatheses can also be conceptualised as situational factors, such as low socio-economic status or having a parent with depression.

Stress

Stress can be conceptualised as a life event that disrupts the equilibrium of a person’s life. For instance, a person may be vulnerable to become depressed, but will not develop depression unless they are exposed to a specific stress, which may trigger a depressive disorder. Stressors can take the form of a discrete event, such the divorce of parents or a death in the family, or can be more chronic factors such as having a long-term illness, or ongoing marital problems. Stresses can also be related to more daily hassles such as school assignment deadlines. This also parallels the popular (and engineering) usage of stress, but note that some literature defines stress as the response to stressors, especially where usage in biology influences neuroscience.

It has been long recognised that psychological stress plays a significant role in understanding how psychopathology develops in individuals. However, psychologists have also identified that not all individuals who are stressed, or go through stressful life events, develop a psychological disorder. To understand this, theorists and researchers explored other factors that affect the development of a disorder and proposed that some individuals under stress develop a disorder and others do not. As such, some individuals are more vulnerable than others to develop a disorder once stress has been introduced. This led to the formulation of the diathesis-stress model.

Genetics

Sensory processing sensitivity (SPS) is a temperamental or personality trait involving “an increased sensitivity of the central nervous system and a deeper cognitive processing of physical, social and emotional stimuli”. The trait is characterised by “a tendency to ‘pause to check’ in novel situations, greater sensitivity to subtle stimuli, and the engagement of deeper cognitive processing strategies for employing coping actions, all of which is driven by heightened emotional reactivity, both positive and negative”.

Sensory processing sensitivity captures sensitivity to environment in a heritable, evolutionary-conserved trait, associated with increased information processing in the brain. Moderating sensitivity to environments in a for-better-and-for-worse fashion. Interaction with negative experiences increases risk for psychopathology. Whereas interaction with positive experiences (including interventions), increases positive outcomes. Mast cells are long-lived tissue-resident cells with an important role in many inflammatory settings including host defence to parasitic infection and in allergic reactions. Stress is known to be a mast cell activator.

There is evidence that children exposed to prenatal stress may experience resilience driven by epigenome-wide interactions.” Early life stress interactions with the epigenome show potential mechanisms driving vulnerability towards psychiatric illness. ancestral stress alters lifetime mental health trajectories via epigenetic regulation.

Carriers of congenital adrenal hyperplasia have a predeposition to stress, due to the unique nature of this gene. True rates of prevalence are not known but common genetic variants of the human Steroid 21-Hydroxylase Gene (CYP21A2) are related to differences in circulating hormone levels in the population.

Psychological distress is a known feature of generalised joint hypermobility (gJHM), as well as of its most common syndromic presentation, namely Ehlers-Danlos syndrome, hypermobility type (a.k.a. joint hypermobility syndrome – JHS/EDS-HT), and significantly contributes to the quality of life of affected individuals. Interestingly, in addition to the confirmation of a tight link between anxiety and gJHM, preliminary connections with depression, attention deficit (and hyperactivity) disorder, autism spectrum disorders, and obsessive-compulsive personality disorder were also found.

Protective Factors

Protective factors, while not an inherent component of the diathesis-stress model, are of importance when considering the interaction of diatheses and stress. Protective factors can mitigate or provide a buffer against the effects of major stressors by providing an individual with developmentally adaptive outlets to deal with stress. Examples of protective factors include a positive parent-child attachment relationship, a supportive peer network, and individual social and emotional competence.

Throughout the Lifespan

Many models of psychopathology generally suggest that all people have some level of vulnerability towards certain mental disorders, but posit a large range of individual differences in the point at which a person will develop a certain disorder. For example, an individual with personality traits that tend to promote relationships such as extroversion and agreeableness may engender strong social support, which may later serve as a protective factor when experiencing stressors or losses that may delay or prevent the development of depression. Conversely, an individual who finds it difficult to develop and maintain supportive relationships may be more vulnerable to developing depression following a job loss because they do not have protective social support. An individual’s threshold is determined by the interaction of diatheses and stress.

Windows of vulnerability for developing specific psychopathologies are believed to exist at different points of the lifespan. Moreover, different diatheses and stressors are implicated in different disorders. For example, breakups and other severe or traumatic life stressors are implicated in the development of depression. Stressful events can also trigger the manic phase of bipolar disorder and stressful events can then prevent recovery and trigger relapse. Having a genetic disposition for becoming addicted and later engaging in binge drinking in college are implicated in the development of alcoholism. A family history of schizophrenia combined with the stressor of being raised in a dysfunctional family raises the risk of developing schizophrenia.

Diathesis-stress models are often conceptualised as multi-causal developmental models, which propose that multiple risk factors over the course of development interact with stressors and protective factors contributing to normal development or psychopathology. For example, a child with a family history of depression likely has a genetic vulnerability to depressive disorder. This child has also been exposed to environmental factors associated with parental depression that increase their vulnerability to developing depression as well. Protective factors, such as strong peer network, involvement in extracurricular activities, and a positive relationship with the non-depressed parent, interact with the child’s vulnerabilities in determining the progression to psychopathology versus normative development.

Some theories have branched from the diathesis-stress model, such as the differential susceptibility hypothesis, which extends the model to include a vulnerability to positive environments as well as negative environments or stress. A person could have a biological vulnerability that when combined with a stressor could lead to psychopathology (diathesis-stress model); but that same person with a biological vulnerability, if exposed to a particularly positive environment, could have better outcomes than a person without the vulnerability.

What is Pharmacotherapy?

Introduction

Pharmacotherapy is therapy using pharmaceutical drugs, as distinguished from therapy using surgery (surgical therapy), radiation (radiation therapy), movement (physical therapy), or other modes. Among physicians, sometimes the term medical therapy refers specifically to pharmacotherapy as opposed to surgical or other therapy; for example, in oncology, medical oncology is thus distinguished from surgical oncology. Pharmacists are experts in pharmacotherapy and are responsible for ensuring the safe, appropriate, and economical use of pharmaceutical drugs.

Background

The skills required to function as a pharmacist require knowledge, training and experience in biomedical, pharmaceutical and clinical sciences. Pharmacology is the science that aims to continually improve pharmacotherapy. The pharmaceutical industry and academia use basic science, applied science, and translational science to create new pharmaceutical drugs.

As pharmacotherapy specialists and pharmacists have responsibility for direct patient care, often functioning as a member of a multidisciplinary team, and acting as the primary source of drug-related information for other healthcare professionals. A pharmacotherapy specialist is an individual who is specialised in administering and prescribing medication, and requires extensive academic knowledge in pharmacotherapy.

In the US, a pharmacist can gain Board Certification in the area of pharmacotherapy upon fulfilling eligibility requirements and passing a certification examination.

While pharmacists provide valuable information about medications for patients and healthcare professionals, they are not typically considered covered pharmacotherapy providers by insurance companies.

What is Dissociative Disorder Not Otherwise Specified?

Introduction

Dissociative disorder not otherwise specified (DDNOS) is a mental health diagnosis for pathological dissociation that matches the DSM-5 criteria for a dissociative disorder, but does not fit the full criteria for any of the specifically identified subtypes, which include dissociative identity disorder, dissociative amnesia, and depersonalisation/derealisation disorder, and the reasons why the previous diagnoses were not met are specified.

Refer to Depressive Disorder Not Otherwise Specified (DD-NOS).

Background

“Unspecified dissociative disorder” is given when the clinician does not give a reason. The International Statistical Classification of Diseases and Related Health Problems (ICD-10) refers to the diagnosis as “Other dissociative and conversion disorders”.

Examples of DDNOS include chronic and recurrent syndromes of mixed dissociative symptoms, identity disturbance due to prolonged and intense coercive persuasion, disorders similar to dissociative identity disorder, acute dissociative reactions to stressful events, and dissociative trance.

DDNOS is the most common dissociative disorder and is diagnosed in 40% of dissociative disorder cases. It is often co-morbid with other mental illnesses such as complex posttraumatic stress disorder, major depressive disorder, generalised anxiety disorder, personality disorders, substance use disorders, and eating disorders.

What is Depressive Disorder Not Otherwise Specified?

Introduction

Depressive Disorder Not Otherwise Specified (DD-NOS) is designated by the code 311 in the DSM-IV for depressive disorders that are impairing but do not fit any of the officially specified diagnoses. According to the DSM-IV, DD-NOS encompasses “any depressive disorder that does not meet the criteria for a specific disorder.” In the DSM-5, it is called unspecified depressive disorder.

Refer to Dissociative Disorder Not Otherwise Specified (DDNOS).

Background

Examples of disorders in this category include those sometimes described as minor depressive disorder and recurrent brief depression.

“Depression” refers to a spectrum of disturbances in mood that vary from mild to severe and from short periods to constant illness. DD-NOS is diagnosed if a patients symptoms fail to meet the criteria more common depressive disorders such as major depressive disorder or dysthymia. Although DD-NOS shares similar symptoms to dysthymia, dysthymia is classified by a period of at least 2 years of constantly recurring depressed mood, where as DD-NOS is classified by much shorter periods of depressed moods.

For most people who suffer the condition, their life will be significantly affected. DD-NOS can make many aspects of a person’s daily life difficult to manage, inhibiting their ability to enjoy the things that used to make them happy. Sufferers of the disorder tend to isolate themselves from their friends and families, lose interest in some activities, and experience behavioural changes and sleeping disorders. Some sufferers also experience suicidal tendencies or suicide attempts. In addition to having these symptoms, a diagnosis of DD-NOS will only be made if the symptoms cause significant distress or impairment in social, occupational, or other important areas of functioning. For the diagnosis to be accurate, a psychiatrist is required to spend extensive time with the patient.

Symptoms of the disorder may arise due to several reasons. These include:

  • Distress due to medical conditions.
  • Environmental effects and situations.

However, the effects of drugs or medication or bereavement are not classified under the diagnosis.

A person will not be diagnosed with the condition if they have or have had any of the following: a major depressive episode, manic episode, mixed episode or hypomanic episode.

A diagnosis of the disorder will look like: “Depressive Disorder NOS 311”.

Concerns

Accurately assessing for a specific Depressive Disorder diagnosis requires an expenditure of time that is deemed unreasonable for most primary care physicians. For this reason, physicians often use this code as a proxy for a more thorough diagnosis. There is concern that this may lead to a “wastebasket” mindset for certain disorders. In addition reimbursement through Medicare may be lower for certain non specific diagnosis.

Treatment

It is possible for this disorder to progress over time. A patient suffering from the disorder can improve the condition with treatments. There are several types of therapies that may improve the condition, but depending on a patient’s experience of the disorder or the cause of the disorder, treatments will vary.

  • Psychotherapy including behaviour therapy, Gestalt therapy, Adlerian therapy, psychoanalytic therapy and existential therapy.
  • Pharmacotherapy through medications including antidepressants.

Loneliness Awareness Week (14-18 June)

This year, Loneliness Awareness Week will take place from 14 to 18 June.

Hosted by the Marmalade Trust, it is a campaign that raises awareness of loneliness and gets people talking about it.

Find out more here and how you can get involved.

In 2020 the campaign reached around 271.5 million people – all without leaving our homes. The campaign saw almost 20,000 charities, organisations, companies and individuals get involved online.

Preparing for a Return to Work After Lockdown

Introduction

Wherever you stand on it, working from home has become the norm for many over the last year.

But with lockdown finally (sort off) easing, organisations are eyeing a gradual resumption of routine business, possibly from the end of July.

Whether you are relishing or dreading the prospect, there are some steps staff across the organisation can take to make sure the process goes smoothly.

With this in mind, how should those in charge approach the return to work?

Below are some tips.

Communicate clearly1. People need time to be able to plan and get used to the idea of when and how they will go back to work.
2. Make sure you are consistent in your messaging and that your team know you are thinking of their welfare.
Be mindful of different tensions1. Some staff have been at work throughout and have made a safe environment that they feel happy in.
2. All of a sudden you will have an influx of people coming in from outside.
3. Meanwhile others have stayed in their bubbles at home for a long time.
4. Some might be a bit gung-ho in their approach to Covid safety measures and others are more rigid.
5. All of these areas can lead to friction.
Be open to new ways of working1. People will have relied more on technology than face-to-face meetings.
2. Coming back together again will take some getting used to.
Ensure staff feel safe1. Physically, everyone must feel confident of the protection measures in place to prevent them catching Covid but, mentally, there is still much uncertainty.
2. They will be wondering if this is permanent or what will happen if infection rates start to rise again.
Good leaders will get everyone in and say, ‘I don’t know exactly how this is going to go, but let’s approach it together’.
Show compassion and empathy1. Some people will be scared. Others can’t wait to get back.
2. Those with families may have additional stressors at home or ongoing childcare issues.
3. Everyone needs to adjust, and leaders should manage their own expectations and offer some leeway.
4. Even senior managers/executives/owners will be feeling anxious.
5. Have open conversations with your peers and managers and be honest if you are nervous.
6. Do things that make you calm, whether that is mindfulness or going for a run.
Take it step by step1. Give it time, and accept there is no ‘normal’ and let everyone find their feet.

Look Out For Your Team

It can be hard to spot signs of stress in your colleagues but when you work closely with someone, you generally know when they are not themselves

Any change in their usual behaviour and performance is a red flag, for example…

  • An outgoing person becoming withdrawn, or the opposite.
  • Missing work or being late when normally punctual.
  • A loss of personal discipline.
  • Showing signs they might be drinking more than usual.
  • Appearing distracted or ‘not quite there’.
  • Uncharacteristic mistakes or procrastinating.
  • Negative statements such as ‘everything is against me’.
  • Seeming more tired than usual or mentioning sleep problems.
  • Low energy or mood.

Ask Twice

If you think someone is acting out of character ask “how are you feeling?” and wait to hear the answer.

If they respond with “I’m fine”, ask “are you sure?”

Three Mindful Moments to Conquer Anxiety

Mindfulness is about bringing yourself back to the present moment. If you find thoughts are overwhelming you, try the following exercises:

  1. Have a brew:
    • But do not just gulp it down.
    • Spend a few moments feeling the warmth of the cup in your hands, smell the aromas, with your eyes open or closed.
    • Sip it slowly and really taste it.
  2. Take a mindful shower:
    • Rather than thinking of your to-do list or things that have stressed you out, notice the feel of the water against your skin, the way the steam moves in the cubicle or perhaps follow the water droplets as they slide down the wall.
  3. Spend time outside:
    • Go to a park, forest, beach or just your back garden for a little while and soak it in.
    • Sit and acknowledge the sights around you, the sounds of the wind in the trees, the sea against the shore, the smells of the flowers and the feel of the sun on your skin.

What is Ego Psychology?

Introduction

Ego psychology is a school of psychoanalysis rooted in Sigmund Freud’s structural id-ego-superego model of the mind.

An individual interacts with the external world as well as responds to internal forces. Many psychoanalysts use a theoretical construct called the ego to explain how that is done through various ego functions. Adherents of ego psychology focus on the ego’s normal and pathological development, its management of libidinal and aggressive impulses, and its adaptation to reality.

Brief History

Early Conceptions of the Ego

Sigmund Freud initially considered the ego to be a sense organ for perception of both external and internal stimuli. He thought of the ego as synonymous with consciousness and contrasted it with the repressed unconscious. In 1910, Freud emphasized the attention to detail when referencing psychoanalytical matters, while predicting his theory to become essential in regards to everyday tasks with the Swiss psychoanalyst, Oscar Pfister. By 1911, he referenced ego instincts for the first time in Formulations on the Two Principles of Mental Functioning and contrasted them with sexual instincts: ego instincts responded to the reality principle while sexual instincts obeyed the pleasure principle. He also introduced attention and memory as ego functions.

Freud’s Ego Psychology

Freud later argued that not all unconscious phenomena can be attributed to the id, and that the ego has unconscious aspects as well. This posed a significant problem for his topographic theory, which he resolved in The Ego and the Id (1923).

In what came to be called the structural theory, the ego was now a formal component of a three-way system that also included the id and superego. The ego was still organised around conscious perceptual capacities, yet it now had unconscious features responsible for repression and other defensive operations. Freud’s ego at this stage was relatively passive and weak; he described it as the helpless rider on the id’s horse, more or less obliged to go where the id wished to go.

In Inhibitions, Symptoms, and Anxiety (1926), Freud revised his theory of anxiety as well as delineated a more robust ego. Freud argued that instinctual drives (id), moral and value judgments (superego), and requirements of external reality all make demands upon an individual. The ego mediates among conflicting pressures and creates the best compromise. Instead of being passive and reactive to the id, the ego was now a formidable counterweight to it, responsible for regulating id impulses, as well as integrating an individual’s functioning into a coherent whole. The modifications made by Freud in Inhibitions, Symptoms, and Anxiety formed the basis of a psychoanalytic psychology interested in the nature and functions of the ego. This marked the transition of psychoanalysis from being primarily an id psychology, focused on the vicissitudes of the libidinal and aggressive drives as the determinants of both normal and psychopathological functioning, to a period in which the ego was accorded equal importance and was regarded as the prime shaper and modulator of behaviour.

Systematisation

Following Sigmund Freud, the psychoanalysts most responsible for the development of ego psychology, and its systematization as a formal school of psychoanalytic thought, were Anna Freud, Heinz Hartmann, and David Rapaport. Other important contributors included Ernst Kris, Rudolph Loewenstein, René Spitz, Margaret Mahler, Edith Jacobson, Paul Federn, and Erik Erikson.

Anna Freud

Anna Freud focused her attention on the ego’s unconscious, defensive operations and introduced many important theoretical and clinical considerations. In The Ego and the Mechanisms of Defense (1936), Anna Freud argued the ego was predisposed to supervise, regulate, and oppose the id through a variety of defences. She described the defences available to the ego, linked them to the stages of psychosexual development during which they originated, and identified various psychopathological compromise formations in which they were prominent. Clinically, Anna Freud emphasized that the psychoanalyst’s attention should always be on the defensive functions of the ego, which could be observed in the manifest presentation of the patient’s associations. The analyst needed to be attuned to the moment-by-moment process of what the patient talked about in order to identify, label, and explore defences as they appeared. For Anna Freud, direct interpretation of repressed content was less important than understanding the ego’s methods by which it kept things out of consciousness. Her work provided a bridge between Freud’s structural theory and ego psychology.

Heinz Hartmann

Heinz Hartmann (1939/1958) believed the ego included innate capacities that facilitated an individual’s ability to adapt to his or her environment. These included perception, attention, memory, concentration, motor coordination, and language. Under normal conditions, which Hartmann called “an average expectable environment,” these capacities developed into ego functions with autonomy from the libidinal and aggressive drives; that is, they were not products of frustration and conflict as Freud (1911) believed. Hartmann recognised, however, that conflicts were part of the human condition and that certain ego functions may become conflicted by aggressive and libidinal impulses, as witnessed by conversion disorders (e.g., glove paralysis), speech impediments, eating disorders, and attention-deficit disorder.

A focus on ego functions and how an individual adapts to his or her environment led Hartmann to create both a general psychology and a clinical instrument with which an analyst could evaluate an individual’s functioning and formulate appropriate therapeutic interventions. Hartmann’s propositions imply that the task of the ego psychologist was to neutralize conflicted impulses and expand the conflict-free spheres of ego functions. Through such effects, Hartmann believed, psychoanalysis facilitated an individual’s adaptation to his or her environment. He claimed, however, that his aim was to understand the mutual regulation of the ego and environment rather than to promote adjustment of the ego to the environment; additionally, he proposed that diminishing conflict in an individual’s ego would help him or her to respond actively to, and shape rather than passively react to, the environment. Mitchell and Black (p.35) stated:

“Hartmann powerfully affected the course of psychoanalysis, opening up a crucial investigation of the key processes and vicissitudes of normal development. Hartmann’s contributions broadened the scope of psychoanalytic concerns, from psychopathology to general human development, and from an isolated, self-contained treatment method to a sweeping intellectual discipline among other disciplines”

David Rapaport

David Rapaport played a prominent role in the development of ego psychology, and his work likely represented its apex. In the influential monograph The Structure of Psychoanalytic Theory (1960), Rappaport organized ego psychology into an integrated, systematic, and hierarchical theory capable of generating empirically testable hypotheses. He proposed that psychoanalytic theory – as expressed through the principles of ego psychology – was a biologically based general psychology that could explain the entire range of human behaviour. For Rapaport, this endeavour was fully consistent with Freud’s attempts to do the same (e.g. Freud’s studies of dreams, jokes, and the “psychopathology of everyday life”).

Other Contributors

While Hartmann was the principal architect of ego psychology, he collaborated closely with Ernst Kris and Rudolph Loewenstein.

Subsequent psychoanalysts interested in ego psychology emphasized the importance of early-childhood experiences and socio-cultural influences on ego development. René Spitz (1965), Margaret Mahler (1968), Edith Jacobson (1964), and Erik Erikson studied infant and child behaviour, and their observations were integrated into ego psychology. Their observational and empirical research described and explained early attachment issues, successful and faulty ego development, and psychological development through interpersonal interactions.

Spitz identified the importance of mother-infant nonverbal emotional reciprocity; Mahler refined the traditional psychosexual developmental phases by adding the separation-individuation process; and Jacobson emphasized how libidinal and aggressive impulses unfolded within the context of early relationships and environmental factors. Finally, Erik Erikson provided a bold reformulation of Freud’s biologic, epigenetic psychosexual theory through his explorations of socio-cultural influences on ego development. For Erikson, an individual was pushed by his or her own biological urges and pulled by socio-cultural forces.

Decline

In the United States, ego psychology was the predominant psychoanalytic approach from the 1940s through the 1960s. Initially, this was due to the influx of European psychoanalysts, including prominent ego psychologists like Hartmann, Kris, and Loewenstein, during and after World War II. These European analysts settled throughout the United States and trained the next generation of American psychoanalysts.

By the 1970s, several challenges to the philosophical, theoretical, and clinical tenets of ego psychology emerged. The most prominent of which were: a “rebellion” led by Rapaport’s protégés (George Klein, Robert Holt, Roy Schafer, and Merton Gill); object relations theory; and self psychology.

Contemporary

Modern Conflict Theory

Charles Brenner (1982) attempted to revive ego psychology with a concise and incisive articulation of the fundamental focus of psychoanalysis: intrapsychic conflict and the resulting compromise formations. Over time, Brenner (2002) tried to develop a more clinically based theory, what came to be called “modern conflict theory.” He distanced himself from the formal components of the structural theory and its metapsychological assumptions, and focused entirely on compromise formations.

Heinz Kohut developed self psychology, a theoretical and therapeutic model related to ego psychology, in the late 1960s. Self psychology focuses on the mental model of the self as important in pathologies.

Ego Functions

FunctionDescription
Reality Testing1. The ego’s capacity to distinguish what is occurring in one’s own mind from what is occurring in the external world.
2. It is perhaps the single most important ego function because negotiating with the outside world requires accurately perceiving and understanding stimuli.
3. Reality testing is often subject to temporary, mild distortion or deterioration under stressful conditions.
4. Such impairment can result in temporary delusions and hallucination and is generally selective, clustering along specific, psychodynamic lines.
5. Chronic deficiencies suggest either psychotic or organic interference.
Impulse Control1. The ability to manage aggressive and/or libidinal wishes without immediate discharge through behaviour or symptoms.
2. Problems with impulse control are common; for example: road rage; sexual promiscuity; excessive drug and alcohol use; and binge eating.
Affect Regulation1. The ability to modulate feelings without being overwhelmed.
Judgement1. The capacity to act responsibly.
2. This process includes identifying possible courses of action, anticipating and evaluating likely consequences, and making decisions as to what is appropriate in certain circumstances.
Object Relations1. The capacity for mutually satisfying relationship.
2. The individual can perceive himself and others as whole objects with three dimensional qualities.
Thought Processes1. The ability to have logical, coherent, and abstract thoughts.
2. In stressful situations, thought processes can become disorganised.
3. The presence of chronic or severe problems in conceptual thinking is frequently associated with schizophrenia and manic episodes.
Defensive Functioning1. A defence is an unconscious attempt to protect the individual from some powerful, identity-threatening feeling.
2. Initial defences develop in infancy and involve the boundary between the self and the outer world; they are considered primitive defences and include projection, denial, and splitting.
3. As the child grows up, more sophisticated defences that deal with internal boundaries such as those between ego and super ego or the id develop; these defences include repression, regression, displacement, and reaction formation.
4. All adults have, and use, primitive defences, but most people also have more mature ways of coping with reality and anxiety.
Synthesis1. The synthetic function is the ego’s capacity to organize and unify other functions within the personality.
2. It enables the individual to think, feel, and act in a coherent manner.
3. It includes the capacity to integrate potentially contradictory experiences, ideas, and feelings; for example, a child loves his or her mother yet also has angry feelings toward her at times.
4. The ability to synthesize these feelings is a pivotal developmental achievement.

Reality testing involves the individual’s capacity to understand and accept both physical and social reality as it is consensually defined within a given culture or cultural subgroup. In large measure, the function hinges on the individual’s capacity to distinguish between her own wishes or fears (internal reality) and events that occur in the real world (external reality). The ability to make distinctions that are consensually validated determines the ego’s capacity to distinguish and mediate between personal expectations, on the one hand, and social expectations or laws of nature on the other. Individuals vary considerably in how they manage this function. When the function is seriously compromised, individuals may withdraw from contact with reality for extended periods of time. This degree of withdrawal is most frequently seen in psychotic conditions. Most times, however, the function is mildly or moderately compromised for a limited period of time, with far less drastic consequences’ (Berzoff, 2011).

Judgment involves the capacity to reach “reasonable” conclusions about what is and what is not “appropriate” behaviour. Typically, arriving at a “reasonable” conclusion involves the following steps: (1) correlating wishes, feeling states, and memories about prior life experiences with current circumstances; (2) evaluating current circumstances in the context of social expectations and laws of nature (e.g. it is not possible to transport oneself instantly out of an embarrassing situation, no matter how much one wishes to do so); and (3) drawing realistic conclusions about the likely consequences of different possible courses of action. As the definition suggests, judgment is closely related to reality testing, and the two functions are usually evaluated in tandem (Berzoff, 2011).

Modulating and controlling impulses is based on the capacity to hold sexual and aggressive feelings in check with out acting on them until the ego has evaluated whether they meet the individual’s own moral standards and are acceptable in terms of social norms. Adequate functioning in this area depends on the individual’s capacity to tolerate frustration, to delay gratification, and to tolerate anxiety without immediately acting to ameliorate it. Impulse control also depends on the ability to exercise appropriate judgment in situations where the individual is strongly motivated to seek relief from psychological tension and/or to pursue some pleasurable activity (sex, power, fame, money, etc.). Problems in modulation may involve either too little or too much control over impulses (Berzoff, 2011).

Modulation of affect The ego performs this function by preventing painful or unacceptable emotional reactions from entering conscious awareness, or by managing the expression of such feelings in ways that do not disrupt either emotional equilibrium or social relationships. To adequately perform this function, the ego constantly monitors the source, intensity, and direction of feeling states, as well as the people toward whom feelings will be directed. Monitoring determines whether such states will be acknowledged or expressed and, if so, in what form. The basic principle to remember in evaluating how well the ego manages this function is that affect modulation may be problematic because of too much or too little expression. As an integral part of the monitoring process, the ego evaluates the type of expression that is most congruent with established social norms. For example, in white American culture it is assumed that individuals will contain themselves and maintain a high level of personal/vocational functioning except in extremely traumatic situations such as death of a family member, very serious illness or terrible accident. This standard is not necessarily the norm in other cultures (Berzhoff, Flanagan, & Hertz, 2011).

Object relations involves the ability to form and maintain coherent representations of others and of the self. The concept refers not only to the people one interacts with in the external world but also to significant others who are remembered and represented within the mind. Adequate functioning implies the ability to maintain a basically positive view of the other, even when one feels disappointed, frustrated, or angered by the other’s behaviour. Disturbances in object relations may manifest themselves through an inability to fall in love, emotional coldness, lack of interest in or withdrawal from interactions with others, intense dependency, and/or an excessive need to control relationships (Berzhoff, Flanagan, & Hertz, 2011).

Self-esteem regulation involves the capacity to maintain a steady and reasonable level of positive self-regard in the face of distressing or frustrating external events. Painful affective states, including anxiety, depression, shame, and guilt, as well as exhilarating emotions such as triumph, glee, and ecstasy may also undermine self-esteem. Generally speaking, in dominant American culture a measured expression of both pain and pleasure is expressed; excess in either direction is a cause for concern. White Western culture tends to assume that individuals will maintain a consistent and steadily level of self-esteem, regardless of external events or internally generated feeling states (Berzhoff, Flanagan, & Hertz, 2011).

Mastery when conceptualized as an ego function, mastery reflects the epigenetic view that individuals achieve more advanced levels of ego organization by mastering successive developmental challenges. Each stage of psychosexual development (oral, anal, phallic, genital) presents a particular challenge that must be adequately addressed before the individual can move on to the next higher stage. By mastering stage-specific challenges, the ego gains strength in relations to the other structures of the mind and thereby becomes more effective in organizing and synthesizing mental processes. Freud expressed this principle in his statement, “Where id was, shall ego be.” An undeveloped capacity for mastery can be seen, for example, in infants who have not been adequately nourished, stimulated, and protected during the first year of life, in the oral stage of development. When they enter the anal stage, such infants are not well prepared to learn socially acceptable behaviour or to control the pleasure they derive from defecating at will. As a result, some of them will experience delays in achieving bowel control and will have difficulty in controlling temper tantrums, while others will sink into a passive, joyless compliance with parental demands that compromises their ability to explore, learn, and become physically competent. Conversely, infants who have been well gratified and adequately stimulated during the oral stage enter the anal stage feeling relatively secure and confident. For the most part, they cooperate in curbing their anal desires, and are eager to win parental approval for doing so. In addition, they are physically active, free to learn and eager to explore. As they gain confidence in their increasingly autonomous physical and mental abilities, they also learn to follow the rules their parents establish and, in doing so, with parental approval. As they master the specific tasks related to the anal stage, they are well prepared to move on to the next stage of development and the next set of challenges. When adults have problems with mastery, they usually enact them in derivative or symbolic ways (Berzhoff, Flanagan, & Hertz, 2011).

Conflict, Defence and Resistance Analysis

According to Freud’s structural theory, an individual’s libidinal and aggressive impulses are continuously in conflict with his or her own conscience as well as with the limits imposed by reality. In certain circumstances, these conflicts may lead to neurotic symptoms. Thus, the goal of psychoanalytic treatment is to establish a balance between bodily needs, psychological wants, one’s own conscience, and social constraints. Ego psychologists argue that the conflict is best addressed by the psychological agency that has the closest relationship to consciousness, unconsciousness, and reality: the ego.

The clinical technique most commonly associated with ego psychology is defence analysis. Through clarifying, confronting, and interpreting the typical defence mechanisms a patient uses, ego psychologists hope to help the patient gain control over these mechanisms.

Cultural Influences

  • The classical scholar E. R. Dodds used ego psychology as the framework for his influential study The Greeks and the Irrational (1951).
  • The Sterbas relied on Hartmann’s conflict-free sphere to help explain the contradictions they found in Beethoven’s character in Beethoven and His Nephew (1954).

Criticisms

A number of authors have criticised Hartmann’s conception of a conflict-free sphere of ego functioning as both incoherent and inconsistent with Freud’s vision of psychoanalysis as a science of mental conflict. Freud believed that the ego itself takes shape as a result of the conflict between the id and the external world. The ego, therefore, is inherently a conflicting formation in the mind. To state, as Hartmann did, that the ego contains a conflict-free sphere may not be consistent with key propositions of Freud’s structural theory.

Ego psychology, and ‘Anna-Freudianism’, were together seen by Kleinians as maintaining a conformist, adaptative version of psychoanalysis inconsistent with Freud’s own views. Hartmann claimed, however, that his aim was to understand the mutual regulation of the ego and environment rather than to promote adjustment of the ego to the environment. Furthermore, an individual with a less-conflicted ego would be better able to actively respond and shape, rather than passively react to, his or her environment.

Jacques Lacan was if anything still more opposed to ego psychology, using his concept of the Imaginary to stress the role of identifications in building up the ego in the first place. Lacan saw in the “non-conflictual sphere…a down-at-heel mirage that had already been rejected as untenable by the most academic psychology of introspection’.

References

Berzoff, J., Flanagan, L.M. & Hertz, P (2011). Inside out and outside in: Psychodynamic clinical theory and psychopathology in contemporary multicultural contexts. (3rd ed. Lanham, MD: Rowman & Littlefield Publishers.

Mitchell, S.A. & Black, M.J. (1995). Freud and beyond: A history of modern psychoanalytic thought. New York: Basic Books.

What is the Harvard Review of Psychiatry?

Introduction

The Harvard Review of Psychiatry is a peer-reviewed medical journal covering all aspects of psychiatry.

Background

The Harvard Review of Psychiatry is the authoritative source for scholarly reviews and perspectives on a diverse range of important topics in psychiatry.

Founded by the Harvard Medical School Department of Psychiatry, the journal is peer-reviewed and not industry sponsored. It is the property of the President and Fellows of Harvard College and is affiliated with all of the Departments of Psychiatry at the Harvard teaching hospitals.

Articles encompass all major issues in contemporary psychiatry, including (but not limited to) neuroscience, psychopharmacology, psychotherapy, history of psychiatry, and ethics. In addition to scholarly reviews, perspectives articles, and columns, the journal includes a Clinical Challenge section that presents a case followed by discussion and debate from a panel of experts.

Subscription includes a CME opportunity in each issue.

What is Logotherapy?

Introduction

Logotherapy was developed by neurologist and psychiatrist Viktor Frankl, on a concept based on the premise that the primary motivational force of an individual is to find a meaning in life.

Frankl describes it as “the Third Viennese School of Psychotherapy” along with Freud’s psychoanalysis and Adler’s individual psychology. Logotherapy is based on an existential analysis focusing on Kierkegaard’s will to meaning as opposed to Alfred Adler’s Nietzschean doctrine of will to power or Freud’s will to pleasure. Rather than power or pleasure, logotherapy is founded upon the belief that striving to find meaning in life is the primary, most powerful motivating and driving force in humans.

A short introduction to this system is given in Frankl’s most famous book, Man’s Search for Meaning, in which he outlines how his theories helped him to survive his Holocaust experience and how that experience further developed and reinforced his theories. Presently, there are a number of logotherapy institutes around the world.

Basic Principles

The notion of Logotherapy was created with the Greek word logos (“reason”). Frankl’s concept is based on the premise that the primary motivational force of an individual is to find a meaning in life. The following list of tenets represents basic principles of logotherapy:

  • Life has meaning under all circumstances, even the most miserable ones.
  • Our main motivation for living is our will to find meaning in life.
  • We have freedom to find meaning in what we do, and what we experience, or at least in the stance we take when faced with a situation of unchangeable suffering.

The human spirit is referred to in several of the assumptions of logotherapy, but the use of the term spirit is not “spiritual” or “religious”. In Frankl’s view, the spirit is the will of the human being. The emphasis, therefore, is on the search for meaning, which is not necessarily the search for God or any other supernatural being. Frankl also noted the barriers to humanity’s quest for meaning in life. He warns against “…affluence, hedonism, [and] materialism…” in the search for meaning.

Purpose in life and meaning in life constructs appeared in Frankl’s logotherapy writings with relation to existential vacuum and will to meaning, as well as others who have theorised about and defined positive psychological functioning. Frankl observed that it may be psychologically damaging when a person’s search for meaning is blocked. Positive life purpose and meaning was associated with strong religious beliefs, membership in groups, dedication to a cause, life values, and clear goals. Adult development and maturity theories include the purpose in life concept. Maturity emphasizes a clear comprehension of life’s purpose, directedness, and intentionality which contributes to the feeling that life is meaningful.

Frankl’s ideas were operationalized by Crumbaugh and Maholick’s Purpose in Life (PIL) test, which measures an individual’s meaning and purpose in life. With the test, investigators found that meaning in life mediated the relationships between religiosity and well-being; uncontrollable stress and substance use; depression and self-derogation. Crumbaugh found that the Seeking of Noetic Goals Test (SONG) is a complementary measure of the PIL. While the PIL measures the presence of meaning, the SONG measures orientation towards meaning. A low score in the PIL but a high score in the SONG, would predict a better outcome in the application of Logotherapy.

Discovering Meaning

According to Frankl, “We can discover this meaning in life in three different ways: (1) by creating a work or doing a deed; (2) by experiencing something or encountering someone; and (3) by the attitude we take toward unavoidable suffering” and that “everything can be taken from a man but one thing: the last of the human freedoms – to choose one’s attitude in any given set of circumstances”. On the meaning of suffering, Frankl gives the following example:

“Once, an elderly general practitioner consulted me because of his severe depression. He could not overcome the loss of his wife who had died two years before and whom he had loved above all else. Now how could I help him? What should I tell him? I refrained from telling him anything, but instead confronted him with a question, “What would have happened, Doctor, if you had died first, and your wife would have had to survive without you?:” “Oh,” he said, “for her this would have been terrible; how she would have suffered!” Whereupon I replied, “You see, Doctor, such a suffering has been spared her, and it is you who have spared her this suffering; but now, you have to pay for it by surviving and mourning her.” He said no word but shook my hand and calmly left the office.

Frankl emphasized that realising the value of suffering is meaningful only when the first two creative possibilities are not available (for example, in a concentration camp) and only when such suffering is inevitable – he was not proposing that people suffer unnecessarily.

Philosophical Basis of Logotherapy

Frankl described the meta-clinical implications of logotherapy in his book The Will to Meaning: Foundations and Applications of Logotherapy. He believed that there is no psychotherapy apart from the theory of the individual. As an existential psychologist, he inherently disagreed with the “machine model” or “rat model”, as it undermines the human quality of humans. As a neurologist and psychiatrist, Frankl developed a unique view of determinism to coexist with the three basic pillars of logotherapy (the freedom of will). Though Frankl admitted that a person can never be free from every condition, such as, biological, sociological, or psychological determinants; based on his experience during his life in the Nazi concentration camps, he believed that a person is “capable of resisting and braving even the worst conditions”. In doing such, a person can detach from situations and themselves, choose an attitude about themselves, and determine their own determinants, thus shaping their own character and becoming responsible for themselves.

Logotherapeutic Views and Treatment

Overcoming Anxiety

By recognising the purpose of our circumstances, one can master anxiety. Anecdotes about this use of logotherapy are given by New York Times writer Tim Sanders, who explained how he uses its concept to relieve the stress of fellow airline travellers by asking them the purpose of their journey. When he does this, no matter how miserable they are, their whole demeanour changes, and they remain happy throughout the flight. Overall, Frankl believed that the anxious individual does not understand that their anxiety is the result of dealing with a sense of “unfulfilled responsibility” and ultimately a lack of meaning.

Treatment of Neurosis

Frankl cites two neurotic pathogens: hyper-intention, a forced intention toward some end which makes that end unattainable; and hyper-reflection, an excessive attention to oneself which stifles attempts to avoid the neurosis to which one thinks oneself predisposed. Frankl identified anticipatory anxiety, a fear of a given outcome which makes that outcome more likely. To relieve the anticipatory anxiety and treat the resulting neuroses, logotherapy offers paradoxical intention, wherein the patient intends to do the opposite of their hyper-intended goal.

A person, then, who fears (i.e. experiences anticipatory anxiety over) not getting a good night’s sleep may try too hard (that is, hyper-intend) to fall asleep, and this would hinder their ability to do so. A logotherapist would recommend, then, that the person go to bed and intentionally try not to fall asleep. This would relieve the anticipatory anxiety which kept the person awake in the first place, thus allowing them to fall asleep in an acceptable amount of time.

Depression

Viktor Frankl believed depression occurred at the psychological, physiological, and spiritual levels. At the psychological level, he believed that feelings of inadequacy stem from undertaking tasks beyond our abilities. At the physiological level, he recognised a “vital low”, which he defined as a “diminishment of physical energy”. Finally, Frankl believed that at the spiritual level, the depressed individual faces tension between who they actually are in relation to what they should be. Frankl refers to this as the gaping abyss. Finally Frankl suggests that if goals seem unreachable, an individual loses a sense of future and thus meaning resulting in depression. Thus logotherapy aims “to change the patient’s attitude toward their disease as well as toward their life as a task”.

Obsessive-Compulsive Disorder

Frankl believed that those suffering from obsessive-compulsive disorder lack the sense of completion that most other individuals possess. Instead of fighting the tendencies to repeat thoughts or actions, or focusing on changing the individual symptoms of the disease, the therapist should focus on “transform[ing] the neurotic’s attitude toward their neurosis”. Therefore, it is important to recognise that the patient is “not responsible for his obsessional ideas”, but that “he is certainly responsible for his attitude toward these ideas”. Frankl suggested that it is important for the patient to recognise their inclinations toward perfection as fate, and therefore, must learn to accept some degrees of uncertainty. Ultimately, following the premise of logotherapy, the patient must eventually ignore their obsessional thoughts and find meaning in their life despite such thoughts.

Schizophrenia

Though logotherapy was not intended to deal with severe disorders, Frankl believed that logotherapy could benefit even those suffering from schizophrenia. He recognised the roots of schizophrenia in physiological dysfunction. In this dysfunction, the person with schizophrenia “experiences himself as an object” rather than as a subject. Frankl suggested that a person with schizophrenia could be helped by logotherapy by first being taught to ignore voices and to end persistent self-observation. Then, during this same period, the person with schizophrenia must be led toward meaningful activity, as “even for the schizophrenic there remains that residue of freedom toward fate and toward the disease which man always possesses, no matter how ill he may be, in all situations and at every moment of life, to the very last”.

Terminally Ill Patients

In 1977, Terry Zuehlke and John Watkins conducted a study analysing the effectiveness of logotherapy in treating terminally ill patients. The study’s design used 20 male Veterans Administration volunteers who were randomly assigned to one of two possible treatments – (1) group that received 8 45-minute sessions over a 2-week period and (2) group used as control that received delayed treatment. Each group was tested on 5 scales – the MMPI K Scale, MMPI L Scale, Death Anxiety Scale, Brief Psychiatric Rating Scale, and the Purpose of Life Test. The results showed an overall significant difference between the control and treatment groups. While the univariate analyses showed that there were significant group differences in 3/5 of the dependent measures. These results confirm the idea that terminally ill patients can benefit from logotherapy in coping with death.

Forms of Treatment

Ecce Homo is a method used in logotherapy. It requires of the therapist to note the innate strengths that people have and how they have dealt with adversity and suffering in life. Despite everything a person may have gone through, they made the best of their suffering! Hence, Ecce Homo – Behold the Man!

Controversy

Authoritarianism

In 1969 Rollo May argued that logotherapy is, in essence, authoritarian. He suggested that Frankl’s therapy presents a plain solution to all of life’s problems, an assertion that would seem to undermine the complexity of human life itself. May contended that if a patient could not find their own meaning, Frankl would provide a goal for his patient. In effect, this would negate the patient’s personal responsibility, thus “diminish[ing] the patient as a person”. Frankl explicitly replied to May’s arguments through a written dialogue, sparked by Rabbi Reuven Bulka’s article “Is Logotherapy Authoritarian?”. Frankl responded that he combined the prescription of medication, if necessary, with logotherapy, to deal with the person’s psychological and emotional reaction to the illness, and highlighted areas of freedom and responsibility, where the person is free to search and to find meaning.

Religiousness

Critical views of the life of logotherapy’s founder and his work assume that Frankl’s religious background and experience of suffering guided his conception of meaning within the boundaries of the person and therefore that logotherapy is founded on Viktor Frankl’s worldview. Many researchers argue that logotherapy is not a “scientific” psychotherapeutic school in the traditional sense but a philosophy of life, a system of values, a secular religion which is not fully coherent and is based on questionable metaphysical premises.

Frankl openly spoke and wrote on religion and psychiatry, throughout his life, and specifically in his last book, Man’s Search for Ultimate Meaning (1997). He asserted that every person has a spiritual unconscious, independently of religious views or beliefs, yet Frankl’s conception of the spiritual unconscious does not necessarily entail religiosity. In Frankl’s words: “It is true, Logotherapy, deals with the Logos; it deals with Meaning. Specifically, I see Logotherapy in helping others to see meaning in life. But we cannot “give” meaning to the life of others. And if this is true of meaning per se, how much does it hold for Ultimate Meaning?” The American Psychiatric Association awarded Viktor Frankl the 1985 Oskar Pfister Award (for important contributions to religion and psychiatry).

Recent Developments

Since the 1990s, the number of institutes providing education and training in logotherapy continues to increase worldwide. Numerous logotherapeutic concepts have been integrated and applied in different fields, such as cognitive behavioural therapy (CBT), acceptance and commitment therapy (ACT), and burnout prevention. The logotherapeutic concepts of noogenic neurosis and existential crisis were added to the ICD 11 under the name demoralisation crisis, i.e. a construct that features hopelessness, meaninglessness, and existential distress as first described by Frankl in the 1950s. Logotherapy has also been associated with psychosomatic and physiological health benefits. Besides Logotherapy, other meaning-centred psychotherapeutic approaches such as positive psychology and meaning therapy have emerged. Paul Wong’s meaning therapy attempts to translate logotherapy into psychological mechanisms, integrating CBT, positive psychotherapy and the positive psychology research on meaning. Logotherapy is also being applied in the field of oncology and palliative care (William Breitbart). These recent developments introduce Viktor Frankl’s logotherapy to a new generation and extend its impact to new areas of research.