Psychiatry & Psychotherapy Podcast - Therapeutic Alliance Part 2: Meaning and Viktor Frankl's Logotherapy

Episode Date: October 30, 2018

Episode CME activity objectives: In the context of a therapeutic alliance, apply the information given in this episode to help draw out meaning in others. Identify who Viktor Frankl was and how his work and legacy have shaped how we understand and utilize meaning in psychiatry. Define psychic determinism. Recognize that meaning is idiosyncratic and unique to each individual. Recognize the multitude of ways people can find meaning in their lives and the various ways they can express and convey this. Summarize the various studies listed in this episode that have shown how meaning and the creation of meaning can have a positive impact. David Puder, M.D. has no conflicts of interest to report. In the celebrated book Man's Search for Meaning, author Viktor Frankl wrote about his intimate and horrific Holocaust experience. He found that meaning often came from the prisoners' small choices—to maintain belief in human dignity in the midst of being tortured and starved and bravely face these hardships together. "The way in which a man accepts his fate and all the suffering it entails, the way in which he takes up his cross, gives him ample opportunity—even under the most difficult circumstances—to add a deeper meaning to his life. It may remain brave, dignified and unselfish. Or in the bitter fight for self-preservation he may forget his human dignity and become no more than an animal." - Viktor Frankl "We who lived in concentration camps can remember the men who walked through the huts comforting others, giving away their last piece of bread. They may have been few in number, but they offer sufficient proof 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, to choose one's own way." - Viktor Frankl Frankl argued that the ultimate human drive is the "will to meaning," which could be described as the meaning to be found in the present and in the future. For example, I have had patients who are suicidal, yet they would not kill themselves, despite part of them desiring death, because they would not get to see their grandkids grow up. The meaning of the future moments and being able to help their grandkids in some small way empowers them to keep going to treatment. People's meaning keeps them going, even when other drives, like sex or desire for power, are completely gone. In this way, Frankl noted, "Focus on the future, that is on the meaning to be fulfilled by the patient in his future…I speak of a will to meaning in contrast to the pleasure principle (or, as we could speak also term it, the will to pleasure) on which Freudian psychoanalysis is centered, as well as in contrast to the will to power on which Adlerian psychology, using the term 'striving for superiority,' is focused." This idea led to the beginning of a new type of therapy—logotherapy. By listening to this episode, you can earn 0.75 Psychiatry CME Credits. Link to blog. Link to YouTube video.

Welcome to the Psychiatry and Psychotherapy Podcast, the podcast to help you in your journey towards becoming a wise, empathic, genuine, and connected mental health professional. I'm your host, Dr. David Puter, a psychiatrist who splits his time practicing psychopharmacology, individual and group psychotherapy, medical director of a day treatment program, medical education research, and teaching, residents, and medical students. Welcome back to the podcast. Today's episode, I am going to be talking about the Therapeutic Alliance part two, and this is on meaning. And this series is dedicated to my mentor, Dr. John Tar, who is an amazing psychoanalyst, and just an amazing resource for me as a young

psychiatrist to be mentored by such a brilliant person and an empathic and a loving person. So one of the topics that we teach together every year is on Therapeutic Alliance. and specifically on meaning and meaning making. And so in this episode, I'm going to talk about Victor Frankel, talk about his work in legacy and logotherapy, and how he sort of talked about meaning and meaning making. We're going to talk about psychic determinism, how meaning is idiosyncratic,

how there are multiple ways of helping people find meaning and techniques and, things that you can do that. And I'm going to summarize various studies that look at meaning and the positive impact of meaning. Had a medical student dig into the studies. Kristen Bishop, really thankful for her and had some other help as well on the blog and article. So if you want to look at that, you can follow the show notes to psychiatrypodcast.com. So in Victorification, Victor Frankl's celebrated book, Man Search for Meaning, he wrote about the horrific Holocaust experience that he was forced into. He found meaning in the midst of the most horrible circumstances that you could possibly imagine yourself being subjected to.

And as I've been thinking about this, I think often we don't think about meaning if everything is going okay. we don't think about like what am I here for what am I doing what is the purpose of all of this and in the midst of being tortured and starved and just having freezing cold temperatures he found that meaning was a very powerful motivator the preeminent motivator that got people through it and I'm going to read a couple quotes from him and talk about his story a little bit. So the first one, the way in which a man accepts his fate and all the suffering it entails, the way in which he takes up his cross gives him ample opportunity, even under the most difficult circumstances, to add a deeper meaning to his life.

it may remain dignified, brave, and unselfish, or in the bitter fight for self-preservation, he may forget his human dignity and become no more than an animal. Here's another one of his quotes that I really enjoy. We who lived in the concentration camps can remember the men who walked through the huts, comforting others, giving away their last piece of bread. They may have been few in number, but they're not. offers sufficient proof that everything can be taken from a man, but one thing, the last of human freedoms, to choose one's attitude in any given set of circumstances, to choose one's own way.

So Victor Frankl argued that ultimate human drive is the will to meaning, which could be described as meaning in the present and in the future. for example, I have patients who are suicidal and some of them so much so that they would have done it except for the meaning that keeps them alive. The meaning of wanting to see their grandkids grow up. The meaning of wanting to get some ideas out to the world, maybe. And when you ask someone about suicidality

and you ask them about what keeps them from doing, it, you quickly get to what is really meaningful. Maybe they say, well, because I'm a religious person, I wouldn't kill myself. And so you can get into the meaning of their religion and what that means to them and how it supports them. The meaning of the future moments and being able to help maybe their grandkids in some small way empowers them to keep going. the meaning of the small moments of you know Victor Frankl described people in the concentration camps who had a book to write and it was in their mind and they hadn't written it and they wanted to get it out to the world

so people's meaning keeps them going even when other drives like sex and the desire for power are gone you know not that those drives aren't there right but that according to Frankl quote focus on the future that is the meaning to be fulfilled by the patient in his future. I speak of a will to meaning in contrast to the pleasure principle, or as we could speak, also term it the will to pleasure,

on which Freudian psychoanalysis is centered, as well as in contrast to the will to power on which Adlerian psychology, using the term striving for superiority, is focused. This idea led to the beginning of a new type of therapy, Logotherapy. It's the idea that meaning is something that we need to focus on with the people that we work with. And I would say if you're a leader focusing on meaning is very powerful as well. So I don't think it just is this, I don't think this is just applicable to psychotherapy. If you're a parent, focus on meaning as well, I would say.

Okay, helping a patient find meaning. How do we help a patient find meaning? First of all, what happens if we don't find meaning? I think it can lead to depression, hopelessness, anxiety, suicidality. As a physician, I see this often. A lot of the times they don't have a great concept on what is meaningful, on what is their purpose, on what are they here to do. And I would say this is true, even if they have incredible, meaningful things that they're doing. It's like they're blind to it to some degree, and that develops like a hopelessness. So, you know, some people just ask people point blank the question. You know, like, what is meaningful? What is your purpose? What is your vision for the future?

But I learned this technique from Dr. Tar, which is a little bit more nuanced. And when I went through my psychoanalytic training, I didn't hear this, actually. So I think it's important to talk about this unique technique. The technique is based off of a principle called psychic determinism, which means everything has meaning.

There is nothing that a person says, no flash of emotion, no change in body posture that is meaningless. We're not obsessing and overthinking, but we're looking at clues as we listen for deeper meanings. What people say, what they don't say, the flashes of emotion on their face, the way in which they say it, the tone in which they say, the change in body posture as they say,

all these things are meaningful and need to be observed and need to be thought that they're not random. So that's the basis of this technique I'm going to be talking about. Because when you believe this, when you view a patience, words, emotions, body language as all meaningful, it changes how you're going to interact with them. The meaning may not be readily apparent. It may be expressed in dreams. Recently, a patient was having nightmares of being alone, of being all alone and no one could connect with them.

No one could be present with them. And it worsened on antidepressants. The nightmares went from once a week to multiple times a week. And the thought that I had when I read that was, well, it was there before the antidepressants. So yes, sometimes antidepressants can make dreams more vivid or they can worsen or increase the intensity of them. But it was there before. So I would be curious and listen and be present with that person. Be present with them.

Have them tell the story of those dreams. have them tell various iterations of those dreams, because usually dreams have slight iterations, slight differences. And then I would have them feel in their body what that feels like. And do they feel that level of loneliness? And does that make them think of other things? You know, does their mind jump to times in childhood where they felt all alone? Do they feel all alone presently with me? And so I would approach things that come. come out of a patient that are distressing as meaningful. So viewing that everything they say has

meaning changes the way you approach and gives you a mindset to really listen and to listen in a different way. Sometimes OCD can be thought of as like one approach to it is like relabeling the thoughts, the obsessive thoughts as meaningless. And sometimes with OCD patients, I've found that if you trace back some of these thoughts, sometimes there is meaning behind it on why a particular obsessive thought is occurring. But also we can look for the deeper meanings in those types of patients that are beyond the obsessive thoughts. So what do you really value? What do you really find meaning in? Can you focus on those things in the midst of some of these obsessive thoughts? Okay. So the meaning may not be readily apparent. And so it may take us a while and we should be curious. I look at the micro expressions. I have a couple episodes on that. I look at the small moments of emotion and think about how does that relate to the context of what this person is telling me. This person yesterday was telling me a story about how they had a difficult childhood or

No, it was actually a good childhood situation. They had a loving religious figure in their life. And while they were talking about that, they were flashing micro-expressions of anger, the emotion of anger. And I was watching him and I was in my mind thinking, what am I missing here? Why is he telling a good story, but he's flashing anger? And it came out that this was a common theme of he had these sort of,

he had these sort of out of the home experiences that were very positive, but in-home experiences were very negative. And so it was a thwartedness or a frustration at not having those in-home positive experiences of connection. So he had to venture out of the home to find his connection with other people. And that's where the anger was. So listening to our patients can help them understand the hidden meaning in their life, even in the midst of difficult times. And I think Victor Frankl illustrates that in his, I would consider it a qualitative study of sorts of studying what was going on during the concentration camps. So even in the midst of trauma, stress, and hardship, there could be hidden meanings, and we should look for those. So rambling is not

random in the end. Sometimes patients will talk, change subjects rapidly. And we think it's random, but it isn't. And I would say even when a schizophrenic patient talks, there's meaning behind what they're saying, meaning behind the delusions, the hallucinations. And for example, in schizophrenia, let's say the person has delusions that they are in an alternative reality where everyone is watching them and everyone is paying attention to them. And as you hear their story, they so deeply crave even the smallest bit of someone focusing on them and giving them the time of day. You know, they're used to people passing by the streets and just not even looking at them, not paying attention to them. And so they're in their...

in their delusion, everyone is paying attention to them. So you could empathize with the distress. It must be incredibly hard to have people just walk past you and to not give you the time of day, to not give your personhood a meaningful sort of reflection or interest. And just giving the empathy towards the distress, I think, can be very powerful. if someone is you sense angry and yet they don't want to express their anger outwardly you might say something like if you were angry in this situation it would make sense so you can normalize and empathize with the distress of the anger even if they don't consciously represent the anger in their story

and that may let them know that it's okay to have the anger if it's there but you're you're putting it in a maybe or perhaps that allows them to also disagree with you. But who would disagree that, you know, in that situation, they wouldn't be entitled to anger. So when you understand the link and understand the meaning, it's possible to tolerate the intensity of the negative feeling to some degree that's there. It helps them develop new meanings about their current and past experiences. So it starts with looking at everything that they're saying as meaningful, and it moves to them developing new meanings about their current and past experience and future. When we sincerely believe that everything a patient says has meaning,

the patient themselves feels meaningful. Ascribing meaning enhances the patient's esteem tremendously and makes them feel safe, enough to continue to talk, to continue to tell their story. I don't think it's as common as we would like to think that someone actually listens to us, for us, not to gain something for themselves, but to actually listen in order to understand. And that's the type of listening that we're doing here. When we listen in this way, we also try to reduce shame enough to get people to feel safe enough to be able to continue to share their uncensored thoughts and feelings. And we reduce shame through normalizing the human experience to some degree.

You know, like it would be normal in that experience to feel anger. Or, you know, it's hard to talk about these things. And it's okay if it's hard to talk about it. And we say those things not because we're trying to do some sort of technique, but because that's the most human caring and compassionate thing to do. it might start as a technique because it's new for you. But eventually if you're able to do it over and over again and kind of adopt the mindset of, yeah, this is something I want to do

because I believe in it as like, this is who I am. Then it becomes authentic. So we want to empathize with the meaning. A stoic epicticus said, men are not moved by events, but by their interpretations. men are not moved by events, but by their interpretations. You know, everything that we do is, we're attaching meaning to things, we're interpreting things. We remember things more that we find meaningful.

We make sense of the world through meaning making. Relationships can allow for deeper understanding and meaning to develop in life. And to strengthen our relationship with our patients, we must understand what it is they're saying and then empathize with that meaning. This is the most important thing we can do sometimes to help our patients. We often think in the context of our own lives, as a therapist or physician or mental health provider.

We need to allow people to be the expert of their own lives. A word of phrase may mean something completely different to our patient than it does to us. And so we have to ask, the patient to help us understand their interpretations and the meaning they assign to events they've experienced or to words that they find meaningful. One example is, even within the same faith tradition, two different people can mean very different things by different words. Forgiveness is one of those words. For some people, it's a bad word. It's a horrible thing. For other people, it's a very

life-giving word. It's almost so much so that I'm hesitant to use that word in the therapy context sometimes because it can attach so much blame to the person like, oh, I should just forgive, you know, like I should just forget that this happened. I should just say that this was my fault. No, that's, and I would, I mean, I would argue, and I think from forgiveness literature that that's not that word really means. It doesn't mean that what happened was okay to happen. It actually probably means that what happened was incredibly wrong. It doesn't mean that you aren't entitled to be angry. Actually, anger is the first step towards forgiveness. And it doesn't mean that you're going to forget because you will remember. It just means that you're going to release the sort of eternal

or temporal judgment, either to higher power or to the court systems. And it means that you're going to not focus on the emotional repercussions of the event that was transgressed against you. So you're not going to spend 60, 70% of your emotional life being angry towards this event. You're going to forgive. So that's what it means for me. But for other people, forgiveness is like this loaded word. And so I think it's really important.

to ask our patients what the different words mean and to not make assumptions. And we have to continually understand that we make assumptions all the time as a way of understanding the world, as a way of not being just confused. And I think especially the further we go on in training, some people get, they can even make more assumptions. And some people can come more into this place of not knowing, of knowing but not knowing, which can be kind of a good place to be in. So we don't want to cause misunderstandings, because those can make people feel isolated, which can lead to strains or ruptures in the relationship. If this happens, try to reconnect, try to step back and say, you know, I feel like I didn't quite

understand you there. This conveys respect and allows the patient to feel heard. I recently had a medical student work with me and I was having her look at an article and I think she wasn't quite sure if I just wanted her to tell me that the article was great or if I actually wanted her true feedback. And I think it's because most people would prefer just to be told that what they're doing is great. But I told her, no, I really want you to pick it apart. I want you to tell me every single error I made. And I want you to tell me if overall it makes sense or not, if you connect with it or not. And that's because I deeply want when I publish something for it to make the most sense it possibly can and for it to be able to help people who read it. If I'm if I'm not open to feedback,

then maybe I'm going to miss something. Maybe I have some blind spots. And those are good. Those are good to bring into the light. But for this for this medical student, she was not used to sort of authority roles being switched like that. You know, there's there's a hierarchy in medicine. And when you're on rotations, it's very evident that this hierarchy exists. And I would say it's sometimes important and that's complicated, especially in life or death situations for a hierarchy. Hierarchy naturally form in life and death situations. And the more life and death they are, I think the more quickly they form. But that's a larger discussion.

Nevertheless, it was the meaning of, hey, I would like feedback. and it was the checking in on what that meaning meant that was really important because otherwise she would have thought that I wanted just something like, you know, oh yeah, it's great, it's great. So that checking in on the meaning was so important there, even in the sort of educational, you know, working together relationships. Okay. So try to connect deeply with patients. with empathy and listening.

Listening to what is said, what is not said, what makes the patient defensive. You know, if we say something that you feel like the patient just increases in their defensiveness, that's important to notice as well and to put to words. And we want to listen to the rhythm, the sound of their vocal cadence, their emotions. Sometimes when someone's talking about something traumatic,

their voice drops in volume. sometimes when it's harder to get words out, they may be in a more traumatic state. In a state of trauma, Barocas area, the left side of the brain, the part of the brain that gets words out is decreased in activity in studies. So we want to watch for the change in how people are talking and the face for emotional cues. And sometimes we'll feel like a patient isn't entitled to the emotional. emotions they're experiencing. We have to search in that place for the meanings they've assigned to their pain. The meaning is what we can empathize with no matter the circumstance.

So we look for the distress. And I would say, you know, patients are entitled to their emotions. I disagree with some people who say, oh, you shouldn't feel that way. I don't know if people can stop feeling that way just by willing it. Emotions are coming up before thoughts. And so emotions are there and it's the meaning behind the emotion that we can look for, especially if the emotions like are confusing to us. If they're confusing to us, maybe they're confusing to them.

Maybe by searching for the meanings, we move them out of a state of a more dissociated, place to actually feeling the emotions and being more grounded. And when we do this, I really truly believe we develop a stronger therapeutic alliance. Here's a quote from Dr. Tar, to feel with a patient and share distress and to hopelessness and mistrust in the future is therapy. You are an observer in taking history, but you're a participant as a therapist. to share it together is therapy. That's Dr. Tar.

So meaning develops emotional endurance. Meaning develops emotional endurance. People who have chronic pain who believe they are enduring it for a deeper meaning report far less physical pain compared to those who do not report a deeper meaning. Even in birthing units, women report the highest amount of pain,

but also have the highest amount of satisfaction. The child being born gives meaning to the pain. And this meaning is so powerful that some women choose to endure the pain without accepting medication. Now, I have no issue with medication during that time period,

but what I'm saying is that there's this there's this thing of meaning that changes things in that. And I've met with women who have had stillbirths. and the meaning and the pain is a very different nature than when talking to a woman who's gone through a birth and had a healthy child. And it's often traumatic. It's often traumatic. And it's really, those are difficult, difficult sessions. And some of the most difficult positions in the hospital, I think, are where I work. We're a tertiary care center for, OB stuff. So we get a lot of high risk OB OB. And because of that, we have a lot more stillbirths. We have a lot more bad outcomes. And that's a really hard job.

Incredibly hard to be delivering children in that context. And I've worked with several people who are in that type of field. and it is very, very difficult. And I have a lot of empathy and true regard because it's, I mean, just the meaning of being there with a woman who is delivering a child that she wished was alive, but is not alive. And being that health care provider, I think can be incredibly meaningful. Because if you weren't there, that woman would be alone. And having someone to share that agony with is very powerful.

Victor Frankel in his book wrote about this, wrote about how the people in the camp would visualize their loved ones and getting home someday and being with their loved ones. Not knowing if their loved ones had died in other camps, but holding on to those memories, those meaningful memories in the midst of the cold, in the midst of people on people cruelty, which I think was part of the worst stuff that went on. People on people cruelty, it's hard to make meaning out of that. And that, I've seen that a lot in some of my recent patients

as like some of the most difficult things to get their head around is why are other humans cruel to other humans? and we have to look for meaningfulness in the midst of that, which seems so horrible. So we want to help our patients find meaning in the midst of their symptoms. Even symptoms that are maladaptive in the way that they present, like eating disorders, cutting harmful behaviors, we want to see it as adaptive. How is it somehow helping this person cope with the realities of their life? And we need to be thinking that they're doing the best that they can possibly do. And in their given set of circumstances, and I think that's helpful.

And how it's adaptive for them, we don't want to judge their symptoms. People feel judgment and people feel shame, and shame drives people further into addiction of sorts. and so we want to help them find new meaningful ways of coping with their realities, but we don't want to shame or burden the people more who are trying to overcome. And a lot of times we don't really understand all of the realities that lead someone to do what they're doing. And so we don't want to assume that they're doing it for superficial reasons, because we don't really know their life. We don't really know what happened to them early on.

And they may not be telling us everything. And what I found is that the more you do longer term work with someone, the more easy it is to understand and to empathize and to sort of see how they got to where they were when they first started seeing you. So here's a few phrases I like to use to convey to the patient that I want to connect. with in this way. What we are talking about together is meaningful. We want to make sure we are understanding each other. I think I know what you mean. Please tell me if blank is what you mean. I want to make sure I'm understanding you and that we are in tune with each other. If you feel

misunderstood, please tell me right away so that I can clear it up as soon as possible. We will know together, find out together. Could you give me an example, elaborate on that? I want to make sure I understand what you're sharing with me. I can understand how that interaction would make you feel that way, in part, you know, because we never truly understand right. So Logo Therapy was created by Victor Frankel, and Man Search for Meaning is kind of his entry-level book to this topic. And it chronicles his journey through the Holocaust.

But what about Logotherapy? Has it survived? It's a meaning-centered approach. And he first published on it in 1938. And it's now known as the third Viennese school of psychotherapy. The Victor Frankl Institute lists the three principles that are the basis for Logotherapy. freedom of will, will to meaning, meaning in life. And the core tenets can be elaborated in another way by the Victor Frankl Institute of Logotherapy in Texas. As life has meaning in all circumstances, even the most miserable ones, our main motivation for living is our will to find meaning in life.

And we have freedom to find meaning. in what we do and what we experience, or at least in the stand we take when faced with a situation of unchangeable suffering. Frankel noted that there are a variety of ways in which we can find meaning, such as by our actions, our experiences, our relationships, our attitude towards suffering,

and it's been used to treat anxiety, depression, OCD, and even schizophrenia. Currently, there are several logotherapy institutes in Africa Asia, Europe, North America, that are focused on educating the public about logotherapy and applying it to find meaning in people's lives. And in this last section, I'm going to go through some of the research that I found, and I'll put links to the studies on my website

with the summaries here. So one study, May 2010, found psychological safety and psychological meaningfulness was significantly related to engagement in work. They found that they could account for 73% of the variance in engagement and work with 62% coming from meaningfulness and 42% coming from psychological safety. So they found that meaningfulness was very important in engagement with work. I thought that was really interesting.

One study in 2016 of patients after heart surgery found those receiving logotherapy had improvements in their mood. It didn't change their physical capabilities post-surgery. However, in patients who had little or no symptom relief and continued limited functions post-off, it still showed an improvement in mood six months after this study was. completed. Another study in 2014, Robata Millie, had the Logotherapy group work on describing what was meaningful, setting goals, and then had the group facilitate each other moving towards their goals. In the treatment group, the meaning to life scores increased and depression scores decreased. Discovering and pursuing meaning is facilitated by helping through the following steps. So these are the

steps they used. Establishing the therapeutic alliance, increasing insight regarding identity, values, and goals, reframing meaninglessness and depression, discovering meaning within the meaninglessness and depression, and pursuing the fulfillment of meaning. Another study, they looked at positive attributes and the link to meaning. This was Zhang 2018. And it showed that in 1,000 elderly people in Hong Kong, the highest level of meaning was associated with happiness, health status, and decreased healthcare utilization. Now, we don't know what comes first.

You know, are happier people just more full of meaning, probably. And people who have more meaning happier, probably. Probably. Probably goes both ways. Another study in 2016 showed that when educational interventions based on the main concept of logotherapy were made, it led to an improvement of the patient's quality of life after a cabbage surgery in person's age 35 or older. And in another study of people with struggling with infertility, they use logotherapy and it showed decreased psychological stress scores. Another case review looked at adding meaning-based interventions into the treatment of PTSD, and it showed positive outcomes, and it kind of made the link that maybe this could be added to other psychotherapies. In a study of breast cancer patients, they showed that logotherapy could be helpful to reduce anxiety.

In another study, it showed how logotherapy sessions could help cancer patients find more meaning in life. Two more studies here. One, a qualitative interview study of nursing home residents. They found that meaning could be found in physical and mental well-being, belonging in recognition, and personal treasured activities. spiritual closeness and connectedness. And in the final study, they looked at meaning in physicians caring for patients. And they had physicians write poetry and then as a group look at the meaning of those poems. And they found that that was meaningful for the participants of the study.

It was more of an exploratory study of the potential use of poetry tell physicians. and one more comment on physicians is that the way that we focus on meaning as physicians changes our approach to things one physician I was talking to recently said that physicians who focused on the patient and the patient's wellbeing were the ones that were able to push through some really dire circumstances

and not get overwhelmed. And so I think there can be a loss of sort of our focus as a mental health providers. We can focus on things that are not, you know, the patient. And those, those things are distractions that we need to sort of notice that we're focusing on, not be judgmental because they're pulling our attention, but just rather than refocus on the things that brought us into medicine. and I would say the majority of personal statements that I've read are incredibly meaningful reasons on going into medicine. And then something happens as people get further along in their career. And I think it's, you know, the different stresses of life.

I was recently meeting with a group of physicians and they were very focused on lawsuits. And I think it's probably because, you know, it's hard to go through your career. medicine without getting sued at least once. And those can be incredibly painful experiences. And I would say even possibly traumatic. And that trauma, you know, like other traumas, keeps us ruminating on the trauma. And it moves us away from the meaning of, you know, the thousands of patients that have been helped. And so it can be helpful, I think, to work through that and to sort of refocus on what is truly meaningful. you know, our families, our connection with patients, the little things.

So, in conclusion, we want to focus on what is said by our patients and those we care about and believe that everything that they say has meaning and that can increase our connectedness with other people. This is fairly intuitive, but I think it takes, and practice to actually do this effectively. And it takes a, you know, a reminder to bring us back into this. So three things. For the provider, this is my message, you know, focus on the small moments of connection between you and your patients.

And that will be pleasurable, actually. For the patients, if patients are listening to this, you know, if you feel like your provider is not hearing you, then gently let them know. And, you know, a mature therapist provider will be open to that feedback and will want to more closely approximate your experience. In the intensive outpatient program I run, I often will have a patient who feels like they can't communicate to the therapist something. And after talking to me, they're able to, and then they feel reconnected to the therapist. And finally, for just the human being who's listening to this, right? We're all human beings. Think about how to do this with our family, with our kids.

You can practice it. You don't have to wait to be in a professional context. You know, you can watch your kids, even if they're super young. And what are the things that they're doing? And how is that meaningful to them? What is their micromomoments of meaning that they're forming as they pursue some small task. I'm big into kind of the Montessori method of progressive education where the child chooses their task and the teacher is really monitoring, trying to get them into progressively more difficult tasks that can be stimulating that they can enjoy. And they try to help the child create their own sense of enjoyment from that task.

and to some degree that's the child finding meaning in the challenge and that's that's good thing so if you haven't read victor frankle's book highly recommend it it's top of the reading list if you haven't read that and it's a short book you can get on audio and listen to it in just a couple hours if if you found this helpful um you want to learn more jump on the website there's an article that came with this. It was written with my little team of volunteers that I so appreciate. And finally, if you haven't checked it out yet, check out the CME portion of my website and consider using this as a resource to get your CMEs. I hope it's as painless as possible. I know getting CMEes is incredibly painful. And if you have other colleagues who need CMEes,

I would highly appreciate, highly appreciate, and be extremely grateful for you sharing this resource. So with that, have a great day, many blessings to you, and I hope that you yourself found this meaningful. I hope that you can observe your own thoughts, your own dreams, and find them more meaningful. And I will leave you there.