depression, existential family

8/6/2019 Depression, Existential Family

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DEPRESSION, EXISTENTIAL FAMILYTHERAPY, AND VIKTOR FRANKLSDIMENSIONAL ONTOLOGY

Jim Lantz

ABSTRACT: In existential family therapy, it is believed that ViktorFrankls dimensional ontology is a useful way to understand the differ-ent levels of depression that are important in both family assessmentand family treatment. This article reviews Frankls dimensional ontol-ogy, its usefulness for existential family treatment, the must, can,and ought levels of family depression, and presents clinical materialillustrating the described existential family treatment approach.

KEY WORDS: depression; existential family therapy; dimensional ontology; ViktorFrankl; Existenzanalyse.

One of the most common problems presented to general medicalpractitioners, psychiatrists, crisis intervention centers, hospital emer-gency rooms, social service agencies, individual psychotherapists, andmarital and family therapists is depression (Lantz, 1978; Lantz &Thorword, 1985; Maxman & Ward, 1995). Although depression is oftendescribed as the kind of problem that responds most effectively tomedications and individual psychotherapy (Maxman & Ward, 1995),family therapists have rather consistently pointed out that depressioncannot be wholistically understood or treated without an adequateunderstanding of the family context of the symptoms of depression(Andrews, 1974; Lantz, 1978; Lantz & Thorword, 1985). In this articletheauthorseeks to providean existential familytherapy understanding

of depression by outlining Viktor Frankls (1955, 1959, 1967, 1969,1975, 1978, 1997) existential dimensional ontology from a family-cen-

Jim Lantz, PhD, is a Professor at The Ohio State University College of SocialWork, 1947 College Road, Columbus, OH 43210, and Director, The Midwest ExistentialPsychotherapy Institute, Worthington, OH.

Contemporary Family Therapy 23(1), March 2001 2001 Human Sciences Press, Inc. 19


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tered point of view. Case illustrations will be presented to show howFrankls dimensional ontology can be used during existential familytherapy to more effectively structure the assessment and treatment ofdepression within its family context. The author believes that the useof Frankls dimensional ontology often results in a more effective, pre-cise, and cost-effective treatment experience for couples and familiesfacing depression.

ABOUT DEPRESSION

Depression strikes between 15 and 25 percent of the general popu-lation of the United States at least once during their lives (Maxman &Ward, 1995). Symptoms of depression can be severe, leading to suicidalattempts to stop the pain, or less severe yet still unpleasant anddisruptive to family life. The etiology of depression is mixed but isgenerally understood to include biological, neurochemical, genetic, psy-chosocial, family, developmental, ecological, and existential factors(Maxman & Ward, 1995).

Depression is generally considered to be a treatable problem, andmost authorities (Frankl, 1955, 1967; Maxman & Ward, 1995) believethat a flexible treatment approach using medications, environmentalmodification, and psychotherapy will most frequently be effective. Inexistential family therapy (Lantz, 1974, 1978, 1993, 2000), ViktorFrankls dimensional ontology can be utilized as a wholistic frameworkaround which to organize a flexible yet systematic approach to thefamily-centered treatment of depression.

FRANKLS DIMENSIONAL ONTOLOGY

In Viktor Frankls (1969)Existenzanalyseapproach to existentialfamily therapy, the we are of family existence includes three dimen-sions and/or levels of understanding. For Frankl (1955, 1969) family

existence (we arewe stand out) includes what we must do, whatwe can do, and what we ought to do. Using Frankls dimensionalontology, it is possible to identify three dimensions of family depression:the must dimension, the can dimension, and the ought dimension.

An outline of Frankls dimensional ontology for use during the existen-tial family treatment of depression is presented in Figure 1.


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FIGURE 1

Family Existence and Viktor Frankls Dimensional Ontology

THE MUST DIMENSION OF FAMILY DEPRESSION

In Frankls (1959, 1969) dimensional ontology, the must level of

family existence refers to those aspects of family life that cannot bechanged by will or choice. For example, all family members must dieif deprived of food, water, or shelter for an extended period of time.There is no will or choice in such a situation. In Frankls (1955, 1969,1978) dimensional ontology, it is understood that certain physical, ge-netic, neurological, and/or biochemical must factors contribute to fam-ily life, and that this must level of family existence is an extremelysignificant factor in the development of many mental health problems,such as depression, mania, and schizophrenia. In an existential familytherapy understanding of depression, it is accepted that chemical im-balances within the central nervous system may contribute signifi-cantly to the development of depression and that medical interventionis usually necessary on the must level of treatment for depression

among family members (Frankl, 1955, 1959, 1969; Lantz, 1978, 1993,2000; Lantz & Thorword, 1985). In existential family therapy, it isbelieved that family members suffering from biologically based depres-sion must continue suffering such depression until biochemical imbal-ances resulting in such depression are treated through medical inter-ventions such as the use of antidepressant medications (see Figure 1)


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(Lantz, 1978, 1993, 2000). In existential family therapy, it is importantto help must dimension depressed family members (as well as otherfamily members) to realize that their must level symptoms of depres-sion are not a result of their weakness or any lack of character orwill (Frankl, 1969; Lantz, 1978; Lantz & Thorword, 1985). For theexistential family therapist (Lantz, 2000), it is extremely important toteach must level depression families to avoid anger toward the selfabout those aspects of depression that family members cannot changethrough will or choice.

During the past 20 years there has been an explosion in under-standing of biochemical (must level) depression and in developmentof medications to help family members cope with or overcome thebiolog-ical (must) component of depression (Frankl, 1997; Maxman & Ward,1995). Such drugs fall into three general categories: the tricyclic drugs,the MAO inhibitors, and a group of second-generation antidepressantsthat include the newest drugs for the treatment of depression. All ofthese drugs probably correct biochemical imbalances that result infamily member must dimension depression and in this way normalizethe depressed family members mood.

In existential family therapy, it is also understood that an impor-tant element of must dimension depression treatment is to help allfamily members learn more about the chemical aspects of depression,

the symptoms of depression and family coping mechanisms that canhelp all family members resist, contain, and manage the impact ofdepression upon family life (Lantz, 1978, 1993; Lantz & Thorword,1985). In existential family therapy, it is believed that psychoeduca-tional methods can provide considerable relief with families andcoupleswho aretrying to deal with must level depression (Lantz, & Thorword,1985). The followingtwocase illustrationsdemonstrate existential fam-ily therapy in a clinical situation where the primary element of depres-sion was must level depression.

The James Family

Mr. and Mrs. James were referred to marital therapy by theirpriest after Mrs. James had complained to her priest about sleepless-ness, crying spells, and guilt about not wanting sex with my husband.

Although the couple was willing to follow their priests advice andengage in marital therapy, both the couple and the existential familytherapist quickly realized that Mrs. James was suffering with mustlevel (biological) depression that required psychiatric intervention and


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medications as the primary mode of intervention. Mrs. James wasreferred to the authors consulting psychiatrist who started her onantidepressant medications and provided (initially) weekly supportiveand educational counseling sessions to help the couple understand andcope with Mrs. James biologically based must depression. Mrs. Jamesresponded well to medications, and within three months was free ofher depressed mood, crying spells, suicidal ideation, reduced level oflibidinal energy, general energy loss, and difficulty eating. Mr. andMrs. James also experienced a considerably improved marital relation-ship with the decreased symptoms.

In this clinical illustration, Mrs. James responded well to medica-tions designed to meet her treatment needs at the must level ofexistence. Although significant marital treatment on the can and/orought levels of family existence was not needed, it is important toremember that successful must level treatment of depression oftenresults in a couples or familys realizing that additional treatment onthe can and/or ought levels of family existence is also necessary(Frankl, 1955, 1969, 1997; Lantz, 1978; Lantz & Thorword, 1985).

The Jackson Family

The Jackson family requested family treatment services after theirson overdosed on street drugs. The son stated that he had tried to kill

himself to end the pain. The family was referred to treatment by thephysician at the emergency room where the son had been treated forthe overdose. At the time of the first family session, the son scored 87(marked depression), the father scored 53 (minimal depression) andthe mother scored 51 (minimal depression) on the Zung (1964) Self-Rating of Depression Scale.

It was difficult to determine any unusual or pathological familyinteractional patterns in the Jackson family. The parents had an openand nurturing relationship with each other and appeared to be support-ive parents who were able to provide appropriate structure, guidance,and warmth to their son. The parents reported that their sons grandfa-ther on the fathers side of the family had committed suicide and thathis uncle on the mothers side of the family had suffered recurrentmajor depressions for many years. In view of this history, the sons

symptoms, and the apparently stable family atmosphere, the son wasreferred to a psychiatrist for a medication evaluation at the end of thefourth family treatment session. The son was placed on an antidepres-sant medication by the psychiatrist. The family continued in familytreatment that focused on helping the parents to protect and supportthe son until it could be determined whether medication was or wasnot helping.


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to learned patterns of family interaction that can be changed throughreflection, practice, and will. Knowledge about the can dimension offamily depression includes the contributions of existential, structural,behavioral, narrative, transactional, solution-focused, and psychoana-lytic family therapy and can help family therapists and their clientsunderstand how patterns of family living often result in depression.Family psychotherapy approaches focusing upon helping the familyor couple to challenge and change dysfunctional problem-solving andinterpersonal patterns can often be extremely effective with a couple

or family suffering can dimension depression. The following clinicalmaterial illustrates how existential family treatment may be useful toa couple or family suffering this type of depression.

The Smith Family

The Smith family requested treatment after their 15-year-old sontold the school guidance counselor that he was having problems study-ing due to concentration difficulties, sleep problems, and a loss of en-ergy. The counselor referred the total family for treatment. At the firstsession the son scored 73 (severe depression), the father scored 53(minimal depression) and the mother scored 38 (normal) on the Zung(1964) Self-Rating of Depression Scale. After a few exploratory family

sessions, the therapist concluded that the sons depression seemedreactive to a family transactional process in which the parents chan-neled marital conflict through their relationship with the son. The sonfelt trapped in the middle and ended up feeling disloyal to bothparents. Intervention was directed toward helping the son to stay outof the middle and toward helping the parents to manifest their maritalproblems to each other in a clear, direct, and congruent way. The sonsdepression quickly lifted, andduringthesixth family session, thefamilymembers were again given the depression rating scale.

On test number two, the father scored 67 (marked depression), themother scored 79 (severe depression) and the son scored 51 (minimaldepression). These test scores reflected a decrease of 22 in adolescentdepression and an increase of 55 in parental depression. At this pointthe focus of treatment changed, and both the therapist and the parents

concentrated upon improving the parents marital relationship. Goodprogress was made and termination occurred after 13 sessions. Attermination the father scored 49 (normal), the mother scored 42 (nor-mal) and the son scored 48 (normal) on the Self-Rating of DepressionScale. The Smith familys scores on the depression scale documentedan increase in parental depression following a decrease in adolescentdepression during conjoint family therapy. This was followed by a de-


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crease in parental depression after the parents worked through someof their marital difficulties.

The Jones Family

The Jones family requested family treatment after their 17-year-old daughter overdosed on her mothers blood pressure medication. Thefamily was referred for treatment after the daughter was released froma medical facility. At the initial treatment session, the daughter scored

73 (severe depression), the mother scored 53 (mild depression) and thefather scored 36 (normal) on the depression inventory.

In the Jones family the mother and father had a distant maritalrelationship and the mother used the daughter as a nurturing object.She was unable to obtain this nurturing from her husband. The daugh-ters role of mothers emotional caretaker inhibited the daughtersability to spend time with peers and also blocked her natural develop-mental push toward autonomy and independence. Intervention focusedupon freeing the daughter from her pathogenic role and helping theparents begin to reestablish mutual nurturing within their maritalrelationship.

At the eighth family session, the family members were given testnumber two. At this time Tina (the daughter) was beginning to distanceherself from her dysfunctional family role. Tina scored 51 (mild depres-sion), the mother scored 82 (severe depression) and the father scored68 (marked depression) on the depression inventory scale. Test numbertwo revealed a decrease of 22 in adolescent depression and an increaseof 61 in parental depression.

The family remained in treatment for a total of 16 sessions, andat the time of termination, the father scored 39 (normal), the daughterscored 32 (normal) and the mother scored 47 (normal) on the depressioninventory. Again in the Jones family, a decrease in adolescent depres-sion coincided with an increase in parental depression at the time oftest number two. And once again, at termination test number threerevealed decreased parental depression that coincided with an im-proved marital relationship and stabilization of a lower level of adoles-cent depression.

The Hubbard Family

TheHubbard family requested treatmentafter their daughter com-plained of energyloss, crying spells,anda sleep disturbance. The familyinitially contacted their family physician, who referred them for fam-


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ily treatment. In the Hubbard family, the daughter also performed thefamily system role of being mothers emotional helper in reaction tothe distant relationship between the parents.

On test number one, the daughter scored 71 (extreme depression),the mother scored 56 (mild depression) and the father scored 47(normal). Test number two was given during family session twelveafter the daughter had begun to have some success moving away fromher pathogenic role. On test two, the daughter scored 34 (normal),the mother scored 66 (moderate depression) and the father scored 83(marked depression) on the depression inventory. There was a decrease

of 38 in adolescent depression and an increase of 46 in parental depres-sion on test number two. Termination occurred after 22 sessions. Ontest number three the father scored 43 (normal), the mother scored48 (normal) and the daughter scored 38 (normal). Again, the Hubbardfamily demonstrated an initial increase in parental depression follow-ing a decrease in adolescent depression. The level of parental depres-sion then decreasedfollowing an improvement in their marital relation-ship.

In the three previous can depression families, an adolescent fam-ily member developed severe depression reactive to problems in theparental relationship. In all three families, there was decreased adoles-cent depression and increased parental depression when the adolescent

was helped to stay out of the parents marital problems (Lantz, 1978,1993, 2000) and the parents began to challenge and change their mari-tal difficulties. The three previously described can level depressionfamilies are typical examples of families that develop a symptomaticadolescent reactive to structural, interactional and/or communicationproblems.

THE OUGHT DIMENSION OF FAMILY DEPRESSION

In Frankls (1955, 1997) ought dimension of existence, there isa focus upon what the couple or family ought to do or is called bylife to accomplish and/or achieve. On the ought level of existence, the

couple or family is understood to be a recipient of meaning opportuni-ties presented to the family by life (Lantz, 1993, 2000). An oughtdimension understanding of depression includes the awareness thatdepression is sometimes a direct result of a couples or familys avoid-ance or repression of the call of life (Frankl, 1955, 1997; Lantz, 1974,1993, 2000). In such a situation, the couple or family develops an


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existential-meaning vacuum that becomes filled with symptoms of de-pression reactive to the familys failure (i.e., bad faith) to respond to thecall of life and to themeaning potentials and opportunities presentedbylife (Frankl, 1975, 1997; Lantz, 1974, 1993, 2000). In Frankls (1975,1997) dimensional ontology, finding the oughts in a familys life canprevent the occurrence of some depression and can often help the coupleor family to overcome the symptoms of depression that grow and flour-ish in an existential-meaning vacuum. This author believes that onlyexistential family therapy and its practitioners have shown an ade-

quate interest in helping depressed couples and/or families to noticeand respond to the meaning potentials and opportunities in life andexploring how this approach can be helpful in the treatment of depres-sion. This existential family therapy approach to the treatment ofought dimension depression may be described as existential reflectiondirected toward discovering Frankls unconscious ought (Lantz,1993). The following clinical material is presented to illustrate oughtdimension family depression and its treatment.

Mr. and Mrs. Sampson

Mr. and Mrs. Sampson requested clinical services after the death

of their son from an AIDS-related illness. Mr. Sampson indicated thathe was having problems sleeping because my conscience is botheringme. Mrs. Sampson stated she was worried about her husband. Mr.Sampson explained, I kicked my son out of the house three years agowhen he told me he was gay. Knowing my son was gay was a big shock.I didnt handle it well. Mrs. Sampson reported that she, her husband,and the son had eventually reconciled and that the son had lived athome for the last three months of his life.

Mr. and Mrs. Sampson both said they felt proud they had beenthere for their son when he was dying. The couple also reported thatthey were fools to have kicked him out of the house, and that theywould always feel guilty about their ignorance. They stated they hadlost a year and a half with their son because of their ignorance, andnow that the son was dead they would give anything to get that time

back. Mr. Sampson reported that he could not sleep at night becausehe kept thinking about his mistake.In this situation the existential family therapist initially encour-

aged the couple to talk about their tragedy and their feelings about it.The therapist was very careful not to give advice and simply listenedto the couple until they felt comfortable that the therapist had someunderstanding of their feelings. It was only after the therapist wasassured that the couple had perceived him to be an empathic person


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whohadworkedhard to understand them that thetherapist waswillingto give the couple a suggestion.

When empathic trust had been developed, the therapist asked thecouple how they might feel about giving talks about the mistake toother parentsthose who hadrecently discovered their son or daughterto be lesbian or gay. They initially felt uncomfortable with this idea,but as time went on, decided it was a really good idea. The couplefelt this suggestion gave them a way to help others and help turn amistake into something useful. Mr. and Mrs. Sampson were linkedwith a gay rights organization for volunteer work and were also pro-

vided with support and training in their public speaking activities. Bythe time this article was written, they had shared their experience andmistake in over 50 speeches. Also, Mr. Sampson no longer experiencesdifficulty sleeping.

The Roberts Family

Mr. and Mrs. Roberts were referred for treatment by Mr. Robertsoncologist. Mr. Roberts had throat cancer and could no longer eat solidfoods. His feeding process was considerably less than dignified. Mr.Roberts reported that he obsessed about solid food, and Mrs. Robertsreported that it gets to me that he cannot even enjoy his food. Forover 40 years the members of the Roberts family had been sitting downat the dinner table and sharing bread. The family had abandonedthis activity reactive to Mr. Roberts inability to eat solid food.

In this family the members had always used the family dinner asa ritual to signify, share, and experience meaning. With the loss of thisritual, the family experienced an emptiness in their daily life. Theyexperienced an existential vacuum. The existential family therapiststask with the Roberts family was complex. One part of the task wasto help the family create a new ritual that family members could useto share and experience meaning. After the Roberts family replacedthe dinner ritual with poker parties and the game of fish, Mr. Robertsreported that he no longer was obsessing about solid foods. Replacingthe lost ritual helped the family discover the family ought of celebrat-ing the closeness and love that they had shared over the past 40 yearsas Mr. Roberts approached his death.

The Jabco Family

Mr. Jabco was brought for admission to a psychiatric hospital byhis adult son and daughter. His presenting problem was labeled as abiological depression by his psychiatrist and the hospital treatmentteam. Mr. Jabco was 68 years old. The onset of his depression occurredsoon after he had lost his wife to her year-long fight with cancer.


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Mr. Jabco had retired one year prior to his wifes death only todiscover that his first year of retirement would be spent helping hiswife deal with her deadly disease. Mr. Jabco had never suffered withdepression before, and there was no history of depression in his familyof origin. Both the son and daughter reported that they were franticbecause Mr. Jabco had said he was thinking about killing himself. Theson and daughter did not want to face the death of both parents. Boththe client and his children reported that Mr. Jabco had not been de-pressed while his wife had been alive.

In spite of the fact that Mr. Jabco exhibited some of the classical

symptoms of a biological depression (energy loss, suicidal thinking,crying spells, and sleep disturbance), he was not suffering from merelybiological (must level) depression. In this clinical situation, Mr. Jabcowas also suffering from an existential vacuum. Mr. Jabco and his chil-dren had suffered a tragedy. When Mr. Jabco was provided an opportu-nity to discuss, explore, and challenge the meaning vacuum he wasexperiencing reactive to the family tragedy, Mr. Jabco was able toovercome his depression. His children were also able to overcome theirfeelings of anxiety.

Mr. Jabco and his adult children were seen together by a familytherapist in a conjoint family interview at the request of Mr. Jabcospsychiatrist. During the initial family interview, Mr. Jabco reportedthat he and his wife had been looking forward to his retirement withgreat expectations of having fun through both travel andcultural activi-

ties. Mr. Jabco reported that for him retirement was now empty and,as far as he could see, so was the rest of his life. He indicated that hewanted to die so that he could again see his wife in heaven. Mr. Jabcobelievedin an afterlife and felt that life on earth could not be meaningfulwithout his wife. He was not aware of what life might be calling himto do on the ought level of existence.

The family therapist asked Mr. Jabco exactly what he and his wifehad planned to do and see after his retirement. Mr. Jabco explained ingreat detail the plans he and his wife had made and the cultural activitiesthey had hoped to experience. Mr. Jabco reportedthat his wife had alwayswanted to visit her relatives in Italy. He sobbed as he explained howunfair it was that his wife would not get to have this visit.

At this point, the family therapist asked Mr. Jabco, Do you thinkyour wife will be disappointed in not getting to hear about your trip

to visit her relatives in Italy or your experience of the other activitiesyou and she had planned? Mr. Jabco immediately stopped sobbing.He remained silent for a few minutes and stared directly at the familytherapist. He then laughed and stated, I always did want to be areporter. He also told the family therapist, That is the kind of questionthat shocks you into seeing a good reason to keep on living.

At the next family interview, Mr. Jabco reported that he had


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stopped having crying attacks, that his food tasted better, that hewas sleeping well, and was getting his energy back. He added, Killingmyself seems like a very bad idea now; I want to get out of this hospitalas soon as possible so I can get on with my retirement.

Both adult children reported that they felt much better and be-lieved that the family therapist had performed magic. The familytherapist thanked the son and daughter for the compliment, but saidthere is no magic in helping an individual remember that their relation-ship with someone they love can still be meaningful after death.

The existential questions used in this clinical illustration were

based upon the beliefs and values of the family. Mr. Jabco and hischildren believed that Mr. Jabco would see his wife again after hisdeath. They also believed that action and behavior are only meaningfulif done in a transcendent way for the benefit of those one loves.

The Existenzanalyse question used by the family therapisthelped Mr. Jabco to see that he could go on living and enjoy his retire-ment in a way that was giving to his wife and compatible with thebeliefs and values of the family. It allowed him and his children to see ameaning potential in retirement that they had not been able to perceivepreviously on a conscious level of awareness. Mr. Jabco is presentlyenjoying his retirement, visiting his children on a frequent basis, andhas had no recurrences of depression.

CONCLUSIONS

In existential family therapy, it is believed that Viktor Franklsdimensional ontology can be used as a framework to ensure that fami-lies suffering depression will be treated in a wholistic manner. Withinthis framework, family depression is understood to include three levels:the must (biological), can (interactional), and ought (existential)dimensions of family existence. Numerous case examples have beenpresented to illustrate the treatment of family depression on all threelevels of existence.

REFERENCES

Andrews, E. (1974). The emotionally disturbed family. Northvale, NJ: Jason Aron-son, Inc.

Frankl, V. (1955). The doctor and the soul. New York: Vintage Press.Frankl, V. (1959). Mans search for meaning. New York: Simon and Schuster.Frankl, V. (1967). Psychotherapy and existentialism. New York: Simon and

Schuster.Frankl, V. (1969). The will to meaning. New York: New American Library.


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Frankl, V. (1975). The unconscious god. New York: Simon and Schuster.Frankl, V. (1978). The unheard cry for meaning. New York: Simon and Schuster.Frankl, V. (1997). Recollections. New York: Dimension Books.Lantz, J. (1974). Existential treatment and the Vietnam veteran family. In Ohio

Department of Mental Health Yearly Report (pp. 3336). Columbus: Ohio Departmentof Mental Health.

Lantz, J. (1978). Family and marital therapy. New York: Appleton-Century-Crofts.Lantz, J. (1993). Existential family therapy: Using the concepts of Viktor Frankl.

Northvale, NJ: Jason Aronson, Inc.Lantz, J. (2000). Meaning-centered marital and family therapy: Learning to bear the

beams of love. Springfield, IL: Charles C Thomas.Lantz, J., & Thorword, S. (1985). Inpatient family therapy approaches. The Psychiat-

ric Hospital, 16, 8589.Maxman, J., & Ward, N. (1995). Essential psychopathology and its treatment. New

York: Norton.Zung, G. (1964). A self rating of depression scale. Archives of General Psychiatry,

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