published: 30 March 2021
Frontiers in Psychology | www.frontiersin.org 1March 2021 | Volume 12 | Article 645926
University of Johannesburg,
Victoria L. Bowers,
Saybrook University, United States
José Manuel García Montes,
University of Almeria, Spain
This article was submitted to
Personality and Social Psychology,
a section of the journal
Frontiers in Psychology
Received: 24 December 2020
Accepted: 22 February 2021
Published: 30 March 2021
Russo-Netzer P and Ameli M (2021)
Optimal Sense-Making and Resilience
in Times of Pandemic: Integrating
Rationality and Meaning in
Front. Psychol. 12:645926.
Optimal Sense-Making and
Resilience in Times of Pandemic:
Integrating Rationality and Meaning
Pninit Russo-Netzer 1
*and Matti Ameli 2
1Department of Advanced Studies, Achva Academic College, University of Haifa, Haifa, Israel, 2Private Practice, Valencia,
The global COVID-19 pandemic has triggered a wide variety of psychological crises
worldwide. In order to respond rapidly and efﬁciently to the complex challenges, mental
health professionals are required to adopt a multidimensional and integrative view.
Rational Emotive Behavior Therapy (REBT) founded by Albert Ellis promotes rationality
and self-acceptance. Logotherapy, pioneered by Viktor Frankl potentiates meaning and
resilience. Both approaches are complementary and mutually enriching. The goal of
this paper is to propose an integrative model of “optimal sense-making,” a concept
that combines both rationality and meaning, as well as the role of self-transcendence
and healthy negative emotions. The model offers a theoretical and clinical foundation
for efﬁcient and effective psychological intervention plans for those affected by the
pandemic. Along with theoretical background, illustrating case studies are presented to
support potential application of the integrative model to affected individuals as well as
the work of ﬁrst-line health professionals during these times of pandemic. Implications
are considered for utilizing theoretical and applied insights from the model to cultivate
resilience in face of adversity and suffering.
Keywords: logotherapy, rational emotive behavior therapy, rationality, meaning, resilience, self-transcendence,
The unprecedented coronavirus pandemic caught us by surprise and has caused so far over
1,250,000 deaths worldwide. Few mental health professionals have experience dealing with the
psychological consequences of such devastating pandemic. This new and challenging situation
requires ﬂexibility, creativity, and integrative attitude from mental health professionals.
Rational emotive behavior therapy (REBT), the pioneering form of cognitive-behavioral therapy
developed by Albert Ellis in the 1950’s and Logotherapy, a meaning-based psychotherapy proposed
by Viktor Frankl in the 1930’s are philosophically based and empirically-supported. Their
integration could lead to the marriage of rationality and meaning, enabling a more stable and
profound foundation to counteract catastrophism and despair in the face of the tragedy. For
example, Dryden (2020) highlighted the importance of rationality to avoid adding horror to the
crisis. Complementarily, the importance of meaning-making has been emphasized as a resource in
Russo-Netzer and Ameli Optimal Sense-Making and Resilience in Pandemic
coping with challenging life circumstances such as adversity,
crisis, and trauma (e.g., Janoﬀ-Bulman and Yopyk, 2004; Damon,
2008; Melton and Schulenberg, 2008; Linley and Joseph, 2011;
Park, 2013; Czekierda et al., 2017). According to the meaning-
making model, for example, perceived discrepancies between
appraised meaning of a particular situation and global meaning
(i.e., general orienting systems of beliefs and goals) create distress,
which generates meaning-making eﬀorts to reduce it. Combining
the two approaches of rationality and meaning, Ameli (2020)
proposed initial ideas on how to use logotherapy as an adjunct to
REBT to help therapists deal with potential personal challenges
during the pandemic. The present paper takes these directions
forward to oﬀer an integrative clinical model of “optimal
sense-making,” based on a brief overview of both REBT and
logotherapy, and illustrated though clinical examples of case
studies related to the current pandemic situation.
Overview of REBT
The American psychologist Albert Ellis (1913–2007) founded
Rational Emotive Behavior Therapy (REBT) in 1955. REBT is
considered the ﬁrst form of Cognitive-Behavioral Therapy (CBT)
and Ellis is considered the grandfather of CBT, and a major
contributor to the cognitive paradigm shift in the ﬁeld of clinical
psychology (David, 2015). Ellis (1962) was highly inﬂuenced by
Greek Stoic philosophers such as Epictetus and Marcus Aurelius.
Ellis proposed the ABC (or ABCDE) model to conceptualize
the role of thinking process in emotional disturbance. The
Astands for Activating events or Adversity, the Bstands
for Beliefs that includes functional or rational beliefs (RBs)
and dysfunctional or irrational beliefs (IBs), and the Cstands
for emotional, behavioral and cognitive Consequences. Those
consequences could also become themselves activating events
(A), producing secondary or meta-consequences (e.g., anxiety
about being anxious or depression about being depressed).
Clients learn through the process of therapy to actively and
vigorously dispute (D) their irrational beliefs in order to generate
eﬀective new philosophies (E) based on healthy, functional and
adaptive beliefs. It is important to note that although REBT
emphasizes B as the main mediator between A and C, it views
cognition, emotion, behavior as interconnected, and interactive
processes, inﬂuencing each other (Dryden et al., 2010; Ellis and
Ellis, 2011; DiGiuseppe et al., 2014).
Ellis believed that a dogmatic and rigid philosophy of
demandingness based on absolutistic beliefs expressed in terms
of “musts,” “should,” “oughts,” and “have to’s” toward self, others,
and life or the world was at the heart of psychological disturbance,
leading to three other types of irrational beliefs: awfulizing
(an extreme exaggeration of the negative consequences of a
situation), frustration intolerance (demanding comfort and ease
at all times and not tolerating discomfort), and global evaluation
of worth of self or others (the idea that human being are
ratable and some are worthless or less valuable than others)
(DiGiuseppe et al., 2014). While rigid and dogmatic beliefs
are at the core of psychological disturbance, psychological
ﬂexibility based on relativism, non-dogmatic preferences and
unconditional acceptance is a key feature of psychological
health (Dryden et al., 2010; DiGiuseppe et al., 2014). Given
that REBT promotes a rational life philosophy emphasizing
unconditional self-acceptance, unconditional other acceptance
and unconditional life acceptance (Ellis and Ellis, 2011), it may be
particularly relevant to the current pandemic situation because
it helps counteract the sense of guilt, shame and blame in
aﬀected individuals, paving the path toward greater sense of
comprehension, purpose, and compassion.
REBT distinguishes between unhealthy/maladaptive and
healthy/adaptive negative emotions. Healthy negative emotions
such as concern, annoyance, sadness, disappointment, and
regret or remorse are based on rational beliefs whereas
unhealthy negative emotions such as anxiety, depression, clinical
anger, shame, and guilt are based on irrational beliefs. For
example, concern is based on the belief “I hope nothing bad
happens to me but I am not immune from it and if it
happens, it would be unfortunate not terrible.” In contrast,
anxiety is associated with the belief “Nothing bad should
happen to me and if it does it would be terrible.” REBT
only targets unhealthy and maladaptive negative emotions
(Dryden et al., 2010; Dryden, 2012; DiGiuseppe et al.,
2014). Dryden (2020) views the concept of healthy negative
emotions as one of the strength of the REBT model. In
face of great loss or tragedy, “taking the horror out of the
tragedy” (Dryden, 2020, p. 300) could be liberating for clients,
since they can still feel painful and embrace strong healthy
REBT is a multimodal approach used in diﬀerent cultures,
which has integrated a variety of cognitive, emotive and
behavioral techniques that can be used with a wide range of
clients (Ellis and MacLaren, 2005). The main goal of REBT is
to identify, dispute and modify rigid, irrational and unhealthy
philosophies based on absolutistic demands, and a lack of
unconditional acceptance of self, others and life/world into
a ﬂexible and healthy philosophy based on preferences and
unconditional acceptance (Ellis and Ellis, 2011). Disputing, the
best-known method of REBT, aims at helping clients to identify
their core irrational beliefs. Functional disputes question the
helpfulness of the client’s belief and the resulting behaviors
and emotions, empirical disputes are centered in ﬁnding out
the if there is empirical evidence that support the client’s
belief, and logical disputing is focused on questioning the
illogical absolutistic demands instead of preferences. A variety
of questioning styles such as Socratic, didactic or humorous are
used (Ellis and MacLaren, 2005; DiGiuseppe et al., 2014). REBT
is an active-directive therapy which emphasizes unconditional
acceptance of clients despite their self-defeating patterns in
order to facilitate and encourage unconditional self-acceptance
(DiGiuseppe et al., 2014).
REBT is a scientiﬁc and evidence-based form of
psychotherapy that has been found eﬀective for a large
spectrum of clinical psychiatric disorders (depression, anxiety
disorders, addiction, eating disorders etc.) and populations
(David et al., 2005). Results of recent meta-analysis related to
the relationship between both irrational and rational beliefs
and psychological distress show a positive correlation between
irrational beliefs and various types of psychological distress
such as anxiety, depression, general distress, anger, and guilt
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Russo-Netzer and Ameli Optimal Sense-Making and Resilience in Pandemic
(Vîsla et al., 2016), and a negative association between rational
beliefs and psychological distress, with the strongest association
being for unconditional acceptance beliefs (Oltean and David,
2018). A thorough review and meta-analysis of REBT over
the last 50 years demonstrates the eﬃcacy and eﬀectiveness of
REBT interventions in the format of psychotherapy, psycho-
education, or counseling for various conditions regardless of
age, clinical status, and delivery format (David et al., 2018).
Yet, the current pandemic situation calls for more breadth
and depth in responding to the crisis and its implications. The
COVID 19 virus has aﬀected humanity in all countries, cultures,
and civilizations. Consequently, humanity is facing a sense of
despair or meaninglessness, and many question the meaning
of their lives. Essentially, the disruption of routine, social
distancing, uncertainty, isolation and loneliness have shaken and
violated important aspects of people’s sense of meaning, such as
comprehension, purpose, and mattering (cf. George and Park,
2016; Martela and Steger, 2016) and has inﬂuenced their mental
and physical well-being (see De Jong et al., 2020). It is thus of
particular importance to go beyond rationality and to integrate
the framework of meaning to not only discover a “why” to say
yes to life in spite of the crisis but to also gain resilience and even
grow in the face of adversity. A Logotherapy- enhanced REBT
has the potential to oﬀer a deep, hopeful and powerful therapy
in the long term. In this context, for example, Frankl (1986)
proposed the term “monoanthropism” or shared humanity,
which can be valuable for both therapists and clients to familiar
with, to understand that they are not alone in this situation.
Overview of Logotherapy
The Austrian neurologist, psychiatrist, and doctorate in
philosophy Viktor Frankl (1905–1997) pioneered Logotherapy
during the 1930’s. It is generally deﬁned as an empirically based
meaning-centered approach to psychotherapy. Frankl (1969)
envisioned logotherapy as an undogmatic system of therapy,
open to its own evolution as well as collaboration with other
psychotherapeutic orientations. It has been called the “third
Viennese School of Psychotherapy” (the ﬁrst one being Freud’s
Psychoanalysis and the second Adler’s individual Psychology).
Logotherapy envisions the human person in three overlapping
dimensions: somatic-physical, psychological, and noetic-
spiritual. Frankl (1969) referred to the spiritual dimension as
“noetic” to avoid religious connotations. The noetic dimension
is considered the healthy of authentically human phenomena
and includes qualities such as self-distancing, self-transcendence,
humor, values, imagination, love, and gratitude. In contrast
with the ﬁrst two dimensions where our reactions are often
automatic, in the third dimension, we can choose how to behave
(Lukas, 1998). Intentionality is the key factor that makes human
beings unpredictable. Frankl’s theory is based on the premise
that human beings are motivated by a “will to meaning,” an
inner pull to discover meaning in life. The fundamental tenets of
logotherapy are freedom of will, will to meaning and meaning
in life (Frankl, 1969). Freedom of will asserts that human beings
have the freedom to choose their response within the limits of
given possibilities, under all life circumstances. Will to meaning
points out that the main motivation of human beings is to search
for the meaning and purpose in their lives. Meaning in life
highlights that life has meaning under all circumstances, even in
unavoidable suﬀering and misery.
We can discover meaning in life in three diﬀerent ways known
as the categorical values. These categorical values are comprised
of the creative values, the experiential values, and the attitudinal
values (Frankl, 1959/1984). The creative values consist of what we
give to the world, like accomplishing a task, creating a work, or
doing a good deed. The experiential values are what we take from
the world, like the experience of truth, beauty and love toward
another human being. The attitudinal values reﬂect the stand we
take toward an unchangeable situation or unavoidable suﬀering
(Frankl, 1959/1984). Tragic optimism (Frankl, 1959/1984) refers
to remaining optimistic through hope, faith and love in spite of
the tragic triad of pain, guilt, and death. This is based on the
principle that life is meaningful under all circumstance and the
human capacity to make the best of any given situation by turning
creatively the negative aspects into constructive ones (Frankl,
1959/1984; Lukas, 1998).
The three main techniques used in logotherapy are
paradoxical intention (using self-distancing through humor
to counteract anticipatory anxiety), dereﬂection (shifting the
focus of attention toward meaning through self-transcendence),
and attitude modiﬁcation (challenging a negative attitude by
activating the will to meaning through Socratic dialogue).
The goal of the logotherapist is to tap into unique human
capacities such as intentionality, responsibility and freedom
of choice, and to broaden clients’ visual scope to help them
discover and actualize the meaning potentials in their lives
(Ameli, 2016a,b). Logotherapy focuses both on the client’s
“current positives” (assets and strengths) and “future potentials”
or possibilities for expansion (Lukas, 1998). The logotherapist
awakens and mobilizes clients’ inner resources and orients them
toward areas where meaning can be found in their unique
situation (Marshall and Marshall, 2017). The logotherapist is
active during the therapy session, pointing out incoherencies,
sharing ideas and disagreeing with clients when their values are
not adjusted to reality (Lukas, 1998).
In clinical practice, logotherapy has been found useful with
problems such as depression, anxiety, alcohol/drug addiction,
psychosis, grief, and despair associated with incurable disease
(Schulenberg et al., 2008; Marshall and Marshall, 2017).
A large number of research studies have been conducted
to validate the main concepts, constructs and tools used in
logotherapy (Batthyany and Guttmann, 2006). The concept of
meaning has been validated by research in logotherapy. The
Purpose in Life test (PIL), a 20-item psychometric tool developed
by Crumbaugh and Maholick (1964) is the oldest and most
investigated instrument that measures the degree to which a
person experiences a sense of personal meaning. The PIL is
consistent with the logotherapy postulate with a high degree
of reliability, shows positive correlations with items such as
self-control, life satisfaction, self-acceptance, emotional stability
and resilience, and is correlated negatively with anxiety and
depression (Melton and Schulenberg, 2008). The Purpose in Life
test-Short Form (PIL-SF; Schulenberg et al., 2011) is a brief four-
item valid and reliable version of the PIL presenting unique
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psychometric contributions beyond other meaning assessment
tools. Recently, Shoshani and Russo-Netzer (2017) developed the
Meaning in Life in Children Questionnaire (MIL-CQ), a 21-item
instrument that measures the presence and sources of meaning in
life in children, based on Frankl’s categorical values, and Russo-
Netzer (2018a) proposed the construct of “prioritizing meaning,”
positively associated with well-being.
Meaning-centered individual and group therapy
psychotherapy programs have also been found as highly
eﬀective and empirically validated in various settings and
populations (e.g., Breitbart and Masterson, 2016; Southwick
et al., 2016; Weathers et al., 2016). These ideas and tools appear to
be especially relevant in the context of the present COVID crisis.
Integration of REBT With Logotherapy
REBT and Logotherapy share many similarities and present a
high degree of compatibility. Ellis (1985) referred to Frankl,
highlighting the importance of values in psychotherapy and
(Frankl, 2004, p. 83) insisted on the importance of questioning
the rational validity of clients’ philosophy of life.
Hutchinson and Chapman (2005) and Lewis (2009) have
proposed innovative ideas to integrate REBT with logotherapy
at the clinical level. Hutchinson and Chapman (2005) argue that
cognitive shifts in REBT and logotherapy are complementary
and propose to augment REBT disputation techniques with
logotherapeutic concepts such as hope, faith and optimism, in
addition to reason. Since REBT diﬀerentiates between healthy
and unhealthy negative emotions, Hutchinson and Chapman
(2005) believe that introducing the concept of meaning could
help clients to better tolerate the adaptive negative emotions
such as sadness, frustration, or disappointment by addressing
their potential inherent meaning. At the metacognitive level,
logotherapy-enhanced REBT could be more eﬃcient to decrease
and counteract secondary disturbance in the form of rumination,
constant self-evaluation or excessive reﬂection on the rationality
of one’s thinking, using the technique of dereﬂection.
Considering the similarities and contrasts between REBT
and logotherapy, both approaches aim at replacing unhelpful
and detrimental beliefs with beneﬁcial ones (Lewis, 2009). In
REBT detrimental beliefs are irrational beliefs and reason is used
to replace them with rational ones while in logotherapy, the
process of meaning discovery is employed to help clients choose
beneﬁcial attitudes, deﬁned as consistent beliefs. Lewis (2009)
points out that in the language of REBT, beneﬁcial attitudes could
correspond to “meaningful attitudes” while detrimental beliefs
could be labeled as “meaningless” or “nihilistic beliefs.” Thus,
beliefs that are both rational and meaningful have the advantage
to lead to self-transcendence and may produce greater beneﬁts
PROPOSAL FOR AN INTEGRATIVE
MODEL: OPTIMAL SENSE-MAKING
Building on the ideas presented by Hutchinson and Chapman
(2005) and Lewis (2009), we propose to include an explicit and
systematic exploration of meaning in the framework of REBT, in
order to promote resilience in the face of the current pandemic.
At the theoretical level, REBT oﬀers a rational and empirically
supported explanation of psychopathology by emphasizing the
four key irrational beliefs (i.e., Demandingness, Awfulizing,
Frustration Intolerance, and Global Evaluation of Worth)
in producing psychological disturbance. According to Ellis,
Demandingness (consisting of demands and “musts”) is the
core irrational belief which is at the heart of psychological
disturbance. Awfulizing, Frustration Intolerance, and Global
Evaluation of Worth are derivatives of Demandingness, each
leading to psychological disturbance as well (DiGiuseppe et al.,
2014, p. 37).
Logotherapy on the other hand, oﬀers a coherent meaning-
centered framework to enhance well-being, and to promote
motivation for change and resilience, in order to face life’s
adversities in spite of suﬀering. When one has a reason, a
purpose, or a “why” to live for, there is a higher probability
to tolerate negative emotions such as pain, sadness, or
disappointment, and in turn to develop perseverance and
discipline, and to make necessary adjustments or even sacriﬁces
for the sake of meaning. Along these lines, previous research
suggests that meaning has been found to be associated with self-
acceptance, emotional stability, resilience, and post-traumatic
growth (e.g., Melton and Schulenberg, 2008; Breitbart and
Masterson, 2016; Southwick et al., 2016; Weathers et al.,
2016).We propose to complement the original Ellis’s emotional
disturbance model of irrational beliefs with Demandingness as
the core irrational belief with a logotherapy based model of
self-transcendence, with Meaning as the core beneﬁcial belief,
conceptualized in Figure 1.
Combining these two models may allow an integrative view
of challenges and adversities experienced by many individuals
during the current pandemic. On the one hand generating
rational thinking by promoting ﬂexibility, relativism, frustration
tolerance, and unconditional acceptance (of self, others, and life)
enables reduced distress and may facilitate the meaning discovery
process. On the other hand, meaning discovery could act as
a buﬀer against irrational beliefs by increasing well-being and
Integrating rationality through REBT’s emotional disturbance
model and meaning through Logotherapy’s model is likely to
generate optimal beliefs, or “optimal sense-making.” We propose
the term optimal sense-making as contextual. It depends on
multiple individual factors such as the person’s strengths, healthy
resources and potentials, personally meaningful values, the
speciﬁc situation at a given time, and all available opportunities
and choices. Optimal sense-making may be deﬁned as an
intentional process of evaluating an adversity through both
the lenses of rationality and meaning in order to motivate
an individual in a given context to realize optimal decisions,
choices and actions in accord to reason and his/her personally
meaningful values, enabling him/her to tolerate the inevitable
negative consequences, within a responsible, meaning-oriented
and self-transcending frame. It is neither hedonistic, positive
nor pleasure-oriented, but rather a realistic, ﬂexible, mature,
and meaningful way of thinking that is likely to help reduce
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Russo-Netzer and Ameli Optimal Sense-Making and Resilience in Pandemic
FIGURE 1 | Logotherapy-based model of self-transcendence: meaning as core.
distress, enhance resilience and generate growth by promoting
acceptance, self-transcendence, and perseverance.
The importance of broadening the scope of existing models to
support the healing and empowering of the clients is in alignment
with Bruner’s (1990) suggestions of moving beyond cognition
and the importance of meaning-making and the cultural context.
More recently, Beck et al. (2020) proposed the Recovery-
Oriented Cognitive therapy (CT-R) to facilitate recovery and
resilience in individuals with serious mental health issues. This
is a strength-based model which emphasizes individuals’ values,
aspirations, and personally meaningful activities. At the clinical
level, the integrative approach based on our optimal sense-
making model presents various advantages such as to assist
in moderating clients’ resistance, increasing their tolerance to
healthy negative emotions, and enhancing their motivation,
openness, and perseverance toward long-term change.
To enhance motivation toward change, it would be useful to
actively seek with resistant, less motivated or inconsistent clients,
a powerful and meaningful reason which self-transcends them
that may provide an ’anchor’ to which they can strive and that
will enable them to better tolerate negative emotions that may
arise and maintain perseverance and hope. Along these lines,
Ameli and Dattilio (2013) presented a clinical case to illustrate
how self-transcendence (i.e., love for a spouse) can be used to
motivate a resistant client suﬀering from generalized anxiety
toward exposure and facilitation of cognitive restructuring. The
construct of meaning based on values could be included as
part of the REBT disputing process as well, by implementing
logotherapeutic techniques such as dereﬂection (i.e., shifting the
focus of attention from the problem toward meaning through
self-transcendence) and attitude modiﬁcation (challenging a
negative attitude by activating the will to meaning through
Socratic dialogue). That may enable to explicitly guide meaning
discovery, and to assess the meaningfulness of the rational beliefs
and the new eﬀective philosophy generated by clients in order to
direct them toward more optimal beliefs and philosophy (both
rational and meaningful).
The concept of ’tragic optimism’ (Frankl, 1986) could be
implemented to help clients (1) turn suﬀering into human
accomplishment, (2) turn guilt into a learning opportunity to
change for the better, or (3) perceive life’s ﬁniteness as an
incentive to use time wisely and to take responsible action
(Frankl, 1959/1984). Along these lines, Lukas (1986) points out
that in many occasions, behind a crisis, there is an opportunity
to grow, and behind the suﬀering, a meaning. She recommends
being cautious and tactful applying logo-philosophy, since it
might be easier for the therapist than the client to discover the
constructive or positive aspects available in face of the loss and
suﬀering. These steps are particularly relevant for the current
pandemic situation. To illustrate that, in the following section
case illustrations and examples related to the pandemic are
presented and discussed.
CASE ILLUSTRATIONS AND EXAMPLES
RELATED TO THE PANDEMIC
The concept of optimal sense-making based on the integrative
model presented, could be valuable in assisting those aﬀected
directly or indirectly by the pandemic. Two examples are
presented below to illustrate the integration of REBT and
logotherapy toward optimal sense-making, at the clinical level.
The ﬁrst one is a real client therapy case. The second one
is the real case of a pulmonologist who faced a near-death-
experience during COVID. Finally, we include recommendations
for working with dysfunctional beliefs held by distressed
health professionals dealing with COVID 19 patients who have
contacted us to receive therapy.
Example 1: Clinical Case
A 67-year-old retired woman, a client with a history of
depression, caught the ﬂu during the lockdown period. She had a
severe cough and felt extremely tired. Her doctor told her that she
did not have the coronavirus and she was not in danger. She was
unable to perform her daily activities and was put on bed rest. She
was living alone. She had been a very hard-working client with a
high level of discipline and perseverance.
As a ﬁrst step, REBT was used to challenge the unhealthy
and dysfunctional beliefs through disputation, in order to turn
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Russo-Netzer and Ameli Optimal Sense-Making and Resilience in Pandemic
them into eﬀective and helpful beliefs. Logotherapy was used as a
second step to enhance a sense of meaning.
C: “This is terrible. Even though I do not have the coronavirus,
we are in the middle of a pandemic, I am sick, alone, and I am not
able to do anything. I don’t have any strength to move on.”
T: I understand that this is a challenging situation for you.
Considering the pandemic and the lockdown, it’s not easy to be
alone and sick in bed. However, I am conﬁdent that together, we
can ﬁnd ways to help you. What is the most important goal that
you would like to achieve by the end of the session?
C: to feel better and get unstuck, to have some motivation to
move on. . .
T: ok. Just to better understand your concern, what is for you
the worst part, or the one thing that you would eliminate?
C: to be honest, being sick with the ﬂu I guess. I am used to
live alone and if I were not sick, it would not be that bad.
T: so for you being sick would be the terrible part of all?
C: correct. Being sick in this pandemic situation.
T: I understand. How do you feel, being sick this
C: I feel like desperate. . . . I know the physician told me I do
not have the coronavirus but this ﬂu thing seems eternal to me. I
T: I can imagine. How often do you feel desperate?
C: at least at some point every day. I feel like crying and not
T: I understand how you could feel that way. To summarize,
you believe that being sick is terrible in this pandemic situation.
You feel desperate at least once a day and feel like crying and not
doing anything. You are stuck, as if your ﬂu was not going to go
away. Does that seem right to you?
C: yes. I just don’t want to feel this way anymore!
T: I totally understand. The good news is that we have learned
together [in previous sessions] some concepts and techniques
that could help you feel better and get unstuck. Going back to
what we learned together about healthy and unhealthy negative
emotions in face of adversity, despair like depression is an
unhealthy emotion because it does not help you to get unstuck
and move forward. What could be a healthy negative emotion
that you would like to feel instead?
C: maybe sad, or disappointed?
T: good! Now let’s see how to get there. Do you remember the
ABC model we learned together some time ago and that you had
the opportunity to practice with some of your issues?
C: yes. I was thinking about it. It’s about your thoughts about
the event determining how you feel, not the event. Therefore, if
I feel an unhealthy emotion that means that I have to change my
thoughts to feel better.
T: good summary! Our beliefs (B) regarding adversity (A)
largely determine how we feel and how we act (C). As you well
recall, when there is an unhealthy negative emotion at C like in
your case here with despair, in order to change it, it’s important
to identify the unhealthy or dysfunctional belief behind it and
turn it into a healthy belief that would lead to a healthy negative
emotion. Do you remember how we did that?
C: yes, although I am not at my best today! I remember I had to
question the belief to see if there were objective data that showed
that it was realistic and if it was useful to reach my goal and see if
there where shoulds or absolutism?
T: very good! You remember quite well. We use disputing
to evaluate the belief based on three criteria: if it is realistic,
based on objective data, logical meaning that it makes sense,
and if it is functional meaning that it’s useful or helpful to reach
your goals. We also learned that shoulds based on absolutistic
demands were unhealthy so we had to challenge them. Now, let’s
ﬁrst examine your belief “being sick is terrible in this pandemic
situation.” Before using the evaluation criteria, based on what we
had learned previously, is there something that jumps at you?
C: the word terrible. I remember that we had to challenge it
because it means as if everything is bad, like the end of the world!
T: you nailed it. Terrible would mean that everything is 100%
bad for you right now or your whole life is ruined because you
are sick in this pandemic situation. Now, using objective data, is
that really true?
C: well, not really. . . . Not everything is bad or ruined. I
just have the ﬂu and I guess that I will get over it even if
it’s taking a long time. At least it’s not dangerous like the
coronavirus. In addition, my sons are wonderful, they are
bringing me food and checking on me even in lockdown
and I can do some little activities like listening to music or
T: it is remarkable that you are able to see that not
everything is negative and to point out objective aspects
related to your issues that are not negative. This is evidence
that your belief is not realistic. Your previous practice
with disputing is paying oﬀ! Now, when we learned
that terms such as terrible, horrible etc... are generally
rooted in demanding absolutely somethings with shoulds,
musts etc. Looking at your belief what are you demanding
C: Yes, I remember that. I guess that I should not be sick in
T: right. Now, using the second logic-based criteria, is it logical
to demand that?
C: No, it doesn’t make any sense. I can’t demand not to be sick,
even if there is a pandemic.
T: right. This belief is not logical. You could wish or prefer not
to be sick but it does not have to be that way even in a pandemic
situation. Does that make sense to you?
C: yes. I remember that we talked about preferences and
wishes. I have my index cards from other beliefs.
T: excellent! Now, let’s focus on the third criteria, the
functional one. How is this belief helping you to reach your goal
of feeling better and being unstuck?
C: It’s clearly not helping. It actually keeps me stuck
T: right. This belief is clearly not helpful since it does
not help you move toward your goals of feeling better
and being unstuck. Now, summarizing, based on the three
criteria, the belief “being sick is terrible in this pandemic
situation” is unrealistic, illogical, and unhelpful. It’s an
unhealthy belief. As long as you hold on to this belief, you
are likely to will feel desperate and stay stuck. Can you
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Russo-Netzer and Ameli Optimal Sense-Making and Resilience in Pandemic
C: yes. If I want to feel better and get unstuck, I will have to
T: good point. Now, let’s see what an alternative healthy could
be, one that would help you move toward your goals of feeling sad
or disappointed instead of desperate and getting unstuck so you
can move forward. Knowing that based on objective evidence, the
word terrible is inaccurate, what would be a more accurate and
C: maybe unfortunate?
T: good! Now, what would be an alternative healthy belief?
C: It’s unfortunate to be sick in this pandemic situation but it’s
not terrible because not everything is bad. The ﬂu will go away
and I will be able to get back to my activities.
T: excellent! You can also add if you want those positive
aspects you mentioned about your sons and doing some
activities. Things that you can do.
C: I like that idea. Seeing the positive is also helpful.
T: right. Now, let’s check if that alternative belief ﬁts with the
three criteria: based on objective evidence, is it realistic, logical
C: yes. It’s all true.
T: how do you feel when you read that belief?
C: I feel like disappointed but at least I can see some light at the
end of the tunnel. I am not that stuck anymore. However, to be
honest with you, I don’t feel motivated to do things even though I
know I can do little things. It’s like, what’s the point. .. Am I being
T: I totally understand. This does not have to do with being
diﬃcult and I am glad that you brought it up! Let’s focus on the
motivation issue. What do you think could motivate you?
C: I don’t know. .. Something maybe that could at least matter
to me. . .
T: I see. What is important for you in life, what really matters
C: my family deﬁnitely. I have two wonderful sons and
grandsons whom I love above all. The other one as you know is
music, playing the piano, my cre ativity. . .
T: great! You also mentioned before that your sons are visiting
you and helping you in spite of the lockdown situation. As a
mother and a pianist, what could be a meaningful gift to your
sons to show them your strength to do things and to move on in
spite of being sick, alone, and conﬁned?
C: good question! Maybe a song? But I am too tired to get on
the piano. . .
T: how about just composing the notes in your head? I know
you are a very talented musician and you told me that you had
C: yes, it’s true. I can try to compose something in my head
T: maybe something related to the pandemic. For example, a
melody that represents for you the pandemic, which is an actual
challenge right now. What are your thoughts?
C: I like that idea. It’s like I can handle the pandemic situation,
I can represent it! Composing the notes in my head will keep me
busy even if it’s not easy right now. Nevertheless, I enjoy doing
this and knowing that it’s a gift for my son is important for me!
When I get better I will just play it on the piano and tape it.
T: fantastic! You see, when there is a meaningful task or
project to fulﬁll, when we choose to do something for the sake
of love, it’s easier to ﬁnd the strength and the motivation to do it
in spite of adversity. This is what meaning is all about. Reaching
beyond ourselves. This is a choice.
C: I agree. Composing that song as a gift for my sons shows
my love and strength to them, even being sick in the pandemic.
They would really appreciate it!
T: sure. It would be like turning this unfortunate or
disappointing period into a creative project, out of love for your
family! Can you see that?
C: yes! I feel more motivated now to do that, it’s like a purpose.
T: Excellent! So, what are your most important takeaways
from today’s session?
C: that being sick in the pandemic is not terrible and that I can
still ﬁnd strength in music and love for my family to keep going!
T: very good! Now what could be your homework for
C: I guess prepare an index card and tape it on my cell phone
to listen to it several times every day or when I feel bad.
T: right. The goal would be to practice and implement the new
healthy and meaningful belief we learned today and an index card
would be a good reminder. Let’s prepare together that card with
all we did today.
Final Index Card With the “Optimal Belief”:
“It’s unfortunate to be sick with the ﬂu in this pandemic
situation but it’s not terrible. The ﬂu will go away and I will
go back to my daily activities. I can take advantage of this
disappointing period to compose in my head the notes of a song
that represents the pandemic for me. That would be a great gift
of love to my family, the proof of my strength to move on in
spite of being sick and alone in the pandemic. They would really
Result: The client recovered from the ﬂu and composed the
song. She shared it with her family and some of her students
and musician friends. They liked her song very much and
congratulated her. She told the therapist “If I have been able to
overcome this, I could overcome anything!”
Analysis: the above example shows how drawing on the
client’s unique talents to come up with a meaningful project,
based on her creative and experiential values, and self-
transcendence (i.e., a gift of love to her family) contributed
to increase her motivation to move on and led to resilience.
REBT was ﬁrst used to De-catastrophize her thinking and
come up with a helpful belief and a healthy negative emotion
(disappointment vs. despair). Logotherapy was then used to turn
disappointment into a motivating and meaningful project for
the sake of her family. This integrative approach resulted in
an optimal philosophy of life to enable her to better face her
This case shows the added value of the integrative model based
on optimal sense-making. Although REBT helped the client
reduce distress and adopt a more ﬂexible and accepting view of
her situation, it was not enough to motivate her to move on.
Logotherapy focused on client’s strengths and values, helping her
discover a worthwhile “why” that increased her motivation and
well-being. It was easier to discover meaning at a second step
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Russo-Netzer and Ameli Optimal Sense-Making and Resilience in Pandemic
since her thinking was already more ﬂexible and healthier. The
combination of both rationality and meaning led to acceptance,
self-transcendence and resilience as proposed in our integrative
model. This shows that optimal sense-making has the potential
to be more eﬃcient and powerful in long term than rational or
meaningful thinking alone.
Example 2: Real Case of a Pulmonologist
Infected With Coronavirus Who Fought to
Anooup Mahewareshi, a 59 year old pulmonologist residing
and working in Southern California contracted the coronavirus
in April 2020. He became seriously sick and didn’t think that
he would make it. He said goodbye to his family and friends.
After spending 9 tough and challenging days at the hospital,
he was ﬁnally able to survive Covid-19 and was released.
The combination of several factors such as the treatment plan
proposed by the doctors (including two long-term friends),
openness to try a new medication, and a strong personal
determination to ﬁght and not give up were key. Anoop
emphasized that “The emotional make-up matters. The support
and prayers of friends and family matters. It is all a very humbling
experience.” He also pointed out to the importance of the
emotional support he received by his long-term Indian doctor
friend of 35 years (member of his treatment team) through his
words “you cannot give up on me. You have to ﬁght” as a turning
point for his decision to not give up. The Indian doctor who is a
very committed and hardworking professional (working 12–14 h
a day) returned to work his work at the hospital after only 2 weeks
of recovery at home.
This case represents both rationality and meaning that seem to
have contributed to survival. An analysis of an in-depth interview
with Anoop is presented below to illustrate the integrative model.
Analysis: This case example shows how rationality, goal
orientation with a plan and trust in signiﬁcant and meaningful
others could increase motivation for survival and hope in the
face of death and hopelessness, leading to post-traumatic growth.
Anoop described himself as already a strong, driven and logical
person. However, he had decided to give up on life (“I kept telling
myself that was like how a person in jails felt like. I was in an
8 by 10 room alone and with nothing to do. . . . I was feeling
very hopeless and helpless. I told myself that it was it and I
gave up. I wanted to let go and die”), and the emotional turning
point occurred with the words of a loving, caring and trusted
doctor friend “you can’t give up on me.” He decided not to
give up and disappoint a friend who knew him also very well.
This has made him set a goal for himself, a worthy challenge.
That meaningful friend helped shift his mindset to survival and
hope. He was able to adopt an optimal form of thinking in his
speciﬁc situation where friendship made a signiﬁcant diﬀerence
“I can’t give up on my friend. This is not an option. I have the
set goal of survival with a coherent plan and I will do whatever
it takes to get there. Just say focused on your plan.” He actively
acted against his initial catastrophic beliefs, and managed to cope
in spite of all the challenges and pain involved. Not only was
he able to face that tragedy without catastrophizing or adding
horror to it, as Dryden (2020) highlighted but he also turned
it into personal achievement. He grew as both a person and
professional because of that traumatic near-death experience. At
the professional level, he is now more compassionate toward his
patients and is able to relate and connect better with them. He
is also very generous with family visits to COVID patients and
give a physician order to allow family members to visit despite
the current restrictions. At the personal level, he testiﬁes that he
has gained more authenticity, more appreciation of life, and a
higher awareness of life’s ﬁnitude and the importance of time. He
is more aware of the value of what matters in life and spends time
doing what he likes and also feels closer to his family. Against all
expectations, he decided to go back to the hospital after only 2
weeks of recovery. Although he is still at risk, when the thought
of Coronavirus comes his mind, he just keeps going (“having
gone through the emotions of near death experience. . . I would
have never been able to imagine that without going through it. I
learned that time is limited and now I do what makes me happy.
I don’t think as much as before. Now, I just do the things that I
really want to do”).
This example is a good illustration of the integrative model:
although rational thinking is helpful, it might not be suﬃcient
to hang on to life, in a near-death situation. Anoop decided to
survive only when a meaningful friend gave him a reason to do
it, for his sake. Meaning, along with a coherent treatment plan
helped him maintain rational thinking, avoid catastrophizing,
and stay focused on his recovery plan and tolerate pain and
discomfort. This shows how rationality based on Ellis’s model and
meaning as proposed in the logotherapy-based model interact to
produce optimal sense-making which leads in this case to post-
traumatic growth. Anoop seems to have interiorized that optimal
philosophy since he was able to return to work by implementing
a combination of rationality and meaning through dereﬂection
in the high-risk hospital setting where he works: “when the fear
of virus comes into my mind, I just keep going.” This shows
how optimal sense-making could also lead to acceptance, self-
transcendence and perseverance in long term as proposed by the
Working With First Line Health
Professionals Struggling With the
It is important to keep in mind that very few health professionals
have previously confronted a global pandemic of this magnitude
or have been trained to deal with one. During the ﬁrst wave of the
pandemic, in many countries, the citizens would applaud every
night the health professionals and they were considered heroes.
First line health professionals who attend many cases of COVID
19 patients and who seek therapy, often have the following types
of beliefs: “I should save everybody. I can’t make errors because
it’s terrible to fail. I will be a failure not a hero. I cannot stand this
painful situation anymore. I am exhausted. I am not qualiﬁed to
deal with this.”
There is a mixture of unhelpful thinking mostly related to self-
downing and frustration intolerance, and a sense of hopelessness
and despair. We suggest that it would be beneﬁcial to integrate
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Russo-Netzer and Ameli Optimal Sense-Making and Resilience in Pandemic
both REBT and Logotherapy strategies to provide them with
psycheducation on both rational and meaningful philosophy
to deal with the pandemic and its consequences. It would be
important to emphasize authenticity, empathy, and tactfulness
in the therapeutic process and adjust it to clients’ individual
characteristic and context, in order to be able to genuinely help
and inspire them to an optimal form of philosophy to face the
pandemic. An example could be the following: “I accept myself
as a fallible and imperfect human being. Realistically, I will not be
able to save every patient and that does not make me a failure, just
human. My self-worth is not function of the number of patients
I save. I am going to take care of myself all I can, in order to
be able to give the best of myself to my patients. My vocation
is stronger than this virus and tolerating this painful situation
means not abandoning my patients, even if it’s exhausting and
tough. Choosing this attitude will help me to learn from my
mistakes, gain more knowledge and build strength so I can move
forward in spite of everything. My patients deserve it.”
An optimal philosophy in the face of the pandemic is not
only realistic and helpful but also meaningful. In working with
healthcare workers, unconditional self-acceptance through REBT
in face of the global pandemic crisis is a very important goal as a
ﬁrst step. As a second step, Logotherapy could be implemented
to highlight the meaning, purpose and values embedded in their
work (e.g., asking why they have decided to choose their career,
to emphasize their vocation and what it means to care for and
serve their patients) and to identify a worthy goal to pursue.
In this context, combining unconditional self-acceptance and
self-transcendence may serve as key to perseverance, frustration
tolerance, learning, and resilience. Highlighting the option to
choose a heroic attitude, or the ’triumph of the human spirit’
(Frankl, 1986) would be more helpful than focusing on the social
concept of a hero. It is the choice of one’s attitude that may also
ultimately lead to post-traumatic growth and humility. It could
also be beneﬁcial to share with them and help them reﬂect on
true stories of health professionals like the example of Anoop,
who have survived the coronavirus and are back to the hospital
dealing attending COVID19 patients. If dealing with awfulizing
beliefs, it would be important to tactfully teach the diﬀerence
between tragedy or crisis and horror as Dryden (2020) pointed
out and the possibility to turn it into a personal accomplishment
(learning, humility etc.) through logotherapy.
SUMMARY AND CONCLUSIONS
In the current critical situation in which many individuals
are ﬁnding themselves in new situations, often more limiting,
a robust, profound, and eﬃcient life philosophy is much
needed in clinical practice to best support clients aﬀected
by the COVID19 pandemic. REBT and logotherapy are
philosophically based, empirically supported, collaborative,
and multicultural orientations with broad applications. They
present multiple similarities that make them highly compatible
and complementary. Building on previous insights proposed
by Hutchinson and Chapman (2005) and Lewis (2009), a
logotherapy-based model of self-transcendence with meaning
as the core beneﬁcial belief is proposed to complement Ellis’
model of emotional disturbance with demandingness as the core
irrational belief. Combining both models at the clinical level
would lead to “optimal sense-making,” an integrative approach
toward adversity which unites both rationality and meaning in
order to assist clients to generate an optimal philosophy of life
that would, in turn, empower them to face the pandemic with
courage and without losing hope.
Recent studies have shown that higher levels of meaning
in life correlate with lower states of anxiety and COVID-19
nski et al., 2020), and that interventions aimed
at ﬁnding meaning in life may help people to cope with
the psychological eﬀects of the pandemic (De Jong et al.,
2020). The examples presented in this paper aimed to show
the relevance of an integrative approach based on optimal
sense-making at the clinical level. The ﬁrst example is a real
clinical case of catastrophic beliefs and despair that illustrates
how integration through optimal sense-making could lead to
motivation for meaningful action and resilience. The second
example is a true case of a pulmonologist who was able to choose
survival and perseverance by uniting a rational philosophy with
meaning through friendship, which resulted in posttraumatic
growth. Finally, suggestions for supporting health care
professionals dealing with Covid-19 patients, based on the model,
A logotherapy-enhanced REBT based on optimal sense-
making has the potential to increase the eﬃciency and
eﬀectiveness of the therapeutic process by integrating reason
and meaning, self-transcendence and self-acceptance, ﬂexibility
and resilience. Furthermore, such approach includes the central
concepts and wisdom of mindfulness-based therapies such
as acceptance, love, gratitude, or compassion, without the
challenges related to the Buddhist dogma or the Eastern
philosophy and their consequent adaptation to the Western
mentality. Once a rational attitude has been gained, the therapist
can address the client’s freedom of choice, values, strengths, and
meaningful goals, as well as his or her sources of meaning in
life (e.g., Lukas, 1998; Wong, 1998). Special attention should
be given to the clients’ own words, beliefs, and experiences,
beyond symptoms of current situation, such as synchronicity
and meaningful coincidence (Jung, 1969; Russo-Netzer and
Icekson, 2020), transformative life experiences (TLE; Russo-
Netzer and Davidov, 2020), and sacred moments (Lomax et al.,
2011). Being mindful to such experiences may enable to elicit
inner wisdom and to uncover “meaning cues” which in turn
may broaden the client’s perspective to see new possibilities
and enable self-discovery (e.g., Lukas, 1998). Based on this
foundation, the therapist can help the client to prioritize meaning
in day to day living as a source of coping and thriving, in
face of challenging times. In this sense, prioritizing meaning
reﬂects individual diﬀerences in the extent to which meaning
is implemented via the decisions individuals make about where
to invest eﬀort in the context of everyday life (Russo-Netzer,
2018a). Such prioritizing has been found to be connected
with happiness, life satisfaction and gratitude among adults.
This suggests that focusing on and prioritizing engagement in
activities that are inherently value-congruent may serve as a
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Russo-Netzer and Ameli Optimal Sense-Making and Resilience in Pandemic
tangible and concrete mechanism for instilling life with meaning
and increasing well-being.
A major aspect of COVID 19 is not only the fear for
one’s health but also the social distancing it entails and the
encompassing sense of uncertainty as to what will happen, how
to cope and what could be the consequences. When we move
beyond zero-sum structures and neat conceptual frameworks to
a more holistic and integrative view, especially in face of the
challenging and uncertain times of the pandemic, we are more
capable of exploring the full and rich range of individuals’ needs
and experiences. Healing inevitably entails acknowledging and
confronting the dark side of human existence, which reﬂects
the dialectical coexistence of positives and negatives (Lomas and
Ivtzan, 2015), and the principle of self-transcendence (Wilber,
1980, 2000; Wong, 2011). The brokenness, downfalls, and defeats,
as well as the glorious highs and victories, are all important and
valid part of our human wholeness (cf. Russo-Netzer, 2018b),
and of our unique ability to leverage suﬀering into mental health
Finally, given that very few mental health care workers have
been confronted with a pandemic of this magnitude, training
therapists on this model during the current crisis could be
challenging. A potential ﬁrst step may be training practitioners
expert in REBT and practitioners expert in Logotherapy on the
proposed integrative model, and to set up pilot clinical trials with
a target group of frontline care-givers (e.g., health professionals
confronted with COVID patients) to assess the validity of the
model based on its level of eﬃciency compared with REBT and
Logotherapy alone. Based on these pilot trials, speciﬁc protocols
could be developed to train practitioners and professionals to
better handle future crisis. Encouraging evidence from recent
multisite training and implementation of pilot programs during
the pandemic support such directions (see, for example, Worley
et al., 2020). Furthermore, given that video and virtual formats
have been shown to be eﬀective similarly to in-person care (e.g.,
Morland et al., 2017), this may be another ﬂexible route for
adapted therapists training during the current crisis.
All authors listed have made a substantial, direct and intellectual
contribution to the work, and approved it for publication.
The authors would like to dedicate this paper to the late Dr.
Arthur Freeman for his valuable contributions to the ﬁeld.
His generosity, openness and humanity have been a source
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Conﬂict of Interest: The authors declare that the research was conducted in the
absence of any commercial or ﬁnancial relationships that could be construed as a
potential conﬂict of interest.
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Frontiers in Psychology | www.frontiersin.org 11 March 2021 | Volume 12 | Article 645926