Recovery, the guiding vision of 21st-century psychiatric care, is a complex idea with differing definitions. Reference Ralph and Corrigan1 Recovery is viewed as an outcome: people with serious mental illnesses show some defined reduction in symptoms and attainment of independent living goals. Recovery is also viewed as a process where pursuit of individually meaningful goals, regardless of outcome, is a reality that must be supported by the mental health system. Central to both of these is hope: the belief in possibilities and optimism, rather than restrictions and poor prognosis. Psychiatric providers are in some ways new to the concept of hope. Long-standing notions of serious mental illness like schizophrenia stem from the writings of Emil Kraepelin, who defined these disorders in terms of a progressive downhill course. Grim prognoses cast a wide pall yielding glum futures. This is a perspective that continued in the Diagnostic and Statistical Manual up through its fourth edition, 2 despite long-term follow-up research. Research has shown most people with schizophrenia are able to attain work and independent living goals when symptoms entirely remit or when they learn to manage their disabilities. Reference Calabrese, Corrigan, Ralph and Corrigan3 Over the course of 50 years, people with lived experience who were frustrated with the status quo in psychiatry told their stories of recovery that led to the research and theory base of the vision. Rather than stealing hope from patients in our clinic, mental health providers learned to instil optimism and promote a sense of future.
At times, hope seems to have limitless potential for promoting well-being and quality of life, which begs the question, might there be limits to the phenomenon of hope? Is it false hope to suggest to a person with formal thought disorder and delusions of reference that she might be able to go to medical school? All principles of clinical practice need to fall under the critical eye of science to make sure we do not hold on to beliefs that are not supported, a task I attempt here. I doubt research will disable hope as an essential process, although it might suggest moderators.
Hope and medical decision-making
Bioethicist William Ruddick Reference Ruddick4 summarised the pros and cons of hope in terms of practices that include clinical deception; omitting important information in framing a medical decision. For example, is it false hope to encourage a patient to enter a medication trial for stage IV breast cancer highlighting positive possibilities while omitting negative probabilities? Ruddick lists advantages of clinical optimism in this light. Hope has clinical benefits; illness seems to wane when the person is hopeful. Hope promotes participation in treatment, especially those services that are demanding and protracted. People who more fully participate in treatment receive more attentive care from medical providers. Absent from Ruddick is a fourth benefit of hope especially relevant to mental health: hope promotes overall well-being by suppressing depression and fostering quality of life. Reference Werner5
However, there may be limitations to hope, especially in cases of deceptive prognosis. Reference Ruddick4 Consider harm wrought by the oncologist for the woman with stage IV cancer. Inaccurate information undermines the patient’s autonomy. She cannot fully determine treatment when unaware of disease parameters that are likely to modify this treatment. She is not, for example, fully informed about clinical and side-effects of the cancer trial without being aware of the boundaries of her prognosis. Most ethicists agree that autonomy trumps beneficence when assessing costs and benefits of clinical behaviour. Ruddick tempers these actions with considerations of the uncertainty of specific medical practices as a function of probabilities and possibilities. Probability is typically the domain of the provider; given hard signs of a disease, what are the chances that specific interventions yield therapeutic outcomes? Possibility is the arena of patients and their families, often influenced by variables beyond science. How might my health change if I put my faith in treatment or God? Ruddick believes medical providers might accommodate statements about hope and probabilities when met by strong assertions of possibilities from family and patient.
Hope and mental illness
What limits are there to hope for people with psychiatric disability? In some ways, hope and mortality seem to yield easier conceptual arguments than hope and psychiatric disabilities. Decisions about mortality, at least in the cancer clinic, seem easier to define than questions about whether a person can go back to work, live independently or get married. Markers of disease predicting death seem a bit more compelling than those of psychiatric symptoms and corresponding disabilities. Psychiatric research has been largely disappointing in identifying predictors of employment and independent living beyond small correlations. Reference Corrigan, Mueser, Bond, Drake and Solomon6 False positives in discouraging a person with schizophrenia from returning to work are high.
Still, false hope has been identified as an important concept in describing limitations of planned behaviour change. Polivy & Herman, for example, explained the dismal results in efforts to decrease smoking, control alcohol and drug use, manage diet and promote exercise by offering a false hope syndrome characterised by unrealistic expectations about the ease and consequences of attempts to change. Reference Polivy and Herman7 False hope results in continued attempts to pursue avenues of behaviour change that are ineffective for the individual. False hope prevents people from objectively assessing their status and goals. Applied to psychiatric disabilities, false hope might suggest that people pursue work goals that exceed true abilities. For example, someone seeks a full-time job as a paralegal when a more realistic job may be a part-time janitorial assistant. They need to replace these erroneous efforts with more realistic goals according to Polivy & Herman.
Snyder & Rand argued that false hope was based on incorrect assumptions. Reference Snyder and Rand8 For example, proponents of false hope suggest failed attempts at behaviour change are downhill and deleterious. Snyder & Rand counter that frequent and evolving efforts at goal attainment eventually lead to success. A false hope model frames behaviour change as black and white, which is contrary to contemporary approaches to change. Abstinence from alcohol, for example, is often tempered with harm reduction models where people are helped to diminish the impact of alcohol use rather than erase it altogether. Reference Marlatt, Larimer and Witkiewitz9 Snyder’s research has shown that higher hope in children and adults leads to better academic, health and mental health outcomes. Reference Snyder10
Conclusions
Hope, however, is not blind. It does not mean individuals forego careful self-assessment and critical thinking. Life’s decisions are more effective when the individual has knowledge about the full range of personal challenges and response options. Mental health service providers, peers and others can help obtain this information. Shared decision-making, for example, provides an approach for skilled providers to assist a person in assessing pros and cons of service options. Reference Drake, Deegan and Rapp11 This includes assessment of where the person currently stands in terms of challenges and skills. Others might help the decision-maker by providing alternative perspectives of a goal. ‘You know, Henry, getting an associate’s degree to pursue licensed practical nursing might be an intermediate step before attempting to get into medical school’. Although, at the end of the day, the decision lies with Henry. While others are plying Henry with information and perspective, they do not undermine his hope, the energy that helps him down the path of whatever he decides to pursue.
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