Cultivating Hope

Jon G. Allen, PhD
Dr. Allen is Senior Staff Psychologist at The Menninger Clinic; Helen Malsin Palley Chair in Mental Health Research and professor of psychiatry in the Menninger Department of Psychiatry and Behavioral Sciences at the Baylor College of Medicine.

Psychiatrist Karl Menninger characterized hope as requiring a motive force for a plan of action. Cultivating hope is the over-arching purpose of treatment at The Menninger Clinic.

Many patients who seek treatment at The Clinic are struggling to hang on to hope or have lost hope altogether. They are grappling with major life problems, such as loss of loved ones, severe conflicts in close relationships, occupational setbacks or failures, and traumas of all kinds. Such recent experiences often act as the last straw in a pileup of stress over the lifetime.

Such serious life problems are intertwined with psychiatric conditions including anxiety, depression, addictions, and personality disturbance; these conditions, in turn, undermine patients’ capacities to cope effectively. Commonly, routine psychiatric care is insufficient to resolve the psychiatric conditions, leading to further demoralization. Thus many patients seek treatment at The Clinic when they feel stuck, trapped, humiliated, alienated—and hopeless.

Aristotle wisely said that we have a better chance of achieving our aim if we have a target. We can begin cultivating hope by thinking clearly about it. Psychologist Paul Pruyser, who worked closely with Karl Menninger, helpfully distinguished hope from optimism and wishful thinking. All three concepts entail positive expectations about the future, but hope is distinctive in presupposing a tragic situation along with serious suffering. Thus, compared to hope, optimism is relevant to less serious matters, such as succeeding at a specific task. Unlike wishful thinking, hope entails facing squarely the reality of the tragic situation. Wishing is easy; whereas hoping is so difficult that it has rightly been called a virtue.

To take Karl Menninger’s point, patients who come to The Clinic struggling to maintain hope need a motive force for a plan of action. University of Kansas psychologist Rick Snyder thought similarly in proposing that hope requires a combination of agency and pathways. Agency is the capacity to initiate action for a purpose; it involves willpower, gumption, and oomph. Psychiatric conditions—chronic anxiety, depression, and addictions—erode health and sap energy, thereby undermining agency. The top priority of treatment is to restore health and energy through various means: medical care, a structured routine that promotes sleeping and eating properly, building coping skills, and becoming engaged in a range of activities and relationships.

But hope requires more than agency, namely, some sense of direction—a pathway to a better future. For those who feel hopeless, The Clinic itself becomes a pathway, sometimes seen as a last resort. Yet making use of treatment must become a means to find a way forward beyond The Clinic.

In a state of hopelessness, a better future is unimaginable; treatment must unlock the imagination. Before they come to The Clinic, many patients are struggling so hard with limited energy to cope with stress that they have no wherewithal to do anything beyond putting one foot in front of the other, day by day. The Clinic provides temporary respite from life stress and allows patients time to reflect, to take stock of their plight with help from professionals and from peers with whom they can identify. Reflecting on the pathway that led into life problems helps chart the pathway out. And the path also must be cleared with a thorough understanding of psychiatric conditions and their proper treatment—and enabling family members to share in this understanding as well.

Patients who seek treatment feeling ashamed, alone, and alienated come to appreciate that the pathway to a better future is best traversed with help from others along the way. Paul Pruyser proposed that hope is predicated on the belief in a benevolent disposition toward oneself somewhere in the universe. The model for benevolence is a caring person, and this model can be extended to encompass nature and spirituality as well. The core of treatment is a caring community, and patients’ sense of engagement and commonality with others overcomes alienation and thereby restores hope.

Yet treatment at The Clinic is merely a temporary way station from which a path further forward must be charted. Treatment must engage imagination in the form of a plan—a plan for further treatment that promises to be effective and a plan for tackling the life problems that have been compounded by psychiatric conditions that blocked forward motion.

From the lofty to the prosaic: hope is concretized in the discharge plan. This plan of action embodies pathways—steps forward—and requires agency to implement. Like hope itself, there is an inescapable existential aspect to the process of leaving the hospital, and anxiety intermingled with excitement is a fitting response. When treatment has been successful, you have become unstuck; you have hope in the form of agency and pathways, a head of steam and a sense of direction. Yet hope is always infused with fear and doubt—without which you would have no need for hope. The existential point: with agency comes responsibility. When you leave, discharge plan in hand, it’s up to you to use it and the skills you’ve developed, and it’s up to you to make use of all the help you need as you continue to move forward.