Psychiatric consultation was requested for both Mr. K. and Mr. T., two oncology patients on neutropenic precautions. Each patient had advanced leukemia for which chemotherapy was failing. The two requests for psychiatric consultation differed, however. For Mr. K., a recommendation was sought for management of neuropathic pain following chemotherapy. For Mr. T., the request was for suicide risk assessment.
When the psychiatric consultant entered his room, Mr. K. interrupted a phone conversation with a friend to speak with the psychiatrist. Fresh flowers were at his bedside and balloons floated from a bedpost. “These days are all extra for me,” Mr. K. commented. “My oncologist told me when this was diagnosed to expect no more than 2 years to live.” Despite the burning pain in his feet and a dismal medical prognosis, Mr. K. spoke spontaneously about the people in his life for whom he felt gratitude. By medical criteria, Mr. K. was dying, yet his being was infused with hope.
Mr. T., by contrast, was on suicide precautions after locking himself in a hotel room and taking large doses of cocaine and heroin. His survival had been accidental. Hotel housekeepers entered his room thinking that it needed cleaning. They found him comatose. Mr. T. spoke bitterly about the neglect, unreliability, and betrayals of family, friends, and lovers. He said he hated that he had ever been born. Mr. T. was also dying but consumed by bitterness, resentment, and despair.
Does Hope Matter?
Mr. K.’s inspired living, despite his terminal illness, makes the point that hope is more than the probable estimate for a desired outcome. His hope was grounded in the stance he had adopted toward living. When hopeful, he could continue to problem solve, to care for himself and others, and to voice his values and commitments. He presented himself as the person he most wanted to be. Hope helped preserve his identity.
Empirical studies have repeatedly found hope to be a major determinant of effective coping with the distress and uncertainty of a cancer diagnosis.1 There is intriguing evidence that hope also may have direct salutatory physiological effects that extend upon positive psychological effects.2
What Is Hope?
Hope requires a definition that can take into account patients such as Mr. K. who live with hope despite a dismal prognosis or enormous daily suffering. Hope must be more than an expectation of success or optimism.
Weingarten3,4 has emphasized hope as a practice. That is, hope at its core is “something you do,” rather than “something you feel.” A practice is a program of action undertaken not for utilitarian reasons, but rather to shape one’s being as a person and how one chooses to live in relation to others.5 Practices are often connected to social, religious, or ideological traditions whose values extend beyond individual motivations.6 Hope as a practice means locating one’s deep desire or commitment and taking a step toward it. As such, hope can be embodied in the practices of relationships, traditions, or institutions, not just limited to the life of an individual person.3,4,6
How Can a Patient’s Hope Be Assessed?
A patient’s capacities for hope often can be assessed by examining how the patient has responded to past or current adversities: How did this affect you? How did you respond to it?7 Pathways for mobilizing hope usually can be grouped into one of three categories: (1) individual problem-solving strategies, (2) relational coping, and (3) mobilizing a core identity.
Hope as problem-solving strategies has been most extensively studied by Snyder and colleagues,8,9 who have defined hope as the product of “pathways thinking” and “agency thinking.” Pathways thinking begins by envisioning a desired future state, then imagining paths from one’s current situation to that future state and the steps along those paths. Agency-thinking is the self-talk that helps sustain a sense of personal agency (ie, that one can act effectively). Pathways-thinking combined with agency-thinking turns “lemons into lemonade,” obstacles into stepping-stones, and traumas into challenges.
For many individuals, however, the intuitive first step when facing adversity is not to start with individual problem-solving, but to ask: To whom can I turn?3,10 Human beings are evolutionarily equipped for utilizing an array of different kinds of relationships that can sustain hope: confiding relationships, attachment relationships, embracing one’s group role, the neighborly relationships of a social network, and generativity toward others in need.2,11
Finally, activating a core identity can mobilize enormous energy for assertively facing, engaging, and struggling with adversity, rather than passively avoiding, withdrawing, or submitting. For one individual, clarity about “this is the person I’m determined to be” matters most; for someone else it is one’s role as a couple partner, family member, or team member; and for another it is an impersonal identity as a member of a religious, national, ethnic, gendered, or political group.
How Can a Clinician Help Mobilize Hope?
Appraising how a patient has coped effectively with past adversities, whether by individual problem-solving, relational coping, or activating a core identity, can help a clinician attune quickly to the patient’s best coping style. For example, Ms. D. was a 24-year-old engineering student who was struggling through a bone marrow transplant for myeloblastic leukemia. As a skilled problem-solver, she felt overwhelmed by feeling so ugly in her edematous body and lonely from separation from loved ones. Overwhelmed by problems she could not solve, she stated, “I just want to give up!” After listening for a few moments, the consultant psychiatrist said, “Let’s make two lists—the first list of what is most important to address, then next most, then next most after that; then a second list of what is hardest to address, then next most, then next most after that.” Together they generated a list of contributors to her demoralization—physical pain, her appearance, insomnia, worries about her school loans, loneliness, fear of dying. Ms. D. and the psychiatrist then chose two items of some importance, but not the hardest challenges, to address first—insomnia and loneliness. As they created an action plan together, Ms. D. commented how much better her spirit felt.
By contrast, Mr. R. primarily coped relationally. Mr. R. was evaluated after a suicide attempt by overdose. His overdose had occurred the day he was diagnosed with prostate cancer, while still grieving the death of his partner 6 weeks earlier. When deciding to end his life, Mr. R. said, “I just felt confused and didn’t know where to turn.” He explained that his partner had always been the organizer and problem-solver in their relationship. In addition to intense grief, he felt overwhelmed by the prospects of cancer treatment.
The psychiatric consultant inquired about his relational world: Who knows what you are going through? Who can you talk with when you are feeling low? Who can be available to help you get to medical appointments? Who might help with food or house cleaning if you were to be ill from treatments? Tell me about your work life— what makes you good at what you do? These questions revealed a rich network of friends and work colleagues who could be called upon for practical assistance with cancer treatment. To check his assessment that Mr. R. primarily coped relationally, the psychiatric consultant asked at the end of interview: “When you talk with someone as we have been talking, does it make the emotional burden that you feel heavier or lighter?” “I feel better talking,” Mr. R. responded. The consultant then recommended a psychotherapist, with whom Mr. R. agreed to meet.
Activating a core identity often mobilizes hope when all else fails. Mr. F. had been a dynamic chief executive officer of a corporation that produced educational software, which he now hoped to offer to the low-income Asian nation of his ancestry through his philanthropy. Now afflicted with weakness, pain, and fatigue from advanced Hodgkin’s disease, Mr. F. felt overwhelmed and discouraged. He felt uncertain that he still had the capabilities for enacting his vision. The psychiatric consultant asked Mr. F. for whom it would most matter that he succeed. He asked what it would have meant to Mr. F.’s deceased father, who had supported his son’s emigration to the United States, for Mr. F. to have returned with such a gift to his native country. The consultant asked what it would mean to the school children of this country who would now have new possibilities for gaining an education. Finally, he asked Mr. F. about the knowledge and skills that had propelled his success as an entrepreneur and businessman, and how those capabilities now spoke to his confidence. “I need to complete this,” Mr. F. stated simply. Later that month Mr. F. traveled to his native country to preside over a strategic planning meeting to address political, language translation, and logistical obstacles so that his new educational initiatives could move forward.
For cancer patients, sustaining hope is vital. Clinically, hope can be best regarded not as a reactive feeling, but as a set of practices that can help a person to keep moving steadily toward desires and commitments, despite the adversities of cancer and its treatment. By examining how a patient has responded to past adversities, a clinician can discern whether a cancer patient’s best hope-building competencies lie in problem-solving as an individual, in relational coping that relies on help from others, or in accessing emotional energy from a core identity. Some patients, of course, can move smoothly across all three hope-building domains, drawing appropriately from each when facing different challenges. After this assessment, the clinician can ally with the patient in planning how to utilize these pathways to build hope.
- Duggleby W, Ghosh S, Cooper D, Dwernychuk L. Hope in newly diagnosed cancer patients. J Pain Symptom Manage. 2013;46:661–670. doi:10.1016/j.jpainsymman.2012.12.004 [CrossRef]
- Harris JC, DeAngelis CD. The power of hope. JAMA. 2008;300(24):2919–2920. doi:10.1001/jama.2008.884 [CrossRef]
- Weingarten K. Hope in a time of global despair. In: Flaskas C, McCarthy I, Sheehan J, eds. Hope and Despair in Narrative and Family Therapy. New York, NY: Routledge; 2007: 13–23.
- Weingarten K. Reasonable hope: construct, clinical applications, and supports. Fam Proc. 2010;49:5–25. doi:10.1111/j.1545-5300.2010.01305.x [CrossRef]
- Griffith JL, Griffith ME. Engaging the Sacred in Psychotherapy: How to Talk with People about their Spiritual Lives. New York, NY: Guilford Press; 2003.
- Griffith JL, Dsouza A. Demoralization and hope in clinical psychiatry and psychotherapy. In: Alarcón RD, Frank JB, eds. The Psychotherapy of Hope: The Legacy of Persuasion and Healing. Baltimore, MD: Johns Hopkins University Press; 2012:158–177.
- Wade A. Small acts of living: everyday resistance to violence and other forms of oppression. Contemp Fam Ther. 1997;19(1):23–39. doi:10.1023/A:1026154215299 [CrossRef]
- Snyder CR, McDermott D, Cook J, Rapoff M. Hope for the Journey: Helping Children through Good Times and Bad. Boulder, CO: Westview/Harper Collins; 1997.
- Snyder CR, ed. Handbook of Hope: Theory, Measures, and Applications. New York, NY: Academic Press; 2000.
- Pullybank Coffey E. Blowing on Embers. Tamarac, FL: Lumina Press; 2007.
- Weihs KL, Enright TM, Simmens SJ. Close relationships and emotional processing predict decreased mortality in women with breast cancer: Preliminary evidence. Psychosom Med. 2008;70:117–124. doi:10.1097/PSY.0b013e31815c25cf [CrossRef]