Maintaining Hope in the Face of Trauma

Maintaining Hope in the Face of Trauma Jon G. Allen, Ph.D. jallen@menninger.edu Are we not more likely to achieve our aim if we have a target? —Aristotle, Ethics

Trauma is not limited to psychiatric disorders • Trauma: persistent adverse effects of exposure to extremely stressful events • Psychiatric disorders • Posttraumatic stress disorder (PTSD) • Other trauma-related disorders • depression, anxiety, dissociative disorders, substance abuse, eating disorders, deliberate self-harm • Existential-spiritual trauma • Distrust, cynicism, resentment, bitterness • Loss of faith, sense of futility or meaninglessness

Posttraumatic Growth • Definition: positive effects that result from a traumatic event • Includes positive life changes as well as increased personal/social resources and coping skills • “Benefit finding” is partly a form of coping • Predicted by personality traits of optimism and religiousness • Relation to psychological and physical health is generally modest (less depression and greater positive well-being) • Relates to ongoing intrusive and avoidant symptoms (indicative of cognitive processing) • Greater relation to positive outcomes when more time since trauma has elapsed Helgeson, JCCP, 2006

Part I Defining Hope

Karl Menninger on hope (1959) I would like to warn you not to expect a scientific analysis…the subject does not permit of that…I speak, rather, to the point of focusing attention upon a basic but elusive ingredient in our daily work. It is the responsibility of the teacher to the student, just as it is of the young doctor to his patient, to inspire the right amount of hope—some but not too much. Excess of hope is presumption and leads to disaster. Deficiency of hope is despair and leads to decay. Our delicate and precious duty as teachers is to properly tend this flame. Freud’s discoveries…enabled us to replace therapeutic nihilism with constructive effort, to replace unsound expectations—first with hope, and then with sound expectations. What can we do better [for our patients] than to dispel their false expectations—good and bad—and then light for them a candle of hope to show them possibilities that may become sound expectations?

Karl Menninger on hope, continued hope implies process; it is an adventure, a going forward, a confident search. In a way it seems curious that the psychoanalytic process, which is so obviously diagnostic, has generally come to be called treatment. Diagnosis is the hopeful search for a way out; but the setting forth on the way which one discovers and the unflinching persistence in making the effort—that is the treatment; that is the self-directed, self-administered change…The psychoanalytic treatment method is a great discovery…the realization that we must encourage each individual to see himself not as a mere spectator of cosmic events but as a prime mover.

Paul Pruyser (1986):Distinguishing hoping from wishing We wish for sunshine after rainy days, for a raise in salary…Wishing is inexhaustible, for there are always more goods to be obtained and people to be jealous of. In contrast, hoping does not deal with objects at all, but is focused on global or existential conditions: One hopes to be liberated when one is in captivity, to be healed when one is sick…This sharp differentiation between hoping and wishing is rarely encountered in the standard psychological literature, which tends to lump hoping, wishing, anticipating, yearning, wanting, aspiring, craving and other words of neediness together under the general rubric of desiring.

Paul Pruyser and Vaclav Havel:Distinguishing hoping from optimism In the optimistic attitude people take some distance from reality so as to minimize or attenuate the obstacles that separate them from their goals; such optimism refers to external things and circumstances. —Pruyser Hope…is not the same as joy that things are going well, or willingness to invest in enterprises that are obviously headed for early success, but, rather, an ability to work for something because it is good, not just because it stands a chance to succeed. Hope is definitely not the same thing as optimism. It is not the conviction that something will turn out well, but the certainty that something makes sense, regardless of how it turns out. —Havel

Paul Pruyser:Hope in humility, tragedy, and reality Hoping has little to do with willing, or striving, or going after something—it is closer to a state of responsiveness than to a feisty initiative, and typically involves a degree of humility…[the attitude of hopeful persons] is one of modesty, both toward other people and toward the vast power and often unfathomable design of reality. Hoping occurs when one feels trapped, is visited by a calamity, or has come to the end of one’s rope in understanding or deed…Hoping presupposes a tragic situation; it is a response to felt tragedy, and is the positive outgrowth of a tragic sense of life To hope, then, one must have a tragic sense of life, an undistorted view of reality, a degree of modesty vis-à-vis the power and workings of nature or the cosmos, some feeling of commonality, if not communion, with other people, and some capacity to abstain from impulsive, unrealistic wishing.

Jerome Groopman (2004) Many of us confuse hope with optimism, a prevailing attitude that ‘things turn out for the best.’ But hope differs from optimism. Hope does not arise from being told to ‘think positively,’ or from hearing an overly rosy forecast. Hope, unlike optimism, is rooted in unalloyed reality. Although there is no uniform definition of hope, I found one that seemed to capture what my patients had taught me. Hope is the elevating feeling we experience when we see—in the mind’s eye—a path to a better future.Hope acknowledges the significant obstacles and deep pitfalls along that path. True hope has no room for delusion. —The Anatomy of Hope

Imagination and hope Imagination…presents the mind with alternative courses of action—the envisaging of possible futures…imagination is the primary locus of human freedom: it is what makes our overt actions free by offering us alternatives, and it is in itself an instance of free action…Certainly, imagination is the most weightless and unconstrained of human faculties, the most fleet and feathery. —McGinn The person who hopes is future oriented in a special sense, namely, by seeing reality as a process of unfolding, and therefore essentially open-ended. This is precisely what may make waiting peaceful, and such a state of calmness stands in sharp contrast to the restlessness and impatience that typically accompany strong wishing. If reality is seen as open-ended, it is also likely to be seen as resourceful, and possibly as novelty producing. —Pruyser

Benevolence, attachment, and hope hope is based on belief in some benevolent disposition toward yourself somewhere in the universe, conveyed by a caring person. —Pruyser It has been shown over and over again that if the encouragement is dogged enough—and the support equally committed and passionate—the endangered one can nearly always be saved…It may require on the part of friends, lovers, family, admirers, an almost religious devotion to persuade the sufferers of life’s worth, which is so often in conflict with a sense of their own worthlessness, but such devotion has prevented countless suicides. —Styron

Practical foundations of hope • Rick Snyder • Agency: goal-directed determination • Pathways: planning of ways to meet goals • Karl Menninger • hope is a motive force (agency) for a plan of action (pathways) • Richard Munich • The patient’s willingness to take agency for the illness is a foundation of treatment

Is there room for blind faith in hope? Man continues to live because he is a living creature not because reason convinces him of the certainty or probability of future satisfactions and achievements. He is instinct with activities that carry him on. Individuals here and there cave in, and most individuals sag, withdraw and seek refuge at this and that point. But man as man still has the dumb pluck of the animal. He has endurance, hope, curiosity, eagerness, love of action. These traits belong to him by structure, not by taking thought. —John Dewey

What to hope for: Surviving vs. thriving • Languishing • devoid of positive emotion • quiet despair • characterizes 20% of the population (without psychopathology) • Flourishing • vital engagement in activities expressive of individuality • 3 components: intimacy, generativity, spirituality • characterizes 20% of the population —Keyes

Part II Challenges to hope: Depression

Depression undermines hope • Undercuts imagination: cannot imagine a different state of mind or different future • Undercuts agency (energy, motivation) • Undercuts flourishing (vital engagement) • Posttraumatic depression combines depression and fear; both promote retreat and isolation • Catch-22: all the things one must do to recover from depression (e.g., be active, socialize, think realistically, sleep well) are made difficult by the symptoms of depression • Pathway out: small steps toward realistic goals

The most important thing to remember during a depression is this: you do not get the time back. It is not tacked on at the end of your life to make up for he disaster years. Whatever time is eaten by a depression is gone forever. The minutes that are ticking by as you experience the illness are minutes you will not know again. No matter how bad you feel, you have to do everything you can to keep living, even if all you can do for the moment is to breathe. Wait it out and occupy the time of waiting as fully as you possibly can. That’s my big piece of advice to depressed people. Hold on to time; don’t wish your life away. Maintaining hope in the face of depression The unexamined life is unavailable to the depressed. That is, perhaps, the greatest revelation I have had: not that depression is compelling but that the people who suffer from it may become compelling because of it…There is great value in specific kinds of adversity….I have found that there are things to be made of this lot I have in life, that there are values to be found in it, at least when one is not in [depression’s] most acute grip. —Andrew Solomon, The Noonday Demon

Part III Challenges to Hope: Evildoing Evil shatters our trust in the world —Susan Neiman Hope is the enemy of evil —Karl Menninger

Definition of evil (Claudia Card) • Evil is a harm that is • reasonably foreseeable • culpably inflicted • deprives others of the basics necessary to make a life possible, tolerable, or decent • Evil person shows • persistent gross negligence or recklessness • persistent and evil motives or intentions • Most evildoers are not evil persons

atrocities harm negligent deliberate culpability Card’s two-dimensional view of evil

impersonal trauma interpersonal trauma attachment trauma nonhuman agent attachment figure human agent Trauma spectrum

Mindblindness versus mentalizing Imagine what your world would be like if you were aware of physical things but were blind to the existence of mental things. I mean, of course, blind to things like thoughts, beliefs, knowledge, desires, and intentions, which for most of us self-evidently underlie behavior. —Simon Baron-Cohen (1995) Mindblindness

Evildoing stemming from mindblindness On Eichmann: whose only personal distinction was perhaps extraordinary shallowness. However monstrous the deeds were, the doer was neither monstrous nor demonic, and the only specific characteristic one could detect…was something entirely negative: it was not stupidity but a curious, quite authentic inability to think. —Arendt: The Banality of Evil

Roy Baumeister on the banality of evil • Understanding evil begins with the realization that we ourselves are capable of doing many of these [evil] things • The perpetrators of evil are often ordinary, well-meaning human beings with their own motives, reasons, and rationalizations for what they are doing • Studies of violent offenders, violent policemen, and rapists suggest that about 5% are motivated by sadistic pleasure

Baumeister: Examples of mindblindness • Frederick Treesh, a spree killer: “Other than the two we killed, the two we wounded, the woman we pistol-whipped and the light bulbs we stuck in people’s mouths, we didn’t really hurt anybody” • A man who captured five different women at gunpoint, raped them, and stabbed them to death: “He said he had always made sure to be ‘kind and gentle’ with them, at least ‘until I started to kill them’” • Magnitude gap • evil acts of much greater importance to the victim than the perpetrator • evil acts have small positive outcomes for perpetrator and large negative outcomes for the victim

High Stakes: Hastening extinction • Men have gained control over the forces of nature to such an extent that with their help they would have no difficulty in exterminating one another to the last man. They know this, and hence comes a large part of their current unrest, their unhappiness and their mood of anxiety. • —Freud, Civilization and its Discontents (1929)

Restoring hope through theodicy (Neiman) • The problem of evil occurs when you try to maintain three propositions that don’t fit together: • Evil exists • God is benevolent • God is omnipotent • Theodicy in the narrow sense is the theological defense of the benevolence and omnipotence of God in the face of evil • Theodicy in the broad sense is any way of giving meaning to evil that helps us face despair

Restoring hope through the Enlightenment (Neiman) • The courage to stop blaming God, think for oneself, and take responsibility for the world • We aspire to make sense of the world in the face of the fact that things go intolerably wrong • Relying on the principle of sufficient reason: the belief that we can find a reason for everything the world presents

Restoring hope through attachment • safe haven provides a feeling of security (regulation of emotional distress) • secure base fosters exploration of the outer world and the inner world, including exploring the world of the mind; caregivers’ and therapists’ role is to provide a secure base for mentalizing

Mentalizing: Definitions • attending to mental states in others and oneself • holding mind in mind • imaginatively perceiving and interpreting the actions of others and oneself as conjoined with intentional mental states, such as desires, needs, feelings, beliefs, and reasons • Note: mentalizing is emotional: the perceiving-interpreting process and the perceived-interpreted states are infused with emotion

The gist of treating trauma in psychotherapy • John Bowlby: the role of the psychotherapist is “to provide the patient with a secure base from which he can explore the various unhappy and painful aspects of his life, past and present, many of which he finds it difficult or perhaps impossible to think about and reconsider without a trusted companion to provide support, encouragement, sympathy, and, on occasion, guidance.” (A Secure Base) • Jon Allen: “The mind can be a scary place.” • Patient: “Yes, and you wouldn’t want to go in there alone!”

traumatizer terrorizing mindblind T R A U M A ALONE,abandoned, neglected, unloved, without needed comforting and making sense AFRAID,terrified, overwhelmed, helpless, out of control + + unmentalized traumatized Mentalizing failures in trauma

Maintaining hope in the face of trauma • Janoff-Bulman: trauma shatters three basic assumptions: • The world is meaningful • The world is benevolent • The self is worthy • sense of meaning • Susan Neiman: hope lies in our refusal to accept a world that makes no sense • benevolence • Paul Pruyser: hope is based on belief in some benevolent disposition toward yourself somewhere in the universe, conveyed by a caring person • self-love • Christine Swanton: bonding with yourself provides strength and vitality; benevolent disposition toward yourself from within yourself. [secure attachment is a model for the ideal relationship with oneself] • borrowed hope: hope that others have for the person

looking inward looking inward looking outward Mentalizing as a basis for hope: meaning, benevolence, and self-love if you want to think, you must see to it that the two who carry on the thinking dialogue be in good shape, that the partners be friends. —Arendt

Maintaining Hope in the Face of Trauma