Monday, 16 September 2013

Is it ethical to instil false hope in people with mental illness?

There's an ethical consensus in medicine that it's wrong to give patients with physical illness false hope. But what about patients with mental health problems? Might the provision of unrealistic optimism be a vital part of their treatment? Or might this serve only to prolong their suffering? Psychiatrist Justine Dembo at the Sunnybrook Health Sciences Centre has explored these delicate issues in a thought-provoking essay.

Dembo highlights research showing the numerous positive illusions to which most psychologically healthy people are prone. This includes feelings that we're better than average, that we have more control over life than we really do, and an unrealistically optimistic take on the future.

Writers like Ernest Becker have observed that we need these illusions to cope with the reality of being human and the fragility of our existence. "A full apprehension of man's condition would drive him insane," he wrote. Consistent with this, there's evidence that the positive illusions most of us enjoy are absent or reversed in people diagnosed with depression and anxiety.

For this reason, says Dembo, instilling hope and optimism in people with mental illness can be an important part of their recovery. A positive mindset can have behavioural consequences including greater sociability and creativity, which have knock-on benefits for a patient, leading to a virtuous circle of recovery.

But what if a therapist or psychiatrist truly sees no hope for a patient? Some people with severe mental illness fail repeatedly to respond to treatment. False hope in such cases can lead to years of suffering, toxic treatments and a loss of trust in the therapeutic relationship. "I would argue that hopelessness in those with mental illness may, at times, be well founded," says Dembo.

She outlines two real case studies from her own career. Patient 1 was a 38-year-old woman diagnosed with schizophrenia and OCD, both treatment-resistant. She had a history of suicide attempts, the last of which was nearly lethal. Dembo and her team met the woman in intensive care and believed she had almost zero chance of recovery. However, they conveyed hope to her each day, and she later restarted treatment. Her symptoms have subsequently cleared and she is back at work. Dembo felt they'd given the woman false hope, but "now in hindsight it seems that we did the right thing."

Patient 2 is a 50-year-old woman with profound difficulties forming relationships. She suffered severe trauma as a child and she's been diagnosed with PTSD, major depression, social anxiety, borderline personality and she's made several attempts on her own life. Three years ago she explicitly asked Dembo for proof that she would recover, or else she wanted to stop treatment. Dembo believed the woman had only a tiny chance of recovery and yet she emphasised to her the "small threads" in her life that gave cause for hope. Today the woman has withdrawn from therapy and "lapsed into hopelessness".

"I would be remiss," writes Dembo, "if I did not point out that her fragments of hope, which I have reinforced, have possibly led to three more years of suffering."

Nonetheless, in weighing up the evidence and considering cases like Patient 1, Dembo confesses that she has undergone a change in her own perspective on this issue. "Prior to delving into this topic, I believed that good mental health necessitates an unbiased appreciation of reality," she writes. But not so today. She concludes "if positive illusions can so greatly enhance an individual's quality of life, productivity, health, and social connections, then perhaps it can be ethically permissible to encourage these illusions, to some optimal extent."

Have you faced this dilemma as a therapist or therapy client? Do you think it's ever right to instil unrealistic hope and optimism in therapy?


Dembo JS, and Clemens NA (2013). The ethics of providing hope in psychotherapy. Journal of psychiatric practice, 19 (4), 316-22 PMID: 23852107

Post written by Christian Jarrett (@psych_writer) for the BPS Research Digest.


Anonymous said...

bit mean to refer to the researcher as "Dumbo" halfway through the article imho

Christian Jarrett said...


Anonymous said...

The danger is that people will latch onto the instances when being all optimistic does seem to 'help', even if they're relatively rare (I've no idea if they are or not).

It just sounds like a similar kind of situation to where trans* people are subjected to a system whose primary concern is to protect the rare person who might 'regret' their decision later, which ends up doing one hell of a lot more damage than is necessary due to the vast majority not falling into that category that society has latched onto.

Anonymous said...

I'm one - unremitting depression since adolescence, PTSD after prolonged violence, ostracism after career and social life-ending whistleblowing. Failed suicide attempts when LD50+ wasn't enough. Subjected to the leers, jeers and sneers of "professional mental health providers" during involuntary incarceration - one of which constituted an armed home invasion. Treatment goal - the only one ever written - "keep in the realm of suicidal ideation". Let me be euthanized and obtain a humane and peaceful death.

Anonymous said...

I am honest about my life, as reflected in this blog*, so I expect nothing but honesty from psych health professionals. I'd rather know the cold hard truth than be lied to with false optimism. I remember a psychiatrist telling me, when I was being discharged from the mental hospital after a breakdown, that it would be a very tough road ahead if I hoped to recover. This news didn't make me feel worse, because his honesty only acknowledged what I had been going through for so many years. It was a refreshing change from the usual sugar-coated talk and useless platitudes one hears from most professionals. The honest truth is that the prognosis for someone in my situation isn't bright. I get it. So is it worth living in likely more pain or is it okay to throw in the towel?


Anonymous said...

Giving patients false information, routinely, is incompatilble with open society and open inquiry. It's only tenable in a closed sociecty with an esoteric priesthood holding the knowledge and everyone else kept in the dark. Do we want to trade our open society with that dark existence?

Anonymous said...

I would argue that there's a difference between offering no hope at all and "tough road ahead if you want to recover." If there's no hope, then what's the point of living? Maybe that's waxing a bit philosophical, but I don't see how you can straight up tell a mental patient that there is no hope for them. I guess this gets to the question you posed at the end.

Anonymous said...

Instill has two L's

Anonymous said...

Not necessarily.

Jayarava Attwood said...

In a sense all optimism is false. At the end we all die and there is nothing 'hope' can do to change this.

I find people actually get angry if I express hopelessness. There is something about losing hope which presses people's buttons somehow. So do we take that away from doctors and expect them to function well? Maybe it's the doctors who cling to hope, or who make more effort if they perceive the situation to be hopeful? Doctors and their attitudes are never neutral in this situation.

This doctor seems to take themselves out of the equation. Hey Doc, you are not objective! Subjectivity is at the heart of all experiences. Why don't you discuss the role your hope or hopelessness had on the situation? Hmmm?

Often when we are caught up in hope and optimism we fail to pay proper attention to what is happening right now and this is itself a source of discomfort and difficulty. How can we make good decisions in the present if we are off in a better future? I hope I'll win the lottery, but I can't plan as if I will. If you are going to feed me misinformation, then I may make the wrong decision.

Maybe what seems like hope to the Dr doesn't seem like enough to the patient? Maybe some people are better off dead? Maybe where there is no hope the Drs have simply underestimated the person because they have a diagnosis? Maybe drugs have skewed the person's personality so much they make poor decisions?

The article seems to highlight how poorly Doctors understand "mental illness". A "false" hope turned out to be a true hope. A elephant under the carpet: they did not know the outcome in advance but were stabbing in the dark and it happened to work.

On the other hand treating mental illness with mental strategies is not so mental. If we could define hope as something less vague like: determination, robustness, or taking initiative, or belief that change is possible, then maybe it's fine to try to get the patient to get involved in improving their own lives rather than allowing them to become the passive recipients of psychiatric drugs?

The initial question is an interesting one, but the approach to it simply spawned more questions. Sure the Doc comes to a hopeful conclusion, but isn't it more to do with what she hopes for as a doc? And the role of her hope is the elephant under the carpet.

Anonymous said...

It is unethical to not give people hope. HOPE makes them well. It is simply wrong to conclude that giving hope is deluding people, If the author did his research, he will find that many people with serious mental illnesses have recovered and are living good lives. I am one of them. So, instead of ignorant asumptions that cause harm to vulnerable people, why doesn't the author get off his lazy ass and actually get the facts and educate himself.

Anonymous said...

There is only so long that the illusion of false hope can last. Eventually, when a patient finds by trial and error that there is no real hope of stable recovery, the outcome is a deeper and more permanent depression than that which originally presented in the patient. Who then is going to provide hope to the person who feels that they have exhausted all avenues of hope and found hopelessness at every turn. I write this as a patient who has found that at the end of the day all the hopes that I had lived for slip or tear away due to my illness and that life is a constant uphill battle with no relief now even in a nice cup of coffee. I am switching off. And I am immune to false hope.

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