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?


What do elite batsmen say to themselves?
In Psychology of Sport and Exercise

Is there anyone lonelier than the dismissed batsman walking back to the pavilion? What do they say to themselves to ease the disappointment? In a new study of the self-talk used by elite batsmen this is just one of six critical phases of a batting innings that were examined.

‘What I said to myself helped me to stay positive, knowing that [my] game plan was a good one,’ said one player about a recent dismissal. He was one of five players who took part in the research, all based at a county cricket club in England. Others described calling themselves names and criticising their shot selection. Throughout the study this kind of negativity was found to be followed by motivational self-talk.

The researchers, Adam Miles (himself an elite cricketer) and Rich Neil, used video footage of their participants’ batting innings from a week earlier. The batsmen watched these short clips of critical junctures in their innings and were asked to reminisce and reflect on what they’d said to themselves at the time.

After watching footage of himself defending the first ball of his innings, one player said that he used the cue word ‘ball’ at that time and throughout his innings to help focus his attention. ‘It’s a routine that enabled me to switch back on between deliveries,’ he said. This was another theme to emerge from the interviews – using self-talk to shift attention from a broad to narrow focus and back again. To shift their focus outwards, the players described assessing the layout of the fielders and looking for gaps. ‘By vocalising the fielding positions it allows me to play shots on instinct,’ said one.

Poor shot execution was often followed by reassuring self-talk: ‘stay cool’, ‘hang in there’, and sometimes also talk designed to simplify the batting challenge, such as ‘watch the ball’ and ‘play straight’. The researchers said that such utterances reduce players' focus on the minutiae of technique, helping to counter the regression to excessive self-focus often associated with choking.

Miles and Neil said the insights from their study highlight ‘the importance of athlete education surrounding the use of self-talk, and more specifically, the type of processes that athletes’ self-talk attends to.’ Unfortunately, there are serious limitations around players reflecting on their self-talk a week after the event, albeit with the aid of video clips. It’s not clear how much insight we have into our self-talk in the present moment, let alone when trying to remember days later.Moreover, the findings of this study are highly subjective, so we can’t really know if the players’ use of self-talk was beneficial in the ways they described. For that we need more experimental tests of different self-talk strategies. Nonetheless, this study makes a valuable contribution to a neglected topic and the use of elite players and video clips is to be commended.


How do you avoid your problems? Different strategies, different outcomes
In  Journal of Occupational Health Psychology

Is it a good idea to disengage from things that stress you? In occupational psychology, it seems to depend on who you ask. The work coping literature describes avoidance coping as a generally counterproductive strategy. Yet literature in the field of work recovery has shown that taking steps to detach from stress can be helpful and healthy. To dig deeper, Bonnie Cheng and Julie McCarthy have published a study looking at how disengagement affects the negative impact of inter-role conflict, such as when work commitments hollow out home life. By unpacking avoidance coping, they find a way to make sense of the conflicting findings.

The study investigated 178 university students with a history of employment over the previous 12 months. Participants completed surveys measuring biographical and behavioural information, together with measures of how much conflict occurred between not only work and family life, but also scholastic demands as well. Taking a steer from recent models, Cheng and McCarthy predicted that when work interferes with family life, it's work satisfaction that should fall, as we perceive the problem to lie with the interfering domain. Satisfaction surveys taken a month later generally bore this out, but what's interesting is how these effects were influenced by the use of behaviours that ordinarily are lumped together as avoidance coping.

Instead, avoidance behaviours were split into two groupings, with behaviours like 'I refuse to think about it too much' labelled cognitive avoidance, and others – such as 'I hope a miracle will happen' – representing escape avoidance. The data showed that the drop in school satisfaction when school conflicted with other domains was amplified by escape avoidance, but dampened by cognitive avoidance. Similarly, work and family conflict only eroded satisfaction when escape avoidance was high. This was in line with the authors' predictions: cognitive avoidance resembles psychological detachment and implies low levels of rumination, whereas the fanciful thinking of escape avoidance distorts reality and may drain resources that could otherwise be invested in improving conditions. It's worth noting that the study also measured psychological detachment separately, but was involved in no effects besides low detachment interacting with cognitive avoidance to make work conflicts even more punishing. This may be a methodological effect or may reflect how psychological detachment is framed as a short-term tactic – detaching for a while this afternoon – whereas coping strategies are more of an abiding disposition.

This research takes a knife to avoidance coping, and unearths two constructs that actually stand against each other. Cognitive avoidance is a case of taking agency over the contents of your mind rather than letting it be annexed by ruminative thoughts, known to exacerbate psychological problems. Escape avoidance casts agency aside, letting unchecked desires clog up mental territory, instead of examining them and, when necessary, putting them to rest.

This post is taken from the Society’s Occupational Digest, written by Dr Alex Fradera. See www.occdigst.org.uk and follow on Twitter @occdigest


The material in this section is taken from the Society’s Research Digest blog at www.researchdigest.org.uk/blog, and is written by its editor Dr Christian Jarrett. Visit the blog for full coverage including references and links, additional current reports, an archive, comment and more.

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