The Paradox of Hope and Hopelessness in the Treatment of Depression
Michael Pariser, Psy.D
Paradox and Process
Paradox has always been an essential part of the analytic process, perhaps because it is an essential part of life. Pizer (1998), who has written extensively on the topic, describes it as “the reciprocally contradictory multiplicity that we are all challenged to bridge in managing our subjective and relational lives” He adds, citing Winnicott (1971), that “it must be tolerated by bridging and bearing the unresolvable (p xii).” To the extent his views hold true for the analytic process in general, I believe they are even more apt when exploring extreme emotional worlds, where powerful dichotomies reign. In particular, there is a paradox that emerges most intensely in the analytic treatment of depression. It involves hope and hopelessness.
On the surface, hope and hopelessness are clearly opposites. Certainly, many depressed patients experience them as such and oscillate between the two poles of the dichotomy. They often arrive in analysts’ offices, for instance, with a history of profound hopelessness that has left them in dread of traumatizing recurrence and bearing fragile hopes for a magical cure that will restore them to a state of pre-traumatic bliss. “I just want to be happy,” is a comment therapists hear often, generally said in a tone of utter simplicity and ingenuousness, as if it might be the easiest thing in the world to accomplish.
While we may chuckle at such psychologically naive aspirations, they are bolstered by important elements of the American culture, including the medical establishment, the insurance companies, CBT literature, and the media, all of which propound the message that depression and other dysphoric affect states are easily treated with a prescription and 6 therapy sessions. For different reasons, analysts sometimes share these goals, which can take many forms: hope, for instance, of a fairy-tale cure from the healer’s great arts, a complete riddance of all pain and suffering, or a cure by a love that extends beyond the consulting room and into the bedroom.
Even more troublesome, some of the hope can be, in Stark’s (2006) formulation, “relentless hope”…a defense against “disappointment in the object” that is either unavailable or imperfect…”a defense ultimately against grieving” (p.1). In the face of such relentlessness, or the rage that results when the hope is dashed, an analyst may have a hard time not feeling hopeless himself.
A more nuanced understanding is that hope and hopelessness co-exist in a state of dialectical tension and as aspects of a complex relationship between individuals and the emotional-experiential world in which they dwell. This way of being in the world might result from a successful analytic treatment that would entail the abandonment of false hopes (transformational, restorative, curative, and other fantasies) and the instantiation of real hope for what life is capable of bringing: a flawed but rewarding existence characterized by meaningful engagement, emotional freedom, and a measure of solid contentment.
It is in bridging from the former, dichotomous understanding to the latter, more complex one that the paradox of which I am thinking comes importantly into play. It is this: that rather than attempting to help the patient out of his depression and hopelessness, a more effective means of treatment in the long run is the deliberate moving into the patient’s world of bleakness and despair. I think of it as a kind of Zen koan: you go in to get out. It is the “surrender” that Ghent (200-) talks about, but it is only the complete surrender into total hopelessness that ultimately leads to the emergence of real hope.
For some clinicians, this idea may be new or antithetical, although for many others, it is de rigeur in effective analytic treatment. As Krystal (1988) points out, “It is a matter of clinical commonplace that the patients who present with the request to be free of certain feelings, e.g. depression, need to have the depression” (p. 21). Even those who accept this notion on principle, however, may find it difficult in practice to move into the patient’s worlds of emotional darkness, especially when the patient’s abject hopelessness triggers the analyst’s own discouragement and sense of ineffectuality. In Maroda’s words, “Nothing quite prepares any therapist for the reality of sitting quietly in a room with another human being who is in intense emotional pain” (2010, p. 6).
As a spur to the analytic courage that would encourage a decision to move towards the patient’s pain, rather than away, and in the hope of making it easier for clinicians to tolerate the kind of profound despair that is the hallmark of depression, in this paper, I will elaborate the paradoxical connection I see between hope and hopelessness and demonstrate the necessity of embracing hopelessness as the most effective road to the instantiation of real hope for a better life. I will begin with an extended case illustration.
Carl is a short, portly man in his late 60’s, with an interesting and funny face, a quality which makes it possible for him to eke out a meager existence as a character actor in film and TV, aided by a small Social Security pension. He is very bright, speaks several languages, has lived in New York and Europe, is very cultivated and has a good sense of humor, but he lives a restricted life in which he has little or no real emotional contact with others. Although he generally has coffee in the morning with other unemployed souls in a local café, by noon he is in his apartment, where he stays for the rest of the day, watching television, looking at porn on the internet, and masturbating.
When he first came to me, Carl was buffeted by his own competing feelings of hope and hopelessness. He had long held out hope to overcome long-standing fears, so that he might effectively pursue his two primary goals: singing opera professionally and finding a woman to marry. He clung tightly to these hopes despte his age (he was then in his late 60’s), his health (he has chronic leukemia), his sexual history (his experiences have been almost exclusively homosexual,) and his previous attempts at therapy (45 years, off and on, mostly on.) Moreover, in order to even attempt to achieve his aims, he would need to engage with other people, which is something that frightens him enormously and something he avoid assiduously. He lives a mostly solitary life of fantasy, television, and masturbation.
Despite these impediments, Carl believed that with my help, he could reach his cherished goals. In other words, he had a lot more hope than I did. But I was in a bind. I could express my doubts to him, but I didn’t imagine he wouldn’t stick around very long once he’d heard them. On the other hand, I could remain silent in the hope that eventually, he would come to the same conclusions I had. Ultimately, I chose to share my feelings, on the grounds that I feel it is not a good idea to attempt psychoanalysis with goals that are radically different from those of my patients.
It didn’t make any difference. Carl simply insisted that he knew better than I did. He conceded that yes, it was unlikely that a man in his late 60’s was going to set the opera world on fire, but he could easily imagine himself singing Sancho Panza to someone else’s Don Quixote in a small-venue production of “Man of La Mancha” or marrying a woman close to his age. Also, he had an explanation about his homosexual activities: engaging in fellatio, the only thing he did, was a “feeding” process, so men’s penises were, at an emotional level, his mother’s breast. I marveled to myself how he’d been able to channel Melanie Klein so effectively.
At the same time, I recognized that it was not outside the realm of possibility that he might know more about his own emotional world than I did. For these reasons, I engaged his aspirations at face value, rather than confronting them; which Carl appreciated. He told me that these were long-cherished aspirations, and he did not want to go to his grave without at least making a real attempt to realize them.
So we tried. We began by exploring the affective issues Carl believed stood in his way, which proved to be even more difficult and complicated than I had expected. We looked at his hopes, his fears, the various obstacles he felt were stopping him. We imagined scenarios and paid close attention to the feelings that arose. We examined his family history and unearthed clues to his reticence. And when he came in each session and dutifully reported his failures to achieve any progress towards his goals, we would investigate his emotional experience and work towards tolerance of his unbearable affect states. This process generated hope for him, and he would resolve to try harder. Then he would go home and masturbate, watch TV, or eat, returning the next session to report his failure once more. Needless to say, it was a very frustrating experience and left me with a profound sense of my own ineffectuality. Carl was stuck. I was stuck. And we were stuck together.
In the face of my mounting hopelessness, I began to look more closely at the repetitive process in which we were engaged. I began to wonder if our being stuck together wasn’t the main point of Carl’s “stuckness”. So long as we were “working on Carl’s issues” we had good reason to be together. Perhaps he imagined that once he’s resolved them, therapy would be over, and he would be back alone in his apartment. In that sense, his failure to achieve his goals even with the help of 45 years of psychotherapy might actually be seen as a success in terms of his ability to maintain ongoing (semi) human relations (they were therapist, after all.)
Reflecting on this idea, I found myself feeling hopeful for the first time in a while. I could imagine this new conception of the case allowing Carl to see that his “real” goals were not to sing opera or get married, but to remain connected with me in a relationship that provided him with a sense of safety and a relief from loneliness. Carl, perhaps unsurprisingly, did not take to this idea, which meant to him abandoning his fondest hopes for his future. Instead, he redoubled his efforts to get me to help him rid himself of his fears so he could take action. I replied that I couldn’t get rid of feelings; it was not within my power to do so. At that point, Carl became deeply ambivalent about treatment. On a number of occasions, he came to my office, felt nauseous, then turned around and went home.
At the same time, however, he did not abandon his hopes. He still came in looking to overcome his fears so he could sing opera and be happily married, then he went home, ate doughnuts and fantasized. We sank into a turgid impasse, which dragged on for months. I got supervision. It didn’t help. Everyone pointed to the fact that his goals, which we therapists saw as fantasy, did not match mine, which were to help him understand the functions of the fantasy. I discussed this incompatibility with Carl. He didn’t budge. He was sure there was a way, if only I didn’t give up hope.
But I did. The hopelessness that I held about Carl’s goals now took over mine. I didn’t want to come to sessions. I just wanted to give up. I’m not proud to say this, but for a while, I gave up any hope of knowing what to do to help Carl, and I surrendered to the hopelessness. I just stopped trying. I continued to come to sessions, of course, and do the best I knew how, but deep in my heart, I knew it was only a matter of time before Carl realized his therapist was only a mechanical analyst…a therapy robot…Sigmund Droid.
It was at that point that I began resonating with something I hadn’t seen before: Carl’s own hopelessness, which was hidden deeply behind the relentless pursuit of his idealized goals. This understanding lined up with the thinking I was doing at the time regarding the traumatic creation of a dissociated world of emotional experience that I call a personal Hell, along with a matching world of perfect happiness, a personal Heaven. If the glorious opera and the white picket fence were his Heaven, they were designed to keep him out of Hell. The way was now clear. Carl and I had to go to Hell. I felt hopeful once again.
Armed with my new understanding, I began to explore with Carl his feared world of darkness and isolation, which crystallized in an image of an underground cavern reached by falling down a deep well. In it, he was alone, surrounded by nothing but the dirt walls. He felt alone and lonely, defective, ashamed. Over time, as he went down the hole again and again, he started speaking of a wish to give up. He thought about quitting treatment. He said he didn’t know how long he could tolerate the pain. He went for medication evaluation. He got a prescription. He couldn’t tolerate the side effects and stopped. He truly felt hopeless. He said he wanted to die.
At first, I held on to hope, but over time, I began to resonate with his hopelessness. I lost confidence again. I wondered: was I doing it right? Was Carl different in some way from my other patients? Might be attempting to apply my cherished theories too broadly and without regard for Carl’s unique subjectivity? Maybe I just needed to be more patient…or less. What was the right thing to do? I was desperate.
I’m not sure how or why, since there was no light at the end of the analytic tunnel, but we both kept going down into Carl’s world of darkness and sitting together. Sometimes we would talk about what we saw or felt. Other times we just sat in silence. Then, almost imperceptibly at first, a kind of light appeared, an emotional lightness. I noticed we could joke a little about what we were feeling, or about the idea of singing opera. It wasn’t quite so serious any more.
And now, for the first time since beginning to work with Carl, I started to feel real hope. So, I think, did he. It wasn’t that he thought he would sing great operas to cheering crowds or marry a woman and raise a traditional family, but he, and I, grew hopeful he could come to accept himself and his emotional life with greater equanimity.
And in point of fact, that is what began to happen. He started to see his depression and his fears as an inevitable legacy of a difficult childhood and as intrinsic aspects of who he is. In response, he moves more freely into and out of his emotional darkness and attempts to avoid it less. He is even talking about depression more openly with the people in his world. Moreover, his rigidly held goals have begun to soften, to be replaced, little by little with a more complex sense of his life and his real possibilities. Instead of opera singing, he is focusing more on his acting pursuits, and as I write this, he just filmed a national TV commercial. Moreover, he is finally, after a long life in the closet, beginning to come out to his friends and family about his romantic interests in other men.
As my work with Carl demonstrates, the road from depressed, dichotomous thinking, characterized by unrealistic hopes and powerful dread (cf. Mitchell, 1993), to a more complex way of being can be a torturous one. When Carl first entered treatment, he was armed with hopes I perceived as antidotal (Stolorow et al, 2002) and did not share. At the same time, with Carl, as with many depressed patients, hopelessness was not far away and was hiding directly behind the overt hopes. It was only by engaging directly with that hopelessness that real hope emerged.
I believe the effectiveness of this paradoxical phenomenon stems from the embodied emotional process of experiencing the analyst’s presence in one’s Personal Hell, which exists as a place of fundamental aloneness, along with the analyst as a caring other, when the basis of depression is of being essentially defective and unable to be cared about. Patients often struggle to make sense of this. They might start by rejecting the analyst outright: “You don’t know how bad it will get,” they might say, “and when you do, you’ll leave.” Or “You don’t really care. You’re only here because you’re being paid.” Over time, they may move into a kind of dynamic tension around the paradox, which might be expressed as, “I trust you but I don’t trust you.” Eventually, living with this paradox for a significant time tends to evoke an emotional dissonance that cannot be resolved through a return to the status quo ante. A developmental accommodation must be made.
To move into depression, however, can be difficult for both members of the dyad. Any move to integrate hopelessness, along with depressions other negative affects, will inevitably result in terror and resistance. Patients fear the pain will be excruciating, overwhelming, and permanent. Analysts may doubt their own as well as their patients’ ability to tolerate long periods in emotional darkness. They may fear that patients will terminate, fragment, or suicide. Courage is certainly needed.
The hopelessness that arose for me over the course of repeated therapeutic failures with Carl was, in the long run, inevitable. Although we try not to succumb to hopelessness, in my experience, it is unavoidable. In every difficult case I’ve ever had, there were moments when I just felt like giving up. Thoughts crowded into my mind such as: “This is too difficult…I don’t know what I’m doing…It’s not working…I’m making my patient suffer for no reason…I’m making my patient worse.” It was no different with Carl. As with all emotions, however, hopelessness can have a motivational point. In this case, it inspired me to investigate our failures, and because I take seriously the idea of relational co-construction, I was able to see ways in which we both contributed; this understanding gave me new hope.
The hopelessness that emerged for me later on in treatment was of a more profound nature. In this case, it seemed that, unlike earlier in the treatment, when I imagined further exploration might be fruitful, now I felt despairing that anything would help free us from the grip of the darkness. My fears were exacerbated by Carl’s claims that he didn’t know if he would be able to tolerate it, and that he was thinking more regularly about wanting to die.
It was in our combined desperation that he went for medication, and it was only due to the fact that Carl could not tolerate the side effects of Welbutrin that I was able to recognize that Carl had moved into a state of complete hopelessness himself, and that this was a good thing. At that point, I was able to make an emotional shift into a resonance with the despair, rather than trying to get rid of it. I did so by accepting not only his hopelessness, but mine for him. In essence, I said to us, “I don’t know with 100% certainty that I’m on the right track, especially seeing how bad you feel, but I don’t know anything else to do. Whatever happens is going to happen. So I’m surrendering into the process and wherever it takes us next. I’m not pulling out of the dive.” He responded by letting go himself of the longing for relief and allowed himself to free-fall into darkness, whereupon he experienced the longed-for relief. In other words, hope turned out not to be the requirement for the analytic exploration, but rather, the outcome.
And that is the ultimate paradox. It takes the complete and total surrender into the experience of hopelessness to finally let go of all the antidotes and fantasies, and to accept one’s fate, to free fall into the realization that no matter what, one is destined to be who one is. At that point, self-acceptance generates hope for acceptance by the world. To use another Zen-like metaphor, the parachute doesn’t open until you’re resigned to hitting the ground.
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