The Role of Hope in Eating Disorder Recovery
By Nicole Siegfried, PhD, CEDS-s
“Talking about hope makes me feel hopeless!” This was the exclamation of one of our clients in a group on ways to build hope in eating disorder recovery. Hope is one of the most elusive, terrifying, and yet essential components of treatment. Hope has been one of the most studied yet least understood aspects of recovery. Clients often simultaneously long for it, fear it, and avoid it; and clinicians often underestimate its necessity to the recovery process.
Hope is a salve to the soul. It is the small voice that whispers us through the inevitable pain of humanness to remind us that there is a “try again” after every failure, a “get back up” after being knocked down, and a “being found” after being lost. Hope has been described as a feeling, cognition, motivation, and spiritual state. Groopman’s (2003) definition of hope as “the elevating feeling we experience when we see—in the mind’s eye—a path to a better future” (p. xiv) captures the future-oriented nature of hope. There is also a past-oriented aspect to hope in which individuals with hope are able to forgive themselves and others for past mistakes and experience gratitude for their journey. Hope also has horizontal and vertical properties. Vertically, hope has been considered a “Velcro construct,” in which other positive emotions stick to it and build on top of it (Peterson & Seligman, 2004, p. 577). In other words, hope attracts other positive emotions, and when clients feel hope, they are more likely to feel joy, peace, and contentment. Horizontally, hope broadens perspective. During times of distress, our range of vision narrows so that we are unable to see possible solutions. Hope expands our view and reveals possibilities that were previously hidden and, as a result, can provide a sense of optimism, relief, and empowerment.
Various theories of hope have been proposed (Abramson, Metalsky, & Alloy, 1989; Beck, 1983; Seligman, 2011; Snyder, 2000), but it appears that hope is more than the sum of its parts and cannot easily be dissected by theory and analysis. Jaklin A. Eliott’s (2005) systematic review of the hope literature best sums up the broad definition of hope with the statement, “Hope…can be positive, negative, divine, secular, interpersonal, individual, social, ideological, inherent, acquired, subjective, objective, a practice, a possession, an emotion, a cognition, true, false, enduring, transitory, measured, defined, inspired, learnt…and the list goes on” (p. 38).
Hope and Eating Disorder Recovery
In mental-health treatment, a lack of hope is a predictor of suicide attempts and completions (Klonsky, et al., 2012), depression (Brothers & Andersen, 2009), physical illness, and mortality (Everson et al., 1996). Alternatively, the capacity for experiencing hope predicts decreased attrition rates (Geraghty, Wood, & Hyland, 2010), abstinence in drug and alcohol recovery (Mathis, Ferrari, Groh, & Jason, 2009), and improved quality of life (Weis & Speridakos, 2011). In eating disorder treatment, hopelessness has been identified as a risk factor for dropping out of treatment (Steel et al., 2000) and a predictor of comorbid depression and suicidality (Miotto, DeCoppi, Frezza, & Preti, 2003). Recently, as part of a larger study, improvements in hopelessness across the course of treatment predicted improvement in eating disorder symptoms from admission to discharge (Siegfried, Bartlett, & Goodwin, 2015). Specifically, clients who had improvements in hope were more likely to have improvements in their eating disorder symptoms at the time of discharge. More research is needed to understand the impact of hope in the treatment of eating disorders and the mechanisms of action by which hope affects recovery.
Building Hope: Importance of Connection
Hope has been conceptualized as a relational concept (Marcel, 1962; Weingarten, 2010). According to Erikson’s (1950) seminal theory of development, hope is the foundation of our earliest, most primal relationship, which sets the stage for other relationships in human growth. Erikson wrote, “Hope is both the earliest and the most indispensable virtue inherent in the state of being alive…if life is to be sustained, hope must remain, even where confidence is wounded [and] trust impaired” (p.115).
When clients come to treatment, they are often disconnected from themselves, others, and their spirituality. Hope is the passageway out of suffering to the peace of recovery, and it is paved with connection. Through connection to the therapist, others, and spirituality, clients are able to build hope, develop connection to self, and enhance recovery.
Building Hope Through Connection to Therapist
The therapeutic relationship has been identified as critical to client success in treatment. In fact, research suggests that the therapy relationship is as important as the type of therapy used in terms of patient outcomes (Norcross & Lambert, 2011). Hope has been identified as the foundation of the therapeutic alliance (Frank, 1968). By accepting the client without judgment, the therapist demonstrates optimism and hope that the client has the capacity for change. “Hope bonding” is a term that has been used to describe the formation of a sound, hopeful therapeutic alliance (Lopez et al., 2000). The fibers of connection between a client and therapist may be strands of hope that attach a client to the therapist, ground the client in therapy, and move the client through recovery. Therapists have been referred to as “hope brokers” or “hope ambassadors” in the therapy process. As clinicians, we hold hope for our clients when they have none and guide them to the pathways toward hope on their road to recovery. I have gone as far as saying that if we, as therapists, do not have hope for a client’s recovery, that client will not recover. Attempting to provide therapy without hope is the equivalent of blocking all of the exits during a fire. Alternatively, when therapists infuse hope into the therapy relationship and into the recovery process, it is as though they clear the smoke and reveal the exits out of suffering.
Building Hope Through Connection to Others
Hope is also cultivated through connection to others. Relationships with others can indirectly and directly affect hope. Similar to the process in the therapeutic relationship, significant others in clients’ lives may hold hope for their recovery, which generates client hope. Through somewhat of an osmotic effect, clients can absorb hope through their relationship with hopeful individuals, which can ultimately enhance their own capacity for hope. Relationships with others also have a direct impact on hope in client recovery by decreasing shame. Individuals who operate from a shame-based perspective are more likely to make internal attributions for negative life events (e.g., “That happened because I am a bad person”) and are more likely to believe that future negative events will occur (e.g., “Bad things happen to bad people”) (Williamson, Sandage, & Lee, 2007). Authentic connection with others provides empathy and compassion, which neutralizes shame (Brown, 2007). Through this process, individuals are reminded of the common humanity of their experience, which may be another avenue of revealing exits to their suffering. Ironically, during the process of suffering, individuals are often drawn to isolation in an effort to hide their shameful experiences. This tendency paradoxically magnifies shame and shrinks hope. As therapists, we can assist clients in recognizing this tendency and the deceivingly protective nature of isolation. We can help clients have compassion for their protective isolating, while helping them recognize its long-term negative impact on their disconnectedness, hopelessness, and shame.
Building Hope Through Spiritual Connection
All spiritualities and religions provide messages of hope—there is the resurrection after the crucifixion, there is peace after pain, enlightenment after aimless wandering, and freedom after bondage. Spirituality has been defined as a sense of connection to something bigger than ourselves, a search for meaning in life, and our deepest values by which we live (Puchalski, 2001). Spirituality has been linked to hope (Ciarrocchi & Deneke, 2006), as well as to various other positive outcomes. The second step of Alcoholics Anonymous of “coming to believe that a power greater than ourselves can restore us to sanity” (Alcoholics Anonymous, 2001, p.25) epitomizes the relationship between spirituality and hope in recovery. A connection to something bigger or greater also reveals exits out of suffering. In addition, spiritual practices bring a sense of meaning or purpose to the pain of being human, which may, in turn, increase connection to others and, as a result, enhance hope.
Although the majority of clients report a desire to have spirituality incorporated into psychotherapy (Morrison, Clutter, Pritchett, & Demmitt, 2009), clients can also be somewhat avoidant of spirituality in treatment (Vaughan, 1991). This avoidance has been linked to fear of shame, fear of discovery, a fear of meaningless to life, and, ultimately, what my friend and colleague Dr. Jim Gerber refers to as fear of hope (J. Gerber, personal communication, November 2015). As clinicians, we need to understand our clients’ inherent fear of hoping at a spiritual level. Avoiding hope can often be a protective mechanism for our clients, for if they do not hope, then they will not be disappointed. Essentially, they live by the motto: “Don’t get your hopes up; you’ll just get let down.” Allowing ourselves to hope is an inherently spiritual practice and requires faith, trust, and willingness. This process is terrifying for all of us, but especially for our clients, who are often exploring the dark realities of betrayal by others, themselves, and, often seemingly, God, their Higher Power, or the universe. Clients often feel guilty about “not hoping” and what that means about their spiritual practices. Clients must have the freedom and safety to explore these aspects of spirituality, hope, and the human condition in therapy without judgment. Assignments or journal prompts such as (1) What does my spirituality “tell me” in terms of hope, faith, and trust? (2) Is there meaning to my emotional pain? and (3) What makes me afraid to hope? may help clarify some of these issues for clients to deepen the discussion in session. Exploration of clients’ spirituality combined with clients’ own spiritual practices increases the experience of human and spiritual connection for clients, which ultimately enhances hope, allowing clients to believe recovery is possible.
Hope is necessary to the process of recovery but often appears somewhat nebulous and mysterious. As therapists, we are tasked with the seemingly impossible challenge of bringing hope to the hopeless. Although this undertaking can appear daunting, it is possible through building an authentic therapeutic relationship, encouraging relationships with others, and enhancing relationship to spirituality. Ultimately, hope is essential for recovery to occur. Thus, as clinicians, creating hope for our clients should not just be our goal, but also our mission.
About the author:
Dr. Nicole Siegfried is a Certified Eating Disorder Specialist (CEDS) and a licensed clinical psychologist. She is the Clinical Director of Castlewood at The Highlands Treatment Center for Eating Disorders in Birmingham, AL and the National Director of Eating Disorder Program Development for Castlewood. She previously served as an Associate Professor of Psychology at Samford University and is currently Adjunct Associate Professor of Psychology at University of Alabama at Birmingham. She is an international speaker and has published research, magazine articles, and book chapters in the field of eating disorders and suicide. Dr. Siegfried is president of the Alabama Regional Chapter of IAEDP. She is a member of the Academy of Eating Disorders (AED) and Co-Chair of the Eating Disorders and Suicide Prevention AED Special Interest Group.
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