‘If hope is one of the most important things in mental health,’ asks Mark Brown, ‘how can we make sure our services don’t destroy it?’
It’s fairly widely recognised that hope is an essential component of getting your life sorted out after it has been interrupted by a period of mental ill health, but what does that actually mean? If it’s so widely accepted that hope is important for what some call ‘mental health recovery’, why do we find that many services offered to people with mental health difficulties tend to fail to inspire it? If we work on the assumption that hope is vital to getting your life sorted and isn’t just a wishy-washy idea that has no place in the nuts-and-bolts of sorting your life out while experiencing mental health difficulties, what can we do to make sure that it is at the heart of services provided to help?
What is hope?
It’s probably good to try to define what I think hope means in the context of sorting your life out. The Oxford English Dictionary defines hope as “a feeling of expectation and desire for a particular thing to happen”. In the case of mental health, that ‘particular thing’ is that things won;t be unbearable horrible forever.
I think hope, at its most basic level, is the feeling that things can be better, or that the way things are today is not how they will be forever. Whether hope is based on belief or upon empirical evidence, it’s still the idea that whatever exists today does not have to persist forever. So, really, hope is recognition that positive change is possible.
When we talk about the first stage of getting your life back on some sort of track after a period of mental ill health being hope we’re actually saying: ‘the first stage of getting your life back on track is believing that you actually can get your life back on track’.
Seems obvious? Good. It should seem obvious, because it is obvious. The opposite of hope is despair, the feeling that nothing can change for the better and that no action will make a difference to that.
How then, if it’s so obvious, do we often feel despair rather than hope after interacting with service that exist only for the stated purpose of helping us get our lives back on track? If hope is indeed the vital first step in getting your life sorted out, how can we make sure that we don’t stop people’s journey to getting sorted before it even starts?
What makes us hope?
To work out why service sometime fail to make us hope, it’s worth looking at what makes up hope and looking at what hope isn’t.
Firstly, what hope isn’t. Hope isn’t just want a lack to be filled. A sense of missing something on its own can cause a sense of loss or a sense of being ignored or even a sense of anger at lacking what others have. This can lead to resentment, despair or even self blaming, where we blame ourselves for not having what it is we lack.
Hope isn’t a belief that you have been cheated out of something that is rightfully yours. A sense that you deserve better without any reasons to indicate why this should be can result in as sense of entitlement, where what you feel you should have does not relate to what may actually be possible. This can also lead to hopelessness when the gap between what you think you should have and what you have is large and where you think that you will not have to take any action to close the gap.
Hope also isn’t deferred satisfaction. A sense that things should be better without practical routes to making them so can result in fantasy or putting off things being better ‘until the next life’ or ‘after the revolution’. Thinking like that can sometimes feel like hopeful belief but it’s actually another form of hopelessness: the idea that everything in the world must change for one particular thing to change.
Hope also isn’t just positive thinking. To experience something as awful and to say to yourself ‘no, this is great’ is not being hopeful, it is a method of acceptance. Not always a bad thing, but not the same as hope.
So, what makes up hope in the context of getting your life back on track? Very simply, hope is the conviction that things that cause you difficulty can be overcome, things that you ant to happen can happen and that outcomes that are beneficial can happen. This conviction either results from, or is reinforced by, evidence that these beneficial outcomes are possible.
Hope and services
If we do ask questions about services we often ask them in terms of ‘how can we make sure this services helps people more?’ When we’re talking about hope, I think it’s more instructive to ask ‘In what ways might this service make us worse by removing our hope that things can change?’
Regardless of what services an organisation is providing, it has the capacity to either give hope or take it away.
In many senses, people take a risk in hoping that services will be able to help them. In other words, they place their trust in services. So then, hope that you can be helped is an act of trust, and based on my attempt to define hope above, the extent to which you receive positive reinforcement of that trust defines how likely you are to remain hopeful.
Services often forget that while their job might only begin when someone arrives at their door, it actually represents the end of a journey of hope for the person who has just arrived in front of them. They have turned up precisely because they hope that a service will be able to help them.
From that point on, the service can either support and nourish the hope that someone feels, or it can take a series of witting or unwitting actions to stunt or completely snuff out that hope.
Services can dispel hope in thousands of ways. On rude member of reception staff can undo a week of therapy. A couple of unreturned telephone calls can leave someone feeling ignored. A badly worded letter can give entirely the wrong impression of what might happen.
All of these things are rarely picked up in satisfaction surveys, because satisfaction surveys only ask whether the service is serving its purpose, not how it serves its purpose.
They’re the cumulative effect of services that forget that they’re actually working for people. This kind of thing happens because there is diffused responsibility for making sure that people have the best experience that they can of a service and what it offers. They are especially prevalent in services that themselves feel lacking in hope, services that feel ignored, overworked, misunderstood, unrewarded. Services that don’t believe things can be better tend to communicate that belief to the people who trust in them to make things better. When individuals raise these issues, the despairing organisation rejects them as criticism rather than recognising them as offers to provide advice about ways in which they can stop destroying hope.
Low expectations and unreasonably high expectations can remove hope from people: Low expectations by actually arguing against someone’s hopes and forcing them to question them; unreasonably high expectations by ignore the realities of someone’s life and again forcing them to question their hopes.
When an organisation, usually by imperceptible increments, begins to slide into despair itself it actually reduces its ability to be effective by managing to destroy hope rather than creating it.
What would happen if we did an audit of hope?
If hope is so vital, how can we make sure our services are engines for creating and sustaining it?
We have to be aware that many mental health services operate under demoralising circumstances, both those inside and outside the public sector. Current instability makes it difficult for people who work for them to feel secure, which compounds the wider sense of instability that is currently a reality for many.
The key is, maybe, to form a coalition between the people who work for organisations and people who use them to find ways of doing things differently. If older ways of doing things are under threat we may be able to find new ways by working together that are better and more hopeful instead of people on both sides of the provider/user split conniving with each other to build a story of despair. Initiatives like Star Wards are a fantastic starting point in thinking about what a coalition of hope might look like. Star Wards gives simple ideas and support to people who work in inpatient mental health wards to make the experience of being there better. The ideas can be done easily, simply and with little expenditure. Most of them are about getting people to do things in less institutional, habitual ways. They say ‘why don’t you stop doing things in that depressing, demoralising and despairing way? Why not do something better instead?’ They work on the principle that the best way to drive up standards is not targets but by giving often fed-up and despairing staff the encouragement to make their worklife and working environment more fun, more alive, more vibrant and more human which in turn brings them closer to patients, because patients are equally fed up and bored.
It’s interesting to ask what would happen if we were to take the ‘Star Wards’ principle into other forms of mental health services?
I’d suggest that the logical first step is for people who use mental health services of any kind to get together and agree on what things organisations do to remove hope from those that use them and make suggestions for how they may be altered.
If we can agree where services make us feel hopeless, either as people who use them or as people who provide them, then we can begin to find ways of changing the things that remove hope into things that give hope.
Would we come up with a different model of delivering mental health help and support? Would we find that sometimes the nuts-and-bolts of delivering mental health services were done in such a way that they undid any of the good that they could potentially provide?
If we were to do an ‘Hope Audit’ on every mental health organisation, working out where services support people sorting out their lives by not removing hope that life can be sorted out, what do you think we’d find?