On Fear of Hope: Recovery Requires Social Resources: An Interview With Ross Ellenhorn

AUSTIN RATNER: Addicts are often said to be in denial about their problem, and sometimes the approach to treatment is to attempt to break through that denial to the truth that the patient or client is an addict. But you've pointed out that there's a stigma that goes with being labeled an addict. And when you're labeled as different and the treatments provided don't seem to work, you can give up hope and collapse back into addiction. So how do you help people out of this conundrum?

ROSS ELLENHORN: First of all, let me clarify that Ellenhorn isn't an addiction treatment program, per se. We work with people who are often called “dually diagnosed,” meaning they both experience difficult events of mind and mood and are engaged in a problematic habit. But I am happy to talk about addiction, independent of mental health concerns, since I believe a lot of our core philosophy applies to the issue. To start with, we need new words for “resistance” and “denial,” since work in the addiction field is completely oriented toward breaking through these supposed skull-bound events. While it's completely ineloquent, I like the term “perturbed relationship with help.” And I believe people will not develop a facilitative relationship with help if they don't have the right psychosocial resources. Or, to put it another way, what's called “resistance” or “denial” isn't just a “what's wrong with them” problem. It's as much, and I believe more so, a “what's happening to them” issue.

To get people ready for treatment is to get as warm a coat of social resources around them as possible. If I'm right about that, that's a giant missing element in most care, right? Most care for addiction and for complex psychiatric events removes people from these resources, often removing them from home and structuring their days around treatment and away from social resources. Over and over, research in social psychology shows that if someone doesn't have a sense of self-efficacy, if they don't have good social support, if they don't have purpose, the world becomes threatening. And I do believe there's a thing called denial, but to fight through denial means to face a challenge not a threat. A challenge is an obstacle we have the resources to deal with. A threat is an obstacle we don't feel we have the resources to deal with. And for someone without good psychosocial resources, what might appear for some of us as challenges feel like threats. At Ellenhorn, we're trying to bolster up the ability for people to be motivated and connected because I'm pretty sure psychosocial resources are the elements that actually get somebody that's called, quote, unquote, “difficult to engage” to engage in treatment. That's why over 70 percent of our work is done outside the office, on an outreach basis, and a lot of it is about helping people get back to work or school, or engage in activities in their community. The majority of the people we work with at Ellenhorn have experienced profound traumas to their social experience, having lost a sense of their social role, their purpose, their competence and their social supports, due to going in and out of treatment. We actually call our clients who engage in problematic habits “triply diagnosed,” because we think their addiction issues are as tied to what we call “psychosocial trauma” as they are to their mental health issues, and the research on dual diagnosis work points in this direction.

AR: Say more about what you mean by fear of hope in the context of addiction.

RE: Hope is not the same as optimism. Optimism is kind of like Reaganesque nonsense. Like “Everything's gonna be great! Great day tomorrow!” Hope is the capacity to move towards something you yearn for despite uncertainty. So every time that you're able to keep going despite not knowing whether you'll get the thing or not, you're hoping. And so hope is central to motivation, since every act of motivation is challenged by uncertainty. (This is what makes Martin Luther King probably the most profound thinker on hope—“creative suffering,” what a term! Creative suffering. It means in your suffering to still come up with creative solutions of what you're going to do with it.) When you hope, you also make the thing that you're yearning for more important than it was before you hoped for it, right? That means that if you don't get what you hoped for you have these profound experiences of disappointment, and the other term for that to me is helplessness.

There's this quote from Erich Fromm about how all of us are basically built for suckling, and that means we're also always dealing with the possibility of disappointment. I think of disappointment in that way: as often a profound event in which we experience that our needs are not met, and from that that we are helpless. “I'm not able to meet my needs. I'm now lacking this thing in my life.” If you've been through this series of events where everybody was excited about your change—getting sober, getting good marks on your improvement on psychiatric symptoms, a professional stamp of approval about you “functioning”—and then things fall apart again, you start to think, “I don't want to hope.” Even, “Hope is my greatest enemy. Because if I hope again, I'm gonna take those steps towards that event again where I'll experience my own helplessness.” And from this, “Staying the same is actually my friend, in my battle against hope.” And that's fear of hope.

We created a scale to measure fear of hope—it's a legitimate scale, these are really good social psychologists that have done this—and the remarkable thing is that people that score high for hope and score high for fear of hope are the most agitated of all the different versions you can come up with. High hope and high fear of hope is like standing on a cliff and being afraid of heights.

AR: That's where I live.

RE: Well, if you're a hopeful person you're always gonna be dealing with fear of hope. But it's a good anxiety, it's existential anxiety. Hope never comes without fear: it takes courage to hope.

AR: Tell me a little more about how all this is put into action.

RE: Well, like I said, about 70 percent of the work is conducted outside the office. But, unlike other programs that might provide “companions” or “coaches” for people, we have trained clinicians, mostly master's level, who help our clients become what we call “more socially articulated.” And they do this through small steps of social inclusion, from taking a yoga class with them, to visiting during lunch breaks at work, to attending classes with them, as only a few examples. That's what the staff are doing all day: they're doing stuff with clients, but with a clinician's ear for issues of motivation. This takes a giant ship and points to another crazy way we approach behavioral issues in the country: we put the most intensive resources into sequestering people—and I would say also into the surveillance of them—and put little clinical resources to the challenges they face in their daily lives. Dealing with somebody who is symptomatic while you're helping them in their daily life takes really good and very intensive psychiatry. Again, it's all about shifting what we mean by “readiness.” Let's not say, “When Fred is no longer psychotic we'll finally get him a job.” Let's say instead, “Let's give him a team, one that meets for rounds each morning that includes Fred's psychiatrist, and let's visit him during his lunch breaks, drive him home from work, give him a place to disclose about his fears of hope and his struggles at work, and assist him in being ‘ready’ right now.” Otherwise, we're in that bizzarro world of “no medicine until you're well.” The medicine is social inclusion; the medicine is pride.