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Hope is essential for mental health recovery. As clinicians, we become the holder of hope for our clients.

Trust and authentic relationships support optimism.

Hope is the glue that permits growth and change to occur, even in dire circumstances.

Hope is an active process that includes a vision or picture of a better future, imagination and fantasy of a better life with more opportunities, trusting that it can happen, and a conviction that it will. It is a belief, despite all odds, that a better life can come.

Clients who experience severe and persistent mental illness for a long period of time, homeless individuals, and substance abusers often don’t have the space to have hope, given their focus on survival and management of their daily lives. The adversity they face is too overwhelming, and they lack the agency to think about it, let alone pursue better lives. Hope is more defined by its absence rather than its presence in their world.

A place to live, food to eat, and medication to alleviate symptoms are the most important contributors to hope. One might view these as welfare services, but they are hope-supporting services.

Trust and authentic relationships support optimism and the development of the belief that positive relationships and life experiences are possible.

Hope is essential for all mental health recovery. We as clinicians become the holders of hope for our clients (when they cannot), whether they suffer from debilitating mental illness, a personality disorder, or both.

Clients with personality disorders pose a unique challenge for holding hope because they are complex, can be difficult, and treatment can take time and may also need a multi-disciplinary approach. Generally, the goal is to relieve immediate distress that may include anxiety, fear, and depression. Treatment should focus on decreasing any risk or self-harming behaviors or traits that cause crisis, as well as the development of better interpersonal relationships and an improvement in the quality of an individual’s life. One way we can provide hope is to offer different treatment options with the caveat that the goal is to improve their emotional lives and diminish their distress, and that the clinician will be an active participant in this endeavor. There are treatment options.

Individuals with severe borderline personality disorder (BPD) present a challenge. For a person who feels so profoundly empty that there is no amount of ‘enough’ that can help them weather their tumultuousness, how do we as clinicians hold hope? When they are critical, defacing towards staff, writing repeated complaints to upper management, where is healing and the development of hope possible?

Honesty and hope are a place to begin, with a focus on different modalities of treatment designed to offer improvement.

Marsha Linehan’s Dialectical Behavior Therapy (DBT) is designed to teach skills in mindfulness, emotional regulation, distress tolerance, and interpersonal effectiveness to manage intense emotions and unstable relationships. It teaches practical skills and techniques to manage overwhelming emotional responses. It helps clients to not only be in more control but feel successful as well.

Mentalization-Based Therapy (MBT) can help these individuals understand their own emotional states and feelings and the reciprocal feelings of others. It explores problematic relationship patterns by analyzing the patient's relationship with the therapist and applying insights to other areas of life, creating more opportunities for more satisfying relationships.

Cognitive-based therapies (CBT) focus on identifying and changing distorted thought patterns and destructive behaviors associated with the disorder

John Gunderson’s treatment is an intensive treatment approach to treat BPD. The focus is on the hypersensitivity of these individuals to rejection and abandonment through talking therapy that provides structure and stability. The emphasis is also on educating patients on the nature of their disorder.

Why Relationships Matter

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It is important to understand that individuals suffering from BPD are not doing so by choice. It is a pervasive, maladaptive way of being in their world that thwarts them from getting their needs met in an appropriate manner. They can be childlike and needy, critical and demanding, self-harming and unstable, angry and provocative, yet at times forgiving and sorrowful.

As the holders of hope, we must weather their storms (and our own) and believe that they are entitled to and deserve a better emotional life than they experience.

Narcissistic personality disorder (NPD) presents an equally challenging group of clients. Their modus operandi is a pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy for others in a variety of contexts.

Some patients may take advantage of or manipulate people to keep feeling in charge and superior.

They often experience themselves as self-important, feeling superior to others and thus deserving special treatment. They approach life with defensiveness and resentment towards others when they are not treated in a fashion they believe they are owed. These characteristics are accompanied by a sense of self that results in a general presentation of arrogance. It is not uncommon for those with NPD to be effacing to others.

Seeking therapy may be initiated by an untenable or precarious work situation, conflicts at home, general interpersonal conflicts or a dissatisfaction in advancing their goals in life.

Patients diagnosed with NPD tend to provoke powerful feelings in their therapist and countertransference reactions can lead to stalemates. We teach these individuals methods to assist them with recovery

Psychoeducation can begin to set the stage for a therapeutic alliance, identifying and working towards realistic goals. Negotiation of the treatment expectations regarding treatment and respective patient-therapist roles, including setting boundaries (i.e. therapists are not always available for phone conversations) but in a compassionate way.

Another aspect of treatment is to help the client to develop an awareness of the factors that affect the patient, like feeling humiliated when being evaluated and consequently experiencing a rage response.

Treatment should be designed to aid the patient in developing a better awareness of maladaptive patterns, increase sense of agency, make progress toward measurable goals, and develop less maladaptive ways of relating to others (e.g., admiration seeking, retaliation).

How do you hold continued hope for someone who seems to feel superior to all and diminishing to others, and who is highly critical and self-important?

Behind the façade is a person who has likely been overly criticized, ignored, felt unimportant to others, infantilized. The behaviors are compensatory for a lack of belief that they are important in the world for who they are.

As holders of hope, clinicians have a task in their work that is unique to the helping professions. It is the glue that permits growth and change to occur even in dire circumstances. It provides optimism in the face of untenable circumstances and often allows others to move forward. Without it, there is no recovery, moving forward or hopes of a better life. It is the foundation of a desire to move forward in desperate odds and provides a solidarity to the idea that in the absence of someone’s ability to look forward, we will hold that desire for them and believe that change can occur in a positive way.

© Psychology Today