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Hopelessness is a well-established predictor of suicide, and inspiring hope is an important goal in mental health care, but there are few studies of hope among persons with suicidal behavior. The aim of this study was to interpret the lived experience of hope in some patients hospitalized for intentional self-harm. Twelve persons that had engaged in suicidal behavior by ingesting an overdose of medication were interviewed shortly after hospitalization and asked to narrate about their hopes. The transcripts were analyzed using a phenomenological hermeneutic method inspired by Ricoeur's theory of interpretation. The naïve reading was one of hope being relational. The structural analysis identified three themes: hopes for life, hopes for death, and the act of hoping. We interpreted the common theme of the interviews as being definite and indefinite relational hopes for life and death. For clinicians, expressions of indefinite hopes may raise concerns about the low likelihood of fulfillment. However, the expression of indefinite hope may serve to avoid experiencing failure, disappointment, and hopelessness.
Hope is a movement of appetite aroused by the perception of what is agreeable, future, arduous, and possible of attainment. (Thomas Aquinas, Summa Theologica, paraphrased by Day, 1991)
The World Health Organization (WHO) estimates that each year one million people die in suicide, and it is estimated that the number of suicide attempts are at least 10-fold that of completed suicides (Fleischmann & Bertolote, 2002), hence suicidal behavior is a major threat to health and well-being. Many countries have responded to the WHOs call for more research and new national policies to prevent suicide and suicidal behavior; most recently Sweden, whose national plan for suicide prevention was confirmed by parliament 2008 (National Program for Suicide Prevention, 2008).
Hopelessness, i.e., absence of hope, is a documented mediator between depression and suicidal behavior, and a predictor of suicide (Beck, 1986; Beck, Weissman, Lester, & Trexler, 1974). Addressing hopelessness and inspiring hope are important aims in mental health care for suicidal patients (Cutcliffe & Barker, 2002; Collins & Cutcliffe, 2003), but empirical evidence on the predictive power of hope in mental health is lacking (Schrank, Stanghellini, & Slade, 2008). There are few studies about hope among persons with suicidal behavior (Farran, Herth, & Popovich, 1995; Grewal & Porter, 2007). We use “suicidal behavior” as intentionally putting one's life in danger (Silverman, Berman, Sanddal, O'Carroll, & Joiner, 2007). The persons interviewed in this study had exhibited suicidal behavior by being hospitalized after ingesting an overdose of medication one to seven days before the interview. Suicidal behavior or suicide attempt is not a clinical diagnosis. Intentional self-harm is the diagnostic category of the International Classification of Diseases version 10 that has replaced suicide attempt in the earlier versions of the International Classification of Diseases, and this category covers self-harm both with and without suicide intent. Therefore, we chose to study patients hospitalized for intentional self-harm.
Our pre-understanding of hope was influenced by Day's (1991) philosophical analysis of hope; a person hopes for something when he/she wants a future state of affairs to be realized, and he/she believes it is possible but not given that it may be realized (Herrestad, 2009). We were inspired by Dufault and Martocchio's (1985) distinction between a belief in future beneficial but indeterminate developments (generalized hope) and a concern with a particular valued outcome or goal (particularized hope), and cutting across this distinction the following dimensions:
Affective: Feelings related to the goal, feelings related to uncertainty of the goal.
Cognitive: Identification of goals, assessment of probability of reaching goals.
Behavioural: Planning, decisions and actions taken to reach goals.
Affiliative: Relational goals, relational ways to fulfilling the goals.
Temporal: Time (un-)specific goals, short/long term, memory access.
Contextual: Circumstances occasioning hope, activation of hope, testing of hope.
The aim of this study was to interpret the lived experience of hope in some patients hospitalized for intentional self-harm. The central research question was how meaning is constructed in the narratives of hope by persons that have recently engaged in suicidal behavior. We chose a phenomenological hermeneutic approach in order to capture the manner of narration of these patients of their thoughts and experiences rather than attempting to fit their narratives to pre-structured categories. Therefore, we used semi-structured interviews, where the interviewer pursued a phenomenological approach to listen carefully to what was said and ask follow up-questions rather than use diagnostic categories. In the analysis, we have chosen an inductive interpretation process in order to let the words of the patients speak for them. We were looking for what common theme could be found in their narratives.
In a general hospital (Aker University Hospital in Oslo), 12 patients, two men and 10 women, were interviewed after being admitted for ingesting an overdose of medication. The patients were selected during the psychiatric interview done by a psychiatric liaison officer. The inclusion criterion was that the patient was diagnosed as having done an act of intentional self-harm according to the International Classification of Diseases version 10. Patients under 18 years or above 60 years, unable to give informed consent, or in need of an interpreter, were excluded from the study.
The interview guide was designed in a semi-structured format to ask about the patient's reflections on the various dimensions of hope described above (Dufault & Martocchio, 1985). We asked about the hopes they entertained during the crisis and at present. After the first six interviews we made a preliminary analysis. We learned that much of the narratives gathered so far were about hopes during the crisis and less about hopes at present. We then changed the interview guide asking more about their hopes in the present situation.
The first author conducted all interviews one to seven days after submission at the hospital. The first author has a background in philosophy and philosophical inquiry, and he did not keep diagnostic categories in mind during the interviews. The temporal proximity to the suicidal crises was sought in order to overcome recall bias, and because of the common clinical experience that patients are more willing to talk openly about what happened immediately after the event. Each patient was interviewed once for approximately 1 h. Interviews were taped with a digital recorder and transcribed by a research secretary. Interviews 1–6 were made in February and March 2006, interviews 7–12 between October 2006 and June 2007. As we were researching the patients lived experiences, the only data available to this project were the recordings and interview transcripts.
This study was approved by the South Norway Regional Committee for Medical Research Ethics (S-05329, 30 November 2005). Person-identifiable data have been deleted from all stored transcripts. The patients included in the study were informed about the project orally and in writing. They were required to sign a written form of consent. They were informed that participation/non-participation in the project would not in any way influence their treatment. The researcher had no influence on the treatment of the patients. The in-patient status provided the possibility of immediate intervention if the interview should cause negative psychological reactions.
When analyzing the transcript texts we have followed the phenomenological hermeneutic method of Lindseth and Norberg (2004). Their method of text analysis is based on Ricoeur's (1976) theory of interpretation. The analytical steps are first to gain an intuitive understanding of the whole text through iterated naïve readings; the reading is naïve in the sense that the researcher reads with a phenomenological attitude and dispensing what might be taken for granted in order to grasp the intuitive sense of the meaning of the text as a whole. The second step is to explain the text through a structural analysis by identifying meaning units and condensing them by formulating sub-themes and themes. Condensation is a way to make sense of each meaning units in everyday words as concisely as possible. Finally, a comprehensive understanding of the whole text was formulated through critical reflection on the findings of the previous steps.
All quotes have been translated from Norwegian by the first author. Patients will hereafter be referred to as informants due to this role being most important with respect to the interviews.
After repeated readings of the interviews, we formulated an intuitive sense of the meaning of the text as a whole. When we arranged the narrated events chronologically we could see that the informants were telling about difficulties leading up to the present suicidal crisis, what they thought and experienced during the present suicidal crisis, and what they had experienced at the hospital and were hoping for at present. At the core of their descriptions were the participants' perceptions of living in relation to others and of their feelings and reactions toward them.
The experience of hope revealed by the narrative accounts was one of hope as relational. Such relational hope was experienced in a number of ways over time. With respect to the time before and during the suicidal crisis, they described how hopes directed toward others had been disappointed, hopes of escaping trouble through suicide, hopes of reunion in death, and hopes of being remembered. With respect to the present situation, they described hopes of getting help and treatment, hopes of restoring health and social position, hopes of being accepted and understood, and hopes of establishing new or improved relations to significant others. This led to the conjecture about the overall meaning of the text as hope is relational.
In the initial part of the structural analysis, the identified meaning units of the narratives were condensed into 20 sub-themes. Nine of the sub-themes referred to the domain of social relations, for example, “hopes of gaining acceptance from others,” “hopes for community with others,” and “hopes of being remembered.” Seven sub-themes, like “hope to get well,” “hope to be happy,” and “hope to escape from something” referred to internal conditions of the informant. The last four, “hope with or without limits,” “hope with or without agency,” “hope talked about as an object,” and “hope as compulsory action” described the activity of hoping itself.
Meaning was constructed across the above sub-themes, and condensed into three themes, involving the meaning of (a) hopes for life; (b) hopes for death; and (c) the act of hoping. Below, the findings will be presented according to the meanings assigned to the sub-themes by the researchers, and thus be held as interpretive filters through which subjective experience is conveyed. We have chosen the most relevant quotes to explain the themes.
The themes, hopes for life, hopes for death, and the act of hoping described the diversity in experiencing hope. Table I illustrates how the comprehensive understanding is supported by the themes, sub-themes, and units of meaning.
The constructed meaning of hopes for life relates to how the informants describe their hopes for a future life. Some of these hopes concern internal conditions of the informant. They express that they want to get well, be happy, be more accepting toward themselves or have strength: “I want to get on my feet again, and I want to go forward.” When asked what she meant about getting on her feet, she said: “I have…a need to get control over myself again.” However, such expressions of hope are placed in a context of the informants being woven into a fabric of social relations. It is illustrative that the next sentence of this informant is: “I have two children whom I feel a lot of shame towards for what I have done.” Hence, the meaning of expressions of hopes for internal qualities, like to get well or being happy, is part of a larger narrative of relating to others.
Most of the hopes the informants have for their future life are concerned with their relations to others. They express hopes that others will accept them, be with them, allow them social roles, or help them along: “Hope for me is to live a normal life and have good contact with my grandchildren.” “That they [her children] can trust that I sort of…am proper, that would be the greatest.” One informant tells about her hopes for the future: “A small hope that if I…if I were to live on, then my family would have understood me, and then I would have happiness.” Asked about what mental pictures she had about what she hoped for, another informant answered:
Yes, then…I might find friends, and maybe of the opposite sex also, and…I do have a little hope that I might meet someone of the opposite sex and…and maybe to get a small job.
One informant also expressed hopes for others being in a situation like herself: “Many who take such an overdose, I hope they survive like me.” Hence, the main bulk of the hopes the informants expressed about their own future are hopes about how others will relate to them or their concerns about others.
The constructed meaning of hopes for death relates to how the informants describe their intentions when ingesting the overdose and their present reflections about what they would achieve by dying. Some of these hopes concerned the wish to die or not to die. Some informants had a clear death-wish. Asked whether she would have died if she had not been found so early, one informant answered: “That was what I wanted. I had planned this for a very long time.” Others expressed ambivalence: “It is a mixture of that it would have been OK [to die] and that really I don't want to.” Some claimed to have no clear intentions at all when ingesting the overdose:
I was quite upset, and acted very impulsively, and simply gobbled all the pills my boyfriend is using…because, I didn't think “oh, I want to die, I want to let everything go.” I didn't think that clearly about what I was doing, I only took them, in a way. Then I started thinking afterwards when things started to happen with my body.
Three quarters (9/12) of the informants expressed at some point in the interview that they acted impulsively when they actually took the overdose of medication; that they did it without considering the consequences. In summary, as death itself can be the object of hope, some expressions of hope are about dying; some both hope to die and hope to live simultaneously, while some did not hope to die even when putting their life at risk.
Two informants expressed hopes that death would bring reunion with people or pet animals that were deceased. Asked about whether she thought about other people than her children after ingesting the overdose, one informant explains:
I wanted to get home. I grew up with my mother, grandmother and grandfather. It means mostly grandfather, because he is possibly the only person in the whole world who is fond of me.
Hence, the meaning of hopes for death expressed by these two informants was that death would mean a continuation of earlier important social relations.
Most of the expressions of hopes for death are concerned with how death will provide an escape from the present unbearable situation. Asked about whether she had a clear thought about what she would achieve by ingesting the overdose, one informant answered: “Yes, I wanted to get away. I wanted to avoid living any longer.” Many of these hopes for escape are hopes of ending relational problems. When asked what in particular she wanted to escape from, one informant answered:
I just think for two, I must be his mum in a way, my boyfriend, a mother…take care…are tired of…yes, I wanted to get away from…everything was just hopeless.
Hence, the meaning of hopes for death expressed by these informants is as a refuge from current problems that to a large degree are relational problems.
Some of the expressions of hopes for death are concerned with communicating a message to others. Some informants expressed hope that their suicide would convey a message to their families. One informant described a hope that her suicide would show her family that she was not guilty of the infidelity her husband accused her of; a motive known from the Greco-Roman legend of Lucretia. Another informant, reflecting on what she hoped when she ingested an overdose, expressed: “I wonder if that could be that, yes that…that wish…well, not to die as I say, but to avenge myself, be full of wrath [“full av faen”: a swear expression], excuse my words.”
Another communicative concern was expressed as the hope of being remembered in a positive way. One informant explained how she sent a text message to her husband in the adjoining room after she had ingested an overdose:
I wanted my husband to convey as much as possible about my family to the children so that they can acquire something from there.
Hence, the meaning of hopes for death expressed by these informants is as a message about themselves to their significant others.
The constructed meaning of the act of hoping relates to how the informants describe the activity of hoping itself. Hence, these expressions are not descriptions of substantial hopes, but about hoping. They are not about what they hope for, but about how they hope; how they perceive hope or how they specify their hopes.
In explaining why people have hope or lack hope, the informants invoke different metaphors for the act of hoping. Some informants describe the act of hoping metaphorically as carrying or pushing objects. One informant describes it this way: “Push all the time that hope in front of you. Now I think that I don't muster to push it any more.” This understanding is also expressed as hopes being like a store of objects that may be full or empty. Other informants describe the act of hoping as a compulsive action. Asked about how she avoids disappointments, one informant answered: “Stop hoping. No, I don't know…you cannot stop hoping either.” Hence, the meaning of the act of hoping is expressed through different metaphors, and whether or not one can lose all hope depends on the metaphor in use.
Specific hopes, however, may lead to disappointment. Some informants describe limits for when a particular hope must be fulfilled: “If I am not…in full swing with something and…well established before I am 30, then…I have given up the hope.” Other informants have hopes that cannot be disappointed because they don't specify an object or a limit to the hope. “You cannot go around and hope all the time and be disappointed. (I: No. So how is it now?) I hope, I hope for the best.” Hence, the meaning of the act of hoping is expressed as either something that will end by a deadline or continue indefinitely.
One informant was specific in placing herself as agent in pursuing what was hoped for: “I will go in the other direction now.” The other informants were unspecific with respect to agency: “I don't want to drink [alcohol] any more…so I must hope there are some measures.” Another example: “And the economic issues must sort themselves out in some way or other.”
As can be seen, these narrations about how they hope are grouped according to whether the act of hoping may stop or not, whether hopes have a limit or not, and whether hopes have a specific agency or not. In attempting to condense these aspects of hoping into a fundamental opposition, we have come to think of hopes as either being definite, i.e., as being a specific hope with a responsible agent and a deadline like a plan that can fail and be discarded, or as being indefinite, i.e., as being a kind of compulsive, wishful thinking without specification of agency or limits. Hence, the common thread in the informant's narratives of the meaning of the act of hoping can be constructed as the theme of having definite or indefinite hopes.
The structural analysis revealed the multitude of meanings constructed by the informants around the experience of hope after having experienced a suicidal crisis. The naïve reading led to the interpretation that hope is relational. The structural analysis has developed this understanding further by emphasizing the relational aspects of the informant's hopes both for their future life and their hopes for death. Even when others are not explicit parts of the object of hope, these hopes are expressed in a relational context. The fact that even the informant's hopes for death are relational hopes has led us to a first formulation of the main theme of the interviews as relational hopes for life and death. In addition we found a third theme to be the meaning of the act of hoping, which we condensed to the theme of having definite or indefinite hopes. When we re-conceptualized the text, we understood the common meaning expressed by all the informants about hope as definite and indefinite relational hopes for life and death.
The aim of this study was to interpret the lived experience of hope in some patients hospitalized for intentional self-harm. We asked the informants to reflect on the various aspects of hope described by Dufault and Martocchio (1985). In the light of our comprehensive understanding our informants emphasize the affiliative aspect of hope more than other aspects. In describing the act of hoping, our informants expressed both definite and indefinite hopes. Hopes can be indefinite in being unspecific concerning what must happen to fulfill the hope, when it must happen, or who must see to it that it happens. We find this distinction between definite and indefinite hopes to be more clarifying than Dufault and Martocchio's distinction between two spheres and dimensions cutting across both spheres. Hence, the expressions of the lived experience of our informants have altered our understanding of the various aspects of hope. However, we still find our initial definition of hope inspired by Thomas Aquinas to be sound, as will be illustrated in the next section.
One might ask whether all the expressions we have quoted really can be regarded as expressions of hope. Would it not be more adequate to regard some of their expressions as expressing intentions, some as expressing mere wishful thinking? When a person expresses a wish to die, should we not interpret this as an expression of hopelessness? We believe these questions may illustrate the difference between our phenomenological hermeneutic interpretation of how the informants narrate about their lived experience in response to our questions about what they hope, and an interpretation according to existing psychological theories or clinical practice.
This difference is better illustrated by an example from the data presented above: “I don't want to drink [alcohol] any more…so I must hope there are some measures.” The informant expresses that she wants a future state of affairs to be realized, a situation where her alcohol problem is solved. She believes it is possible but not given that it may be realized, so this is the expression of a hope according to our definition. No deadline is mentioned, and the expression “so I must hope there are some measures” may indicate that her sense of agency and responsibility for realizing this hope is low, so this is the expression of an indefinite hope. A clinician may regard this as an expression of mere wishful thinking, but that involves a clinical judgment about the impossibility of stopping to drink alcohol without her own active participation.
Measured with Snyder's definition of hope (Snyder, 1994), our informant is only expressing wishful thinking, as Snyder include agency and planning as part of his definition of hope. We find his definition of hope too narrow as we believe it is possible to hope that others will do something or that something will happen without one's own participation: e.g., I can hope that the sun will be shining tomorrow, even though I am unable to influence the weather. I would regard my hope for sunshine as mere wishful thinking only if I actually thought there was no possibility that the sun will shine tomorrow.
This distinction between hope and wishful thinking is similar to the distinction between sound and false hopes (Farran et al., 1995). Clinicians are often concerned not to encourage false hope or wishful thinking because they are concerned that the person will become disappointed and experience hopelessness. This is a valid concern, and it is noteworthy that only one of our informants expressed a clear sense of agency in connection with her description of the act of hoping. However, the expression of indefinite hopes may be seen as a way of protecting oneself from disappointment and hopelessness rather than inviting it. The person chooses to decrease the chance of failure in being unspecific concerning what must happen, when it must happen, or who must see to it that it happens, rather than to increasing the likelihood of fulfillment of the hope by expressing an adequate plan to achieve the goals hoped for. If the clinician is uneasy about encouraging such hopes, it is because he sees the fulfillment of hopes as more valuable than the maintenance of hope itself. Nevertheless, keeping an indefinite hope may also prevent a feeling of hopelessness.
Above we are close to inferring that the informants express indefinite hopes in order to protect themselves from disappointment. In discussing how to interpret the interviews one is easily led into speculation about what motives the informants may have had for expressing what they did. Such “reading between the lines” presupposes theories of communication or psychology. Due to the choice of methodology, our study is not adequate to confirm or disconfirm such theories. Nonetheless we will briefly mention two such theory driven interpretations as they may raise critical questions which may fuel further research.
Labov claims that the fundamental cohesion of discourse is not at the level of speech acts but at the more abstract level of interaction where status and role are negotiated (Labov, 1982). If Labov's theory of communication is right, the informants may have chosen, consciously or not, to describe their hopes in ways that might defend or increase their status in the eyes of the interviewer and themselves. If they perceived threat of a loosing status because of their acts of self-harm, such a defense may have been an urgent need. As we have seen, some of their hopes for life are explicitly about being perceived as respectable. In the light of this, the expression of indefinite hopes may have been motivated by the need to defend status and self-worth. By avoiding agency, the informant may be seen to avoid the blame for an eventual failure. We may also question whether the relational emphasis of their expressed hopes is influenced by such needs to defend their status as respectable persons. A replication of our study with the use of an anonymous questionnaire might indicate whether the emphasis on indefinite and relational hopes may have been influenced by the presence of an interviewer. However, we do not consider the use of anonymous questionnaire to be more objective, as any expression of hope is done with some communicative intention.
A psychological theory with special relevance for our study is Baumeister's (1990) theory of suicide as escape from self. According to Baumeister, suicidal acts are the result of a series of mental moves to escape an interpretation of oneself as a failure. These moves may involve a constricted time perspective, concrete thinking with a focus on immediate movements and sensations, absence of distal goals and an avoidance of high-level interpretation of the situation. The consequences of cognitive deconstruction may be disinhibition with respect to irrational acts, evasion of responsibility to avoid implicating or assessing the self, lack of emotion due to the striving to keep emotion out of awareness, fantasy, and irrational thoughts.
This theory is helpful in making sense of the expressions about acting impulsively and not thinking about the consequences that we found were expressed by three quarters of our informants. In the light of this theory, these informants did not entertain hopes about what they would achieve by ingesting an overdose of medication because such hoping requires a high-level interpretation of the situation. It is also possible that the expressions of indefinite hopes are reflecting such mental moves to escape an interpretation of oneself as a failure and to preserve a feeling of self-worth.
A number of measures were taken to ensure validity and transparency during and following the analysis. The researcher's pre-understanding is stated, and reflections are made about the context and the influence of the researcher. According to Malterud (2001), subjectivity arises when the effect of the researcher is ignored, and thus forms a threat to scientific principles of knowledge production. After the initial analysis, the authors discussed the developing explanations and interpretation of the findings on several occasions to determine whether the sub-themes and themes represented what they actually were supposed to. Efforts were made to identify data that were inconsistent or that challenged the comprehensive understanding. The presentation of the findings is as detailed and complete as possible, allowing the reader to view the material on which the statements rest. A possible limitation of the method used in this study is that the construction of the whole, the comprehensive understanding, should cover the naïve reading and all the parts of the structural analysis. This could lead the researcher to overlook and not present contradictory findings in order to follow the method in a rigorous way.
Life as text, that is the researcher's interpretation and presentation of the stories, does not represent life as lived or experienced. Hence, our interpretation is not established truth, but verisimilitude (Bruner, 1986). Drawing on the ideas of Ricoeur (1991), we argue that the focus should be more on the kind of reflections and actions that the findings of the present study create in the reader when assessing transferability. This notion represents a naturalistic and analytic way of generalization. The clinician must make the final judgment about whether the descriptions and interpretations we have given in the present study are sufficiently analogous to be used as a precedent for cases she or he is engaged in.
Contrary to the view that suicidal behavior indicates an extinction of relational hopes and withdrawal from social relations, our interpretation of the hopes expressed by our informants indicate that they are deeply occupied with relational concerns. This knowledge may be of clinical importance to professionals who seek to help patients who have been hospitalized after acts of intentional self-harm. The discussion of why our informants predominantly express indefinite hopes may also be of clinical relevance as the clinician should be aware that disappointment can be avoided either by fulfilling a hope or by maintaining an unfulfilled hope. Sometimes a person may find it more important to maintain hope than to see the hope fulfilled.
The lived experience of hope in patients hospitalized for intentional self-harm could be understood as definite and indefinite relational hopes for life and death. This comprehensive understanding was informed by the naïve reading leading to an understanding that hope is relational, and a synthesis of the three themes found in the structural analysis of the meaning of hopes for life, of hopes for death, and of the act of hoping. That their hopes for both life and death are relational hopes may have clinical implications as this indicates that they are deeply occupied with relational concerns.
Our interpretation of the lived experience of hope has led us to the distinction between definite and indefinite hopes which we see as more useful than the model of the various distinctions and aspects of hope that informed our pre-understanding. On the basis of the discussion we have gained the understanding that expressing indefinite hopes may serve the function of protecting the informant against experiencing failure and disappointment. Clinicians should be aware that sometimes maintaining hope may be more important to the patient than seeing hope fulfilled.
The authors would like to thank the following for their contributions to this project: The 12 informants for their willingness to be interviewed. Trond Jørgensen, Svein Staff, Ellen Munthe-Kaas, Synnøve Fougner (psychiatric liaison office Aker University Hospital), Trine Jensen, Mads Friberg (transcriptions), Helge Svare (assistance in preliminary analysis), Latha Nrugham, and the research forum of National Centre for Suicide Research and Prevention (iterated draft discussions).
This study was partially supported by the Norwegian Directorate of Health. The authors report no conflict of interests.