Orne, M. T. On the nature of effective hope. International Journal of Psychiatry, 1968, 5, 403-410.
Recognizing the importance of hope as a non-specific factor in psychotherapy, the rational components of effective hope are emphasized. The close relationship between the society's ethos and its attitude toward and acceptance of psychotherapy are discussed. In relation to Dr. Frank's conceptualization, some of the reasons why one might anticipate negative results from quantitative studies of psychotherapy and the implications for future research in this area are discussed.
THE IMPORTANCE of hope in the outcome of psychotherapy is eloquently documented by Jerome Frank. It is a dimension which cuts across the therapist's theoretical predilections, the kind of patients treated, and the nature of their symptoms. Perhaps one of the reasons why the importance of hope has not been explicitly recognized is the implication that it refers to archaic, primitive mechanisms more appropriately discussed in the context of religion than that of science. Frequently such a mechanism is juxtaposed against logic, reason, or rational secondary process thought. This type of dichotomy is inappropriate here. Clearly Dr. Frank is not talking about the kind of hope characterized by "I hope it snows tomorrow." On the contrary, what is meant is a very specific kind of expectation which will affect the patient's attitudes, beliefs, and actions during treatment and its eventual outcome.
The intellectual link between persuasion and hope (two concepts which Dr. Frank has used extensively) and suggestion and propaganda is easily made. It is well to remember, however, that much of what is often ascribed to archaic, primitive, and irrational aspects of the individual (which are believed to make him vulnerable to suggestion and propaganda) may in fact be based on eminently sound and logical principles. A classic study by Lorge [1] on persuasion and propaganda, for example, purported to show that identical sentences ascribed to different significant persons such as Jefferson or Lenin elicited agreement or disagreement based on the subject's attitude toward the individual to whom they were ascribed rather than on their intrinsic meaning. Subjects would agree with the sentence when ascribed to Jefferson, whereas essentially the same content ascribed to Lenin was likely to be rejected. It remained for Asch [2] to demonstrate that it was not the subjects' suggestibility which would cause them to accept or reject an idea by knowing its source, but rather that knowing the source helped to provide a context for an isolated statement. Since subjects knew a good deal about the views of the individuals, and the sentences were somewhat ambiguous stimuli, their interpretation was radically altered. In other words, the subject's knowledge about the beliefs of the individual to whom the statements were attributed significantly altered his perception of what the sentence intended to con-
The substantive work, upon which the theoretical outlook presented in this paper is based, has been supported in part by the Matz Foundation and the Institute for Experimental Psychiatry.
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vey, and the subject's attitudes were determined by the meaning that he then perceived.
In a like manner, nonspecific factors such as hope are usually conceived as based on irrational components whereas, in fact, effective hope contains major rational elements. If we wish to study it as a variable, it is essential to analyze it and its components so that it may become possible to manipulate and, hopefully, augment it.
Effective hope would logically require at least three major components:
• The individual must recognize that the problem or discomfort can potentially be relieved. Without recognizing the possibility of change, it does not seem likely that an individual would undertake any action to alter the current state of affairs.
• The individual must believe that effective means of bringing about the desired change exist.
• In the context of psychotherapy at least, it is essential that the patient view the therapist as being willing and able to provide the means by which the desired change may take place.
Many factors will tend to augment these essential components. For therapy to continue, some mechanisms to maintain hope despite inevitable setbacks are essential. It is likely, for example, that even a rudimentary understanding by the patient of the mechanisms by which the treatment works is apt to be very helpful and will maximize his conviction that help is available. In addition, knowledge of other instances where the treatment he is about to receive was effective will have a similar effect. Knowledge or conviction that a particular therapist has in the past effectively treated others with similar problems would certainly be helpful. Also, having made a commitment to undertake a given procedure -- perhaps at some cost -- would tend to maximize the individual's effective hope. A long list of variables could be developed which would tend to affect one or more of the major components and therefore influence effective hope. Irrational and transference factors will undoubtedly play a role but it is likely that the more prosaic aspects of the kind upon which we normally pass common-sense judgment are equally or more important. Things we see, hear, or read from presumably reputable sources about our problems, the type of therapeutic treatment and the therapeutic agent, the therapist's reputation, manner of conduct, etc., the apparent intuitive sense which a given procedure has, will all affect the patient's effective hope. I am calling attention to the importance of these apparently mundane and rational aspects because of the tendency to dismiss hope solely as a function of the inspirational or charismatic qualities of the therapist.
Two aspects deserve special consideration. One is the extent to which the therapist likes and cares about his patient. While it would be easy to explain the importance of this parameter by pointing out that it is reasonable for a patient to believe that a therapist who seems to like him will more likely help him, it is entirely possible that it may be an important factor in its own right, independently affecting the outcome of treatment. (For a fuller discussion of such a concept, see [3]).
Finally, the therapist's own belief in, and conviction about, the treatment he is practicing seems particularly important. In the sense of maximizing the patient's expectations of help, no other single factor seems quite as effective. A sincere, unquestionable faith in the merit of what one is doing is convincing to the patient, almost regardless of the technique involved, its scientific merit, or its appeal to the patient's intuitive sense; and I would hypothesize that one of the vital components supporting effective hope, and directly affecting therapeutic outcome, is the conviction of the practitioner that he is providing a meaningful, rational
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treatment for his patient. The more novel or deviant the treatment approach, the more important the therapist's convictions would be; in the case of highly institutionalized treatment, the society would provide support for the patient's belief in the effectiveness of the treatment, making the therapist's convictions less essential.
The importance of the therapist's convictions about the value of his treatment and the nature of the problem he is attempting to relieve is highlighted in another aspect of Dr. Frank's paper. In the context of emphasizing the methodological difficulties for evaluating outcome, he indicates that fiveand ten-year follow-ups are meaningful in the evaluation of a treatment for leukemia but are hardly relevant in the evaluation of a treatment for the common cold. From such a point of view it is appropriate to argue that "we shall consider an aspect of psychotherapy to be worth at least a second look if it produces short-term improvement by any clearly defined criterion."
It is strange, that such an eminently rational and reasonable position should strike the reader as peculiarly novel. Implicit is a challenge to that basis of psychodynamic psychiatry which postulates that symptoms merely reflect underlying problems, and the task of psychotherapy is to treat those underlying problems. If the patient's condition is viewed as analogous to the common cold, no basic change of the underlying personality is anticipated; rather, his ability to overcome his immediate difficulties may be transiently increased.
This point of view is diametrically opposed to the basic philosophy underlying the psychoanalytic viewpoint, which closely parallels the medical model of illness. Freud speaks in terms of mental structures analogous in many ways to a description of anatomy. The dynamic and somewhat mechanistic view of mental forces clearly reflects the impact of physiology. The idea of fixation at various stages of development reflects embryological concepts, and the manner in which unacceptable impulses and memories are dealt with is seen as similar to the way in which the organism deals with foreign bodies.
In the early literature of psychoanalysis, the correctness of an interpretation was demonstrated by its effect on the patient's symptoms. One easily gains the impression that the spread and success of psychoanalytic ideas were based not only on clinicians' impressions, but also on quantitative evidence of their effectiveness in curing patients. Unfortunately this has not been the case. As Frank has pointed out elsewhere [4], and as has been argued in a more vigorous fashion by Eysenck [5], no quantitative evidence is available for or against the view that insight-oriented therapy is, in fact, more effective in bringing about symptomatic relief than any other form of therapy. Certainly the dramatic acceptance of psychoanalysis in the United States anticipated any systematic effort at evaluating its effectiveness.
The reason why this viewpoint was so widely accepted probably does not lie so much in its efficacy as a therapeutic practice, but rather in its implications about the nature of man. It is relevant that the impact of psychoanalytic thinking was far greater in the United States than in Europe, and in this country was most pronounced in those areas which have been associated with what Weber [6] has called the Protestant ethic. The Protestant ethic equated success in a materialistic sense with the favor of the Almighty. Ignorance and poverty became sins, and progress and cleanliness virtues. Man was made responsible for his station in life. In the United States particularly, this related well to the ideal of a classless society where every man could become president.
In such a context, physical illness was one of the few acceptable reasons for failing to succeed. This led to the unusually impor-
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tant role of the physician in American life. (For an insightful discussion, see [7].) The importance of the kinds of social factors which have in recent times received much emphasis -- such as educational and job opportunities -- was denied, and the individual was expected to rise above any such difficulties as ignorance and poverty in the Horatio Alger tradition. The concept of the unconscious and its role in the individual's life, however, provides a way in which the idea of responsibility can be maintained, yet the dilemma of the individual explained. By defining psychological problems as illnesses, and their treatment as medical, the moral stigma was eliminated. For such a redefinition to be successful, however, it would be helpful to not only perceive the problems as illnesses, but also to assume that they can thereby be definitively and successfully treated. The psychodynamic point of view, presented in the context of medical practice, appealed to disparate segments of American opinion; not only to those who supported an essentially liberal philosophy of environmental causation (where it was readily adapted to emphasize the importance of interpersonal relationships), but also to the conservative, traditional representatives of the culture. Thus, psychiatric treatment is frequently accepted as mitigating by the courts, and even by "enlightened employers." The cultural significance of illness and attitudes toward medical treatment may be the most important reason why American psychoanalysts insisted on medical training for practitioners of an essentially psychological treatment.
It is, incidentally, not surprising that in a more traditional society, where the classic Catholic ethos prevailed, psychoanalytic thought was not widely adopted. Material success was not seen as evidence of divine favor and poverty did not preclude spiritual riches; on the contrary, "the meek shall inherit the earth." Here, instead of being responsible for one's position in life, the world order tends to be seen as fixed and society as segmented into rigid classes. The ideal goal is to adapt to one's place in the nature of things, with such societies placing a negative value on achievement beyond one's family or peer group. Satisfaction is sought in family and emotional relations, rather than in work, etc. Man's nature, as well as his place in the world, is seen as essentially given, and vague discomfort without focal symptoms is accepted as in the nature of things. Under those circumstances, only clear-cut instances of overt symptoms would be seen as relevant to treatment.
A great many individuals seek and receive psychotherapeutic care in the United States who would not consider seeking such help in countries that do not share this general attitude to the nature of man and the role of psychotherapy. I have tried to suggest that part of the acceptance of psychotherapy depends upon the assumption that the condition being treated is analogous to a developmental defect which is correctible with proper treatment, but which would not correct itself without it. This is in contradistinction to a common cold which is a transient illness for which no definitive treatment exists, nor is any necessary. In the first case, psychotherapy would be an essential medical need; in the other, it would at best be seen as a luxury. Undoubtedly a change of perception from the former to the latter would have far-reaching effects on the public's attitude toward psychotherapeutic intervention.
The manner in which psychotherapy is conceptualized would thereby seem to be closely related to the way in which society sees the individual and his responsibilities. Its legitimacy will be based in major part on that related, culturally sanctioned activity most highly valued by a society. In many primitive societies, for example, religious
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activity and medical treatment are closely intertwined and provide the equivalent of psychotherapeutic help. In others, where medical practice has already been differentiated from religious functions, advice and guidance remain the responsibility of the clergy. In the United States, where medicine has played a peculiarly significant societal role, psychotherapy is typically carried out in a medical context, but other legitimization is also possible. Considering the increasing importance that science has given everyday life, it may provide the model of psychotherapy of the future. By defining many problems as behavioral instead of psychological (in the psychodynamic sense), conditioning or other forms of behavior therapy become readily acceptable.
Dr. Frank has focused upon those aspects of psychotherapy which are related to the patient's hopes for, and expectations of, therapy and to the function of the therapist as a person. This approach tends to deemphasize the importance of what the therapist actually does. In view of the many claims by the various schools of psychotherapy that they embody the only meaningful and valid approach to treatment, such an attitude is indeed understandable and would seem supported by the finding of Fiedler [8] that therapeutic practice becomes remarkably similar among experienced therapists, regardless of their initial training. On the other hand, this very observation also suggests that what the therapist does must make a considerable difference. Regardless of the theoretical predilections with which a therapist begins practice, his behavior seems to move toward a common denominator as he accumulates experience. This very uniformity in practice which has been observed among therapists of widely differing theoretical persuasions would suggest that it must make a difference what the therapist does and it seems likely that therapists learn to behave the way they do because they have learned that it is effective with their patients. Unfortunately, few studies of therapy have focused upon these aspects of therapists' behavior.
There is one consequence of psychotherapeutic treatment which seems directly relevant to the matter of hope and which appears to me an inevitable by-product of successful treatment. Patients seem to learn to perceive the vicissitudes of life in such a manner that the same problems which previously would have led to discouragement and inactivity no longer prevent them from continuing to strive toward their goals. Their capability to maintain hope in the face of adversity may be brought about by increased confidence in one's ability, increased resources, learning to restructure environmental pressures in a less disturbing fashion, and so forth. (For a discussion of a related concept, see [9].) This change has been conceptualized in a variety of ways, most typically as increased frustration tolerance. Such a result of treatment may well be self-perpetuating insofar as the individual's ability to persist in purposive activity increases his odds of achieving the kind of situations he requires. In turn, his ability to achieve such situations will facilitate the individual's subsequent ability to withstand environmental pressures. This may help to explain why the patients who are most successfully treated are the ones who appear to require the least help; that is, they have the wherewithal so that they can almost achieve their goals without help. If an individual does not have, or acquire, the resources to enable him to ultimately "make it" in real life, the mechanism described here cannot become self-perpetuating, and the results of psychotherapeutic help, if any, are typically transient.
Unfortunately, it is all too easy to call attention to problems and hypothesize reasons why certain psychotherapeutic practices may or may not be acceptable, or even
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effective. This fails to address itself to the question of evaluating any specific set of psychotherapeutic manipulations. It is fashionable to cite negative findings in such a context; however, the very process of investigation makes positive findings unlikely. It is possible to compare the treatment results between no treatment and some treatment, and here, depending upon the outcome criterion chosen, some positive findings have been demonstrated [10]. As Dr. Frank has pointed out, however, nonspecific factors may account for much of this evidence. It becomes a formidable task indeed to evaluate different therapeutic approaches since the effects of therapy take time and, unfortunately, the interactions between therapist and patient are extremely complex. Different therapeutic points of view frequently lead to the same behavior on the part of the therapist, though the derivations involved are usually conceptualized in different terms. Furthermore, far more goes on in such a context than is explicitly recognized by the therapist. The differential effect of any particular therapeutic procedure would have to be sufficiently great to be recognized despite the large number of other variables present, such as differences in the therapists' skills and the patients' severity of illness. Further, the criterion measures of outcome are often difficult to define and several such measures which have considerable face validity intercorrelate very poorly, as Fiske [11] has shown.
The great difficulty encountered in demonstrating a significant effect due to a specific psychotherapeutic intervention is in direct contrast to the clinician's conviction that predictable changes are directly related to what the therapist does. Not only do clinicians observe this with their own patients, but also in patients that are treated by another therapist whom they are supervising. Because no quantitative studies have shown effects due to specific interventions, there is a tendency to discount such clinical observations because they are subject to selective recall, experimenter-bias, and self-fulfilling prophecies. It would seem surprising indeed, however, if it made no difference what the therapist did; if it does make a difference, such could most readily be recognized within the single case, where the effect of inter-individual differences, with reference to both patients and therapists, are eliminated. We may merely lack sufficiently powerful research techniques to be able to demonstrate specific effects, given the error variance introduced by individual differences.
Another problem in psychotherapy research, perhaps even more troublesome, is closely related to Dr. Frank's work on the role of hope itself. This is the interaction between the effect of specific therapeutic intervention and such relatively nonspecific factors as patient's hope and therapist's expectations.
Drug research provides a useful model which illustrates this problem since here, as Dr. Frank points out, the specific pharmacological action, analogous to the effect of specific therapeutic manipulations, can readily be distinguished from the placebo effect, which is analogous to the nonspecific therapeutic factors.
A considerable number of studies, for example, have been carried out to evaluate the effect of meprobamate as a therapeutic agent. Despite the insistence of clinicians who have used the drug that it has a specific therapeutic effect, several carefully controlled investigations, using a double blind design, have failed to observe significant differences between meprobamate and placebo. It remained for Fisher, Cole, Rickels and Uhlenhuth [12] to study the interaction between drug effect and expectations. In a collaborative study they employed two groups of therapists, one consisting of enthusiastic physicians who believed in the effect of drugs and gave them with conviction and the other of more skeptical doc-
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tors who maintained a more "scientific" attitude. Their findings, at least regarding the instance of "no-shows," were striking. Among the skeptical physicians there was no significant difference between meprobamate and placebo, while with the therapeutically-oriented physicians meprobamate showed a marked effect in reducing the number of dropouts even though a double blind procedure was employed. The study strongly suggests that a real drug effect may become apparent only in interaction with appropriate therapeutic enthusiasm on the part of the physician who is administering the drug. If the drug is administered without such a positive attitude, no drug effect may be apparent. Obviously such a study can be carried out most easily in the area of psychopharmacology, but the implications for psychotherapy research are clear. It is entirely possible that the absence of a strong positive attitude toward the psychotherapeutic technique on the part of the therapist will prevent any significant therapeutic changes, whereas the presence of such attitudes will lead to significant changes, even without an effective specific therapeutic manipulation. The effects of specific therapeutic interventions, in short, may become clear only in the presence of appropriate therapist attitudes which we have conceptualized here as significantly related to effective hope.
The degree of complexity which is involved in attempting to evaluate psychotherapy is sufficiently great to maintain almost any position in the light of almost any data. This all too easily justifies the attitude of some clinicians that meaningful investigations are unnecessary since "we know what works, and psychotherapy research is impossible anyway." Unfortunately, therapist conviction is a nonspecific variable affecting treatment and, as a result, it may be that what therapists know works -- works. This does not mean, of course, that given an equal conviction and a different course of action, it might not work better. It is merely very difficult to demonstrate this to be true. Some things, however, do seem dear: If we hope to learn anything about the effectiveness of specific therapeutic manipulations, it is essential that we study clinicians who have strong positive convictions about psychotherapy. For studies directed at these issues to become feasible, it will be essential to be able to classify patients in ways that are significantly related to their response to psychotherapy -- thereby decreasing the interpatient variability. It will be equally important to develop ways of defining and rigorously controlling what the therapist is actually doing, as opposed to being willing to accept his statement about what he is doing.
At best there is a tedious and difficult road ahead. In the meanwhile, a delicate balance between scientific skepticism toward, and uncritical acceptance of, the clinician's insights is needed. That we lack the tools to test such insights adequately should cause us neither to reject them out of hand nor to make them articles of faith. One meaningful approach may be to seek laboratory models where it becomes possible to rigorously study analogs to the complex processes that normally occur in treatment. Despite the difficulties such a course entails, it may, in the long run, be the most efficient way to draw meaningful inferences about situations where the variables would otherwise be too many, too complex, and require too long study to be feasible.
References
1. LORGE, I. with CURTISS, C. C. Prestige, Suggestion and Attitudes. J. soc. Psychol., 7:386-402, 1936.
2. ASCH, S. E. The Doctrine of Suggestion, Prestige and Imitation in Social Psychology. Psychol. Rev., 55:250-276, 1948.
3. ROGERS, C. R. Client-Centered Therapy. New York: Houghton Mifflin, 1951.
4. FRANK, J. D. Persuasion and Healing. Baltimore, Md.: Johns Hopkins Press, 1961.
5. EYSENCK, H. J. The Effects of Psychotherapy. Int. J. Psychiat., 1:99-178, 1965.
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6. WEBER, M. The Protestant Ethic and the Spirit of Capitalism. (Transl. by T. Parsons.) New York: Chas. Scribner's Sons, 1958.
7. PARSONS, T. Illness and the Role of the Physician: A Sociological Perspective. Amer. J. Orthopsychiat., 21:452-460, 1951.
8. FIEDLER, F. E. A Comparison of the Therapeutic Relationships in Psychoanalytic, Nondirective and Adlerian Therapy. J. consult. Psychol., 14:436-445, 1950.
9. KELLY, G. A. The Psychology of Personal Constructs. New York: Norton, 1955.
10. LUBORSKY, L., AUERBACH, A. H., HOLLENDER, M. and COHEN, J. Factors Influencing the Outcome of Psychotherapy: A Review of the Quantitative Literature. Manuscript in preparation.
11. FISKE, D. W., CARTWRIGHT, D. S. and KIRTNER, W. L. Are Psychotherapeutic Changes Predictable? J. abnorm. soc. Psychol., 69:418-426, 1964.
12. FISHER, S., COLE, J. O., RICKELS, K. and UHLENHUTH, E. H. Drug-Set Interaction:
The Effect of Expectations on Drug Response in Outpatients. In BRADLEY, P. B.,
FLUGEL, F. and HOCH, P. (Eds.), Neuropsychopharmacology. Vol. 3. New York: Elsevier,
pp. 149-156, 1964.