Melanie, a 47-year-old partner at a top civil engineering firm in Boston, could not accept the fact that she was staring at tacky art in a physician’s waiting room. Sitting there, her thoughts drifted back to her advisor in college, who cautioned her that it would not be easy to succeed in a male-dominated field. But she was a fighter and would not be deterred. Her drive had been easily identified by her supervisors, and she was continually rewarded with broader responsibilities. Indeed, her personal and professional lives were textbook descriptions of how to use ingenuity and grit to overcome grim obstacles. But this was different. This was her body betraying her. She could deal with the unexplained weight loss and the yellow tint that had altered the colour of her eyes. But then came the pain. Deep, boring, twisting pain. The agony catapulted her to seek medical attention and, within a week, the work-up was complete. Pancreatic cancer.
Inside her office, Dr Tamika was reviewing the PET scans and mulling over what to say to Melanie. After 20 years in practice, it seemed like having these conversations had gotten only harder. Surely someone as bright as Melanie had Googled pancreatic cancer and seen the adjectives (deadly, devastating) and the clichés (‘the tumour that gives oncology its reputation’) that go along with this particular malignancy. She had undoubtedly already uncovered the fact that long-term survival was achievable only in a relatively small percentage of cases. Dr Tamika wanted to provide hope. But, under these circumstances, wouldn’t it be less than totally truthful to talk about hope? Perhaps, Dr Tamika pondered, she should instead speak with Melanie about her goals for the time she had left, preparing her for the likely scenario that it would be only a matter of months. That felt more honest, but wouldn’t Melanie’s hope be crushed?
Dr Tamika’s thoughts capture what we call ‘the double-bind of hope’. Oncologists and other physicians who care for seriously ill patients such as Melanie often find themselves entangled by such a predicament. On the one hand, they worry that sharing the whole truth about a medical situation might destroy their patients’ hopes, leading to despair. But they also worry about the opposite strategy: that not accurately providing all relevant medical information or putting too rosy a spin on that information could lead patients down a path of false hope, denying them the time and space to emotionally prepare themselves and their families for whatever awaits.
Caught in this bind, physicians are tempted to throw up their hands and conclude that addressing hope isn’t their job. But this isn’t a tenable conclusion either. Ignoring people’s need for hope won’t make it go away.
This dilemma results from an overly narrow view – one commonly held in the medical world – that equates ‘hope’ with ‘cure’. If we buy into this equation, it means accepting that hope simply isn’t accessible for patients for whom cure isn’t possible, unless, of course, they deny the medical truth.
But these treacherous waters are navigable for physicians willing to follow a new body of research in psychology and accept a broader understanding of hope, one that allows the inclusion of difficult truths. And because unpleasant realities permeate our lives beyond the realm of illness, this new understanding may also pay dividends no matter what difficulties we’re facing.
Hope is not wishful thinking, optimism, or ‘the power of positive thinking’. There’s nothing wrong with being optimistic, of course. Research shows that optimism is associated with many beneficial outcomes. But that doesn’t mean it’s the same as hope. The Cambridge Dictionary defines optimism as ‘the feeling that in the future good things are more likely to happen than bad things’. The influential psychologists Charles Carver and Michael Scheier, who have built careers studying optimism, describe it as the tendency to believe that outcomes in life will generally be positive, favourable or desirable. In other words, optimists simply believe things will work out for the better. The future is bound to be good. For this reason, they’re often said to wear rose-coloured glasses or see the glass as half full – sometimes with cherry soda.
Hope isn’t the same as glass-half-full thinking, however. Hope is applicable even when the glass is only a third full or has nothing in it at all. That’s because true hope isn’t about living in a fantasy world; it’s about living in this one. For instance, it doesn’t deny suffering and pain.
The book Supersurvivors (2014) – co-authored by one of us, David B Feldman, with Lee Daniel Kravetz – profiles 16 trauma and tragedy survivors who went on to do things that made the world a better place. A through-line in their stories was something called ‘grounded hope’. Even though all of these survivors exemplified a hopeful, forward-looking spirit, they were also firmly grounded in the realities of their situations. When James Cameron, the only survivor of a 1930 lynch mob, established the first chapter of the National Association for the Advancement of Colored People (NAACP) in Anderson, Indiana, worked to desegregate housing in Milwaukee, Wisconsin, and ultimately founded America’s Black Holocaust Museum, he wasn’t under any illusion that the world was a wonderful place where things would easily work out fine. In contrast, he understood the staggering resistance he would face, but believed that his efforts might nonetheless help to build a better life for Black Americans. As he wrote in his autobiography A Time of Terror (1982): ‘With faith and a prayer over my lips forever, I was determined to keep my hands on the throttle and my eyes upon the rails.’
When people have hope, their goals are more likely to become reality
People who, like Cameron, fight for important causes aren’t necessarily doing so because they see the world through rose-coloured glasses. Likewise, the scientists who valiantly struggle to end the COVID-19 pandemic or the patients with cancer who choose to undergo treatments with painful side-effects know the road will be hard, but they push forward because they’ve found goals worth keeping their ‘hands on the throttle’ for. That’s the source of their hope.
Hope, at its heart, is a perception. Unlike most perceptions, however, this one has the possibility of creating reality. Most of the time, we think of reality as creating our perceptions. Look around you right now and notice the objects in your environment. They all exist in reality before you perceive them. But hope is a special kind of perception: it’s a perception of something that doesn’t yet exist. It’s a perception of what is possible.
And research shows that, when people have hope, their goals are more likely to become reality. In a study in the Journal of Social and Clinical Psychology in 2009, Feldman and colleagues asked college students to name seven goals they wanted to accomplish within the next several months. Then the students were given a brief psychological test, known as the Goal-Specific Hope Scale, for each of these goals. Three months later, they were asked to look back at their list of goals and rate how much progress they had made for each. The results were straightforward: those who had greater hope for a goal at the beginning of the study were more likely to report having accomplished that goal by the end of the study.
This isn’t because hope has magical powers. It’s because, when people believe a goal they care about is possible to achieve, they’re more likely to take steps to make it happen.
This kind of hope stands in contrast to a saying you’ve probably heard before: ‘Hope is not a strategy.’ It’s true, of course, that the mere feeling of hope isn’t a strategy: although the feeling can buoy us up when we’re down, it’s not going to solve our problems.
But hope is more than a feeling. It’s a way of thinking that pushes us to take action. The actor Jane Fonda certainly expressed this perspective when she said: ‘Hope is activism.’
Her assertion accords nicely with the most widely researched model of hope in the psychological literature, known simply as Hope Theory. Although dubbed a ‘theory’, this model has been supported by hundreds of studies since it was first proposed by the psychologist C R Snyder in 1989.
Snyder took a grassroots approach. Over the course of a working sabbatical year from his job at the University of Kansas, he approached community leaders, including politicians, clergy, educators and business leaders, asking them to name the most hopeful people they knew, using whatever definition of hope they wanted. Then, he interviewed as many people on their lists as he could. What he discovered was a surprisingly simple, yet powerful view of hope.
Namely, he realised that hopeful people shared three things in common – goals, pathways and agency. Although Snyder called these the three ‘components’ of hope, it may be more useful to think of them as the three conditions for hope to thrive.
In the past century, human beings learned to fly, landed on the Moon, networked the globe, and eradicated diseases
First, his hopeful interviewees had a clear sense of what their goals were, and felt committed to those goals. In other words, they had something for which to hope. Although the word ‘goal’ tends to conjure images of formal objectives such as getting a raise or graduating from school, Snyder observed that people’s goals are often distributed across many areas of life, from career-related outcomes to social or even spiritual aspirations. In fact, goals inspired by our most cherished personal values tend to give rise to more motivation and satisfaction.
Second, Snyder’s hopeful interviewees had pathways – more colloquially known as plans or strategies – they believed would allow them to reach their goals. In other words, they believed that there was at least something they could do to move toward achieving the goals they’d embraced. According to Hope Theory, when people don’t act, it’s often because they don’t believe there is any way to achieve their goals or, if a pathway does exist, it just seems too long or difficult. But hopeful people tend to break down complex or difficult pathways into an array of smaller steps that can be tackled one at a time. They’re under no illusions that all their pathways will work, however. They understand that bad things can and often do happen. So, realising that some of their plans could become blocked, they tend to try lots of different pathways.
Finally, Snyder’s interviewees had an abiding belief in their capabilities, something he called ‘agency’. Although they recognised that working toward their goals would be difficult, they still believed that – deep down – they might be capable of accomplishing them if they kept trying. As in Watty Piper’s popular children’s book The Little Engine That Could (1930), beliefs such as ‘I think I can’ fuelled their hope and motivated them to act.
In other words, far from being naive positive thinking, hope is a realistic, yet forward-looking set of beliefs that drives our efforts to bring about a better future. As Barack Obama expressed in the title of his book The Audacity of Hope (2006), hope is audacious. It involves taking a cold, hard look at reality, but nonetheless being bold enough to believe that a better future is possible. Some might call it foolhardy (a synonym for audacious), but many goals people believed were once impossible turned out to be possible. In the past century, human beings learned to fly, landed on the Moon, networked the globe, and eradicated or dramatically reduced once-widespread diseases such as polio and smallpox.
Since the early 1990s, hundreds of studies have shown that this form of hope is robustly related to both psychological and physical wellbeing.
It’s relatively simple for researchers to examine the connection between hopefulness and mental health. Studies typically involve administering measures of wellbeing to large samples of people, along with one of a small arsenal of psychological tests of hope – often the 12-item test of pathways and agency known simply as the Hope Scale. Perhaps not surprisingly, such studies find that greater hope is linked with lower levels of depression and anxiety. In many ways, hope is the inverse of such feelings. Whereas depression often leads people to believe there is nothing they can do to improve their lives, when people experience hope, they tend to believe just the opposite. By that same token, if anxiety could speak, it might say something like: Bad things are coming down the road and there’s no way to stop them. Hope, on the other hand, might respond: Even if bad things do happen, you’ll be able to handle them and possibly still achieve the goals that are most important to you.
A growing body of research links hope with better physical health as well. High-hope people are more likely than their lower-hope counterparts to be non-smokers, exercise regularly, and eat healthier diets. Following serious injury, they’re more likely to fully commit to rehab and achieve greater functioning afterwards.
Hope is also related to better coping in people with physically painful medical conditions, including those with paralysis due to spinal cord injury and adolescents who have survived serious burns. In one simple yet illustrative study of the hope-pain connection, researchers asked people to fill out the Hope Scale and then undergo the so-called ‘cold pressor’ challenge: to submerge their non-dominant hand (usually the left) in a tub of freezing water and keep it there as long as possible. High-hope people kept their hands submerged nearly 30 seconds longer than their low-hope counterparts, for a total duration of about 2 minutes, on average. That’s a long time, considering that after only 3-4 minutes the hand tends to go numb and tissue damage can occur.
Those who rated their hope as higher tended to survive longer than those who rated their hope as lower
This greater pain tolerance may result, at least in part, from lower levels of pain catastrophisation, the tendency to ruminate on sensations of pain. It’s not that high-hope people don’t notice the pain. They do. It’s just that they may focus even more on the goals they’re trying to accomplish. Given that what we focus on tends to grow perceptually stronger (and what we don’t focus on becomes perceptually weaker), this may lead to lowered perceptions of pain. It’s the psychological equivalent of looking away when we’re about to get a shot in the arm.
In addition to these findings, there is even emerging evidence that hope predicts longevity in people with cancer. Along with our collaborators Marie Bakitas, Jay Hull and Mark O’Rourke, we recently re-analysed a database of more than 500 patients with advanced cancers who were receiving palliative care. We split the sample into two large groups – those with high hope and those with low hope – and examined whether patients who began the study with higher hope lived longer. It’s important to say that we weren’t able to use the usual 12-item Hope Scale (mentioned earlier) in this study, because we were limited to re-analysing data that had already been collected. Instead, we determined which people were high versus low in hope through their answers to three straightforward questions that asked them to rate how much they agreed with statements such as ‘I feel hopeful’. Much to our amazement, those who rated their hope as higher tended to survive longer than those who rated their hope as lower.
Keep in mind that the people in this study were very ill. They all had advanced cancers that physicians estimated were likely to take their lives within a year or two. Presumably, most of them knew that cure was not in the cards. And yet, hope predicted longer survival. So, what was their hope about?
This question might seem nonsensical if we assume that ‘hope’ and ‘cure’ mean the same thing. But Snyder’s definition of hope shows why this isn’t necessarily the case. Hope can exist whenever people have a goal they care about, believe pathways exist that could lead to that goal, and feel empowered by personal agency.
Hope may be invested in the goal of cure, of course. Given recent advancements in oncologic treatments, hope for cure glows brightly for many people. Moreover, people certainly sometimes live longer than physicians expect. But, when cure isn’t possible despite the best efforts of doctors, patients and families, that doesn’t mean hope also is no longer possible.
A few years back, Feldman and his research assistants visited the homes of dozens of people with terminal cancers who had elected for hospice care. Because receiving hospice care generally means discontinuing curative efforts, they were curious about whether these patients still felt hopeful. So, they administered the Hope Scale and found that, indeed, these patients’ levels of hope were just as high as people continuing to receive curative care, even though only a third of them said they had the goal of being cured. So, what were they hoping for? They talked about hopes that were diverse and beautiful, including to ‘resume my hobby of digital photography’, ‘take a helicopter ride’, ‘do some writing about my life’, ‘spend time with my grandchildren’, ‘pass on what I have to the world’, and ‘enjoy the rest of my days’. For these patients, hope was thriving, even in a situation other people might consider hopeless.
One patient, ‘Ned’, perhaps best illustrates hope in this context. A man with a tremendous sense of humour, he had spent his whole life collecting jokes. In fact, Ned knew more than 1,000 of them. ‘And that’s not including the dirty ones,’ he often said with a grin. At the age of 84, when the heart failure he had lived with for several years began more rapidly progressing and he wasn’t able to care for himself at home, he entered an inpatient hospice. Late one evening, a member of staff discovered him quietly crying in his room. When she gently asked Ned what was on his mind, he replied: ‘All my jokes will die with me. My grandkids will never get to hear them.’
In response, she suggested that Ned begin writing them down, lending him a notebook and pen. With joy and enthusiasm, he filled every page with jokes. By the time he was given a second notebook, however, he had become too weak to write. So, the hospice staff took turns sitting by his bedside, taking dictation. Then, about a week later, Ned made an unusual request. ‘I want to give a stand-up comedy act,’ he said. The care team enthusiastically agreed. His spirits rose substantially over the next few days as he prepared. Then, 72 hours later, came the big moment. Almost the entire staff gathered along with other patients to hear Ned’s routine. From his bed, which had been wheeled into the hallway, he delivered a stunning performance. His audience was in stitches, and his face beamed with joy. At that moment and the days leading up to it, he had all the conditions for hope to thrive: a goal that was truly meaningful to him, a way to get there, and the agency to make it happen. Although Ned died only a week later, he knew he had given his audience – and himself – the most meaningful gift he could imagine.
Active hope is the psychological engine that drives efforts to bring about important goals
Most of us can hardly fathom what it must be like for Ned and other patients with terminal illnesses. But the fact that they can experience hope shows us that the double-bind we referred to at the beginning of this article is a false one. Knowing the truth, even when it’s grim, does not preclude experiencing hope. Hope is possible even under dire circumstances.
It’s an insight perhaps more important now than ever before. There’s no doubt that the past two years have been among the most traumatic in recent memory for many people. On 11 March 2020, COVID-19 was declared a pandemic by the World Health Organization. Since then, millions have fallen prey to this horrible disease. Against this backdrop, our world has also reeled from ongoing racial injustice, political unrest and natural disasters, among many other calamities. Few would use the word ‘hopeful’ to describe the times we live in. Instead, words such as ‘tragic’ and ‘heartbreaking’ come to mind. People are afraid, sad, angry and grief-stricken.
To be clear, hope won’t magically put an end to racism, eradicate COVID-19, cure cancer or instantaneously bring about any other important goals. But active hope is often the psychological engine that drives people’s efforts to do so. As the essayist and activist Rebecca Solnit wrote in The Guardian in 2016:
Your opponents would love you to believe that it’s hopeless, that you have no power, that there’s no reason to act, that you can’t win. Hope is a gift you don’t have to surrender, a power you don’t have to throw away.
No matter who or what your opponents are in life, hope isn’t something you have to give up, ever.
Whenever you feel hopeless, ask yourself what you can do to set the conditions for hope in your life and in the world around you. What goals are meaningful to you? What pathways can you enact – even small ones – to move toward those goals? And, what inspires your agency, the will to keep going even when things are unimaginably tough?
As Melanie entered Dr Tamika’s office, she didn’t recognise her own gait. Her tentative steps bore no resemblance to her usual confident strut. Dr Tamika, the kind of physician who didn’t enter medicine simply to communicate with patients, but to commune with them, picked up on Melanie’s fear. But, even in fear there may be an opportunity for hope, she thought.
‘I know you’re afraid, and I don’t blame you for that,’ Dr Tamika said. ‘What you’re facing is one of the hardest cancers I know. But we’re going to try our best to beat the cancer. And maybe we will. But, no matter what happens, I’ll never abandon you. What is it that you want for your life right now?’
Dr Tamika’s words were not just reassuring, they were exactly what Melanie needed to hear.
‘You have no idea how important it is for me to hear you say that,’ she told Dr Tamika. ‘I want to do everything I can to beat the cancer, but also I want to make sure the pain is controlled and that whatever treatment we choose still leaves plenty of room to check the boxes on my bucket list, just in case.’
At that moment, Melanie had hope. It wasn’t a hope based on seeing the world through rosy glasses or assuming that everything would magically turn out all right. She knew cure would be a long shot. But her hope was grounded in something more solid than mere positive thinking: there were goals worth striving for and someone who would be there to help. In life’s uncertainties, sometimes that’s the best any of us can ask for.
To read more about hope, visit Psyche, a digital magazine from Aeon that illuminates the human condition through psychology, philosophy and the arts.
