Robert Hilliker dissertation

Institute for Clinical Social Work

HOPE & DESPAIR: WORKING TOWARDS A COHESIVE NARRATIVE

A Dissertation Submitted to the Faculty of the Institute for Clinical Social Work in Partial Fulfillment for the Degree of Doctor of Philosophy

By

ROBERT L. HILLIKER

Chicago, Illinois May 2023

Dedication I dedicate this study to my lovely wife, Maria Elena. You are my best friend and a wonderful mother to our five beautiful daughters. Maria, when I was accepted into the doctoral program you bought me a new Apple MacBook laptop. Nobody had ever purchased a gift that expensive for me. It floored me. But more importantly, you put a note with it that read “throughout school you have studied the ideas of others, now it is time to create your own.” So, I dedicate this to you, my love.

I also dedicate it to each of our girls: Anna Theodorah, Carmela Jane, Mary Fiorella, Emelia June, and Francesca Bea. All of you girls are so bright, full of life, and love, I cannot wait to see what new ideas you create and contribute to the world. You bring me so much joy and I am grateful each day that I get the chance to be your father.

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Acknowledgements I want to offer continued acknowledgement to my wife and daughters without whom I would not have nearly the same motivation, purpose, and joy in life. I also want to offer a special acknowledgement to three critical people that assisted this study and my efforts tremendously: Taylor Johnson, Sevana Malkasian, and Nikki Hune. Each of you contributed significantly to my being in this position, so from the bottom of my heart I offer you my sincere gratitude.

To my chair, Dr. Jim Lampe, thank you for your guidance and support throughout the doctoral program, and to each person on my committee thank you for the time and attention you gave to ensure I could be successful in this process.

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Table of Contents Page Dedication........................................................................................................................................ii Acknowledgements........................................................................................................................iii List of Figures.................................................................................................................................ix List of Tables...................................................................................................................................x CHAPTER I. INTRODUCTION.....................................................................................................1 Purpose Statement.......................................................................................................................1 Significance of the Study to Social Work Practice and Research...............................................2 Description of the Research Problem..........................................................................................3 Conceptual Framework................................................................................................................4 Research Hypotheses and Questions...........................................................................................5 Statement of Assumptions...........................................................................................................6 Hope & Despair.......................................................................................................................6 Misconceptions About Hope...................................................................................................7 Reasonable Hope.....................................................................................................................9 Background & Rationale...........................................................................................................10 Conclusion.................................................................................................................................11 CHAPTER II: LITERATURE REVIEW......................................................................................12 Introduction................................................................................................................................12 Description of Techniques Employed in the Literature Review...............................................12 Theories on Hope.......................................................................................................................14 Hope Theory: Rainbows in the Mind....................................................................................15 Theory of Reasonable Hope..................................................................................................18 Relevant Works Related to the Topic of Hope..........................................................................21 Historical References to Hope...............................................................................................21 Hope and Chronic Illness.......................................................................................................25 Measuring Hope.....................................................................................................................26 Hope and Despair..................................................................................................................27 Phenomenological Studies of Hope and Despair...................................................................28 Efficacy of Hope....................................................................................................................28 Hope in Therapeutic Process.................................................................................................29 Hope, Depression & Suicidality............................................................................................29 Hope: Definitions and Uses from the Psychoanalytic Literature..............................................35 iv

Lack of Operational Clarity and Why We Should Care............................................................36 Summary Points from the Literature.........................................................................................37 Gaps in the Existing Literature..................................................................................................37 Concluding Remarks.................................................................................................................38 Chapter III......................................................................................................................................40 METHODOLOGY........................................................................................................................40 Qualitative Research..................................................................................................................40 Grounded Theory.......................................................................................................................41 Glaser.....................................................................................................................................42 Strauss & Corbin....................................................................................................................42 Constructivist Grounded Theory...............................................................................................43 Charmaz.................................................................................................................................43 Rationale for Constructivist Grounded Theory.....................................................................44 Role of the Researcher...............................................................................................................45 Description of the Study............................................................................................................46 Sampling................................................................................................................................46 Theoretical Sampling.............................................................................................................47 Recruitment Protocol.............................................................................................................49 Data Collection/Generation.......................................................................................................50 Ethical Considerations...............................................................................................................51 Demographic Questionnaire..................................................................................................52 Participant Interviews............................................................................................................52 Theoretical Sufficiency/Saturation........................................................................................53 Data Analysis.............................................................................................................................54 Field Notes.............................................................................................................................55 Research Memos....................................................................................................................56 Coding Procedures.....................................................................................................................57 Initial Coding.........................................................................................................................58 Focused Coding.....................................................................................................................58 Theoretical Coding................................................................................................................59 Constant Comparison.............................................................................................................60 Qualitative Rigor and Trustworthiness......................................................................................60 Summary....................................................................................................................................60 CHAPTER IV: FINDINGS...........................................................................................................62 v

Overview....................................................................................................................................62 Sample Characteristics...............................................................................................................63 Results for the CGT Analysis....................................................................................................64 Developing Final Codes from Initial Codes..........................................................................64 Support...................................................................................................................................70 Developing Core Categories from the Final Codes...............................................................76 Developing Theoretical Propositions from the Core Categories...........................................83 Summary....................................................................................................................................86 CHAPTER V: IMPLICATIONS AND RECOMMENDATIONS................................................88 Overview....................................................................................................................................88 Interpretation of Findings..........................................................................................................89 Towards a Theory of Hope and Despair....................................................................................93 Limitations and Recommendations...........................................................................................98 Limitations of the Study........................................................................................................98 Recommendations for Future Research.................................................................................99 Recommendations for Future Practice.................................................................................100 Conclusion...............................................................................................................................101 References....................................................................................................................................103 Appendix A: Flyer Promoting the Research Study.....................................................................112 Appendix B: Informed Consent...................................................................................................113 Appendix C: IRB Approval.........................................................................................................116 Appendix D: Demographic Questionnaire..................................................................................117 Appendix E: Interview Guide for Research Study......................................................................118 Appendix F: Grounded Theory Process......................................................................................119 Appendix G: Screening Interview Script.....................................................................................120 Appendix H: List of Tables & Figures........................................................................................121 Appendix I: Excel Excerpt Image of Coding Notes....................................................................134 Appendix J: Field & Coding Notes.............................................................................................145 Appendix K: Excel Excerpt Image of Codebook........................................................................152 Appendix L: Coding Memos.......................................................................................................153

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List of Figures Page Figure 1. Quadrants for Psychoanalytic Literature Defining and Usage of Hope.........................36 Figure 2. Data Generation..............................................................................................................51 Figure 3. Definition of Despair......................................................................................................57 Figure 4. Definition of Hope.........................................................................................................57 Figure 5. Coding Memo 1..............................................................................................................65 Figure 6. Coding Memo 2..............................................................................................................66 Figure 7. Codng Memo 3...............................................................................................................69 Figure 8. Coding Memo 4..............................................................................................................71 Figure 9. Coding Memo 5..............................................................................................................72 Figure 10. Coding Memo 6............................................................................................................73 Figure 11. Coding Memo 7............................................................................................................73 Figure 12. Coding Memo 8............................................................................................................74 Figure 13. Theory of Hope and Despair........................................................................................90

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List of Tables Page Table 1. The Two Major Types of Goals in Hope Theory............................................................16 Table 2. Implicit and Explicit Operative Processes and Their Respective Emphases in Hope Theory as Compared to Selected Positive Psychology Theories...................................................17 Table 3. Study Sample Characteristics..........................................................................................63 Table 4. CGT Analysis, Step 1: From Initial Codes to Focused Codes........................................66 Table 5. CGT Analysis, Step 2: From Focused Codes to Core Categories...................................78 Table 6. CGT Analysis, Step 1: From Initial Codes to Focused Codes........................................83

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CHAPTER I. INTRODUCTION Purpose Statement The purpose of this constructivist grounded theory research was to develop and understand the concepts of hope and despair in order to support and improve outcomes for adults engaging in psychotherapy. The research concepts of hope and despair were generally defined by the emergence of themes, patterns, and co-created meaning in the data collected during qualitative interviewing of research subjects. This was accomplished through the development of a grounded theory about hope and despair for adults seeking therapeutic support from clinical social workers, as well as clinical psychologists. Unlike typical top-down theoretical models of research, constructivist grounded theory is an inductive, bottom-up method that re-positions the researcher’s role. As Mills et al. (2006) describe, constructivist grounded theory is “ontologically relativist and epistemologically subjectivist…[it] reshapes the interaction between researcher and participants in the research process and in doing so brings to the fore the notion of the researcher as author” (p. 6). It is the role of a constructivist grounded theory to not presuppose too much before beginning fieldwork and participant interviews. Therefore, it was hard to predict exactly what this study would yield that will be additive to the study of hope. However, drawing from several years of professional experience and anecdotal observation of the clinical phenomena of hope, and the collection of robust participant data the study yielded meaningful results that will ultimately support the improvement of treatment outcomes.

Hope and despair have vital roles in clients’ pursuit of therapy, the success of therapeutic engagement, and the overall outcome of therapy (Snyder, 1999, 2002, 2004). Despite the critical function of hope there still lacks an organizing construct or theory for how psychodynamically oriented clinicians can harness the clinical power of hope in service of their clients’ wellness. It

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was the purpose of this study to explore the roles of hope and despair in the process of healing using a constructivist grounded theory approach. Further, it was the intent to provide a framework for understanding hope and despair in treatment and develop insight into the techniques used to explore and instill hope. While the literature on hope has grown significantly in the past two decades it is largely centered on the role of hope in the course of chronic illness or recovery from physical health conditions (Lohne, 2008; Hammer et al., 2009; McLean, 2011).

Lastly, another intent of this body of work was to develop a more cohesive narrative regarding the role of hope and despair in all forms of healing, and thus provide research that appeals to a broader audience who can benefit from this work.

Significance of the Study to Social Work Practice and Research Many authors from a variety of disciplines have written about hope and the vicissitudes of hope. However, there was a need to explore how hope can be actively leveraged to support therapeutic change. The vast majority of clinically focused graduate programs concentrate on psychological theory and basic therapeutic techniques. Yet, common factors theory provides evidence that hope, expectancy, and placebo account for the same percentage of therapeutic change as therapeutic technique (Hubble et al., 1999). Despite this understanding, little research has been conducted to determine how clinicians might activate, cultivate, and work to sustain this fundamental hope for recovery within the patient. It was therefore the purpose of this study, and hopefully future research studies, on the topic of hope to determine how helping professionals can begin to talk about, understand, and ultimately leverage hope in service of their patient’s well-being.

In his book The Vital Balance, Karl Menninger (1963) writes about the classic and contemporary understanding of hope. Historically speaking, the Greeks viewed hope as the worst

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of evils, and indeed many modern thinkers have echoed this sentiment. Menninger (1963), however, speaks to the more positive aspects of hope as he discusses the Hebrew conception, stating: “in a sense the whole history of the Jews is a study of hope; hope springing out of all their discouragements and misadventures and disasters,” (p. 381). It was my aspiration that this research study might shed light on the modern notion of hope, and to outline the relational determinants of hope that can be employed to improve outcomes in therapy.

Whether doing home visits for state mental health agencies, delivering outpatient service to people with substance dependence in a community agency, or working with acute mental illness in an inpatient setting; clinical social workers work with clients that are overwhelmed with despair and struggling to find hope for their wellness. This dissertation research study set out to contribute to the field of Social Work by more accurately defining hope and despair from a grounded theory perspective, offering definitions that reflect a shared human experience. From there we can determine how to harness the clinical power of these concepts to support behavior change and improve treatment outcomes.

Description of the Research Problem Hubble et al. (1999) found that hope, expectancy, and placebo account for 15% of therapeutic change, which is equivalent to the benefit derived from therapeutic technique.

Despite a longstanding understanding about the role of hope in creating therapeutic change there has yet to be any substantial systematic attempt to understand, and thereby harness the power of hope in service of therapeutic change. In reviewing the relevant literature on the topic of hope and despair it became clear that while hope has been studied in multiple professional settings, the research conducted has largely centered on hope as it relates to chronic illness (Lohne, 2008; Hammer et al., 2009; McLean, 2011). Other studies have focused on trait hope and hope as an

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individual attribute (Bernardo, 2010; Ong et al., 2006). Of the articles that focused on hope as a relational component of treatment there has not been a systematic study of the assertions made in these papers (Allen 2005, 2006; Weingarten, 2010). Another gap seems to be a consensus on an operational definition of hope. Several studies make use of Snyder’s (1994, 2002) definition of hope as relating to goals, pathways, and agency, but no study has undertaken the task of building an operational definition of hope from the ‘ground’ up. Kaethe Weingarten (2010) acknowledges that while “therapists ‘know’ that hope is beneficial…few have written about exactly what hope is and why it is advantageous” (p. 6). This provided several openings for this study to fill important gaps in the literature.

Conceptual Framework In reviews of the literature on grounded theory it is clear that there are definitive camps and lines drawn in the sand about the process for thinking about and conducting grounded theory research. It began with Glaser and Strauss’ (1967) development of what is now considered classic grounded theory, which Glaser maintains is the appropriate way to do grounded theory research (Glaser, 1967). Strauss split from Glaser and in collaboration with Corbin has organized a variation of classic grounded theory (Strauss & Corbin, 1997). Other researchers have since applied a range of variations including modern, post-modern, critical, and constructivist points of view within the overarching frame of grounded theory (Charmaz, 2006; Mills et al., 2006; Thornberg, 2012). In order to best understand the appropriate process for application and implementation of a grounded theory for this study of hope and despair, I first conducted a thorough literature review on technique and application of these various schools of thought within grounded theory research. A mixed methods design that incorporates not only grounded theory, but also relies on quantitative elements was also studied before making determinations

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about the methodology employed for this study (Plano & Creswell, 2008).

After careful review of the literature, it was decided that the theoretical approach that fit both my clinical perspective, as well as the purpose of this study was that of constructivist grounded theory. Developed by Kathy Charmaz (2006), constructivist grounded theory is a contemporary variation of Glaser’s classic grounded theory. Charmaz (2006) uses the basic framework of grounded theory but posits additionally that the data collected is co-created by the researcher and participant, and is then reflected in the process of coding and interpreting the data.

This constructivist viewpoint allows for the inclusion of multiple realities, rather than the idea of grounded theory leading to a single truth.

Research Hypotheses and Questions Unlike other research methodologies, a grounded theory approach begins with an area of interest or a general topic rather than an explicitly stated hypothesis. Most methodologies enter the phase a data collection with one or more clearly stated hypothesis, in a grounded theory approach the researcher seeks to develop a hypothesis or theoretical propositions based on the themes emerging from the data collected (Charmaz, 2006).

I developed a qualitative interview and collected participant data on the topic of hope, and also despair. However, in an effort to stay true to form with grounded theory research any hypotheses or theoretical propositions will only be generated as thematic patterns emerge from the data collected and coded from participants. I posited a total of three research questions that I sought to answer with the findings from this research study. Below are the research questions that the study addressed: 1. What roles do despair and hope play in the process of psychotherapy?

2. Was hope a central theme in the process of change that takes place in psychotherapy?

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3. Is the concept of despair a starting point for the instillation and cultivation of hope in treatment?

One difficulty I encountered is that having extensively reviewed much of the existing literature on hope there are several potential hypotheses that could have been constructed. Even the notion of including research questions regarding despair implies a hypothesized link between these concepts of hope and despair. The assertion that these concepts may exist in a dialectical relationship seems to assert an unspoken hypothesis making a grounded theory approach to this topic particularly challenging. That said, it is believed that a grounded theory approach to this topic offered important insight into a deeper understanding of hope and its role in the healing process.

Statement of Assumptions I have attempted to outline several of the working assumptions I could not fully divorce myself from as I assumed the role and responsibility of conducting credible research. My interest in the topic of hope and despair is born from my personal experience and the professional experience of working with clients in clinical practice. As a result, I have formed opinions on the matters at hand, which I will attempt to outline here. I will share some of these working assumptions up front, understanding that they invariably color the lens through which I worked with the qualitative data collected.

Hope & Despair It is often said among psychotherapists and other helping professionals that we come by this work honestly, and for me this notion could not be more truthful. I sought for some time early in my work to disavow this notion of the “wounded healer,” however, I have come to embrace that it is my deep understanding of suffering that allows me to connect to the experience

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of my patients. Furthermore, it is this understanding of suffering that is uniquely and inextricably bound to the construct of hope. The working premise of this study is in part that hope and despair exist in a dialectical relationship and both are fundamental aspects of why people seek help and the efficacy of therapeutic support (Byrne & McCarthy, 2007; McLean, 2011; Hubble et al., 1999; Lambert, 2004).

A working assumption is that this study of hope could not have been undertaken without the acknowledgment of its relationship to despair. All stories of hope have a connection to the lack thereof, and in order to devise a meaningful study of hope it must include an exploration of despair. Since patients often present with despair and lacking hope, it is important to understand what factors might move them on the continuum from despair to hope. Several authors have discussed hope as being in a dialectical relationship with despair, but as of yet have not systematically researched this topic (Flaskas, 2007; Flaskas et al., 2007; McLean, 2011).

Therefore, it was the purpose of this study to work from the ground up in devising a constructivist grounded theory on hope and despair and their respective roles in the healing process.

Misconceptions About Hope I believe there are several common misconceptions about hope, and that what is often referred to as hope is actually a perversion of the concept that is attempted to be studied in this research. As Weingarten (2010) shares, hope is not “a butterfly, a rainbow, an undemanding bird that perches in one’s soul”; no, indeed those things are not hope as I am referring to it (p. 7).

Hope is not simply a wish for a positive outcome in some future event. If hope were simply wishful thinking, then one might easily misconstrue the notion of hope to be some kind of optimistic defensive structure of the human psyche. Jon Allen (2006) speaks to this point exactly

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as he recalls teachings from his mentor Paul Pruyser, in which Pruyser advocated, “we can best start defining hope by distinguishing it from optimism and wishful thinking.” Jerome Groopman, an oncologist-hematologist, speaks about hope in the most realistic of terms and makes clear the distinction between hope and optimism. Groopman (2004) writes, “Hope acknowledges the significant obstacles and deep pitfalls… True hope has no room for delusion” (p. xiv). While these constructs of hope and optimism have shared characteristics, only hope seems able to bear the weight of the despair and desperation that often accompanies depression and other forms of mental illness (Allen, 2006).

Other misconceptions about hope also exist. For instance, some may subscribe to the idea that in order to have hope one must first be rid of all despair. This might persist in the idea that hope is an either-or proposition; one either has hope or does not. This study sought to suspend the belief that one must be absent of despair or hopelessness in order to have hope. Instead, I embraced the concept that both hope and despair can, and often do, exist simultaneously in each of us because they are two sides of the same coin (Weingarten, 2010). As Nietzsche (1891) wrote in Thus Spoke Zarathustra: Before my highest mountain I stand and before my longest wandering; to that end I must first go down deeper into pain than I ever descended, down into its blackest flood… Whence come the highest mountains? I once asked. Then I learned that they came out of the sea. The evidence is written in their rocks and the walls of their peaks. It is out of the deepest depth that the highest must come to its height.

In his characteristic style, Nietzsche illuminates the concept of what I might call the ‘necessity of despair.’ In order for one to grasp hope they must first trust that their pain and despair, hold the key to their growth. In the words of my dear friend and colleague, Eric Williams, “we do our

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best growing in the valleys of our lives.” Though low valleys run the risk of being flooded, they simultaneously offer us the richest soil in which to plant and have the origins of hope take root.

Reasonable Hope As I combed the literature, I was exposed to ideas from Victor Frankl (1963) and later Groopman (2004) both discussing hope and courage as pertaining to the biological determinants of an individual’s health and well-being. Simultaneously, Menninger (1963) spoke of the idea that hope can carry an entire people. In the recent history of therapeutic thought hope has often been construed as pertaining solely to the individual. While hopefulness can be considered an individual attribute, we must also understand hope as a relational construct with a reach that extends far past that of the individual psyche.

Menninger (1963) asks the question, “What, then, is the modern notion about hope? Are we Greeks or are we Jews?” (p. 381). In short, I think that the construct of hope, as I am referring to it, is very much like that of the Jews. The Jews suffered unthinkable tragedy and crimes against them during the Holocaust, yet those that emerged from concentration camps starving and disease stricken had, in the face of unbelievable despair, maintained hope. This idea leads us to the recently rearticulated construct of hope that Weingarten (2010) has so appropriately named “reasonable hope,” which she describes as being “a variant of hope” (p.7). Weingarten (2010) offers us five characteristics of reasonable hope on which to build in our work with patients.

Weingarten (2010) writes: “Reasonable hope is: relational; consists of a practice; maintains that the future is open, uncertain, and influenceable; seeks goals and pathways to them; and accommodates doubt, contradictions, and despair” (p. 8). While I find that Weingarten’s tenets for the construction of reasonable hope are by no means groundbreaking news, they offer what other publications on hope lack- the ability to articulate clear pathways for the application of

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hope in clinical treatment. I operate in my practice with clients utilizing these constructs of reasonable hope, which is another bias I carried into this study. That said Weingarten’s (2010) work has a significant limitation in that her proposed constructs have not been studied formally to determine if her assumptions bear out in the data collected from research participants. It was an aspiration initially that this study could support or refute the assumptions of Weingarten’s (2010) reasonable hope. However, further studies utilizing a two-person (patient and therapist) data collection model would be necessary, and offer opportunities for future research studies to be conducted on this topic.

Background & Rationale My professional interest in the topic of hope and its relationship to despair began with my post-graduate fellowship training at The Menninger Clinic. However, my interest in hope precedes my professional interest and begins with my own personal story of grappling with hope and despair in an abusive, impoverished, alcoholic and mentally unstable home. My first introduction to the concept of hope as a child was a bible verse that I memorized, Jeremiah 29:11, “for I know the plans I have for you declares the Lord, plans to prosper you and not to harm you, plans to give you a hope and a future.” I memorized this verse and recited it because the words lent me some sense of hope in an otherwise hopeless situation. Beyond these words it was relationships that provided the greatest sense of hope to me as an adolescent. I was fortunate to have been intervened on and been given access to support and therapy at thirteen years old. It was in this process of therapeutic work around my own pain and despair that I found hope in and through my relationships with others.

When I got to Menninger as a Post-graduate Fellow, I read works by Karl Menninger, Jon Allen, and Kaethe Weingarten about the role of hope in psychotherapy and their writings

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deeply resonated with me. All the sudden my personal experience of hope began to have a language wrapped around it that I could make sense of in my therapeutic work. Particularly Weingarten’s (2010) concept of reasonable hope became a construct that profoundly impacted the way I approach both my professional and personal work.

Conclusion There is a body of literature that studies the concept of hope, but it largely focuses on the fields of nursing and palliative care, specifically exploring hope in the face of chronic or terminal illnesses. This study attempted to look at applied uses of hope in therapy to determine if it has a positive impact on therapy outcomes. Understanding more about hope and its utility to the therapeutic process can contribute to the field of clinical social work by helping clinicians understand more about the explicit use of hope in therapy. The methodology that provided the best framework for this study was a constructivist grounded theory approach, first written about

by Charmaz (2006). This approach not only fits with the nature of the study, but also with my own orientation and philosophical beliefs. In the next chapter I will present a comprehensive literature review that incorporates evaluation of articles on hope, despair, and information that is pertinent to my study. The third chapter will begin to provide more discussion on the methodological background, as well as the structure and processes used for the completion of data collection. Chapter four will discuss the results of the study findings and interpretations of the data and the fifth chapter will complete my study with further discussion of the process, the findings, and the implications for future research.

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CHAPTER II: LITERATURE REVIEW Introduction As discussed in my introductory remarks hope and despair may play a significant role in the clients’ pursuit of therapy as well as the success of therapeutic engagement, and ultimately the overall outcome of therapy. Despite the critical function of hope there still lacks an organizing theory for how clinicians can understand and harness the clinical power of hope in service of their clients’ wellness. As stated previously, it is the purpose of this study to provide a framework for understanding the role of hope and despair in the process of healing; and furthermore, how a constructivist grounded theory approach may provide insight into the skillsets associated with hopefulness. While the literature on hope has grown significantly in the past two decades it is still being widely written about as it pertains to chronic illness or recovery from physical health conditions (Hammer et al., 2009; Lohne, 2008; McLean, 2011). In the psychoanalytic literature, several basic themes on hope emerged from the review and will be covered later in this chapter. Most of the existing literature that does pertain to hope in therapy pertains primarily to cognitive behavioral approaches to therapy. It appears that cognitive behavioral theorists have proposed organized theories about hope as construct, while the psychoanalytic literature does not have a unified theory about hope and its use in therapy.

Description of Techniques Employed in the Literature Review I began my preliminary review of the literature on hope several years ago during my work as a fellow at The Menninger Clinic. Therefore, many of the articles used in this review were obtained at that time through The Menninger Clinic library and the Texas Medical Center digital library archive, of which The Menninger Clinic is an affiliate member. In compiling additional articles for this review, I utilized my access to the University of North Carolina (UNC)

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library system database, which I was granted access for by a family member that was a researcher at UNC. I chose to utilize the UNC library system due to the larger selection of databases for peer-reviewed journals available in their collection. Additionally, several articles were obtained from a review of the literature using some basic keyword searches in the Robert Morris University (RMU) library database. Following this broad search of the academic literature on hope a more specific review of the psychoanalytic literature on hope was completed.

For the collection of psychoanalytic texts, I utilized the PEP Web database, as well as obtaining several invaluable articles for review and insights on this subject from one my faculty consultants, Gregory Rizzolo. Most recently, another updated literature review was conducted through my library access at the University of Houston Graduate College of Social Work, which yielded several new publications that have occurred since my initial queries on the subject of hope.

The key search terms utilized in the online scholarly database searches pertaining to the topic of hope were hope, hoping, hopelessness, hope theory, optimism, despair, role of hope in psychotherapy, impact of hope, efficacy, suffering, radical hope, resilience, borrowed hope, reasonable hope, and measures of hope. The inclusion criteria for the selection of articles were based on the following: the degree of relevance to the topic of hope and despair, credibility as a peer-reviewed journal article or a book resource from a credible academic author, recent publication (within the last 15 years) unless it was a seminal article reflecting important historical data on the topic. The exclusion criteria used in this literature review was as follows: Outdated articles were excluded unless they had historical or contextual relevance to the topic, and there was no use of journal articles that were not peer-reviewed.

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Theories on Hope Two theories of particular interest in relation to this proposed constructivist grounded theory study of hope were that of hope theory from Snyder (1994), and reasonable hope by Weingarten (2010). In hope theory, Snyder (2002) provides a cognitive basis for defining and leveraging hope to support therapeutic processes. Snyder (2002) defines hope “as the perceived capability to derive pathways to desired goals and motivate oneself via agency thinking to use those pathways” (p. 249). Hope theory is therefore constructed from three basic parts: goals, pathways, and agency. One of my mentors, Jon Allen (2005, 2006) focuses on Snyder’s use of agency and pathways as the cornerstone for the treatment of depression, as well as recovery from trauma. The limitation of both Snyder’s (2002) and Allen’s (2005, 2006) work is that they focus on hope as a purely cognitive construct attributable to individual characteristics.

Allen (2005, 2006) does, however, write and lecture extensively about a concept he calls ‘borrowed hope’ in which the therapist actively lends hope to the patient regarding their ability to recover. Weingarten (2010) focuses even more on the relational constructs of hope as expressed in the course of therapeutic treatment. Weingarten (2010) presents five basic tenets for the use of reasonable hope in the course of therapy, they are as follows: reasonable hope is relational; it is a practice; it maintains that the future is open, uncertain, and able to be influenced; it seeks goals and pathways to them; it accommodates doubt, contradictions, and despair. This framework incorporates the cognitive aspects of Snyder (1994) work while focusing explicitly on the role of hope in the technical and relational aspects of psychotherapy.

What Weingarten (2010) lacks however is a systematic review of her tenets for the use of reasonable hope in therapy. Both Snyder (1994) and Weingarten’s (2010) work lacks a theoretical anchor for their ideas in that neither of their theories have an organizing

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metapsychology. Psychoanalytic literature discusses hope in the context of multiple traditions within psychoanalytic theory. This makes the psychoanalytic works of Menninger, Frankl, Kohut, Mitchell, Ahktar, and others particularly useful for this study since they have an organizing metapsychology and a context in which to understand the role of hope in psychotherapy. Before discussing the psychoanalytic perspectives on hope in greater details I would like to review more thoroughly the theories that Snyder (1994) and Weingarten (2010) have proposed, as they are currently the most focused approaches to using hope in therapeutic process that I have encountered in my research on the topic.

Hope Theory: Rainbows in the Mind Snyder (2002) describes that in the early stages of his research on hope he had a conversation with Karl Menninger at his home during which he realized that “hope, as [he] was coming to define it, was primarily a way of thinking, with feelings playing an important, albeit contributory role” (p. 249). This insight coupled with his observations from interviews with people brought Snyder and his colleagues to the important trilogy in their operational definition of hope: goals, agency, and pathways (Snyder et al., 1999). Snyder (2002) defines goals thinking as having two primary types, a positive goal outcome or a negative goal outcome. Achieving, sustaining, or increasing an intended outcome defined a positive goal outcome, whereas deterring temporarily or permanently the unwanted outcome defined a negative goal outcome. Table 1 offers a helpful chart for understanding Snyder’s (2002) statement on goal types. Table 1 was created by Snyder and is being replicated here to demonstrate Snyder’s (2002) position on goal thinking within his larger work on hope theory.

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Table 1 The Two Major Types of Goals in Hope Theory Type 1—Positive goal outcome A. Reaching for the first time.

B. Sustaining present goal outcome C. Increasing that which already has been initiated Type 2—Negative goal outcome

A. Deterring so that it never appears.

B. Deterring so that its appearance is delayed

Snyder (2002) goes on to discuss pathways thinking as an essential aspect of human cognition. Our desired goal can only be reached by imagining a pathway to that goal, a path from point A to point B, and I agree with this basic assertion of pathways thinking. However, Snyder (2002) also posits the idea of high-hope and low-hope people, which defines hope as a trait. This assertion of hope as a trait denies the concept of the relational components of hope, and it reads to me as too deterministic. In other words, Snyder (2002) is essentially saying that if you are a low-hope individual then you are less likely than high-hope individuals to engage in productive pathways thinking. This notion of the trait being stable, if not fixed, concerns me, and does not fit with the more relational stance in psychoanalytic treatment. Snyder (2002) goes on to discuss agency thinking, which simply is “the perceived capacity to use one’s pathways to reach desired goals—is the motivational component in hope theory” (p. 251). Snyder (2002) then describes the development of three specific psychometric instruments he developed with colleagues to measure hope: the trait hope scale, the state hope scale, and the children’s hope scale. This is followed by an important comparative study of hope theory against five other related theories.

The following table 2 adapted from Snyder (2002) offers us a succinct model for comparison of the five selected theories alongside hope theory: 16

Table 2 Implicit and Explicit Operative Processes and Their Respective Emphases in Hope Theory as Compared to Selected Positive Psychology Theories Processes Theory

Hope Attributions Outcome value Goal thinking Agency thinking Pathways thinking Emotions

Optimism: Seligman (1991)

Optimism: Scheier & Carver (1985)

+++ + +++

++ + + ++ +++

+++

++

SelfEfficacy

SelfEsteem

ProblemSolving

+

++

++

+++ +++ + +

+++ ++ + +++

+++ +++ + +

Note. + = process is implicit part of model; ++ = process is explicit part of model; +++ = process is explicit and emphasized in model. Therefore, interpret more plus signs (none to + to ++ to ++ +) as signifying greater emphasis attached to the given process within a particular theory.

Snyder (2002) then goes on to discuss the potential positive impact hope has on academics, athletics, physical health, and psychotherapy. It is this last aspect about the role of hope in psychotherapy that of course interests me most. Snyder (2002) describes that across various theoretical approaches to psychotherapy hope thinking plays a role in treatment outcomes. In his words Snyder (2002) offers, “irrespective of the specific psychotherapy system, the beneficial treatment changes reflect the clients’ learning of more effective pathways goaldirected thinking, along with the agency motivation to use the pathways” (p. 262).

Snyder (2002) also looks at factors that undermine hope, which is an important aspect to consider. It seems that the major factors in undermining hope in children is, of course, abuse and neglect but another factor was the loss of a parent (Snyder, 2002). Other factors in the loss of hope for children pertained to circumstances in which boundaries were lacking or inconsistent,

and when parents were too forceful of their own aspirations onto the child (Snyder, 2002). For 17

adults the primary factors for the loss of hope seem to be related to a traumatic event or the loss of a loved one, especially a partner (Snyder, 2002).

Theory of Reasonable Hope Weingarten (2010) has coined the term “reasonable hope” which she describes as being “a variant of hope” (p.7). Weingarten (2010) offers us five characteristics of reasonable hope on which to build in our work with patients, “They are that reasonable hope: is relational; consists of a practice; maintains that the future is open, uncertain, and influenceable; seeks goals and pathways to them; and accommodates doubt, contradictions, and despair” (p.8). While I find that Weingarten’s tenets for the construction of reasonable hope are by no means new news, they offer what other publications on hope lack- the ability to articulate clear pathways for the application of hope in clinical treatment.

We begin then with the first tenet of Weingarten’s (2010) theory: hope is relational.

Weingarten (2010) speaks to this idea succinctly when she writes, “I hope because we hope” (p.

8). Other theorists have commonly overlooked hope as being a relational construct and instead have focused their attention on attempting to quantify hope in the individual (Elliot & Olver, 2002; Flaskas, 2007; Snyder, 2002; Weingarten, 2010). While this idea of hope in the individual is critical to the healing process it often begins with what Jon Allen calls “borrowed hope” in which the patient borrows hope from the therapist for their recovery. Through borrowed hope patients come to hold internally the necessary hope required to propel their journey forward. This aspect of reasonable hope exemplifies the importance of the therapeutic relationship in generating hope and the “we” involved in the process of nurturing hope. To say that reasonable hope is relational does not mean every individual experiences hope in the same way or draws hope from the same places, in fact quite the opposite is true. Every individual has their own lens

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with which they view the world and through which they look to find hope (Brown, 2008). The relational dynamics of reasonable hope are concerned with the process of seeking. As one of my mentors once shared with me “it is not so much about what you find, but the earnestness with which you seek.” In this process of earnest seeking, the patient often finds hope in places that had not been anticipated, such as the secure attachment to the therapist. However, case studies often demonstrate that it is not only the relationship with the therapist that generates and nurtures hope, instead hope can come from all facets of the patient’s life.

The second tenet of reasonable hope is that it is a practice (Weingarten, 2010). So, we not only talk about hope with patients, but we do hope with patients (Marcel, 1951; Weingarten, 2010). In essence, practicing reasonable hope with patients requires us to rethink hope as a verb rather than a noun. This idea fits well with the practice of psychodynamic psychotherapy, with individuals and in groups, because it calls for a focus on the “here and now” process of therapy (Weingarten, 2010, p. 8). I believe that we begin the facilitation of this process by making the implicit, explicit (Allen, 2006). The patient has come to you because they in some way, large or small, through ‘capital T or lower-case t’ trauma claim to have lost hope (Allen, 2006). Our work is to open a dialogue about where this hope might have gone, and to assess with them what shreds of hope might remain. This becomes the inroad to practice the cultivation of hope throughout the therapeutic process.

The next tenet of making reasonable hope with patients is to “maintain that the future is open, uncertain, and influenceable” (Weingarten, 2010, p. 8). When one clings to the idea that the future is already determined and that they have no influence or ability to make changes, it is easy to become overwhelmed with a sense of hopelessness. Often patients experience the uncertainty of their future as anxiety provoking and scary, and it is not our work to convince

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them otherwise. Instead, we can offer up the possibility that another narrative might also exist, perhaps one that is rooted in hopefulness about the opportunities the future might hold. In creating such a dialogue, we segue into the next task of reasonable hope, “seeking goals and pathways to them” (Weingarten, 2010, p.9) Goal setting is therapy 101, as is creating a plan of action to attend to those goals.

However, unlike the protocol-inspired checklist of goals involved in state required treatment plans, I am speaking to the idea of co-creating specific, measurable, attainable goals that work to inspire hope in the patient. Again, this is not new thinking in psychotherapy, Karl Menninger (1963) spoke to this idea as a motive force and a plan of action. Snyder et al. (1999) also spoke to this point in what he called agency and pathways. I am not speaking to the originality of the idea of goal setting in treatment; instead, I am focusing on the necessity of this task in cocreating hope with patients. Allen (2006) speaks to this when he writes that while “agency is essential for hope, it’s not sufficient. You also need a pathway: a sense of direction, a way forward, something specific to do or to hope for” (p. 251). Working to find agencies and pathways is not straightforward work given the complexity and acuity of the patients we often see in treatment, and it is easy for clinicians to find themselves feeling hopeless. Any clinician can probably recall a time in which they felt hopeless considering some overwhelming constellation of problems presented to them by a patient. The good news about reasonable hope is that it is not about being perfect or doing things perfect, instead it is about working with the patient towards good enough. Weingarten (2010) states this succinctly when she writes, “reasonable hope is a humble hope. It allows reasonable goals to trump ideal ones. It is satisfying to do less than everything that needs to be done to ensure that something be done” (p. 10).

The fifth tenet of reasonable hope references the point I made earlier that hope exists in a

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dialectic relationship with despair, doubt, and contradiction (Byrne & McCarthy, 2007; Weingarten, 2010). This is perhaps the most challenging task for patients and therapists because it demands of us that we simultaneously hold two equals yet opposing truths. But as one of my recent individual therapy patients said at the end of our work together “I know now that in the face of despair I have found hope and that if this is possible then I can have hoped no matter what I might face.” My patient was not attempting to rid himself of despair but instead found hope for his future in essence because of his despair. This balancing act of acknowledging the hopelessness and despair that exists in life while still creating a space for hope to exist is what makes our work particularly challenging. It is this aspect of reasonable hope has little to do with the science of psychotherapy and instead reflects much more about the artistic and creative qualities of our work with patients.

Relevant Works Related to the Topic of Hope This section will review the literature that pertains to the general topic of hope, though it is not directly linked with hope in the context of psychotherapy and therapeutic outcomes. That said, these are historical and relevant studies which provide an important backdrop for conceptualizing hope and its philosophical underpinnings.

Historical References to Hope Beginning with the historical context of hope provides us with a rich backdrop upon which to explore contemporary ideas surrounding hope. Historically speaking, the Greeks viewed hope as the worst of evils, and indeed many modern thinkers have echoed this sentiment.

Aristotle used the term elpis to describe hope as neutral term essentially meaning anticipation or expectation (Gravlee, 2000). Aquinas (1485) published his Summa Theologica in which he argues that hope is a virtue. He makes several points about the nature of hope and its connection

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to the theological virtues of faith and agape (often described either as love or charity). Of particular interest to me was a reply to an objection in which Aquinas (1485) states “hope, as a theological virtue, regards something arduous, to be obtained by another's help.” This idea highlights for me the relational nature of hope, which I will expound on later in this chapter.

Kant also discusses hope in his Critique of Pure Reason (1781) in which he seeks to answer three questions: What can I know? What should I do? What may I hope? In response to this third question Kant (1781) describes that we can hope for a God that is just and a soul that is immortal. I understand that these are gross summaries of hundreds of years of philosophical thought so please forgive me, and suffice in my basic point that from Aristotle, to Aquinas, to Kant that hope has been a central idea that humans have grappled with and attempted to understand.

In more contemporary but still historical writings on hope, Marcel (1951) writes in his Homo Viator: Introduction to a Metaphysic of Hope about several key concepts which directly correspond with contemporary theorizing about hope in therapy. Essentially, Marcel (1951) describes hope in direct relationship to despair and says that it is despair that provides the reason for one to hope. He described what Snyder (2002) much later calls pathways thinking, the idea that hope provides the creative basis for which one imagines a path forward even though one cannot be seen from the state of captivity that is despair (Marcel, 1951). Later he asserts, “Hope is always associated with a communion, no matter how interior it may be. This is so true that one wonders if despair and solitude are not at bottom necessarily identical” (p. 58). This idea of hope as a process of communion with another is what Weingarten (2010) explains as the relational aspect of hope that is vital to progress in therapy. In the recent history of therapeutic thought, hope has often been construed as pertaining solely to the individual, so Marcel (1951)

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was before his time in positing the relational quality of hope. Victor Frankl (1963) and much later Groopman (2004) both discussed hope and courage as pertaining to the biological determinants of an individual’s health and well-being. I maintain that while hopefulness can be considered an individual attribute, we must also understand hope as a relational construct with a reach that extends far past that of the individual psyche (Hilliker, 2012; Weingarten, 2010).

Frankl’s (1963) work does provide us with meaningful insights that exemplify the very nature of what Karl Menninger (1963) was also writing about at the same time, the idea that hope can carry not only an individual, but also an entire people. In the aftermath of World War II and the sheer scale of human tragedy, the likes of which had never been seen before, Frankl (1963) offered a pathway for making meaning of all that people had endured. While Frankl (1963) did not discuss hope explicitly, his introduction of Logotherapy provided a framework for people to find healing through making meaning of their suffering. This thought lends itself as the basis for later thinking about the dialectical relationship between hope and despair. Frankl (1963) in some ways offered the notion that perhaps people found hope not despite despair but because of it, which is a point I will take up later in my discussion of the literature on hope and despair.

Menninger (1963) also speaks to the more positive aspects of hope born out of despair as he discusses the Hebrew conception: “In a sense the whole history of the Jews is a study of hope; hope springing out of all their discouragements and misadventures and disasters,” (p. 381).

Unlike many of the historical references, Menninger (1959, 1963) spoke to the macro idea of hope as a philosophical and cultural matter, as well as the micro aspects of hope and its impact on individuals in treatment. Menninger (1959, 1963) did not conduct formal research studies on hope, but he did attempt to demonstrate that it is an essential element for progress in treatment.

Menninger (1959) described finding the right balance of hope, because too little hope would lead

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to despair and too much hope would lead to presumption. True hope operates as the fulcrum balancing between presumption and despair (Menninger, 1959). As Menninger (1959) stated, It is the responsibility of the doctor to his patient to inspire the right amount of hopesome but not too much. Excess of hope is presumption and leads to disaster. Deficiency of hope is despair and leads to decay (p. 485).

In his book The Vital Balance, Menninger (1963) describes the intangibles of hope, faith, and love (agape). He writes passionately about how these three aspects must be a part of any successful treatment. Our patients must trust us and in turn we must trust in them, have faith in them. Faith from Menninger’s (1963) perspective was inextricably bound to hope because if you did not need faith then hope would also be unnecessary. In other words, if you were relatively certain of something, then you would not hope for it, nor would faith be necessary. However, if you are uncertain of something then you must have faith, some might say you must trust the process, therefore you would also need to maintain hope for an intended outcome. Further, Menninger implores us to love our patients, and as he says so eloquently “tend the flames of hope” in their lives (Menninger, 1963, p. 381).

Paul Pruyser was another doctor from The Menninger Clinic that took up the discussion of hope. Many of his thoughts on the topic of hope have been articulated through his protégé Jon Allen in his contemporary written works. Allen (2005) writes, Unlike wishing and optimism, Pruyser construed hope as pertaining to serious concerns, a response to felt tragedy: To hope…one must have a tragic sense of life, an undistorted view of reality, a degree of modesty vis-à-vis the power and workings of nature or the

cosmos, some feeling of commonality, if not communion, with other people, and some

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capacity to abstain from impulsive, unrealistic wishing (p. 22).

Pruyser (1987) described hope as being “based on a belief that there is some benevolent disposition toward yourself somewhere in the universe, conveyed by a caring person” (p. 670).

Pruyser’s comments underscore two things the presence of hope in the face of despair and the relational nature of hope. As an interesting aside, both Allen (2005) and Snyder et al. (1999) were connected to Karl Menninger and Paul Pruyser, which means that much of the contemporary thinking about hope in relation to therapy can be traced back to these connections at The Menninger Clinic.

Hope and Chronic Illness Interestingly some of the first grounded theory studies focused on patients with chronic illness, and when exploring the literature on hope it was found that many of the studies also used patients with chronic illness or physical ailment (Elliot & Olver, 2002; Glaser & Strauss, 1967; Groopman, 2004; Hammer et al., 2009; Lohne, 2008; McLean, 2011). However, the contemporary studies using this population did not employ grounded theory technique, instead they focused on trait hope and used quantitative measures to study this construct (Bernardo, 2010; Ong et al., 2006). Multiple studies also focused on the role of hope and hopefulness in the recovery process following severe physical injuries such as spinal cord injuries (Brennan, 2009; Chan, 2009; Hammer et al., 2009). The review of these studies while helpful for the purposes of understanding research design, however the topic content itself proved less than helpful in my pursuit to understand applications for hope in the therapeutic context.

Most recently, there have been important studies related to the application of hope theory

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from Snyder et al. (1999) to improve outcomes for patients dealing with physical illnesses.

Specifically, Ghazavi et al. (2015) used hope theory in a quasi-experimental study with 38 diabetic patients. In the experimental group the intervention was 120-minute sessions twice weekly for a total of four weeks (Ghazavi et al., 2015). The results showed that “hope therapy significantly increased hope in diabetic patients after intervention in the study group compared to control (p < 0.001)” (p. 75). Another important study by Shahgholian et al. (2015) looked at the effects of hope therapy on depression, anxiety, and stress for patients undergoing hemodialysis.

In this clinical trial, 50 patients were selected, and hope therapy was provided for 60–90-minute sessions weekly for a total of eight sessions (Shahgholian et al., 2015). Again, the results quoted here show the connections between hope, depression, anxiety, and stress: there was a significant difference in mean scores of depressions, anxiety, and stress in hope therapy group before, immediately after, and 1 month after intervention (p < 0.05), while there was no significant difference in mean scores of depression, anxiety, and stress before and immediately after intervention in the placebo group” (Shahgholian et al., 2015, p. 694).

These two studies, while applied in the context of medical setting, show the application and utility of hope therapy to improve mental health and treatment outcomes.

Measuring Hope Schrank et al. (2008) found a total of 32 psychometric instruments for the assessment of hope. Schrank et al. (2008) did a comparative analysis of all 32 measures to determine whether they were reliable, valid, sensitive to change, and being actively used and cited in other papers.

Among the top measures identified were the Dispositional Hope Scale, the State Hope Scale, the Miller Hope Scale, the Gottschalk Hope Scale, the Herth Hope Index, the Hunter Opinions and

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Personal Expectations Scale (HOPES), and the Children’s Hope Scale. All of these measures were shown to be reliable, valid, used in multiple studies, and sensitive to change. The only exception was that the HOPES was shown to not be sensitive to change (Schrank et al., 2008).

One common theme in these measures however is that they are trait defined and measure hope as an individual characteristic, rather than a relational, intersubjective process.

Studies that More Closely Align with the Current Research Study Hope and Despair Initially I thought that my connection between hope and despair was a novel idea, then I conducted a thorough review of the literature and found that the largest body of work on hope relates to its dialectic with despair (Allen, 2005, 2006; Beck et al., 2003; Flaskas, 2007; Flaskas et al., 2007; Jenmorri, 2006; Marcel, 1951; McLean, 2011; Weingarten, 2007, 2010). At first, I was disappointed because I wanted to make a novel discovery, but I realize now that this body of literature on hope and despair may serve as an important foundation for this proposed study. In a case study, Byrne and McCarthy (2007) describe how a story of despair unfolds into a redemptive narrative of hope for a family. In their study they transcribe notes from sessions with a mother being investigated for trying to suffocate her infant son, and the father of the son is also present and part of the sessions (Byrne & McCarthy, 2007). Through these sessions, the intervening social worker seeks to understand and hold opposing truths of hope and despair. This is best exemplified as Byrne and McCarthy (2007) describe, “a space was co-created with them and witnessed by their professional helpers in which the realities of child protection and family integrity were constantly juxtaposed” (p. 16). Ultimately, the parents, with the help of their social worker on the case, were able to reconcile this event and move forward successfully, but only really after grappling with this dialectic of despair and hope. Despair is often what has been

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identified as the driving force or motivation for help seeking, and hope is thought by some to be the antidote to despair (Hilliker, 2012; Marcel, 1951; Weingarten, 2010). It may be the case that in fact despair is the foundation upon which a state of hopefulness can be achieved (Hilliker, 2012). In other words, hope exists not despite despair, but because of despair. This idea may provide an essential factor for exploration in this proposed study.

Phenomenological Studies of Hope and Despair In the literature review the two articles that were most closely aligned with my desired approach to the study of hope were two phenomenological studies (Smith, 2007; Steinbock, 2007). These studies reviewed the phenomenon of hope and despair during recovery from mental illness (Smith, 2007; Steinbock, 2007). Smith’s (2007) study was particularly aligned with my interests on hope and despair as he shared the phenomenon of recovery from addiction. Smith (2007) makes clear that hope is not the same as optimism, a point that is shared by several authors cited in this review (Allen, 2005, 2006; Snyder, 2002; Weingarten, 2010). Steinbock (2007) further delineates between desperation, pessimism, hopelessness, and despair. In this phenomenological study, Steinbock (2007) offers valuable, albeit wordy, distinctions between these terms, as well as demonstrating their connection to the concept of hope.

Efficacy of Hope In multiple meta-analyses of factors that contribute to positive outcomes in therapy it was concluded that hope plays an important role in the process of recovery (Hubble et al., 1999; Lambert, 2004). Hubble et al. (1999) found that hope, expectancy, and placebo account for 15% of therapeutic change, which is equivalent to the benefit derived from therapeutic technique.

Despite this longstanding understanding about the role of hope in creating therapeutic change, there have been very few systematic attempts to understand and thereby harness the power of

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hope in service of therapeutic change (Babits, 2001; Feldman & Dreher, 2012; Valle et al., 2006). Current studies that apply hope theory in therapy demonstrate that hope provides a positive impact on treatment outcomes in a variety of contexts, thereby validating some of the claims made about the efficacy of hope (Ghazavi et al., 2015; Larsen & Stege, 2010b; Levi et al., 2012a; 2012b; Shahgholian et al., 2015; Schrank et al., 2011). One challenge is that in the Hubble et al. (1999) study hope is considered in combination with expectancy and placebo.

Howver, I would argue that current studies showing hope interventions as being more impactful than placebo or control groups (Ghazavi et al., 2015; Shahgholian et al., 2015). Therefore, I believe that hope should be considered as a separate variable in future studies to determine more accurately its impact on treatment outcomes.

Hope in Therapeutic Process Weingarten (2010) provides the most comprehensive discussion of the technical use of hope in psychotherapy, while other studies have focused on the impact of trait hope in predicting or impacting therapeutic outcomes (Bernardo, 2010; Cleveland, 2008; Ong et al., 2006). Other studies have focused on the use of hope in the therapy process, both in brief and long-term therapeutic engagements (Babits, 2001; Feldman & Dreher, 2012; Ghazavi, et al., 2015; Larsen & Stege, 2010b; Levi et al., 2012a, 2012b; Shahgholian et al., 2015; Schrank et al., 2011).

Though none of these studies have been conducted using a constructivist grounded theory approach to determine the role of hope as a co-constructed process in treatment.

Hope, Depression & Suicidality Grewal and Porter (2007) undertake the use of hope theory in attempt to understand suicidal action, but their considerations are only theoretical. Collins and Cutcliffe (2003) completed two case studies in which they demonstrated that the use of CBT, with an emphasis

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on the therapeutic relationship, was essential to the process and of patients working through hopelessness. More recently, Huen et al., (2015) conducted a confirmatory factor analysis with 2106 research participants and concluded, “hope and hopelessness are two distinct but correlated constructs. Hope can act as a resilience factor that buffers the impact of hopelessness on suicidal ideation. Inducing hope in people may be a promising avenue for suicide prevention” (p. 15). In another study, Sun et al., (2014) conducted a hierarchical regression analysis with 517 college students and found that “hope can significantly moderate the effect of rumination on depression” (p. 3).

Larsen and Stege (2010a) employed a qualitative case study methodology using 5 therapists with a total of 11 clients in the study. While the results did not measure reduction in depression or other symptoms the study did have some important findings. Specifically, the explicit use of the word hope was used by 4 out of 5 of the therapists with a total of 10 out of the 11 clients in the study (Larsen & Stege, 2010a). In fact, hope or iterations of the word were used 124 times over the course of 10 sessions (Larsen & Stege, 2010a). The therapists intentionally deployed the use of hope during their sessions. Furthermore, this study found that there was a multi-dimensional use of hope, which included the following: cognitive goals focus, hope as behavior, temporal aspects of hope, hope as embodied emotion, and hope in relationships (Larsen & Stege, 2010a). Lastly, this study found that psychoeducation about hope was an important function in the treatment, as well as the exploration of threats to one’s hope (Larsen & Stege, 2010a).

Hope & Post Traumatic Stress Disorder Levi (2013) was the first author in the review of the literature that expressly developed an intervention for therapy that combines CBT principles of hope with a psychodynamic approach.

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Levi (2013) proposes a five-phase model for the treatment of PTSD with combat veterans, which includes the following: A connection phase an agency and pathway phase (developing a goal-oriented decisionmaking pattern and learning to plan toward goal achievement); a reconstruction phase; a phase of processing the conflict characteristic of PTSD by utilizing the natural power of hope; and a summary and separation phase (p. 150).

The study then walks readers through each of these phases and presents case material corresponding with each phase of this approach (Levi, 2013). The author concludes with results describing the client’s progress in treatment, in which he states “the active aspect of the phenomenon of hope helped to improve the patient’s ability to choose and created internal degrees of freedom. In other words, active behavior generated an active and adaptive form of hope, and goal-centered activities allowed the patient to process the conflict” (Levi, 2013, p.

168).

This same author produced two other studies with colleagues looking at combat veterans with PTSD as well. One study followed 10 Israeli soldiers through the treatment of their PTSD utilizing a phenomenological approach, while the other focused on intertwining aspects of hope and trauma (Levi et al., 2012a). Levi et al. (2012a) worked with 10 Israeli combat veterans to collect data regarding their stories of trauma and the role that hope played in their lives.

Participants were asked the same two questions: How do you define hope? What is the meaning of hope for you? “After addressing these general questions, the interviews proceeded to reveal the role of hope in the participant’s life before the traumatic event, at the time of the traumatic event, and after the traumatic event” (Levi et al., 2012a, p. 1674). This study is of particular interest to me since it is most closely aligned with the structure of the study I am conducting.

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That said, the specific qualitative methodology differs in that it was a phenomenological study and not a grounded theory, however, the data collection procedures and thematic analysis was similar to my study. I used a semi-structured interview process, recorded the interviews, and transcribed the recordings, then organized the themes, definitions of themes, and subthemes that emerged from the data collected (Levi et al., 2012a). Four themes emerged from the data, and they are listed below with definitions of the themes and their subthemes organized by Levi et al.

(2012a, p. 1675): 1. Definition of hope- Participants’ descriptions and characterizations of the phenomenon of hope based on conscious and unconscious aspects; Subthemes included: a source of life, a means for accomplishing personal goals, an idiosyncratic quantifiable phenomenon, a desirable yet unattainable end state, describe and communicate in particular manners.

2. Sources of hope- Participants’ explanations concerning the foundation of hope along with the basis of hope in their life while using a developmental perspective; Subthemes included: genetic change, parents, additional socialization agents, military service, work environments and new nuclear family.

3. Forms of hope- Informants’ descriptions of the various configurations of hope, which are the results of the individual maturity process along with life events and experiences; Subthemes included: infancy-survival hope, childhood form of hope, adolescent hope, adult hope.

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4. Clashes between hope and trauma- Participants’ descriptions of the devastating effects of trauma on the individual’s hope, along with the interchange that exits between hope and trauma while coping and recovering from the traumatic event(s); No subthemes were identified.

As Levi et al. (2012a) describe, “The results indicate the integrative, multidimensional, characteristics of the phenomenon of hope, focusing on its subjective meaning among people suffering from chronic PTSD” (p. 1681). The authors then produced a second study, which looked at “binary phenomenon in which hope develops but may also be arrested, is conscious but also unconscious, and strengthens the individual but may also weaken one” (Levi et al., 2012b, p.1). All of the participants in this study had suffered wartime traumas and the results demonstrate some important considerations for my research study. This study, unlike others that have emphasized a CBT approach or quantitative analyses of hope, uses a combined CBT and psychodynamic perspective; utilizing qualitative interviewing to collect data that reflects the lived experiences of participants (Levi et al., 2012b). The use of excerpts from participants really drives home the value of listening to people’s stories of hope to assist in the continued definition and application of the concept of hope.

Psychoanalytic Literature on Hope Freud and Klein both used the word hope in their work extensively but neither used the term in a clinical context. Jung’s exploration of shadow and light comes closer to capturing the idea of hope and despair in the clinical situation, but still lacks an explicit exploration of the role of hope in psychotherapy. Menninger (1963) was one of the earliest psychoanalytic writers to discuss hope as part of the clinical technique and curative process of analysis. Frankl (1963)

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discussed in an existential context the way in which the patient’s misery often gives way to meaning, which reflects some important aspects of the role of hope and despair in psychotherapy.

Kohut & Wolf (1978) describe the defensive capacities of hope in the form of the idealhungry personality that must idealize a hoped for other only to be let down and left in need of a new God. The ideal-hungry personalities seek to find an “idealizable self-object…always with the hope that the next great figure to whom the ideal-hungry attaches himself will not disappoint him” (Kohut & Wolf, 1978, p. 421). Later, Kohut (1984) discussed not only the defensive aspects, but also the curative properties of hope in psychotherapy. In one case example, Kohut (1984) offer the idea that hope was the adaptive quality that allowed the patient to persist through a traumatic childhood. In other words, the patient was able to maintain some basic self-structure by simply holding onto the hope that he would at some future time find a suitable self-object with whom he could attach.

Mitchell (1995) draws heavily on the work of Kohut in his book Hope and Dread in Psychoanalysis. However, Mitchell (1995) adds to the conversation by further illustrating both defensive and adaptive capacities of hope in treatment, as he speaks to the role of the analyst in cultivating, sustaining, and failing the hopes of the patient. Mitchell (1995) seems to be the first contemporary author to take a deep dive into the role of hope as a technical aspect of treatment and of the therapeutic relationship itself. Mitchell (1995) uses his integrative relational perspective to inform a two-person understanding of the capacities of hope in analysis. On the heels of Mitchell’s (1995) work, Akhtar (1996) speaking from a Kernbergian ego psychology perspective differs from Mitchell. Akhtar (1996) explores hope as pathological optimism and

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expresses that the role of the analyst is the “rupturing [of] the patient’s excessive hope,” and then working to reconstruct “the early scenarios underlying the need for excessive hope” (p. 723724).

Hope: Definitions and Uses from the Psychoanalytic Literature I have constructed a summary of the basic definitions and uses of hope in the psychoanalytic literature, and provided a table of the four quadrants of hope that were gleaned from the analytic literature. Here is a list of the defensive and adaptive uses of hope described by various psychoanalytic authors: Adaptive Hope- Hope in the service of change: ● Hope is a mysterious variable that is part of the analytic situation. ● Hope is an important aspect of the analytic attitude. ● Hope is an outcome of successful treatment. ● Hope is something the patient brings. ● Hope is something the analyst brings or instills in the treatment. ● The word hope gets used often but is rarely fully explicated.

Defensive Hope- Hope in the service of defense: ● Excessive Hope as a defensive idealization comes out of the patient’s fear of the object’s aggression. ● Other idealization- I am guilty because I want to hurt you so instead, I idealize you to mitigate the damage I would otherwise wish to inflict upon you. ● Hope as a defense against mourning, loss, and depression. ● Hope as part of the ideal-hungry personality and the need to attach to an idealized selfobject.

In the psychoanalytic literature these definitions and uses of hope can be broken into four basic quadrants, in Figure 1 below: 35

Figure 1 Quadrants for Psychoanalytic Literature Defining and Usage of Hope Defensive Uses

Adaptive Uses

(1-person psychology)

(1-person psychology)

Defensive Uses

Adaptive Uses

(2-person psychology)

(2-Person psychology)

Note. Researcher developed.

Lack of Operational Clarity and Why We Should Care The lack of operational clarity of core concepts in psychoanalysis is a long-standing difficulty that frankly few people seem interested in remedying. Different camps within psychoanalysis carve out their definitions and uses of various concepts and they devise new iterations of older concepts, which differ drastically from their original uses. The intentions for this phenomenon vary but the consequences are consistent. Lack of operational clarity and basic agreement on the application of core concepts has led to a diffuse system of thought that grapples to find readership, much less adherence to the various theoretical schools. While I do not intend to remedy this larger problem within psychoanalysis, my reasonable hope is to conduct a study that uses constructivist grounded theory to delineate clear, consistent definitions and uses of 36

hope. This could then be used to improve understanding and the application of hope as a technique in psychoanalytic treatment.

Summary Points from the Literature The review of literature on hope produced a vast number of historical references to the idea of hope and its role in human suffering (Frankl, 1963; Menninger, 1963; Nietzsche, 1966).

The contemporary references largely focused on hope in the context of chronic illness and recovery from physical ailments (Brennan, 2009; Chan, 2009; Elliot & Olver, 2002; Groopman, 2004; Hammer et al., 2009; Lohne, 2008; McLean, 2011). Of the resources that focused on hope in the therapeutic context they tended to concentrate on the quantitative analysis of hope as a personality trait or individual attribute, rather than the role of hope in the interpersonal context of therapy (Babits, 2001; Bernardo, 2010; Cleveland, 2008; Feldman & Dreher, 2012; Ghazavi et al., 2015; Larsen & Stege, 2010b; Levi et al., 2012a, 2012b; Ong et al., 2006; Shahgholian et al., 2015; Schrank et al., 2011). Another major focus in the literature that was reviewed is that of hope and its relationship to despair (Allen, 2005, 2006; Beck et al., 2003; Flaskas, 2007; Flaskas et al., 2007; Jenmorri, 2006; McLean, 2011; Weingarten, 2007, 2010). The psychoanalytic literature uncovered various definitions and uses of hope in treatment, which were synthesized down into defensive and adaptive uses of hope. Several articles were identified that may support the aims of my future study, however, much was discovered or uncovered during this review that has added the potential for several new directions for my study.

Gaps in the Existing Literature In reviewing the relevant literature on the topic of hope and despair it became clear that while hope has been studied in multiple professional settings, the research conducted has largely

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centered on hope as it relates to chronic illness (Hammer et al., 2009; Lohne, 2008; McLean, 2011). Other studies have focused on the trait hope and hope as an individual attribute (Bernardo, 2010; Ong et al., 2006). Of the articles that focused on hope as a relational component of treatment there has not been a systematic study of the assertions made in these papers (Allen, 2005, 2006; Weingarten, 2010). Another gap seems to be a consensus on an operational definition of hope. Several studies make use of Snyder’s (1994) definition of hope as relating to goals, pathways, and agency, but no study has undertaken the task of building an operational definition of hope from the ‘ground’ up. This leaves several openings for this proposed study to fill important gaps in the literature. It is the role of a constructivist grounded theory to not presuppose too much before beginning fieldwork and participant interviews, therefore, it is hard to predict exactly what this proposed study might yield that will be additive to the study of hope. Menninger (1963) asks us “What, then, is the modern notion about hope?

Are we Greeks or are we Jews?” (p. 381). It is my hope that this research study might shed light on the modern notion of hope. A further aim will be to determine if there are relational factors regarding hope that we might employ to benefit outcomes in therapy.

Concluding Remarks The analyst operates much like a grounded theorist in that they take the lived experience of the patient, then code the information albeit informally, and then develop a theory that is reapplied. The analyst moves in a cycle from bottom up to top-down processing of the clinical information, unlike the grounded theorist that collects experiences, codes it in the words of the subject, and then produces a book with the information yielded. Therefore, the purpose of this constructivist grounded theory study will be to develop a theory of hope and despair that supports and improves outcomes in therapy. Specifically, this will be accomplished through the

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development of a constructivist grounded theory about hope and despair for adults seeking

therapeutic support from clinical social workers. It is intended that this study will help determine how helping professionals can begin to talk about, understand, and ultimately leverage hope in service of their patient’s well-being.

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Chapter III METHODOLOGY The methods in this chapter describe the qualitative approach and procedures that were selected to construct a theory on the subject of hope and despair. This chapter begins with a brief introduction on qualitative inquiry, followed by a more comprehensive understanding and rationale of constructivist grounded theory. A detailed description of the study is provided, along with the implementation of specific sampling and recruitment strategies, data collection methods, and data analysis procedures. Constructivist grounded theory works on the assumption that a researcher, by virtue of being human, interjects subjectivity into the process with the participant, thereby co-creating an understanding of the information provided in the qualitative interviews. In seeking to develop a theory of hope and despair, the study will address these research questions: a) What roles do despair and hope play in the process of psychotherapy? b) Was hope a central theme in the process of change that takes place in psychotherapy? c) Is the concept of despair a starting point for the instillation and cultivation of hope in treatment?

In this chapter the following areas will be covered: (a) rationale for the approach, (b) description of the research sample, (c) overview of the research design, (d) process for data collection, I data analysis and synthesis, (f) issues of trustworthiness, and (g) limitations of the study. The chapter concludes with a summary of the content that was discussed.

Qualitative Research Generally, qualitative inquiry aims to gain a better understanding of the meaning and significance from the perspectives of individuals’ lived experiences. Bloomberg and Volpe (2012) explained that qualitative inquiry embodies a constructivist perspective as it posits the

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existence of multiple truths and realities, a direct contrast from the positivist perspective utilized in quantitative research. Qualitative research also seeks to understand the process of a particular topic, idea, or phenomenon, not simply to emerge from data collection with a quantifiable outcome. Some qualitative researchers take a constructivist perspective. Constructivism constructs knowledge rather than passively breathing in information, and my philosophical paradigm best fits with this type of constructivist qualitative inquiry.

Grounded theory does not believe a researcher is free from influence, but instead accounts for a researcher’s perspective in the coding and memoing process (Creswell, 2007, 2014). Specifically, my research topic on hope and despair does not seek to quantify hope as an individual trait, but instead seeks to understand the role(s) of hope and despair in the context of the therapeutic relationship. Therefore, a qualitative design is the best fit for my research study.

Grounded Theory Grounded theory is an approach to qualitative research that has important implications regarding a review of the literature prior to the collection of data. A concern posed by one of the founding fathers of grounded theory, Barney Glaser (1978), is that a review of the literature before the collection of data will create assumptions that influence the data. Therefore, it seems relevant that this chapter begins with a discussion of the literature on the methodological approach itself, both its historical origins and its implications regarding the use of literature review during research (Mills et al., 2006). Following the discussion of the evolution of grounded theory, this dissertation explored pertinent findings on the topic of hope. In reviewing the literature available about hope there was also a thorough study of the concept of despair and its dialectical relationship to hope.

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While certainly a more exhaustive discussion of the methodology of grounded theory will be discussed in the subsequent chapter it seemed an appropriate place to begin a discussion of the literature on grounded theory. To move forward with an approach to the topic of hope, it was important to first understand the variations and foundational principles behind grounded theory.

Glaser Glaser and Strauss are often referred to as the founding fathers of grounded theory research. In 1967 Glaser and Strauss published their seminal text on grounded theory entitled The Discovery of Grounded Theory: Strategies for Qualitative Research, which offered insight on the construction and use of a grounded theory approach. They maintained that grounded theory was a systematic qualitative approach that sought to create a theoretical understanding of issues of importance to people using the data collected objectively (Charmaz, 2006). Glaser (1978) formed a system whereby a researcher began with an open-ended question, did very little preliminary review of the subject matter, and used everything stated in semi-structured interviews as data. Glaser (1978) maintained that “there is a need not to review any of the literature in the substantive area under study” (p. 31), which is quite different from other methodological approaches that depend heavily on the use of extensive literature reviews. The idea was that the data was collected, coded, sorted, and used to construct a theory from the ground up instead of the classic top-down processes of other research methodology (Mills et al., 2006). As Glaser and Strauss advanced their work, they eventually came to a fundamental split in their belief about how to conduct grounded theory research.

Strauss & Corbin As the chasm between Strauss and Glaser grew wider, Strauss broke away to develop his own formulation of how grounded theory should be practiced. Strauss partnered with Corbin and

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together they advanced the methodology of grounded theory with new emphasis placed on creating a more rigorous, quantitative process for coding and sorting data collected from interviews. However, they have been largely criticized for having the “technical tail…wag the theoretical dog” (Melia, 1996, p. 376). To create more rigor in the grounded theory approach Strauss and Corbin seem to contradict themselves. [HN1] As Mills et al. (2006) discuss “their work demonstrates a mixture of language that vacillates between postpositivism and constructivism” (p. 28). In one article, Strauss and Corbin (1998) take the position of attempting to be researchers free of bias, but in later articles discuss the inability for conducting grounded theory without some influence based on biases (Strauss & Corbin, 1998). As for their stance on literature reviews, they viewed the preliminary review of literature related to the topic as a significant additive to their ability to conceptualize the data that was presented (Strauss & Corbin, 1998).

Constructivist Grounded Theory Charmaz Further along the spiraling path of variations on classic grounded theory, Charmaz (2000) developed a definitive stance as a constructivist grounded theorist. In her work, Charmaz (2000) removed all doubt regarding subjectivity as she presented her idea that constructivist grounded theory is an ethnographic process of storytelling that is co-created by both the participant and a researcher. This is a clear break from classic grounded theory, but it seems to reflect the postmodern sentiment of honoring the co-constructed and bidirectional relationship between therapist and patient, researcher, and participant.

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Charmaz (2006) is the principal author on matters pertaining to constructivist grounded theory and she describes: A constructivist approach places priority on the phenomena of study and sees both data and analysis as created from shared experiences and relationships with participants and other sources of data...A constructivist approach means more than looking at how individuals view their situations. It not only theorizes the interpretive work that research participants do, but also acknowledges that the resulting theory is an interpretation...The theory depends on the researcher’s view; it does not and cannot stand outside of it (p.

130).

As Mills et al. (2006) argue, “all variations of grounded theory exist on a methodological spiral and reflect their epistemological underpinnings” (p. 26).

Rationale for Constructivist Grounded Theory The constructivist grounded theory approach is what resonates most with my perspective on research and practice based on the following: its emphasis on co-constructed meaning; the belief in multiple truths or realities; and the use of preliminary reviews of relevant literature to support the conceptualization of theory. A brief history was provided outlining the development and adaptations made to grounded theory from the 1970s through the present. For the purpose of this study, it is most relevant to focus on the constructivist theory that will be utilized in this research design.

In selecting a research design the purpose and intention of the study were heavily considered. The expressed aim of this study is to provide a deeper understanding of hope and despair with the desire that from the information yielded therapists may be able to harness the clinical power of hope to improve outcomes in treatment. The very selection of this subject

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matter, as well as the assumption regarding the dialectical relationship between hope and despair is evidence of the need for a constructivist perspective. From this perspective the assumptions made were transparent and considered in the construction of the theory, rather than being built into the direction of the questions and never accounted for explicitly. Classic grounded theory has a positivist philosophical underpinning that seems to conflict with my own relational, constructivist philosophical perspective and approach to psychotherapy. Besides constructivist grounded theory being more philosophically aligned with my own worldview, I believe that it serves as a more useful research construct for this particular study of hope and despair as they relate to the experiences of clients that have undergone psychotherapy.

Another important consideration in this study concerns the representativeness of the sample. Charmaz (2006) offers that grounded theory sampling is “aimed towards theory construction and not population representativeness” (p. 6). However, in this study my intention is to create a cohesive narrative regarding hope and despair that will assist therapists in using hope to improve therapeutic outcomes. Therefore, it is my belief that this sample must represent a diverse and representative sampling, which will produce constructs that are generalizable across therapeutic populations.

Role of the Researcher My professional interest in the topic of hope and its relationship to despair began with my post-graduate fellowship training at The Menninger Clinic. However, my interest in hope precedes my professional interest and begins with my own personal story of grappling with hope and despair in an abusive, impoverished, alcoholic and mentally unstable home. My first introduction to the concept of hope as a child was a bible verse that I memorized, Jeremiah 29:11, “for I know the plans I have for you declares the Lord, plans to prosper you and not to

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harm you, plans to give you a hope and a future.” I memorized this verse and recited it because the words lent me some sense of hope in an otherwise hopeless situation. Beyond these words it was relationships that provided the greatest sense of hope to me as an adolescent. I was fortunate to have been intervened and been given access to support and therapy at 13 years old. It was in this process of therapeutic work around my own pain and despair that I found hope in and through my relationships with others.

While my interest in the topic of hope and despair began as a deeply personal exploration, it has now become a cornerstone of my professional thinking. In conducting this research from a constructivist grounded theory perspective, I intend to operationalize definitions of hope and despair that emerge from qualitative interviewing; then attempt to construct what factors might account for the shift from despair to hope. It is hoped that the identification of these factors will better equip Social Workers to assist clients and will bolster treatment efficacy and improve treatment outcomes.

Description of the Study This study utilized Charmaz’s (2014) constructivist grounded theory (CGT). CGT was selected as the specific method for this study in aim to generate a new working theory, grounded in the data, to explain the complex relationship between hope and despair. To achieve this aim, this study aimed to answer the following research questions: (1) What are the experiences of individuals about hope and despair during psychotherapy? (2) How do individuals navigate and understand the dialectical relationship between hope and despair?

Sampling Initially, participants were purposely sampled to meet the criteria of the study. For example, to be eligible to participate, individuals must have completed a minimum of six months

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in a course of psychotherapy and completed therapy within five years of the first research interview. Additional criteria included being between 18-70 years of age and having prior experience with either individual, couples, family, or group psychotherapy. Participants were excluded from the study in the event that they were under 18 years of age, actively experiencing psychosis, and/or under the influence of illicit substances at the time of the interview. The intended sample size for this study was a minimum of 20 participants. According to Creswell (2007), 20 participants is an appropriate sample size for constructivist grounded theory studies.

In this dissertation, a sample of 20 participants reflected a more representative sample in which people shared a common understanding of both topics: hope and despair. Considering that CGT emphasizes the generation of a new working theory, grounded theorists remain attentive to data saturation, a point in which no new themes or patterns emerge from within the data in order (Charmaz, 2006). Thus, another benefit of this sample size (n = 20) was that it allowed for the development of hope and despair concepts to represent a more diverse breadth of life experiences.

Theoretical Sampling Purposive sampling strategies are commonly used in qualitative research, which helped to both identify and ensure that all participants were particularly knowledgeable about the topic of study (Plano & Creswell, 2008; Palinkas et al., 2015). After initial purposive sampling, and as the theory began to develop from within the analysis, theoretical sampling was next used to identify subsequent participants. As Charmaz (2006) wrote “initial sampling in grounded theory is where you start, whereas theoretical sampling directs you where to go” (p. 100). Theoretical sampling is specific to CGT and is defined by Mills et al., 2006, p. 69) as, “a process of identifying and pursuing clues that arise ‘’ from ongoing data collection, analysis, and coding.

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Therefore, as data were continually collected and the theory began to emerge, I paid close attention and determined which types of data were necessary for the development of the overall theory.

In a CGT approach, the focus is on developing a theoretical understanding of a particular phenomenon based on the data collected, rather than on testing pre-existing hypotheses or looking for correlations between specific variables. While correlations between variables may emerge during the data analysis process, the focus in CGT is not on quantitatively analyzing or measuring these relationships, but on developing a rich, detailed understanding of the phenomenon being studied. Rather than pre-defining variables to investigate, the CGT approach involves an iterative and flexible process of data collection and analysis, where a researcher aims to identify and understand the concepts, categories, and relationships that emerge from the data (Charmaz, 2006).

While a CGT approach may involve looking for connections between various aspects of the data, it is not focused on identifying correlations between specific variables and does not typically involve the use of statistical analysis or hypothesis testing. Having studied the issues of hope and despair extensively for over six years now I am well versed in the existing theories regarding hope and despair that are discussed in the literature. There is significant evidence from previous studies to suggest a dialectical relationship between hope and despair, which does create an a priori assumption that impacts the construction of my research questions (Byrne & McCarthy, 2007; Flaskas et al., 2007; Hilliker, 2012; Weingarten, 2010). However, the use of a constructivist grounded theory approach to this study is intended to mitigate the impact of a priori knowledge and hypotheses, and instead seeks to use this knowledge only if it assists in explaining themes and patterns that emerge from the data.

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Context. The study was conducted in two separate recruitment sites in the southern United States. Ethos Wellness-Lovett was one of the sites, which is a researcher’s place of business. The culture and work environment of Ethos Wellness-Lovett are one of collaboration and client-centered care. There are other academics working and conducting research within the building. I am one of the managing partners of the building and therefore need to be particularly mindful of dynamics of power when seeking to recruit participants for the study. I will discuss these specific ethical considerations later in this chapter.

Perceptual. In conducting this study, I ensured that I accounted for participant perceptions that impacted the subject matter being studied. These perceptions were captured in the process of data collection and synthesis and were explicitly explored within the study to determine the potential impact of these identified perceptions.

Recruitment Protocol Participants were recruited from two clinical mental health settings: one in the midwestern United States and the second in the southern U.S. A structured recruitment protocol was developed, and the plan for recruitment at these two sites was to display flyers in multiple departments of each site, which will clearly state the inclusion and exclusion criteria, the purpose of the study, and the contact information to obtain additional information.

Ethos Wellness. Lovett provides services for the indigent as well as individuals that can afford private pay services. Additionally, recruitment from Ethos Wellness- Lovett provided participants that presented with addictive disorders and co-occurring mental health conditions, which provided even more diversity to the sample and impacted the data that emerged regarding

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hope and despair. The other site was the University of Houston (UH) which has a main campus of nearly 50,000 students, and Ethos Wellness- Lovett serves thousands of Houstonians annually, which allowed for the study to reach its full sample size of 20 participants.

The plan for recruitment at these two sites was to display flyers in multiple departments of each site, which clearly stated the inclusion and exclusion criteria, the purpose of the study, and the contact information to obtain additional information (Appendix A). In addition to the simple display of flyers in different departments, the flyers were also given to other area clinicians by therapists at Ethos Wellness- Lovett and the UH Counseling Center. Interested faculty members at UH were identified, and I asked these faculty members to pass out flyers or make flyers available to their students in classes. Of course, these faculty members were not allowed to recruit for my study directly, but simply shared the information on my study.

Data Collection/Generation Data were generated through participant interviews, which were conducted remotely and transcribed verbatim. The interviews were constructed using a semi-structured protocol script, which was refined throughout the data collection and analysis period to ensure continuous exploration of emerging themes. A demographic questionnaire was also administered to obtain descriptive background information about the sample. All data were stored without participant identifiers to protect confidentiality and uphold ethical standards for conducting research.

Interview 1 focused on the broad topic of the study and lasted approximately one hour.

Interview 2 focused on more specific topics related to the emerging themes and lasted an average of 50+ minutes. All participants were compensated $20 for their time and effort.

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Data were generated through an initial interview and a follow-up interview. Out of all 20 participants, 18 completed both interviews. Although all participants were informed from the outset about future contact about the follow-up interview two participants only completed the initial interview.

Ethical Considerations All data were stored without participant identifiers to protect confidentiality and uphold ethical standards for conducting research. Additionally, participants were informed about the purpose of the study and their rights as research participants, including their right to withdraw from the study at any time without penalty. Informed consent (Appendix B) was obtained from all participants prior to beginning the study, and the study was approved by the Institutional Review Board [IRB] (Appendix C) at the Institute for Clinical Social Work. Figure 2 shows the workflow for data generation.

Figure 2 Data Generation

Note. Researcher developed.

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Demographic Questionnaire A demographic questionnaire was developed to obtain descriptive background information about the characteristics of the sample (Appendix D). All participants completed this demographic questionnaire either over the phone or through a password protected university Zoom account directly after they were screened into the study. This questionnaire asked basic demographic questions as well as other questions regarding their interest in the study and understanding of the scope and aim of the study. I collected all demographic information from each participant prior to beginning the interview.

Participant Interviews Participant interviews were constructed using a semi-structured protocol script or interview guide (Appendix E). This protocol served as a guide to explore the topic of study and to address the questions identified for the purposes of the study. Interviews were conducted by me (RH), and two additional interviewers (TJ & SM). To provide consistency, all interviewers were trained to conduct the interview process.

In this study, all interviews were conducted remotely with each participant completing two separate interviews at two different time points. Because interviews were held remotely, participants were in a location of their choice. During the interview process, I and the trained interviewers demonstrated our utmost sensitivity to the questions and topics that emerged. For example, I maintained a compassionate and caring tone, which was essential in gaining significant knowledge and insight from each participant (Elmir et al., 2011). More specifically, I utilized curiosity, empathic attunement, and other clinical communication techniques to both encourage and facilitate open and respectful dialogue throughout the interview process.

Following interview completion, all interviews were transcribed verbatim. To maintain

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confidentiality, texts were deidentified immediately after the interview for the protection of participants’ identities. These interviews were assigned markers using fruit names and numbers.

Deidentified interviews were transcribed verbatim. An example of a participant transcript can be found in Appendix G. Consistent with CGT, as data generation and analysis progressed, some interview questions were refined for clarity, while other new questions were added to the interview script.

Specifically, interview questions were revised to ensure continuous exploration of emerging themes as new concepts arose from within the data (Charmaz, 2014). This helped the interviewers to clarify participants’ understandings of hope and despair, which also provided additional clarity on relevant topics that emerged into the development of the theory. Questions that were added during data collection and analysis period were included on the interview guide and marked with an asterisk (Appendix C). As stated earlier, all participants were offered $20 compensation for their time and effort.

Theoretical Sufficiency/Saturation Theoretical sufficiency or saturation is an important concept in qualitative research that refers to the point at which data collection and analysis have been conducted to the extent that new data no longer yield significant new information or insights (Charmaz, 2014). The point of saturation is the point at which the sample is deemed to be adequate, and researchers have gathered enough data to answer their research questions fully. The concept of theoretical sufficiency is a critical component of qualitative research as it provides researchers with the confidence that the results of the study are not influenced by any sampling or data collection bias, and that the data is representative of the study population (Charmaz, 2014).

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Saturation can be achieved in different ways depending on the type of qualitative research study being conducted. In grounded theory, saturation is reached when no new concepts or categories emerge from the data, and a researcher is confident that the theory generated from the data is comprehensive and robust. In contrast, in phenomenological research, saturation is achieved when a researcher has collected enough data to capture all the participants’ experiences and perspectives on the phenomenon being studied (Guest et al., 2006; Morse, 2015).

Saturation is not always easy to achieve, and the number of participants required to reach saturation may vary depending on the research question, study design, and the level of complexity of the phenomenon being studied (Guest et al., 2006; Morse, 2015). Nevertheless, I attempted to achieve theoretical sufficiency by taking several steps. First, I conducted a thorough literature review to identify existing knowledge and identify gaps in the current research. This helped me in defining the research question and selecting the appropriate participants and data collection methods. Second, I used purposive sampling to select participants that were most likely to provide rich and diverse data. This allowed me to ensure I identified participants who had experienced the phenomenon being studied. Third, I used multiple data collection methods such as interviews, memoing, and rigorous coding to triangulate data and increase the chances of saturation.

Data Analysis Data were analyzed using a combination of strategies outlined in CGT by Charmaz (2014). Data analysis began with the first interview transcript, and followed an iterative process that included open, focused, and theoretical coding. As the study progressed, succeeding data

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were next analyzed and compared to one another. These constant comparative strategies (e.g., analysis within and across cases) were followed by memo writing, and the incorporation of theoretical frameworks (Charmaz, 2000, 2006, 2014; Glaser, 1978).

Coding and analysis procedures were conducted both by hand and through qualitative analysis software. All data was de-identified and interview transcripts were kept in protected Microsoft Word files and then imported into NVvivo 1.6.2. NVivo is a computer software program that aids researchers in organizing and analyzing unstructured qualitative data.

According to Bezley (2007), qualitative software programs improve data accuracy by aiming to reduce the potential for human error. In this dissertation, NVivo was particularly beneficial in organizing and managing the data to ensure that the volume of information did not become overwhelming during analysis. Additionally, NVivo helped to visualize the analysis, moving between increasing layers of abstraction, and successively allowing for greater insight.

NVivo was primarily utilized during the initial coding process. However, as more interviews were obtained, I began developing tables in Excel to investigate and organize trends across all participants which I have included an example images of in Appendix I. These tables were color-coded, and data were indexed into prospective categories. This process was particularly important in the evolving construction of emerging theory. A step-by-step process map demonstrating the process for data collection and analysis can be found in Appendix E. Field Notes Field notes were constructed during and immediately after each interview and were considered invaluable resources for reflection throughout data analysis procedures. As I documented my initial thoughts and impressions, these field notes allowed me to fully immerse

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myself in the data while also serving as critical sources in which I reviewed later in the analysis process. Appendix J provides an example of a field note which offers some insights and understanding of this aspect of the research process.

Research Memos In CGT, and particularly in this dissertation, memo writing was considered an essential component to both data collection and data analysis methods. Charmaz (2006) described memos as the “pivotal intermediate step between data collection and writing drafts of papers…because it prompts you to analyze your data and codes early in the research process” (p. 72). Stated differently, Lempert (2007) emphasized that memo writing is simply the task of asking questions of the data.” In this study, it is important to note that the memos differed from the first impressions captured though the field notes. Rather, throughout the entirety of this research, I wrote extensively on both case-based (e.g., participant-based) and conceptual comprehensive memo writing. This was evident as each memo served as a tool to deepen the engagement and interpretation of the overall data (Charmaz, 2014). As patterns and themes continuously emerged from within the data, these memos were crucial in the identification of concepts and ideas, which led to the organization of theory development (Charmaz, 2006, 2014). More specifically, I wrote conceptual memos in reference to the emergence of initial codes as subsequent focused codes began to develop (Charmaz, 2006, 2014). To offer a visual depiction, Figures 3 and 4 represent conceptual models.

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Figure 3 Definition of Despair

Note. Researcher developed.

Figure 4 Definition of Hope

Note. Researcher developed.

Coding Procedures Coding is a process that bridges data collection, research findings, and emergent theory together. Essentially, this provides the analytic space required for researchers to define the meanings embedded within the data, and to begin building the analytic framework that constructs 57

the analysis (Charmaz, 2014). As previously mentioned, three types of coding strategies were used in this study: open, focused, and theoretical. These processes of coding helped to assign interpretative labels to ideas, constructs and concepts that arose from the data (Carmichael & Cunningham, 2017; Saldana, 2016).

Initial Coding Initial coding was the first stage in creating analytic interpretations in this study. This type of coding supports researchers in remaining open to explore all theoretical possibilities that can be grasped from deep within the data (Charmaz, 2006, 2014). To practice initial coding, the interview transcripts were first imported into NVivo 1.6.2. I closely read and immersed myself in the data while concurrently studying and naming each line, segment, and incident (Charmaz, 2006, 2014). Hence, I employed line-by-line open coding strategies and paid close attention to in vivo codes. Generally, in vivo codes aim to preserve the precise words and solidify participants’ thoughts and ideas of their experience (Charmaz, 2014). During this process, I also strived to remain open-minded and refrain from attaching potential codes into my preconceived notions about where the data should originally fit. While many of these initial codes included words from multiple participants, it was important to be congruent with traditional CGT methods. Therefore, additional codes were developed when more interviews were completed and evaluated.

Focused Coding The next phase of coding incorporated focused coding strategies. Focused coding is more conceptual than initial coding, as it progresses the research into a more theoretical direction (Charmaz, 2006, 2014). This phase is also more attentive to the sorting and synthesis of the data, with the most significant and consistent recurring codes earmarked as the focus of the analysis (Charmaz, 2014). Thus, during this process, coding began transitioning into a more traditional

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pen-to-paper approach as data were next primarily coded by hand. Through memo writing and analysis, coding progressively became focused. However, it was also essential for me to review the codes and determine whether the established codes matched the data, or whether I needed to further investigate the previously gathered information. I therefore continuously reflected on whether I needed to conduct additional interviews or if the data saturation was achieved. This process resulted in numerous iterations of data generation through memo writing and analysis.

Additionally, I constructed several conceptual designs to better understand the significance and meaning behind each code. These conceptual designs helped me to visually depict key patterns and relationships that arose from initial coding. Through this process, I was able to determine which codes best represented the data, which was also supportive to sorting and managing the data (e.g., some codes were condensed and collapsed into a single code when similar codes shared distinctive features).

Theoretical Coding Theoretical coding was the final coding stage utilized in this dissertation. While the first two coding procedures were provisional, theoretical coding evaluated the categories of codes related to other categories to bring smaller elements of information back together. Thus, this stage supported a more theoretical application to the analysis. Through theoretical coding, core concepts were identified and linked together, resulting in the development of a theoretical framework that explained the complex relationships between these factors and their impact on hope and despair. Theoretical coding was thus a critical component of the dissertation, providing a comprehensive understanding of the data and leading to the development of a novel theoretical contribution to the field.

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Constant Comparison Constant comparison strategies were employed after I completed preliminary analyses with each interview. These strategies supported me in the process of discovering similarities and differences from the data. In response, I was able to gain a deeper understanding of the relational patterns between both codes and emerging categories. In this dissertation, I began with comparing numerous initial codes from the first interview. All identified codes were compared to newer codes within the same transcript. I next compared these codes to interviews coded previously. Following this process, new data were constantly compared to prior interviews to help differentiate any relevant similarities and differences within participants’ data. Constant comparison methods were also employed with the use of numerous memos and some field notes.

Field notes were analyzed using constant comparative methods and next coded for saturated thematic, but theoretical concepts.

Qualitative Rigor and Trustworthiness Qualitative rigor and trustworthiness are important considerations in qualitative research.

In CGT, reflexivity is a key strategy to ensure rigor and trustworthiness. Reflexivity involves a researcher critically reflecting on their own assumptions and biases throughout the research process. In CGT, memo writing is a common technique used to facilitate reflexivity. Memo writing involves a researcher reflecting on their observations and thoughts about the data, which can help identify biases and assumptions. Overall, reflexivity is an important strategy to ensure the rigor and trustworthiness of qualitative research.

Summary This chapter describes the qualitative approach and procedures used in the study to develop a theory on hope and despair. I provided a comprehensive understanding and rationale

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for constructivist grounded theory, which works on the assumption that I and the participants cocreate an understanding of the information provided in qualitative interviews. The study addressed seven research questions related to hope and despair in the context of psychotherapy.

The chapter covers the rationale for the approach, research sample, design, data collection, analysis and synthesis, issues of trustworthiness, and limitations of the study. The chapter also discusses, more specifically, the constructivist perspective of qualitative research, which aims to understand the meaning and significance of individuals’ lived experiences, and how grounded theory accounts for my perspective in the coding and memoing process.

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CHAPTER IV: FINDINGS Overview Researchers have argued that hope and despair play an integral role in the pursuit of therapy, patient outcomes, and recovery from loss and traumatic events (Snyder, 2002, 2004; Snyder et al., 1999). In this chapter, I provide the results of the CGT analysis based upon the purpose of the study, which was to develop grounded theory research addressing the roles of despair and hope in the process of psychotherapy, the central theme in the process of change that occurs during psychotherapy, and how the concept of despair may be a starting point for the installment and cultivation of hope in treatment. Identifying results for the CGT analysis led to an initial twenty focused codes derived from seven initial codes. Initial codes were aggregated into four core categories representing the pursuit of hope through experiences of despair.

The CGT analysis results are discussed at length in the following sections. In this chapter, I first discuss sample characteristics. Data is then provided regarding the twenty focus codes derived from the seven initial codes. Next, quotes are provided in correspondence, with participant frequency count. Data is then supplied regarding core categories, of which four core categories are reviewed and their relationship to the focus codes, participant quotes, and empirical literature. The subsequent sections of Chapter 4 review the core categories and associated theoretical propositions, which are discussed in tandem with a detailed review of the constructivist grounded theory of hope and despair developed from the textual information. First, I will review the sample characteristics of the participants in this research study in Table 3.

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Sample Characteristics The sample characteristics of the study participants are discussed below. The variations in age, gender, race and ethnicity, and place of residence are discussed in Table 3. I also briefly reviews the mean age of participants, reasons for treatment, and forms of therapeutic treatment obtained.

Table 3 Study Sample Characteristics Age

Gender

Race/Ethnicity

Place of Residence

30

Female

Asian; Indian Origin

Chicago, IL

25

Female

White

Chicago, IL

40

Female

White

Houston, TX

28

Female

N/A

N/A

70

Female

White

Valperaso, IN

51

Female

White/Scandinavian

Ukon, OK

61

Male

White

Houston, TX

37

Female

White

Cypress, TX

34

Male

Mexican/White

Houston, TX

45

N/A

N/A

N/A

53

Female

White

Houston, TX

30

Female

N/A

N/A

53

Female

N/A

N/A

28

Female

White

Houston, TX

54

N/A

N/A

Houston, TX

33

Male

Mixed – other – Asian

Houston, TX

54

Female

White

Houston, TX

32

Male

White

Houston, TX 63

Age

Gender

Race/Ethnicity

Place of Residence

39

Female

Latina

Houston, TX

55

N/A

N/A

Chicago, IL

Nineteen participants completed semi-structured interviews for this study. Participants’ ages ranged from 25 to 70 years old. The mean age of the participants was 42.6. Most participants were White women. Participants varied in therapeutic sessions attended from 151000 or more sessions. Participants attended therapy for 2.5 months to over 20 years. The mean average therapy duration for participants was 5.4 years. Participants also engaged in various types of therapy, such as psychodynamic therapy, person-centered therapy, and family therapy.

Three participants were unsure of the specific type of therapy used in their sessions. The participants expressed a variety of reasons presenting for treatment, such as loss, grief, anxiety and depression, divorce, life transitions, relationship trauma, substance abuse, abusive relationships, trauma, addiction, chronic illnesses, and attachment issues. Next, the results of the CGT analysis are discussed at length.

Results for the CGT Analysis Developing Final Codes from Initial Codes Twenty focused codes derived from seven initial codes. The decision rule for focusing initial codes was at least three iterations of coding without further disaggregating an initial code into additional focused codes (or relatively granular codes, Saldana, 2016).

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Figure 5 Coding Memo 1 Coding Memo 1 While exploring the perceptions of participants I found myself commonly returning to how individuals reflected upon feelings of hopelessness versus helplessness when defining despair. Participants seem to return to defining despair while also defining hopelessness, and vice versa. Participants also considered emotional reflections as depression or feeling anxious. Participants also found themselves considering factors such as how indecision led to the furthered sense of helplessness and hopelessness, which even exasperated their feelings of despair.

The initial code, shown as Coding Memo 1 in Figure 5, frequencies represented the repetition of textual information associated with a similar conceptual value and topic, such as feelings of control and learning to cope. The focused codes were the result of the three iterations of coding via development from the related initial code topics. The first initial code (frequency counts labelled in the accompanying parentheses) gaining perspective was developed into the focused codes of accepting loss (19), accepting change (19), and learning from the perspectives of others who experienced loss as change (13). The second initial code becoming resilient was aggregated into the focused codes of becoming resilient (24) and psychotherapy. Ascribing meaning resulted in the focused codes of constructive life changes (24), being open to change (29), destructive life changes (21), resistance to life changes/no life changes (10).

The initial code of relationships resulted in identification of the focused codes associated with avoiding relationships (16), maintaining relationships (9), and making new relationships (19). Sense of control initial code revealed focused codes associated with feelings of no control (29), feelings of control (21), and vacillation between feelings of control, no control (17).

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Figure 6 Coding Memo 2

The focused codes (Figure 6) resultant from the initial code outlook included hope that the future will be positive (39), lack of hope that the future will be positive (16) and vacillation between feelings of hope, no hope (37). Associated quotes and a review of initial and focused code frequency count is examined in Table 4.

Table 4 CGT Analysis, Step 1: From Initial Codes to Focused Codes Initial code

Focused codes

Example direct quotation

Frequenc y count

Gaining perspective

Accepting loss

“I saw it...where this wasn’t gonna work anymore, like it wasn’t working, it wasn’t gonna work, there was no way I could make it work, so you know everything since that shift away from knowing that it couldn’t’ be that way was hopeful.” (Audrey 10)

19

Accepting change

“Strangely, I think, ya know just seeing that it’s happening, I feel like I’ve run into more trouble and had more problems when I didn’t actually understand how upset I was and give myself permission kind of to be really upset and even recognize it’s happening.” (April 1)

19

Learning from the perspectives of others who experienced

“I was seeing people that had similar backstories to me that now were in a professional setting and I was like ‘huh, so I’m not like always gonna be like this, there can be something changing.”

(Ava 18)

13

66

Initial code

Focused codes

Example direct quotation

Frequenc y count

Learning to cope

“...I’m starting to, to learn how to cope with it.

And, how to handle it...” (Barry 13)

24

Psychotherap y

“...the therapist I work with provided a sense of, I think, empowerment for me...” (Percy 16).

21

The meaning of loss

“...it seems true that a lot of that is despair, loss, loss of a job, a spouse, a career, a child, something that moves us...” (Hanley 20).

24

The loss of meaning

“...like paralyzed is the w- that’s where, like I – fearful, um, you know inept...like those are the things I feel when I feel despair is like that I have completely, I can’t move...” (Audrey 10).

14

Constructive life changes

“I’m in the midst of following my own passion to social work and listening to my gut and truly listening to my own sense of direction, my own internal compass, and I’m kind of being true to myself.” (April 1).

24

Being open to change

“Just recognizing that there is so much more than in the here and now, there’s so much more than what my eyes can see....” (Tammy 19).

29

Destructive life changes

“The primary coping mechanism for all this stuff was isolation and substances, helped me with like what I thought was reducing the level of despair I guess” (Ava 18).

21

Resistance to life changes/no life changes

“...I really went through like a good week where I was just devastated. And I was just angry, and I was just pissed off. And…I really withdrew.”

(Stephanie 18).

10

Avoiding relationships

“...I just um, felt sad um, and was unavailable to my husband and kid...” (Tammy 19).

16

Maintaining relationships

“I’m so lucky that I, I had family that was encouraging, they, they did many things wrong.

The one thing that they did right was let me know that I, I am loved. And I think that really fucking mattered.” (April 1).

9

loss as change Becoming resilient

Ascribing meaning

Making life changes

Relationships

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Initial code

Sense of control

Outlook

Focused codes

Example direct quotation

Frequenc y count

Making new relationships

“...get help like reach out to somebody. Um, connect to another human being. You know it doesn’t have to be a therapist, you know for me it wasn’t that wasn’t the first person but, but somebody...” (Audrey 10).

19

Feelings of no control

“a feeling of the floor dropping out from under you, one being stuck in it, with, with a, a lack of momentum to move forward or even backward.”

(April 1).

29

Feelings of control

“...I think it was a sense that um, (laughs) and this is gonna sound terrible, that I could control the situation? Or, or maybe, maybe the word isn’t that I could control the situation, but I had more agency.” (Percy 16).

21

Vacillation between feelings of control, no control

“I have the power to move this in a way that won’t be so painful or will bring relief, but you don’t even feel like, you don’t know what to do so it’s sorta that sense of loss of agency.”

(Audrey 10).

17

Hope that the future will be positive

“You know that I’m not stuck in this loneliness, despair situation for my whole life. That there is something out there that I, that will get me better. You know and having that hope that things will be better.” (Barbara 14).

39

Lack of hope that the future will be positive

“I remember just sitting in the driveway kind of covered in humidity, and feeling what I still think today was, of sitting at, the edge of the pit of depression. I, I felt like I was in a really dangerous place, psychologically” (April 1).

16

Vacillation between feelings of hope, no hope

“...Despair and hopelessness would be kind of on the same spectrum or like on one end of the spectrum opposite of hope...” (Percy 16).

37

In the first focused code, feelings of control, participants discussed the process of regaining control after experiencing loss, trauma, and other complex scenarios that occurred in 68

their lives. For example, Barbara 14 stated that gaining control pushed themselves towards help “...the tunnel vision was so strong, I didn’t see any other way out....” While Perry 17 noted: You can’t hold on to feeling any more than you can control when they come in and out of your life. But knowing that, if you can at least understand that intellectual level, it becomes a little bit less heavy because, you know, you kind of understand that emotions come in waves (Perry 17).

For some participants learning to cope was an integral part of the recovery process as well as grappling with constructs of hope and despair. Audrey 1 stated, “the only thing I could do was organize my closet. And that was a hopeful event because it calmed my nerves...” For Ava 18, learning to cope was not a linear path to recovery “I didn’t see people that much, I was intoxicated all the time...what I thought then was that it gave me some sense of control over how I felt...” and Barry 14 “I’m starting to, to learn how to cope with it. And how to handle it. And, I mean, what I’ve been doing lately, I mediate a lot...” Participants in learning to cope and feelings of control emphasized that these are both nonlinear paths that fluctuated during their process of recovery during a challenging experience or period of loss.

Figure 7 Coding Memo 3 Coding Memo 3 During my consideration of how participants discussed their experiences of despair, I also wondered what contributors of despair play a role in coping had, controlling, and accepting loss. Participants discussed various changes that occurred while they coped and experienced despair. Career changes were also a critical factor that both encouraged hope as a contributor and led to experiencing hope despite despair.

The process of accepting loss is also associated with accepting change and learning from the perspectives of others who experience loss as change (Figure 7). When discussing accepting loss, Audrey 10 stated, “...everything since that shift away from knowing that it couldn’t be that 69

way was hopeful.” Margo 5 contended that “I can’t tell you how grateful I am that I’m learning the things I am and I’m feeling the way I am like right now compared to even five years ago.”

Participants also felt that the process of accepting loss required accepting the idea of change, both in themselves and in the ways they adapted to a traumatic experience. For example, Linda 11 emphasized, “Here’s what we’re doing. The kids are going to be OK. You’re going to be OK,” and Percy 16 felt that “...kind of making peace with what is and whatever internal thing maybe weather is absolute and sheer, I don’t know, utter sadness or rage... trying to make space for it.” During the process of accepting loss and accepting change participants reflect on the support received from others who had similar experiences and could supply guidance. Ava 18 stated I was seeing people that had similar backstories to me that now we’re in a professional setting, and I was like, ‘huh, so I’m not like always gonna be like this, there can be something changing, I can like to live the life that I enjoy and not have to constantly be in and out of hospitals and you know offices (Ava 18).

Support In reference to support, April 1 “...people were very supportive of our family while my dad was sick...” and Penelope 7 “...the group of people, the social life to um have people talking about things I understood. And it wasn’t just one person; it was that whole group of people.”

Through validation of other support groups’ experiences, accepting loss, and accepting the idea of change, participants expressed a growth pattern that led them through the emotions of hope and despair (Figure 8).

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Figure 8 Coding Memo 4

Learning to cope and psychotherapy were two critical therapeutic approaches that participants explored while accepting and coping with loss in their lives. Many participants used psychotherapeutic options either at a time of need or through expressing concern over their wellbeing to friends and family. For example, Audrey 10 noted, “Like for me that was like just an idea that I could ask somebody, you know, for like to help me on something that I couldn’t figure out myself,” and Linda 11, “I was like out of it, to place where I feel like I needed additional support.”

Margo 5 reinforced the importance of understanding that self-imposed loneliness was not a useful path to recovery “...it was kinda cognitively knowing that and then the other part was, um, because I felt like I was all alone like I was literally just by myself in that despair.” Other participants used various coping mechanisms, some useful and others more detrimental to their health, to cope with loss, such as Paula 4 “I really didn’t have anybody to talk to about it...” and Perry 17 “. I only feel that I’ve been able to come up with mechanisms to handle stress and feelings of despair and negative emotions know that I am out of the worst of my depression...”

However, Leslie 12 also used personal faith for their aid “...realizing that like, my hurt and my pain, and which some was like self-imposed, and some was just, just happened...could be turned 71

into a blessing...” coping skills combined with seeking therapeutic help was a crucial element of the process of recovery from loss and despair to hopefulness (Figure 9).

Figure 9 Coding Memo 5

Seeking a renewed understanding of the meaning of loss required many participants to understand the loss of meaning in terms of their physical fulfillment, career choices, and the absence of an individual no longer in their lives. April 1 described the meaning of loss as a complex process of self-discovery “... [I] set myself up for failure for this thing to happen again where I only imagine a very limited version of myself? And then, when it was done, then I apparently ceased to exist. So, I, that was also part of it, looking forward” and Barbara 14 “You feel sad, you know, you feel it, and then you move on. Like for me, that that’s a fucking huge thing. Like, I feel sad, and I don’t need it to change that feeling...” While discovering the loss of meaning was a bittersweet experience for Perry 17, “I can look at the good memories. But even they were kind of tainted by just my overall outlook at life,” and Stephanie 8, “it can mean the loss of hope, but it can also just be not being able to see the options, a sense of loneliness...” For all participants, the process of discovering the meaning of loss was inherently gained through exploring the loss that occurred during the complicated journey of recovery and self-exploration.

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Figure 10 Coding Memo 6 Coding Memo 6 Hope also helped them to realize their need to change, adapt, and grow regardless of trauma and loss. Initiating hope was both based upon therapy as well as the hope that therapy would help them. When they were in therapy, participants hoped that there would be a role of the treatment in terms of improving their life. Help also aided in the initiation of seeking help. However, all participants who expressed hopelessness were less likely to seek or initiate treatment. .

Constructive life changes require being open to change while also recognizing past destructive life changes. Figure 10 shows this through coding memo 6. However, resistance to life changes/no life changes was an integral part of recovery for many individuals from loss.

Barbara 14 recognized a shift to positive changes after recognizing stagnation “despair was like a motivator for me to seek help...” and Barry 13 “I’ve learned that um, at least in my case, uh, a small, healthy amount of anxiety over things helps a lot. But, when that anxiety turns into, I mean, helps a lot because it helps me, uh, motivates me to do better.” Karen 2 highlighted a recognition of a need to grow personally to fulfill new life changes “I feel like through some of the despair that I experienced, especially in my marriage, that I stunted my emotional growth.

So, I’m allowing myself to take time to catch up.”

Figure 11 Coding Memo 7

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Figure 11 illustrates the coding memo 7 which explains that participants relying on friends, family, and therapists consider them a part of their hopefulness through each transition.

For Audrey 10, experiencing past loss led to a sense of poor self-thought that hindered growth temporarily “I think the biggest contributor since I’ve been out of my house was my own, my own thoughts.” Margo 5 also emphasized the struggle with coping with loss while maintaining sobriety “the agony and the hurt and the pain that I was feeling. I never slipped into that black hole that I had slipped in before.” For Paula 4, isolation was often a sense of solace to cope with the trauma experienced in their life “I probably wouldn’t get out of my pajamas or what I slept in, I would probably watch TV most of the day...I would not call anybody...” Similar to Paula 4, Stephanie 8 initially felt incapable of accepting or initiating life change “I really went through like a good week where I was just devastated. And I was just angry, and I was just pissed off, and I really withdrew.” Regardless of the participant’s pathway towards life change, the process was often nonlinear and shaped by a sense of withdrawal, poor coping regulations, or a tendency to shift towards the support of others.

Figure 12 Coding Memo 8

Relationships were a crucial part of coping with despair and experiencing hopefulness.

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For participants, avoiding relationships, making new relationships, and maintaining new relationships or commonly reported experiences. Figure 12 showed through coding memo 7 that participants were less likely to interact in relationships with others if they had a negative viewpoint of themselves or poor self-confidence. Tammy 19 initial responses included withdrawal from close family and friends “...I just felt sad and was unavailable to my husband and kid...” while April 1 expressed the importance of focusing on maintaining their family relationships “I’m so lucky that I, I had family that was encouraging, they, they did many things wrong. The one thing that they did right was let me know that I am loved, and I think that fucking mattered.” For participants, such as Audrey 10, it was essential to reach out for help which may also aid other individuals who lacked social or family support systems “...get help like reach out to somebody... connect to another human being. You know it doesn’t have to be a therapist, you know for me it wasn’t that wasn’t the first person but, but somebody...” the process of maintaining, making new relationships, or avoiding relationships was often dependent upon the individual social circle, and their own relationship with the definitions of despair and hope.

Participants’ outlook was mainly based on their perception of hope. For some, hope was a positive future, while others felt that there was a lack of hope for a positive future. Most participants also expressed the vacillation between feelings of hope and no hope. For example, Barbara 14 reflected on the hope that things would improve their recovery “You know that I’m not stuck in this loneliness, despair situation for my whole life. That there is something out there that I, that will get me better. You know and having that hope that things will be better.” While April 1 highlighted a converse experience in which the future seemed unlikely to improve based upon the loss and trauma they were experiencing at that point in their life “I remember just

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sitting in the driveway kind of covered in humidity, and feeling what I still think today was, of sitting at, the edge of the pit of depression.” However, for Percy 16 “...Despair and hopelessness would be kind of on the same spectrum or like on one end of the spectrum opposite of hope...”

Many participants reflected similar reflections, such as Percy 16, in terms of describing hope and despair on a continuum of emotions, which arose in various emotional strengths during a cyclical period of recovery from trauma and loss.

Developing Core Categories from the Final Codes Following the coding of interview data, the focused codes were then reviewed for conceptual similarity. The concepts were literature based and are reviewed in Chapter 2. The identified focused codes also correspond with the peer-reviewed literature discussed in Chapter 2. For example, therapeutic change for some participants was recognized through gaining perspectives from others who experienced loss as change. Snyder (2002) argued that the therapeutic treatment of clients offers an opportunity for goal achievement and motivation to accept and grow from loss. Researchers also emphasized that gaining hope through therapeutic change can be a critical pathway toward accepting loss and mitigating the difficulties experienced through trauma (Babits, 2001; Feldman & Dreher, 2012; Valle et al., 2006). The focused code psychotherapy is also a commonly discussed topic in peer-reviewed literature. For example, Snyder (1994) argued for five tenants of which hope can be explicitly obtained through therapeutic courses. The process of gaining hope through relational and practiced-based approaches can be obtained for some individuals through therapy, according to Snyder (1994).

Weingarten (2010) also stressed the importance of psychotherapy that focuses on the relational aspects of discussing traumatic experiences of loss. Snyder (1994) and Weingarten (2010) highlighted the importance of psychotherapy and understanding how hope is realized,

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implemented, and relationally obtained through therapeutic practices and perspectives from others who have experienced loss.

The focused code of vacillation between feelings of hope and no hope is aligned with previous research discussing the concepts of despair and hope. According to the work of Menninger (1963) and Snyder (2002), hope and despair occur on a wavelength rather than a singular or disparate course. Menninger (1963) argued that hope is a process or way of thinking, while Snyder (2002) argued that definitions of hope are aligned through an understanding of goal pathways and outcomes. Furthermore, the tenants of Weingarten (2010) correspond with the understanding of how hope can be practiced and obtained through therapeutic resources, goal seeking, and acknowledgment of despair. The juxtaposition between despair and hope is of particular importance to understanding participants’ reported vacillation between feelings of hope and no hope, which is not a singular event but occurs through the recognition of both feelings. Hilliker (2012) emphasized that despair also occurs as a simultaneous feeling or reflection when discussing hope. Participants who experienced severe also experienced the thought of hope in terms of seeking health and recognizing a need for change in their life (Hilliker, 2012; Marcel, 1951; Weingarten, 2010). The reviewed research and the focused codes of this study supply a framework for centering upon the ideology that hope may exist because of despair, which is discussed further when reviewing the following core categories.

The category of hopelessness resulted due to the conceptual relatedness of the focused codes loss of meaning, destructive life changes, resistance to life changes, avoiding relationships, feeling of no control, and lack of hope that the future will be positive. The combined frequency account for the core category of hopelessness was 106.The second core category, hopefulness, resulted through the combined focus codes constructive life changes, making new relationships,

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feelings of control, and hope that the future will be positive. The frequency count for the core category of hopefulness was 104.The third core category, hopelessness acknowledgement, resulted from the combination of accepting loss, learning from the perspective of others, and being open to change. The frequency count for hopelessness acknowledgement was 61. The fourth core category, learning-to-hope, resulted from the combination of vacillation between feelings of control, no control, vacillation between feelings of hope, no hope, becoming open to change, finding meaning and loss, psychotherapy, and learning to cope. The total frequency count for the fourth core category learning-to-hope was 152. Table 5 includes five core categories developed from the 20 codes presented in Table N (above).

Table 5 CGT Analysis, Step 2: From Focused Codes to Core Categories Core categories

Focused codes (from Table N)

Definition

Participa nt count

Frequen cy count

Participants expressed loss of meaning that occurred during traumatic events. Loss of meaning was expressed through difficulty relating to others, emotional distress, and inability to cope with loss.

11

14

Destructive life changes varied from participant to participant. However, destructive life changes often occurred at the initial period of loss and resulted in avoidance, inability to maintain relationships, and self-medicating behaviors.

13

21

Resistance to Participants expressed resistance to life life changes changes after initial loss or trauma. For some participants, resistance to life changes was a result of inability to accept loss and consider the possibility of change.

7

10

Avoiding Avoiding relationships was a common relationships theme amongst participants’ reflections.

8

16

Hopelessne Loss of ss meaning

Destructive life changes

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Core categories

Focused codes (from Table N)

Definition

Participa nt count

Frequen cy count

Participants emphasized feelings of no control in their life after loss. Lack of control led them to struggle with their emotions, relationships, and growth after trauma.

15

29

Lack of hope Participants struggled with hope that the that the future would be positive after each future will be traumatic event or loss. Participants positive struggled with the understanding of how things could potentially improve after a difficult experience or trauma.

11

16

Hopefulnes Constructive Some participants engaged in constructive s life changes life changes to overcome loss or trauma experienced. Such examples included seeking therapy, help from friends, and engaging in practices such as meditation or exercise.

13

24

Making new Seeking new relationships aided in some relationships participants’ ability to adapt to despair.

New relationships included helpful friends, rekindled relationships with family, and potential seeking therapy relationships.

12

19

Feelings of control

Hopefulness was abated by feelings of control by participants. Hopefulness led to feeling of controlling the situation and allowed them to seek help or coping mechanisms that would abate feelings of despair or loss.

13

22

Hope that the Participants reflected hopefulness was also future will be associated with an increased likelihood to positive view the future as positive. Seeking hope also led to a renewed optimism regarding the future of their life.

16

39

Avoiding relationships was often due to the inability to cope with the emotional trauma experienced based upon a specific event, or loss.

Feelings of no control

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Core categories

Focused codes (from Table N)

Definition

Participa nt count

Frequen cy count

Acknowledging hopelessness led participants to an improved ability to accept loss. Participants that were able to accept loss also expressed an acknowledgement of the potential for hope in their life.

12

19

Learning from the perspectives of others

Learning from the perspectives of others was associated with their ability to acknowledge the potential for hope.

Participants that expressed acknowledgement of hopelessness or more likely to feel that the perspectives of others aided in their ability to grow and accept loss.

11

13

Being open to change

Participants discussed the importance of hopelessness and the need to change.

Participants that were more likely to change or be open to change, express their understanding and feeling of hopelessness.

18

29

Vacillation between feelings of control, no control

Participants learned to hope based upon their understanding of a feeling of control and no control which occurred during a traumatic event or loss. As participants recognized a consistent shift or spectrum of emotions, they were more likely to discuss how they learned to hope.

12

17

Vacillation between feelings of hope, no hope

Participants also reflected on feeling both hope and no hope after loss or traumatic event. The feeling of lacking, or having hope, was an integral part of their growth process.

17

37

Becoming open to change

Being open to change allowed participants to learn to hope. A participant that discussed their ability to opening themselves up to potential change also discussed their ability to learn how to hope.

18

29

Finding

For participants that could express or

13

24

Hopelessne Accepting ss loss acknowled gement

Learningto-hope

80

Core categories

Focused codes (from Table N)

Definition

Participa nt count

Frequen cy count

meaning in loss

explore the potential meaning found during loss, they were also more likely to learn how to hope.

14

21

Learning to cope was integral to 15 participants ability to succeed in seeking and learning hope behaviors. Learning how to cope with loss and trauma allowed for participants ability to express a desire to seek help.

24

Psychotherap Seeking psychotherapy was a key element y of participants who were learning or had learned to hope. Hope aided their ability to seek therapy and push themselves towards understanding how therapeutic approaches would aid their own personal growth and healing process.

Learning to cope

The core category, hopelessness, was combined by considering the focus codes of loss of meaning, destructive life changes, resistance to life changes, avoiding relationships, feelings of no control, and lack of hope that the future will be positive. Participants within the core category of hopelessness reflected upon how the process of destructive life changes as well as resisting life changes, can lead to an increased sense of hopelessness. Furthermore, as participants experienced the process of losing meaning based upon loss, hopelessness increased. Other factors related to the core category included avoiding relationships and feeling as if they did not have control of their life. Participants that felt no control of their life were more likely to avoid relationships such as family and friends and express a sense of hopelessness. Alongside a sense of hopelessness was a lack of hope that the future would be positive. Together, these focused codes illustrate the factor of hopelessness which defined many individuals’ journey from despair

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over the loss to hope.

The second core category, hopefulness, is framed by individuals’ constructive life changes, making new relationships, feelings of control, and hope that the future will be positive.

Participants expressed a sense of hopefulness or were more likely to discuss constructive life changes that occurred, such as seeking help or therapeutic changes. Participants were also more likely to review how they made new relationships while seeking aid and expressing a sense of hopefulness. Furthermore, participants that expressed the feeling of control are more likely to feel a sense of hopefulness regarding the future and their ability to change and grow. Participants who perceived potential for a positive future also expressed hopefulness.

The third core category, hopelessness acknowledgment, reflects upon individuals’ acceptance of loss, being open to change, and learning from the perspectives of others.

Participants discussed how accepting loss also led them to acknowledge their hopelessness.

Furthermore, as a sense of hopelessness was acknowledged, it was more likely that they would both be open to change and learn from the perspectives of others. Hopelessness acknowledgment is key to exploring loss and the emotions of despair and hope. The final core category, learningto-hope, includes the focused codes of vacillation between feelings of control, no control, vacillation between feelings of hope, and no hope, becoming open to change, finding meaning and loss, psychotherapy, and learning to cope. Learning-to-hope was not a linear pathway for all participants.

Many participants consistently felt a vacillation between feelings of control and no control in their lives. These feelings of fluctuation between control and no control led them to

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learn how to hope as a means of overcoming these overwhelming feelings. In tandem, participants did not always feel hope but instead felt no hope. The oscillation between these emotions led participants to learn to hope while becoming open to change. Learning-to-hope led participants to learn how to change based on new opportunities, opening to others, and coping.

The process of coping also allowed them to seek psychotherapeutic options. Participants that sought psychotherapeutic options were more likely to learn to hope or to find a sense of personal growth based upon hope. Lastly, finding meaning and loss was the central element of learningto-hope. Participants that found meaning and loss also discussed the process of learning to help, expressing hope, and considering the spectrum of despair to hope.

Developing Theoretical Propositions from the Core Categories Following the categorizing of the focused codes, the core categories were analyzed for patterns (Glaser, 2002). The potential patterns amongst two or more categories were positive, negative, null, and contingent. Table 6 presents the results of the pattern analysis in terms of direct and indirect effects amongst the core categories. The four theoretical propositions are the key findings for the constructivist grounded theory analysis. Each theoretical proposition includes at least two core categories.

Table 6 CGT Analysis, Step 3: From Core Categories to Theoretical Propositions #

Theoretical proposition

Proposed direct effect

1

Despair acknowledgement mediates the relationship between despair and learning-tohope.

Despair to despair acknowledgement.

Learning-to-hope mediates the relationship between despair acknowledgment and hopefulness.

Despair acknowledgement to Learning-tohope.

2

Despair acknowledgement to learning-tohope.

Learning-to-hope to hopefulness.

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Theoretical proposition

Proposed direct effect

3

Learning-to-hope without despair acknowledgement will return one to despair.

Despair to learning-to-hope.

Hopefulness without learning-to-hope will return one to despair acknowledgement.

Despair acknowledgement to hopefulness.

4

Learning-to-hope to despair.

Hopefulness to despair acknowledgement.

Taken together, the theoretical propositions imply that hope and despair are linked via two mechanisms, despair acknowledgement and learning to hope. Consistently throughout the pattern analysis, study participants associated the acknowledgement of despair as being fundamental to learning-to-hope. Hence, theoretical proposition 1: Despair acknowledgement mediates the relationship between despair and learning-to-hope. Though pattern matching is a qualitative analysis technique to detect implicit patterns amongst concepts both within and across qualitative data units (e.g., interview transcripts), these patterns can also be demonstrated explicitly in singular responses by study participants. To illustrate, Ava presented the dichotomy of hope and despair explicitly in terms of the core categories of hopelessness acknowledgement and learning-to-hope: Um, so for me, when considering despair at the lowest like the point that it was like a state of being that seemed constant, even though that might be an irrational belief. It felt constant. Um, and then on the flip side, the hope was like coming from that deep despair. I can’t explain the phenomena that inspired so much hope.

Whether it be, like I said, those resources to get treatment, family support. But I really don’t know how that, like, welled up inside. And I’m not really, like 84

religious or that kind of thing, so I don’t weight it to it that stuff, I just don’t like, it’s a weird phenomenon.

Consistently throughout the pattern analysis, study participants associated learning-tohope and the acknowledgement of despair. Hence, theoretical proposition 2: Learning-to-hope mediates the relationship between despair acknowledgment and hopefulness. Though this theoretical proposition was the result of pattern analysis for the totality of each participant’s responses during the interviews, the proposition was also presented succinctly in singular responses by some of the participants. Barbara presented the mechanisms of despair acknowledgement and learning to hope in terms of participating in Alcoholics Anonymous: If I didn’t have hope that I’d get sober, then I wouldn’t gotten sober. Right. If I if I didn’t know what living life sober was going to be like, I wouldn’t have gotten sober. So short answer here. But like, if there was no hope, then I would continue doing what I was doing. So life is somewhat is somewhat numb and you know, I can go on to it until I die. If I didn’t have hope that I could quit, others quit and my life would get better. Then I went and she’s going to AA today. I wouldn’t keep doing what I’m doing.

Ava presented the same mechanisms, but in terms of the support of family and friends: Um, so for me, when considering despair at the lowest like the point that it was like a state of being that seemed constant, even though that might be an irrational belief. It felt constant. Um, and then on the flip side, the hope was like coming from that deep despair. I can’t explain the phenomena that inspired so much hope.

Whether it be, like I said, those resources to get treatment, family support.

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And Audrey presented the mechanisms of despair acknowledgement and learning to hope in terms of psychotherapy:

If you’re going to therapy you are going for a reason and if you don’t have hope, like, like as if that’s not part of the equation, then what are you doing? Right?

Because in my mind and I think back, it’s like the hope that things can be different is really, or the hope that you can manage something or that the hope that you can, that you can impact something is profoundly a part of the process.

The third and fourth theoretical propositions were not a function of the pattern analysis but rather of the logic of the patterns that elicited propositions 1 and 2. This practice of constructivist grounded theory development the pattern analysis is due diligence insofar that the fundamental nature of theory is that it is falsifiable (Kelle, 2007; Sharma et al., 2022).

Accordingly, it is appropriate to develop theoretical propositions sans patter analysis insofar that they are extensions of the logic of those theoretical propositions elicited by pattern analysis (Kelle, 2007; Sharma et al., 2022). Accordingly, propositions 3 and 4 are addressed in Chapter 5 with a recommendation for an eventual mediation model approach to testing the constructivist grounded theory of hope and despair.

Summary The constructivist grounded theory analysis began with the disaggregation of seven initial codes into 20 focused codes. This process was an iterative one of coding for “within initial code” differences until three iterations of focused coding without the creation of new focused codes or the revision or omission of extant focused codes. The constructivist grounded theory analysis then continued with the aggregation of the 20 focused codes into four core categories. The

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decision rule for combining focused codes into core categories was prior empirical research and theory that demonstrated an association between one or more of the focused codes. The last phase of the constructivist grounded theory analysis was pattern matching for associations among one or more core category. Accordingly, each theoretical proposition addressed two or more of the core categories. The results of this final phase of the process were four theoretical propositions, two based on pattern analysis and two that are due diligence extensions of the logic represented by the propositions elicited by the pattern analysis. Chapter 5 includes discussion of the eventual testing of the constructivist grounded theory of hope and despair – first with replication of the current study in different, purposively-selected contexts with different samples, later with the validation of multi-item scales for larger N mediation analysis.

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CHAPTER V: IMPLICATIONS AND RECOMMENDATIONS Overview Hope plays a tantamount role in patients’ lives and recovery from loss (Allen, 2006; Snyder, 2002; Weingarten, 2010). Individuals who have experienced loss and trauma discuss an emotional spectrum characterized by hope and despair (Snyder, 2002, 2004; Snyder et al., 1999).

Previous researchers emphasized the importance of considering hope and despair when considering traumatic events, loss, and the pursuit of therapy (Snyder, 2002, 2004; Snyder et al., 1999). However, research on hope and despair is discussed as individual characteristics without the presence of a holistic framework for therapeutic treatment. My aim in this study was to develop grounded theory research addressing the roles of despair and hope in the process of psychotherapy, the central theme in the process of change that occurs during psychotherapy, and to review the concept of despair may be a starting point for the installment and cultivation of hope in treatment. Using CGT analysis, I identified initial codes, focused codes, and core categories that represented participants’ relationship with feelings of hope and despair.

In this chapter, I discuss the implications of the identified results. The grounded theory research results are discussed at length. I also review the relevancy of peer-reviewed literature, previously discussed in Chapter 2, in tandem with the results of the CGT analysis. Elements in which the CGT findings differed or conferred with previous research are discussed in the current chapter. I provide recommendations toward theory and practice based on the findings of this study. Chapter 5 is concluded with a discussion of the most salient findings of the CGT analysis and the relationship with the theoretical understanding of hope and despair when considering the concepts of loss and trauma.

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Interpretation of Findings The first step of CGT analysis revealed initial codes, of which twenty focus codes were derived based on the recommendations of Saldana (2016) for CGT analysis using textual data.

Throughout chapter 4, the research reviewed these codes, using relevant tables and participants’ quotes to deepen the thick description. The initial codes included accepting loss, accepting change, learning from the perspectives of others who experience loss as change, learning to cope, psychotherapy, the meaning of loss, the loss of meaning, constructive life changes, being open to change, destructive life changes, resistance to life changes and no life changes, avoiding relationships, maintaining relationships, making new relationships, feelings of no control, feelings of control, vacillation between feelings of control and no control, the hope of the future will be positive, lack of hope in the future will be positive, and vacillation between the feelings of hope and no hope. Following the development of focused codes, I identified a series of core categories based on aggregated similar conceptual values. The core categories led to the development of the theoretical propositions and the CGT theory of hope and despair.

Presuming that the findings of the current study eventually will be replicated with constructivist grounded theory studies for different contexts and samples and presuming that eventual reliability and validity tests elicit reliable and valid multi-item scales for the core categories found in the current study, Figure 13 is presented to depict the mediation model for testing the theoretical propositions of the current study. The solid lines represent theoretical propositions 1 and 2, the dashed lines theoretical propositions 3 and 4.

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Figure 13 Theory of Hope and Despair

Note. Researcher developed The first theoretical proposition identified refers to despair acknowledgment as a mediator with the relationship between despair and learning to hope. Based upon this first theoretical proposition, I proposed two direct effects. Firstly, despair to despair acknowledgment.

In this process, participants who experienced despair due to loss or trauma were required to acknowledge the despair. Secondarily, despair acknowledgment led to learning to hope as a direct effect. An indirect effect of the first theoretical proposition was despair to learning to hope. Resultantly, participants who experienced despair to learn to hope were able to conceptualize the experiences of loss and trauma by recognizing two key emotions, despair, and hope.

Research from Snyder et al. (1999) identified the importance of hope and despair in terms of the pursuit of therapy by clients who have experienced trauma or loss. Yet, previous research lacked a theoretical consideration of the process of hope and despair in the client’s pursuit of well-being. Researchers also acknowledged the importance of understanding hope’s role in recovery. In contrast, others have emphasized the need for a cohesive consideration of hope and despair within the treatment framework for the betterment of patients through therapeutic 90

treatment (Hammer et al., 2009; Lohne, 2008; McLean, 2011). Furthermore, research in the past primarily focused on the role of hope when considering factors such as chronic illness or other physical ailments illness (Hammer et al., 2009; Lohne, 2008; McLean, 2011). While hope is often discussed within therapeutic treatment settings, the understanding of the cohesive nature of hope alongside despair when considering therapeutic treatments, progress, and the pursuit of therapy was unknown before the development of the current theory.

In consideration of previous literature, the first theoretical proposition of the hope and despair theory offered the opportunity to understand the role that despair, and hope played together in the therapeutic process. Most importantly, the first theoretical proposition identifies the critical role of despair in terms of mediating a relationship between learning to hope. Thus, the current study expands upon previous literature and offers a novel approach to framing the concepts of hope and despair by understanding that despair acknowledgment mediates the relationship between clients’ experiences of learning to hope. If patients cannot acknowledge despair, they will most likely find themselves returning to despair without hope.

The second theoretical proposition argues that learning to hope mediates the relationship between despair acknowledgment and hopefulness. The first direct effect of the second theoretical proposition was that despair acknowledgment led to individuals’ ability to learn to hope. The second direct effect was learning to hope to hopefulness. The indirect effect of the second theoretical proposition was despair acknowledgment leads to hopefulness. In this theoretical proposition, the knowledge obtained from participants and the CGT analysis illustrated that individuals must first acknowledge their despair. After acknowledging despair, they can learn to hope. Learning to hope ultimately leads individuals to feelings of hopefulness.

Overall, despair acknowledgment can lead to hopefulness.

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Researchers in the past recognized that hope significantly influences patient outcomes.

However, the role of hope was based upon its individual value and not in a relationship with despair or as a mediating factor (Bernardo, 2010; Ong et al., 2006). Furthermore, hope in terms of treatment has often been considered more as an operational definition (Allen, 2005, 2006; Weingarten, 2010) which may open opportunities for renewed goal obtainment and treatment outcomes (Snyder, 1994) but have yet to consider the role of a cohesive framework between hope and despair in terms of patient outcomes and pursuit of therapy. In the second theoretical proposition, I identify what help mediates the relationship between despair acknowledgment and hopefulness.

The second theoretical proposition recognizes hope’s role in mediating the relationship between despair acknowledgment and hopefulness. Furthermore, the second theoretical proposition illustrates the role of despair acknowledgment, hopefulness, and the importance of the patient’s ability to learn to hope in recovery. The second theoretical proposition supplies added information to empirical literature and social work researchers by identifying the crucial role of hope. Thus, participants must first acknowledge despair to gain hopefulness. The second theoretical proposition expands upon previous empirical literature and demonstrates added information for practitioners within social work and other therapeutic avenues.

The third theoretical proposition recognizes that participants that learned hope without acknowledging despair will ultimately return to feelings of despair. The direct effect is despair leads to learning hope. Learning to hope can lead to despair. This theoretical proposition indicates that participants attempting to merge feelings of despair directly to hope that acknowledgment of despair may experience less efficacious outcomes regarding growth and therapeutic recovery. The final theoretical proposition indicates that participants that learn to

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hope without despair acknowledgment will ultimately return to the first step, despair. The final proposition leads us to the final stage of the cyclical nature of despair and hope. In previous studies, hope was considered essential and advantageous to individuals’ recovery (Weingarten, 2010). Both hope and despair are discussed as disparate concepts that may arise during recovery but are not considered within a conceptual framework. The current study provides an opportunity to understand the relationship that occurs between hope and despair, the procedures of these two conceptual values that may lead to more effective therapeutic support, and a new framework for aiding psychotherapists and helping professionals (Byrne & McCarthy, 2007; Hubble et al., 1999; Lambert, 2004; McLean, 2011), which was absent in the literature before this dissertation.

The final theoretical proposition indicates that individuals that express hopefulness without learning to hope will ultimately return to despair acknowledgment. The first direct effect of this proposition is that despair acknowledgment is critical to hopefulness. However, hopefulness will always lead to despair and acknowledgment if individuals have yet to learn to hope. Thus, further emphasizing the importance and circular nature of the CGT theory of hope and despair in which individuals must first acknowledge despair, learn to hope, and gain hopefulness. Together, the final theoretical proposition completes the core constructs of the theory of hope and despair and emphasizes the importance of representing despair and hope within a metaphorically symbolic relationship to growth and healing for patients who have experienced loss and trauma. A cohesive consideration of the theory of hope and despair is discussed next.

Towards a Theory of Hope and Despair Propositions developed with a constructivist grounded theory does not a theory make (Glaser, 2002; Suddaby, 2006). What is required to transition from the results of a constructivist

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grounded theory analysis to falsifiable theory in any field of scientific inquiry is replication of the constructivist grounded theory analysis for different contexts and samples (Bamberger & Pratt, 2010; Glaser, 2002; Suddaby, 2006). For constructivist grounded theory to transition to theory by way of replication in different contexts with different samples and testing with largerN samples and thusly with more efficient forms of data collection and analysis, it must be parsimonious (Glaser, 2002).

As for replication of the current study in different contexts with different samples, the first step will be to replicate this study in different contexts with different samples. In research design terms, this means transitioning from theoretical sampling to purposive sampling (Gentles et al., 2015). The reason for the shift to purposive sampling is that the core categories and theoretical propositions for the current study must demonstrate reliability across different situations and persons (Gentles et al., 2015). However, doing so is not to imply a transition from a constructivist grounded theory approach to a theory-drive, qualitative mode of inquiry, e.g., phenomenology of one ilk or another. To establish the propositions developed from the current analysis, these same or similar theoretical propositions must be elicited reliably from pattern analyses of interview transcripts for different samples in different contexts.

The purposive selection criteria for potential replication of the theoretical propositions elicited by the current study must facilitate “within type” replication. The sample for the current study included persons who experienced despair due to different life experiences, e.g., loss of a sibling, substance use disorder, et cetera. This will be a challenging purposive sample selection criterion to implement validly and reliably because some of the participants in the current study experienced despair due to multiple such experiences (Andrade, 2021; Campbell et al., 2020). A second (series of) purposive sampling approach is to facilitate “within type” replication of the

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current study using demographic categories. An alternative proxy is to purposively select from support groups focused on the development of communities of individuals who suffer from despair due to the same life event or experience, e.g., substance use disorder, spousal bereavement, war veteran status. Another approach to purposive sample selection for the replication of the current study is demographic-based purposive sample selection. Though more readily developed with reliability and validity, such purposive sample selection criteria typically are not conducive to establishing theory from grounded theory per, save exceptions wherein one or more of the core categories from the initial constructivist grounded theory analysis were conceptually related to one or more demographic category (Etikan & Bala, 2017).

Once the current study design is replicated for different samples in different contexts, the results of these future studies would have to, over time, reliably demonstrate convergent and divergent validity for the same (or similar) core categories. The replication process should be iterative until such is the case (Hak & Dul, 2009). Once there are reliable results across multiple contexts and samples for the constructivist theory of hope and despair, then the theoretical propositions from this body of study may be tested empirically for internal validity first, then for both internal and external validity, again by way of a series of replicative, but this time quantitative, studies (Choy, 2014). Preceding such study must be the development of a multiitem scale for each of the core categories: despair, despair acknowledgement, learning to hope, and hopefulness. The scales must be tested for reliability with exploratory then confirmatory factor analyses. They must be tested for convergent and divergent validity by way of the appropriate statistical tests (Trochim & Donnelly, 2001).

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There are two mediation models depicted in Figures 3 and 4, each with a focal hypothesis. The first mediation model has despair as an independent variable and learning-tohope as the dependent variable. The mediating variable, despair acknowledgement, would be the focus of the eventual hypothesis test using the appropriate inferential statistical techniques, per the results of preliminary analysis of the nature of the data for each variable. The first hypothesis (H1) in Figure 3 would be that despair acknowledgement mediates the predictive relationship between despair and learning-to-hope, all else equal. The second mediation model has despair acknowledgement as an independent variable and hopefulness as the dependent variable. The mediating variable, learning-to-hope, would be the focus of the eventual hypothesis test using the appropriate inferential statistical techniques, per the results of preliminary analysis of the nature of the data for each variable. The second hypothesis (H2) in Figure 4 would be that learning-to-hope mediates the predictive relationship between despair acknowledgement and hopefulness, all else equal.

These hypotheses are motivated not just by the presumption of replication of the current study for different samples in different contexts, but also per the extant literature. In the pursuit of recovery, participants must acknowledge despair and learn to hope. First, acknowledging despair mediates the relationship between despair and learning to hope. Secondly, learning to hope mediates the relationship between despair acknowledgment and hopefulness. Third, individuals that learn to hope without acknowledging despair will ultimately return to the phase of despair, which interrupts the growth and healing recovery process. Finally, individuals that experience hopefulness without learning to hope will also return to the process of despair acknowledgment. Thus, indicating the significance of acknowledging despair and learning to hope.

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I assumed that hope could not be achieved without acknowledging the relationship of despair. The knowledge obtained from participants and the CGT analysis performed revealed the truth of this research assumption. Furthermore, I found that despair is not a purely dialectical relationship with hope (Flaskas, 2007; Flaskas et al., 2007; McLean, 2011) but is systematically related during the healing process for patients who have experienced trauma or loss.

Furthermore, through the perceptions of participants and the theoretical propositions identified through the GT analysis, I illustrated that while everyone may ultimately define hope uniquely, the nature of acknowledging despair to learning to hope is of critical importance to an effective healing process for the patient. The theory of hope and despair may give researchers and practitioners a renewed understanding of hope and despair by considering how to treat patients undergoing loss and trauma. The constructivist-based approach to developing this theory allowed for consideration of the participant’s experiences. The organizing theory may ideally supply a framework that aids clinicians and supports clients’ well-being and growth.

Research from Allen (2006) and Groopman (2004) found that hope is often considered alongside the constructs of despair but has yet to be genuinely considered within a holistic framework that may define outcomes for patients experiencing each of these emotions. The development of the CGT theory of hope and despair addressed the purpose of this study and allowed for potential positive outcomes for patients’ engagement in psychotherapy. Seminal research from Menniger (1963) plays a critical role in patients’ therapy and pursuit. Furthermore, Hubble et al. (1999) argued that understanding the role of hope outside of limited definition may supply information that Parkers therapeutic technique changes the field of psychotherapy. Based upon the previous research reviewed throughout this dissertation, the CGT theory of hope and despair supplies a framework that acknowledges despair, hope, and the mediating relationship

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which plays a key role in patients’ growth and recovery from loss and trauma. The identified theoretical framework provides an opportunity to understand hope and despair’s role in treatment. Furthermore, the framework allows for a renewed understanding regarding the role of hope, despair, and recovery from loss and trauma within a cohesive narrative. Ultimately, practitioners and researchers may find the theory of hope and despair useful for social work and helping professionals, as discussed in the following recommendations.

Limitations and Recommendations In the following section, I discuss the recommendations for future research and future practice and presents the limitations noted within the study. The recommendations are based on the constraints of the current study. Additionally, I review potential applications of the theory of hope and despair for practitioners. First, the recommendations for future research, which include expanding geographic context, ethnicity, and population examinations, are discussed. The limitations are discussed and provide a basis for future research and practice.

Limitations of the Study Several limitations must be noted that include the limitations of grounded theory. As this theory relies on an iterative recruiting process through theoretical sampling, the evolutions, and iterations of each new round of interviews required reliable participants to continue participation over a long period. Further, this limitation is based on the selected geographical context and population, which could be considered too limiting, and thus a need for more reliable and eligible participants was found.

There was a noted limitation with the population, as diversity within the participants needed to be considered. Since cultural differences play a role in the experiences of hope and despair during recovery from trauma and loss, adding participants from different cultural

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backgrounds should be considered. As a limitation, the lack of cultural diversity within the sample created a shortage of expanded experiences within the data collected.

Another limitation was considered in the timeliness of data collection. With grounded theory, the continuous collection of data requires the flexibility of both researcher and participants. Several rounds of collection are necessary to collect the required data. Further, it is essential to reach theoretical saturation, and again, several rounds of data collection must happen, so scheduling is considered imperative.

Data analysis presents a fourth limitation. The analysis for this research was challenging in keeping track of the numerous patterns and comparisons. A large amount of data was collected and organized and categorizing while managing it proved difficult. This limitation was fundamental in determining the reliability of the data and the result.

Recommendations for Future Research The first recommendation for research is to expand upon the current theory using various geographical contexts and populations. The current research was developed through a diverse set of individuals of differing complex trauma and treatments. However, future researchers need to consider the theory of hope and despair through differing patient populations to understand the potential variations in this theory among varying contexts. The second recommendation for researchers is to implement the theory of hope and despair among differing cultural contexts.

Cultural differences may play a role in the experiences of hope and despair during your recovery from trauma and loss. Finally, researchers are recommended to expand upon the theory of hope and despair and differing cultural sets to understand how variations in recovery from loss potentially affect or mediate the relationship between despair and hope.

A third recommendation for future researchers is to consider the theory of hope and

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despair amongst different ethnic populations. Researchers in the past have acknowledged that ethnicity plays a role in the acceptance of loss, trauma response, and the stigma of seeking therapeutic treatment. As such, an inclusive theory of hope and despair may be further developed by considering ethnic differences and the previous recommendations for reviewing cultural differences and complex trauma amongst differing geographical contexts. Employment review of the previous recommendations for future research may further expand upon the theory of hope and despair and allow the treatment context to be applied to various settings for the best efficacious treatment of patients regardless of background.

Recommendations for Future Practice The proposed study allows for a framework for understanding the role of hope and despair in therapeutic treatment amongst patients who have experienced trauma and loss. From a theoretical perspective, the information may be utilized by therapists working within the field of social work. Perspectives obtained from the CGT theory of hope and despair may be used by social workers to further understand how patients can overcome experiences of trauma and loss by recognizing the cyclical nature of hope, despair, and growth through learning to hope.

Practitioners are recommended to implement the theory of hope and despair to develop new techniques that can foster effective outcomes for patients who have experienced trauma and loss.

The hope and despair theory may offer new perspectives to practitioners and social workers who offer opportunities for clients to heal undergone difficult scenarios.

The second recommendation for future practice is to implement the theory of hope and despair while considering which phase of recovery participants present during therapeutic seeking. For example, participants who have most recently experienced trauma or loss may find themselves at distinct phases within the theory of hope and despair. Thus, it is recommended for

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practitioners to closely consider which phase of recovery participants are experiencing. In addition, understanding if participants have acknowledged despair, learned to hope, or have attempted to learn to hope without acknowledging despair is critical to fully implementing the theory of hope, despair, and practice. Researchers should consider these factors when understanding how to best implement the theory of hope and despair.

Conclusion Hope is often defined as a fleeting emotion that patients may use to gain recovery from potential loss. Despair, though sometimes discussed within the continuum of hope, is restricted to an experience initiated during the first stages of recovery. The CGT theory of hope and despair was identified through participants’ reflections on trauma and loss. The final proposed theory allows a potential conceptual framework for which researchers may discuss and acknowledge the role that despair and hope play in a treatment course. Furthermore, the research theory of hope and despair developed a nuanced consideration of acknowledging despair, learning to hope, and experiencing hopefulness. Individuals that attempt to bypass acknowledgment of despair, or fail to learn to hope, will often find themselves returning to despair. Acknowledgment of this relationship between hope and despair is critical to the improved support of patient outcomes in therapy and growth through loss.

The theory of hope and despair potentially offers social work and helping professions a potential framework for understanding a productive pathway to obtain treatment. In this chapter, I emphasize the potential recommendations for research and practice. Future researchers are recommended to expand upon the theory of hope and despair by examining populations who have experienced loss and trauma of diverse ethnicity, culture, and geographic context. Finally, practitioners are recommended to implement the theory of hope and despair to benefit the

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client’s well-being and support therapeutic recovery from trauma and loss.

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Appendix A: Flyer Promoting the Research Study

VOLUNTEERS NEEDED FOR RESEARCH STUDY ABOUT HOPE & DESPAIR

● Have you received therapy in the past? ● Do you have personal insights about hope and despair? ● Are you over the age of 18?

If you answered Yes to these questions, you may be eligible to participate in a study for people who have stories to tell about hope and despair.

The purpose of this study is to research and find out what the experience and meaning of hope and despair is for people who have completed psychotherapy.

Confidentiality is assured.

This study will be carried out by Robert Hilliker LCSW, LCDC (Principal Researcher), supervised by James Lampe, PhD, LCSW (Dissertation Chair), and under the auspices of the Institute for Clinical Social Work, 401 S. State St., Ste. 822, Chicago, IL. Please contact Robert Hilliker at rhilliker@icsw.edu or (713) 470-9878 X 701 for more information.

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Appendix B: Informed Consent

113

114

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Appendix C: IRB Approval

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Appendix D: Demographic Questionnaire 1. What is your age?

2. What is your gender?

3. What is your race/ethnicity?

4. What is your place of residence?

5. What is an approximate number of therapy sessions you have attended?

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Appendix E: Interview Guide for Research Study Initial Open-Ended Questions 1. How would you define hope in your own words?

2. How would define despair in your own words 3. Tell me about a time, if any, where you felt despair in your life 4. What contributed to this sense of despair?

5. Do you think there is any difference between hopelessness and despair?

6. Tell me about a time, if any, where you felt hopeful in your life?

7. What contributed to this sense of hope?

Intermediate Questions 1. What, if anything, did you know about [hope & despair]?

2. Who, if anyone, was involved in your experiences regarding [hope & despair]?

3. Tell me about how you learned to handle despair?

4. What positive changes, if any, would you attribute to hope in your life?

5. Could you describe a typical day when you are feeling despair? Now what about a day when you are feeling hopeful?

6. Tell me how you would describe the person you are now. What have been the main contributors to this?

7. Could you tell me the most important lessons you learned through experiencing despair?

Ending Questions 1. What do you think are the most important things to consider when contemplating [hope & despair]?

2. In discussing [hope & despair] in this interview do you have any new insights about these concepts?

3. After having experienced despair, what advice would you give to someone is currently experiencing this feeling?

4. Is there anything else you think I should know to understand [hope & despair] better?

5. Is there anything you would like to ask me?

Questions Specific to Psychotherapy Experiences (2nd interview): 1. What role has hope played, if any, in your seeking help? Or in the course of your therapeutic process?

2. What role has despair played, if any, in your seeking help? Or in the course of your therapeutic process?

This interview format was adapted from Charmaz, K. (2006, pgs. 30-31). Constructing grounded theory. London: Sage Publications.

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Appendix F: Grounded Theory Process The process map for a constructivist grounded theory process typically involves the following steps: 1. Data collection: The researcher collects data through various methods, such as interviews, observation, and documents.

2. Initial coding: The researcher reads through the data and identifies initial codes or concepts that capture the essence of the data.

3. Memoing: The researcher writes reflective memos about their thoughts, ideas, and interpretations of the data.

4. Focused coding: The researcher identifies the most significant codes and uses them to guide further data collection and analysis.

5. Theoretical sampling: The researcher selects additional data sources based on the emerging theory.

6. Theoretical coding: The researcher identifies the core categories or concepts and explores their relationships.

7. Memoing and memo analysis: The researcher continues to write reflective memos and analyzes them for emerging themes and patterns.

8. Theoretical saturation: The researcher continues to collect and analyze data until theoretical saturation is reached, meaning that no new categories or concepts are emerging.

9. Theoretical integration: The researcher integrates the categories and concepts into a coherent theory.

10. Writing: The researcher writes up the theory and findings, including quotes and examples to support the theory.

11. Review: The researcher seeks feedback and review from others, including participants, colleagues, and peers.

12. Refinement: The researcher refines the theory and findings based on feedback and review.

13. Dissemination: The researcher shares the theory and findings through publications, presentations, and other means.

This was adapted from Charmaz (2006, p. 11). Constructing grounded theory. London: Sage Publications.

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Appendix G: Screening Interview Script “Thank you for your interest in my research. Again, my name is Robert Hilliker and I’m a doctoral student conducting research through the Institute for Clinical Social Work in Chicago, Illinois. There are a few things I need to confirm before we move forward. I’m looking to better understand the concepts of hope and despair among people with former therapy experience. I also have to confirm a few things about you to make sure you qualify for my study. Do you mind if I ask you a few questions now?”

Screening Questions 1. How old are you? _______ years old (if 17 or younger than disqualify) 2. How long ago was your last therapy session? (must be at least 6 months ago from present date but not more than 5 years) ___________________ 3. Can you remember what type of therapy you had? (CBT, psychodynamic psychotherapy?) Or what were you getting therapy for? (would exclude anyone sounding like they were getting treatment for schizophrenia/schizoaffective, etc.): ________________________________________________________________________ ________________________________________________________________________ 4. How long were you in therapy? _________________ 5. Can you tell me why the therapy ended? ________________________________________________________________________ ________________________________________________________________________ 6. Can you remember if you were prescribed any medications during your therapy?

[Yes/No] If Yes, what type(s): ________________________________________________________________________ ________________________________________________________________________ 7. Are you currently taking any medications? [Yes/No] If Yes, what type(s): ________________________________________________________________________ ________________________________________________________________________ 8. Do you have a personal experience with despair? [Yes/No] If Yes, can you talk about it?

If No, disqualify 9. Do you have a personal experience with hope? [Yes/No] If Yes, can you talk about it? If No, disqualify 10. Is there anything that you can think of that might deter you from participating or providing me with honest answers? [Yes/No] If Yes, possibly disqualify 11. Would you be willing to be interviewed twice for up to 60 minutes? [Yes/No] If No, disqualify 12. Are you okay with being compensated $20 for each of the one-hour interviews? [Yes/No] If No, disqualify 13. Are you okay with being audiotaped? [Yes/No] If No, disqualify

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Appendix H: List of Tables & Figures Table 7 The Two Major Types of Goals in Hope Theory Type 1—Positive goal outcome A. Reaching for the first time.

B. Sustaining present goal outcome C. Increasing that which already has been initiated Type 2—Negative goal outcome

A. Deterring so that it never appears.

B. Deterring so that its appearance is delayed

Table 8 Implicit and Explicit Operative Processes and Their Respective Emphases in Hope Theory as Compared to Selected Positive Psychology Theories Processes Theory

Hope Attributions Outcome value Goal thinking Agency thinking Pathways thinking Emotions

Optimism: Seligman (1991)

Optimism: Scheier & Carver (1985)

+++ + +++

++ + + ++ +++

+++

++

SelfEfficacy

SelfEsteem

ProblemSolving

+

++

++

+++ +++ + +

+++ ++ + +++

+++ +++ + +

Table 9 Study Sample Characteristics Age

Gender

Race/Ethnicity

Place of Residence

30

Female

Asian; Indian Origin

Chicago, IL

25

Female

White

Chicago, IL

40

Female

White

Houston, TX 121

Age

Gender

Race/Ethnicity

Place of Residence

28

Female

N/A

N/A

70

Female

White

Valperaso, IN

51

Female

White/Scandinavian

Ukon, OK

61

Male

White

Houston, TX

37

Female

White

Cypress, TX

34

Male

Mexican/White

Houston, TX

45

N/A

N/A

N/A

53

Female

White

Houston, TX

30

Female

N/A

N/A

53

Female

N/A

N/A

28

Female

White

Houston, TX

54

N/A

N/A

Houston, TX

33

Male

Mixed – other – Asian

Houston, TX

54

Female

White

Houston, TX

32

Male

White

Houston, TX

39

Female

Latina

Houston, TX

55

N/A

N/A

Chicago, IL

Table 10 CGT Analysis, Step 1: From Initial Codes to Focused Codes Initial code

Focused codes

Example direct quotation

Frequenc y count

Gaining perspective

Accepting loss

“I saw it...where this wasn’t gonna work anymore, like it wasn’t working, it wasn’t gonna work, there was no way I could make it work, so you know everything since that shift away from knowing that it couldn’t’ be that way was hopeful.” (Audrey 10)

19

122

Initial code

Becoming resilient

Ascribing meaning

Making life changes

Focused codes

Example direct quotation

Frequenc y count

Accepting change

“Strangely, I think, ya know just seeing that it’s happening, I feel like I’ve run into more trouble and had more problems when I didn’t actually understand how upset I was and give myself permission kind of to be really upset and even recognize it’s happening.” (April 1)

19

Learning from the perspectives of others who experienced loss as change

“I was seeing people that had similar backstories to me that now were in a professional setting and I was like ‘huh, so I’m not like always gonna be like this, there can be something changing.”

(Ava 18)

13

Learning to cope

“...I’m starting to, to learn how to cope with it.

And, how to handle it...” (Barry 13)

24

Psychotherap y

“...the therapist I work with provided a sense of, I think, empowerment for me...” (Percy 16).

21

The meaning of loss

“...it seems true that a lot of that is despair, loss, loss of a job, a spouse, a career, a child, something that moves us...” (Hanley 20).

24

The loss of meaning

“...like paralyzed is the w- that’s where, like I – fearful, um, you know inept...like those are the things I feel when I feel despair is like that I have completely, I can’t move...” (Audrey 10).

14

Constructive life changes

“I’m in the midst of following my own passion to social work and listening to my gut and truly listening to my own sense of direction, my own internal compass, and I’m kind of being true to myself.” (April 1).

24

Being open to change

“Just recognizing that there is so much more than in the here and now, there’s so much more than what my eyes can see....” (Tammy 19).

29

Destructive life changes

“The primary coping mechanism for all this stuff was isolation and substances, helped me with like what I thought was reducing the level of despair I guess” (Ava 18).

21

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Initial code

Relationships

Sense of control

Outlook

Focused codes

Example direct quotation

Frequenc y count

Resistance to life changes/no life changes

“...I really went through like a good week where I was just devastated. And I was just angry, and I was just pissed off. And…I really withdrew.”

(Stephanie 18).

10

Avoiding relationships

“...I just um, felt sad um, and was unavailable to my husband and kid...” (Tammy 19).

16

Maintaining relationships

“I’m so lucky that I, I had family that was encouraging, they, they did many things wrong.

The one thing that they did right was let me know that I, I am loved. And I think that really fucking mattered.” (April 1).

9

Making new relationships

“...get help like reach out to somebody. Um, connect to another human being. You know it doesn’t have to be a therapist, you know for me it wasn’t that wasn’t the first person but, but somebody...” (Audrey 10).

19

Feelings of no control

“a feeling of the floor dropping out from under you, one being stuck in it, with, with a, a lack of momentum to move forward or even backward.”

(April 1).

29

Feelings of control

“...I think it was a sense that um, (laughs) and this is gonna sound terrible, that I could control the situation? Or, or maybe, maybe the word isn’t that I could control the situation, but I had more agency.” (Percy 16).

21

Vacillation between feelings of control, no control

“I have the power to move this in a way that won’t be so painful or will bring relief, but you don’t even feel like, you don’t know what to do so it’s sorta that sense of loss of agency.”

(Audrey 10).

17

Hope that the future will be positive

“You know that I’m not stuck in this loneliness, despair situation for my whole life. That there is something out there that I, that will get me better. You know and having that hope that things will be better.” (Barbara 14).

39

Lack of hope that the

“I remember just sitting in the driveway kind of covered in humidity, and feeling what I still

16

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Initial code

Focused codes

Example direct quotation

Frequenc y count

future will be positive

think today was, of sitting at, the edge of the pit of depression. I, I felt like I was in a really dangerous place, psychologically” (April 1).

Vacillation between feelings of hope, no hope

“...Despair and hopelessness would be kind of on the same spectrum or like on one end of the spectrum opposite of hope...” (Percy 16).

37

Table 11 CGT Analysis, Step 2: From Focused Codes to Core Categories Core categories

Focused codes (from Table N)

Definition

Participa nt count

Frequen cy count

Participants expressed loss of meaning that occurred during traumatic events. Loss of meaning was expressed through difficulty relating to others, emotional distress, and inability to cope with loss.

11

14

Destructive life changes varied from participant to participant. However, destructive life changes often occurred at the initial period of loss and resulted in avoidance, inability to maintain relationships, and self-medicating behaviors.

13

21

Resistance to Participants expressed resistance to life life changes changes after initial loss or trauma. For some participants, resistance to life changes was a result of inability to accept loss and consider the possibility of change.

7

10

Avoiding Avoiding relationships was a common relationships theme amongst participants’ reflections.

Avoiding relationships was often due to the inability to cope with the emotional trauma experienced based upon a specific event, or loss.

8

16

Hopelessne Loss of ss meaning

Destructive life changes

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Core categories

Focused codes (from Table N)

Definition

Participa nt count

Frequen cy count

Feelings of no control

Participants emphasized feelings of no control in their life after loss. Lack of control led them to struggle with their emotions, relationships, and growth after trauma.

15

29

Lack of hope Participants struggled with hope that the that the future would be positive after each future will be traumatic event or loss. Participants positive struggled with the understanding of how things could potentially improve after a difficult experience or trauma.

11

16

Hopefulnes Constructive Some participants engaged in constructive s life changes life changes to overcome loss or trauma experienced. Such examples included seeking therapy, help from friends, and engaging in practices such as meditation or exercise.

13

24

Making new Seeking new relationships aided in some relationships participants’ ability to adapt to despair.

New relationships included helpful friends, rekindled relationships with family, and potential seeking therapy relationships.

12

19

Feelings of control

Hopefulness was abated by feelings of control by participants. Hopefulness led to feeling of controlling the situation and allowed them to seek help or coping mechanisms that would abate feelings of despair or loss.

13

22

Hope that the Participants reflected hopefulness was also future will be associated with an increased likelihood to positive view the future as positive. Seeking hope also led to a renewed optimism regarding the future of their life.

16

39

12

19

Hopelessne Accepting ss loss acknowled gement

Acknowledging hopelessness led participants to an improved ability to accept loss. Participants that were able to accept loss also expressed an acknowledgement of the potential for hope

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Core categories

Focused codes (from Table N)

Definition

Participa nt count

Frequen cy count

in their life.

Learningto-hope

Learning from the perspectives of others

Learning from the perspectives of others was associated with their ability to acknowledge the potential for hope.

Participants that expressed acknowledgement of hopelessness or more likely to feel that the perspectives of others aided in their ability to grow and accept loss.

11

13

Being open to change

Participants discussed the importance of hopelessness and the need to change.

Participants that were more likely to change or be open to change, express their understanding and feeling of hopelessness.

18

29

Vacillation between feelings of control, no control

Participants learned to hope based upon their understanding of a feeling of control and no control which occurred during a traumatic event or loss. As participants recognized a consistent shift or spectrum of emotions, they were more likely to discuss how they learned to hope.

12

17

Vacillation between feelings of hope, no hope

Participants also reflected on feeling both hope and no hope after loss or traumatic event. The feeling of lacking, or having hope, was an integral part of their growth process.

17

37

Becoming open to change

Being open to change allowed participants to learn to hope. A participant that discussed their ability to opening themselves up to potential change also discussed their ability to learn how to hope.

18

29

Finding meaning in loss

For participants that could express or explore the potential meaning found during loss, they were also more likely to learn how to hope.

13

24

Psychotherap Seeking psychotherapy was a key element

14

21 127

Core categories

Focused codes (from Table N)

Definition

Participa nt count

y

of participants who were learning or had learned to hope. Hope aided their ability to seek therapy and push themselves towards understanding how therapeutic approaches would aid their own personal growth and healing process.

Learning to cope

Learning to cope was integral to 15 participants ability to succeed in seeking and learning hope behaviors. Learning how to cope with loss and trauma allowed for participants ability to express a desire to seek help.

Frequen cy count

24

Table 12 CGT Analysis, Step 3: From Core Categories to Theoretical Propositions #

Theoretical proposition

Proposed direct effect

1

Despair acknowledgement mediates the relationship between despair and learning-tohope.

Despair to despair acknowledgement.

Learning-to-hope mediates the relationship between despair acknowledgment and hopefulness.

Despair acknowledgement to Learning-tohope.

Learning-to-hope without despair acknowledgement will return one to despair.

Despair to learning-to-hope.

Hopefulness without learning-to-hope will return one to despair acknowledgement.

Despair acknowledgement to hopefulness.

2

3

4

Despair acknowledgement to learning-tohope.

Learning-to-hope to hopefulness.

Learning-to-hope to despair.

Hopefulness to despair acknowledgement.

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Figure 14 Quadrants for Psychoanalytic Literature Defining and Usage of Hope Defensive Uses

Adaptive Uses

(1-person psychology)

(1-person psychology)

Defensive Uses

Adaptive Uses

(2-person psychology)

(2-Person psychology)

Figure 15 Data Generation

129

Figure 16 Definition of Despair

Note. Researcher developed.

Figure 17 Definition of Hope

Note. Researcher developed

130

Figure 18 Coding Memo 1 Coding Memo 1 While exploring the perceptions of participants I found myself commonly returning to how individuals reflected upon feelings of hopelessness versus helplessness when defining despair. Participants seem to return to defining despair while also defining hopelessness, and vice versa. Participants also considered emotional reflections as depression or feeling anxious. Participants also found themselves considering factors such as how indecision led to the furthered sense of helplessness and hopelessness, which even exasperated their feelings of despair.

Figure 19 Coding Memo 2

Figure 20 Coding Memo 3 Coding Memo 3 During my consideration of how participants discussed their experiences of despair, I also wondered what contributors of despair play a role in coping had, controlling, and accepting loss. Participants discussed various changes that occurred while they coped and experienced despair. Career changes were also a critical factor that both encouraged hope as a contributor and led to experiencing hope despite despair.

Figure 21 Coding Memo 4

131

Figure 22 Coding Memo 5

Figure 23 Coding Memo 6 Coding Memo 6 Hope also helped them to realize their need to change, adapt, and grow regardless of trauma and loss. Initiating hope was both based upon therapy as well as the hope that therapy would help them. When they were in therapy, participants hoped that there would be a role of the treatment in terms of improving their life. Help also aided in the initiation of seeking help. However, all participants who expressed hopelessness were less likely to seek or initiate treatment. .

Figure 24 Coding Memo 7

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Figure 25 Coding Memo 8

Figure 26 Theory of Hope and Despair

Note. Researcher developed.

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Appendix I: Excel Excerpt Image of Coding Notes

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135

136

137

138

139

140

141

142

143

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Appendix J: Field & Coding Notes

ROBERT’S CODING NOTES SELF-REMINDERS 1. When participants reported depression (and addiction for that matter) as an experience of despair, I coded this into Health because there was no other place for it.

2. Move “other definitions of hope” into definitions of “Hope as Attitude” 3. Re-examine optimism stuff into “attitude” as well 4. Remember: attribute coding = positive changes 5. Make sure I marked significant other as significant other in the “who” instead of family 6. Recode interviews to include “despair” if they mentioned despair in the definition of hope 7. Recode / re-examine Defense-Adaptation codes 8. Recode how hope is associated with time and despair 9. Recode for physical health diagnoses/ all dx 10. Under-coded Resilience under “Lessons Learned” 11. Is there a demographic questionnaire/dx for this study?

12. Do you happen to have any of the missing data?

13. Do you have memos already written? If not, it’s ok – Notability 14. Do you have Charmaz (2006) book?

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Can NVivo be used in conjunction with traditional pen-to-paper methods to triangulate analysis, findings, and help to build trustworthiness?

15. Some people had the desire to create /be creative on a typical day of hope. Where to code?

16. Should isolation be coded for “Typical Day of Despair”?

17. can defense-adaptation (hope) be similar to cognitive distortions (despair)?

18. Does “who” need to be separated? Who for hope / who for despair rather than conflated?

19. Make a graphic representation of H & D GENERAL THOUGHTS 20. Is connection another experience of hope if disconnection is an experience of despair?

21. Hope is Born out of Despair > People have hope because of despair 22. Where does trauma fit in? trauma in despair 23. Abuse is connected to powerlessness 24. Relationship disconnection is connected to loss 25. Where does gratitude fit in the experience of hope? - coping 26. What about loneliness/ isolation?

27. How does an unstable childhood contribute to hope and despair?

28. How does relational turmoil contribute to hope and despair? Versus relational support?

29. How does mental health (depression/addiction - common) contribute to hope and despair?

30. Some of the last general questions might perhaps be some of the most fascinating.

31. Did the participants who defined despair as hopelessness also report that hopelessness and despair are synonymous to each other, or no?

32. Look at imagery section and descriptive phrases for possible theme title names 33. How did the experience of negative versus positive therapy impact participants’ H&D? 34. H&D as temporary versus permanent 35. Is feeling stuck or paralyzed associated with permanence?

36. Where does coping fit in?

CODING NOTES BY PARTICIPANT 1. AUDREY a. Defining Despair: Deep despair is grief; despair – is no matter what you do, it won’t change. No agency, no choice; despair is isolation, hope is connection b. Defining Hope: “when I decided that I didn’t know what to do and that I needed to own that and seek help in some way” / hope is seeking help c. The opposite of hope is despair d. Experience of Despair: wrecked childhood, feeling trapped, suicide ideation, trying to meet everybody else’s’ expectations/perfectionism struggles e. “Nobody gave me. Permission to just be me” f. “Hope in a jar” > authenticity g. Mental shifting > attribute to positive change / hope h. Role of despair in help seeking – “despair is the driver” … “It’s always been the driver. I’ve always recognized despair” 146

i. Therapy (psychoanalysis) led to more agency, don’t have to be paralyzed anymore j. Lessons Learned: important to ask for help, connect to people when in despair k. Most Important: despair is not permanent; a shifting dynamic. Hope – “we don’t’ actively engage it very much and I think that’s one of the problems” l. New Insights: “we don’t practice hope nearly enough and we don’t actually impart to people that that it is something that we can grasp a hold of” 2. APRIL a. Journey, path, and past come together and establishes meaning b. “But despair to me it feels like hope is really far away or hard to get to” Interviewer (Taylor): compared to The Vital Balance “our job as therapists is to tend the flames of hope.” < whether H&D explicitly discussed c. Typical day of hope: free and creative d. Process of knowing oneself is very important e. Most Important: H&D are fleeting states; “This too shall pass” f. Role of despair in therapy: “We don’t play around with despair as much as we have, various versions of how we use hope” g. Anything Else: Despair is unique to each person and “the context doesn’t always make sense to someone else” h. “Despair thrust me into seeking help” i. Therapy as a way to move forward / a form of movement 3. AVA a. Talks a lot about addiction b. Despair manifest in isolation – “nothing will improve” – a sense of permanence c.

4. BARBARA a. “Hope is a Catalyst for Change” b. “Despair was a motivator (driving motivation) in seeking help” c. “The installation of hope formed out of the despair” d. Defining Despair: “really wanting to change but not having the resources, the motivation, or maybe like the psycho-education to make that change. feeling stuck. That things are be this way forever. it’s not gonna be like, a good thing, it’s like, the negative feelings of fear and insecurity, loneliness, depression, that these will be symptoms that I carry with myself for my whole life, and I won't be able to get myself out of it” e. Defining Hope: “finding something outside of myself that, that can solve my problems, or something within myself that can solve my problems. having that glitter, glimmer of things will be better eventually, that I’m not stuck in this loneliness, despair situation for my whole life. That there is something out there that I, that will get me better. having that hope that things will be better” f. “People that are in the profession are the worst clients” > Haha g. Role of despair in help seeking: “probably the strongest motivator” – desperation 147

got so bad h. Most Important: “when considering despair at the lowest like the point that it was like a state of being that seemed constant, even though that might be an irrational belief” … “on the flip side, the hope was like coming from that deep despair. I can't explain the phenomena that inspired so much hope” … “the despair felt much easier to be like, yeah this is why things are horrible. This is, I can tell you, that’s why I feel like this. With hope, I was like uh, I don’t know” i. Support and trust = “factors” of hope j. Dx: addiction 5. BARRY a. Kidnapped in Mexico = major trauma > other traumas less important / noncomparable to participant b. Defining Despair: “When you're at the end of the road and you don't see a way out” c. Defining Hope: “when you have something to look forward to, that you have an expectation of something happening” d. “Most important lesson that I’ve learned through experiencing despair… I’d say that just things, things get better. Eventually. I’ve learned that at least in my case, a small, healthy amount of anxiety over things helps a lot. But, when that anxiety turns into, I mean helps a lot because it helps me, motivates me to do better and because I’m very strict. a healthy amount of anxiety is helpful to me. But, when it goes down to despair, that’s not very healthy or very helpful” 6. CONNIE a. Despair gave way to hope b. “Habits are hard to change” c. Lack of connection main contributor of despair d. Addiction is the distraction that covers up all the pain e. Despair is the driving factor f. Despair as a primary emotion g. Hope also a driving factor in asking for help; hope to get better h. Lol, (conversing about spider catching technique) i. Despair is overwhelming j. I Do Not know where to code “Psychedelic adventuring” as healing for this participant; the only person who reported this experience 7. HANLEY (long-winded) a. “Suffering” in the definition of despair. How many others defined despair with the word/concept of suffering? b. Despair is a motivator c. Hope is a gift /gratitude? (gift) d. When I’m hopeful I’m going to reach out, when I’m in despair, I’m not e. Loss, relational disconnection, health issues, stress pile-up led to depression which also contributed to despair f. Agency/goals important contributors to hope, but seems like these career goals are 148

also meaningful to participants’ own experiences – which commonalities of meaning-making careers are different in the helping profession compared to other professions g. Despair, function, hope: “almost like a three stage: despair, function, hope, and in function they would see me cry and then hope they would see me laugh. And in despair I would completely isolate” h. Despair explicitly talked about – yes; how? In terms of loss > “but so often we want to take ownership of something which almost creates a greater sense of despair because then we blame” i. Most Important: (H&D) “operationalizing what that means for each person and not assuming that it means the same thing for all people” … “hope is about the belief and the possibility of what we don't know yet and what isn't realized yet. I think with despair - that it is survivable. that the opposite of survivable, if you didn't believe that, would be death” j. New Insights: “I have thought about it in terms of I think whenever we think about clients and their loss and their suffering and where they're at. I think historically, I've probably thought about it more about as a loss of hope versus experiencing despair. I think for myself, recognizing that, maybe exploring that more” … “I do think about hope as being a possibility. I think on some levels despair can be mitigated. If you're if you're in a good place, it's like, they don't do surgery on you if you have the flu and you've got pneumonia cause you're already weakened. I think despair is probably magnified if we're already weakened… maybe it wouldn't have caused us despair at another time in our life. But depending on how many different things are going on and our support and what we have to work with, maybe we experience that differently. I definitely think that I experience despair differently” k. Did not code “The Havening” / participant frequently derails in conversational responses 8. KAREN a. Hope overrides despair b. Attribute of hope: positive changes in life are the catalyst of hope 9. LINDA a. Perspective taking is gratitude b. Perspective taking is the tools-asking for help 10. MARGO 11. PAULA (missing interview 1) 12. PERCY 13. Survivor of 11 years of child sexual assault 14. Despair = a sense of drowning 149

15. PERRY a. Dx: depression – a feeling of out of control; isolation b. Defining Despair: a complete loss of hope; can’t foresee a good future; rock bottom; stuck c. Defining Hope: “the belief of something better to come. belief is the key word there” i. Possibility of good/change to come d. Despair clouds everything else e. Role of despair in help seeking: “I felt so awful, felt bad enough that it was a motivator to get help. But like I said, I think my depression symptoms had been sort of sneaking up on me and I probably justified it, or like, you wouldn't be happy right now because this, I would just qualify it in a way. I think it had to reach that really low point for me, or a really low point for me to actually make the move towards getting help. I don't think I could have motivated myself to do much, but what I could do was you know, make a phone call, and schedule an appointment with a psychiatrist.” f. “I think that usually when you’re in despair, its highly un-motivating for doing anything and that includes getting help. I think you have to reach your lowest point to realize that I am not going to get out of this without help. Once you realize that you can’t just pull yourself out of it by yourself, I would say I got motivated to seek outwardly other options.” g. Role of hope in help seeking: I must have had some because I felt motivated enough to seek out help. Hope would probably have been the primary motivator for going or calling the psychiatrist or any time I sought out help it’s always been backed by some hope, even if it didn't feel front and center, it’s not something that I felt that I was so hopeful. I probably felt like there was no hope, but there must have been a tiny bit because hope was like the only motivator to seeking out help.

Even if it was small, I must have believed somewhere deep down that there was a solution to the problem. So, I’d say it was the primary motivator.” h. Most Important (despair): “look underneath and see if you can be more specific about how you're feeling” … “It's never exactly that feeling all the time forever.

These things are short lived, most are short lived. timing is everything when you're going through it. You have to go through. But the point is that you're moving. And that’ll get you somewhere if you just keep going.” i. New Insights: I don’t grasp H&D as well as I thought I did 16. PENELOPE 17. PAM (missing interview 1) a. Role of despair in help seeking: “There have been times where it’s motivated me to seek help” in addition to “Honestly probably some of the functional challenges that demand attention (chuckles) end up being what leads me there” b. Participant struggles with severe dissociation – trauma related to death of son c. Role of hope in seeking therapy: “The instinct to look for hope does motivate me to keep trying and going. once you’ve had a taste of hope, I feel like I had an 150

appetite for it, and that also helped. the more hope I’ve experienced the less comfortable I am in the absence of it. as therapy progresses, I feel like the expectation for hope, as a need, motivates a lot of why I continue going to therapy” d. Despair comes from a place of comfortability (“a strange comfort and familiarity” which is “why you would struggle with actually letting go of it.” Despair is a heavy blanket “proprioceptive input from a weighted blank” that “serv[es] a purpose”) e. “It was hard to know if hope was gonna really be able to replace that and be strong enough to give you that grounding” – reminds me of needing a higher power stronger than the disease of addiction f. Most Important: “curiosity is always the place to start”… creating enough safety to be curious about despair and hope without expectations about which one you’re going to choose

i. Therapist was a model for hope > “intangible concept, to have a tangible connection with it through another person that’s really helpful” ii. “that’s probably a pitfall for a lot of Christian counselors and just the church in general, is this idea that despair is sin, and that you’ve chosen it, and that to be what God expects of you’re gonna choose hope. And I think that shuts you down, then you lose access to the hope to begin with, and it just adds despair to you. So, being able to create that safe environment, and curiosity, definitely wanting to develop self awareness while you can notice it and recognize both of them. I feel like with my therapist and then now, as a therapist, there is that element of, she didn’t expect me to have hope, but she also let me see her hope. And I was able to experience it with her presence in the room without the expectation that I could take it on myself. I probably struggle more now as a therapist, that I expect myself to have that hope to give to clients. But I go right back to what I just told you, is I know that if I’m having that expectation versus just an awareness and noticing and following the curiosity, then, I’m losing my own access to it.”

g. New Insights: “To have hope you almost have to have despair” < “it helped me immensely” personally and professionally

18. LESLIE 19. RACINE 20. STEPHANIE (missing interview 1) 21. TANNER 22. TAMMY a. Hope is associated with a safe place

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Appendix K: Excel Excerpt Image of Codebook

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Appendix L: Coding Memos Coding Memo 1 While exploring the perceptions of participants I found myself commonly returning to how individuals reflected upon feelings of hopelessness versus helplessness when defining despair. Participants seem to return to defining despair while also defining hopelessness, and vice versa. Participants also considered emotional reflections as depression or feeling anxious. Participants also found themselves considering factors such as how indecision led to the furthered sense of helplessness and hopelessness, which even exasperated their feelings of despair.

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