Is it ethical to instil false hope in people with mental illness?

There's an ethical consensus in medicine that it's wrong to give patients with physical illness false hope. But what about patients with mental health problems? Might the provision of unrealistic optimism be a vital part of their treatment? Or might this serve only to prolong their suffering? Psychiatrist Justine Dembo at the Sunnybrook Health Sciences Centre has explored these delicate issues in a thought-provoking essay.

Dembo highlights research showing the numerous positive illusions to which most psychologically healthy people are prone. This includes feelings that we're better than average, that we have more control over life than we really do, and an unrealistically optimistic take on the future.

Writers like Ernest Becker have observed that we need these illusions to cope with the reality of being human and the fragility of our existence. "A full apprehension of man's condition would drive him insane," he wrote. Consistent with this, there's evidence that the positive illusions most of us enjoy are absent or reversed in people diagnosed with depression and anxiety.

For this reason, says Dembo, instilling hope and optimism in people with mental illness can be an important part of their recovery. A positive mindset can have behavioural consequences including greater sociability and creativity, which have knock-on benefits for a patient, leading to a virtuous circle of recovery.

But what if a therapist or psychiatrist truly sees no hope for a patient? Some people with severe mental illness fail repeatedly to respond to treatment. False hope in such cases can lead to years of suffering, toxic treatments and a loss of trust in the therapeutic relationship. "I would argue that hopelessness in those with mental illness may, at times, be well founded," says Dembo.

She outlines two real case studies from her own career. Patient 1 was a 38-year-old woman diagnosed with schizophrenia and OCD, both treatment-resistant. She had a history of suicide attempts, the last of which was nearly lethal. Dembo and her team met the woman in intensive care and believed she had almost zero chance of recovery. However, they conveyed hope to her each day, and she later restarted treatment. Her symptoms have subsequently cleared and she is back at work. Dembo felt they'd given the woman false hope, but "now in hindsight it seems that we did the right thing."

Patient 2 is a 50-year-old woman with profound difficulties forming relationships. She suffered severe trauma as a child and she's been diagnosed with PTSD, major depression, social anxiety, borderline personality and she's made several attempts on her own life. Three years ago she explicitly asked Dembo for proof that she would recover, or else she wanted to stop treatment. Dembo believed the woman had only a tiny chance of recovery and yet she emphasised to her the "small threads" in her life that gave cause for hope. Today the woman has withdrawn from therapy and "lapsed into hopelessness".

"I would be remiss," writes Dembo, "if I did not point out that her fragments of hope, which I have reinforced, have possibly led to three more years of suffering."

Nonetheless, in weighing up the evidence and considering cases like Patient 1, Dembo confesses that she has undergone a change in her own perspective on this issue. "Prior to delving into this topic, I believed that good mental health necessitates an unbiased appreciation of reality," she writes. But not so today. She concludes "if positive illusions can so greatly enhance an individual's quality of life, productivity, health, and social connections, then perhaps it can be ethically permissible to encourage these illusions, to some optimal extent."

Have you faced this dilemma as a therapist or therapy client? Do you think it's ever right to instil unrealistic hope and optimism in therapy?

Further reading

Dembo JS, and Clemens NA (2013). The ethics of providing hope in psychotherapy. Journal of psychiatric practice, 19 (4), 316-22 PMID: 23852107