Fear of Hope
Ross Ellenhorn on the psychosocial resources needed for change
Ross Ellenhorn is a sociologist and clinical social worker who has developed an innovative treatment program for psychiatric and psychosocial recovery which bears his name: Ellenhorn. Influenced by current research on “psychosocial resources” in social psychology, Kurt Lewin’s work in field analysis, psychoanalyst Donald Winnicott’s theories on play, and the “community integration” model of psychosocial rehabilitation, Ellenhorn’s model is an intensive “treatment without walls” approach to helping individuals experiencing complex events of mind and mood and problematic habits. Instead of removing suffering people from society, Ellenhorn sends clinicians out into the field to accompany them in their daily lives. The goal is not simply symptom reduction, but something its founder believes is more complex and difficult to achieve: “the recovery of a person’s social being.”
Ellenhorn told TAP editor in chief Austin Ratner that the origins of the program lie in his personal history. When in junior high in Claremont, California, he’d been assigned to special ed classes, an experience he found “profoundly labeling.” He was eleven years old and thought to himself, “I’m not gonna be able to make it as an adult.” That kind of demoralizing identification—“a spoiled identity,” as Ellenhorn describes it, referring to the work of sociologist Erving Goffman—“was more debilitating for me, and caused me more problems for decades, than any so-called disability.” He describes the Ellenhorn program as a “memorial to that traumatic event.”
The “unsaid event in most treatment settings,” Ellenhorn says, is an injury to patients’ sense of hope. “Their chief complaint is ‘I’m afraid of trying again.’” Ellenhorn calls this “fear of hope” and aims his program at providing enough external support to overcome it so that a patient can recover the ability to “metabolize help.” “That’s the gold,” says Ellenhorn, “and once a person develops a better relationship with help, the world is an oyster as far as what’s next treatment-wise. Whether they see a psychiatrist or a shaman, they’re basically ready to change.” Helping people build better relationships with help is central at Ellenhorn. “If somebody comes into a session with one of the clinicians and says, ‘that thing you said last week, I’ve applied it and it really helped,’ they’re done with us. They don’t need the ‘hospital without walls’ we provide, because they can be effective leaders in their recovery.”
Ellenhorn has written three books on his philosophies: Parasuicidality and Paradox: Breaking Through the Medical Model, How We Change (and the Ten Reasons We Don’t), and Purple Crayons: The Art of Drawing a Life. Ellenhorn and Ratner met twice in December 2023, once via Zoom and once in person, and corresponded via email. They discussed fear of hope, Ellenhorn’s work with individuals labeled “difficult to engage” or “resistant,” the current problems with treatment for mental health and addiction, and the importance of the social context for recovery.
AUSTIN RATNER: Addicts are often said to be in denial about their problem, and sometimes the approach to treatment is to attempt to break through that denial to the truth that the patient or client is an addict. But you’ve pointed out that there’s a stigma that goes with being labeled an addict. And when you’re labeled as different and the treatments provided don’t seem to work, you can give up hope and collapse back into addiction. So how do you help people out of this conundrum?
ROSS ELLENHORN: First of all, let me clarify that Ellenhorn isn’t an addiction treatment program, per se. We work with people who are often called “dually diagnosed,” meaning they both experience difficult events of mind and mood and are engaged in a problematic habit. But I am happy to talk about addiction, independent of mental health concerns, since I believe a lot of our core philosophy applies to the issue. To start with, we need new words for “resistance” and “denial,” since work in the addiction field is completely oriented toward breaking through these supposed skull-bound events. While it’s completely ineloquent, I like the term “perturbed relationship with help.” And I believe people will not develop a facilitative relationship with help if they don’t have the right psychosocial resources. Or, to put it another way, what’s called “resistance” or “denial” isn’t just a “what’s wrong with them” problem. It’s as much, and I believe more so, a “what’s happening to them” issue.
To get people ready for treatment is to get as warm a coat of social resources around them as possible. If I’m right about that, that’s a giant missing element in most care, right? Most care for addiction and for complex psychiatric events removes people from these resources, often removing them from home and structuring their days around treatment and away from social resources. Over and over, research in social psychology shows that if someone doesn’t have a sense of self-efficacy, if they don’t have good social support, if they don’t have purpose, the world becomes threatening. And I do believe there’s a thing called denial, but to fight through denial means to face a challenge not a threat. A challenge is an obstacle we have the resources to deal with. A threat is an obstacle we don’t feel we have the resources to deal with. And for someone without good psychosocial resources, what might appear for some of us as challenges feel like threats. At Ellenhorn, we’re trying to bolster up the ability for people to be motivated and connected because I’m pretty sure psychosocial resources are the elements that actually get somebody that’s called, quote, unquote, “difficult to engage” to engage in treatment. That’s why over 70 percent of our work is done outside the office, on an outreach basis, and a lot of it is about helping people get back to work or school, or engage in activities in their community. The majority of the people we work with at Ellenhorn have experienced profound traumas to their social experience, having lost a sense of their social role, their purpose, their competence and their social supports, due to going in and out of treatment. We actually call our clients who engage in problematic habits “triply diagnosed,” because we think their addiction issues are as tied to what we call “psychosocial trauma” as they are to their mental health issues, and the research on dual diagnosis work points in this direction.
So how do you get people to that? I think it happens through people building faith in themselves again. “I’m strong enough to handle this.” You can’t help a person get more hope, but you can help them feel, “I can see the challenge in this next task, and it’s not a threat,” and “If this goes wrong I’m still gonna be standing here.” Does this person have faith in themselves and others to get through this and are they able to be innovative when they face a problem in front of them? Both those things require some level of faith in yourself, and so how do you rebuild a person’s faith so they can look at their problems and decide what they want to do with their life?
“We say a person is ready to return to the world when they are ‘well,’ when in fact our wellness is dependent on the medicine of psychosocial resources. We’re saying, in a sense, you can have the most important medicine for your recovery when you recover.”
AR: Say more about what you mean by fear of hope in the context of addiction.
RE: Hope is not the same as optimism. Optimism is kind of like Reaganesque nonsense. Like “Everything’s gonna be great! Great day tomorrow!” Hope is the capacity to move towards something you yearn for despite uncertainty. So every time that you’re able to keep going despite not knowing whether you’ll get the thing or not, you’re hoping. And so hope is central to motivation, since every act of motivation is challenged by uncertainty. (This is what makes Martin Luther King probably the most profound thinker on hope—“creative suffering,” what a term! Creative suffering. It means in your suffering to still come up with creative solutions of what you’re going to do with it.) When you hope, you also make the thing that you’re yearning for more important than it was before you hoped for it, right? That means that if you don’t get what you hoped for you have these profound experiences of disappointment, and the other term for that to me is helplessness.
There’s this quote from Erich Fromm about how all of us are basically built for suckling, and that means we’re also always dealing with the possibility of disappointment. I think of disappointment in that way: as often a profound event in which we experience that our needs are not met, and from that that we are helpless. “I’m not able to meet my needs. I’m now lacking this thing in my life.” If you’ve been through this series of events where everybody was excited about your change—getting sober, getting good marks on your improvement on psychiatric symptoms, a professional stamp of approval about you “functioning”—and then things fall apart again, you start to think, “I don’t want to hope.” Even, “Hope is my greatest enemy. Because if I hope again, I’m gonna take those steps towards that event again where I’ll experience my own helplessness.” And from this, “Staying the same is actually my friend, in my battle against hope.” And that’s fear of hope.
We created a scale to measure fear of hope—it’s a legitimate scale, these are really good social psychologists that have done this—and the remarkable thing is that people that score high for hope and score high for fear of hope are the most agitated of all the different versions you can come up with. High hope and high fear of hope is like standing on a cliff and being afraid of heights.
AR: That’s where I live.
RE: Well, if you’re a hopeful person you’re always gonna be dealing with fear of hope. But it’s a good anxiety, it’s existential anxiety. Hope never comes without fear: it takes courage to hope.
AR: And you’re talking about fear of hope as an obstacle to change and as an obstacle to treatment.
RE: Yeah. Every time you go see your addiction counselor it’s like, “Oh, here’s that person who wants me to get better. They want me to get on that path again and—”
AR: “I don’t believe I can do it.”
RE: Yep and “I don’t believe I can deal with the disappointment if I do it and it doesn’t work. Oh yeah, it’ll be too much for me.”
AR: “And so therefore I’m gonna go back and just stay the same: continue to use, or keep a low profile as a ‘mental patient.’”
RE: Exactly! And what the person is doing by staying the same is actually rather graceful in its own way: they’re trying to protect their hope. They’re holding on to their hope. They’re saying, “I don’t really want this to get injured again, I got this hope here and I don’t want it to be exposed and hurt again right now and so I’m holding on to hope.” So what we see as hopeless behavior is actually hopeful behavior, it’s just that there’s such fear of hope that staying the same becomes the person’s guard. And until a person can develop some faith in themselves, some self-efficacy, they’re not going to take the risk of dashed hope again.
I learned it through psychiatric patients, in a community mental health center years ago, in a group I ran on change. I basically asked members in this group “why aren’t you changing,” and their answers were close to uniform: “Well, I just don’t want people to get excited about my change,” or “I don’t want to get my hopes up again.” Rarely did they say, “because of my symptoms.” That means we have an enormous “chief complaint” problem in this country, in which clients of the mental health system see existential struggles over disappointment as their problem in change, while clinicians are describing their complaints as skull-bound. How does one move past this kind of crisis in self-belief? Well one way you don’t do that is by entering a world of pure treatment, your days marked hour-by-hour with the pressure to “get better.” The best way to get there is to vigorously treat people for all the psychiatric events and problematic habits while they live on their own, and pursue a purpose, while making their own sandwiches for lunch, getting some form of a job or going to school or volunteering. That often, truly, takes a hospital without walls, since we need to combine all the social recovery stuff with good psychiatric and addiction treatment. However, we live in the US, with a twisted view of “readiness,” in which we say a person is ready to return to the world when they are “well,” when in fact our wellness is dependent on the medicine of psychosocial resources. We’re saying, in a sense, you can have the most important medicine for your recovery when you recover.
AR: Tell me a little more about how all this is put into action.
RE: Well, like I said, about 70 percent of the work is conducted outside the office. But, unlike other programs that might provide “companions” or “coaches” for people, we have trained clinicians, mostly master’s level, who help our clients become what we call “more socially articulated.” And they do this through small steps of social inclusion, from taking a yoga class with them, to visiting during lunch breaks at work, to attending classes with them, as only a few examples. That’s what the staff are doing all day: they’re doing stuff with clients, but with a clinician’s ear for issues of motivation. This takes a giant ship and points to another crazy way we approach behavioral issues in the country: we put the most intensive resources into sequestering people—and I would say also into the surveillance of them—and put little clinical resources to the challenges they face in their daily lives. Dealing with somebody who is symptomatic while you’re helping them in their daily life takes really good and very intensive psychiatry. Again, it’s all about shifting what we mean by “readiness.” Let’s not say, “When Fred is no longer psychotic we’ll finally get him a job.” Let’s say instead, “Let’s give him a team, one that meets for rounds each morning that includes Fred’s psychiatrist, and let’s visit him during his lunch breaks, drive him home from work, give him a place to disclose about his fears of hope and his struggles at work, and assist him in being ‘ready’ right now.” Otherwise, we’re in that bizarro world of “no medicine until you’re well.” The medicine is social inclusion; the medicine is pride.
This interview has been edited and condensed.
Published in print issue 58.1.
The medicine is pride