by Yvonne Dolan
Note: This article was originally published in The Psychotherapy Networker (2003) January/February issue and reprinted (2015)by The Psychotherapy Networker online.
It was a completely full morning flight to Los Angeles. Despite the post 9-11 security procedures, our United Airlines flight was actually leaving on time. Everyone, passengers and crew alike, seemed in pretty good spirits. Then I noticed the man seated across the aisle. He was hunched over, his face in his hands, the muscles in his back shaking. He nodded almost imperceptibly when the attendant gently touched his shoulder and reminded him to fasten his seat belt in preparation for takeoff.
A few minutes into the flight, I heard the muffled sound of sobbing. After a few minutes, I leaned across the aisle and asked, “Are you okay?” He shook his head. “Is there anything I can do?” Again, he shook his head.
A little later, a flight attendant walked down the aisle, noticed the man’s sobbing, and asked, “Do you need anything?” He shook his head and cleared his throat.
“My wife and all four of my kids were killed last night in a car accident. I’m on my way back to Hawaii to make the funeral arrangements. I moved over here [the flight had originated in Chicago] for my work.” His voice broke. “They were going to join me when the school term ended. ”
“I don’t know what to say, sir,” the attendant said gently. “I’m so sorry. Are you sure there isn’t anything I can get you?” Again, he shook his head. “I just need to get through the next two flights, so I can do what needs to be done. Our family is all flying over from the mainland for the funeral and I’m going to have to pick them up and make arrangements. I was up all night last night after they called me, so I’m going to try to get some sleep.”
“Ring the call bell if you need anything, sir, “the attendant murmured. As she walked away, the man looked across the aisle at me. “I just need to focus on what needs to be done. That’s the only way I can get through this.” Then he folded the airline blanket across his chest and closed his eyes.
To most people, this man would hardly qualify as “hopeful.” His misery and his story make it easy to conclude that he was, literally, without hope. Easy, but wrong. True, he undoubtedly felt hopeless, but he was not hopeless, he had not succumbed to despair. Even in the face of his catastrophe, he was taking small, tentative but active, steps back toward the realm of life. By focusing on what he needed to do in the immediate future–get some sleep, pick up his relatives, and begin making arrangements–he was assuming a future, a time for which plans needed to be made, people contacted, tasks met, even if, for now, that future encompassed only the next few hours or days. Despite his acute grief, he was saying, in effect, “this is impossible, but I’ll find a way to get through it.”
Making his plans didn’t change what had happened or his feelings about it, but it gave him some small measure of control in otherwise uncontrollable circumstances. It also provided him with a rough map for what would undoubtedly be a brutal journey through a wilderness of suffering. For the time being, he was alive and coping; he hadn’t been defeated by despair, and that in itself was a harbinger of hope to come.
There’s Hope in Activity
As therapists, we’ve been trained to think that we should focus primarily on emotions. We often elicit negative emotions, believing that they must be purged before there’ll be room for hope and other positive emotions. We’re particularly anxious to assuage trauma survivors, whose desperate, unbearable pain seems to demand immediate relief. We frequently assume that all clients must feel hopeful and believe that life is meaningful before they’ll make much progress in therapy or in life.
But the fact is that in the wake of catastrophe, it’s often impossible to summon up the least glimmer of hope or faith or sense of life’s meaning. How, for example, can you suggest to someone whose child has been shot in a schoolyard, who has lost a home to a hurricane, or who’s been raped as a child by family members that there’s hope for the future, that they’ll feel “better” someday? To clients who have suffered such profound trauma, it’s ludicrous to suggest that they can be coaxed into feeling hopeful about the future.
In these cases, the trauma therapist may be in something of a bind. Trying to “drain off” negative emotions by focusing on the pain–asking clients to rehash what happened or to speak repeatedly about their terrible feelings–is likely to make them feel worse. Just asking such clients an open-ended question about their emotional state–“How do you feel today?”–may exacerbate already terrible feelings or call forth a sense of numbness and apathy.
But favoring positive emotions and subtly trying to subdue negative ones can backfire. Asking these clients to imagine a time when they won’t feel suicidal or reframing their trauma as an opportunity to “grow” can trivialize their suffering and inadvertently insult them. These efforts may also strike them as manipulative, as though the therapist is trying to maneuver them into a hopeful response they’re not ready for.
How do we get beyond this impasse? We can begin by looking again at the ways people have found consolation and support in the thousands of years before psychotherapy was developed. Throughout history, human beings have found rough relief and a modicum of comfort in the immediate obligations and habits of ordinary, daily life. The greatest incentive to go on coping lies in their relationships with other people, not only those who comfort and support them, but those who depend upon them. Sometimes, the simplest act can have profound power. I learned recently of a Red Cross survey given to disaster survivors, asking them to name the most helpful “intervention” they’d experienced right after the disaster. Many said they most appreciated being given a cup of coffee by an aid worker. It wasn’t fancy trauma therapy, but I suspect the familiarity and ordinary helpfulness of the act implied to survivors that, in spite of catastrophe, normal life was still going on. In receiving a cup of coffee lay some small kernel of hope for the future.
In my 25 years of treating traumatized people, I’ve found that in these crisis situations dissecting negative emotions or trying to rev up positive ones isn’t the most useful step we can take. This isn’t to say we should avoid discussions about how clients feel–far from it. But talking with clients about what they’re doing and how they’re coping provides not only a framework for them to talk about how they feel, but a real-life scaffolding for the eventual construction of more positive emotions. Hope follows action, rather than the other way around. Helping clients become aware that what they’re doing–even if it’s “merely” coping and “just” getting by–can be the first step toward rebuilding their sense of agency and control.
I first began thinking about the healing power of activity and its “hope-implicit” quality when I was a young therapist-in-training, working in a shelter for abused and runaway teenagers. Every one of these kids had experienced severe and prolonged abuse, and virtually all suffered from acute post-traumatic stress. As an all-night staff person, my job was to help them get to sleep–an almost impossible task because for my charges sleep was a realm of nightmares and flashbacks. Talking with them about their traumas just heightened their distress, and asking them “positive” questions–about what they wanted to do with their lives, what they liked, what would make them feel safer–didn’t engage them.
Desperately casting around for a solution, I began to ask more specific questions about the immediate future. “What would you like to do tomorrow? What do you need to get that done? How will you know tomorrow night that you had a decent day?” Several said they wanted to contact brothers, mothers, or friends to find out if they were okay. Others said they wanted to go outdoors; they’d been cooped up inside for too long. Still others said they wanted to wash their hair, take a bath, get clean clothes. This doesn’t sound like therapy, nor does it provide much in the way of emotional breakthroughs. But it worked. Talking about practical, immediate plans calmed them down and helped them sleep. I believe that the practical details of their lives reminded them that they were more than their traumas, and gave them concrete realities that, at least momentarily, jostled them out of their inner turmoil.
Drawing on my shelter experience, I work with trauma clients to help them identify actions they can take to keep going. But sometimes trauma clients no longer have a sense of who they are and why they should continue living–except that they feel they have to go on for the sake of their kids, their grandchildren, their spouses, or even the person they’ve lost. Many clients who cannot imagine going forward for themselves can summon up some last ounce of strength on behalf of those they love.
Focusing on Day-to-Day
Germaine, came to see me after her adolescent son had been killed in a gang-related shooting. She’d just lost her job, was drinking heavily, and was almost paralyzed with grief. She entered therapy not to make herself feel better, but so that she could go on living for the sake of her other two children.
At that point, nothing I could say would make her feel better. I told her how sorry I was for what happened to her son, and how painful I imagined this must be for her whole family. “How have you managed up until now?” I asked. This focused her on what she was doing and offered her an indirect opportunity to express her feelings. Germaine said she’d been going to a support group, and while it helped to get dressed, get out of the house, and be with others, the overall experience wasn’t particularly useful. “I feel like I’m being swallowed up by how much it hurts, like I could, literally, drown in the pain.”
Germaine was a former crack addict, but had been clean for six years. She’d resisted taking drugs again, but she was drinking heavily. “These feelings aren’t ever going to go away,” she said. “And just talking about it isn’t going to cut it. I have to have some sort of concrete plan of what I’m going to do to fill up the time or I’ll die of grief. What am I going to do?”
Of course, I didn’t know the answer. But clients often have within themselves the budding solutions to their own dilemmas, though they may not recognize it at the time. Germaine had come up with a potential way out of her hell when she said she needed a “concrete plan” of action. I thought we should try to construct one. I asked her if there had been anything at all that had helped to make these past few months a little bit more bearable. She was silent for several minutes, staring at the floor.
“It helps when I make a list,” she said finally. “Some days, when I get up in the morning, I make a list of what I need to do and, somehow, those days seem to go a little bit easier–maybe because I have a plan, sort of like a map for getting through the next few hours. When I don’t have my list, it’s a lot worse. I can just sit and cry all day.”
I asked her how the list helped. She said that it wasn’t so much the list itself that helped, but that the act of making it put her completely in the present. Listing the most mundane chores–“go to grocery store,” “pick up Michael’s shoes from repair shop,” “make kids’ lunches for tomorrow”–and then doing them helped her “get back to living, at least for the time being,” she said. In a sense, she could do hope before she could feel hope. This focus reflects a great human wisdom found in many major spiritual traditions: that being consciously mindful, maintaining full awareness of what’s going on in the present can bring some solace and peace when all else fails.
It struck me that concentrating on her list-making and following through with the tasks when she felt so terrible must have taken extraordinary effort. “How did you do it?” I asked.
“I guess I just made up my mind.”
“But just how did you make yourself get up in the morning?”
“I told myself I had to do it.”
“What did you do to convince yourself?”
“Well, I gave myself a lot of shit, as I lay there, telling myself it was a lousy thing to do to my kids–just let them fend for themselves while I wallowed in bed.”
This pursuit of minutiae can have a powerful impact on the client. In answering the questions, Germaine acknowledged her own agency and strength. If I were to praise her, no matter how sincerely, for managing to get up every morning, it might have sounded condescending. Focusing her attention on what she was doing for herself helped her to recognize her own strength and her ability to keep going despite her pain.
I saw Germaine weekly for a year and a half, keeping the focus on her own efforts. One of the most powerful and respectful ways to help clients actively find new meaning for their lives is to ask them to imagine someone who loves them telling them what they’re accomplishing. When I asked Germaine what she was doing right, she responded like many depressed and grieving people that she wasn’t doing anything right. So, I rephrased the question, “Well, imagine that your kids are remembering what you did during this past week. What would they say you’d done right?” After a pause, she said, “I guess they would say that I’d put a meal on the table every night, and that I took them to church on Sunday, and that we went to the movies one evening.” Once, I asked her what a favorite aunt, who was deceased, might have said to her. For the first time, she smiled softly and said in a small voice, “She would tell me I was doing good, taking care of the kids and all, and that she was proud of me for not hitting the bottle at the end of the day.”
Session by session, Germaine gradually began to immerse herself in the mundane stuff of daily life, and her despair seemed to lessen over time. But she seemed to grow more anxious about her children. She worried that she hadn’t been a good enough mother, expressing guilt for neglecting them while addicted to crack. She wondered if she’d been responsible for her son’s death. Now, though still grieving for the one she’d lost, she felt increasingly frightened for the other three, and anxious about her own capacity to guide them through childhood.
“Suppose that you dream that many years have passed and your children–who are now adults–are sitting around the kitchen table with you, telling you that you did a great job as a mother and describing all the things you did completely right while raising them,” I said. “Now, suppose you wake up and can’t remember the dream, but find yourself doing all the things they said made you a great mother. What would be the first things your kids would notice you doing?”
Germaine closed her eyes and smiled. “I would go to every parent-teacher meeting. And I would make sure they told me where they were going to be every hour of the day–even if they fought me on it. And I would help them with their homework. And I would push them to finish school. I would keep on loving them, and let them know how much I loved them every day.” Because she was already beginning to do some of these things, it slowly dawned on her that she was already becoming the kind of mother her kids needed.
By asking this type of question, the therapist makes a kind of hypnotic suggestion that communicates–indirectly, without ever denying the client’s ongoing pain–that there is something significant to hope for. If the question is worded right, the client will answer it not by expressing a wish for the impossible, but by setting out realizable goals. I didn’t ask Germaine the kind of question that would provoke her to wish for her son to be alive again. Instead, she could wish for something entirely achievable, through her own efforts–something that would help her become the mother she wanted to be.
Starting with Baby Steps
Though focusing on mundane tasks in the present can seem impossibly beside the point for someone who has suffered a life-shattering event, it can help build, inch by inch and then yard by yard, a pathway out of despair and into the fullness of life. A Japanese doctor told me a story about how powerful this kind of mindfulness can be. Mr. Tanaka, a recently retired patient of his, had been admitted to a hospital after trying to commit suicide. For nearly 50 years, Mr. Tanaka had suffered from severe back pain as a result of tubercular meningitis he’d contacted at 15. He’d endured 30 operations, to no avail. Every treatment–physical therapies, nerve-blocks, drugs–had failed. Indeed, the pain was getting worse and he was now confined to a wheelchair. Stuck at home and in constant pain, he’d lost all hope and had attempted suicide. The doctor asked him how he’d managed to get through his painful life to that point.
“Well, I’m a very optimistic man at heart, and that has helped me,” Mr. Tanaka answered. “While the pain was awful, I just buried myself in work, which relieved it a tiny bit. I also believed the pain would become much less some day–and that made me optimistic. But now that I know I’ll never have relief, I feel there is no hope.”
Not knowing what else to offer, the doctor grabbed at this lifeline. “Could you do something for me?” he asked Mr. Tanaka. “When you feel even a little bit more comfortable, please notice and remember the occasion, and notice why and how it occurs.”
Each time he saw Mr. Tanaka over the next few weeks, the doctor encouraged him to notice when his pain was less severe. For six weeks, nothing. But one day, Mr. Tanaka came in smiling. “Since you began asking me to notice times I feel better, I’ve been thinking about it. A couple of days ago, on the way home from the dentist, I stopped in the park by the riverside. I ate sandwiches and fed the crumbs to the pigeons. They started going after the crumbs, and I really enjoyed watching them. In fact, I became so absorbed in watching them that I didn’t have any pain at all while I was there!”
The doctor encouraged him to continue noticing other times he became so involved he didn’t notice the pain. Gradually, Mr. Tanaka noted more and more activities during which the pain disappeared. He also noticed that the pain didn’t seem to be getting any worse. He began gardening and fishing and even took a short trip with his wife. Seven years later, the doctor told me, Mr. Tanaka was still improving.
Strangely enough, the “distraction” of living fully in the present seems to be the only real cure for the terrible things life can do to us, the only real source of hope in hopeless situations. As therapists and healers, we can’t make people feel hopeful, nor can we reverse the tragedies that make them feel hopeless. But we can help them slowly begin building, out of life’s own materials, a place in which hope can nest.
Note: This article originally appeared in The Psychotherapy Networker Magazine.
Dolan, Y.M. (2003, January/February) The pragmatics of hope: What to do when all seems lost, Psychotherapy Networker, 27, 39-43,