Hope or Delusion? Issues in Addiction Psychotherapy

By Joseph Avery and Jonathan Avery 05/05/16

Are delusions simply “extreme hopes” to be treated with extreme caution? 

Hope or Delusion? Issues in Addiction Psychotherapy

One of the oft-mentioned maxims in psychiatry is the notion that one should not attack a delusion until the patient’s resources are able to withstand the loss. In the treatment of patients who present with both substance use disorder and delusional ideation, therapists can be confronted with scenarios that complicate the question further. Here, Joseph Avery, an attorney and addiction researcher, and his brother, Jonathan Avery, a psychiatrist, grapple with two cases that highlight the ways in which hope, worry and delusional thinking cross paths...Dr. Richard Juman

The Wall Street Journal, in a recent article concerned with agency and human flourishing, called hope “an emotion we all need more of.” In the Motivational Interviewing framework outlined by Miller and Rollnick, one of the quadripartite forms of “change talk,” which the therapist seeks to evoke from the patient, is optimism for change. The therapist’s job is to have the patient overhear herself expressing optimism for new behaviors, for a different way of living. In other words, a large part of the change process is hope.

A middle-aged woman presented with Alcohol Use Disorder. She was drinking between twelve and twenty alcoholic beverages per day, with consumption taking place from 6 p.m. onwards. Reared in an orthodox Christian sect, she said that her drinking was an “insult” to her God. She also thought it a long-term threat, though not an immediate one, to her physical health. She did not consider herself an alcoholic, as she drank primarily wine, beer, and cocktails, never “hard stuff straight from the bottle. I don’t like vodka.”

When asked in what ways she might fill the time she typically spent drinking, she could think of only one, and she was reluctant to relay it. “You know Senator X of course…” she started. She described meeting a state senator at a presidential debate viewing party held at the Metropolitan Club, an evening that concluded with his looking back at her when “forced” to depart from the event by an assistant. She subsequently made attempts to see the man, all of which were foiled, she said, by his busy schedule. The link between the question—how will the usual drinking hours be spent sober?—and her answer—do you know the senator?—was that, in spite of their limited contact, she deemed dating and marriage imminent. “I’ll be busy,” she said. “I’ll have to help him network. And we’ll be doing intellectual things. We'll go to Broadway shows. There won't be time to drink. Maybe an occasional glass of champagne. Or wine. I know wine. I can talk wine with anyone.”

Part of the reason she had come for help was that she felt pressed to purge herself of perceived obstacles to the health of this relationship, of which she considered her excessive drinking one. When asked how likely it was that she would be spending private time with the senator, she smiled. “You don’t understand. We had a night at the Met Club. It’s in the works.” 

DSM-5 defines delusions as “fixed beliefs that are not amenable to change in light of conflicting evidence” (DSM-5, 87). Note that the patient, in her delusional narrative, was not unrealistic concerning her drinking. She understood that, even if she was busy with a new relationship, she might still drink (champagne, wine) sometimes. She anticipated that the relationship, with the concomitant pressures of being married to a public servant, would be stressful and would likely precipitate drinking. In other words, she made it clear that although she was seeking treatment, although it was her intent to stop drinking, a part of her would refuse to imagine a future without alcohol.

Is it better to think of her as a hopeful person, as opposed to a deluded one? At first glance, delusions may seem to be of the same class as hopes. They are just extreme hopes. There is a more significant difference. Delusions are beliefs about the current state of the world. Hopes are future-oriented. Her delusion was not that she would be married to the state senator; it was that the relationship was in the works, actually happening. Her hope, perhaps, was that the relationship would come to be. The Oxford English Dictionary has hope as an “expectation of something desired, a feeling of expectation and desire combined.”

A further difference is that delusions are static and hopes, dynamic. Hoping implies action. Eric Partridge traces hope to German and Old English words signifying “to hop; if rightly, the basic idea would be ‘a leaping, or to leap, with expectation.’” In other words, to hope is to remain quiescent, while one’s mind hops towards the desired—or the undesired—this is one of hope’s tricks. It does not entail actual movement, but rather fantasized movement. Delusions, to the extent that they are static (i.e., merely claims about the current state of the world), are more honest. They do not give the appearance of progress. 

Conversely, hopes track truth more nearly than do delusions, as their claims about reality, about future realities, are more normative. Of course, this does not mean that delusions are unmoored from truth. Freud writes in Moses and Monotheism, “It has long been recognized that delusions contain a piece of forgotten truth, which had at its return to put up with being distorted and misunderstood, and that the compulsive conviction appertaining to the delusion emanates from this core of truth and spreads to the errors that enshroud it.” If Freud is correct, delusions are not extreme hopes. Delusions are negotiations with unacceptable truths, problem-solving by means of distorting the real. Hopes, on the other hand, may be fantasies that tell lies about progress being made, and the common expression “never lose hope” may be a rather insidious attempt to maintain the status quo. The question we must ask, of course, is why? The deluded individual is so honest that he changes, by great effort, the world around him. He is a builder. The hopeful individual is so dishonest that he feigns building so that others (and a part of himself) might allow him to preserve the world as it is. In the context of addiction, the question is, “Why preserve?”


A 62-year-old man presented with a 20+ year history of opioid use. He expressed no desire to continue using: “I don't even get high. I really don't. It just helps my stomach.” He was retired, somewhat comfortable financially, with generally intact romantic and social relationships. His only professed hope was that he would stop using opioids. “I'm on board,” he said. “I'm in your hands. By next year, I hope to be off this stuff.” 

Over the next few weeks, he spoke of disadvantages of the status quo—financial waste, inability to travel due to the addictive need, mental stress, fatigue—and advantages of change—visits to an elderly parent who lived out of the country, a stronger relationship with his wife due to a decreased need to lie, greater long-term physical health. His optimism for change never wavered. Indeed, when the new year came around and he was still injecting 10 bags of heroin per day, he maintained hopeful that our work would lead to abstinence. Six months later, his hopes remained firm. He made daily reports to his wife about the work we were doing. And he did not stop using. 


We see consanguinity of hopes and worries. Worrying, like hoping, assumes a future. Worrying is closed because it never questions the objects of its focus. “It domesticates self-doubt” (Phillips, 58). Hoping is closed because it domesticates the wish. Whereas those wishes that originate as impulses are both pure (in the sense of being untempered) and likely to be in conflict with other wishes, hoping, which is more truly a product of conscious processes, is ambivalence masquerading as certainty. There is no room in hoping for counter-hopes. One does not hope for sobriety while also hoping to continue drinking. One could hope for sobriety someday and also hope for another drink now, but when these hopes enter the same forecast space, sustenance of them becomes untenable. To contrast, one may want to drink and also want not to drink; indeed, this is a key realization for the drinker in recovery. Hoping, in its closure, does not allow for such thoughts. 

Counterintuitively, hoping may be a way of engendering obstacles. To hope is to assert that the thing for which one hopes is at hazard. A hopeful person, it turns out, may be an antithetical person. His desire is not for the hoped-for object but rather for its opposite, not to change but to remain where he is, immobile—and still hoping.

The traditional narrative, that hope is a precipitator of behavioral change, remains persuasive, as does, we think, the notion that hope might be a means perpetuating stasis. The pith of the paradox likely is found in the thing itself. When one feels hopeful, what exactly is one feeling? In the context of a Substance Use Disorder (SUD), it could be the case that hope exists (for surely the word points to something) but not the case that much of what we call hope is hope. What, we should ask and answer carefully, are we calling hope?

The intransigence of addiction and the ubiquity of professions of hope by individuals with SUDs can make us wonder to what extent these hopes relieve discomfort by providing an illusion of choosing and acting. Treatment-seeking drug and alcohol users inhabit a paradoxical space, doing what they claim not to want to do and failing to do what they claim to want to do. It is the puzzle of the twinned desires, of the self that baffles the reflective self, that makes substance use such a strange and interesting topic. For the sake of both the therapist and the patient, this essential strangeness should not be elided by the assumptions and certainties that often accompany hope.

The Authors would like to acknowledge Susan Sugarman, PhD.

Joseph J. Avery, JD, has worked in substance use research at the New York State Psychiatric Institute. He will begin a PhD in Psychology at Princeton University this fall. Jonathan D. Avery, MD, is an Assistant Professor of Clinical Psychiatry at Weill Cornell Medical College.


Freud, S. Moses & Monotheism, Part III, Section 1. Retrieved from https://archive.org/stream/mosesandmonothei032233mbp/mosesandmonothei032233mbp_djvu.txt

Miller, R. M. & Rollnick, S. (2002). Motivational Interviewing (2nd ed.). New York: The Guilford Press. 

Partridge, E. (1966). Origins: A Short Etymological Dictionary of Modern English. London, Melbourne and Henley: Routledge & Kegan Paul. 

Phillips, A. (1993). On Kissing, Tickling, and Being Bored. Cambridge: Harvard University Press.

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