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From the Department of Nursing Science
University of Turku
Turku, Finland
Supervised by
Professor Emerita Sirkka Lauri, RN, PhD
Department of Nursing Science
University of Turku
and
Professor Emeritus Ville Lehtinen, MD, PhD
National Research and Development Centre for Welfare and Health
Helsinki
Reviewed by
Associate Professor Merja Nikkonen, RN, PhD
University of Oulu
Department of Nursing and Health Administration
and
Professor Hasse Karlsson, MD, PhD
University of Helsinki
Institute of Clinical Medicine
Department of Psychiatry
ISBN 951-29-2539-7 (PRINT), 951-29-2736-5 (PDF)
ISSN 0355-9483
Painosalama Oy – Turku, Finland 2003
“One cloud is enough to eclipse all the sun.”
THOMAS FULLER.
To my father and Kallu
Virpi Pyykkö
“IF ONLY I COULD” ~ “THERE IS ALWAYS A LOOPHOLE”
Hope and hopelessness experienced by the severely depressive and non-
depressive elderly
Department of Nursing Science, University of Turku
Annales Universitatits Turkuensis
Painosalama Oy, Turku, Finland 2003
ABSTRACT
The aim of this research was to structure a conceptual model of hope and hopelessness
based on dictionary definitions, and to verify this model on the basis of the experiences of
the severely depressive and non-depressive elderly. This research has produced a substantive
theory of hope and hopelessness which is based on the experiences of the depressive and
non-depressive elderly, and on the concept analysis of hope and hopelessness based on
English dictionary definitions. The patients who participated in the research were 65 years old
and older men and women (n=22) who had been admitted to a psychiatric hospital because
of major depression, and another group: the non-depressive elderly (n=21), who were
recruited from the pensioners’ clubs. The data were collected in interviews using the Clinical
Assessment Tool, developed by Farran, Salloway and Clark (1990) and Farran, Wilken and
Popovich (1992), and it produced 553 pages of written text, which were analysed using the
ATLAS/ti programme. ATLAS/ti is a tool for analysing qualitative data and is based on
Grounded Theory. The medical and nursing records of the depressive elderly completed source
triangulation. The concept analysis of hope and hopelessness was made on the basis of the
definitions of English dictionaries (n=103), using semantic analysis and the ATLAS/ti programme.
The most important hope-promoting factors were human relations, health and managing in
everyday living. Autonomy, self-determination and feeling of security were highly appreciated
among the elderly. Hopelessness, on the other hand, was most often associated with the
same factors: human relations, health and everyday living. Especially, losses of significant
others were experienced as strongly hope-diminishing. Old age had brought freedom from
duties concerning others, but now, when you finally had an opportunity to enjoy yourself,
you could not accomplish anything; you were clasped in the arms of total inability, depression
had come. The most obvious difference in the life course of the depressive and non-
depressive elderly was the abundance of traumatic experiences in the childhood and youth of
the depressive elderly. The continuous circulation of fearful thoughts was almost touchable,
and suicidality was described in connection with these thoughts. You were afraid to be awake
and also to go to sleep. Managing day by day was the goal.
The research produced the Basic Social Process (BSP) of hope: achieving - maintaining -
losing, which expresses a continuous balancing between Being without and Being with. The
importance of the object of hope was combined with the amount of hope and
disappointment. The process of approaching defined the realisation of hope and the process
of withdrawal that of losing. Joy and security versus grief and insecurity defined the Being
with and Being without. Two core categories were found. The first one “If only I could”
reflects lack of energy, lack of knowledge, lack of courage and lack of ability. The other one
“There is always a loophole” reflects deliberate tracing of possibilities and the belief in finding
solutions, and managing.
Keywords: Hope, hopelessness, depression, old person, Grounded Theory.
Virpi Pyykkö
”JOS VAIN PYSTYISIN” ~ ”AINA ON OLEMASSA TAKAPORTTI”
Toivo ja toivottomuus vakavasti depressiivisten ja ei-depressiivisten vanhusten
kokemana
Hoitotieteen laitos, Turun yliopisto.
Annales Universitatis Turkuensis
Painosalama Oy, Turku, 2003
TIIVISTELMÄ
Tämän tutkimuksen tavoitteena oli tuottaa käsitteelinen malli toivosta ja toivottomuudesta
englanninkielisten sanakirjojen määrittelyihin perustuen ja varmistaa se vakavaa depressiota
sairastavien ja ei-depressiivisten vanhusten toivon ja toivottomuuden kokemuksiin perustuen.
Tutkimuksen tuloksena syntyi substantiivinen teoria toivosta ja toivottomuudesta, joka
perustuu depressiivisten ja ei-depressiivisten vanhusten kokemuksiin ja englanninkielisten
sanakirjojen pohjalta tehtyyn käsiteanalyysiin toivosta ja toivottomuudesta. Tutkimukseen
osallistuneet potilaat olivat 65- ja yli 65-vuotiaita miehiä ja naisia (n=22), jotka olivat
sairaalahoidossa vakavan masennuksen vuoksi. Toisen ryhmän muodostivat samanikäiset ei-
depressiiviset vanhukset (n=21), jotka toimivat eläkeläisryhmissä. Tiedot koottiin
haastattelemalla. Haastattelu perustui Clinical Assessment Tool - haastattelurunkoon, jonka
ovat kehittäneet Farran, Salloway ja Clark (1990) ja Farran, Wilken ja Popovich (1992).
Haastattelu tuotti 553 sivua tekstiä, joka analysoitiin käyttämällä ATLAS/ti- ohjelmistoa, joka
on Grounded teoriaan perustuva kvalitatiivisen aineiston analyysiohjelma. Depressiivisten
potilaiden sairauskertomuksia käytettiin täydentävänä lähteenä. Käsiteanalyysi toivosta ja
toivottomuudesta perustui englanninkielisiin sanakirjoihin (n=103) ja ne analysoitiin ATLAS/ti-
ohjelmalla.
Tärkeimmiksi toivoa edistäviksi tekijöiksi nousivat ihmissuhteet, terveys ja selviytyminen
jokapäiväisessä elämässä. Vanhukset arvostivat autonomian, itsemääräämisoikeuden ja
turvallisuudentunteen korkealle. Erityisesti läheisten menetys koettiin vahvasti toivoa
vähentävänä tekijänä. Vanhuus merkitsi vapautta muihin liittyvistä velvollisuuksista, mutta
nyt, kun vihdoinkin oli mahdollisuus nauttia, ei pystynytkään saamaan mitään aikaiseksi;
täydellinen kyvyttömyys oli ottanut valtaansa, depressio oli alkanut. Selkein ero elämänkulun
aikana tutkittavien ryhmien välillä oli depressiivisillä potilailla traumaattisten kokemusten
runsaus lapsuudessa ja nuoruudessa. Jatkuva pelottavien ajatusten mielessä pyöriminen oli
miltei käsin kosketeltavaa ja niihin liittyi myös itsemurhariski. Sekä valveillaolo että
nukkumaanmeno pelottivat. Tavoitteena oli selviytyä päivä kerrallaan.
Tutkimus tuotti toivon perusprosessin (BSP - basic social process): saavuttaminen – ylläpitä-
minen – menettäminen, joka on jatkuvaa tasapainoilua osallisuuden ja osattomuuden välillä.
Toivon kohteen tärkeys liittyi toivon ja pettymysten määrään. Prosesseina lähestyminen ku-
vaa toivon toteutumisen konkretisoitumista ja vetäytyminen toivon menettämistä. Ilo ja tur-
vallisuus ja toisaalta suru ja turvattomuus kuvaavat osallisuuden ja osattomuuden kokemus-
ta. Kaksi ydinkategoriaa muodostui: 1) ”Jos vain pystyisin” - kuvaa energian, tiedon, rohkeu-
den ja kyvyn puutetta ja 2) ”Aina on olemassa takaportti” - kuvaa mahdollisuuksien määrä-
tietoista jäljittämistä, uskoa selviytymiseen ja siihen, että ratkaisu on löydettävissä.
Avainsanat: Toivo, toivottomuus, depressio, vanhus, Grounded teoria
CONTENTS
1 INTRODUCTION.................................................................................................13
2 REVIEW OF THE LITERATURE.............................................................................15
2.1 THE GROUNDS OF HOPE AND HOPELESSNESS.................................................................15
2.2 PHILOSOPHICAL ASPECTS OF HOPE AND HOPELESSNESS....................................................18
2.3 WELL-BEING AND ILL-BEING.....................................................................................23
2.4 HOPE IN NURSING.................................................................................................25
2.5 HOPELESSNESS AND DESPAIR....................................................................................26
2.6 DEPRESSION AS A DIAGNOSED DISEASE.......................................................................27
2.7 SUICIDAL BEHAVIOUR.............................................................................................30
3 PURPOSE OF THE STUDY AND THE RESEARCH QUESTIONS..................................35
4 METHODOLOGICAL APPROACH AND RESEARCH DESIGN.......................................37
4.1 SYMBOLIC INTERACTIONISM.....................................................................................38
4.2 SEMANTICS - SEMANTIC ANALYSIS (RESEARCH AREA 1)...................................................39
4.3 GROUNDED THEORY (RESEARCH AREAS 2 AND 3)..........................................................40
4.4 HERMENEUTICS (RESEARCH AREA 3)...........................................................................41
4.5 THE RESEARCH DESIGN...........................................................................................43
5 METHODS..........................................................................................................44
5.1 DATA AND DATA COLLECTION...................................................................................44
5.1.1 ENGLISH DICTIONARIES....................................................................................44
5.1.2 INTERVIEWS OF THE DEPRESSIVE AND NON-DEPRESSIVE ELDERLY..................................45
5.1.2.1 Tools of the analysis.............................................................................46
5.1.2.2 Participants..........................................................................................48
5.1.3 NURSING AND MEDICAL RECORDS OF THE DEPRESSIVE ELDERLY....................................50
5.2 DATA ANALYSIS....................................................................................................50
5.2.1 DATA ANALYSIS OF THE DICTIONARIES..................................................................52
5.2.2 DATA ANALYSIS OF THE INTERVIEWS OF THE DEPRESSIVE AND NON-DEPRESSIVE ELDERLY.....54
6 RESULTS............................................................................................................64
6.1 THE CONCEPTS OF HOPE AND LOST HOPE.....................................................................64
6.1.1 THE ETYMOLOGY OF HOPE.................................................................................64
6.1.2. SYNONYMS OF HOPE.......................................................................................65
6.1.3 RELATED CONCEPTS OF HOPE.............................................................................66
6.1.4 LOST HOPE BASED ON DICTIONARY DEFINITIONS......................................................68
6.1.5 HOPE AND LOST HOPE BASED ON THE DICTIONARY DEFINITIONS...................................68
6.2 HOPE AND HOPELESSNESS EXPERIENCED BY THE SEVERELY DEPRESSIVE ELDERLY.....................70
6.2.1 THE PSYCHIATRIC CARE HISTORY OF THE INTERVIEWED DEPRESSIVE PATIENTS..................70
6.2.2 MONTGOMERY-ÅSBERG DEPRESSION RATING SCALE VALUES OF THE DEPRESSIVE PATIENTS.73
6.2.3 EXPERIENCES OF HOPE AND HOPELESSNESS IN SEVERE DEPRESSION...............................74
6.2.4 “WEAKENING PULSE OF LIFE” - THE PROCESS OF HOPING-LOSING HOPE.........................92
6.2.5 THE MEANING OF HOPE AND HOPELESSNESS EXPRESSED IN THE INTERVIEWS....................93
6.3 HOPE AND HOPELESSNESS EXPERIENCED BY THE NON-DEPRESSIVE ELDERLY..........................94
6.3.1 THE MEANING OF HOPE AND HOPELESSNESS IN THE INTERVIEWS.................................121
6.4 DIFFERENCES BETWEEN HOPE AND HOPELESSNESS DEFINED BY THE TWO GROUPS..................122
6.5 THE BSP - BASIC SOCIAL PROCESS, ACHIEVING - MAINTAINING -LOSING..............................127
6.6 THE MEANING OF HOPE AND HOPELESSNESS BASED ON THE DICTIONARY - AND EMPIRICAL DATA 128
6.6.1 CONCLUSION ON DICTIONARY DEFINITIONS..........................................................129
6.6.2 CONCLUSION ON THE EMPIRICAL DEFINITIONS.......................................................129
7 SUMMARY OF THE RESEARCH FINDINGS...........................................................132
7.1 THE CORE CATEGORIES, BSP, AND THE DIMENSIONS OF HOPE AND HOPELESSNESS...............132
7.1.1 THE CORE CATEGORY “IF ONLY I COULD”.............................................................133
7.1.2 THE CORE CATEGORY “THERE IS ALWAYS A LOOPHOLE”............................................133
7.2 SUMMARY OF ALL THE DATA...................................................................................133
7.2.1 INABILITY AND ABILITY...................................................................................134
8 ETHICAL ASPECTS OF THE STUDY.....................................................................136
8.1 THE ELDERLY AS PARTICIPANTS...............................................................................136
8.2 DEPRESSIVE PATIENTS AS PARTICIPANTS....................................................................137
8.3 THE ROLE OF THE RESEARCHER...............................................................................137
8.4 PERMISSION AND CONSENT....................................................................................138
9 DISCUSSION....................................................................................................139
9.1 THE PREMISES...................................................................................................139
9.2 ASSESSING QUALITATIVE RESEARCH.........................................................................141
9.3 EVALUATION OF THE METHODS...............................................................................143
9.4 EVALUATION OF THE FINDINGS...............................................................................144
9.5 COMPARISON OF THE RESEARCH FINDINGS WITH EARLIER RESULTS....................................146
9.6 PRACTICAL IMPLICATIONS OF THE RESEARCH...............................................................149
9.7 SUGGESTIONS FOR FURTHER RESEARCH.....................................................................151
REFERENCES..........................................................................................................152
ACKNOWLEDGEMENTS............................................................................................162
APPENDICES (1-28)
LIST OF FIGURES
FIGURE 1. Philosophical aspects to hope and hopelessness........................................23
FIGURE 2. The research design 1995-2003................................................................43
FIGURE 3. The year of birth of the depressive elderly.................................................49
FIGURE 4. The year of birth of the non-depressive elderly..........................................50
FIGURE 5. The number of codes in content-based code families based on
dictionary definition.................................................................................53
FIGURE 6. The number of code families in the interviews of the depressive
elderly....................................................................................................55
FIGURE 7. An example of code building and meaning.................................................57
FIGURE 8. Structuring the data from the initial 40 code families into three
categories...............................................................................................61
FIGURE 9. An example of the analysis made by the ATLAS/ti programme of the
interactional dimension of the depressive elderly.......................................62
FIGURE 10.The process of the analysis......................................................................63
FIGURE 11.Elements of structuring the results of the study.........................................64
FIGURE 12.The semantic field of the synonyms of hope in English dictionaries
(n=103)..................................................................................................66
FIGURE 13.Hoping process based on English dictionary definitions (n=103).................69
FIGURE 14.Hospital days in mental hospital of the depressive elderly (n=22)...............73
FIGURE 15.Montgomery-Åsberg Depression Rating Scale values of the 22
depressive elderly within two weeks from admission to psychiatric
hospital..................................................................................................74
FIGURE 16.The number of codes in each factor in interviews of the depressive
elderly....................................................................................................75
FIGURE 17.An experience of life of a depressive elderly..............................................77
FIGURE 18.Hope-diminishing factors in the lives of the depressive elderly (n=22).........79
FIGURE 19.Hope-promoting factors in the lives of the depressive elderly (n=22)..........80
FIGURE 20.Summary of the hope-diminishing factors in the lives of the
depressive elderly....................................................................................81
FIGURE 21.Summary of the hope-promoting factors in the lives of the depressive
elderly....................................................................................................81
FIGURE 22.Hope-diminishing factors in personal experiences of the depressive
elderly....................................................................................................84
FIGURE 23.Hope-promoting factors in personal experiences of the depressive
elderly....................................................................................................85
FIGURE 24.Summary of the hope-diminishing factors in the personal experiences
of the depressive elderly..........................................................................86
FIGURE 25.Summary of the hope-promoting factors in the personal experiences
of the depressive elderly..........................................................................87
FIGURE 26.Hope-diminishing factors in the relations of the depressive elderly..............89
FIGURE 27.Hope-promoting factors in the relations of the depressive elderly................90
FIGURE 28.Summary of the hope-diminishing factors in the relations of the
depressive elderly....................................................................................91
FIGURE 29.Summary of the hope-promoting factors in the relations of the
depressive elderly....................................................................................91
FIGURE 30.An example of a personal meaning of hope...............................................93
FIGURE 31.Hope-diminishing factors in the lives of the non-depressive elderly..............98
FIGURE 32.Hope-promoting factors in the lives of the non-depressive elderly.............100
FIGURE 33. Conclusion on the hope-diminishing factors in the lives of the non-
depressive elderly...................................................................................103
FIGURE 34. Conclusion of the hope-promoting factors in the lives of the non-
depressive elderly...................................................................................103
FIGURE 35.Hope-diminishing factors in the personal experiences of the non-
depressive elderly..................................................................................108
FIGURE 36.Hope-promoting factors in the personal experiences of the non-
depressive elderly..................................................................................109
FIGURE 37.Summary of the hope-diminishing factors in the personal experiences
of the non-depressive elderly..................................................................111
FIGURE 38.Summary of the hope-promoting factors in the personal experiences
of the non-depressive elderly..................................................................112
FIGURE 39.Hope-diminishing factors in the relations of the non-depressive
elderly..................................................................................................116
FIGURE 40.Hope-promoting factors in the relations of the non-depressive elderly.......117
FIGURE 41.Summary of the hope-diminishing factors in the relations of the non-
depressive elderly..................................................................................120
FIGURE 42.Summary of the hope-promoting factors in the relations of the non-
depressive elderly..................................................................................121
FIGURE 43.The Basic Social Process (BSP): Achieving - Maintaining - Losing...............127
FIGURE 44.The basic social process (BSP) and the core categories of the
meaning of hope and hopelessness in the lives of the depressive and
non-depressive elderly...........................................................................132
FIGURE 45.The process of hope and hopelessness based on philosophical
definitions, dictionary definitions (n=103), and experiences of the
depressive (n=22) and non-depressive (n=21) elderly.............................134
LIST OF TABLES
TABLE 1. Facts about the interviews.......................................................................46
TABLE 2. An example of codes and meaning units...................................................58
TABLE 3. Psychiatric care periods of the depressive patients (n=22)..........................71
TABLE 4. The care periods in mental hospital of the severely depressive 22
elderly patients 1995-2001.......................................................................72
TABLE 5. Hope-promoting and hope-diminishing factors in past, present and
future in the lives of the depressive elderly..............................................122
TABLE 6. Hope-promoting and hope-diminishing factors in past, present and
future in the lives of the non-depressive elderly.......................................123
APPENDICES
Appendix 1. Turun terveydenhuollon eettinen toimikunta, tutkimuslupa-anomus/Research
application, ethical committee
Appendix 2. Mielenterveyskeskuksen johtoryhmä, tutkimuslupa-anomus/Research application,
Board of mental health organisation
Appendix 3. Selvitys haastattelututkimuksesta 1997-1999/Explanation of the research contents
Appendix 4. Suostumus osallistumisesta tutkimukseen/Consent for participation in the
research
Description:The aim of this research was to structure a conceptual model of hope and hopelessness based on dictionary definitions, and to verify this model on the basis of the experiences of the severely depressive and non-depressive elderly. This research has produced a substantive theory of hope and
