In cases of hopelessness, depression can be an insidious and immediate problem. Melges and Bowlby acknowledge that the hopelessness and despair of a severely depressed person is characterized distinctively by certain beliefs and behaviors. The depressed person can no longer perceive and differentiate an effective connection between a plan of action and the aim he or she has set. This, in turn, leads to a loss of self-confidence, which results in the person's depending more on others. Lastly, there develops a reluctance and hesitancy to set long-range goals since previous investment of time and energy has resulted in disappointment, failure, frustration, and defeat. Depression, according to Melges and Bowlby, is most acute when that connection between action and goals is truly separated, perhaps because of a wounded servicemember's new physical or cognitive challenges.

The importance of this connection and its impact on depression is reiterated by others as well, although the terminology of discussion may vary. Psychoanalyst E. Bilbring suggests that when the ego is shocked into the reality of its own helplessness in terms of personal aspirations, a person will lose the incentive and motivation to pursue goals when the results seem so futile. Again, once the connection between action and results is lost, depression follows. R.S. Lazarus uses the term "reinforcers" and states that depression is a function of insufficient reinforcers. D. Maddison and G.M. Duncan talk about the "frustration of personal striving" resulting from illness or disability that inhibits and suppresses the fulfillment of plans. Researcher Martin Seligman discusses the direct correlation between helplessness and depression as do A. Beck and A.H. Schmale, who define hopelessness as a core characteristic of depression. Seligman takes things one step further and identifies two types of helplessness. One is universal and precipitated by factors and elements within the environment and the other is personal and fueled by a catalyst for both "internal and external helplessness." Since the connection between helplessness, hopelessness, and depression has been clearly

linked, it is reasonable to assume that a servicemember challenged with posttraumatic stress disorder could become profoundly depressed since the depth of depression leaves no room for spirituality, which is at the core of hope.

R.J. Lifton says that "…despair predisposes to depression, prevents or delays recovery from it, (and) leads to its recurrence. When severe depression combines with despair, suicide is likely to be a serious option. To commit suicide, a person has to feel that the future is devoid of hope." S.M. Jourard suggests that a person commits suicide because

his or her perception has become so distorted and twisted as to feel that others want him to stop living. These extreme and distorted thoughts, once again, show the communal nature of hope. When the relationship to community of man, present and future, is lost, the notion of spirituality is also obliterated and annihilated. One can no longer look to others in an effort to gain assurance that some hope still exists. According to W.F. Lynch, "…hopelessness engenders isolation, shame, and withdrawal. Hopelessness is a silent admission of total defeat and a reluctant resignation to the status quo, to a life devoid of human love."

"Therefore, in other words, it may be that if a servicemember with a chronic disability has a why, then he/she can face the how of coping with that disability. Thus, the spiritual question regarding a chronic condition becomes its purpose, not its mechanism."

Hope has its roots in spirituality. Spirituality is a phenomenon that is evident in the lives and traditions of all cultures and people. M. Burkhardt states that "spirituality is understood to involve a personal quest for meaning, to relate to the inner essence of a person, to include a sense of relationship with self, others, nature, and ultimate other, and to be the integrating factor of the human person." D. Ley and I. Corless mention that "the concept of spirituality transcends such separations and manifests itself as a state

of "connectedness" to God, to one's neighbor, to one's inner self. It has variously been described as man's relation to the infinite, as the capacity to be energized from beyond ourselves, and as the basic quality of a person's nature—what the person is and what the person does. Inherent in all of these definitions is a sense of dynamism, of movement, or reaching out."

The literature is filled with references to the term spiritual. R. Dunphy discusses the term spiritual as "…the dimension of the human experience which transcends the immediate awareness of one's self. It is manifest in a variety of experiences: when someone questions the purpose of existence, when someone is filled with a sense of personal limitations and an awareness of the need to depend on a greater power, or when someone feels the joy of loving a friend unconditionally." S. Granstrom discusses the term spiritual as a broader concept than that usually referred to in the formal sense and, therefore, not necessarily having a religious, denominational connotation.

M. Hay suggests three categories that are universal to all spirituality, which accounts for the way in which spiritual development occurs in human experience. First, spirituality occurs in the context of communities of which one is a part. Secondly, spirituality results in an enhancement of one's inner resources for dealing with the challenges of life, including that of dying. And, finally, spirituality's objective is the giving of meaning to one's reality. This is to say that the scope of spiritual concerns encompasses matters of community, inner resources, and meaning.

Hay also discusses spirituality as an experience and capacity for "transcending one's working realities (physical, sensory, rational, and philosophical), in order to love and be loved within one's communities, to give meaning to existence, and to cope with the exigencies of life." Hay points out that when a person's capacity to transcend "working realities" is reduced through suffering, spiritual diagnoses may be made and treatment alternatives considered.