East Asian Arch Psychiatry 2014;24:95-103

ORIGINAL ARTICLE

Dr Beate Schrank, MD, King’s College London, Institute of Psychiatry, London, United Kingdom; Medical University of Vienna, Department of Psychiatry and Psychotherapy, Vienna, Austria.
Ms Tamsin Brownell, MSc, King’s College London, Institute of Psychiatry, London, United Kingdom.
Prof Andre Tylee, PhD, King’s College London, Institute of Psychiatry, London, United Kingdom.
Prof Mike Slade, PhD, King’s College London, Institute of Psychiatry, London, United Kingdom.

Address for correspondence: Dr Beate Schrank, Health Service and Population Research Department (Box P029), King’s College London, Institute of Psychiatry, Denmark Hill, London SE5 8AF, United Kingdom.
Tel: (20) 7848 0704; Fax: (20) 7848 5056; email: beate.schrank@kcl.ac.uk

Submitted: 24 March 2014; Accepted: 26 May 2014

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What is Positive Psychology?

The academic discipline of positive psychology (PP) developed from Martin Seligman’s 1998 presidential address to the American Psychological Association.¹ He maintained that psychology so far had mostly addressed only one of its original aims, i.e. curing mental illness, whilst largely neglecting the 2 other aims, i.e. helping people to lead more productive and fulfilling lives; and identifying and nurturing high talent. Consequently, Seligman dedicated his presidency at the American Psychological Association to initiating a shift in the focus of psychology towards the positive aspects of human experience, positive individual traits, and more generally, the positive eatures which make life worth living.² In this context, the term “positive” was only ambiguously defined as what “promises to improve the quality of life and also to prevent the various pathologies that arise when life is barren and meaningless”.²

Seligman and Csikszentmihalyi² originally conceptualised PP as a “new movement” in psychology. This notion of a movement was considered necessary in order to counteract the perceived powerful focus of psychology on the negative aspects of life and ill health. A number of definitions of PP have since been proposed but no clear boundaries have been defined for the field. A systematic review conducted in 2011 found 53 published definitions of PP spanning 6 core domains: (i) virtues and character strengths, (ii) happiness, (iii) growth, fulfilment of capacities, development of highest self, (iv) good life, (v) thriving and flourishing, and (vi) positive functioning under conditions of stress.³

Since its introduction, a wealth of research and opinion papers, books, and journal special issues have been published and a dedicated PP journal has been established. Networks, courses, and research centres have been created, and sizeable amounts of money have been allocated to PP research, education, and training by various funders.⁴ Positive psychology has also received broad and international media coverage.

Along with the rapid evolution of PP and the extensive publicity, PP also generated some criticism which falls into 5 overlapping domains. First, PP was criticised for denying or openly devaluing closely related prior work.⁵ Early-stage publications were met with strong disapproval due to their implicit or explicit assumption that PP had newly created its constituent topics of interest.⁶ In fact, there is a long history of movements and psychological schools that also attended to the positive aspects of life. However, whilst many of the research topics examined in PP have been studied before (e.g. attachment, optimism, love, and emotional intelligence), other topics in PP were less popular before and were boosted through the introduction of PP. These included gratitude, forgiveness, awe, inspiration, hope, curiosity, and laughter.⁷

A second concern was that PP rhetoric was polarising and created a false dichotomy of a new ‘positive’ and an old ‘negative’ or ‘usual’ psychology.^8,9 In reality, the large majority of academic work in psychology may be considered neither positive nor negative, but neutral.⁷ In clinical practice, an exclusive focus on the positive was criticised for creating a “tyranny of positive attitude” preventing people from expressing negative emotions,⁹ and helping people to avoid difficult but necessary therapeutic processes.¹⁰

A third criticism concerns the feasibility of discriminating positive and negative variables. This criticism pertains to 2 areas: (i) the processes by which variables have a positive or negative effect; and (ii) the measurement of variables as either positive or negative. Variables may not be invariably positive or negative.^8,11 For example, research showed that dispositional pessimism can have debilitating motivational effects while defensive pessimism can help people deal with anxiety, adapt, and perform better than strategic optimists.¹² A PP intervention helping defensive pessimists to be more optimistic might deprive them of a useful coping strategy¹² because a pessimistic attitude can, in some circumstances, be more adaptive than an optimistic attitude. Automatically assigning any variable of interest, especially emotions, to positive or negative valences without regard for wider context may create research results of questionable value and generalisability.⁸

The fourth criticism is that PP concepts neglect the cultural context of human activity, and reflect the individualism ethic of American society.¹³ Identity, virtue, and a ‘good life’ may have different meanings in different cultures, so it may be difficult to arrive at one universal definition of such concepts.⁶ The same issue has been explored in relation to recovery.¹⁴ Applying a narrow set of values may lead to research results that are not generalisable or to the development of interventions which are not applicable across populations.

Finally, from a more philosophical perspective, PP has been criticised for its lack of a developed framework for investigating complex topics such as character, virtues, or happiness.^9,15 Despite the repeated reference to Aristotle, ethical considerations were found largely missing.¹⁶ This relative lack of attention to conceptualisation and theoretical underpinnings may arise from the emphasis within PP research on empiricism.

Positive psychology has come a long way in response to these criticisms. Pre-existing resource-oriented psychological approaches and research on positively framed topics are now acknowledged.¹⁷ Positive psychology is argued to have developed as a result of a different perspective on these topics, namely, to challenge the traditional focus of psychology on negative issues. Whilst it may be the case that it is often negative emotions which reflect more immediate problems to be addressed and are, hence, the focus of more traditional psychological principles, PP broadens this perspective. Instead of focusing on responding to problems, PP focuses on the need to identify the positive qualities that help individuals to not only overcome problems, but also to go forward and flourish.² Furthermore, PP focuses on the development of a quantitative evidence base for its constituent topics, on which there has been less emphasis in antecedent resource-oriented approaches.

Statements on the perspective of PP have been adjusted to be less polarising, by redressing what is still perceived as an imbalance but focusing on “understanding the entire breadth of human experience from loss, suffering, illness, and distress through connection, fulfilment, health, and well-being.”⁴ The potentially oversimplified division of positive and negative variables remains largely unresolved. More research is needed to explore why variables may be perceived as positive or negative, and to develop measures allowing a more flexible assignment of valence. Contextual factors now receive increasing attention, especially when it comes to creating a supportive context for interventions.¹⁸

However, empirical research considering the complexities of cultural diversity and societal problems is still scarce, and an increased emphasis on ethics and complex, philosophically informed frameworks is so far merely stated as a future goal of PP. The increasing acknowledgement and inclusion of earlier works, especially from humanistic approaches, may be a first step towards creating a more differentiated and theoretically informed picture of positive emotions and states in PP.⁶

Historical Developments and Predecessors of Positive Psychology

A number of researchers and therapists have framed their approach as positive, strength- or resource-oriented, providing a rich knowledge base for PP to build on. Examples of earlier ‘positive’ approaches within mental health systems include New Thought, Mental Hygiene Movement, Individual Psychology, or Humanistic Psychology, as well as a range of psychotherapy methods.

New Thought is one of the early but still well- known movements that emphasised the transformational power of positive thinking. It became popular in the late 19th century together with other mind-cure movements promising happiness, material success and good health, which helped people focus on and practise positive mental suggestions.¹⁹ Positive psychology interventions today also include exercises that aim to refocus attention towards the positive.²⁰

The Mental Hygiene Movement had widespread influence from the beginning of the 20th century until the 1940s, particularly in the United States. Its aim was to facilitate the attainment of physical and mental health through perfect adjustment to society by developing and preserving those human values and achievements which contribute to a balanced mental life for the individual.¹⁹ The attainment of perfect health, adjustment, achievement, and balance is reminiscent of the early conceptual framing of PP, as is the fact that the mental hygiene movement also focused on education and postulated the importance of scientific studies in their field.

More complex and comprehensive schools of thought attending to the positive were to follow in the middle and later parts of the 20th century. Alfred Adler founded the school of Individual Psychology which emphasises the healthy functions of a person. He considered the 3 “tasks of life” to be occupation, social relationships, and love. Similar to PP, Adlerian Psychology acknowledged human strength and the potential for higher levels of mental health and well- being. However, in comparison with PP, it more strongly stressed the social embeddedness and connectedness of the individual.²¹

Similar to Martin Seligman, Abraham Maslow, who founded Humanistic Psychology in the 1950s, criticised the fact that psychology had focused too much on negatives, illnesses and sins, instead of potentials, virtues, aspirations, and psychological height.²² Maslow²³ proposed that humanistic psychology should be based on the study of healthy, creative individuals, and empirically investigate the lives and patterns of self-actualised persons. Maslow²³ even used the term ‘positive psychology’. Of all the predecessors, humanistic psychology bears most resemblance with PP in that they both aim to focus on what is healthy and growth- oriented within people.²⁴

Carl Rogers developed person-centred psychotherapy, one of the best-known humanistic psychotherapy approaches. Rogers’ theory assumes that people have an inherent tendency towards growth, development, and optimal functioning. In his therapy, a non-judgemental and unconditionally positive regard is adopted towards clients in order to help them realise their true positive potential.²⁵ Further contemporary, resource-oriented therapeutic approaches include systemic family therapy; solution-focused therapy; socio-therapy and therapeutic communities; music therapy; self-help groups and mutual support groups; peer support and consumer-led services; and befriending.²⁶ All of these approaches share at least some possible therapeutic strategies with PP interventions. Examples include using the family as a resource (e.g. family therapy), focusing on strengths (e.g. solution-focused therapy), or on social relationships (e.g. befriending).

Research Evidence in Positive Psychology

Positive psychology was originally conceptualised as a discipline strongly based on high-quality quantitative research such as observational studies or randomised controlled trials. This should allow the methods of natural sciences and evidence-based medicine to be applied to the study of well-being.^2,27 The reliance on quantitative scientific methods was also initially used to set the PP movement apart from earlier approaches to human flourishing, which may arguably have placed more emphasis on qualitative research.^24,28

In terms of content, today PP serves as an umbrella term to accommodate research endeavours which started both before and after the introduction of the movement by Seligman and Csikszentmihalyi.² Related research spans a diverse range of disciplines, such as education,²⁹ organisational behaviour management,³⁰ sport psychology,³¹ family medicine,³² cancer care,³³ and brain injury rehabilitation.³⁴ For example, cross-sectional and observational studies have investigated various positive emotions such as joy, contentment, love, and gratitude, as well as other positive aspects such as creativity, self-efficacy, optimism, resilience, empathy and altruism, compassion, humour, and life satisfaction.³⁵ These have informed the creation of systematic measures of character strength and virtues.²⁷ This variety of topics and areas makes it difficult to place specific research within or outside the spectrum of PP.

Among the areas of work in PP research is the development and investigation of strategies that would make people permanently happier. A range of approaches intended to promote well-being have been tested in intervention research such as mindfulness therapy, forgiveness therapy, gratitude therapy, and various forms of well-being therapy.³⁶ Some of the most promising among the strategies have been combined into one overall intervention manual, named positive psychotherapy (PPT).²⁷

Positive Psychology in (Mental) Health Services

Public health activities aim to prevent disease, premature death, and disability in the population. Mental health problems strongly contribute to the burden of morbidity, mortality, and impairment in the population and are, hence, an important field for public health specialists.³⁷ Indeed, recent public health literature reflects an increased focus on psychological health and well-being, in addition to disorder and disability.³⁸ Reasons why such a shift may be beneficial include the high prevalence of mental health problems and the possible preventive value of fostering well-being for health behaviours.

In mental health services research, the strong focus on illness, symptoms, and deficits as the target for change has begun to shift towards strengths and resources only in recent decades. The World Psychiatric Association remarks in its official journal that “psychiatry has failed to improve the average levels of happiness and well-being in the general population”,³⁹ suggesting that the promotion of well-being is among the goals of the mental health system. This shift in the mental health field somewhat coincides with the consumer-led recovery movement, which has evolved since the 1980s and argues for a focus on well-being regardless of the presence of mental illness. Recovery in this context refers not to symptom remission but to people (re-)engaging in their life on the basis of their own goals and strengths, and finding meaning and purpose through constructing and reclaiming a valued identity and valued social roles.⁴⁰ These goals of the recovery movement appear highly congruent with those of PP. The 2 movements, recovery and PP, are complementary.^40,41 They share a similar focus, but the former has so far been largely built on personal accounts, theories, and opinions with empirical research lagging behind,⁴² while the latter offers a quantitative research focus in need of defensible theories and contextual knowledge on which to base its application.

Positive psychology was originally associated with the scientific study of optimal human functioning and with refocusing psychology away from adversity and illness towards understanding “how normal people flourish under more benign conditions”.² Positive psychology approaches have since been successfully expanded to various populations including people with disorders and those in adverse conditions.

Positive Psychotherapy

One therapeutic approach to evolve from PP is PPT,^20,27 which aims to increase well-being in its recipients.²⁰ It has to be distinguished from 2 other groups of therapeutic interventions: (i) those which share the same name, and (ii) those which share the same aim.

First, several authors proposed therapeutic interventions which they called ‘positive psychotherapy’. For example, Nossrat Peseschkian founded a PPT approach in the 1970s which assumes that people have 2 basic capacities: to love and to know. It is a conflict-centred and resource-oriented psychotherapy that also works with the unconscious.^43,44 Further examples are Milton Erickson’s hypnotherapy approach⁴⁵ which he framed in a positive way, causing some authors to call his methods PPT,⁴⁶ and positive group therapy for cancer patients, focusing on post- traumatic growth.⁴⁷

Second, other therapies have aims similar to PPT, i.e. to attain well-being, happiness, or a good life, but they use different strategies to reach these aims. Examples include Fordyce’s “happiness intervention”,⁴⁸ Fava et al’s “well- being therapy”,⁴⁹ and Frisch’s “quality of life therapy”.⁵⁰ All these offer a well-being or life satisfaction component but attend to troublesome issues and problems first and treat well-being as an add-on. This distinguishes them from PPT which has a primary focus on personal strengths, positive emotions and other positive resources, in order to indirectly target symptoms and deficits.

Positive psychotherapy was originally developed for people with depressive symptoms following the hypothesis that depression cannot only be treated effectively by reducing its negative symptoms but also by directly and primarily building positive emotions, character strengths, and meaning.^20,51 The intervention is based on Seligman’s early theory of authentic happiness, in which a good life consists of 3 components: (i) positive emotions (pleasant life), (ii) engagement (engaged life), and (iii) meaning (meaningful life).⁵²

Similar to cognitive behavioural therapy (CBT) for depression,⁵³ PPT assumes a cognitive bias towards the negative in humans and uses techniques aiming to shift attention, memory, and expectations away from the negative and the catastrophic towards the positive and the hopeful.²⁰ However, in contrast to CBT the focus of PPT exercises is on training and experience, i.e. external and behavioural, and less on cognitive insight. A fundamental assumption of PPT is that people have both an inherent capacity for happiness and a susceptibility to psychopathology. Clients are perceived as autonomous, growth-oriented individuals. Distressing, unpleasant, or negative states and experiences are not denied⁵⁴; in part, they are even explicitly elicited, but in doing so clients are encouraged to focus on positive aspects of such experiences.

There are 5 fundamental principles of PPT.⁵⁵ First, PPT broadens and builds therapeutic resources, similar to other psychotherapies. Positive psychotherapy broadens the client’s perspective by encouraging him to undertake exercises which can elicit positive emotions, help generate new ideas, and frame difficult situations more positively.

Second, PPT exercises use specific strategies to help clients think about negative situations by conducting careful positive reappraisals. Third, PPT also includes experiential and skill-building exercises which focus on clients’ identification and development of key strengths to increase their confidence and motivation. Fourth, PPT deals with problems by teaching clients to actively think about their positive qualities and helping them realise they can use these to solve their problems. Finally, PPT helps clients by re-educating their attention, memory, and expectations away from the negative and towards a more positive mindset.

Positive psychotherapy can be applied in group and individual formats. It exists in a 6-session and a 14-session version with all exercises designed to address 1 or more of the 3 components of authentic happiness.^20,54 Exercises include, for example, identifying character strengths and using them more in daily life, keeping a blessings journal, focusing on good instead of bad memories, savouring moments and activities, using forgiveness and gratitude to create positive emotions, or helping others.⁵⁵ Apart from using specific exercises, PPT relies on a skilled and knowledgeable therapist to specifically look and probe for clients’ strengths, and help them realise how these strengths can be associated with their personality, goals, values, as well as intra- and inter-personal life.

Research Evidence on Positive Psychotherapy

A meta-analysis of 51 studies of positive interventions, including therapies focusing on mindfulness, positive writing, gratitude, forgiveness, or kindness demonstrated significantly improved well-being and decreased depressive symptoms in people with depression.⁵⁶ A more recent meta- analysis of 39 randomised PP studies involving a total of 6139 participants also concluded that PP interventions can be effective in enhancing subjective and psychological well-being and reducing depressive symptoms.⁵⁷

Several of the included interventions successfully used single components of PPT. For example, undergraduate students writing about “one’s best possible self” showed increased well-being⁵⁸; students writing about intensely positive experiences each day for only 3 days reported enhanced positive mood and decreased health centre visits for up to 3 months⁵⁹; and students and people with neuromuscular disease keeping a blessings journal for 10 weeks also showed increased well-being.⁶⁰ Individual PPT exercises were also tested in randomised controlled trials with self-referred general population samples^61-63 including mildly depressed people²⁷ against no-treatment control and placebo (e.g. recording childhood memories). Significantly positive effects of PPT exercises were noted on happiness and there was reduction in depression for most exercises and for a follow-up period of up to 6 months. Individual exercises also produced an increase in self-esteem and decrease in physical symptoms in a community sample with low well-being and high self-criticism, especially when doing active as compared to passive exercises.⁶⁴

However, while individual exercises may produce benefits, there is also evidence for a dose-response relationship. A randomised controlled trial assigning healthy individuals to receiving 2, 4, or 6 exercises over 6 weeks or a no- treatment control showed that those receiving 2 or 4 exercises experienced significant decreases in depressive symptoms.²⁷ Meta-analysis confirmed that assigning multiple and different positive activities, in general, is more effective than employing just one.⁶⁵

Positive psychotherapy as a package has so far been tested in at least 14 published studies involving healthy participants as well as participants with physical or mental illnesses, as summarised in the Table.^20,66-78

Published studies on PPT have a number of limitations including potential selection bias, lack of diagnostic assessments, small sample sizes, lack of randomisation, or lack of blinding. Moreover, the cultural background of clients is usually not considered although there is evidence for its differential effect on benefit.⁵⁶ Hence, overall, research evidence for the efficacy of PPT has to be rated as preliminary but promising.

Positive Psychotherapy for People with Severe Mental Illness

There is strong evidence that subjective well-being is not only a desirable outcome in its own right, but also a significant predictor of symptomatic response in the treatment of people with schizophrenia^79,80 and is strongly associated with medication compliance in this group.¹⁵ However, no established structured intervention exists for increasing the subjective well-being of people with severe mental illnesses.

Given the evidence from other client groups outlined in the Table, including depression,^20,73,75,76 those with suicidal ideation⁷⁶ and suffering from substance abuse disorders,⁷⁴ PPT appears to be a promising approach for also increasing well-being in people with severe mental illness. Furthermore, preliminary evidence exists for its feasibility and potential usefulness in people with psychosis. A small uncontrolled study of 6-session PPT over 10 weeks showed significant increases in well-being, savouring beliefs, hope, self-esteem, and personal recovery scores as well as a decrease in paranoid, psychotic, and depressive symptoms.⁷⁸

However, despite aiming to adapt the intervention for people with cognitive impairments, feedback indicated that most participants found it difficult to understand.⁷⁸ The study did not elicit any specific modifications to the intervention for the client group and did not attempt to account for the social-cultural context.

To deal with the challenge of culture and context, 14-session PPT was adapted for clients with severe mental illness in South London, a multicultural European city. This involved a systematic review on well-being,⁸¹ a qualitative study exploring the processes of improving well- being in people with psychosis,⁸² and a qualitative study and expert consultation to adapt PPT for the new client group.⁸³ Evidence from a pilot randomised controlled trial⁸⁴ testing the adapted PPT intervention, i.e. WELLFOCUS PPT, appears promising, particularly in terms of symptom reduction. Well-being remains a difficult-to-target domain. This may be due to conceptual problems, measurement issues, or intervention variables such as timing and follow- up.

Overall, PPT can be seen as a promising intervention to support recovery in people with common mental illness, and preliminary evidence suggests it can also be helpful for people with more severe mental illness such as psychosis. Fully supporting recovery requires a focus on well-being in addition to standard service outcome variables such as symptoms or service use. More conceptual work may be needed in this client group to define and conceptualise well-being, and to identify shared and distinguishing features compared to other concepts such as quality of life or happiness⁸⁵ and recovery.⁸⁶ A theoretically defensible conceptual underpinning may help address the problems of measuring such a highly complex and individual construct. Finally, further optimisation of PPT and evaluation in a definitive randomised controlled trial will generate the evidence base for how PPT can support well-being — and through that recovery — in people with severe mental illness.

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