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By Milton Spett
The core theoretical concept of positive psychotherapy (PPT) (Seligman et al. American Psychologist, Nov. 2006) is that increasing positive experiences and emotions is more beneficial to our patients than reducing dysfunctional cognitions and behavior. Beck asserts that negative cognitions cause negative emotions, but Seligman argues that negative emotions cause negative cognitions.
According to Seligman, depression (and probably other disorders) can be more effectively treated by helping patients to:
1. Increase positive emotions.
2. Engage more fully in life.
3. Find meaning in life. This refers to joining and serving some cause that is bigger than oneself, such as religion, politics, profession, family, community, or nation.
Techniques for Increasing Positive Emotions
Savoring: Fully experience and enjoy activities you normally rush through. For example, savor your food, focusing on the taste, temperature, and feel of each piece of food in your mouth.
Three Blessings Exercise: Every night before you go to bed, write down three good things that happened that day, and why they happened. Research has found this exercise to be the most valuable of those exercises studied.
Gratitude Letter: Choose a person who has done something important for you, whom you have never thanked properly. Write down exactly what that person did and exactly how this helped you. Then read the letter to that person.
Comparison Exercise. To more fully appreciate what you have, think about others who are worse off than you.
Techniques for Engaging Fully in Life
Signature Strengths: Write down your most important strengths. These are personal characteristics that are universally valued such as creativity, bravery, kindness, fairness, forgiveness, gratitude, and honesty. Patients can use the “VIA Signature Strengths Questionnaire” at www.AuthenticHappiness.org to identify their signature strengths.
Using Strengths: Every day, do one thing which utilizes a signature strength in a new way.
Strength Stories: Tell someone about a time when you used one of your signature strengths.
Active/Constructive Responding: Tell another person very specifically what you admire about them or something they did.
Life Legacy: Write down how you would like to be remembered.
Create “Flow” (total involvement in what you are doing): Match endeavors with skills to create flow. An endeavor that is too difficult causes anxiety. An endeavor that is too easy causes boredom.
Lets Go to the Research
Seligman et al. report on two studies. The first study found that for patients with Beck Depression Inventory (BDI) scores of 10 to 24, positive psychotherapy was superior to a no-treatment control group on both the BDI and the Satisfaction With Life Scale. These advantages remained at the three-month, six-month, and one-year follow-ups.
In the second study with patients who met the criteria for major depression, PPT led to significantly more symptomatic improvement, remission from major depression, and happiness, compared to both treatment as usual (TAU) and TAU + medication. In this second study, PPT patients received a combination of PPT and standard CBT interventions. This was because depressed patients expect to talk about their troubles and might experience the failure to do so as unempathic. Treatment as usual therapists provided whatever treatment they deemed appropriate.
Seligman et al. note that there is a noticeable dropout rate in traditional CBT. In their second study only 13% of the PPT patients dropped out compared with approximately 35% in the treatment as usual groups. The authors suggest that the CBT focus on cognitive errors and faulty information processing may be counterproductive by intensifying patients’ negative feelings and impeding the therapeutic alliance.
It is difficult to draw any conclusions from these studies because the first study had no comparison treatment, and the second study did not include a specific comparison therapy that has been shown to be effective for depression. Nevertheless, combining PPT interventions with CBT interventions appeals to common sense, and the lower dropout rate for PPT is suggestive.
Clinical Vignette: Annie suffered from generalized anxiety disorder and low self-esteem. She had trouble keeping up in school, believed that she was stupid, and viewed herself as a “loser.” She began to make progress only when I stopped disputing her self-criticisms and started pointing out her unusual competence and success in handling a wide variety of difficult relationship problems.
Conclusion: PPT interventions, especially focusing on signature strengths, are very effective with many patients. These interventions are particularly useful in establishing a strong therapeutic alliance in the initial session or sessions. Until research tells us when to use which PPT interventions, we must rely on our common sense and our clinical judgment in deciding when to employ CBT techniques and when to use PPT interventions.
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