Positive Psychotherapy: Using Strengths to Promote Balance

Editor’s note: Tayyab Rashid, PhD, CPsych, is a clinical psychologist at the University of Toronto in Scarborough. His continuing education presentation for GoodTherapy.org, titled Positive Psychotherapy: The Application of Positive Psychology in Clinical Settings, is scheduled for 9 a.m. PDT on June 20. This event, free to GoodTherapy.org members, is good for two CE credits. For details, or to register, please click here ^[1].

Positive psychotherapy (PPT) is a therapeutic endeavor of the contemporary movement of positive psychology ^[2]. While the traditional therapies target symptoms and positive interventions target strengths, PPT systematically amplifies positive resources; specifically, positive emotions, character strengths, meaning, positive relationships, and intrinsically motivated accomplishments. Positive psychotherapy neither suggests that other psychotherapies are negative nor is meant to replace empirically validated treatments. PPT is about redesigning the therapeutic landscape—allocating equal attention and effort to positives as much to negatives. It is meant to be an incremental change to balance therapeutic focus on strengths and weaknesses.

Focusing exclusively on negatives or positives in psychotherapy might be easier. But integrating both to strike a balance that captures the essence of the people we treat is challenging, if not impossible. PPT attempts to integrate symptoms with strengths, risks with vulnerabilities, weaknesses with virtues, and deficits with skills to discern inherent complexities of people in a balanced way. This doesn’t reduce people to mere conglomerate of syndromes nor enhances them to embodiments of strengths.

Positive psychotherapy acknowledges that, all things being equal, the human brain is not defaulted to neutral. It attends and responds more strongly to negatives than to positives. Psychopathology exacerbates this propensity. Cultivation of positives for people in therapy, therefore, becomes even harder, and dwelling on negatives easier. However, if psychotherapy can create a process, help people to rise above their default and learn to attend and amplify their positives, it could not only eliminate symptoms but also engender well-being. The toughest challenges of life require exploring and using the toughest internal resources, which in turn build resilience.

Therefore, PPT’s central premise is that accentuation of strengths, along with amelioration of symptoms, is a better therapeutic approach. Much like health is better than sickness, security is better than fear ^[5], relaxation is better than stress ^[6], co-operation is better than conflict, and hope ^[7] is better than despair. Indeed, there are exceptions when negatives may be more appropriate, but generally, positives are more adaptive and functional than negatives.

Positive psychotherapy is based on three assumptions. First, people inherently desire growth, fulfillment, and happiness ^[8] instead of just seeking to avoid misery, worry ^[9], and anxiety ^[10]. Psychopathology engenders when the growth is thwarted. Second, positive resources such as strengths are authentic and as real as symptoms and disorders. These are not defenses, Pollyanna-ish illusions, or clinical byproducts of symptom relief that lie at the clinical peripheries without needing attention. The final assumption is that effective therapeutic relationships can be formed through the discussion and manifestation of positive resources, not just thorough lengthy analysis of weaknesses and deficits.

PPT is primarily based on Seligman’s notion of happiness and well-being (Seligman, 2002 and 2012). Seligman parses highly subjective notions of happiness and well-being into five scientifically measurable and manageable components: (1) positive emotion, (2) engagement, (3) relationships, (4) meaning, and (5) accomplishment, with the first letters of each component forming the mnemonic PERMA (Seligman, 2011). These elements are neither exhaustive nor exclusive, but it has been shown that fulfillment in these elements is associated with lower rates of depression ^[11] and higher life satisfaction (Bertisch et al., 2014; Headey, Schupp, Tucci, and Wagner, 2010; Sirgy and Wu, 2009).

It should also be noted that Peseschkian in Germany has also worked on positive psychotherapy ^[12] for more than 20 years and is distinct from PPT discussed here. Peseschkian’s approach to therapy is inherently and systematically integrative, incorporating cross-cultural, multidisciplinary, therapeutically, and psychologically inter-theoretic (Peseschkian, 2000). PPT, on the other hand, is rooted in the current movement of positive psychology.

PPT can be divided into three phases (see Table 1). The first phase focuses on helping people to articulate a balanced narrative and by exploring their strengths from multiple perspectives. Personally meaningful goals are framed using strengths of people in therapy. The middle phase focuses on cultivating positive emotions and confronting, in a supportive way, negative memories, experiences, and feelings which keep people stuck—thwarting their growth. The final phase focuses on exploring positive relationships and facilitating processes which nurture these relationships, and on exploring meaning and purpose.

Throughout the course of PPT, people explore their strengths and gradually take deeper dives to reflect, introspect, acknowledge, attribute, and amplify them, without dismissing, minimizing, or overlooking their problems. For example, PPT engages people in discussions about, say, an injustice done whilst also focusing on recent acts of kindness. Similarly, along with insults, hubris, and hate, experiences of genuine praise, humility, and harmony are deliberately elicited. Pain associated with the trauma ^[13] is empathetically attended to whilst also exploring the potential for growth. A critical component of this integration is to help people learn ways to use their strengths to solve problems that might be maintaining their symptoms. People are encouraged to develop practical wisdom and psychological flexibility through the careful consideration of which signature strength is relevant to the problem, whether it conflicts with other strengths (e.g., should one be honest or kind?), and translate abstract signature strengths into concrete attainable and sustainable actions and habits (Kashdan and Rottenberg, 2010).

PPT has been empirically validated through 13, albeit small, pilot studies, including eight randomized and five nonrandomized studies conducted by using a PPT manual, treating depression, anxiety, schizophrenia ^[14], and borderline personality. Results of these studies show that PPT is effective, with moderate effect sizes in reducing symptoms and enhancing well-being. PPT does equally well when compared with well-established treatments such as cognitive behavioral therapy (CBT) ^[15] or dialectical behavior therapy (DBT) ^[16]. For a summary of these studies, please see Rashid (in press; Rashid and Seligman, 2013; Seligman, Rashid, and Parks, 2006).

Exercises in PPT work due to a number of factors. For example, these exercises reeducate attention, memory, and expectations away from the negative and catastrophic, and toward the positive and optimistic ^[17] outcomes. For example, when a person keeps a gratitude ^[18] journal, the bias toward ruminating only about what has gone wrong is counteracted. The person is more likely to end the day remembering positive events and completions, rather than troubles and unfinished business. Similarly, the gratitude visit may shift a person’s memory away from the unfavorable aspects of past relationships to savoring the good things about interactions with friends and family. This reeducation of attention, memory, and expectation is accomplished verbally as well as via journal writing. The identification and use of signature strengths allows people to think more deeply about their positive qualities, which is likely to bolster self-confidence and prepares them to better handle adversities.

Like any therapeutic endeavor, PPT is not immune from triggering ^[19] or even causing negative and uncomfortable emotions. For example, awareness of strengths may be uplifting, but this could be dampened by realization that surrounding environments are not conducive to express, use, or enhance these strengths. People may also feel uncomfortable that they are kind, forgiving, and prudent. However, these very strengths may be taken for granted by others. The therapist attends and attunes to nuances of strength expressions and invites creativity to develop insights and prepares people to behave differently and more adaptively. Thus, PPT, despite its apparent emphasis on positives, is not exclusively about positives. Rather, it is about developing refined understanding of integration of positives and negatives.

Positive psychology in general is criticized for overlooking negatives. It would be naive and utopian to conceive of a life without negative experiences. As such, PPT does not deny negative emotions nor encourage people to see the world through rose-colored glasses. Rather, it aims to validate these experiences, whilst gently encouraging people to explore their effects and seek out potential positives from difficult and traumatic experiences. During these explorations, the therapist needs to be careful to avoid offering empty platitudes, such as pointing out the positive opportunities that trauma, loss, or adversity may present for a person’s development and growth. Amid the warmth, understanding, and goodwill created in the therapeutic milieu of PPT, listening mindfully and facilitating affective expression allows the therapist to help people explore, reflect upon, and notice both successes and setbacks. In so doing, people can learn how to encounter negative experiences with a more positive mind-set and reframe and label those experiences in ways that are helpful. By working diligently to articulate the genuine and authentic positives of a person’s experience, the PPT therapist does not create a Pollyanna-ish or Pangloss-ian epitome of happiness or a caricature of positive thinking. The therapist neither minimizes, nor masks as positives, unavoidable negative events and experiences such as abuse, neglect, and suffering. Such issues are dealt with in PPT using standard clinical protocols.

In conducting PPT, some caveats are in order. First, PPT is not prescriptive. It is a descriptive approach based on converging scientific evidence which documents the benefits of attending to the positive aspects of human experience. Second, PPT is not a panacea, nor is it appropriate for all people in all situations. It is not a “one-size-fits-all” approach. Furthermore, in PPT, therapists should not expect a linear progression of improvement, as the motivation to change long-standing behavioral and emotional patterns fluctuates during the course of therapy. Finally, rigorous outcome studies are needed to extrapolate generalizability and articulate the role of mediating variables.

Table 1: Positive Psychotherapy (PPT): An Overview of PPT Model

Session and Topic		Description
1	Orientation to PPT; lack of positive resources	Psychological distress is discussed as lack of or diminished positive resources such as positive emotions, engagement, relationships, meaning, and accomplishment (PERMA). Exercise: Person writes one-page, real-life story which called for the best in him or her and which ends positively, not tragically.
2	Character strengths	Character strengths are introduced. Notion of engagement and flow is discussed. Exercise: Person identifies his or her signature strengths in-session and completes an online self-report measure at home. Two others (a family member and a friend) also identify (not rank) the person’s five most salient signature strengths.
3	Signature strengths and positive emotions	Signature strengths are discussed. Person compiles his or her signature strengths profile, incorporating various perspectives. Exercise: Person devises specific, measurable, and achievable goals targeting specific problems. The benefits of positive emotion are discussed. Exercise: Person starts a “blessing journal” to record three good things every night (big or small).
4	Good vs. bad memories	The role of negative memories is discussed in terms of how they perpetuate psychological symptoms. The role of good memories is also highlighted. Exercise: Person writes about feelings of anger and bitterness and their impact in perpetuating distress.
5	Forgiveness	Forgiveness is introduced as a tool to transform anger and bitterness and to cultivate neutral or positive emotions. Exercise: Person describes a transgression, its related emotions, and pledges to forgive the transgressor. Letter is not necessarily delivered.
6	Gratitude	Gratitude is discussed as an enduring thankfulness. The roles of good and bad memories are discussed again, with an emphasis on gratitude. Exercise: Person writes and delivers in person a gratitude letter to someone he or she never properly thanked.
7	Mid-therapy check	The forgiveness and gratitude assignments are followed up. Experiences related to signature strengths and “blessing journal” activities are discussed. Person in therapy and therapist discuss therapeutic gains, hurdles, and ways to overcome these hurdles. Exercise: Person completes the forgiveness and gratitude assignments.
8	Satisficing vs. maximizing	Concepts of satisficing (good enough) and maximizing are discussed. Exercise: Person devises ways to increase satisficing.
9	Hope and optimism	Optimism and hope are discussed in detail. Person thinks of times when important things were lost but other opportunities opened up. Exercise: Person thinks of three doors that closed and then asks, “What doors opened?”
10	Positive communication	Active-constructive—a technique of positive communication—is discussed. Exercise: Active-constructive responding: Person looks for active-constructive opportunities.
11	Signature strengths of others	The significance of recognizing and associating through character strengths of family members is discussed. Exercise: Family strengths tree: Person asks family members to take the complete signature strength measure. A family tree of strengths is drawn up and discussed at a gathering.
12	Savoring	Savoring is discussed, along with techniques and strategies to safeguard against adaptation. Exercise: Savoring activity: Person plans a savoring activity using specific techniques.
13	Gift of time and positive legacy	The therapeutic benefits of helping others are discussed. Exercise: Gift of time: Person makes plans to give the gift of time doing something that also uses signature strengths. Person writes a brief description how he or she would like to be remembered.
14	The full life	Full life is discussed as the integration of pleasure, engagement, and meaning. Therapeutic gains and experiences are discussed, and ways to sustain positive changes are devised.

References:

1. Bertisch, H., Rath, J., Long, C., Ashman, T., and Rashid, T. (2014). Positive psychology in rehabilitation medicine: A brief report. Neuro Rehabilitation. doi:10.3233/NRE-141059
2. Headey, B., Schupp, J., Tucci, I., and Wagner, G. G. (2010). Authentic happiness theory supported by impact of religion on life satisfaction: A longitudinal analysis with data for Germany. The Journal of Positive Psychology, 5, 73–82.
3. Kashdan, T. B., and Rottenberg, J. (2010). Psychological flexibility as a fundamental aspect of health. Clinical Psychology Review, 30, 865–878.
4. Peseschkian, N. (2000). Positive Psychotherapy. New Delhi: Sterling Publishers.
5. Rashid, T. (in press). Positive Psychotherapy: A strength-based approach. Journal of Positive Psychology.
6. Rashid, T., and Seligman, M. E. P. (2013). Positive Psychotherapy. In D. Wedding and R. J. Corsini (Eds.), Current Psychotherapies. Pp. 461-498. Belmont, CA: Cengage.
7. Seligman, M. E. P. (2011). Flourish: A visionary new understanding of happiness and well-being. New York: Simon & Schuster.
8. Seligman, M. E., Rashid, T., and Parks, A. C. (2006). Positive psychotherapy. American Psychologist. 61, 774-788.doi: 10.1037/0003-066X.61.8.774
9. Sirgy, M. J., and Wu, J. (2009). The pleasant life, the engaged life, and the meaningful life: What about the balanced life? Journal of Happiness Studies, 10, 183–196.