Running Title: Positive Psychology and Mental Illness

Cite as: Schrank B, Brownell T, Tylee A, Slade M (2014) Positive psychology: An approach to supporting recovery in mental illness, East Asian Archives of Psychiatry, 24, 95-103.

Positive psychology: an approach to supporting recovery in mental illness

Running title: Positive psychology and mental illness

Authors: Beate Schrank, MD1,2; Tamsin Brownell, MSc1; Andre Tylee, PhD1; Mike Slade,

Affiliations:

1 King’s College London, Institute of Psychiatry

2 Medical University of Vienna, Department of Psychiatry and Psychotherapy

Corresponding author:

Beate Schrank

Health Service and Population Research Department (Box P029), King's College London,

Institute of Psychiatry, Denmark Hill, London SE5 8AF

Email: [email protected]

Phone: 020 7848 0704

Fax: 020 7848 5056

1 Abstract

Objectives: This paper reviews the literature on positive psychology with a specific focus on people with mental illness. It describes the characteristics, critiques and roots of positive psychology (PP) and positive psychotherapy (PPT), and summarises the existing evidence on PPT.

Results: PP aims to re-focus psychological research and practice on the positive aspects of experience, strengths and resources. Despite a number of conceptual and applied research challenges the field has rapidly developed since its introduction at the turn of the century and today serves as an umbrella term to accommodate research investigating positive emotions and other positive aspects, such as creativity, optimism, resilience, empathy, compassion, humour, or life satisfaction. PPT is a therapeutic intervention that evolved from this research.

It shows promising results for reducing depression and increasing wellbeing in healthy people and those with depression. PP and PPT are increasingly being applied in mental health settings, but research evidence involving people with severe mental illness is still scarce.

Conclusions: The focus on strengths and resources in PP and PPT may be a promising way to support recovery in people with mental illness, such as depression, substance abuse disorders and psychosis. More research is needed to adapt and establish these approaches and provide an evidence base for their application.

Key Words: rehabilitation, psychiatry, psychology, psychotherapy, health services

2 What is Positive Psychology?

The academic discipline of Positive Psychology (PP) developed from Martin Seligman’s 1998

Presidential Address to the American Psychological Association1. He maintained that psychology so far had mostly addressed only one of its original aims, i.e. curing mental illness, whilst largely neglecting the two 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 Psychology Association to initiating a shift in psychology’s focus towards the positive aspects of human experience, positive individual traits, and more generally the positive features 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” (p.5).

Seligman and Csikszentmihalyi2 originally conceptualised Positive Psychology as a “new movement” (p. 5) 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 on ill health. A number of definitions of PP have since been proposed but no clear boundaries defined for the field. A systematic review conducted in 2011 found 53 published definitions of PP spanning six 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 stress3.

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 funders4. PP has also received broad and international media coverage.

3 Along with the rapid evolution of Positive Psychology and the extensive publicity, PP also generated some criticism which falls into five overlapping domains. First, PP was criticised for denying or openly devaluing closely related prior work5. Early stage publications were met with strong disapproval due to their implicit or explicit assumption that PP had newly created its constituent topics of interest6. 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), others topics in PP were less popular before and boosted through the introduction of PP, e.g. gratitude, forgiveness, awe, inspiration, hope, curiosity, or laughter7.

A second concern was that PP rhetoric was polarising and created a false dichotomy of a new ‘positive’ and an old ‘negative’ or ‘usual’ psychology8,9. 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 emotions9, and helping people to avoid difficult but necessary therapeutic processes10.

A third criticism concerns the feasibility of discriminating positive and negative variables. This criticism pertains to two 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 negative8,11. 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 optimists12. 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 a positive or negative valences without regard for wider context may create research results of questionable value and generalizability8.

4 The fourth criticism is that PP concepts neglect the cultural context of human activity, and reflect the individualism ethic of American society13. Identity, virtue, or a ‘good life’ may have different meanings in different cultures, so it may be difficult to arrive at one universal definition of such concepts6. The same issue has been explored in relation to recovery14.

Applying a narrow set of values may lead to research results that are not generalizable 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 happiness9,15. Despite the repeated reference to Aristotle, ethical considerations were found largely missing16. This relative lack of attention to conceptualisation and theoretical underpinnings may arise from the emphasis within PP research on empiricism.

PP has come a long way in response to these criticisms. Pre-existing resource oriented psychological approaches and research on positively framed topics are now acknowledged17.

PP 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 focussing on responding to problems, PP focusses on the need to identify the positive qualities that help individuals to not only overcome problems, but also to go forward and flourish2. Furthermore, positive psychology 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 focussing on “understanding the entire breadth of human experience, from loss, suffering, illness, and distress through connection, fulfilment,

5 health, and wellbeing.”4. The potentially over-simplified division of positive and negative 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 interventions18. 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 PP17. 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 PP6.

Historical developments and predecessors of Positive Psychology

A number of researchers and therapists have framed their approach as positive, strengths 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,

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, provided people focus on and practice positive mental suggestions19. PP interventions today also include exercises that aim to re-focus attention towards the positive20.

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

6 mental life for the individual19. 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 focussed 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 the person. He considered the three

“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 wellbeing. However, in comparison with PP it more strongly stressed the social embeddedness and connectedness of the individual21.

Similar to Martin Seligman, Abraham Maslow, who founded Humanistic Psychology in the

1950’s, criticised the fact that psychology had focussed too much on negatives, illnesses and sins, instead of potentials, virtues, aspirations and psychological height22. He 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. Maslow even used the term ‘positive psychology’. Of all predecessors, humanistic psychology bears most resemblance with PP in that they both aim to focus on what is healthy and growth oriented within people23.

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-judgmental and unconditionally positive regard is adopted towards clients in order to help them realise their true positive potential24. Further contemporary resource oriented therapeutic approaches include systemic family therapy; solution focussed therapy; socio-therapy and therapeutic communities; music therapy; self-help groups and mutual support groups; peer support and

7 consumer led services; and befriending25. 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), focussing on strengths (e.g. solution focussed therapy), or on social relationships (e.g. befriending).

Research evidence in PP

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 wellbeing2,26. The reliance on quantitative scientific methods was initially also used to set the Positive Psychology movement apart from earlier approaches to human flourishing, which may arguably have placed more emphasis on qualitative research23,27.

In terms of content, today Positive Psychology serves as an umbrella term to accommodate research endeavours which started both before and after the introduction of the movement by Seligman and Csikszentmihalyi. Related research spans a diverse range of disciplines, such as education28, organizational behaviour management29, sport psychology30, family medicine31, cancer care32 and brain injury rehabilitation33. 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 satisfaction34.

These have informed the creation of systematic measures of character strength and virtues26. This variety of topics and areas makes it difficult to place specific research within or outside the spectrum of PP.

8 Among the areas of work in positive psychology research is the development and investigation of strategies that would make people permanently happier. A range of approaches intended to promote wellbeing have been tested in intervention research, such as mindfulness therapy, forgiveness therapy, gratitude therapy and various forms of wellbeing therapy35. Some of the most promising amongst the strategies have been combined into one overall intervention manual named Positive Psychotherapy (PPT)26.

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 specialists36. Indeed, recent public health literature reflects an increased focus on psychological health and wellbeing in addition to disorder and disability37. Reasons why such a shift may be beneficial include the high prevalence of mental health problems and the possible preventive value of fostering wellbeing 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 wellbeing in the general population”38 (p.71), suggesting that the promotion of wellbeing 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 wellbeing 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 roles39. These goals of the recovery movement appear highly

9 congruent with those of PP. The two movements, recovery and PP, are complementary39,40.

They share a similar focus, but the former has so far been largely built on personal accounts, theories, and opinions with empirical research lagging behind41, while the latter offers a quantitative research focus in need of defensible theories and contextual knowledge on which to base its application.

While PP 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 (p.5) – PP approaches have since been successfully expanded to various populations including people with disorders and in adverse conditions.

Positive Psychotherapy

One therapeutic approach to evolve from Positive Psychology is Positive Psychotherapy

(PPT)20,26, which aims to increase wellbeing in its recipients20. It has to be distinguished from two 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 one positive psychotherapy approach in the 1970s which assumes that people have two basic capacities: to love and to know. It is a conflict-centred and resource-oriented psychotherapy that also works with the unconscious42,43. Further examples are Milton Erickson’s hypnotherapy approach which he framed in a positive way, causing some authors to call his methods positive psychotherapy44, and positive group therapy for cancer patients, focussing on post-traumatic growth45.

10 Second, other therapies have aims similar to Positive Psychotherapy, i.e. to attain wellbeing, happiness, or a good life, but they use different strategies to reach these aims. Examples include Fordyce’s (1977)46 “happiness intervention”, Fava et al’s (1998)47 “wellbeing therapy” and Frisch’s (2006)48 “quality of life therapy”. These all offer a wellbeing or life satisfaction component but attend to troublesome issues and problems first and treat wellbeing as an add-on. This distinguishes them from PPT which has as its primary focus personal strengths, positive emotions and other positive resources to indirectly target symptoms and deficits.

PPT was developed originally 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 meaning20,49. The intervention is based on Seligman’s early theory of authentic happiness, in which a good life consists of three components: (i) positive emotions (the pleasant life), (ii) engagement (the engaged life), and (iii) meaning (the meaningful life).

Similar to cognitive behavioural therapy (CBT) for depression50, 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 toward the positive and the hopeful20. 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 denied51, in part they are even explicitly elicited, but in doing so clients are encouraged to focus on positive aspects of such experiences.

11 There are five fundamental principles of PPT52. First, PPT broadens and builds therapeutic resources, similar to other psychotherapies. PPT broadens the client’s perspective by encouraging him to undertake exercises which can elicit positive emotions, help generate new ideas and more positively frame difficult situations. Second, PPT exercises use specific strategies to help clients think about negative situations by conducting careful positive reappraisals. Third, PPT also includes experiential and skills-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.

PPT 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 one or more of the three components of authentic happiness20,51. 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 others52. 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 and 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 wellbeing and decreased depressive symptoms for people with depression53. A more recent meta-analysis of 39 positive psychology randomised studies involving a total of

12 6,139 participants also concluded that positive psychology interventions can be effective in enhancing subjective and psychological wellbeing and reducing depressive symptoms54.

Several of the included interventions successfully used single components of PPT. For example, undergraduate students writing about “one’s best possible self” showed increased wellbeing55; students writing about intensely positive experiences each day for only three days enhanced positive mood and decreased health centre visits for up to three months 56; and students and people with neuromuscular disease keeping a blessings journal for 10 week also showed increased wellbeing57. Individual PPT exercises were also tested in RCTs with self-referred general population samples 58-60 and including mildly depressed people61 against no-treatment control and placebo (e.g. recording childhood memories) showing significantly positive effects of PPT exercises on happiness and 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 wellbeing and high self-criticism, especially when doing active as compared to passive exercises62. However, while individual exercises may produce benefits, there is also evidence for a dose response relationship. An RCT assigning healthy individuals to receiving two, four, or six exercises over six weeks or a no-treatment control showed that those receiving two or four exercises experienced significant decreases in depressive symptoms61. Meta-analysis confirmed that assigning multiple and different positive activities in general is more effective than employing just one63.

PPT 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 Table

--- Table 1 here –

13 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 benefits64. 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 wellbeing is not only a desirable outcome in its own right, but also a significant predictor of symptomatic response in the treatment of people with schizophrenia78,79 and is strongly associated with medication compliance in this group15.

However, no established structured intervention exists for increasing the subjective wellbeing of people with severe mental illnesses.

Given the evidence from other client groups outlined in Table 1, including depression20,72,74,75, those with suicidal ideation75 and suffering from substance abuse disorders73, PPT appears to be a promising approach for also increasing wellbeing 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 six-session PPT over 10 weeks showed significant increases in wellbeing, savouring beliefs, hope, self-esteem, and personal recovery scores as well as a decrease in paranoid, psychotic, and depressive symptoms77.

However, despite aiming to adapt the intervention for people with cognitive impairments, feedback indicated that most participants found it difficult to understand77. 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 a multicultural European city, i.e. South London. This involved a

14 systematic review on wellbeing80, a qualitative study exploring the processes of improving wellbeing in people with psychosis81, and a qualitative study and expert consultation to adapt

PPT for the new client group82. Evidence from a pilot RCT83 testing the adapted PPT intervention, i.e. WELLFOCUS PPT, appears promising, particularly in terms of symptom reduction. Wellbeing 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, positive psychotherapy 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 wellbeing 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 wellbeing, and to identify shared and distinguishing features compared to other concepts such as quality of life or happiness84 and recovery85. 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 wellbeing – and through that recovery – in people with severe mental illness.

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23 Table 1: Evidence on PPT in healthy people and people with somatic and mental illnesses Reference Design Populatio Recruitment N Control Group(s) PPT Intervention Assessment Results n from Times Healthy individuals and community samples

Lü 201365 RCT College College 34 No treatment adapted from 6- Baseline, post- PPT group showed students psychology session PPT, for treatment a significant with high class 16 weeks increase in and low positive trait affect trait positive affect Significantly Parks-Sheiner RCT University Mass 110 No treatment 6-session PPT, for Baseline, post 66 improved 2009 students university 6 weeks intervention, 3, 6 depression in with mild- email and 12 month Study 1: intervention group moderate follow-ups post-treatment, depression maintained until 6-months follow- up. Significant increase in life satisfaction in both groups post- treatment Study 2: RCT Communit Internet self- 361 No treatment 6-session PPT, for Baseline, post No significant y sample referral 6 weeks intervention, 1, 3, results for 6, 12 month depression, follow-ups life satisfaction or positive emotion Study 3: RCT Communit Internet self- 267 No treatment 6-session PPT, for Baseline, post Significant y sample referral 6 weeks intervention, 1 and decrease in 3 month follow- depressive ups symptoms in PPT group post- intervention, not maintained at follow-up. Significant increase in life satisfaction in

24 PPT group post- intervention, maintained at 1 month follow up. No significant result for positive emotions Rashid 2004 67 RCT Not stated Not stated 65 Not stated Readings, Not stated Significant watching assigned increase in abstract only films on character character strength strengths, writing in intervention reaction papers compared to weekly, class room control group discussions and out-of-class exercises Rashid 2008 68 RCT Middle Not stated – 22 None Not stated – Not stated – Limited school abstract only abstract only abstract only description. students “Substantial” change in happiness reported for the intervention group compared to control group. Ouweneel 2013 69 Controlled trial Communit Website self- 311 No treatment 25 online Baseline, post- significantly with self-selection y sample referrals assignments over intervention stronger increase to intervention or 8 weeks, covering in self-efficacy control three areas: levels and positive happiness, goal- emotions in setting and intervention resource-building compared to control group Goodwin 2011 70 Uncontrolled Communit Internet, 11 None adapted from 6- Baseline, post- No significant study y sample flyers, session PPT, with treatment changes in with high 5 additional relationship anxiety Professional exercises, for 10 functioning, scores referrals weeks relationship satisfaction, stress or anxiety

25 Somatic disorders

Huffman 2011 71 RCT Acute Three 30 Active control, i.e. meditation. 8 weekly exercises, Baseline, post- The PPT group cardiovasc inpatient with weekly intervention showed greater ular cardiac units Attentional control, i.e. recalling events telephone calls: improvement in disease from past week (1) three good depressive things, (2) symptoms, anxiety, gratitude, (3) best happiness and possible self health-related (health), (4) best quality of life possible self compared to the (relationships), (5) two control and (6) three acts conditions post- of kindness and intervention (7) and (8) a repeat of one component Mental disorders

Asgharipoor RCT Out- Referral by 18 CBT 12 weekly Baseline, post- Significant 201272 patients therapists sessions, unclear intervention increases in with major use of exercises happiness in both depressive focusing on the groups. disorder three domains of a good life Seligman 2006 20 RCT Mild to University 40 Placebo therapy, i.e. recording earliest 6 session PPT, 6 Baseline, post The intervention moderately attended – memories weeks intervention, 3, 6, group showed a Study 1: -depressed method 12 month follow significant students unclear up decrease in depressive symptoms at 6 and 12 month follow up compared to control group. No significant changes in life satisfaction. Study 2: RCT Severely Referred from 46 Two control groups: treatment as usual 14 session PPT, 12 Baseline, post The intervention depressed Counselling with or without anti-depressant medication weeks intervention group showed less students and depressive Psychological symptoms, better

26 Services at overall University of functioning, Pennsylvania higher life satisfaction and happiness compared to both control groups post-intervention.

Study 3: Uncontrolled Communit Website self- 50 None Exercises from 14- Baseline, post- Limited study y sample referrals session PPT: 1 intervention description. In the with exercise a month (tested after each first month, 50 depression for a user- exercise) subscribers had determined baseline score number of months indicating severe depression. After each completed the three blessings task and returned to the website approx. 14 days later, 94% were less depressed (mild-moderate depression) Akhtar 2010 73 Controlled trial – Young Alcohol and 20 No treatment 8 weekly sessions Baseline, post- Significant not stated if adults (14- drug including intervention, 6 and increase in randomised 20 years) treatment savouring, 12- week follow- happiness, with service for gratitude, ups optimism and substance young people strengths, positive emotions abuse relaxation, goal- post-intervention issues setting, in intervention relationships, group, and nutrition and decrease in resilience. happiness, optimism and positive emotions in control group. Cuadra-Peralta Quasi- Outpatient Mental health 18 CBT 9 weekly sessions Baseline, post Positive 2010 74 experimental, s with clinic in Chile adapted from 14- intervention psychology was

27 comparing PPT to depression session PPT more effective existing CBT than behavioural group. therapy in decreasing depressive symptoms Huffman 2014 75 Uncontrolled People Inpatient 61 None 9 exercises, 1 each Pre and post each All exercises were study with psychiatric day: gratitude, exercise associated with suicidal unit strengths, acts of significant ideation or kindness, improvements in behaviours meaningful hopelessness and activities, counting optimism, except blessings, best for optimism possible self, following the forgiveness and forgiveness behavioural exercise (which commitment saw a small improvement) Kahler 2013 76 Uncontrolled Communit self-referral 19 None Adapted from 6- Baseline, after Inferential study y sample from session PPT, 7 each session, post- statistics not wanting to newspaper weeks, plus intervention, 5, 13, calculated. 6 stop advert, radio, transdermal 23 week follow- participants smoking TV, facebook, nicotine patch for ups ceased smoking and with community 8 weeks and were abstinent low events at 23 week follow- positive up. No substantial affect mood changes during or after the intervention Meyer 2012 77 Uncontrolled People Mental health 16 None adapted from 6- Baseline, post- Significant study with services in the session PPT, for intervention, post increase in schizophre US 10 weeks, plus booster session wellbeing, nia booster session savouring beliefs, after 16 weeks hope, self-esteem and personal recovery scores, and significant decrease in symptom severity post-intervention.

28 Results maintained at 16- week follow-up except for self- esteem