CBT and Positive Psychology

While CBT is now well established as treatment for many disorders and has been widely disseminated, Positive Psychology and, in particular, how this approach can be helpful with psychological problems is less familiar to many therapists. The therapy approach which has been labelled Positive Psychotherapy (Rashid and Seligman 2018) stems from Positive Psychology which has accumulated a considerable literature and is associated with the work of Martin Seligman, Barbar Frederickson, Sonya Lyubomirsky and others. Many readers may be familiar with concepts like Gratitude, Random Acts of Kindness and Benevolence but may not be aware of ways of turning these into therapeutic interventions. The book mentioned above , (Rashid and Seligman 2018) is therapist guide to how to apply positive psychology principles therapeutically and there is also a sister client workbook by the same authors which are both highly recommended.

There are now 10 or more randomized controlled trails showing the benefits of Positive Psychotherapy in depression, substance abuse, BPD, PTSD and psychosis. CBT has recently incorporated some of the concepts into an integrated CBT and Positive Psychology approach in Positive CBT (Bannink, 2013) and Quality of Life Therapy (Frisch 2005). In addition, there are a textbook on this combined approach for the treatment of psychosis (Slade 2017).

While more traditional Psychotherapy including CBT as initially practiced aims largely at reducing/alleviating distress or at altering behavior, positive psychology and more modern CBT is aimed at increasing well-being and argues that distress reduction does not produce happiness or well-being and focusses on active ways to build well-being. To paraphrase Martin Seligman, we should not just remove the weeds but also grow flowers. In this same spirit, modern adaptations of traditional CBT such as Strengths-Based CBT (Padesky &Mooney 2012) and resilience-focused CBT (Neenan, 2016) often involves two distinct stages (1) symptom-reduction and problem-resolution and (2) building resilience and strengths to ensure maintenance of gains and to facilitate increased well being. In this version of CBT the desired outcome of therapy might be wellbeing, flourishing, having meaning and not just symptom reduction alone.

Research in positive psychology has consistently shown that there 5 critical factors involved in attaining well being. This is represented by the now well-known acronym PERMA which can be elaborated as follows;

Positive Emotion (the pleasant life)

Engagement (the engaged life)

Relationships (positive interactions and doing for and connecting with others)

Meaning (the meaningful life)

Accomplishment (having a sense of attaining goals)

In therapy practice there are some general strategies arising from both Positive Psychotherapy and from CBT itself and associated approaches such as Acceptance and Commitment Therapy (ACT) which can facilitate each of these 5 objectives.

*Positive Emotion

Included here might be;

- Pleasure scheduling and recording (which CBT for depression targets)

- Savoring (this strategy involves a mindful approach using all the senses to enhance the feeling of pleasure, not just doing something for pleasure)

- Mindfulness (often a part of CBT augmentation for many issues)

* Engagement

This might involve;

  - Absorption in whatever one is engaged with (this involves a mindset of deliberate attention and dealing with distractions which can be acquired as a skill)

  - Being in flow (this again refers to losing oneself in an activity or being totally mentally involved in some activity which is important to an individual)

  - Using individual “signature” strengths in practical ways (recognizing what is a strength one values such as empathy and finding ways to use it in daily life)

*Relationships

Included here might be;

- Gratitude(many therapists encourage their clients to become aware of things they are grateful for of and express gratitude for them)

• Benevolence (a focus on being helpful, gracious and generous to others which reaps benefits to the giver through positive emotional consequences)

• Altruism (shifting focus from self-involvement to other involvement as a means of enhancing relationships and personal happiness)
• Random acts of kindness (many studies show benefits to both the recipient and the person who initiates these actions)
  Forgiveness and relationship repair (ways to mend and improve damaged relationships which can draw on the Gottman Method and other interventions used in CBT for couples)

*Meaning

This might include; 

- Identifying what is valued or gives meaning to life (a therapists might ask clients what kind of person they would ideally want to be or what impact they wish to have during their lives)

- Values assessment and commitment to values-based living (this is an important part of both ACT and positive psychology and both have  questionnaires to evaluate values and how much they appear in the person’s daily life)

- Obituary or funeral tribute (this is the idea of someone considering what they would like to be said about them after their demise which dovetails with who they want to be)

- Identify signature strengths and use daily in creative ways (as an example, someone who values or has identified altruism as a strength will plan ways to implement this regularly)

*Accomplishment

To facilitate a greater sense of accomplishment many of the strategies of CBT and Behavioral activation can be helpful here and these would include; 

- Daily goal setting/activity scheduling (planning activities that are important and scheduling them on a daily basis)

- Daily review of accomplishments (at the end of the day reviewing one’s goals, how many were attained and evaluating how much accomplishment is experienced)

- Mastery and pleasure ratings (going back over the days’ activities which have been recorded and assigning pleasure and/or accomplishment ratings to each activity)

- Graded assignments (breaking down activities which are difficult into small steps to facilitate completion)

- Problem solving (having a systematic approach to solving problems which can give a sense of competency or accomplishment)

An example is given below of how a CBT therapist, incorporating some of the precepts of positive psychology involving strengths and resiliency might help a client who is struggling with a stressful current situation.  

The therapist might have the client do the following exercise.

Think of a time you handled a tough situation well/in a positive way in your past (illness, family issue, life stress). It can be a major or minor negative event that brought out the best in you.

• What was the situation exactly?
• What did you do to cope/get through/manage the situation?
• What character strengths/personal attributes do you think you showed in this situation?

Persistence __Optimism__ Open-mindedness__ Kindness__

Self-control __Forgiveness__ Keeping perspective__ Courage__

Integrity/honesty__ Capacity to love__ Energy__ Empathy___

Loyalty__ Fairness/justice__ Leadership__

• Do you believe you have some of these character strengths more generally and, if so, which?

Now switch attention to the present.

• Describe a current challenge you are facing
• When did it start? How long has it been going on?
• What are it’s effects?
• Are any of those strengths you’ve used in the past relevant here in terms of dealing with this challenge? If so, which?
• Are you over-using (too much) or under-using (too little) one of your strengths?
• Are you using the right strength or the strengths appropriate to this situation?
• What adaptive changes can you make? Specifically, what strength will you try to employ here and how will you do this in concrete action?

As can be seen there are many client friendly ways to incorporate positive psychology ideas into CBT practice which can really enhance the effectiveness and overall positive effects of therapy on individuals both in terms of reducing suffering and on improving well being.

Resources:

• Bannink, F. (2013) Practicing positive CBT. From reducing distress to building success. Wiley.
• Frisch, M. (2005) Quality of Life Therapy : Applying a Life Satisfaction Approach to Positive Psychology and Cognitive Therapy. John Wiley.
• Neenan, M. (2017) Developing resilience: A Cognitive behavioral approach. Routledge.
• Padesky, C. A & Mooney, K.A. (2012) Strengths-based cognitive-behavioral therapy: A Four step-model to build resilience. Clinical Psychology and Psychotherapy, July-August, ,283, -290.
• Rashid, T. & Seligman, M. (2018) Positive psychotherapy: Clinician Guide. Oxford University Press.
• Rashid, T. & Seligman, M. (2018) Positive psychotherapy workbook. Oxford University Press.
• Slade, P. et al (2016) Positive psychotherapy for psychosis; A Clinician’s Guide and Manual. Routledge.
• Web site: https://www.authentichappiness...