Positive Psychotherapy: Clinician Manual

I’m not a clinician. I didn’t play one on TV. I didn’t sleep at a Holiday Inn Express last night. However, I did read Positive Psychotherapy: Clinician Manual. It’s a toolbox for counselors and clinical psychiatrists for want to help clients reach their capacity for positivity in their lives beyond the ailment that may have driven them to seek help in the first place. It’s a recognition that just fixing the problems isn’t enough and the problems that people come in with are more frequently the result of other problems.

Seligman

In an indirect way, Marty Seligman suggested that I read the book. I had read Flourish and was preparing for our work on burnout (see ExtinguishBurnout.com). I wrote Dr. Seligman, and he answered. His brief response confirmed what I already suspected. Learned helplessness, a lack of hope, and burnout had the same root. They were, in imprecise terms, the same thing. I thanked him and eventually asked for places where I could learn more. The response blew me away. It had references and people to reach out to for more information. One of the people I should reach out to was Tayyab Rashid, who had some at the time unpublished guidance for clinicians trying to help patients with psychotherapy.

By the time I reached him (after reading The Hope Circuit), Positive Psychotherapy: Clinician Manual was published, so I bought it.

Clinical Context

While I’m not a clinician, I’m very interested in the topic of psychotherapy and what does and doesn’t work. It was early 2015 when I published my review of The Heart and Soul of Change: Delivering What Works in Therapy. It was 2016 before I returned to the topic of psychotherapy to look at how patients – and the public at large – were assessed in The Cult of Personality Testing. I followed that with a critical view in Science and Pseudoscience in Clinical Psychology. Finally, in August of 2016, I got around to House of Cards: Psychology and Psychotherapy Built on Myth, which had an even more critical view of the profession.

Despite the many critical pieces in my reading list, I’m generally very positive on the capacity for someone to be helped through talk therapy. It is my belief that what we make of the world is largely in our head. It’s the reality that we don’t see the world – we see, and then our brain creates the world (see Incognito). Helping refocus thinking can be powerful if done well.

Positive Psychology

Psychology got stuck. The problem was that it was focused on problems and their resolutions. Instead of asking the question about what people could become and how they could thrive, it was stuck in survival mode. Psychology became niched around dealing with the negatives of life’s equation, and it needed a push to get out of the rut. That push came when Marty Seligman took the helm of the American Psychological Association (APA). He made it his mission to drive forward the idea that it was just as important to help people reach their happiness potential as it was to address misery.

Mental health had come to mean a lack of disorders listed in the DSM (currently DSM-V), but health isn’t the same as the absence of illness. Mental health needed to be reframed so that it actually meant health.

Positive Psychotherapy: Clinician Manual is designed to bring the tools that have been discovered and developed into a clinical setting for the benefit of the patients.

Strengths

Central to the practice of positive psychology is a focus on the strengths of an individual rather than their weaknesses. Instead of looking to fill in potholes in the road of the patient’s life, positive psychology builds new roads and bridges to places people never knew they could reach. It builds these on the strengths of the individuals. By helping the person understand their strengths, they can better leverage them. By understanding how to enhance strengths, they can get more benefit from them.

Strengths are largely defined as the strengths listed in the Values in Action (VIA) test, which is available for free at authentichappiness.org. Everyone has some strengths in the list of 24 in the VIA test. We all, in fact, possess some degree of these strengths. Our combination of strengths represents our ability to get things done.

The clinician manual spends a great deal of time in the session-by-session section, walking clients through what positive psychology is, evaluating their strengths, and confirming those strengths. It is from this firm foundation that other skills are taught.

Dealing with the Negative

It’s important to note that just because the approach is positive psychology doesn’t mean the negative event, barrier, or dysfunction isn’t addressed. Instead of overwhelming the conversation and relationship by focusing on negative aspects, the overall tone is more balanced by recognizing the positives and acknowledging the negative outcomes.

Despite the positive descriptor, psychology, done correctly, is rarely easy. It’s hard for someone to be vulnerable enough to allow themselves to see how they may be contributing to their problems and what changes they may need to make for it to get better.

Consider a physical example. Someone comes to a doctor because of tinnitus (ringing in the ears). The discovery is high blood pressure, and, in addition to a pill that is supposed to help, the doctor explains that weight loss is critical. Weight loss isn’t easy. It’s takes careful management of what and how much food you eat – and how much you exercise. The representing problem was the result of an underlying problem, high blood pressure, which itself was a side effect of being overweight. Losing weight is hard work – and something that not everyone is successful at.

In psychological terms, the hard work still must be done to address the core problems that are causing someone to feel bad.

Attitude of Gratitude

Some of the activities in the sessions aren’t focused around specific strengths but are designed to help change attitudes. Gratitude, whether in the form of a general approach or through the use of a specific gratitude journal, has far-reaching effects and acts as a lubricant for further clinical work. Barbara Fredrickson, another leader in positive psychology, in her book Positivity explains the power of gratitude. A three to one ratio of positive to negative experiences– which can be fueled by gratitude – can powerfully change your relationships.

She’s not alone, as Matthieu Ricard in Happiness explains the role of gratitude in joy. Rick Hansen explains in Hardwiring Happiness how gratitude can be a powerful force to wire happiness into your very being.

Open and Closed Memories

Much of the challenge that we have today is in the hurts encountered in the past that we’ve not yet healed. In the language of the clinician manual, these are open memories. That is, these memories haven’t been fully processed and still cause emotional disturbance or pain. Fully processed memories are said to be closed memories. Closed memories generate neutral or positive emotions. (See Changes that Heal for another perspective on these hurts.)

Here, I struggle not so much in the goal of working to minimize hurts and to address painful memories but in the concept that we can close all memories. There’s plenty of work that says how we feel about something is largely based on how we choose to process it. (For one instance, see How Emotions Are Made.) However, I am not convinced that some memories can ever be fully closed in the sense that they don’t trigger a negative emotion. (See Emotion and Adaptation for more on positive and negative valences to emotion.)

It’s been nearly six years since I lost my brother to an airplane accident. I did a great deal of work, both then and since, to come to terms with what happened, and the result that it had on me personally and on my family. For the most part, I’m OK and have been for some time. However, sometimes, small things will set me into a sense of monumental loss. The pain around the obvious clues are mostly gone. I can see airplanes and even fly without being overwhelmed by it. But, sometimes, it just sneaks up on you, and you feel an overwhelming sense of loss.

For the most part, the memory is closed. It no longer creates pain daily. However, I’m not sure that it will ever be completely closed, nor that it can be.

Post Traumatic Growth

Everyone is familiar with post-traumatic stress disorder (PTSD), but few are aware of its mirror image, post-traumatic growth (PTG). Where PTSD debilitates, PTG empowers. Because there’s a focused awareness of PTSD and the pain it brings, few people consider that trauma isn’t always bad. Taleb in Antifragile explains that stress in a certain range can make people less fragile. Like muscles that are torn down in exercise and rebuilt stronger, mental health growth can come through the right kind of struggles.

One of the greatest challenges as a parent is in identifying which stresses to allow for our children so they may grow – and which ones to protect them from that would be too difficult for them to navigate alone. (See The Psychology of Not Holding Children Accountable for one aspect of this.)

Forgiveness

Holding a resentment towards someone is like drinking poison and expecting them to die. Forgiveness relieves you of that poison with no impact – positive or negative – on the other person. Forgiving someone is an important step in healing but is too often misunderstood. Forgiving someone isn’t forgetting the harm they caused nor releasing them of their responsibility to make things right. It is just that you’re no longer holding the harm inside yourself.

While it’s often difficult to accept the power of forgiveness for the fear that you’re somehow making it OK for the other person to have harmed you, it doesn’t mean that. In The Evolution of Cooperation, Robert Axelrod explains that some of the best solutions for modeling behavior seem to echo what we see in life. A Tit-for-Tat program is effective when modeling what happens when two independent actors can choose to work in their own or mutual best interests.

Economists play a game called the ultimatum game, where one person is given ten dollars to split between themselves and another person any way they would like. But the second person gets to decide, based on the split, whether the money is returned, or both get to keep their portions. When the split gets too far out of balance, the second person generally prevents both from getting the money. This makes no sense to economists, because the second person gets something even if it’s small, and turning down the money means they get none, too. In the context of Axelrod’s work, it does make sense.

We’ve evolved with a sense of justice, and when someone takes advantage of us, we want to make them aware that their behavior isn’t socially acceptable. We want them to pay – and that’s part of what has allowed us as a species to develop our social relationships. Even John Gottman in The Science of Trust: Emotional Attunement for Couples makes the point that the Nash equilibrium, where parties are looking for the best overall outcome, instead of the Neumann-Morgenstern equilibrium, just their own interests, is preferred. That is to say that we’re deeply wired so that we keep people in line through consequences. Fighting that urge when it’s not helpful is difficult but there is hope.

Hope

Of all the positive psychology ideas, my favorite concept is hope. Martin Seligman in The Hope Circuit explains that the idea of learned helplessness should be replaced with the idea that we either learn we have control over our environments or we fail to learn that lesson. Hope, as it shows up as the placebo effect in clinical trials, is challenging to get past. Double-blind studies are designed to ensure that hope doesn’t influence the results. (See Acedia & Me and Warning: Psychiatry Can Be Hazardous to Your Mental Health for more on the role of hope as a placebo.)

The value of hope is its ability to hold off the evils of the world – or at least hold off mental maladies like depression.

Depression

Sapolsky in Why Zebras Don’t Get Ulcers estimates that, by 2020, depression is projected to be the second leading cause of medical disability on Earth. It’s sometimes called “the common cold of mental illness” because of its prevalence. Depression is a big deal in terms of its impact on society and on people individually. Depression robs people of their ability to feel joy. Instead of being filled with a mixture of good and bad, they can only feel the bad.

Part of depression is the expectation is that the situation will remain the same or get worse over time. The result is a fatalistic point of view that denies the person can have any positive influence over the outcomes they get.

Positive psychology teaches, however, that depression isn’t a permanent condition. Through hope, it is possible to conquer depression and to use the values and strengths that the individual has.

Virtues

Though much is made of a person’s individual strengths, these strengths fit into a larger, virtuous framework. The information about these virtues and strengths is reproduced directly below:

Virtue: Wisdom & Knowledge—strengths that involve acquiring and using knowledge

Creativity: Thinking of novel and productive ways to do things
Curiosity: Openness to experience; taking an interest in all of ongoing experience
Open-mindedness: Thinking things through and examining them from all sides
Love of learning: Mastering new skills, topics, and bodies of knowledge
Perspective: Being able to provide wise counsel to others

Virtue: Courage—emotional strengths which involve exercise of will to accomplish goals in the face of opposition, external or internal

Bravery: Not shrinking from threat, challenge, or pain
Persistence: Finishing what one starts; persisting in a course of action in spite of obstacles
Integrity: Speaking the truth and presenting oneself in a genuine way
Vitality & Zest: Approaching life with excitement and energy; not doing things half-way or halfheartedly; living life as an adventure; feeling alive and activated

Virtue: Humanity—interpersonal strengths that involve tending and befriending others

Love: Valuing close relations with others, in particular those in which sharing and caring are reciprocated; being close to people
Kindness: Doing favors and good deeds for others; helping them; taking care of them
Social intelligence: Being aware of the motives and feelings of self and others; knowing what to do to fit into different social situations; knowing what makes other people tick

Virtue: Justice—strengths that underlie healthy community life

Citizenship & Teamwork: Working well as member of a group or team; being loyal to the group; doing one’s share
Fairness: Treating all people the same according to notions of fairness and justice; not letting personal feelings bias decisions about others; giving everyone a fair chance
Leadership: Encouraging a group of which one is a member to get things done and at the same time maintain good relations within the group; organizing group activities and seeing that they happen

Virtue: Temperance—strengths that protect against excess

Forgiveness & Mercy: Forgiving those who have done wrong; accepting the shortcomings of others; giving people a second chance; not being vengeful
Humility & Modesty: Letting one’s accomplishments speak for themselves; not seeking the spotlight; not regarding oneself as more special than one is
Prudence: Being careful about one’s choices; not taking undue risks; not saying or doing things that might later be regretted
Self-regulation [Self-control]: Regulating what one feels and does; being disciplined; controlling one’s appetites and emotions

Virtue: Transcendence—strengths that forge connections to the larger universe and provide meaning

Appreciation of beauty and excellence: Noticing and appreciating beauty, excellence, and/or skilled performance in all domains of life, from nature to arts to mathematics to science
Gratitude: Being aware of and thankful for the good things; taking time to express thanks
Hope & Optimism: Expecting the best in the future and working to achieve it; believing that a good future is something that can be brought about
Humor & Playfulness: Liking to laugh and tease; bringing smiles to other people, seeing the light side; making (not necessarily telling) jokes
Spirituality: Knowing where one fits within the larger scheme; having coherent beliefs about the higher purpose and meaning of life that shape conduct and provide comfort

Framework of Understanding

Learning about one’s strengths provides a mechanism to create understanding. By understanding zest as a strength, you can understand why you may sometimes be prone to jumping into things with too much energy. Unlike the Enneagram, the ViA assessment doesn’t speak of how your strengths can be overused. (For more on the Enneagram, see Personality Types: Using the Enneagram for Self-Discovery.) However, Positive Psychotherapy: Clinician Manual makes a point to explain how you can over- or underuse your signature strengths and there by get less than optimal results.

The key is that, as humans, we are always trying to make sense of the world around us. The more tools we have to make sense in a positive way, the more possibilities we have to see the world as a positive place. Investigating our strengths gives us both a way to build on what we have and a way to understand how we may not have been successful as we would like. In a way, it helps our sense of trust in ourselves.

Trust

Trust is a critical concept for humans. It allows us to move to vulnerability and the intimacy that we crave. (See Trust => Vulnerability => Intimacy for more.) It also provides the framework for our societies. (See Trust: Human Nature and The Reconstitution of Social Order for more.) Positive psychology doesn’t discount the reality that sometimes trust is violated, but it builds upon our need to trust ourselves.

I trust that if you read Positive Psychotherapy: Clinician Manual, you’ll find something valuable, whether you’re a clinician or not.