"You've got to spread joy up to the maximum.  Bring gloom down to the minimum.  Otherwise pandemonium ... Liable to walk upon the scene".  Bing Crosby sings

In the last blog post "Accentuate the positive: an exciting new psychotherapy development", I described the encouraging results being reported by researchers exploring the potential benefits of taking a more Positive Psychology style approach to helping depression and anxiety.  I particularly highlighted Michelle Craske, Alicia Meuret & colleagues' recent publication "Positive affect treatment for depression and anxiety: a randomized clinical trial for a core feature of anhedonia".  So what emerges from a more careful reading of this paper?

Well firstly the authors argue convincingly that a focus on increasing positive/pleasant feelings is relevant for anxiety sufferers as well as for those struggling with depression.  And the sample was selected as suffering from moderate to severe depression and/or anxiety with some disruption in their activities.  It's worth noting that they were not selected because they had unusually severe anhedonia (an inability to feel pleasure in normally pleasurable activities).  Of the 93 participants in their intent-to-treat group, there were lots of people who qualified for more than one diagnosis ... so 51 qualified for a depressive diagnosis and 80 for an anxiety diagnosis.  The anxiety sub-group included people with social anxiety disorder, generalised anxiety disorder, panic disorder, PTSD, OCD, eating disorders, and more.  So they were a really broad mix of sufferers with a wide variety of diagnoses.  This is encouraging because it suggests that this positively focused treatment approach can benefit a high proportion of those coming to mental health professionals for help.

And how were they assessed and monitored?  Well, a key measure was the Positive & Negative Affect Scale (PANAS) as well as the DASS-21 (to assess depression, anxiety & stress levels), and a measure of suicidal thoughts.  The PANAS includes 10 questions assessing 'positive emotions' and 10 assessing 'negative emotions' - giving subscales for PANAS-P and PANAS-N.  Here is a downloadable copy of the PANAS both as a Word doc and as a PDF file.  And here is a chart - again as a Word doc and as a PDF file - that allows one to estimate how these scores compare to the general population (and to the Craske study participants).  I personally feel that the positive emotions assessed by the PANAS are over-narrow, so I use the PANAS as a before & after treatment measure (so I can make direct comparions to the Craske results) but prefer the broader Barbara Fredrickson Positive Emotions Assessment measure week on week (again available here as a Word doc and a PDF file). 

What did they actually do in Positive Affect Training (PAT) ?  The researchers write "The treatments involved 15 weekly hour-long individual sessions.  Each treatment was composed of three modules targeting behaviors (Sessions 1–7), cognitions (Sessions 8 –10), and ... compassion (Sessions 11–14).  Skills from prior modules were reinforced throughout subsequent modules.  Session 15 addressed relapse prevention.  Interventions were supported by daily worksheets for between-session exercises."  They go on to say "PAT is a novel intervention specifically designed to target deficits in reward sensitivity (see Craske et al., 2016, for conceptual framework and detailed treatment description).  Here's the descriptive overview from the 2016 Craske paper (see table below):

The first module (7 sessions), “Augmented Behavioral Activation Training,” combines planning for pleasurable activities (reward approach-motivation) and reinforcement of mood effects of those activities (reward learning) with “in-the-moment” recounting designed to savor pleasurable moments (reward attainment). The behavioral training extends beyond traditional pleasant event scheduling or behavioral activation (Dimidjian et al., 2006; Lewinsohn, 1974) by training optimization of positive emotions through the recounting exercises that comprised the majority of session content.  During recounting, participants were guided to close their eyes, visualize and recount in present tense the moment-to-moment details (surroundings, emotions, physical responses and thoughts), focusing on experiences of their most positive affect. Mood state was measured before and after recounting exercises, with therapist reinforcement of positive mood induction effects. Recounting shares some elements with directed imagery within cognitive therapy for rumination, although directed imagery is specifically aimed at counteracting negative thoughts or emotions (Watkins et al., 2011).

The second module (3 sessions), “Cognitive Training: Attending to the Positive,” includes exercises for identifying positive aspects of experience (approach-motivation and attainment), in which participants were guided to delineate positive features of recent events that were judged to be neutral or negative. They were also guided to identify aspects of their own behavior that contributed to positive outcomes (reward learning), and practiced present-tense imagining of details (situations, emotions, physical responses, and thoughts) of future positive events (approach-motivation; Holmes, Mathews, Mackintosh, & Dalgleish, 2008; Holmes, Murray, Perron, & Rail, 2006; Pictet, Coughtrey, Mathews, & Holmes, 2011). The third module (4 sessions), “Compassion Training: Cultivating the Positive,” includes loving kindness, generosity, gratitude and appreciative joy exercises designed to savor positive experiences (reward attainment; Froh, Kashdan, Ozimkowski, & Miller, 2009; Hofmann, Grossman, & Hinton, 2011; Wood, Froh, & Geraghty, 2010)."

This is so interesting.  It reminds me of Sonja Lyubomirsky's helpful distinction between 'Happiness in our lives' and 'Happiness with our lives'.  So this Craske, Meuret et al intervention we've been looking at seems to emphasise 'Happiness in our lives'.  They emphasise the evolutionary importance of the approach/reward/engagement behavioural system without which animals wouldn't be motivated or reinforced in their crucial search for food, shelter, social connection, mating, and other survival/reproduction needs.  Without this engagement with others & the world, our lives are over before they've begun.  So the Craske/Meuret emphasis is on reinvigorating/accentuating three aspects of the reward/engagement system ... that we can savour, appreciate & enjoy positive experiences much more fully again (Happiness in); that we begin to look forward to such experiences & become motivated again to pursue them ... as well as seeing that our behaviours are central to these rewarding engagement experiences occurring; and that thirdly we develop habits/attitudes of warm connection with others & the world that root this enhanced Happiness in our lives deeply into how we are in the world.  Remember that Barbara Fredrickson's 'broaden-and-build' understanding of positive/pleasant emotions clarifies how feeling good more often not only increases immediate life enjoyment, but also builds improvements in our life resources such as improved social connections, increased productivity, greater energy, and so on.

More to follow ...