Chang et al. BMC Psychology (2022) 10:111 https://doi.org/10.1186/s40359-022-00816-6 # Positive mental health in psychotherapy: a qualitative study from psychotherapists perspectives [PDF](https://1drv.ms/b/s!AjMUohsNFeHbhLZgQTo6UWLi2HN64w?e=5gvNcl) Sherilyn Chang1, Rajeswari Sambasivam1, Esmond Seow1, Mythily Subramaniam1, Hanita Ashok Assudani2, Geoffrey Chern‑Yee Tan3,4, Sharon Huixian Lu2 and Janhavi Ajit Vaingankar1* --- [[Positive Psychology Index]] --- - Positive Mental Health (PMH) Interventions - The therapists defined PMH as - Acceptance - Normal functioning and thriving in life - Resilience - Positive overall evaluation of life - absence of negative emotions and presence of positive emotion states - Hedonic approach: pleasure attainment and pain avoidance - Eudemonic approach: 'Meaning and self-realisation and define in terms of the degree a person is fully functioning' - Psychological wellbeing 6 dimensions [Ryff CD, Keyes CLM. The structure of psychological well‑being revisited. J Pers Soc Psychol. 1995;69:719–27.] - **autonomy** - **environmental mastery** - **personal growth** - **purpose in life** - **positive relations with others** - **self-acceptance** - Keyes also considers **Social Wellbeing** - [Keyes CLM. The mental health continuum: from languishing to flourishing in life. J Health Soc Behav. 2002;43:207–22.] - **Spirituality** - [Mirabzadeh A, Baradaran Eftekhari M, Falahat K, et al. Positive mental health from the perspective of Iranian society: A qualitative study [version 2; peer review: 2 approved]. F1000Research. 2018. https://doi.org/10. 12688/f1000research.13394.2. ] - [Vaingankar JA, Subramaniam M, Lim YW, et al. From well‑being to positive mental health: conceptualization and qualitative development of an instrument in Singapore. Qual life Res Int J Qual life Asp Treat Care Rehabil. 2012;21:1785–94. https://doi.org/10.1007/s11136‑011‑0105‑3.] ==Can I use the above dimensions?== - Positive Psychology therapies includes: - Wellbeing therapy - Positive psychotherapy - Mindfulness-based interventions, gratitude-promoting exercises - have been incorporated into traditional psychotherapies # Effectiveness of PMH interventions - Meta-analysis - mindfulness-based interventions - reduce symptoms most consistent for depression, pain, smoking and addiction - [Goldberg SB, Tucker RP, Greene PA, et al. Mindfulness‑based interventions for psychiatric disorders: a systematic review and meta‑analysis. Clin Psychol Rev. 2018;59:52–60. https://doi.org/10.1016/j.cpr.2017.10.011.] - [Chakhssi F, Kraiss JT, Sommers‑Spijkerman M, Bohlmeijer ET. The effect of positive psychology interventions on well‑being and distress in clinical samples with psychiatric or somatic disorders: a systematic review and meta‑analysis. BMC Psychiatry. 2018;18:211. https://doi.org/10.1186/ s12888‑018‑1739‑2.] - Jankowski et al - urged researchers and therapist to continue to integrate symptom reduction and wellbeing promotion .. to foster client flourishing - [ankowski PJ, Sandage SJ, Bell CA, et al. Virtue, flourishing, and positive psychology in psychotherapy: an overview and research prospectus. Psychotherapy. 2020;57:291–309.] This paper want to understand therapists attitude towards PMH, and potential challenges and difficulties in integrating PMH interventions in clinical setting. # Methods Qualitative, interview. Focus Group Discussions. Nvivo software. Coding Participants - 38 # Themes ## 1. Acceptance - "PMH was defined as having the ability to accept things that happened in life and acknowledging the outcomes that resulted. Acceptance was in relation to not just negative events, but also acceptance of ‘difficult emotions’ and where one is in life." ## 2. Normal Functioning and thriving in life - "“having PMH was defined as being able to function normally. At the individual level, a functioning person was described as someone leading a balanced and healthy lifestyle, and able to manage stress and not be overwhelmed by it. The idea of optimal functioning pertained to various aspects in life including occupation, relationship with others, and being an active and contributing member of the society.” (Chang et al., 2022, p. 4)" - "“thriving which encompassed the idea of growth” (Chang et al., 2022, p. 4)" ## 3. Resilience - "“Resilience was often described by participants as a trait that would help their clients to ‘bounce back’ from adversities, and also as a coping resource to support normal functioning in spite of challenges.” (Chang et al., 2022, p. 5)" ## 4. Positive overall evaluation of life - "“The keywords in this theme were ‘quality of life’, ‘good life’, ‘fulfilled life’ and ‘life satisfaction’. Definitions captured in this theme described the concept of PMH as an all-encompassing, overall evaluation of one’s life that generated a broad sense of wellness or a feeling of ‘good living” (Chang et al., 2022, p. 6)" - "“keywords such as ‘goals’, ‘values’, ‘purpose’, ‘meaningful’ and ‘aspirations’ were often mentioned and participants described these as constituents of a ‘good life’.” (Chang et al., 2022, p. 6)" ## 5. Absence of negative emotions and presence of positive emotion states - "“This theme relates to the emotional state of an individual and the definitions of PMH encompassed the absence of distress and the presence of positive emotions. PMH was defined as the removal of mental illness symptoms or distress, and also it meant experiencing positive emotions and state such as ‘happiness’, ‘hope’ and ‘joy” (Chang et al., 2022, p. 6)" # Views and Concept of PMH 1. Novel and valuable 1. Not all participants concurred with the relevance and significance of PMH - Need to focus on client's immediate issues firsts. 1. "I think positive psychology is not that much used in our setting maybe because we have quite a lot of patients in quite severe conditions and talking about positive psychology is like... we are at this level and then you are talking about positive psychology. So maybe in our setting, clinical setting, we don’t really talk about positive psychology and I find that it’s more of a marketing thing... like it’s great and we are doing these classes in school and all that but I think there are other things that are more important to be done. – FGD 2" 2. Reservations with terminology 1. Usage implied that clients have to strive towards a positive state all the time, which is "not natural" 2. Suggest ters like "mental wellness", "positive living", or sticking to words that were used by their clients. 3. Factors influencing PMH 1. Individual level 1. Clients' personality 2. Interpersonal level 1. Support from family, friends.. mismatched values or misaligned expectations in relationships with others 3. Community and social-cultural level 1. Stigma in society etc. 1. Creating awareness, improving mental health literacy. # Discussion - PMH in psychotherapy mean reducing distress and increasing positive emotions - Studies have shown effectiveness on wellbeing and reducing stress in clinical samples including major depressive disorder and schizophrenia , effect comparable to CBT - [Jankowski PJ, Sandage SJ, Bell CA, et al. Virtue, flourishing, and positive psychology in psychotherapy: an overview and research prospectus. Psychotherapy. 2020;57:291–309] - [Chakhssi F, Kraiss JT, Sommers‑Spijkerman M, Bohlmeijer ET. The effect of positive psychology interventions on well‑being and distress in clinical samples with psychiatric or somatic disorders: a systematic review and meta‑analysis. BMC Psychiatry. 2018;18:211. https://doi.org/10.1186/ s12888‑018‑1739‑2] - [Geerling B, Kraiss JT, Kelders SM, et al. The effect of positive psychology interventions on well‑being and psychopathology in patients with severe mental illness: A systematic review and meta‑analysis. J Posit Psychol. 2020;15:572–87. https://doi.org/10.1080/17439760.2020.1789695] - [Chaves C, Lopez‑Gomez I, Hervas G, Vazquez C. A comparative study on the efficacy of a positive psychology intervention and a cognitive behavioral therapy for clinical depression. Cognit Ther Res. 2017;41:417–33. https://doi.org/10.1007/s10608‑016‑9778‑9.] # When to use PMH? - Some say not appropriate to address "meaning in life" with all clients - Depend on client's readiness - address other pressing issues first. - [Hill CE, Kanazawa Y, Knox S, et al. Meaning in life in psychotherapy: the perspective of experienced psychotherapists. Psychother Res. 2017;27:381–96. https://doi.org/10.1080/10503307.2015.1110636.] - [[Purpose and Meaning in Life]] - Need future studies to examine factors that could potentially influence effectiveness of these interventions **Careful not to label experiences a "positive" or "negative", everything should be in context.** - "*Another finding worth discussing is that a number of participants were skeptical towards the use of the word ‘positive’. It is hard to discern if this reservation among our study participants is attributable to their background in clinical psychology and hence, the focus on deficits, or the unfamiliarity with PMH  construct. The contention being that this terminology creates a dichotomy which is not an accurate nor ideal portrayal of mental health, and working towards a positive state all the time is not inherently desirable nor achievable. This echoes the argument by McNulty and Fincham that because psychological traits and processes have to be best understood in context [33], it would be prudent to avoid labeling them as positive or negative.*" - [McNulty JK, Fincham FD. Beyond positive psychology? Toward a contextual view of psychological processes and well‑being. Am Psychol. 2012;67:101–10. https://doi.org/10.1037/a0024572.] **But perhaps it's just misconceptions about what is positive psychological interventions.** What is [[Positive Mental Health Interventions]] - [Magyar‑Moe JL, Owens RL, Conoley CW. Positive psychological interventions in counseling: what every counseling psychologist should know Ψ. Couns Psychol. 2015;43:508–57. https://doi.org/10.1177/0011000015573776.] - [Hart KE, Sasso T. Mapping the contours of contemporary positive psychology. Can Psychol Can. 2011;52:82–92.]