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The objective was to assess the feasibility and acceptability of nine positive psychology exercises delivered to patients hospitalized for suicidal thoughts or behaviors, and to secondarily explore the relative impact of the exercises. Participants admitted to a psychiatric unit for suicidal ideation or behavior completed daily positive psychology exercises while hospitalized. Likert-scale ratings of efficacy (optimism, hopelessness, perceived utility) and ease of completion were consolidated and compared across exercises using mixed models accounting for age, missing data and exercise order. Overall effects of exercise on efficacy and ease were also examined using mixed models. Fifty-two (85.3%) of 61 participants completed at least one exercise, and 189/213 (88.7%) assigned exercises were completed. There were overall effects of exercise on efficacy (χ(2)=19.39; P=.013) but not ease of completion (χ(2)=11.64; P=.17), accounting for age, order and skipped exercises. Effect (Cohen's d) of exercise on both optimism and hopelessness was moderate for the majority of exercises. Exercises related to gratitude and personal strengths ranked highest. Both gratitude exercises had efficacy scores that were significantly (P=.001) greater than the lowest-ranked exercise (forgiveness). In this exploratory project, positive psychology exercises delivered to suicidal inpatients were feasible and associated with short-term gains in clinically relevant outcomes.
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Feasibility and utility of positive psychology exercises for suicidal inpatients
Jeff C. Huffman, M.D.
, Christina M. DuBois, B.A.
, Brian C. Healy, Ph.D.
, Julia K. Boehm, Ph.D.
Todd B. Kashdan, Ph.D.
, Christopher M. Celano, M.D.
, John W. Denninger, M.D., Ph.D.
Sonja Lyubomirsky, Ph.D.
Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
Harvard Medical School, Boston, MA, USA
Biostatistics Center, Massachusetts General Hospital, Boston, MA, USA
Department of Psychology, Chapman University, Orange, CA, USA
Department of Psychology, George Mason University, Fairfax, VA, USA
Benson Henry Institute for Mind Body Medicine, BostonMA, USA
Department of Psychology, University of CaliforniaRiverside, Riverside, CA, USA
abstractarticle info
Article history:
Received 12 July 2013
Revised 3 October 2013
Accepted 5 October 2013
Positive psychology
Objective: The objective was to assess the feasibility and acceptability of nine positive psychology exercises
delivered to patients hospitalized for suicidal thoughts or behaviors, and to secondarily explore the relative
impact of the exercises.
Method: Participants admitted to a psychiatric unit for suicidal ideation or behavior completed daily positive
psychology exercises while hospitalized. Likert-scale ratings of efcacy (optimism, hopelessness, perceived
utility) and ease of completion were consolidated and compared across exercises using mixed models
accounting for age, missing data and exercise order. Overall effects of exercise on efcacy and ease were also
examined using mixed models.
Results: Fifty-two (85.3%) of 61 participants completed at least one exercise, and 189/213 (88.7%) assigned
exercises were completed. There were overall effects of exercise on efcacy (χ
=19.39; P= .013) but not ease
of completion (χ
=11.64; P=.17), accounting for age, order and skipped exercises. Effect (Cohensd)of
exercise on both optimism and hopelessness was moderate for the majority of exercises. Exercises related to
gratitude and personal strengths ranked highest. Both gratitude exercises had efcacy scores that were
signicantly (P=.001) greater than the lowest-ranked exercise (forgiveness).
Conclusion: In this exploratory project, positive psychology exercises delivered to suicidal inpatients were
feasible and associated with short-term gains in clinically relevant outcomes.
© 2014 Elsevier Inc. All rights reserved.
1. Introduction
Patients who are psychiatrically hospitalized for a suicide attempt
or suicidal ideation (SI) are at very high risk for suicide following
discharge [13], with rates of suicide shortly postdischarge more than
100 times greater than the rate in the general population [4]. Despite
this high risk of suicide, there has been relatively limited study of
formal interventions to reduce suicidality during or shortly after
psychiatric admission.
Existing interventions for suicidal patients (e.g., cognitive behav-
ioral therapy [5,6] and dialectical behavior therapy [7,8]) typically
target negative emotions and cognitions. However, positive cognitions
and emotions also appear to be important in reducing suicide risk, and
reducing negative emotions may not automatically increase positive
psychological states. For example, optimism and depression are only
moderately correlated (median r=.43 in 10 studies [9]), signaling
that these constructs are not simply two sides of the same coin.
Optimism, gratitude and other positive states have been associated
with reductions in hopelessness, suicidal ideation and suicide
attempts, often independent of depression [1016]. Positive emotions
in suicidal patients have been linked to improved problem-solving
[17], and a study of patients hospitalized for self-harm found that low
positive future orientation more strongly predicted recurrent self-
harm after discharge than did global hopelessness [18]. Therefore,
explicit targeting of positive cognitive and emotional states like
gratitude and positive future orientation may have effects on suicide
risk above and beyond standard approaches.
Positive psychology (PP) interventions could represent an inno-
vative and effective adjunctive tool for patients at high suicide risk.
PP-based exercises focus on cultivating or amplifying a specic
positive cognition or emotion. Representative interventions focus on
General Hospital Psychiatry 36 (2014) 8894
Funding: This work was supported in part by grant R01-DP00336 from the US
Centers for Disease Control and Prevention to Dr. Herbert Benson. There was no
other funding source.
Corresponding author. Massachusetts General Hospital, 55 Fruit Street, Blake 11
Boston, MA 02114. Tel.: +1 617 724 2910; fax: + 1 617 724 9155.
E-mail address: (J.C. Huffman).
0163-8343/$ see front matter © 2014 Elsevier Inc. All rights reserved.
Contents lists available at ScienceDirect
General Hospital Psychiatry
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expressing optimism, generating gratitude and reestablishing life
purpose [1922]. In contrast to more intensive interventions, PP
exercises require minimal provider training, are often straightforward
and enjoyable, and are accessible to a variety of patients, including
those who cannot attend in-person appointments.
Overall, PP exercises have been successfully used by more than
4000 participants in over 50 clinical trials [20,21], though typically in
nonclinical populations. However, PP exercises, including those
focusing on gratitude, mindfulness and using strengths, have led to
(often persistent) improvements in mood symptoms in patients with
depressive symptoms [19,23,24], and a prior intervention on
meaningful goals in older adults with suicidal thoughts led to greater
self-efcacy and psychological well-being [25].
Such interventions have the potential to be useful for patients in
crisis. These exercises could be easily administered to hospitalized
patients, with the goal of increasing positive psychological states by
discharge, when suicide risk is high. In addition, these interventions
could be used postdischarge, and an efcient exploration of feasibility in
suicidal patients could also inform that future implementation. Still, it
has been unclear whether PP exercises would be feasible or acceptable
in a broad population of hospitalized suicidal patients, or whether they
would impact clinical outcomes in this seriously ill cohort, with valid
concerns that such exercises may be a bridge too far.
Accordingly, in this study, we examined as a primary aim the
feasibility and acceptability of nine PP exercises in patients admitted
to a psychiatric unit for SI or a suicide attempt. Secondarily, we sought
to explore the self-reported efcacy of the exercises as a whole and to
compare such efcacy ratings among individual exercises.
2. Methods
2.1. Study overview
This study assessed the feasibility of PP exercises among suicidal
inpatients ( identier=NCT01398891). While hos-
pitalized, participants completed one randomly assigned PP exercise
daily under the guidance of a study trainer, self-assessed their
optimism and hopelessness immediately before and after exercise
completion, and rated the ease and utility of each exercise.
Institutional Review Board approval was obtained prior to all
study procedures.
2.2. Participants
Eligible participants were adults admitted to the inpatient
psychiatric unit at an urban academic medical center, for SI or
following a suicide attempt, between May 2011 and February 2013.
The 24-bed inpatient psychiatric unit is housed within the general
hospital and cares for a broad population of adults 18 years and older.
Mood disorders are the most common primary diagnosis, although
the unit cares for patients across the spectrum of psychiatric illness.
The mean admission duration is approximately 9 days.
2.3. Inclusion and exclusion criteria
Inclusion criteria for the study were admission to the unit for SI
(passive or active) or a suicide attempt conrmed by medical record.
Potential participants were identied by review of the unit census,
followed by a discussion with the patients attending psychiatrist to
determine eligibility. Patients who expressed interest in an optional
study were then assessed by a physician or social work investigator
for exclusion criteria.
Patients were excluded if they were to be discharged within 24 h
or were unable to meaningfully participate due to inability to
communicate in English or cognitive decits identied by a six-item
screen [26]. Patients were also excluded if they had current psychotic
symptoms (identied via the Mini International Neuropsychiatric
Interview) [27]. If patients met all study criteria, they were provided a
verbal description of the study and written consent form, and
informed consent was obtained from a licensed study investigator.
Of note, although primary admission diagnosis was recorded,
patients were not excluded from the study based on their primary
psychiatric diagnosis. While studying a more homogeneous sample of
patients can increase internal validity, the goal of the project was to
identify the acceptability and utility of PP exercises in a broad
population of suicidal patients given that clinical implementation of
the exercises in this setting would likely occur across diagnoses rather
than in a single diagnostic cohort.
2.4. Study design
Prior to the recruitment phase, nine exercises were identied via
published literature [19,2839] or directly from researchers, and
modied appropriately for this population. Additional text outlining
the rationale and instructions for each exercise was added to create
written packets for each exercise to be provided to patients. Staff
members involved in intervention delivery (a licensed clinical social
worker and a Bachelors-level research coordinator with relevant
inpatient clinical experience) were trained in several stages. They
reviewed a provider training manual created specically for the
project (exercise packets and training manual available from the
authors); this manual described the rationale and procedures for each
exercise, provided guidance for maintaining the focus of the
interaction solely on the PP exercise and its review, and contained
specic advice to convey to participants to facilitate completion of the
given exercise (e.g., methods of brainstorming). Staff also completed
relevant background reading about PP, observed sessions and
completed all exercises in pairs to gain experience performing and
reviewing each exercise. Once enrollment was ongoing, sessions were
reviewed with the principal investigator, who provided feedback.
2.5. Exercises
The nine PP exercises were selected after literature review and
consultation with senior team members. The exercises were as
follows (with related citations):
Gratitude letter [19,32,33]: Participants recalled anothers kind
act and wrote a letter to the person that described feelings of
gratitude associated with this event. Participants could send the
letter if desired.
Personal strengths [19,40]: Participants completed a brief survey
of personal strengths, selected a strength (e.g., perseverance,
humility) to be used deliberately in the next 24 hours and then
wrote about how they used the strength and the outcome.
Acts of kindness [34,35]: Participants performed three kind
acts for others within a single day and wrote about the acts and
the outcome.
Important, enjoyable and meaningful activities [36]: Participants
intentionally completed three acts in a single day a pleasurable
act done alone (e.g., reading), a pleasurable act done with others
(e.g., playing cards), and a meaningful or important act (e.g.,
creating a blood sugar log) and wrote about them.
Counting blessings [19,28,37,38]: Participants recalled three
events in the past week for which they were grateful and
recorded them in detail.
Best possible self (social relationships) [29,32,33]: Participants
imagined and wrote about their best possible future interper-
sonal relationships and considered how to take steps toward
these relationships.
89J.C. Huffman et al. / General Hospital Psychiatry 36 (2014) 8894
Best possible self (accomplishments) [29,32,33,39]: Participants
imagined and wrote about their best possible future accom-
plishments and considered how to actualize this future.
Forgiveness letter [30,41,42]: Participants selected a hurtful
event that occurred at least 2 years prior and wrote a letter to a
transgressor. The goal of the letter was to forgive the transgressor
for at least some aspect of the event. The letter was not to be sent.
Behavioral commitment to values-based activities [31]: Partic-
ipants selected from an extensive list a principle that guided the
way they hoped to live (e.g., being physically t, creating beauty)
and then made (and wrote about) a small step toward
reconnecting with this principle.
2.6. Procedures
To help characterize this population, enrolled participants com-
pleted baseline measures of depression (Quick Inventory of Depres-
sive SymptomatologySelf-Report [QIDS-SR] [43]), hopelessness
(Beck Hopelessness Scale [BHS] [44]) and optimism (Life Orientation
Test Revised [LOT-R] [45]). Baseline demographic and psychiatric
characteristics were obtained through chart review.
After completion of baseline measures, a study trainer met with
each participant for approximately 10 min to provide and review a
brief introductory packet that described the rationale for using PP
exercises in this setting. The trainer provided guidance on exercise
completion and described the structure of the study (daily exercise
completion, exercise ratings before and after completion, and daily
meetings to review exercises).
The participant was then assigned a PP exercise to be completed in
the next 24 h. The order of exercise assignment for each participant
was determined via random number generator. The trainer provided a
written exercise packet, and participants were told to complete the
activity and write about it in the packet.
At the front of each exercise packet was a preexercise rating sheet
with a pair of ve-point Likert scales on which participants rated their
current levels of optimism and hopelessness (1 = not at all optimistic,
5=completely optimistic;1=not at all hopeless,5=very hopeless);
this was completed immediately prior to undertaking the exercise.
After exercise completion and before review with the study trainer,
participants completed a postexercise rating sheet at the end of the
packet. This sheet included the same scales for optimism and
hopelessness, along with scales regarding ease of completion (1 =
not at all easy,5=very easy) and overall utility (1=not at all helpful,
5=very helpful). Finally, the sheet contained open-ended questions
about how the exercise was useful and how it could be improved.
We chose hopelessness and optimism as key outcome measures
due to their established links to suicidality [1012]. Hopelessness has
been associated with completed suicide, independent of severity of
mood symptoms [46,47], and therefore we chose hopelessness rather
than depression as our primary negative psychological measure,
especially given the transdiagnostic nature of our study cohort. We
chose to utilize this guided self-help approach (rather than creating a
psychotherapeutic intervention) to provide participants some sup-
port and guidance around exercise completion without developing an
intervention that would require extensive training, schooling or cost.
These factors are aligned with suggestions to create interventions
packaged for wide dissemination [48].
Each weekday, following exercise completion, the study trainer
met with the participant to discuss the prior exercise and to assign a
new exercise. These meetings typically lasted 15 min. On weekends,
participants were assigned two exercises, and both were reviewed the
following Monday. Participantsinvolvement was complete at
discharge or after completion of all nine exercises, whichever came
rst. If an exercise was not completed, it was skipped. If participants
had clear clinical worsening or expressed suicidal thoughts, study staff
personally notied clinical teams and asked participants if they
wished to suspend participation.
2.7. Statistical analyses
Descriptive statistics (e.g., proportions, means) were calculated for
baseline characteristics and all individual exercise ratings. Indepen-
dent-samples ttests and χ
analyses were used to compare baseline
characteristics between participants who completed at least one
exercise and those who did not.
The primary goal of the study was to assess the feasibility and
acceptability of the exercises as a whole. To assess these metrics, we
calculated the proportion of enrolled participants who completed at
least one exercise, rates of overall exercise completion and mean
number of exercises completed per participant.
The secondary goal of our study was to rank the exercises to identify
the most promising interventions for future study. To compare metrics
among individual exercises, we recorded rates of exercise completion,
prepostchanges in optimism and hopelessness, and ratingsof ease and
utility for each exercise. Given that there were multiple ratings of
exercise efcacy, we created, a priori, an efcacy score that combined
three ratings (pre-/postexercise change in hopelessness + prepost
change in optimism + overall utility= efcacy score, with higherscores
indicative of greater efcacy) for completed exercises.
Given that not all subjects completed each exercise and to account
for the order of exercise administration and age (given data about
greater impact of PP exercises in older adults [20]), we compared
scores across the exercises on all outcome variables (change in
hopelessness, change in optimism, utility, ease, efcacy score) using
mixed-effects regression models with a patient-specic random effect
and xed effects for age and exercise order. Using this model, adjusted
means for each outcome and exercise were calculated, and a global
test comparing all exercises was used to assess whether there was a
signicant overall effect of exercise on outcomes independent of
exercise order or age.
Since participants occasionally did not complete an assigned
exercise, two approaches were used for analysis in the presence of
missing data. The rst approach analyzed all available data assuming
that noncompletion of an exercise was uninformative about the
missing value and therefore used the efcacy score and ease as
described above. Because subjects with missing data may have failed
to complete an exercise because the exercise was difcult or had poor
perceived utility for the subject, a second approach created a modied
efcacy score that assumed no prepost change and assigned the
lowest utility score when an exercise was not completed. After the
value was imputed, the same mixed model from above was used for
analysis. We similarly created a modied ease score using for
uncompleted exercises.
In addition, unadjusted (i.e., raw) prepost changes in optimism
and hopelessness for each individual exercise were also investigated
using paired ttests. From this analysis, we calculated Cohensd(effect
size [49]) and the proportion of participants experiencing a prepost
improvement of one or more points in hopelessness and optimism (if
not at the ceiling value on the preexercise rating). All quantitative
analyses were performed using Stata version 11.0 (StataCorp, College
Station, TX, USA); all tests were two-tailed.
Finally, open-ended qualitative responses were transcribed and
independently reviewed for themes by two staff members with
experience in qualitative research. A list of themes was generated and
combined, with disagreements resolved via discussion and review of
the primary material.
3. Results
Fig. 1 displays the recruitment and enrollment ow for the study.
Fifty-two (85.3%) of 61 consenting participants completed baseline
90 J.C. Huffman et al. / General Hospital Psychiatry 36 (2014) 8894
measures and at least one exercise. Participants who completed at
least one exercise did not differ signicantly on any baseline
characteristic from those who dropped out (all PN.10).
Table 1 displays the baseline characteristics of the 52 participants
who completed at least oneexercise. Major depressive disorder was the
primary diagnosis in 82.7% (n=43) patients. Participants had moderate
to severe depression at enrollment (QIDS-SR=16.49 [standard devia-
tion {S.D.}6.08]; cutoff for severe depression=16 [43]) and moderate to
severe hopelessness (BHS=11.37 [S.D. 5.80]; cutoff for high suicide
risk=9 [50]). In total, 189 (88.7%) of 213 assigned exercises were
completed, with participants completing a mean of 3.63 (S.D. 1.93) out
of 4.10 (S.D. 2.05) assigned exercises. The most common reported
reason for exercise noncompletion was insufcient time (n=9).
Table 2 displays participant ratings using adjusted means
calculated via mixed models and the proportion of participants who
completed each exercise. Individual exercise completion ranged from
77% (best possible self social relationships) to 100% (counting blessings).
Prepost optimism and hopelessness improved across exercises, with
adjusted mean change between 0.24 and 1.12 for optimism and
between 0.30 and 1.20 for hopelessness.
With respect to individual exercise efcacy, there was an global
effect of exercise on modied efcacy scores, independent of age and
exercise order (χ
=19.39; df=8, P=.013), suggesting that exercise
content had a signicant effect on efcacy. Regarding specic
exercises, the gratitude letter,counting blessings and personal strengths
exercises had the highest efcacy and modied efcacy scores,
whereas the forgiveness letter, best possible self (social relationships)
and values-based activities exercises had the lowest efcacy and
modied efcacy scores. Though pairwise comparisons were not
specied beforehand, exploratory analyses demonstrated that the
forgiveness letter had a signicantly lower adjusted mean modied
efcacy score than the gratitude letter (adjusted mean difference=1.9
[95% condence interval {CI} 0.83.0]; P=.001) and counting blessings
(adjusted mean difference=1.8 [95% CI 0.72.9]; P=.001) indepen-
dent of age and exercise order; these effects remain signicant after
Bonferroni correction.
Modied ease scores (Table 2) suggested that four exercises (acts
of kindness; important, enjoyable and meaningful activities; gratitude
letter and personal strengths) ranked highest (adjusted mean modied
ease scores=3.503.55 among these four exercises), while forgiveness
letter (adjusted score=2.70) ranked lowest. There was no signicant
effect of exercise on modied ease scores (χ
=11.64; df=8; P=.17).
Paired ttest analyses (Table 3) demonstrated that unadjusted pre
post changes in optimism and hopelessness were statistically
signicant (Pb.01 in most cases) for all exercises except the
forgiveness letter, which had a nonsignicant change in optimism
(P=.38). At least half of participants experienced a one-point
improvement in optimism and hopelessness for each individual
exercise except the forgiveness letter. Cohensdfor each exercise other
than the forgiveness letter ranged from 0.48 to 1.19 for both optimism
and hopelessness.
The majority of qualitative comments were positive (138 of 190
comments [72.3%]), with most comments focusing on the high ease of
Fig. 1. Diagram of recruitment and enrollment.
Table 1
Baseline demographic, diagnostic and self-report data
Characteristic Participants completing at
least 1 exercise (n=52)
Age (mean [S.D.]) 41.63 (14.68)
Women (n[%]) 33 (63.5%)
Caucasian (n[%]) 49 (94.2%)
Primary diagnosis (n[%])
Major depressive disorder 43 (82.7%)
Bipolar affective disorder 6 (11.5%)
Generalized anxiety disorder 1 (1.9%)
Eating disorder 1 (1.9%)
Posttraumatic stress disorder 1 (1.9%)
Insurance (n[%])
Uninsured/free care/connector health plan 7 (13.5%)
Medicare 12 (23.1%)
Medicaid 8 (15.4%)
Commercial 25 (48.1%)
Baseline scores (mean [S.D.])
LOT-RTotal 15.00 (6.24)
LOT-ROptimism 7.55 (3.61)
LOT-RPessimism 7.45 (3.35)
BHS 11.37 (5.80)
QIDS-SR 16.49 (6.08)
Note. All scores based on n=52 unless otherwise noted.
91J.C. Huffman et al. / General Hospital Psychiatry 36 (2014) 8894
completion and generation of positive emotions related to the
exercises; negative comments focused on feeling too overwhelmed
to complete the writing portion or to carry out an activity requiring
interpersonal engagement. A substantial (n=9) number of negative
comments were related to the forgiveness letter, with themes related
to the aversive nature of recalling a past slight and having negative
feelings emerge when writing about the event.
4. Discussion
In a population of suicidal patients with high levels of hopelessness
and depression, on our primary aim, we found that administration of
PP exercises was feasible and well accepted. Nearly 90% of assigned
exercises were completed, a substantial nding considering that
participants were in crisis and receiving additional intensive treat-
ment. However, a small proportion of participants were unable to
participate in exercise completion, suggesting that a subset of this
population may be too severely ill or distressed to engage even in this
simple intervention.
Furthermore, regarding our secondary aim, PP exercises were
associated with improvement of hopelessness and optimism, central
therapeutic targets in this clinical cohort because of their independent
links to suicidal thoughts and behaviors [50,51], with moderate effect
sizes on these key outcomes. This suggests that PP interventions may
impact meaningful clinical outcomes, at least in the short term, in this
important high-risk cohort.
The number of previous exercises completed had the potential to
impact outcome assessments. We addressed this in two ways. First,
Table 2
Pre-/postexercise ratings (exercises listed in order of adjusted modied efcacy score)
Change in
Change in
Utility Efcacy Modied
Ease Modied
Gratitude letter
21/23 (91.3%)
1.00 (0.20) 1.13 (0.22) 3.84 (0.22) 5.90 (0.44) 5.59 (0.47) 3.69 (0.24) 3.50 (0.28)
Counting blessings
25/25 (100%)
0.69 (0.19) 0.78 (0.20) 4.01 (0.20) 5.48 (0.40) 5.52 (0.46) 2.97 (0.23) 2.97 (0.27)
Personal strengths
16/18 (88.9%)
0.81 (0.23) 0.79 (0.25) 4.25 (0.25) 5.79 (0.50) 5.29 (0.53) 3.91 (0.28) 3.53 (0.32)
Acts of kindness
18/21 (85.7%)
1.20 (0.22) 0.83 (0.23) 3.59 (0.23) 5.65 (0.47) 5.02 (0.49) 3.91 (0.26) 3.55 (0.29)
Important, enjoyable and meaningful activities
25/26 (96.2%)
0.59 (0.19) 0.78 (0.20) 3.87 (0.20) 5.22 (0.41) 4.86 (0.45) 3.75 (0.23) 3.51 (0.27)
Best self (accomplishments)
22/25 (88.0%)
0.76 (0.20) 0.76 (0.21) 3.31 (0.21) 4.82 (0.42) 4.48 (0.45) 3.20 (0.24) 2.98 (0.27)
Behavioral commitment to values-based activities
18/19 (94.7%)
0.50 (0.23) 0.58 (0.25) 3.49 (0.24) 4.60 (0.49) 4.32 (0.54) 3.38 (0.28) 3.17 (0.32)
Best self (social relationships)
20/26 (76.9%)
0.84 (0.21) 0.53 (0.23) 3.79 (0.22) 5.17 (0.45) 4.12 (0.46) 3.93 (0.25) 3.19 (0.27)
Forgiveness letter
24/30 (80.0%)
0.30 (0.19) 0.24 (0.20) 3.77 (0.20) 4.34 (0.41) 3.69 (0.41) 3.14 (0.23) 2.70 (0.25)
189/213 (88.7%)
0.73 (0.09) 0.71 (0.10) 3.77 (0.10) 5.20 (0.21) 4.72 (0.22) 3.51 (0.12) 3.21 (0.12)
Note. Ratings are adjusted means and standard errors from random-effects model accounting for age and exercise order. All ratings based on ve-point Likert scales. Modied
efcacy index and ease scores accounted for participants who were assigned but did not complete an exercise.
Table 3
Paired ttests assessing pre- and postexercise changes in hopelessness and optimism, separated by exercise
Exercise Mean improvement
95% CI tPvalue Cohensd(mean/S.D.) Improvement
Pre/post change in hopelessness
Counting blessings 0.64 0.271.01 3.53 0.002 0.71 12/21 (57.1%)
Best self
0.77 0.301.25 3.40 0.003 0.72 11/19 (57.9%)
Best self
(social relationships)
0.80 0.331.27 3.56 0.002 0.80 10/17 (58.8%)
Forgiveness letter 0.29 0.060.52 2.60 0.016 0.53 6/22 (27.3%)
Gratitude letter 1.05 0.601.49 4.93 b0.001 1.08 14/16 (87.5%)
Important, enjoyable and meaningful activities 0.68 0.351.01 4.24 b0.001 0.85 8/16 (50.0%)
Acts of kindness 1.17 0.651.69 4.74 b0.001 1.12 12/13 (92.3%)
Personal strengths 1.00 0.351.65 3.30 0.005 0.83 8/15 (53.3%)
Values-based activities 0.50 0.410.96 2.30 0.035 0.54 8/16 (50.0%)
Across all: 95/157 (60.5%)
Pre/post change in optimism
Counting blessings 0.80 0.281.32 3.18 0.004 0.64 11/21 (52.4%)
Best self (accomplishments) 0.73 0.291.16 3.46 0.002 0.74 13/19 (68.4%)
Best self (social relationships) 0.50 0.010.99 2.13 0.047 0.48 9/17 (52.9%)
Forgiveness letter 0.13 0.160.41 0.90 0.38 0.18 5/22 (22.7%)
Gratitude letter 1.14 0.701.58 5.43 b0.001 1.19 15/16 (93.8%)
Important, enjoyable and meaningful activities 0.76 0.441.08 4.88 b0.001 0.98 15/18 (83.3%)
Acts of kindness 0.78 0.121.43 2.52 0.022 0.59 9/13 (69.2%)
Personal strengths 0.81 0.251.37 3.10 0.007 0.78 9/15 (60.0%)
Values-based activities 0.44 0.090.79 2.68 0.016 0.63 8/16 (50.0%)
Across all: 95/173 (54.9%)
On 15 Likert scale. Improvement scores based on participants with greater than or equal to one-point (positive) changes in hopelessness and optimism. Denominator based on
participants who completed exercises but did not have ceiling scores for prehopelessness or preoptimism.
92 J.C. Huffman et al. / General Hospital Psychiatry 36 (2014) 8894
we accounted for potential improvements in preexercise baseline
ratings over time by measuring pre/post changes in optimism and
hopelessness (rather than just postexercise scores). In addition, the
random-effects model (estimating the effect of each exercise)
accounted for the ordering of the exercise, suggesting that differences
in outcomes for different PP exercises were not caused solely by
differences in the number of previous exercises completed.
Though the primary goal of this pilot project was to assess overall
feasibility and utility, we found meaningful variability in the degree to
which exercises were experienced as easy to complete and clinically
useful. Though the cumulative effect of the package of exercises may
have inuenced outcomes, the global test of exercise efcacy found
that specic exercise type, independent of exercise order, was
signicantly associated with self-reported efcacy.
Straightforward exercises that did not require substantial
introspection appeared to perform best. For example, exercises on
gratitudethe gratitude letter and counting blessingshad high
utility scores and were associated with substantial improvements
in optimism. This nding is consistent with prior work that has
linked gratitude to lower levels of depression, hopelessness and
suicidal thoughts/attempts [13,5256], though is in some contrast
to a study that found a gratitude letter to reduce depressive
symptoms in mildly, but not more severely, depressed participants
[57]. The exercise focusing on a personal strength was also
associated with substantial improvements in this population and
was perceived as easy to complete, consistent with prior work
nding this exercise to be associated with prolonged improvement
in depressive symptoms [19].
In contrast, the forgiveness letter exercise performed most poorly.
Qualitatively, many patients experienced a resurgence of anger or
sadness when recalling a past slight and found it difcult to move past
these feelings in the midst of crisis [58]. In addition, exercises focused
on life purpose and optimism had lower efcacy ratings than most
other exercises (though with CohensdN.4 on optimism and
hopelessness in all cases). Asking patients to take on bigissues
such as life purpose or imagining an optimal future might have been
more difcult for some patients at this stage. Alterations in delivery or
timing (e.g., after some symptom recovery) might render these
exercises more useful in this population.
This preliminary study had several limitations. Our sample was a
largely Caucasian population on a single psychiatric unit. There were
no sham or control exercises. Participants concurrently received
psychological and psychopharmacological interventions during ad-
mission, although ratings were completed in the narrow window
between exercise initiation and completion, minimizing potential
noisefrom other interventions. However, this meant that we were
not able to assess the overall/cumulative effect of the exercises as a
package. Additionally, patients may have felt compelled to rate higher
improvements in symptoms after exercise completion than before,
either to justify their participation or to please the researchers,
although as noted there were substantial differences in improvement
among various exercises. Finally, in this initial study that was
primarily aimed at feasibility (and short-term effects on optimism
and hopelessness), we did not serially measure suicidality via a
validated scale or obtain postdischarge outcomes, and thus, we cannot
make claims about the ultimate impact of these exercises on suicide
risk postdischarge.
In conclusion, PP exercises administered to suicidal inpatients
were well accepted, were completed at high rates and appeared to
be associated with self-rated improvements in clinically relevant
short-term outcomes. Specic exercises, especially those related to
gratitude and using personal strengths, appeared to be most
effective in this context. Additional work is needed to conrm
this pilot work, rene suboptimal exercises, test the exercises in a
larger cohort with a control group and assess their impact on
longer-term outcomes.
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... Sampling proces ed on hospitalized patients(Ducasse et al., 2019;Huffman et al., 2014). In addition, the percentage of those who properly committed to gratitude intervention was very low (8.9%). ...
... On the other hand, a small suicide prevention effect (d = 0.22) was observed for those who appropriately committed to gratitude intervention. The results of this study are consistent with those of previous studies(Ducasse et al., 2019;Huffman et al., 2014) that have shown the suicide preventive potential of gratitude intervention. Those who are at high risk of suicide do not necessarily visit hospitals, and alternative methods of support are ...
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【Abstract】Gratitude has received attention as a protective factor that contributes to suicide prevention,and several studies have shown that gratitude intervention in hospitalized patients has asuicide prevention effect. We conducted a gratitude intervention for suicidal internet users, andexamined the feasibility and effectiveness of the intervention. This is a single-arm study of gratitudeintervention ("counting blessings") among Japanese internet users with high suicidal ideation(N = 225). The experiment consisted of a baseline period of approximately 4 weeks and an interventionperiod of approximately 4 weeks. The main factor measured was suicidal ideation. Thedropout rate was 16.5% during the baseline period and 24.5% during the intervention period.Commitment to gratitude intervention was significantly associated with reduced suicidal ideation,after controlling for mean suicidal ideation in the baseline period and other demographic variables.Gratitude intervention has the potential to develop into a suicide prevention tool that can beused by suicidal internet users who do not necessarily have access to psychiatric care.
... Studies have shown that cyberbullying is positively associated with suicidal tendencies in adolescents. However, because positive mental health can significantly modify the effects of cyberbullying, it may be beneficial to consider fostering well-being in clinical and prevention programs for student populations [11]. Liu Xuezhou died by suicide. ...
... Studies have shown that cyberbullying is positively associated with suicidal tendencies in adolescents. However, because positive mental health can significantly modify the effects of cyberbullying, it may be beneficial to consider fostering well-being in clinical and prevention programs for student populations [11]. ...
Cyberbullying has become a serious problem to teenager groups though the high range of internet spreading. This study explores the association between cyberbullying and suicidal ideation by examining the "Liu Xuezhou suicide case. This study complements Chinese case studies on the suicidal ideation of adolescent victims of cyberbullying, revealing that cyberbullying can promote psychological problems in adolescent victims and cause them to develop suicidal ideation. Cyberbullying led to serious psychological problems for Liu Xuezhou, which in turn led to his inability to withstand the pressure to commit suicide. The issue of cyberbullying must be emphasized by schools and parents in order to reduce the damage to teenage victims.
... Adherence and acceptability results indicate that the MMPI was well received and liked by participants, especially due to the innovative nature of both the content and the group exercises in relation to usual psychotherapy topics, so we believe it would be a good complementary intervention to individual therapy in this population. Specifically, the mean rate of participants' attendance (82%) could be considered remarkable, as it is slightly higher than results obtained in other PPIs studies with healthy populations (Page & Vella-Brodrick, 2013) as well as with clinical samples (e.g., Celano et al., 2017;Chaves et al., 2017;Huffman et al., 2014). In the same vein, exercises adherence was also remarkable (70%), and participants rated extraordinarily high their level of satisfaction (3.6 points out of 4). ...
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Early adulthood is a critical transitional period, when the individual faces many challenges related to their development as a fully autonomous individual. However, it can also be an important period for developing resilience, positive interpersonal and behavioral patterns, especially for people who have difficulty trusting others. Thus, the early introduction of positive resources and practices can have both immediate and prophylactic effects for young adults. This is randomized control study aimed to examine the efficacy of a theory-driven, multi-component, positive psychology group intervention to improve well-being in a clinical sample of 77 young adults with paranoid tendencies compared to a waiting-list group. Results showed that the intervention protocol was highly acceptable for participants, with high participant satisfaction, attendance, and adherence rates. At the end of the group therapy, mixed-effect models for repeated measures reflected that the participants had a significant improvement in some of the primary well-being outcomes with medium and large effect sizes (ranging 0.57–0.89). These changes were maintained in the follow-up assessment after 3 and 6 months. The results of this randomized control trial provide further evidence that a positive psychology approach can help promote eudemonic well-being and self-esteem for young people seeking psychotherapy in a University Psychology Clinic.
... El número de avances en la investigación de la salud que se han producido en el campo de la Psicología Positiva han sido numerosos. Por ejemplo, existen terapias en el marco de la Psicología Positiva que han mostrado mejorar significativamente los síntomas de la depresión, incluida la ideación suicida (Celano et al., 2017;Huffman et al., 2014;Proyer et al., 2015;Santos et al., 2013), mejorar la calidad de vida de personas con cáncer y sus familias (Casellas-Grau., 2014;Cerezo et al., 2014;Damreihani et al., 2018), y tener efectos beneficiosos en pacientes con dolor crónico (Hendriks et al., 2020;Peters et al., 2017). Respecto a los efectos beneficiosos de carácter más subjetivo y emocional, obtenidos mediante tratamientos en Psicología Positiva, en muchas ocasiones se miden en términos de la que probablemente es una de las variables más importantes de esta disciplina: el bienestar, variable que en psicología puede encontrarse dentro de dos categorías diferentes: bienestar subjetivo y bienestar psicológico. ...
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This study quantitatively reviews all published information about the relationship between moral foundations and well-being, both hedonic and eudaimonic. The results show a significant relationship between moral foundations and well-being in most of the well-being subscales included, especially those referring to eudaimonic well-being. However, the results generally depend on the moral foundation and the well-being subscale considered. Este estudio revisa cuantitativamente toda la información publicada acerca de la relación entre fundamentos morales y el bienestar, tanto hedónico como eudaimónico. Los resultados muestran una relación significativa entre los fundamentos morales y el bienestar en la mayor parte de las subescalas del bienestar incluidas, especialmente las referidas al bienestar eudaimónico. No obstante, los resultados dependen en general del fundamento moral y de la subescala del bienestar consideradas.
... There is emerging evidence for psychological therapies in acute care settings, including cognitive behavioural therapy (CBT), dialectical behaviour therapy (DBT), interpersonal psychotherapy, and positive psychology interventions (Schramm et al. 2008;Mueller et al. 2013;Huffman et al. 2014;Schefft et al. 2019;Tebett-Mock et al. 2020;Kouvaras et al. 2022;Williams et al. 2022). A recent systematic review has shown that psychological therapy in acute care services leads to significant improvements in clinical, economic and patient experience outcomes, including reductions in depression, anxiety, and hospital readmission rates (Paterson et al. 2018). ...
'Comprehend, Cope and Connect' (CCC) is an evidence-based psychological intervention for psychological crisis designed for use in inpatient settings. The aims of the current study were to gain the perspectives of multidisciplinary team (MDT) staff, patients and carers to inform the design of a potential CCC training programme for MDT staff to deliver CCC interventions. Staff, patient and carer perspectives on developing a CCC training programme were collected through video call-based group consultations and written feedback. Thematic analysis was employed to organise and explore latent themes within the data. Thirteen MDT inpatient staff and an expert patient and carer panel of four participated in the study. Feedback showed that the CCC model supported staff in understanding patients beyond labels in a patient-centred and led capacity, and that CCC was helpful in bringing clarity to crisis. Staff participants stated that learning and practicing psychological skills and encouraging confidence would be important when training staff in CCC. They identified needs to embed CCC into ward culture and integrate CCC with care planning for successful implementation of CCC in inpatient settings. The patient and carer panel focused on the needs of patients, concluding that CCC training should emphasise the need to understand patient experience, and promote compassion and empathy. These findings provide evidence for what staff, patients, and carers consider to be important when training MDT staff to deliver CCC interventions in an inpatient setting and form a foundation for implementation of CCC training.
... It encourages future research on PPIs in the field of romantic relationships. The study also aligns with research into activities such as the "Best Self for Relationships" intervention (i.e., imagining one's future life with a particular focus on relationships with thinking about the best possible romantic life one can imagine), which could be beneficial in increasing optimism and alleviating feelings of hopelessness (e.g., Huffman, 2014). Also, this aligns with findings from programs targeting happiness in couples (e.g., Hilpert et al., 2016). ...
Suicidality and self-harm among adolescents and young adults need immediate attention and support. This is often seen as a ‘cry for help’ where a feeling of entrapment experienced by individuals pushes them to see self-harm as a coping mechanism. Lack of social support and co-morbid emotional disorders influences suicidal ideation into planning and action. A general feeling of helplessness that gets triggered often leads to anguish. These emotions get internalized and directed inwards leading to self-directed anger which facilitates a suicidal act. Early detection and identification can prevent the loss of lives and help individuals to learn effective ways of coping. Gatekeeper Training for caregivers, teachers, and their peers will help in detecting the early signs of suicide risk. Intervention based on positive psychology will help not only in crisis management but also as preventive and maintenance therapy in holistic mental health. The concepts of hope, forgiveness, self-compassion, gratitude, and resilience can be incorporated into the intervention programs to build a better therapeutic system for youths dealing with suicidality. Practicing effective coping mechanisms every day and making it a ritual of one’s daily life is the need of the hour. Integrating adaptive ways of emotional expression and learning matured means to deal with painful emotions and trauma is what needs to be incorporated into the intervention plan. The chapter focuses on these aspects and aims to make a connection between assessing and easy identification of youths in distress related to suicidality and providing a holistic intervention to help them cope with the situation.
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This study tested an integrative model linking experiences of need frustration and need satisfaction with suicidal ideation through a risk-enhancing (via anxious-depressive symptoms) and a risk-reducing pathway (via positive cognitions) in adolescents. The generalizability of the model based on the clinical status of the participants was also explored. A matched sample of referred (n = 210) and non-referred (n = 210) adolescents aged between 12 and 17 years old completed self-report measures of psychological need-based experiences, suicidal ideation, positive cognitions, and anxious-depressive symptoms. Structural equation modeling was used to explore the proposed model. Mediation analysis showed that need frustration was positively associated with suicidal ideation through anxious-depressive symptoms, while need satisfaction was negatively associated with suicidal ideation through positive cognitions. Invariance analysis pointed to limited differences in the model associations as a function of clinical status. These initial findings suggest the relevance of consider need frustration and need satisfaction in explaining suicidal ideation. The integration of risk and protective factors and the study of the generalizability of the data across the clinical status of adolescents provide preliminary implications for the development of interventions to prevent suicidal ideation.
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"By now, it has become a bromide that the U.S. constitution and culture are built on the pursuit of happiness (Myers, 1992). According to this political philosophy, government should allow citizens to strive towards their own conception of happiness, and should assist them as much as possible to reach this goal. In return, citizens ought to make the most of the opportunity, ultimately contributing to the common good of all. The enduring appeal of this American ideal rests on the very plausible assumption that happiness is the fundamental objective of all human effort and activity, in all cultures, whether people are aware of it or not. By taking action, humans aim towards more positive conditions and feelings than they currently experience, or towards more positive future feelings than what they might otherwise experience if they failed to act (Carver & Scheier, 1998). Accordingly, becoming happier is not only a hugely popular topic on the self-help shelves, it is increasingly becoming a stated policy goal of world governments, with the gross national happiness of the country (rather than its gross domestic product) as the primary quantity to be maximized "
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Theory and research suggest that people can increase their happiness through simple intentional positive activities, such as expressing gratitude or practicing kindness. Investigators have recently begun to study the optimal conditions under which positive activities increase happiness and the mechanisms by which these effects work. According to our positive-activity model, features of positive activities (e.g., their dosage and variety), features of persons (e.g., their motivation and effort), and person-activity fit moderate the effect of positive activities on well-being. Furthermore, the model posits four mediating variables: positive emotions, positive thoughts, positive behaviors, and need satisfaction. Empirical evidence supporting the model and future directions are discussed.
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In a variation on Pennebaker's writing paradigm, a sample of 81 undergraduates wrote about one of four topics for 20 minutes each day for 4 consecutive days. Participants were randomly assigned to write about their most traumatic life event, their best possible future self, both of these topics, or a nonemotional con- trol topic. Mood was measured before and after writing and health center data for illness were obtained with participant con- sent. Three weeks later, measures of subjective well-being were obtained. Writing about life goals was significantly less upset- ting than writing about trauma and was associated with a sig- nificant increase in subjective well-being. Five months after writ- ing, a significant interaction emerged such that writing about trauma, one's best possible self, or both were associated with decreased illness compared with controls. Results indicate that writing about self-regulatory topics can be associated with the same health benefits as writing about trauma.
Anxiety and depression are common responses to trauma and bereavement. However, gratitude and spirituality may be helpful to individuals experiencing anxiety and depression in response to a loss, and therefore empirical investigation into the links between these variables is warranted. This study investigated the relationships between gratitude, spiritual/ religious variables, anxiety and depression across multiple religious groups. Two independent samples consisting of n = 120 Christians (Catholic, Mainline Protestant, Evangelical Protestant and Morman) and n = 234 Jews (Orthodox, Conservative, Reform and Other) were recruited. Measures of gratitude, general religiousness, religious practices, and positive core beliefs about God (trust in God) were administered alongside measures of trait anxiety and depression. Statistically significant correlations emerged between all variables, suggesting that gratitude and spirituality are protective factors against anxiety and depression.
Numerous accounts of research on promoting forgiveness in group settings have been published, indicating that forgiveness can be promoted successfully in varying degrees. Many have suggested that empathy-based interventions are often successful. It takes time to develop empathy for an offender. We report three studies of very brief attempts to promote forgiveness in psychoeducational group settings. The studies use ten-minute one-hour, two-hour, and 130-minute interventions with college students. The studies test whether various components-namely, pre-intervention videotapes and a letter-writing exercise-of a more complex model (the Pyramid Model to REACH Forgiveness) can produce forgiveness. Each study is reported on its own merits, but the main lesson is that the amount of forgiveness is related to time that participants spend empathizing with the transgressor. A brief intervention of two hours or less will probably not reliably promote much forgiveness; however, one might argue that it starts people on the road to forgiving.
Numerous accounts of research on promoting forgiveness in group settings have been published, indicating that forgiveness can be promoted successfully in varying degrees. Many have suggested that empathy-based interventions are often successful. It takes time to develop empathy for an offender. We report three studies of very brief attempts to promote forgiveness in psychoeducational group settings. The studies use ten-minute, one-hour, two-hour, and 130-minute interventions with college students. The studies test whether various components - namely, pre-intervention videotapes and a letter-writing exercise - of a more complex model (the Pyramid Model to REACH Forgiveness) can produce forgiveness. Each study is reported on its own merits, but the main lesson is that the amount of forgiveness is related to time that participants spend empathizing with the transgressor. A brief intervention of two hours or less will probably not reliably promote much forgiveness; however, one might argue that it starts people on the road to forgiving.
Psychological interventions to treat mental health issues have developed remarkably in the past few decades. Yet this progress often neglects a central goal-namely, to reduce the burden of mental illness and related conditions. The need for psychological services is enormous, and only a small proportion of individuals in need actually receive treatment. Individual psychotherapy, the dominant model of treatment delivery, is not likely to be able to meet this need. Despite advances, mental health professionals are not likely to reduce the prevalence, incidence, and burden of mental illness without a major shift in intervention research and clinical practice. A portfolio of models of delivery will be needed. We illustrate various models of delivery to convey opportunities provided by technology, special settings and nontraditional service providers, self-help interventions, and the media. Decreasing the burden of mental illness also will depend on integrating prevention and treatment, developing assessment and a national database for monitoring mental illness and its burdens, considering contextual issues that influence delivery of treatment, and addressing potential tensions within the mental health professions. Finally, opportunities for multidisciplinary collaborations are discussed as key considerations for reducing the burden of mental illness. © The Author(s) 2011.