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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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... Specifically, NAI communities experience disproportionate rates of depression, suicidality (Shalala et al., 1998), tobacco use (Spillane et al., 2020b), and cardiovascular disease (Castor et al., 2006). At the same time, PPIs have been found to be feasible and efficacious among non-NAI groups in targeting depression (Rashid, 2015) and suicidality (Huffman et al., 2014), improving likelihood of successful smoking cessation (Kahler et al., 2015), and increasing treatment adherence in cardiovascular disease (Huffman et al., 2014;Nikrahan et al., 2016). Surprisingly, however, it does not appear that PPIs have been formally employed in a systematic way to target these outcomes in NAI communities. ...
... Specifically, NAI communities experience disproportionate rates of depression, suicidality (Shalala et al., 1998), tobacco use (Spillane et al., 2020b), and cardiovascular disease (Castor et al., 2006). At the same time, PPIs have been found to be feasible and efficacious among non-NAI groups in targeting depression (Rashid, 2015) and suicidality (Huffman et al., 2014), improving likelihood of successful smoking cessation (Kahler et al., 2015), and increasing treatment adherence in cardiovascular disease (Huffman et al., 2014;Nikrahan et al., 2016). Surprisingly, however, it does not appear that PPIs have been formally employed in a systematic way to target these outcomes in NAI communities. ...
Positive psychology research has led to the development of brief interventions designed to promote positive emotions: positive psychological interventions (PPIs). Randomized controlled trials examining PPIs have found them to be effective in increasing well-being and decreasing depressive symptoms. PPIs have been studied in samples consisting primarily of White Americans; however, PPIs may be useful for members of North American Indigenous groups. PPIs align well with Indigenous views on health, which tend to be strengths-based, holistic, and encompassing the whole body (including the medicine wheel’s four dimensions of spirit, mind, heart, and body). This paper provides a framework for the adaptation of PPIs for Indigenous communities and a review of preliminary data on the relationships between positive psychological characteristics and health outcomes including substance use. Implications include the potential widespread impact of culturally adapted PPIs given their alignment with Indigenous thoughts on health and relative ease of administration.
... As Broad-and-Built Theory, Wingate et al. (2006) stated that clinicians might be expected to bring the greatest treatment effects by deliberately inducing positive emotions in therapy (e.g., by asking patients to think about the best times in their lives) -even when working with suicidal patients. In line with this assumption, positive psychology interventions have been shown to be feasible in dealing with suicidal inpatients (Huffman et al., 2014). ...
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Many Malaysian adolescents are experiencing stress due to high self-expectations in achieving academic grades. As a result, many adolescents are experiencing suicidal ideation; therefore, it is imperative to find important protective factors to minimize the chances of such adolescents committing suicide. This study aimed to assess whether or not there is a relationship between positive mental health, academic stress and suicidal ideation among Malaysian adolescents residing in Johor Bahru. This study also explored whether or not positive mental health serves to mitigate the relationship between academic stress and suicide suicidal ideation. The participants were a 210 Malaysian adolescents residing in Johor Bahru, aged 15-20 years. The participants Mala completed the Assessing Academic Stress, Positive Mental Health Questionnaire and Suicide Behavior Questionnaire. Data were analysed using correlation, regression, and PLS-SEM. The findings revealed that academic stress does cause suicidal ideation in Malaysian adolescents. The results of the correlation analysis showed that there is a negative association between positive mental health with academic stress and suicide ideation. Furthermore, this study found that positive mental health does serve as a significant mediator between academic stress and suicidal ideation. Academic stress leads to suicidal ideation, but positive mental health could be significant protective factor. Therefore, there is a need for parents, teachers and peers to promote positive mental health at home and in school, which is essential in curbing academic stress and suicidal ideation.
... It can be thought that well-being, which can contribute to the cognitions positively, may be related to emotions and behaviours. Developing optimism, strengthening gratitude, and redefining life goals were among positive psychology interventions (Bolier et al., 2013;Huffman et al., 2014;Lyubomirsky and Layous, 2013). Being positive can be accepted as a driving force for individuals to reveal their worldview, mental energies, relationships and potentials (Fredrickson, 2001). ...
... The use of signature strengths increases happiness and decreases depression (e.g., Seligman et al., 2005;Gander et al., 2013;Proyer et al., 2015). Strengthbased interventions have been found to be effective in enhancing positive emotion (e.g., Seligman et al., 2006;Drozd et al., 2014) and life satisfaction (e.g., Rust et al., 2009;Duan et al., 2013), or improving levels of hopelessness and optimism (e.g., Huffman et al., 2014). In particular, character strengths may buffer from the negative effects of cognitive vulnerabilities (e.g., perfectionism, self-criticism, or excessive need for approval) that can lead to psychological ill-being, such as depression symptoms (Huta and Hawley, 2010). ...
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The increasing value of character strengths in the prediction of well-being and psychopathology, after the effects of functional social support and sociodemographic variables are accounted for, is examined. Participants were 1494 Spanish-speaking students between the ages of 18 and 68 (43.3% men and 56.7% women) who completed measures of character strengths, functional social support, subjective well-being, psychological well-being, and symptoms of psychopathology. Functional social support had predictive value in explaining the variability of each component of well-being and psychopathology. Regarding character strengths, theological strengths had the greatest predictive power for life satisfaction (β = 0.41), positive affect (β = 0.49), affect balance (β = 0.45), purpose in life (β = 0.60), self-acceptance (β = 0.50), environmental mastery (β = 0.47), and positive relations with others (β = 0.25). Emotional strengths made the strongest contribution to the variance explained (β = 0.41) of autonomy, and intellectual strengths were the strongest predictive variable for personal growth (β = 0.39). Strengths of restraint had the greatest predictive power for the global severity index of psychopathology (β = –0.27). Functional social support and character strengths have strong links to mental health. Positive interventions to develop these variables could contribute to enhance well-being and prevent psychological distress.
... The practices and intentional activities that put us on the path to greater subjective and eudaimonic well-being are called positive interventions. Also known as positive psychological interventions (Parks & Schueller, 2014), positive psychology exercises (Huffman et al., 2014), and positive activities (Lyubomirsky & Layous, 2013), such interventions are defined as "treatment methods or intentional activities aimed at cultivating positive feelings, positive behaviors, or positive cognitions" (Sin & Lyubomirsky, 2009;p. 467). ...
Interactive Journaling is a structured writing process that motivates and guides individuals toward positive change and greater well-being in target life areas. This paper maps the properties of Interactive Journaling to core properties and criteria of positive interventions – activities within the field of positive psychology that are empirically validated and strive to promote well-being. These properties include underpinnings in the evidence-based paradigm of expressive writing, an emphasis on participant agency and person-activity fit, and other evidence-based norms within the practice of Interactive Journaling. Based on this alignment, Interactive Journaling can be considered a positive intervention. Existing positive interventions may also be enhanced when integrated into the Interactive Journaling framework. Researchers are invited to examine Interactive Journaling more closely using validated well-being measures and new populations.
... Bu & Duan, 2019; Duan & Bu, 2017;Dubreuil et al., 2016; Forest et al., 2012;Hassaniraad et al., 2021; Koydemir & Sun-Selışık, 2016; Leventhal et al., 2015;Mitchell et al., 2009;Quinlan et al., 2012), satisfacción vital(Duan et al., 2013;Proctor, Tsukayama, et al., 2011), felicidad(Chérif et al., 2020;Gander et al., 2012a;Mongrain & Anselmo-Matthews, 2012;Senf & Liau, 2013;Woodworth et al., 2016), afecto positivo(Meyers & van Woerkom, 2016), balance de afecto positivo y negativo(Drozd et al., 2014), capital psicológico(Meyers & van Woerkom, 2016), uso de las fortalezas del carácter(Dubreuil et al., 2016; Forest et al., 2012), pasiones armónicas(Forest et al., 2012), resiliencia y autoeficacia(Leventhal et al., 2015).Por su parte,Huffman et al. (2014) plantearon que la aplicación de una intervención basada en fortalezas del carácter mejora la esperanza y optimismo en pacientes con riesgo suicida. A su vez, una intervención basada en fortalezas del carácter ha aumentado la satisfacción vital y felicidad en adultos mayores(Ho et al., 2014).Asimismo, las intervenciones basadas en fortalezas del carácter disminuyeron la ansiedad(Duan & Bu, 2017), depresión(Duan & Bu, 2017;Gander et al., 2012a;Mongrain & Anselmo-Matthews, 2012;Seligman et al., 2006;Senf & Liau, 2013;Woodworth et al., 2016) y emociones negativas(Bu & Duan, 2018;Tapernon, 2020); de igual forma, redujeron el estrés negativo en adultos mayores internados con discapacidades físicas crónicas(O'Donnell, 2013). ...
Good character is a principal area in Positive Psychology. The current thesis assesses character strengths with mixed method: quantitative though factor analysis and qualitative using content analysis. Main purpose is evaluate and analyze the character strengths factors in participants from Ecuador, Peru and Paraguay to identify whether international findings are replicated; and verify replication in each country independently. A non probabilistic intentional sample was used: 854 university students (273 Ecuadorians, 277 Peruvians and 304 Paraguayan). Participants completed Inventario de Virtudes y Fortalezas del Carácter IVyF (Cosentino & Castro Solano, 2012) and Protocolo de Cualidades Positivas (Castro Solano & Cosentino, 2013). Main results show three character strengths factors: moderation, progress and fraternity. Secondly, this three factor model is the most parsimonious and replicable despite some differences. Finally, dimensional structure has intercultural differences because each countries have specific relations. Main conclusion show three factors of character strengths and intercultural differences in dimensional structure of each country. Data has limitations: used sample could not be an average citizen of each culture and countries were considered as national culture. Future studies should research intracultural differences in character strengths, identify causes of intercultural differences in each population and analyze character strengths in others Latin-American countries.
Background : Young people in their teens and twenties don’t seek treatment immediately for mental health issues. This is due to the perceived stigma linked to mental health, pragmatic inconveniences to reach clinical settings, and the tediousness to seek help or engage with adults in traditional ways. Alternative approaches aside from drugs administration are needed. Method : We conducted an internet-delivered pilot randomized controlled trial directed to Hikikomori and Futōkō experienced subjects. This study aimed to understand the difference in efficacy for an intervention using a fictional story vs factual scientific information (self-aid texts), as well as the feasibility of an internet delivered program .. Evaluation of emotional transportation and mental health related measures were administered at base line before the program and at one week after the completion of the program. Results : 40 participants were enrolled. A post-intervention (T2) Independent T-student showed that Emotional Transportation was significantly lower for the intervention group than for the control group at T2. Relaxation was significantly higher for the intervention group than for the control group at T2. For the other outcome variables, the difference was not statistically significant. An ANCOVA showed that there was a significant effect of groups on emotional transportation (lower in the intervention group). There was a significant effect of groups on empathy (lower in the intervention group); for the other variables the effects of groups were not detected. Conclusions : The results showed a significant diminishment in emotional transportation and empathy for the interventional group contradicting the hypothesis that an enhancement of emotional transportation mediates the positive mental health effects. A marginal improvement in relaxation in the intervention group (T-test) was found. In the posthoc analysis, the positive effects on the relaxation of pre-intervention (habitual) high emotional status of participants were confirmed. This trial is registered with UMIN , ID UMIN000044204.
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Background: Despite the potential for benefit, resilience remains an emergent area in late-life mental health care, and evidence of resilience intervention for suicide among nursing home residents is especially limited. This study aims to evaluate the effects of a resilience-targeted program based on the "I have, I am, and I can" strategy on suicidal ideation and related problems. Methods: From the 562 nursing home residents who were contacted, 68 with suicidal ideation were recruited and then randomly assigned to a resilience intervention group (eight-week resilience training; n = 34) or a wait-list control group (eight-week health education; n = 34). Self-reported suicidal ideation, and depression and anxiety symptoms as outcomes, and resilience as potential mediators were assessed at baseline, postintervention, and one-month follow-up. Results: Resilience training participants reported significant improvement in suicidal ideation (group × time interaction x 2 =12.564, p = 0.002) and depression symptoms (x 2 =9.441, p = 0.009) compared to wait-list control group participants. Changes in resilience mediated the intervention's effects on changes in suicidal ideation and depression symptoms. Limitations The observed effects must be considered preliminary due to the small sample size. Conclusions: The findings support the benefits of resilience training based on the "I have, I am, and I can" strategy in reducing suicidal ideation and suicide-related symptoms in nursing home older adults, and provide insight into possible mechanisms.
Suicide involves ideations and/or attempts that can lead to death. Its increase in adolescence demands preventive and health-promoting public policies. Objectives: 1) to disclose, by means of documentary analysis, the indexes and methods of suicide by sex in a city of Goiás between the years of 2005 and 2012; 2) to endorse the prevalence of ideation and attempted suicide among adolescents; 3) to assess a relationship between idea and suicide attempt and behavioral problems, and 4) to analyze sociodemographic and clinical risks associated with suicide attempts. A probabilistic sample of 368 adolescents (13 to 18 years old), responded to the Youth Self Report. There is a high prevalence of suicide in the city (M = 2.37 cases/year in a city with approximately 2,200 adolescents). 12.8% of the sample reported attempting suicide, and 18,2% thought to commit suicide, of which 47.8% actually attempted suicide. Ideation and attempted suicide correlated significantly with all behavioral problems surveyed. Variables such as suicidal ideation and type of school were predictors of suicide attempts.
Growing evidence suggests that online positive-psychological interventions effectively increase well-being, and a wealth of evidence describes cognitive-affective responses to such interventions. Few studies, however, have directly compared responses across popular exercises such as the best-possible-self intervention, the gratitude letter, or self-compassionate writing. In addition, current evidence is ambiguous regarding the effects of potential moderator variables such as trait gratitude and emotional self-awareness. To address these issues, we randomized 432 German adults to perform either optimism, gratitude, self-compassion, or control writing interventions in an online setting. Participants reported trait gratitude and trait emotional self-awareness before the interventions, as well as momentary optimism, gratitude, self-compassion, positive affect, and current thoughts immediately after the interventions. Results indicate higher momentary optimism after the best-possible-self intervention and higher momentary gratitude after the gratitude letter than after the control task. There were no differences when comparing the best-possible-self intervention with the gratitude letter. Both interventions increased the number of positive self-relevant thoughts. The self-compassion condition showed no effects. Moderation analysis results indicate that neither emotional self-awareness nor trait gratitude moderated the intervention effects. Future studies should compare responses across different positive-psychological interventions using more comprehensive exercises to ensure larger effects.
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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.