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Positive Psychotherapy in Cancer: Facilitating Posttraumatic Growth in Assimilation and Accommodation of Traumatic Experience



Being diagnosed with cancer and undergoing subsequent treatment can produce high levels of distress among patients. Several psychotherapeutic approaches have sought to help cancer patients manage these negative impacts. In addition, however, there is now increasing evidence regarding the collateral positive outcomes of the cancer experience, it being concluded that positive life changes may also result from such adversity. Consequently, therapies focusing on the emergence of these positive changes have also been developed. In this chapter, we describe a positive psychotherapy for cancer survivors, one which aims to facilitate posttraumatic growth as a way of achieving a significant reduction in negative emotional states (emotional distress or posttraumatic symptoms). A further goal of this positive psychology approach in cancer is to work with positive emotions and positive functioning so as to promote healthy lifestyles, a return to work, and social supportive behaviors.
“Positive psychotherapy in cancer: Facilitating posttraumatic growth
in assimilation and accommodation of traumatic experience
Description of a positive psychotherapy protocol focused on
facilitating posttraumatic growth through assimilation and accommodation
of the traumatic experience in cancer.
Strategic approaches and specific techniques. Empirical evidence of
Cristian Ochoa Arnedo, PhD
Institut Català d’Oncologia.
Hospital Duran i Reynals. Avinguda Gran Via de l’Hospitalet, 199-203.
08908 l’Hospitalet de Llobregat (Barcelona). Spain.
Telephone: (+34) 93 3357011 (ext. 3717)
Fax: (+34) 93 2607181
Anna Casellas-Grau
Universitat Autònoma de Barcelona.
Departament de Psicologia Bàsica, Evolutiva i de l’Educació.
Edifici B. Campus de la UAB. 08193 Bellaterra (Cerdanyola del Vallès - Barcelona).
Telephone: +34 93 885 6481
The Comprehensive Guide to Post-Traumatic Stress Disorders. Colin Martin, Victor R.
Preedy and Vinood B. Patel (Eds.). 2015
Being diagnosed with cancer and undergoing subsequent treatment can produce high levels of
distress among patients. Several psychotherapeutic approaches have sought to help cancer
patients manage these negative impacts. In addition, however, there is now increasing evidence
regarding the collateral positive outcomes of the cancer experience, it being concluded that
positive life changes may also result from such adversity. Consequently, therapies focusing on
the emergence of these positive changes have also been developed. In this chapter we describe a
positive psychotherapy for cancer survivors, one which aims to facilitate posttraumatic growth
as a way of achieving a significant reduction in negative emotional states (emotional distress or
posttraumatic symptoms). A further goal of this positive psychology approach in cancer is to
work with positive emotions and positive functioning so as to promote healthy lifestyles, a
return to work, and social supportive behaviors.
Keywords (5-10)
Psycho-oncology, positive psychology, psychotherapy, posttraumatic growth, cancer.
PPC Positive psychotherapy for cancer
PTG Posttraumatic growth
QoL-Quality of Life
1. Introduction
Severe illnesses like cancer are adverse experiences with a high psychological impact. Many
studies have explored the negative psychological consequences of cancer, which include
fatigue, distress and depression (Haberkorn et al., 2013; Sheppard, et al., 2013). In fact, the
mere diagnosis of cancer is reported to produce distress in 35-38% of patients (Faller et al.,
2013). There is now a considerable body of evidence associating this distress with poorer
quality of life (QoL), less adherence to cancer treatments and worse general survival, as well as
a less healthy lifestyle and poorer self-care. However, it is also known that in addition to stress
and distress a cancer diagnosis can trigger positive life changes in survivors (Cordova, et al.,
2001; Ochoa, 2009; Ochoa, et al., 2013; Sawyer, Ayers, & Field, 2010). In the literature these
positive changes are referred to as posttraumatic growth, benefit finding, or stress-related
growth, among other terms. As a result of these findings the focus of research on the
psychological impact of cancer has shifted towards the understanding of how positive
psychological outcomes may emerge from the cancer experience and of how such outcomes
may be facilitated through psychological interventions.
2. Positive interventions
Traditionally, the focus of therapy has been on damage repair, with many practitioners learning
little about how a good life might be encouraged (Rashid & Seligman, 2013). Over the last two
decades, however, psychology has placed greater emphasis on the positive aspects of human
functioning, and this has led to a number of positive psychology interventions being proposed,
including well-being therapy (Fava, et al., 1998), quality of life therapy (Frisch, 1998), and
Seligman’s positive psychotherapy (Seligman, et al., 2006), among others. In this context, it is
now acknowledged that whereas people can develop little strength or make few personal
changes from their negative emotions, their positive emotions can indeed serve to enhance
strengths and drive personal changes; furthermore, these positive emotions can also act as a
buffer against negative states such as stress (Castilla & Vázquez, 2011). Building on these ideas
and findings from the field of positive psychology the goal of positive psychotherapy in cancer
(PPC) is to address not only suffering and damage but also growth and personal development,
and to do so in an integrated way (Ochoa, et al., 2010). The central premise of PPC is to make
psychological intervention more closely focused on patients’ positive resources, such as positive
emotions, personal meanings, and strengths (including existential and spiritual meaning), at the
same time as addressing their psychopathological symptoms and emotional distress (Ochoa, et
al., 2010; Rashid, T., & Seligman, 2013). One of the basic assumptions of PPC, which is
relevant in cancer and derives from the humanistic-existential tradition, is that individuals have
an inherent desire for growth, fulfillment, and happiness, rather than merely seeking to avoid
misery, worry, or anxiety. In this chapter these positive changes will be referred as
posttraumatic growth (PTG), a phenomenon that implies changes in 1) the view of oneself
(better confidence, self-esteem, and empathy), 2) the view of others (closer and more intimate
relationships with people, and easier communication), and 3) one’s life philosophy or existential
position (focusing on the present moment, greater appreciation of life, change in life priorities
and values, increased interest in spiritual issues and the issue of meaning in life). In this context,
the basic aim of PPC is to facilitate PTG in patients, caregivers, and patients’ significant others.
Based on extensive research and a review of the literature on trauma and the growth process
after undergoing cancer (Sumalla, et al., 2009) our PPC program was developed to complement
and enhance more traditional psychological treatments, such as those focused on stress
management (Antoni, 2003) . More specifically, the PPC program is aimed at cancer survivors
with moderate or severe problems of adjustment after completing their cancer treatment.
3. A guide to facilitating positive life changes in cancer by means of the PPC
The main aim of PPC is to promote positive life changes (e.g., PTG) in cancer survivors by
managing the psychotherapeutic elements related to the emergence of such changes. The
authors of a clinical guide to promote personal growth (Calhoun & Tedeschi, 1999) regard this
proposal as a new perspective on coping with potentially traumatic events, one which can be
integrated by therapists from various schools into their work. PPC has mainly been developed as
a group-based therapy (Ochoa et al., 2010) and it primarily integrates elements from the
cognitive-behavioral and humanistic-existential perspectives, along with strategies and tasks
from positive psychology. Table 1 shows the modules and sessions that form part of the PPC
program, as well as their corresponding objectives and the therapeutic elements used to achieve
them. In the next section we describe and justify the different components of the program.
------------------ INSERT TABLE 1 APPROXIMATELY HERE ---------------------
Practice and Procedures
The therapeutic focus
In addition to integrating elements from cognitive-behavior and humanistic approaches through
therapist narratives (Spiegel & Classen, 2000) the PPC program also draws upon common
components of group therapy. Group-based interventions share some therapeutic elements that
are specially important to be applied on cancer. All group-based therapies promote emotional
expression and release (catarsis), help oneself to realize that his or she is not the only one who is
suffering (universality), as well as offer a guide and information to the therapist, facilitates
altruism cohesion, more socialization and interpersonal learning.
Formal aspects of the program
The formal aspects of the program, in other words, the number and duration of sessions and the
group composition (8-12 members), are based on the general recommendations featured in the
main manuals and literature regarding group interventions in cancer. Specifically, the program
consists of 12 weekly sessions of 90-120 min of length, with two follow-up sessions being held
at 3 and 12 months post-intervention. Groups are formed around one month after completing
primary cancer treatment, it being considered that this is a suitable point at which to begin
psychotherapy given the aim of favoring the survivor’s psychosocial adaptation. Indeed, this is a
critical point because illness control shifts from medical staff to survivors themselves, and this
generates important life issues, which can be summarized in a question that most patients pose:
“And what now?”
Stages of psychotherapy
Sessions are spread across four modules (see Table 1) of different lengths and with different
aims, and they are adapted to the pace of the group. The general objective of the first two
modules is assimilation of the cancer experience, while the final two modules are focused more
on encouraging accommodation and personal transformation (growth) from the illness
Having suffered from cancer and the threat it poses to life, most patients find they
experience a progressively greater sense of the inherent human desire for growth, fulfillment,
and happiness. Clearly, a key part of patients’ suffering is related to the possibility of death that
a cancer diagnosis provokes. However, another part of their suffering relates to the realization
that the need for growth, for positive life changes, is being frustrated. Personal growth is
facilitated through the assimilation of lived experiences as something belonging to oneself, and,
above all, through achieving a renewed vision of oneself, of others, and of the world. This kind
of renewal is especially necessary when the experience of cancer cannot be integrated into the
existing view of illness, or is only integrated at the cost of considerable suffering or distress.
Most models of growth from adversity distinguish between the assimilation and the
accommodation of the adverse experience (e.g., cancer). In general, a distinction is made
between, on the one hand, patients who change their interpretation of their experience so that it
fits into their existing world view (assimilation), and, on the other, patients who change their
world view in order to integrate their experience (accommodation). The assimilation process
tends to appear immediately after the adverse event and includes emotional expression,
processing, and regulation as coping strategies focused on the management of the event,
although the relationship between adversity and assimilation is not strictly sequential. The
strategies used in the initial stages of the PPC program seek to capitalize on this process of
assimilation, before moving on, in the intermediate and final stages of the intervention, to
strategies that address the process of accommodation or personal transformation. A number of
factors associated with both assimilation and accommodation have been related to the process of
personal growth from adversity (Zoellner & Maercker, 2006), although many authors consider
that real growth only takes place through the accommodation process (Joseph & Linley, 2006;
Sumalla et al., 2009). Consequently, our group-based program devotes more session time to
accommodation than to assimilation. In the following paragraphs we describe the specific aims
of each module and the strategies used to facilitate personal growth (see Table 1).
Module 1: Promoting attitudes that facilitate growth and encouraging emotional
expression and processing of the cancer experience
a) Promoting curiosity about life, group universality and cohesion, and openness to change
The first aim of this module is to promote attitudes within the group that may facilitate personal
growth: curiosity about life, universality, and openness to change. Curiosity about life is one of
the survival mechanisms that facilitate the development of new abilities and ways of
understanding reality, and, therefore, it can encourage growth. People who score higher on
personality dimensions such as “openness to experience”, and who are imaginative, emotionally
reactive, and intellectually curious, are more likely to experience growth (Tedeschi & Calhoun,
1996). Thus, group-based interventions should aim to promote patients’ curiosity and openness
not only on the individual level but also within the group setting, such that group members
transmit their curiosity and openness to one another. This work, which is characteristics of the
initial group sessions, normally revolves around the question of identity after cancer: “Who am I
after having suffered this disease?” The first step in helping patients to assimilate losses is to
facilitate self-dialogues about how things were before and how they are now after the illness,
and then to encourage them to share this with the other group members. It is also important to
help them identify the influence that the adverse event has had on their life, as this is normally a
step prior to facilitating growth in cancer (Cordova, 2008). By enabling patients, during these
initial sessions, to see that the question of identity involves elements (e.g., emotions, reactions,
affected relationships) that are shared with other members, the therapist can begin to build
group cohesion through the experience of universality. “I am not the only one who feels this
way” is a common initial expression of this universality, with patients gaining some comfort
through their identification with the group. At the same time, it is also important to explore their
implicit theories or beliefs regarding the likelihood of personal change, as well as the issue of
what each member hopes to get from the group. In this regard, the therapist may ask questions
like: “Do you think that, in general, people don’t change, or that experiencing a disease like
cancer can change your life?”; or “How would we know that the group has been useful for each
one of you? The responses given to these questions serve to indicate the initial motivation
towards change and may influence the likelihood that personal growth will be experienced.
b) Working with positive and negative emotions: body awareness, symbolization, and
adaptive emotional reframing
The second aim of this module is the processing and expression of positive and negative
emotions. This focus, which is especially characteristic of the initial stages of PPC, is consistent
with the work of Stanton and colleagues (Stanton, et al., 2000), who state that emotion-focused
coping consists of two factors: 1) emotional processing, that is, active efforts to explore,
discover, and understand emotions; and 2) emotional expression, that is, verbal and non-verbal
efforts to communicate or symbolize what is expressed emotionally. Research with women with
breast cancer has reported long-term benefits of emotional expression during therapy, including
increased vigor, a reduction in distress, and a better quality of life (Stanton et al., 2000). It is
important to encourage emotional processing and expression during the early stages of cancer as
this can facilitate the realization of positive life changes. In a longitudinal study of 167 women
with breast cancer and their partners, patients’ benefit finding was predicted by their emotional
expression at the time of diagnosis, whereas partners’ benefit finding was predicted by their
emotional processing at the same point (Manne et al., 2004). The strategies used to promote
emotional processing can be grouped into those that favor increased awareness (especially
somatosensory), those that favor the symbolization of emotions, and those that help patients to
regulate and give meaning to their emotions.
During the first sessions of the PPC program the focus is mainly on negative emotions
(sadness, fear, anger, and blame), because bearing witness in a group normally heightens a
person’s pain in relation to his or her illness. Our work with negative emotions draws upon a
similar approach described by Greenber & Paivio (2000). At the same time as working with
negative emotions, we progressively introduce work with positive emotions.
While the damaging impact that negative emotions can have on health is irrefutable,
evidence regarding the positive effect of positive emotions on health has also begun to emerge.
An important review (Pressman & Cohen, 2005) suggested that stable positive affect is
associated with less morbidity and greater longevity, although limited data are as yet available
regarding the effect of more intense and transitory positive emotions (e.g., states of happiness or
jubilation). Positive emotions have, however, been linked to increased resistance against
adversity (resilience), given their role in preventing, minimizing, and/or modulating negative
emotions (Tugade & Fredrickson, 2004). In her broaden-and-build theory of positive emotions,
(Fredrickson, 2001) argues that negative emotions tend to involve clear and specific responses
designed to solve immediate problems of survival, such that the range of possible responses a
person can adopt is reduced. By contrast, positive emotions broaden our repertoire of thoughts
and actions, build resource reserves for future crises, and seek to resolve issues related to
development, personal growth, and social connection. Therefore, the aim of working with
positive emotions (or positive affect in a broader sense) is to attenuate and reduce emotional
distress and to broaden a person’s ways of behaving, thinking, feeling, and linking with others.
In the initial sessions of the PPC program, positive emotions are managed through the
following exercises:
b.1. Becoming aware of positive emotions
Emotional distress commonly blocks some patients from becoming aware of the
positive emotions they may still experience. Noting those moments in which patients
experience positive emotions is important throughout therapy, but it is particularly
important in the early stages in order to buffer the emotional distress that may be evoked
when first bearing witness. Positive emotions also help to demystify the effect of talking
about the most painful emotions, and can encourage patients not to avoid them. In the
process they become aware of their capacity to experience pleasurable states, they realize
that they can both cry and smile. Pointing out positive emotions also helps to reduce and
limit unproductive rumination, thereby breaking the vicious circles that are likely to
characterize patients’ thought processes.
The awareness of positive emotions can also be encouraged by drawing attention to a
patient’s non-verbal discourse. For example, a patient may be crying with downcast eyes
while explaining how she has suffered during her cancer treatment, and then suddenly she
realizes she has used up all the tissues. At this point she looks at the therapist, smiles and
says: “Sorry, I finished the box”. The therapist may then highlight all those other gestures
that suggest positive emotions, such as smiling, an upright posture, or looking directly into
the eyes of others. This work can then continue within the group as a whole, for example: 1)
emphasizing the comments that encourage her to appropriate these positive emotions
(e.g., “you’ve done it on your own”), 2) underlining changes in posture (openness: head
upright and back, looking ahead), 3) highlighting the effect of transmission, attraction and
connection between this patient and the group (“you’ve surprised me in a really good way”,
“you look great”), and 4) the positive model she generates (“yes you can, as can everyone in
the group”).
In those cases where changes are less spectacular, small gestures or expressions, such as
a shy, funny face or smile, can be used to suggest the emergence of a positive emotion and
to focus on and intensify this experience.
b.2. Symbolization of emotional experience
The person who suffers an extreme event such as cancer may, at times, find it
impossible to describe the experience. However, expressing the emotions associated with it
is a basic prerequisite for emotional processing. Simple strategies like assigning an
emotional label to the patient’s unfinished sentences may be useful. For example, a therapist
could explain to the: “When you go to the hospital, you sit down in the waiting room and
hear your name called, you feel… (Silence)”.
In most cases the emotions overlap and their expression becomes difficult. For this
reason, other types of somatosensory elements, guided imagination, or metaphors are often
b.3. Adaptive emotional reframing: giving meaning to the symptoms of distress
as normal responses to abnormal situations. “The positive intention of the stress
Another common therapeutic intervention in the initial sessions is related to facilitating an
adaptive explanation of the emotional distress caused by the illness in terms of “the positive
intention of the stress symptom”. Faced with these symptoms of distress (e.g., posttraumatic
symptoms) the patient is encouraged to re-conceptualize them from a positive point of view,
without resorting to the mistaken idea that “what is happening to you is normal” (see Table
2 for some examples). In most of these examples, giving a positive meaning to emotions is
complemented by elements that would indicate when the symptom may be maladaptive
(e.g., when a patient feels angry the anger may be a way of presenting oneself as
unavailable to others, thereby allowing the experience to be assimilated without being
disturbed, in other words, it is an adaptive function; however, if the anger is maintained it
could become a social problem by generating isolation and solitude).
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Module 2: Emotional regulation and coping
The aim of this module is to facilitate the emergence of aspects related to psychosocial
regulation and coping among group members. Relevant strategies in this regard are:
a) Copying styles and emotional regulation: awareness and emotional balance
The focus here is not only on exploring negative emotions but also on recognizing and
working with positive emotions. Thus, we not only ask about how cancer and its
consequences have affected patients but also about how they have managed to
overcome, resist, and survive the illness. Patients are considered to be the experts in
relation to their experience, and the therapist’s job is to facilitate the patient’s role as
observer-protagonist. During the interventions of each group member the therapist
should aim to highlight the positive emotions that are present at that time. Drawing
attention to positive emotions is especially important during these early stages, since
they have a buffering effect on emotional distress and favor reconceptualization of the
cancer experience from a positive perspective.
a) Horizons of positive change
Identifying small positive changes or improvements and highlighting them can help
promote the feeling that recovery is possible (Pérez-Sales, 2008), if not from the illness
itself, then at least from the associated psychological symptoms. In this context,
questions such as “How would we know that you are beginning to feel better?” can help
to establish a realistic horizon of positive change.
b) Personal strengths and memories of success in coping with past adverse events
It is important to point out the positive elements of coping with adversity that cancer
patients may overlook, as these aspects reflect their underlying strengths or qualities
(Pérez-Sales, 2008). The identified strengths can then be used as the basis for change or
for developing an alternative way of coping. Asking patients about past situations that,
in emotional terms, echo their current situation (e.g., “Have you ever felt like that
before?”) can help to establish parallels with past situations, thereby encouraging them
to draw upon the skills and strengths that were useful then and will likely be of help
now. Obviously, the most useful aspects are those that are remembered as successful
coping skills.
Module 3: Growth facilitation
a) Giving meaning to the experience
In her review of the meaning-making literature, including the question of how giving meaning
to experience facilitates adaptation to stressful situations, (Park, 2010) synthesizes the concept
of meaning as follows: “meaning connects things”. When experiencing growth from adversity, a
number of changes take place in the meaning of significant life events. Survivors from cancer,
in their attempt to bring some kind of coherence to their life experience, often try to integrate
and to give answers to those aspects of their life that have been questioned by their illness. This
search for new meanings is, for most of them, the basis of their posttraumatic growth. In the
PPC program two strategies are used in order to explore an alternative and constructive view of
these aspects:
a.1. Work with recent and remote positive biographical memories
The role of traumatic memories in relation to posttraumatic stress symptoms has been widely
studied (Leskin, et al., 1998). More recently, however, this work has been complemented by
research on strategies for encouraging and retrieving positive autobiographical memories.
Although the use of written exercises or guided imagery (Ochoa, et al., 2010; Serrano, et al.,
2004) to favor these processes may initially heighten a person’s awareness of loss, this approach
also encourages a re-experiencing of pleasant sensations, as well as personal and relational
autobiographical realization, a sense of fulfillment, and, if all goes well, personal growth. In
addition, recalling positive memories makes it more likely that the behavior or experience they
refer to will be repeated (Wirtz, et al. 2003). In the context of cancer, positive memories may
lead patients towards the wish to visit significant places or people once again, putting them in
touch with a core identity that the disease could not eliminate. In the PPC program we normally
suggest working with: 1) Recent positive memories during the cancer process (e.g., What
would you like to remember from this difficult period? Do you remember any story or pleasant
or funny moment that helped you cope with your illness?); and 2) Remote positive
autobiographical memories. Usually, between sessions six and seven, we suggest that the
therapist begins to work with these memories in three steps: 1) Retrieving through guided
imagery a pre-illness life episode in which the person felt good, where he or she experienced
sensations that are now missed (e.g., freedom, a sense of calm, bravery, etc.); 2) Opening their
eyes and talking about the episode, during which time the group can explore how these
sensations remain present; and 3) How might these sensations be experienced again in the
future? The intervention here is based on building hope through goal-setting, through the
development of skills that can help the person to achieve these aims and to generate the self-
motivation that is required to do so.
a.2. Guidelines for Personal Realization
Psychotherapists often look for connections between facts, people, and emotions in order to
identify problematic patterns that might explain patients’ suffering or emotional distress.
However, it is also worthwhile looking for connections between those satisfactory aspects that
emerge time and again and which generate meaning, self-realization, and a sense of purpose in
life. These positive views of significant connections among past, present, and future life are
what we call Guidelines for Personal Realization (Ochoa, et al., 2010; Vázquez, et al., 2014).
Although these guidelines may be sought through direct questions to the patient (e.g., “What
things have left a positive impression on your life?”), it is better if patients reach their own
insights into these aspects. In the context of cancer, the guidelines that are easiest to identify are
those connected to significant relationships which help patients to maintain a sense of greater
continuity after the disease (e.g., “family members who were there”, “my partner has made me
feel loved”, “the hobbies that make me feel useful and valid”, etc.).
b) Relational growth
One of the relevant indicators of an improvement in mental health and personal growth is the
capacity to transcend one’s ego (Joseph, 2011). Relational growth has to do with an interest in
others and a commitment to them, as well as loving and being loved. These are key elements in
the facilitation of personal growth among cancer patients. However, the effects of trauma and
growth after an illness are not limited to survivors, but are also relevant to those relatives or
significant others who help with, witness, and experience the patient’s illness. In fact, a review
focused on cancer survivors and their partners (Ochoa et al., 2013),concluded that significant
others around cancer patients experience vicarious personal growth, which is transmitted and
closely related to patient’s personal growth. In the PPC program the strategies used to facilitate
relational growth are:
b.1. Promoting and arousing interest in others
Many psychological interventions are focused on promoting empathy, that is, on the ability to
experience the emotions and intentions of others, and to understand their limitations. In our
positive psychotherapy model we often use an “anthropological task” (Nardone, et al., 1999) to
encourage a patient’s interest in others following illness. Specifically, we invite group members
to carry out an “anthropological investigation of between one and three people they know over
a period of a few weeks. They are asked to write down all the things that make these people
suffer or which they are worried about, as well as the things that make them smile and those
activities that help the patient make contact with that person (talking, sharing, etc.). The aim of
this exercise is to help patients shift their focus away from themselves towards others, thereby
encouraging them to broaden their social network and, hopefully, increase their wellbeing.
b.2. Positive models against adversity
Cancer survivors may spontaneously wish to have contact with someone who has had the same
cancer Therapy groups and patient networks reflect this willingness to share and deal
collectively with the problems being faced. This kind of contact can often be a source of
personal growth if the person agrees to interact freely, and the group provides its members with
the experience of positive role models. Weiss (2004) demonstrated the importance of this
modeling in women who had contact with other breast cancer survivors who perceived benefits
of their experience, noting significantly personal growth in those seeking benefits (positive life
changes) in contrast to women who had not had that contact. In our program we encourage
patients to think about a significant person in their life who had overcome an important
difficulty (ideally, a severe illness) and we then ask them what it is that makes this person
special. What are this person’s virtues? How does he or she behave in this situation?
b.3. Gratitude and forgiveness
In severe and chronic illnesses, interpersonal relationships may be affected by the relative
balance or imbalance between what is given and what is received. It is common for survivors to
make a mental checklist of people who have helped them and those who have not. Gratitude and
forgiveness interventions are focused on this process of assessment and its consequent
strengthening or reparation of personal relationships. Gratitude-based interventions, therefore,
aim to facilitate an awareness of having received something positive from someone, as well as
seeking ways of thanking them (gratitude letters, public recognition, etc.). With forgiveness-
based interventions the aims are 1) to encourage empathy towards the aggressor when this has
personal meaning, 2) to recognize one’s own faults and defects, 3) to value the type of
attribution and behavior shown by the aggressor, trying if possible to reduce the perceived
intentionality, and 4) to reduce rumination on the event or events, as this favors a desire for
revenge and reduces the likelihood of forgiveness.
Module 4: Existential and spiritual aspects and group conclusion
Foreseeing recurrence and increased awareness of mortality and transience
Leaving religious or spiritual beliefs aside, a severe disease generates primary emotions and
makes people think about their existence and meaning in life. A person may become aware of
his or her own mortality, which can lead to a heightened interest in existential and spiritual
concerns. Indeed, cancer patients often ask transcendental questions about death, freedom,
loneliness, and meaningless (Yalom, 2000). In this context, growth in illness may be regarded
as a different existential position, one which emerges from increased awareness and clarity and
the depth of these existential worries. In our group work the question that serves to open up
these existential topics on a deeper level is “How do you think you would cope with a cancer
relapse?”. The most common answer involves worries about the loss of significant others, a fear
of suffering, or loss of autonomy, among other issues.
Dealing with emotional and existential numbness
In group interventions, narratives of emptiness and existential numbness often emerge through
expressions of disillusionment, defenselessness, and the feeling of living without waiting for
anything. Making this explicit at the right time can help some group members to react against
this image.
Transcendence and regret as a constructive pathway: working with values, legacy, and the
possibility of becoming a role model at the end of life
Anticipating the possibility of relapse is another way of dealing with topics related to
transcendence, and it can be guided through questions like: How would you like to be
remembered in the event of your death? What values would you like to pass on to others before
you die? Questions such as these facilitate the transmission of intergenerational values, of the
possibility of leaving behind a legacy for significant others, and they can help the patient
position him or herself in a transcendent way in relation to others.
Although regret is not normally constructive it can be used as a way of encouraging
change, for example through questions such as: How would you like to experience and
remember the period prior to relapse? What things would you like not to regret in the event of a
Farewell letter
This is used as a way of capturing what has been learnt and reflected upon during the group
experience, and it aims to address questions such as: What has taking part in this group meant
for me? What things are still pending for me to do once the group is over? The farewell letter
also prepares the ground for later follow-ups (at 3 and 12 months after the group ends).
4. Evidence for the effectiveness of positive psychotherapy in cancer
Several recent meta-analyses report a consistent relationship between variables related to
psychological wellbeing (positive emotions, growth, or benefit-finding) and associated health
outcomes such as mortality, physical health indicators and the degree of recovery in physical
illness (Vázquez, 2013). In addition, the overall results of meta-analyses in the field of cancer
show that patients who experience PTG are better adapted after the disease, showing improved
mental health and better perceived physical health (Helgeson, Reynolds, & Tomich, 2006;
Sawyer et al., 2010). In particular, PTG in cancer has been associated with less emotional
distress and fewer posttraumatic symptoms (Sawyer et al., 2010). Although high levels of
posttraumatic stress have been linked to loss of quality of life in cancer patients (Cordova et al.,
1995), this association is buffered (Morrill et al., 2006) by the presence of PTG, suggesting that
growth can be an avenue which therapists could use to enhance quality of life among cancer
survivors. PTG has also been associated with more health-promoting behaviors (Milam, 2004)
upon survival. For example, growth has been linked to better adherence to routine surveillance
checks in women with breast cancer (Sears, et al., 2003). Note, however, that the adaptive value
of personal growth in cancer patients must not be understood in relation to the absence of
emotional distress but, rather, as a way of channeling, metabolizing and dampening it (Ochoa,
In general, meta-analytic studies show that positive psychology interventions are effective for
various clinical problems (Bolier et al., 2013; Sin & Lyubomirsky, 2009), although more studies
using control groups and longer follow-up are required (Bolier et al., 2013). A recent systematic
review (Casellas-Grau, et al., 2014) of positive psychology interventions for survivors of breast
cancer concluded that these interventions are able to increase quality of life, wellbeing,
posttraumatic growth, hope, meaning, happiness, optimism, life satisfaction and benefit finding.
The PPC program has also been evaluated and was shown to be effective. Specifically, PPC was
found to be capable of reducing emotional distress and posttraumatic stress, as well as,
facilitating PTG among cancer patients (Ochoa, 2009; 2010; 2012), when compared with a list
group and also with a standard cognitive-behavioral stress management therapy (Antoni, 2003).
Moreover, preliminary studies of outcomes at 3 and 12 months follow-ups indicate that the PPC
program generates higher rates of stress management than the standard cognitive-behavioral
management therapy (Ochoa, 2012).
Key facts (expanded areas of interest in bullet form 5-15)
Cancer patients and their significant others experience a range of negative states.
These negative states can, however, trigger the emergence of growth and positive life changes
which have a strong adaptive value.
Positive psychotherapies promote growth and are now opening up an interesting and useful area
of research.
Facilitating growth in cancer patients may be a better therapeutic strategy for reducing distress
than is traditional stress management
Positive psychotherapies reduce distress and posttraumatic symptoms, and also facilitate growth
Summary points (5-10 sentences in bullet form that summarize the entire chapter)
The experience of a disease like cancer can produce negative emotions and states among
Negative states can, however, trigger the emergence of positive life changes and positive
emotions among cancer survivors.
Positive psychotherapy aims to promote positive life changes such as posttraumatic growth in
cancer survivors.
Our positive psychotherapy program comprises four modules spread across 12 sessions that
recreate the natural and therapeutic process of assimilation and accommodation of the cancer
The four modules address emotional processing and expression, emotional regulation and
coping, the facilitation of growth, and existential and spiritual aspects.
Positive psychotherapy in cancer has proved effective in reducing distress and facilitating PTG.
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... The first intervention to focus on this constructive stress-growth balance was positive psychotherapy in cancer (PPC) (Ochoa & Casellas-Grau, 2015;Ochoa et al., 2010). PPC embraces elements from humanisticexistential perspectives, along with strategies and tasks from positive psychology. ...
... The general objective of the first two modules is to assimilate the cancer experience, while the final two modules focus on encouraging accommodation and personal growth from the experience of having the illness (see supplementary table 2). The PPC program is manualized, and the guide is available in Spanish (Ochoa et al., 2010) and English (Ochoa & Casellas-Grau, 2015). Although many authors consider that real growth only takes place through the accommodation process (Joseph & Linley, 2006;Sumalla et al., 2009), a number of factors associated with both assimilation and accommodation have been linked to the process of personal growth resulting from adversity (Zoellner et al., 2008). ...
This randomized controlled trial compared the efficacy of cognitive behavioral stress management (CBSM) and positive psychotherapy in cancer (PPC) to reduce post-traumatic stress symptoms (PTSS) and distress, and to promote post-traumatic growth (PTG) in cancer survivors. Participants were 140 adult women randomly allocated to CBSM (n = 73) or PPC (n = 67). PTSS, distress, and PTG were assessed at pre-and post-intervention, and at 3-and 12-month follow-ups. Analysis showed PPC was more effective in decreasing PTSS (b = −7.61, p <.001) and distress (b = −3.66; p <.001) than CBSM, but neither therapy significantly increased PTG (b = 0.77, p = .76). The relational veracity of PTG and its role predicting reduced PTSS was observed only in the PPC arm. In conclusion, PPC appears to be a valid therapeutic option for assimilating and accommodating the experience of cancer after treatment completion.
... It is widely accepted in clinical settings that the way to reduce post-traumatic stress and improve PTG in meaning-making interventions is by creating sustainable continuity and coherence with pre-cancer identity narratives, now enriched and integrated with information on threat and mortality (Ochoa and Casellas-Grau, 2015). New approaches, such as positive psychotherapy, propose new strategies to work with in the search for meaning in cancer. ...
... The first intervention that focused on facilitating PTG to reduce post-traumatic stress was Positive Psychotherapy in Cancer (PPC) (Ochoa et al., 2010;Ochoa and Casellas-Grau, 2015). The intervention was designed after having extensively reviewed the literature exploring trauma and growth processes in the aftermath of cancer (Sumalla et al., 2009). ...
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Post-traumatic stress and growth are common responses to adverse life events such as cancer. In this article, we establish how cancer becomes a "fertile land" for the emergence of stress and growth responses and analyze the main mechanisms involved. Stress-growth responses on adjusting to cancer is potentially determined by factors like the phase of the illness (e.g., initial phases vs. period of survivorship), patient's coping strategies, meaning-making, and relationships with significant others. We also review the mechanisms of constructive and adaptative stress-growth balances in cancer to study the predictors, interrelated associations, triggering mechanisms, long-term results, and specific trajectories of these two responses to cancer. Finally, we update the evidence on the role of these stress-growth associations in psychologically adjusting to cancer. Together with this evidence, we summarize preliminary results regarding the efficacy of psychotherapeutic interventions that aim to facilitate a constructive psychological balance between stress and growth in cancer patients. Recommendations for future research and gaps in knowledge on stress-growth processes in this illness are also highlighted. Researchers are encouraged to design and use psychotherapeutic interventions according to the dynamic and changeable patients' sources of stress and growth along the illness. Relevant insights are proposed to understand the inconsistency of stress-growth literature and to promote psychotherapeutic interventions to facilitate a constructive balance between these key responses in cancer.
... Therefore, PPC focuses closely on a patient's positive resources, such as positive emotions, strengths, and personal meanings (Ochoa et al., 2010;Rashid & Seligman, 2013) because its assumption is that individuals have an inherent desire for growth, fulfillment, and happiness, rather than merely seeking to avoid misery, worry, or anxiety. A substantial portion of suffering, emotional distress, and psychopathology in cancer is related to the enormous and urgent need to make positive life changes (growth), which arises after the total or partial awareness of their mortality (Ochoa & Casellas-Grau, 2015). Then, an important part of a cancer survivor's suffering could be related to the frustration of this need of growth after the threat to life. ...
... The general objective for the first two modules was the assimilation of the cancer experience, while the final two modules focused on encouraging accommodation and personal transformation (growth) from the illness experience. The manualized program and guide is available in Spanish (Ochoa et al., 2010) and English (Ochoa & Casellas-Grau, 2015). ...
... Level 4: This consists of a psychotherapy group offered by a specialized clinical psychologist. It is conducted through videoconference and is structured in eight weekly 90min sessions, with a positive psychology approach [25]. ...
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Health education and psychosocial interventions prevent emotional distress, and the latter has been shown to have an impact on survival. In turn, digital health education interventions may help promote equity by reaching a higher number of cancer patients, both because they avoid journeys to the hospital, by and having a better efficiency. A total of 234 women recently diagnosed with breast cancer in a comprehensive cancer center used the digital ecosystem ICOnnecta’t from March 2019 to March 2021. ICOnnecta’t consists of four care levels, provided to patients according to their level of distress. The second level of this intervention consists of an educational campus, which was analyzed to track users’ interests and their information-seeking behavior. Overall, 99 out of 234 women (42.3%) used the educational campus. There were no significant differences in sociodemographic and clinical variables between the campus users and non-users. Among users, the median number of resources utilized per user was four (interquartile range: 2–9). Emotional and medical resources were the contents most frequently viewed and the audiovisual format the most consulted (p < 0.01). Resources were used mainly within the first three months from enrolment. Users who were guided to visit the virtual campus were more active than spontaneous users. Offering an early holistic health educational platform inside a digital cancer ecosystem, with health professionals involved, can reach more patients, promoting equity in the access of cancer information and prevention, from the very beginning of the disease.
... 37 Large effect sizes were found in study 12,36,38 the remaining interventions had a small to moderate effect size. 33 Two studies delivered PCC, 54 one compared it to a WL control condition 36 and one compared to a + intervention. 38,55 Positive Psychotherapy helps cancer survivors to develop stress ...
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Objective: We reviewed the evidence regarding the effectiveness of therapist-led interventions for reducing symptoms of traumatic stress in cancer survivors METHODS: This systematic review was completed in accordance with the guidelines illustrated by Popay and colleagues and the following online databases, PsychInfo, Medline, CINAHL, were searched for peer-reviewed literature. Further studies were searched through Google Scholar and manually scanning the reference lists of all included studies. The PRISMA guidelines were followed to report results. Results: Sixteen studies were identified, their quality varied and the interventions broadly fell into two categories: CBT-based and non-CBT interventions. Effect sizes were small to moderate in twelve studies and large in four. Drop-out rates were mostly low. Conclusion: This review has demonstrated that the research in this field is still scarce and due to the data mostly suggesting a small to moderate effect, firm conclusions cannot be drawn on the effectiveness of the included interventions. This article is protected by copyright. All rights reserved.
... -Level 4. Group psychotherapy: The most intensive and specialized intervention in our digital ecosystem consists of group psychotherapy delivered through videoconference. It comprises eight weekly 90 min sessions, and is based on a positive psychology approach [29]. These sessions are led by a clinical psychologist specialized in psycho-oncology. ...
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Psychosocial interventions prevent emotional distress and facilitate adaptation in breast cancer (BC). However, conventional care presents accessibility barriers that eHealth has the potential to overcome. ICOnnecta’t is a stepped digital ecosystem designed to build wellbeing and reduce psychosocial risks during the cancer journey through a European-funded project. Women recently diagnosed with BC in a comprehensive cancer center were offered the ecosystem. ICOnnecta’t consists of four care levels, provided according to users’ distress: screening and monitoring, psychoeducation campus, peer-support community, and online-group psychotherapy. Descriptive analyses were conducted to assess the platform’s implementation, while multilevel linear models were used to study users’ psychosocial course after diagnosis. ICOnnecta’t showed acceptance, use and attrition rates of 57.62, 74.60, and 29.66%, respectively. Up to 76.19% of users reported being satisfied with the platform and 75.95% informed that it was easy to use. A total of 443 patients’ needs were detected and responsively managed, leading 94.33% of users to remain in the preventive steps. In general, strong social support led to a better psychosocial course. ICOnnecta’t has been successfully implemented. The results showed that it supported the development of a digital relation with healthcare services and opened new early support pathways.
... Dicho tratamiento se basa en el programa de Psicoterapia Positiva Grupal en cáncer diseñado para supervivientes al finalizar los tratamientos oncológicos primarios. El manual de este programa de tratamiento grupal ha sido publicado tanto en español (40) , como en inglés (41) . Se sigue un modelo psicoterapéutico que integra elementos cognitivoconductuales y humanístico-experiencial desde una perspectiva de construcción de narrativas terapéuticas (42) . ...
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Introducción: A pesar de que los tratamientos psico-oncológicos han demostrado su efectividad en disminuir el malestar emocional y mejorar la calidad de vida de las personas con cáncer, aún existen numerosas barreras que limitan su acceso. La transformación a online de esta atención se plantea como una solución para aumentar la cobertura del servicio y mejorar su coste-utilidad. Objetivo: Crear un ecosistema digital de salud para reducir el impacto del cáncer, aumentando el bienestar y la calidad de vida del ciudadano con cáncer. Método: Programa dirigido a pacientes diagnosticadas de cáncer de mama en fase de supervivencia aguda. Es un programa de atención escalonada dividido en 4 niveles de intervención jerarquizados por complejidad: Nivel 1, cribado y monitorización psicosocial; Nivel 2, Campus: psicoeducación y educación sanitaria; Nivel 3, soporte psicosocial comunitario; y Nivel 4, tratamiento psicoterapéutico grupal. Resultados: En 2019, 259 mujeres fueron incluidas en el programa (39,91% de los nuevos casos de cáncer de mama en los centros participantes). Solo el 3,47% (n = 9) requirió atención clínica especializada (Nivel 4). Conclusión: El programa Iconnecta’t adopta un modelo integrado de atención psicosocial en cáncer que se adecúa a las necesidades específicas de los supervivientes. Da solución a algunas de las barreras de la atención sanitaria tradicional, democratizando el acceso a los servicios mediante el uso de tecnologías de uso común en la mayoría de ciudadanos. En un futuro próximo se prevé la implementación progresiva a otras neoplasias, junto con un ensayo clínico controlado y aleatorizado que evaluará su eficacia.
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Background/Objective Environmental factors such as psychosocial stress have demonstrated to have an impact on the breast cancer (BC) course. This study aims to explore the impact of psychotherapy and stressful life events (SLE) on BC survivors’ illness trajectories. Method 68 women with BC underwent Positive Psychotherapy or Cognitive-Behavioral Stress Management and 37 patients were included as a control group. The effects of distress reduction and SLE on their 5-year recurrence were investigated. Additional analyses examined the effect of receiving vs. not receiving psychotherapy and of the type of therapy on survival and disease-free interval, DFI. Results A one-point decrease of the Hospital Anxiety and Depression Scale (HADS) after psychotherapy predicted a lower risk of 5-year recurrence, OR = 0.84, p = .037, 95% CI = 0.71-0.99). Also, a one point-increase in the number threatening SLE (OR = 1.92; p = .028, 95% CI = 1.07-3.43) was related to higher 5-year recurrence. Conclusions The findings highlight the necessity of studying not only a given situation (i.e., psychotherapy, SLE) but its specific impact on individuals.
Purpose This study was conducted to determine the effect of psychoeducation of the positive psychotherapy (PPT)-based balance model applied to university students on spirituality index levels of their subjective well-being. Design and Method The research was conducted as a quasi-experimental study with a one-group pretest–posttest design. The population of this study was composed of undergraduate students of a university and the sample was composed of the students taking Intern Practice Course of Psychiatric Nursing. In the study, the data were collected using a Personal Information Form and Spirituality Index of Well-being. Findings Frequency, percentage, Shapiro–Wilk test, and Wilcoxon Signed-Ranks tests were used to assess the data of the study. As a result of the statistical analysis, the students obtained significant results in the total score of Spirituality Index of Well-Being and the subscales of “Self-Efficacy” and “Life Schemes” (p < 0.05). Conclusion PPT-based balance model education increases the subjective well-being levels of the students significantly. Practice Implications PPT has a positive effect on the subjective well-being levels of individuals with spirituality index, this method should be used more in clinical studies with healthy or sick people.
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Introduction Psychosocial interventions for patients with breast cancer (BC) have demonstrated their effectiveness at reducing emotional distress and improving quality of life. The current digitisation of screening, monitoring and psychosocial treatment presents the opportunity for a revolution that could improve the quality of care and reduce its economic burden. The objectives of this study are, first, to assess the effectiveness of an e-health platform with integrated and stepped psychosocial services compared with usual psychosocial care, and second, to examine its cost–utility. Methods and analysis This study is a multicentre randomised controlled trial with two parallel groups: E-health intervention with integrated and stepped psychosocial services vs usual psychosocial care. An estimated sample of 338 patients with BC in the acute survival phase will be recruited from three university hospitals in Catalonia (Spain) and will be randomly assigned to one of two groups. All participants will be evaluated at the beginning of the study (T1: recruitment), 3 months from T1 (T2), 6 months from T1 (T3) and 12 months from T1 (T4). Primary outcome measures will include number of clinical cases detected, waiting time from detection to psychosocial intervention and proportion of cases successfully treated in the different steps of the intervention, as well as outcomes related to emotional distress, quality of life, post-traumatic stress and growth, treatment adherence and therapeutic alliance. Secondary outcomes will include the acceptability of the platform, patients’ satisfaction and usability. For the cost–utility analysis, we will assess quality-adjusted life years and costs related to healthcare utilisation, medication use and adherence, work absenteeism and infrastructure-related and transport-related costs. Ethics and dissemination This study was approved by the Ethics committee of the Institut Català d’Oncologia network in Hospitalet, Spain. Findings will be disseminated through peer-reviewed journals, reports to the funding body, conferences among the scientific community, workshops with patients and media press releases. Trial registration number Online Psychosocial Cancer Screening, Monitoring and Stepped Treatment in Cancer Survivors (ICOnnectat-B),NCT04372459.
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The aim of this study was to examine the efficacy of life review based on autobiographical retrieval practice for treating depressed older adults. Forty-three adults aged 65-93 with clinically significant depressive symptomatology and no dementia were randomly assigned to treatment or to no treatment. The results indicated significant differences between experimental and control groups after 4 weeks of autobiographical retrieval practice. At posttest, those in the treatment condition showed fewer depressive symptoms, less hopelessness, improved life. satisfaction, and retrieval of more specific events. The findings suggest that practice in autobiographical memory for specific events may be among the components of life review that account for its effectiveness and could be a useful tool in psychotherapy with older adults.
Cancer as a Traumatic StressorTheoretical FrameworksWorking with Individuals Facing CancerFuture ResearchSummary
Severe diseases such as cancer although generate high stress and emotional distress in survivors and their significant others, can also be a stimulus to promote posttraumatic growth. The mechanisms of this post-traumatic growth (vicarious vs secondary) in significant others have not been studied. This review examines the evidence and relationship between posttraumatic growth in cancer survivors and their significant others, mainly in their partners and parents, regarding these vicarious or secondary growth transmission mechanisms. We conclude that, in general, posttraumatic growth in significant others is a vicarious experience closely linked to the cancer survivor's growth. However, being a woman, mother or suffer an advanced cancer facilitate secondary posttraumatic growth processes insignificant others.
Resumen Las enfermedades graves como el cáncer, aunque generan elevado malestar emocional y estrés en los super-vivientes y en sus otros signiicativos, también pueden suponer un estímulo en la generación de crecimiento postraumático en ambos. Los mecanismos de cómo se produce este crecimiento postraumático (vicario vs. secundario) en los otros signiicativos no se han estudiado. En esta revisión se analizan la evidencia y relación del crecimiento post-traumático en supervivientes de cáncer y en sus otros signiicativos, princi-palmente sus parejas, madres y padres, en relación a estos mecanismos de transmisión vicario o secundario. Se concluye que, en general, el crecimiento post-traumático en los otros signiicativos es una experiencia vicaria íntimamente ligada al crecimiento del superviviente en cáncer, aunque ser mujer, madre o sufrir un cáncer avanzado facilitan procesos de crecimiento post-traumático secundario en los otros signiicativos, que se diferencian del superviviente. Palabras clave: crecimiento post-traumático vicario, crecimiento post-traumático secundario, otros signiicativos, parejas, padres. Abstract Severe diseases such as cancer although generate high stress and emotional distress in survivors and their signiicant others, can also be a stimulus to promote posttraumatic growth. The mechanisms of this post-traumatic growth (vicarious vs secondary) in signiicant others have not been studied. This review examines the evidence and relationship between posttraumatic growth in cancer survivors and their signiicant others, mainly in their partners and parents, regarding these vicarious or secondary growth transmission mechanisms. We conclude that, in general, posttraumatic growth in signiicant others is a vicarious experience closely linked to the cancer survivor's growth. However, being a woman, mother or suffer an advanced cancer facilitate secondary posttraumatic growth processes insigniicant others.
In this article, the author describes a new theoretical perspective on positive emotions and situates this new perspective within the emerging field of positive psychology. The broaden-and-build theory posits that experiences of positive emotions broaden people's momentary thought-action repertoires, which in turn serves to build their enduring personal resources, ranging from physical and intellectual resources to social and psychological resources. Preliminary empirical evidence supporting the broaden-and-build theory is reviewed, and open empirical questions that remain to be tested are identified. The theory and findings suggest that the capacity to experience positive emotions may be a fundamental human strength central to the study of human flourishing.
In this article, the author describes a new theoretical perspective on positive emotions and situates this new perspective within the emerging field of positive psychology. The broaden-and-build theory posits that experiences of positive emotions broaden people's momentary thought-action repertoires, which in turn serves to build their enduring personal resources, ranging from physical and intellectual resources to social and psychological resources. Preliminary empirical evidence supporting the broaden-and-build theory is reviewed, and open empirical questions that remain to be tested are identified. The theory and findings suggest that the capacity to experience positive emotions may be a fundamental human strength central to the study of human flourishing.
“Doc, I want to be happy” is a desire often uttered by clients, yet rarely addressed in psychotherapy. Rather, psychotherapy does a good job of making clients less depressed and less anxious by uncovering childhood traumas, untwisting faulty thinking or adjusting dysfunctional relationships. The positive aspects of human experience have traditionally not been the focus in psychotherapy. Positive Psychotherapy (PPT) is empirically validated psychotherapy that directly builds positive emotions, character strengths, and meaning to undo psychopathology and promote happiness. This chapter argues that psychotherapy can also be a place to accentuate positives, in addition to the undoing of negatives. Providing a conceptual and theoretical underpinning of PPT, the chapter describes how to conduct PPT, its applications in multicultural settings, potential mechanism of change and a summary of pilot studies. Finally, some caveats and future directions are also offered.