Abstract
The primary objective of this exploratory study will be to investigate the possibility of increasing the efficacy of a cognitive-behavioral therapy (CBT) program for depression by integrating positive psychological interventions (PPI) into more traditional CBT group treatment curriculum. The secondary objective will be to increase availability of onsite mental health counseling services to an underserved population of students enrolled in a charter high school and job- training program for at-risk, transition age youth (ages 18-25) in San Diego County. Based on the broaden-and-build theory of positive emotions, it is hypothesized that participants who receive CBT curriculum with the additional PPI components will: a) report larger reductions in overall scores for depressive symptomology and identification with maladaptive early schemas; and b) report greater increases of daily experiences of positive emotions and overall scores on both agency and pathways thinking subscales between pre- and post-treatment assessments.
Utilizing Positive Emotions to Treat Depression
The ability to cultivate positive affect is thought to be important because “low levels of positive affectivity predict both slower recovery from depressive episodes and increased risk of subsequent relapses” (Karwoski, Garratt, & Ilardi, 2006; p. 163). The desire to experience more positive emotions is not inherently absent among those seeking treatment for depression. More often than not, the client’s desire to access or connect with positive emotions is high but his or her perceived capacity to cultivate positive emotions in the present moment may be underestimated or skewed by the flooding of negative emotions commonly experienced with depression. So how can an individual utilize positive emotions if his or her habitual thought- action repertoires used to access positive emotions have become problematic (i.e. substance use), are no longer available (i.e. recent or unresolved loss), or are perceived as blocked or seemingly unattainable due to current symptoms (i.e. anhedonia) or circumstances (i.e. lack of resources)?
The theory behind the proposed treatment curriculum below is based on the integration of three key components: 1) established cognitive-behavioral therapy (CBT) curriculum for depression; 2) the broaden-and-build theory of positive emotions, which suggests that positive emotions expand a person’s thought-action repertoire thus resulting in a greater accumulation of personal resources and skills over time (Frederickson, 2001); and 3) the conception of emotions as “self-perpetuating emergent systems energized by the reciprocal causal links between the cognitive, behavioral, and somatic mechanisms through which emotions are instantiated (Garland, Fredrickson, Kring, Johns, Meyer & Penn, 2002; p. 5).” Psychoeducational material and skill building regarding downward spirals triggered by negative emotions are common components of traditional treatment curriculum for depression however, Garland et al. (2010) suggest that upward spirals (the use of positive emotions to trigger self-perpetuating cycles that
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lead to optimal functioning and enhanced social openness) are incredibly important yet grossly overlooked and underutilized.
While it may seem disingenuous or counterintuitive at first, utilizing novel behavioral activities focused on eliciting positive emotions can help trigger upward spirals of emotion even within the context of treatment for individuals experiencing high levels of depression. For example, Huffman, DuBois, Healy, Boehm, Kashdan, Celano et al. (2014) explored patients’ perceptions of the efficacy and suitability of various positive psychology based interventions within the context of an inpatient psychiatric unit at an urban academic medical center for suicidal ideation or attempted suicide. Despite the fact that all of these participants were in crisis and concurrently receiving intensive assessment and treatment, close to 90% of assigned positive psychology based activities were completed. Additionally, these findings indicated that these interventions focused on magnifying positive emotions and cognitions were effective in both reducing feelings of hopelessness and increasing feelings of optimism. The top three interventions found to be most effective, as well as considered easy to complete by participants within this clinical population, included the gratitude letter, personal strengths, and counting blessings exercises.
A common socially constructed misconception regarding positive psychology is that the aim of the interventions are to simply change negative feelings into positive ones by “thinking happy thoughts.” However, the goal of utilizing positive emotions in the treatment of depression is not to minimize the client’s current suffering or teach the client how to escape or avoid experiencing negative mood states. On the contrary, the goal is to utilize both the short-term and long-term functional advantages of experiencing positive emotions based on the broaden-and- build theory (Fredrickson 2001) via specific interventions that evenly target both downward and
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upward spirals of emotion systems (Garland et al., 2010; Fredrickson & Joiner, 2002) to help enhance a client’s sense of self-efficacy, resilience, and range of positive coping skills.
Cognitive-Behavioral Therapy – Treatment as Usual (CBT – TAU)
After several decades, CBT has become one of the most extensively researched and supported psychosocial interventions for depression and will be the basis for core curriculum for both treatment groups. The content of the shared curriculum is based on the work of Beck (1995), Burns (1989), Greengerger & Padesky (1995), and Kabat-Zinn & Santorelli (1993). Karwoski, Garratt, and Ilardi (2006) found a large amount of overlap between conceptual and technical elements of CBT and positive psychology that are already shared therefore, elements of CBT-TAU that will carry over into the enhanced positive psychology based curriculum as well include: establishing a strong therapeutic alliance, a focus on discrete goals and the here-and now, cognitive reappraisal, client as collaborative partner, pleasant activities scheduling, identifying and reviewing success experiences, mood monitoring, relaxation training, and problem solving.
Cognitive-Behavioral Therapy + Positive Psychological Interventions (CBT + PPI)
The proposed CBT+PPI curriculum was designed to approach treatment with a more overt focus on client strengths, and interventions focused on cultivating positive emotions within the context of previously established CBT curriculum for treating depression. Though elements of the CBT-TAU curriculum have been found to be effective in helping clients view situations more realistically (Beck, 1995; Burns, 1989; Greengerger & Padesky, 1995), they may not be as effective as certain PPI’s with assisting clients in addressing negative life events in which the use of problem-focused coping is not a possibility. It is hypothesized that concepts of positive psychology such as meaning making, acceptance, or benefit finding may be more effective than
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standard reframing techniques in these particular situations.
In addition to gratitude and personal strengths oriented interventions (Lomas, Froh, Emmons, Mishra & Bono, 2014; Louis & Lopez, 2014; Seligman, Park, & Peterson, 2004), other core components of the CBT+PPI curriculum include the incorporation of psychoeducation regarding the broaden-and-build theory (Fredrickson, 2001), and the 40% window of intentional activity that can influence overall happiness regardless of influence of one’s genetic set point (50%) and/or life circumstances (10%) (Lyubomirsky, 2007). Mindfulness practice will also be introduced in both groups however; the integration of mindfulness in the form of the loving- kindness meditation (LKM; Salzberg, 1995) will be used only in the CBT+PPI group. The purpose of using this specific meditation is to induce an expansion of attention and increased experience of positive emotions towards self and others both during and after meditation. Fredrickson, Cohn, Coffee, Pek, and Finkel (2008), found that participants who invested at least 1 hour each week in this form of meditation reported gradual and cumulative increases in experiencing a wider array of positive emotions, across a larger variety of situations, over the course of nine weeks. Investigators posit that practicing LKM may be one way to outpace the hedonic treadmill (Lyubomirsky, 2007); “LKM appears to be one positive emotion induction that keeps on giving, long after the identifiable ‘event’ of the meditation practice” (Fredrickson et al., 2008; p 19).
Two main treatment outcome improvements that are expected to emerge from the data as a result of the simultaneous targeting of both downward and upward spirals in the CBT+PPI curriculum include:
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Hypothesis 1: Participants in the CBT+PPI group will report larger reductions in overall scores for depressive symptomology and identification with maladaptive early schemas between Week 1 and Week 12 than participants in the CBT-TAU group.
Hypothesis 2: Participants in the CBT+PPI group will report greater increases in daily experiences of positive emotions and overall scores for both hope theory subscales between Week 1 and Week 12 than participants in the CBT-TAU group.
Method
Participants
Urban Corps of San Diego County is a nonprofit organization that provides an opportunity for at-risk, transition age youth between the ages of 18 to 25 to obtain a high school diploma and on-the-job training. The number of students enrolled in the program fluctuates between an average of 150 to 200 students each semester, many of which identified lack of support, resources, and difficult life circumstances such as gang involvement, interpersonal and/or community violence, substance use, court involvement, foster care, homelessness, immigration issues, or war refugee status as major barriers to successfully obtaining a high school diploma or consistent employment. In order to help provide increased access to support and resources, Urban Corps has implemented an onsite counseling program staffed primarily by University of San Diego Clinical Mental Health Counseling graduate students who obtain clinical supervision from licensed mental health clinicians throughout his or her practicum placement portion of the degree program. Although onsite counseling services are available to all enrolled students, only a limited amount of time slots are available for weekly individual counseling sessions, leaving a large group of students on a waiting list.
Participants for this study will be recruited from this waiting list of students that are requesting counseling services for depression. Potential participants will be asked to complete a
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screening interview by the practicum students’ clinical supervisor in order to assess for safety and suitability for inclusion in these group settings. Students who are unable to meaningfully participate due to any of the following exclusion criteria will be connected to more appropriate community agencies: current psychotic symptoms, cognitive deficits, inability to communicate in English, and/or currently experiencing acute crisis state.
Measures
Pre-treatment scores will be collected during the participant screening interview (TI) and post-treatment scores will be collected during each participant exit interview, which will be conducted after the final group meeting on week 12 of treatment (T2) for both groups. Pre- and post-treatment scores will be measured using the following instruments:
Inventory of Depressive Symptoms-Clinician Rated (IDS-C30)
The Inventory of Depressive Symptoms-Clinician Rated (IDS-C30; Rush, Carmody, & Reimitz, 2000) is a semi-structured interview used to assess severity and frequency of specific depressive symptoms present over the last 7 days; this clinician-rated version of the IDS will be conducted by the onsite clinical supervisor at T1 and T2 to assess for suitability and safety of study participants.
Schema Questionnaire-Short Form
The Schema Questionnaire-Short Form (SQ-SF; Young, 1998) is a self-report measure that consists of 75 items rated on a 6-point Likert-scale (1 = completely untrue of me; 2 = mostly untrue of me; 3 = slightly more true than untrue; 3 = slightly more true than untrue; 4 = moderately true of me; 5 = mostly true of me; 6 = describes me perfectly). These items are thought to represent 15 early maladaptive schemas (EMS) including: emotional deprivation, abandonment, mistrust/abuse, social alienation, defectiveness, incompetence, dependency,
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vulnerability to harm, enmeshment, subjugation of needs, self-sacrifice, emotional inhibition, unrelenting standards, entitlement, and insufficient self control; higher scores indicate a greater presence of a specific EMS (Young, 1998; Welburn, Coristine, Dagg, Pontefract, & Jordan, 2002).
Trait Hope Scale
The Trait Hope Scale is comprised of 10 items that are meant to assess two cognitive components of hope theory: 1) agency thinking, the belief that one has been/will be personally able to achieve one’s goals, and 2) pathways thinking, the belief that there are multiple ways to achieve one’s goals (Snyder et al., 1991; Snyder, Rand & Sigmon, 2002). Participants are asked to indicate on a 4-point Likert scale how much he or she agrees or disagrees (4= definitely true, 1 = definitely false) with statements related to agency thinking and pathways thinking subscales. This assessment will be completed once at T1 and then again at T2.
Modified Differential Emotions Scale
The Modified Differential Emotions Scale (mDES; Garland et al., 2010) will be used as a weekly self-report mood-tracking system to assess 19 specific emotions including: amusement, compassion, contentment, gratitude, hope, joy, interest, love, pride/accomplishment, anger, contempt, disgust, embarrassment, guilt, sadness, shame, fear, and surprise. Participants in both treatment groups will be asked to rate his or her strongest experience of the aforementioned emotions within the last 24 hours using a 4-point Likert scale. Each participant will complete the mDES during intake, and will then be given instructions and a folder containing 12 mDES forms. Participants will be asked to complete one mDES per week within 24 hours prior to arriving to each weekly session. Completed scales will be handed into the group facilitator at the beginning of the each session as part of both groups’ check-in procedure, and scores will be
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charted to keep a running log of potential changes in these specific positive and negative emotions for each participant between T1 and T2.
Demographics Questionnaire
A brief demographics questionnaire will also be administered at T1 to collect participants’ age, gender, ethnicity, and last grade completed prior to enrolling in Urban Corps charter school and job training program.
Procedure
In order to help reduce the wait times and leverage available resources to serve higher ratios of the student population on a weekly basis, the option to include a no-treatment control group for this study was substituted with the decision to provide two active treatment groups. Participants will be randomly assigned to one of the proposed curriculum groups: Cognitive- Behavioral Therapy – Treatment as Usual (CBT – TAU) or Cognitive-Behavioral Therapy + Positive Psychological Interventions (CBT + PPI). Each topic covered in the CBT-TAU group will also be covered in the CBT+PPI group however, participants in the CBT + PPI group will receive additional interventions based on the aforementioned literature supporting their potential efficacy to trigger upward spirals towards recovery due to the effects of broadening and building client’s perceived capacity to initiate and sustain positive emotional states, despite the presence of depressive symptomology. Both groups will meet for 12 consecutive weeks; the breakdowns of weekly topics and exercises for both groups are listed in the Appendices.
Analysis
Analyses will be conducted using SPSS and will consist of a 2 group (CBT-TAU, CBT- PPI) x 2 group (Gender) MANOVA with 4 dependent variables (IDS-C30, SQ-SF, mDES and Trait Hope Scale scores at T1 and T2), as well as follow-up on significant statistical findings
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using Univariate Analyses.
Expected Results
It is expected that results of the data analyses will support both hypotheses and meet the study’s objective of increasing access to, and the efficacy of CBT treatment curriculum for depression. As a result of integrating interventions aimed at increasing upward spirals into existing curriculum targeted at decreasing downward spirals, participants in the CBT+PPI group are expected to report larger reductions in depressive symptomology and identification with maladaptive early schemas, as well as greater increases in daily experiences of positive emotions and overall scores in agency and pathways thinking subscales when compared with participants in the CBT-TAU group.