The effect of positive psychology interventions on well-being and distress in clinical samples with psychiatric or somatic disorders: a systematic review and meta-analysis.

BACKGROUND: Although positive psychology interventions (PPIs) show beneficial effects on mental health in non-clinical populations, the current literature is inconclusive regarding its effectiveness in clinical settings. We aimed to examine the effects of PPIs on well-being (primary outcome), depression, anxiety, and stress (secondary outcomes) in clinical samples with psychiatric or somatic disorders. METHODS: A systematic review and meta-analysis was conducted following PRISMA guidelines. PsycINFO, PubMed, and Scopus were searched for controlled studies of PPIs in clinical samples between Jan 1, 1998 and May 31, 2017. Methodological quality of each study was rated. We used Hedges' adjusted g to calculate effect sizes and pooled results using random-effect models. RESULTS: Thirty studies were included, representing 1864 patients with clinical disorders. At post-intervention, PPIs showed significant, small effect sizes for well-being (Hedges' g = 0.24) and depression (g = 0.23) compared to control conditions when omitting outliers. Significant moderate improvements were observed for anxiety (g = 0.36). Effect sizes for stress were not significant. Follow-up effects (8-12 weeks), when available, yielded similar effect sizes. Quality of the studies was low to moderate. CONCLUSION: These findings indicate that PPIs, wherein the focus is on eliciting positive feelings, cognitions or behaviors, not only have the potential to improve well-being, but can also reduce distress in populations with clinical disorders. Given the growing interest for PPIs in clinical settings, more high quality research is warranted as to determine the effectiveness of PPIs in clinical samples. TRIAL REGISTRATION: PROSPERO CRD42016037451.

Investigating the Direct Impact of a Gamified Versus Nongamified Well-Being Intervention: An Exploratory Experiment.

BACKGROUND: Gamification is a promising strategy to increase the effectiveness of Web-based mental health interventions by enhancing engagement. However, because most studies focus on the longer term effects of gamification (eg, effectiveness or adherence at the end of the intervention period), there is limited insight into how gamification may enhance engagement. Research implies that gamification has a direct impact at the time of use of the intervention, which changes the experience of the users, and thereby motivates users. However, it is unclear what this direct impact of gamification might be and how it can be measured. OBJECTIVE: The objective of this study was to explore the direct impact of gamification on behavioral, cognitive, and affective engagement in the context of a Web-based mental health intervention and to explore whether and how the different components of engagement are related. METHODS: A pilot (n=19) and a real-life (n=75) randomized between-groups experiment was carried out, where participants used a gamified or nongamified version of the same Web-based well-being intervention for a single session. Participants (68%, 64/94 female, mean age 23 years) were asked to use the intervention in one session for research purposes. Gamification elements included a map as visualization of the different lessons, a virtual guide, and badges. Later, behavioral, cognitive, and affective engagement were measured. RESULTS: The pilot experiment showed no differences between the gamified and nongamified intervention. However, in the real-life experiment, participants in the gamified intervention scored higher on cognitive engagement, that is, involvement (P=.02) and some elements of affective engagement, that is, flow as a combination of cognitive and affective engagement (P=.049), and the emotions "interest" (P=.03) and "inspiration" (P=.009). Furthermore, the effect of gamification on cognitive engagement was mediated by the influence of gamification on specific positive emotions. CONCLUSIONS: The gamified intervention seemed to be able to increase cognitive engagement and the combination of cognitive and affective engagement but not behavioral and affective engagement alone. However, positive emotions seem to play an important role in mediating the effect of gamification on engagement. In conclusion, we cannot say that gamification "works" but that the design of an intervention, in this case, gamification, can have an impact on how participants experience the intervention.

Complaint-Directed Mini-Interventions for Depressive Complaints: A Randomized Controlled Trial of Unguided Web-Based Self-Help Interventions.

BACKGROUND: Prevention of depression is important due to the substantial burden of disease associated with it. To this end, we developed a novel, brief, and low-threshold Web-based self-help approach for depressive complaints called complaint-directed mini-interventions (CDMIs). These CDMIs focus on highly prevalent complaints that are demonstrably associated with depression and have a substantial economic impact: stress, sleep problems, and worry. OBJECTIVE: The aim was to evaluate the effectiveness of the Web-based self-help CDMIs in a sample of adults with mild-to-moderate depressive symptoms compared to a wait-list control group. METHODS: A two-armed randomized controlled trial was conducted. An open recruitment strategy was used. Participants were randomized to either the Web-based CDMIs or the no-intervention wait-list control group. The CDMIs are online, unguided, self-help interventions, largely based on cognitive behavioral techniques, which consist of 3 to 4 modules with up to 6 exercises per module. Participants are free to choose between the modules and exercises. Assessments, using self-report questionnaires, took place at baseline and at 3 and 6 months after baseline. The control group was given access to the intervention following the 3-month assessment. The primary goal of the CDMIs is to reduce depressive complaints. The primary outcome of the study was a reduction in depressive complaints as measured by the Inventory of Depressive Symptomatology Self-Report (IDS-SR). Secondary outcomes included reductions in stress, worry, sleep problems, and anxiety complaints, and improvements in well-being. Data were analyzed using linear mixed models. RESULTS: In total, 329 participants enrolled in the trial, of which 165 were randomized to the intervention group and 164 to the control group. Approximately three-quarters of the intervention group actually created an account. Of these participants, 91.3% (116/127) logged into their chosen CDMI at least once during the 3-month intervention period (median 3, range 0-166). After 3 months, there was a significant reduction in depressive symptomatology for participants in the intervention group compared to participants in the wait-list control group (reduction in depression: mean -4.47, 95% CI -6.54 to -2.40; Cohen d=-0.70). Furthermore, significant effects were observed for sleep problems, worry, anxiety, and well-being, with effect sizes ranging from -0.29 to -0.40. The intervention did not significantly reduce stress. At 6-month follow-up, the improvements in the intervention group were generally sustained. CONCLUSIONS: This study shows that the online self-help CDMIs have a positive impact on various mental health outcomes. Future research should focus on which specific strategies may boost adherence, and increase the reach of the CDMIs among people with low socioeconomic status. CLINICALTRIAL: Netherlands Trial Register (NTR): NTR4612; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=4612 (Archived by WebCite at http://www.webcitation.org/6n4PVYddM).

What, how and when do families communicate about ALS? A qualitative exploration of parents' and children's perceptions.

Objectives: In families with a parent diagnosed with amyotrophic lateral sclerosis (ALS), children's adaptation depends among others on how their parents communicate with them about the disease and its trajectory. The aim of this study was to explore parents' and children's perceptions of ALS-related family communication. Methods: A qualitative analysis using a conventional content analysis approach was applied to interview data previously collected from 21 parents (8 with ALS) and 15 children (age 13-23 years) about their experiences living with ALS. Results: Three themes emerged from the interviews: communication topics, styles and timing. Communication topics include facts about disease and prognosis, feelings, care and equipment, and the end. Although most parents perceived the familial communication style concerning ALS as open, the interviews revealed that both parents and children sometimes avoid interactions about ALS, because they do not know what to say or how to open the dialogue, are afraid to burden other family members, or are unwilling to discuss. Communication timing is directed by changes in the disease trajectory and/or questions of children. A family-level analysis showed that ALS-related family communication is sometimes perceived differently by parents and children. Conclusions: The study provides a better understanding of what, how and when parents and children in families living with ALS communicate about the disease. Most families opened the dialogue about ALS yet encountered challenges which may hamper good familial communication. Through addressing those challenges, healthcare professionals may facilitate better communication and adaptation in families with a parent with ALS.

Effects of a brief compassion exercise on affect and emotion regulation in patients with personality disorders.

BACKGROUND AND OBJECTIVES: Cultivating compassion seems a promising strategy for ameliorating emotion dysregulation in patients with personality disorders (PDs). Thus far, empirical evidence is lacking. This study aimed to examine whether a brief compassion exercise compared to a neutral exercise would positively impact on (implicit) positive affect (PA) and (implicit) negative affect (NA) and foster the use of more adaptive emotion regulation strategies in an adult clinical sample with PDs. METHODS: A total of 24 patients admitted to a Dutch day-hospital treatment center for PDs participated in a two-group cross-over study. Participants were randomly allocated over two groups that were both given the compassion and neutral exercise, yet in a different order. Assessments took place prior to and following each exercise. Participants completed questionnaires assessing (implicit) PA and NA and emotion regulation strategies. RESULTS: Multilevel analyses did not yield significant differences between the neutral and compassion exercise in terms of adaptive and maladaptive emotion regulation and implicit PA. The compassion exercise was able to significantly decrease implicit NA among participants, relative to the neutral exercise. A significant interaction effect was observed between exercise and sequence of exercises on PA and NA. LIMITATIONS: Limitations include the brief duration of the exercises, the control exercise and the low reliability for the emotion regulation measure. CONCLUSIONS: The compassion exercise decreased implicit NA but seemed not able to impact on PA, NA and emotion regulation in patients with PDs.

Stigma experienced by ALS/PMA patients and their caregivers: a mixed-methods study.

OBJECTIVE: Previous work suggests that stigma negatively impacts quality of life in people living with amyotrophic lateral sclerosis (ALS) and progressive muscular atrophy (PMA). This study aimed to explore experiences of enacted stigma (experienced discrimination) and felt stigma (shame, fear of exclusion) among Dutch ALS/PMA patients and their caregivers. A secondary aim was to assess associated factors of enacted/felt stigma among patients. METHODS: A two-phase mixed-methods study was conducted, comprising cross-sectional surveys among 193 ALS/PMA patients and 87 caregivers, and semi-structured interviews with 8 ALS/PMA patients and 11 family caregivers. Descriptive and multivariable regression analyses along with qualitative content analysis were used to analyze survey and interview data. RESULTS: Survey findings indicate that patients and caregivers experience enacted and felt stigma. Interviews with both patients and caregivers revealed two manifestations of enacted stigma, including social exclusion (e.g. relationship distancing) and stigmatizing attitudes/behaviors displayed by others (e.g. staring), and three manifestations of felt stigma, including alienation (e.g. shame/embarrassment), perceived discrimination (e.g. feeling judged) and anticipated stigma (e.g. fear of exclusion). Patients and caregivers engaged in concealing and resisting responses to stigma. More bulbar symptoms, King's clinical stage, younger age and living without a partner were significantly associated with enacted/felt stigma among patients. CONCLUSIONS: Our findings reveal a range of perceptions and experiences underlying enacted/felt stigma among ALS/PMA patients and their caregivers that may serve as conversation topics in clinical practice. Future research may shed more light on the determinants as well as the consequences of stigmatizing experiences among patients and caregivers.

Parental and child adjustment to amyotrophic lateral sclerosis: transformations, struggles and needs.

BACKGROUND: Amyotrophic lateral sclerosis (ALS), progressive muscular atrophy (PMA) and primary lateral sclerosis (PLS), together referred to as ALS, are life-limiting diagnoses affecting not only patients but also the families surrounding them, especially when dependent children are involved. Despite previous research highlighting the vulnerability of children in these families, they are, as yet, often overlooked in healthcare. Efforts are needed to better support children in families living with ALS, both directly and through strengthening parents in their parental role. This study sought to gain a better understanding of parental and children's experiences, struggles and support needs in families living with ALS. METHODS: Semi-structured interviews were conducted with 8 parents with ALS, 13 well parents and 15 children, together representing 17 families. Interview data were analyzed using qualitative content analysis. RESULTS: Three major themes were identified relating to (1) ALS-related transformations in families' homes, activities, roles and relationships, that trigger (2) distress among families, which, in turn, evokes (3) emotional, psychological, educational and practical support needs. For emotional and practical support, parents and children mainly rely on their own family and social network, whereas they seek educational and psychological support from healthcare professionals. CONCLUSIONS: Our findings imply that ALS care professionals may foster family adjustment to living with ALS, most notably through encouraging parents to engage in a dialogue with their children about the many transformations, struggles and needs imposed by ALS and teaching them how to start the dialogue.

New Evidence in the Booming Field of Online Mindfulness: An Updated Meta-analysis of Randomized Controlled Trials.

BACKGROUND: There is a need to regularly update the evidence base on the effectiveness of online mindfulness-based interventions (MBIs), especially considering how fast this field is growing and developing. OBJECTIVE: This study presents an updated meta-analysis of randomized controlled trials assessing the effects of online MBIs on mental health and the potential moderators of these effects. METHODS: We conducted a systematic literature search in PsycINFO, PubMed, and Web of Science up to December 4, 2020, and included 97 trials, totaling 125 comparisons. Pre-to-post and pre-to-follow-up between-group effect sizes (Hedges g) were calculated for depression, anxiety, stress, well-being, and mindfulness using a random effects model. RESULTS: The findings revealed statistically significant moderate pre-to-post effects on depression (g=0.34, 95% CI 0.18-0.50; P<.001), stress (g=0.44, 95% CI 0.32-0.55; P<.001), and mindfulness (g=0.40, 95% CI 0.30-0.50; P<.001) and small effects on anxiety (g=0.26, 95% CI 0.18-0.33; P<.001). For well-being, a significant small effect was found only when omitting outliers (g=0.22, 95% CI 0.15-0.29; P<.001) or low-quality studies (g=0.26, 95% CI 0.12-0.41; P<.001). Significant but small follow-up effects were found for depression (g=0.25, 95% CI 0.12-0.38) and anxiety (g=0.23, 95% CI 0.13-0.32). Subgroup analyses revealed that online MBIs resulted in higher effect sizes for stress when offered with guidance. In terms of stress and mindfulness, studies that used inactive control conditions yielded larger effects. For anxiety, populations with psychological symptoms had higher effect sizes. Adherence rates for the interventions ranged from 35% to 92%, but most studies lacked clear definitions or cut-offs. CONCLUSIONS: Our findings not only demonstrate that online MBIs are booming but also corroborate previous findings that online MBIs are beneficial for improving mental health outcomes in a broad range of populations. To advance the field of online MBIs, future trials should pay specific attention to methodological quality, adherence, and long-term follow-up measurements.

Effect of Psychotherapy for Borderline Personality Disorder on Quality of Life: A Systematic Review and Meta-Analysis.

Whereas several meta-analyses have shown that psychotherapy is effective for reducing borderline personality disorder (BPD) pathology, the overall impact of psychotherapy for BPD on quality of life (QoL) remains as yet unclear. Because impaired QoL is associated with poor long-term outcomes after therapy for BPD, this seems a timely and relevant issue. The authors conducted a systematic review and meta-analysis of randomized controlled trials of psychotherapies for adults diagnosed with BPD that reported results of QoL at posttreatment. Fourteen trials were included (1,370 individuals with BPD). Psychotherapies for BPD relative to control conditions showed significant effect sizes for QoL (Cohen's d = 0.31; 95% CI [0.18, 0.44]), and for BPD pathology (d = 0.43; 95% CI [0.23, 0.64]). The effect on QoL was not significantly moderated by the effect on BPD pathology. Psychotherapies for BPD have a positive effect on QoL of patients with BPD. However, more studies are needed to examine the impact of psychotherapy on QoL and long-term outcome, including recovery.

Exploring compassionate attributes and skills among individuals participating in compassion-focused therapy for enhancing well-being.

OBJECTIVES: The conceptual approach of compassion underlying compassion-focused therapy (CFT) is based on theoretical rather than empirical grounds. The aim of the present study was to seek empirical support for components of compassion as outlined in the theoretical model underpinning CFT, and to explore which components, if any, matter most for improving well-being. DESIGN: A sequential exploratory mixed methods design was employed. METHODS: Alongside a randomized controlled trial (RCT), we systematically examined 625 emails sent by 87 RCT participants to five counsellors during the course of a well-being enhancing CFT self-help intervention, to identify theoretically based compassionate attributes and skills. Next, in a quantitative analysis, we compared participants who did and did not show clinically relevant improvement on well-being with regard to the occurrence of compassionate attributes and skills. RESULTS: Although the theoretical model of compassion integral to CFT was largely supported by the emails, it was slightly simplified so as to better fit the data. The adjusted model comprises five compassionate attributes (i.e., care for well-being, sensitivity, empathy, distress tolerance, and common humanity) and four compassionate skills (i.e., compassionate attention, reasoning, behaviour, and feeling/sensation). Three illustrative cases are presented to contribute to a better understanding of fundamental components of compassion. Quantitative analyses indicate that participants showing clinically relevant improvement on well-being expressed significantly more compassionate feeling/sensation compared to those who did not. CONCLUSIONS: We found preliminary evidence for the conceptualization of compassion underlying CFT. Compassionate feeling/sensation bears particular interest when well-being is the intended outcome of CFT. PRACTITIONER POINTS: Individuals participating in compassion-focused therapy for enhancing well-being experience a wide range of compassionate attributes and skills. Compassion-focused therapy may instigate well-being if a client is able to experience compassionate feeling/sensation.

Pathways to Improving Mental Health in Compassion-Focused Therapy: Self-Reassurance, Self-Criticism and Affect as Mediators of Change.

Objective: The working mechanisms of compassion-focused therapy (CFT) remain understudied. Drawing on the theoretical model underlying CFT, we examined four putative working mechanisms - self-reassurance, self-criticism, positive/negative affect - in relation to changes in well-being and psychological distress. Methods: Data of a waitlist randomised controlled trial (N = 242) investigating the effectiveness of a self-help CFT-intervention in a non-clinical sample were analysed. Using single and multiple mediation models, we assessed if changes in self-reassurance, self-criticism and positive/negative affect during the intervention (3-month interval) mediated changes in well-being and depressive/anxiety symptoms from baseline to follow-up (6-month interval) compared to the waitlist condition. Results: For each outcome, single analyses revealed that the effects of CFT were significantly mediated by self-reassurance and self-criticism. The mediating role of affect differed across outcomes. In combined models, self-reassurance emerged as a significant mediator for well-being and anxiety symptoms. Additionally, positive and negative affect were found significant mediators of the effects on depressive and anxiety symptoms, respectively. Conclusion: This study provides preliminary empirical evidence that CFT operates through cultivating self-reassurance, reducing self-criticism and regulating positive and negative affect in a non-clinical sample. To advance the development of CFT, further exploration of therapeutic change processes and their interplay is needed.

Development and validation of the forms of Self-Criticizing/Attacking and Self-Reassuring Scale-Short Form.

Studies investigating the effectiveness of compassion-focused therapy (CFT) are growing rapidly. As CFT is oriented toward helping people deal with internal processes of self-to-self-relating, having instruments to measure these processes is important. The 22-item Forms of Self-Criticizing/Attacking and Self-Reassuring Scale (FSCRS) has been found a useful measure. In the present study, a 14-item short form of the FSCRS (FSCRS-SF) suited to studies requiring brief measures was developed and tested in a Dutch community sample (N = 363), and cross-validated in a sample consisting of participants in a study on the effectiveness of a guided self-help compassion training (N = 243). Confirmatory factor analysis (CFA) indicated acceptable to good fit of the FSCRS-SF items to a three-factor model. Findings regarding internal consistency were inconsistent, with Study 1 showing adequate internal consistency for all subscale scores and Study 2 demonstrating satisfactory internal consistency only for the reassured self (RS) subscale score. Furthermore, the results showed that the FSCRS-SF subscale scores had adequate test-retest reliability and satisfactory convergent validity estimates with theoretically related constructs. In addition, the FSCRS-SF subscale scores were found to be sensitive to changes in self-to-self relating over time. Despite mixed findings regarding its reliability requiring further investigation, the FSCRS-SF offers a valid and sensitive measure which shows promise as a complimentary shorter version to the original FSCRS suited to nonclinical populations. Given that the FSCRS is increasingly used as a process and outcome measure, further research on this short form in nonclinical and clinical populations is warranted. (PsycINFO Database Record

The Factor Structure of the Forms of Self-Criticising/Attacking & Self-Reassuring Scale in Thirteen Distinct Populations.

There is considerable evidence that self-criticism plays a major role in the vulnerability to and recovery from psychopathology. Methods to measure this process, and its change over time, are therefore important for research in psychopathology and well-being. This study examined the factor structure of a widely used measure, the Forms of Self-Criticising/Attacking & Self-Reassuring Scale in thirteen nonclinical samples (N = 7510) from twelve different countries: Australia (N = 319), Canada (N = 383), Switzerland (N = 230), Israel (N = 476), Italy (N = 389), Japan (N = 264), the Netherlands (N = 360), Portugal (N = 764), Slovakia (N = 1326), Taiwan (N = 417), the United Kingdom 1 (N = 1570), the United Kingdom 2 (N = 883), and USA (N = 331). This study used more advanced analyses than prior reports: a bifactor item-response theory model, a two-tier item-response theory model, and a non-parametric item-response theory (Mokken) scale analysis. Although the original three-factor solution for the FSCRS (distinguishing between Inadequate-Self, Hated-Self, and Reassured-Self) had an acceptable fit, two-tier models, with two general factors (Self-criticism and Self-reassurance) demonstrated the best fit across all samples. This study provides preliminary evidence suggesting that this two-factor structure can be used in a range of nonclinical contexts across countries and cultures. Inadequate-Self and Hated-Self might not by distinct factors in nonclinical samples. Future work may benefit from distinguishing between self-correction versus shame-based self-criticism.