Positive Thinking Revisited: Positive Cognitions, Well-being and Mental Health

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1 Clinical Psychology and Psychotherapy Clin. Psychol. Psychother. 7, 1±10 (2000) Positive Thinking Revisited: Po...

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Clinical Psychology and Psychotherapy Clin. Psychol. Psychother. 7, 1±10 (2000)

Positive Thinking Revisited: Positive Cognitions, Well-being and Mental Health Andrew K. MacLeod*1 and Richard Moore2 1 2

Royal Holloway, University of London, UK Addenbrooke's NHS Trust, Cambridge, UK

There has been relatively little attention given to the issue of positive cognition in psychological research and therapy. This paper explores reasons for this neglect and presents empirical and conceptual support for the importance of positive cognition in mental health. Evidence is presented that positive and negative aspects of experience are mediated by separate psychological systems rather than being opposite ends of a single dimension. We then review research that describes the potential importance of positive cognition in psychological disorders, especially in recovery and relapse in depression. Finally, we present suggestions for evaluating the validity and helpfulness of positive cognitions within therapy, and discuss some therapeutic approaches that focus on increasing positive cognition and well-being. The case for positive cognitions being important is argued mainly in the context of depression and the therapeutic applications are discussed mainly in relation to cognitive therapy, but the arguments may well be applicable to other disorders and other therapeutic approaches. Copyright # 2000 John Wiley & Sons, Ltd.

INTRODUCTION There has been little attention given to the role of positive experiences in mental health and wellbeing, especially when compared with the extensive research literature on negative experiences and mental health. For example, Diener et al. (1999) point out that the ratio of articles examining negative psychological states to those examining positive states is 17 to 1. This situation reflects the prevailing view in health research generally, where an illness model predominates despite the World Health Organization's definition of health as `a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity' *Correspondence to: Dr Andrew MacLeod, Department of Psychology, Royal Holloway University of London, Egham, Surrey TW20 0EX, UK. Email: [email protected]

Copyright # 2000 John Wiley & Sons, Ltd.

(WHO, 1948, p. 28 cited in Ryff and Singer, 1998). Why is this the case? The neglect may have arisen from the belief that whilst positive cognitions might be important for happiness their presence is not important for eliminating or reducing psychological disorder. This view would be most clearly encapsulated by the idea that it is the role of therapists to try to reduce psychological distress and disability but not to bring about happiness in their clients. The therapist's job is complete when depression or anxiety or disability return to within some normal range. We will review relevant evidence and argue that deficits in positive cognitions are important components of particular disorders, and are also important in recovery and protection from psychological disorders, particularly depression. A second possible reason for positive cognitions not having received much attention is that they are

2 seen as the inverse of negative cognitions. In other words positive and negative thinking are seen as opposite ends of a single continuum. Therefore, if therapy is aimed at reducing negative thinking, then it will, in effect, also increase positive thinking. We will review a wealth of evidence that this unidimensional view of positive and negative aspects of experience is misleading, and that positive and negative aspects of experience, including cognitions, are better thought of as reflecting the operation of two separate systems. The implication of this view is that it becomes important to take a twodimensional view of mental health, focusing on high positive- as well as low negative-thinking. A third reason for the neglect of positive cognition is the (understandable) suspicion in which positive thinking is sometimes held by therapists. The situation at the end of therapy where the patient thanks the therapist for all his or her help with positive thinking is generally not welcomed by cognitive therapists. Despite patients thinking that positive thinking is a good thing and being supported in this by a self-help literature on the power of positive thinking, cognitive therapists usually try to distance themselves from the idea that they are trying to foster positive thinking. This goes back to some of Beck's original writings on cognitive therapy which assert that cognitive therapy is about thinking realistically rather than positively: `Cognitive therapy can be called the power of realistic thinking . . . ``Positive thinking'', in contrast, consists of substituting one global abstraction, ``I'm a wonderful person'', for another, ``I'm a bad person'' ' (Beck et al., 1979, pp. 298±299). The result has been that standard cognitive therapy emphasizes the strategy of addressing unrealistically negative thinking. The research base of cognitive therapy has also focused mainly on studies of negative thinking in the onset and maintenance of emotional disorders. We propose that positive thinking can be accommodated within a cognitive therapy framework, and discuss some ways of distinguishing valid from invalid positive thinking. The evidence we review will not necessarily be comprehensive and some of the points we make in relation to clinical practice could be considered to be somewhat speculative. However, the aim of the paper is to stimulate thinking on the topic of positive experience and to suggest links between the relevant theoretical and empirical literature and clinical practice. Having signalled the importance of positive cognition and experience, it should become clear that there is considerable scope for further theoretical and empirical work. Copyright # 2000 John Wiley & Sons, Ltd.

A. K. MacLeod and R. Moore

POSITIVE AND NEGATIVE EXPERIENCE AS TWO SEPARATE SYSTEMS Although it makes sense, intuitively, to think of positive and negative aspects of experience as opposite ends of a continuum, there is now substantial evidence that they are best thought of as reflecting the operation of two separate systems. Ito and Cacciopo (1998) put forward several models of the relationship between positive health and illness. One model is unidimensional with illness at one pole, positive health, or resilience, at the other pole, and the mid-point representing absence of illness or resilience. Interestingly, even in this unidimensional view, attention to positive, resilience factors becomes important as those who are further towards the positive will be less vulnerable to illness. However, Ito and Cacciopo conclude that it is better to think in terms of a bi-dimensional model of illness-promoting factors and resiliencepromoting factors. Health states represent activity of both dimensions. Activity on these dimensions cannot be converted into a single score that represents the balance of the two dimensions as there will be qualitative differences between, for example, people who are high on both illnesspromoting and resilience-promoting factors compared to those who are low on both. Fincham (1997) has put forward this argument in the field of marital quality where he has argued that positive marital quality and negative marital quality are best thought of as separate dimensions. The inadequacy of taking a balance score is illustrated by qualitative differences between couples who are high on both dimensions (termed `ambivalent') and couples who are low on both (`indifferent'). Such couples would be indistinguishable on a unidimensional view or on taking a balance score, although there are likely to be very significant differences between them. This failure to take account of positive and negative aspects of experience separately is to be found in the states of mind approach to positive and negative cognition (Schwartz and Garamoni, 1989). In this model, positive and negative cognitions are measured separately, but are then amalgamated to provide a balance score, the exact balance being thought to relate to certain types of psychopathology. The view of positive and negative aspects of experience as being independent has been given great impetus by the work of Tellegen and his colleagues on the structure of affect (e.g. Watson et al., 1988). These authors argued that positive affect (PA) and negative affect (NA) are best Clin. Psychol. Psychother. 7, 1±10 (2000)

Positive Thinking, Well-being and Mental Health thought of as orthogonal dimensions rather than two ends of the one dimension. In their system, PA is a dimension that runs from pleasurable engagement (e.g. enthusiastic, active and alert), to unpleasant disengagement (e.g. sad, bored, lethargic). NA is a measure characterized by unpleasurable engagement at the high end (e.g. anger, fear, and disgust) through to pleasurable disengagement at the low end (e.g. calm, serene, peaceful). Theoretically, how someone is feeling on one dimension should not have implications for their position on the other dimension, and studies do generally find that scores on the dimensions are uncorrelated or only slightly negatively correlated (Watson et al., 1988). The dimensions are also thought to apply to more enduring features of personality, in which case they are referred to as Positive Emotionality and Negative Emotionality (Tellegen, 1985). When discussed in terms of personality, the dimensions are very close to, or perhaps synonymous with, the Eysenckian dimensions of Extraversion and Neuroticism. Anxiety and depression have also been conceptualized in terms of these two underlying dimensions (Clark and Watson, 1991). Anxiety is a state of high NA whereas depression is thought to be a mixed state of high NA and low PA. Low PA is therefore important in discriminating depression from anxiety. A subcomponent of NA thought to be specific to anxietyÐautonomic hyperarousalÐhas also been suggested (Clark and Watson, 1991), therefore giving depression-specific features (low PA), anxiety-specific features (increased hyperarousal) and features shared between depression and anxiety (general NA). The model has been further revised as evidence has suggested that hyperarousal is a lower order factor that is associated specifically with panic disorder rather than being a factor common to all anxiety disorders (Brown et al., 1998; Mineka et al., 1998). The work on the structure of affect appears to map onto other work separating positive and negative psychological systems. A number of theorists have identified two basic motivational systems, mediating positive and negative aspects of experience (Fowles, 1994; Gray, 1994). Gray outlined a Behavioural Inhibition System (BIS) which is concerned with anticipating and avoiding undesirable outcomes and a Behavioural Approach System (BAS) which coordinates responses in anticipation of attaining a desirable outcome. The two systems function independently, though they can influence each other, and control quite different behavioural repertoires as well as having distinctive Copyright # 2000 John Wiley & Sons, Ltd.

3 neurological bases (Gray, 1994; Fowles, 1994). The BIS is thought to primarily involve serotonergic and noradrenergic pathways, particularly the dorsal ascending noradrenergic bundle linking the locus ceoruleus to the hippocampal system (Gray, 1994) with the BAS being mediated by dopaminergic pathways (Depue and Iacono, 1989). Davidson (1998) expands the two-system view to include some degree of hemispheric specialization for the two systems. The parallels with the work on affect is obvious, particularly when it is considered that anxiety is thought to represent primarily activation of the BIS whereas depression can also have heightened BIS activity but is particularly characterized by low BAS activity (Depue and Iacono, 1989; Clark et al., 1994; Fowles, 1994). The distinction drawn between positive and negative aspects of experience at the levels of motivation and affect should also be true in the case of cognitions. Expectancies for negative outcomes should be related to the negative system whereas positive outcome expectancies should be related to the positive system. MacLeod et al. (1996) in two studies found support for this position in factor analyses of a number of self-report measures. Expectancies for negative future events loaded onto a factor along with NA and both anxiety and depression, whereas expectancies for positive future events loaded onto a factor with PA (low) and depression. The independence of positive and negative outcome expectancies has also been shown in clinical groups. A series of studies by MacLeod and colleagues has measured positive and negative cognitions using a future-thinking task. In this procedure, individuals are presented with time periods in the future, for example, the next week or the next year, and are asked to think of as many things that they are going to be doing or that are going to happen to them in each time period. A set time, usually 1 min, is allowed for individuals to generate as many events as possible and the total number of items generated is recorded. The time periods are presented twiceÐonce to elicit positive items (things the person is looking forward to) and once to elicit negative items (things the person is worried about or not looking forward to). The independence of positive and negative cognitions is shown by the fact that parasuicidal individuals (who have a recent episode of non-fatal, deliberate self-harm) show a reduction in positive responses, relative to controls, but do not differ from controls in their number of negative responses (MacLeod et al., 1993, 1997a). Furthermore, in studies Clin. Psychol. Psychother. 7, 1±10 (2000)

4 comparing anxious and depressed individuals, the distinction between positive and negative responses follows the two-system approach already discussed: relative to controls, anxious participants show an increase in negative expectancies but no decrease in positive expectancies whereas depressed participants show both an increase in negative and a reduction in positive expectancies (MacLeod and Byrne, 1996) or only a reduction in positive expectancies (MacLeod et al., 1997b). In conclusion, there is a great deal of evidence across a whole range of research domains that positive and negative aspects of experience are best thought of as reflecting the operation of separate systems rather than being opposite ends of the one system. The clear implication of this view is that mental representations and processing of positive as well as negative aspects of experience should be taken into account in any understanding of psychological disorders and in any approach to intervening in these disorders.

POSITIVE THINKING AND MENTAL HEALTH There is a vast amount of research demonstrating the undoubted importance of negative experiences in psychological disorders, both in terms of stressful life events (see Kessler (1997) for a review) and negative cognitions (Williams, 1992). However, there are strong indications from the research literature that positive experiences are also important in psychological disorder. An early study that indicated the important role that positive experiences might play in psychological disorder was carried out by Phillips (1968). He reported results of a community survey that attempted to shed some light on the oft-reported social class differences in the rates of mental disorders. The survey assessed the frequency of both positive and negative experiences in the respondents. He found that positive and negative experiences were independent of each other. That is, those who reported having had the greatest frequency of positive experiences recently were not necessarily those who also reported having had the fewest negative experiences. High and low social class groups did not differ on the frequency of negative experiences, but twice as many individuals in the high social class group reported having had many positive experiences in the past month. The results were interpreted as showing the importance of positive experiences in mental health, either directly Copyright # 2000 John Wiley & Sons, Ltd.

A. K. MacLeod and R. Moore or through offering protection in the face of stressful experiences. More recent research has focused on the idea that positive experiences might play a distinct role in psychological disorder, particularly in terms of what happens after the onset of a disorder. There is an emerging trend from these studies that positive experiences have an important role to play in the processes of recovery, persistence, and relapse. George Brown and colleagues (Brown et al., 1992) found in a community sample that recovery from episodes of anxiety or depression was associated with the occurrence of a positive life event. Those who had recovered by the follow-up stage of the study (1 year later) were more likely to have experienced a positive life event that preceded the recovery. Such events appeared to have their effect either through increasing a sense of security (`anchoring' events), or through providing an increased sense of hope for the future, what the authors called `fresh start' events. These fresh start events were particularly important in recovery from depression, whereas anchoring events occurred more in the context of recovery from anxiety. Positive events have been implicated in recovery from other disorders. For example, Ray et al. (1995) assessed events that had happened over a 1-year period to a group of patients suffering from ongoing chronic fatigue syndrome. They found that positive events were associated with lower scores on a range of measures, including fatigue, anxiety, and depression, and concluded that positive life events and experiences may be an important contributor to recovery in chronic fatigue syndrome. From the research on the impact of negative events on depression it is clear that events have their impact not simply through the fact that they happen. The importance of events depends in large part on the way in which they are interpreted. Several studies also point to this interaction in the role of positive events in recovery. Needles and Abramson (1990) followed up a sample of undergraduate students to look at recovery from elevated levels of hopelessness as a function of positive events. However, they also predicted that for reduction in levels of hopelessness to take place, not only would positive events have to occur but those events would also have to be interpreted in a particular way. Based on hypotheses derived from the hopelessness theory of depression (Abramson et al., 1989) the authors found that reductions in levels of hopelessness were associated with the occurrence of positive life events in the intervening period, combined with having an attributional style Clin. Psychol. Psychother. 7, 1±10 (2000)

Positive Thinking, Well-being and Mental Health that explained those events in stable and global ways. In other words, the perceived reasons for the positive events occurring were the kinds of reasons that could bring about other positive events in the future as well as the present. More recently, Johnson et al. (1998) carried out a similar study, but this time looking at decreases in depression symptoms as well as hopelessness within a group of depressed patients. Over a short-term follow-up (12 to 24 days) reductions in hopelessness and in depression symptoms were associated with having an internal, stable, global style for positive events occurring within the follow-up period. As well as recovery from depression an equally important outcome is relapse following recovery. Despite advances in treatment, rates of relapse following recovery remain high. Prevention of relapse is a valuable therapeutic goal, and understanding some of the factors involved in relapse therefore becomes very important. Research has shown the occurrence of negative life events to play a role in relapse, particularly where those events match an area of psychological vulnerability within the individual (Segal et al., 1992). Less attention has been paid to the role of positive events, though Fava (1999a) has argued for the importance of positive well-being in preventing residual symptoms of a depressive episode from becoming prodromal symptoms for another episode. In one study looking at the role of positive thinking, Ilardi et al. (1997) followed up a sample of 50 depressed patients over an average of just over 4 years, and looked at predictors of relapse. All patients in the study were initially assessed as inpatients during the index episode of depression. As part of the assessment, they were asked to complete the Attributional Style Questionnaire (ASQ; Seligman et al., 1979). This required them to provide explanations (attributions) for why a number of hypothetical positive and negative results would have happened to them. Responses are coded for internality, globality and specificity. Among several predictors of relapse, they found that adaptive attributions for positive events were inversely related to relapse. That is, those who attributed positive events to internal, stable, and global factors showed lower rates of relapse. Interestingly, attributional style for negative events showed no relationship to relapse risk. Further support for the independence of positive and negative attributions comes from Ilardi and Craighead (1999) who found that in previously depressed patients DSM-IV Axis II ( personality disorder) pathology correlated with maladaptive attributions Copyright # 2000 John Wiley & Sons, Ltd.

5 for negative events but showed no relationship to attributions for positive events. What emerges from the studies discussed here is preliminary evidence for positive experiences (which includes the person's processing of positive events as well as the events themselves) being important in recovery from depression and in maintaining that recovery. Interestingly, and in contrast to the role of negative events, Frank et al. (1996) did not find any influence of positive events on onset of depression. In their study, the occurrence of positive events did not delay onset, in contrast to negative events that decreased time to onset. Thus, one conclusion that can be drawn, albeit tentatively, is that positive experiences are more important in recovery and relapse prevention than in onset. However, clearly much more work needs to be done before such a conclusion is accepted.

THERAPY: WHEN IS POSITIVE THINKING VALID? The third reason we suggested for the neglect of positive thinking arises from therapeutic practice. The argument here is that positive cognition has sometimes been viewed with suspicion within cognitive therapy because it raises the possibility of creating illusory rather than accurate thinking. The rationale behind cognitive therapy is that psychological disorders arise out of inaccurate, negative thinking which needs to be corrected. It is therefore important to clarify when positive thinking might be a helpful thing that should be encouraged within therapy, versus when the traditional scepticism is more appropriate. Specifically, are there any criteria that can be established to distinguish valid and helpful positive thinking from invalid and ultimately unhelpful positive thinking? One possibility is that positive thinking is valid when it is an accurate reflection of reality, that is, when the thought corresponds to some external reality. Leaving aside the definitional problems of what might constitute reality, is this a useful heuristic for validating positive cognitions? Consider some examples of apparently positive thoughts taken from therapy sessions conducted by one of the authors with two different patients: (1) I'm a nice person; (2) I'm good at my job. If positive thoughts need simply to be realistic in order to have positive effects, then a positive mood shift would be guaranteed if patient 1 was in fact nice and if patient 2 was indeed good at his job. Clin. Psychol. Psychother. 7, 1±10 (2000)

6 However, both examples 1 and 2 were associated with continuing or worsening low mood, despite the fact that they appeared realistic in that the individual in example 1 did appear to be a nice person and there was evidence that the second individual was good at his job. The negative effects of these apparently positive thoughts seems in these cases to lie in factors other than their realism or otherwise. There are two factors that might account for this: the specific memories related to the positive thoughts and the higher level meanings attached to the thoughts. In the first example, the positive cognition occurred in the context of the patient recalling a specific incident of arguing with his wife. His assertion of being a nice person did nothing to lessen the distress of recalling this painful experience. Rather, it served to increase his confusion and frustration. In this case, the specific memory associated with the positive thought was not consistent with its content. In other cases it may be that there is no accompanying specific memory at all. To have positive effects, positive thoughts need to be underpinned by access to specific experiences consistent with those thoughts. There is extensive evidence that depressed individuals have difficulty recalling specific memories, both positive and negative (e.g. Moore et al., 1988; Williams and Scott, 1988). This difficulty may partly arise out of behavioural avoidance, where individuals lead a restricted lifestyle, avoiding a broad range of different types of situations because of fear of a negative outcome. A consequence of such avoidance is that opportunities for positive experiences are restricted. On the other hand, some individuals may cope not by avoiding situations but by suppressing certain kinds of thoughts and the feelings that accompany them. Williams (1996) proposes that such an avoidant processing style develops when children who suffer negative events learn to process and recall such events in a generic, non-specific form as a means of controlling affect. This non-specific way of processing aversive experiences generalizes to all types of events and so positive experiences will also be processed in this generic way. Clinically, this avoidant processing style may manifest as patients easily being able to report that a certain positive event occurred but requiring considerable prompting to recall any specific details about the event that are relevant to its emotional tone. However, example 2 illustrates that being associated with specific supportive instances is not necessarily sufficient for a positive thought to have a positive effect. Person 2 was able to recall Copyright # 2000 John Wiley & Sons, Ltd.

A. K. MacLeod and R. Moore ample specific examples of being good at his job. Such examples and the assertion that he was good at his job did little to help him feel less depressed. This may have arisen because he had a view of himself as inadequate at some higher level in his cognitive system, a sense of inadequacy that was continually being reinforced by his feeling of depression. At times when he was not depressed, his good job performance was indeed enough to compensate for any latent sense of inadequacy. However, being depressed rendered the compensation inadequate and reflecting on his good performance made this patient feel more desperate. This higher level meaning is often described clinically in terms of a schema. From a theoretical perspective Teasdale and Barnard (1993) have distinguished between two levels of processing of meaning in the cognitive system: in addition to meanings that can be represented in terms of specific propositions, they describe an implicational level of processing that corresponds to a more generic, holistic level of meaning. Implicational meanings integrate sensorimotor and proprioceptive information along with specific propositional thoughts to represent a holistic sense or feeling. Teasdale and Barnard (1993) propose that it is meanings at the implicational level, rather than specific propositions, which can produce depressive affect. Although the patient in example 2 could endorse the specific proposition of being good at his job, it is possible that an implicational level meaning related to inadequacy remained active due to being maintained by sensory and propositional information about his depressed state. For positive cognition to have positive affective consequences, positive meanings at a higher schematic or implicational level will need to be activated. However, some individuals may lack the high level schemas or meanings that are necessary for effective positive cognition. Padesky (1994) has used the idea of self-prejudice to describe how this manifests as a tendency to ignore, dismiss, or discount potentially positive experiences. For example, a patient referred to one of the authors for depression appeared to be depressed because he believed he had failed an important exam. On subsequently hearing that he had passed the exam, he remained depressed as he was convinced that he had not deserved to pass. He did not seem to have available schemas or higher level meanings that would enable him to process effectively information related to his personal success and competence. We have suggested several criteria beyond the simple realism or accuracy of a thought which need Clin. Psychol. Psychother. 7, 1±10 (2000)

Positive Thinking, Well-being and Mental Health to be met for a positive cognition to be beneficial. Positive cognitions will have positive effects when they are associated with memories of specific experiences consistent with that thought and when the high level meanings attached to the positive cognitions are also positive.

IMPLICATIONS FOR THERAPY If positive cognitions are undermined by factors that detract from the specificity of information available in memory and that suggest a lack of positive schemas or high level, implicational meanings, how can psychological therapies effectively foster positive cognition? One way is by enhancing the likelihood of specific positive memories being available. We suggested earlier that behavioural and cognitive avoidance may limit the accessibility of specific memories. In combating behavioural avoidance behavioural techniques such as activity scheduling are important for increasing engagement in potentially pleasurable situations. Cognitive techniques may also be used to train patients to encode and access specific memories. From the outset in cognitive therapy patients are asked to monitor specific experiences through keeping activity schedules, monitoring levels of mastery and pleasure and recording thoughts at times of particular distress. Use of Socratic questioning also demands specific examples, evidence facts, details of who was there, what was going on, the precise things that were said, and so on. All these techniques have in common the requirement for patients to process specific memories and experiences. Even if the experiences being recalled are negative, there is less opportunity for information processing to remain in `depressive interlock' (Teasdale and Barnard, 1993). This refers to a state where high level depressive implicational meanings activate ruminative verbal propositions which, in turn, reinforce the high level meanings. Such a vicious cycle is self-perpetuating with little reference to additional internal or external information. When processing is frequently re-directed to specific memories and experiences, there is a likelihood that eventually a positive memory or experience will be hit upon. Although activation of a high level positive schema is not guaranteed, this processing of specific positive experiences will increase the chance of a positive affective shift. Thus, training patients to think more specifically may have positive effects. Copyright # 2000 John Wiley & Sons, Ltd.

7 However, even processing of specific positive memories will only result in positive affect when there are high level positive schemas or meanings available to the person. As already described, in some patients this does not appear to be the case. For people who seem to be deficient in these high level representations, therapy has to work to create the schemas required for assimilating specific positive experiences. This approach is the most explicit in attempting directly to foster positive cognition in cognitive therapy and has been developed most clearly by Christine Padesky (Padesky, 1994). Padesky (1994) suggests that where a patient has limited ability to process positive information at all, some groundwork needs to be done to help the patient establish a framework for processing positive information. Initial stages of working to build positive schemas involve helping the person to define what the schema means and to establish criteria for judging whether particular events reinforce that idea. Once this framework has been established the patient can work to collect examples of events that can build up the new idea. Patients are often asked to keep a positive data log of as many specific examples as possible that fit the new schema and often need considerable help from the therapist in recognizing suitable events. Where, perhaps as a result of the avoidance or other behaviours resulting from negative beliefs, the patient's life seems to be completely empty of experiences which could support the new schema, it can sometimes be helpful to get the patient to imagine themselves or certain experiences they might have in a way consistent with the new schema, before discussing how they could work toward bringing those experiences about. These techniques all involve trying to set in place some high level global meaning about the person or his or her life, but the durability of the new idea depends on then grounding it in specific details through imagination or discussion, which then leads on to encoding specific experiences in memory in association with the new idea. Such schema-focused techniques have concentrated on establishing high level meanings that are explicitly evaluatively positive. Some of the high level meanings that cognitive therapy may help to establish may be implicitly rather than explicitly positive. For example, therapy may help people to re-engage in valued activities and the associated high level meanings may reflect a sense of involvement or engagement without an explicit self-referential or evaluative slant. A further example of an implicitly positive meaning is the Clin. Psychol. Psychother. 7, 1±10 (2000)

8 development of mindful awareness of thoughts as thoughts, or meta-awareness (Moore, 1996). When they respond to therapy, some patients, rather than saying that they used to have negative thoughts but now view things differently, say things like `I still get the same thoughts but I can see it now', or `Now I know they are just thoughts'. This sense of thoughts as thoughts appears to be inherently positive for some people. We have argued that thoughts that are positive in content do not always have positive effects, but, conversely, positive cognitive processing does not have to be explicitly positive in content. In addition to techniques within traditional cognitive-behaviour therapy likely to enhance positive cognition and new developments within cognitive therapy aimed at fostering positive cognitions, there are beginning to emerge therapies that have as their explicit aim the task of improving positive well-being. In Bologna, Giovanni Fava and his colleagues have developed an approach they call well-being therapy (Fava et al., 1998; Fava, 1999b). The therapy is targeted at improving wellbeing in those who have recovered from depression, based on the rationale that absence of well-being will create vulnerability to relapse. The therapy is based on eight, fortnightly sessions and utilizes some traditional cognitive therapy techniques but with the focus on positive experiences and wellbeing. Diary-keeping is used to identify and contextualize episodes of well-being and also to identify thoughts and beliefs that prematurely interrupt well-being. Specific domains of wellbeing, such as purpose in life and personal growth, are assessed and sessions focus on rectifying areas where the person has any deficit. In a similar vein, Frisch (1998) has developed Quality of Life Therapy (QOLT) which focuses on increasing quality of life in a range of life domains, again using traditional techniques such as problem-solving, cognitive restructuring, pleasure scheduling, but with the focus on improving quality of life rather than tackling symptoms of disorder.

A. K. MacLeod and R. Moore operation of two separate psychological systems. The clear implication is that it becomes important to consider positive as well as negative aspects of experience in understanding health, and this includes positive cognitions. Absence of the positive is different from presence of the negative, and may be just as important. We have also reviewed evidence showing that positive experiences, including the way these experiences are processed, are important for mental health. Third, we have suggested ways of thinking about the adaptiveness of positive cognitions; specifically, positive cognitions will be helpful when they are linked to associated specific memories and when they relate to high level meanings about the self. Finally, we have discussed how positive cognitions might be accommodated within mainstream cognitive therapy and described several new therapeutic approaches that focus explicitly in improving well-being. Our aim has been to highlight the importance of positive aspects of experience and suggest possible applications to therapy, rather than to provide a comprehensive review of the literature and restrict ourselves to well-established findings. Research into positive cognitions is, in fact, relatively sparse, and a number of areas deserve further attention. There is considerable scope for introducing the role of positive cognitions into both models of psychological disorder and interventions for those disorders. There is also a clear need to understand more in the way of distinctions between different aspects or dimensions of positive experiences. In the area of well-being Ryff and colleagues have identified different dimensions of well-being, such as autonomy, environmental mastery, and positive relations with others. Fava et al. (1998) utilize these dimensions in their approach to well-being therapy but there is clearly a lot more scope for understanding psychological disorders in terms of different dimensions of positive experience. Finally, in terms of trying to understand the relationship between different levels of meaning, there is a need for better tools to discriminate at an empirical level what is a high level schema or implicational meaning from lower level propositions or thoughts.

CONCLUSIONS AND FUTURE RESEARCH We have outlined several reasons for why positive cognitions have been neglected in thinking and research about psychological disorders. In response to these reasons we have argued that there is strong evidence that positive and negative aspects of experience are best thought of as reflecting the Copyright # 2000 John Wiley & Sons, Ltd.

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