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Part I

Developing a Positive Clinical Psychology

The Wiley Handbook of Positive Clinical Psychology, edited by Alex M. Wood, and Judith Johnson, John Wiley & Sons, Incorporated, 2016. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/brenauuniv/detail.action?docID=4513033. Created from brenauuniv on 2023-09-25 06:07:39.

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Positive Clinical Psychology (PCP) is not new. As shown in chapters throughout this book, clinical psychology has a long history of incorporating the positive into clinical practice. From Maslow (1954) onward there have been calls to change clinical psychology to focus more on the positive in life, and even the term “positive clinical psychology” has been used in the past (see, e.g., Duckworth, Steen, & Seligman, 2005; Maddux, Chapter 2, this volume). What is new is the movement from wise but isolated calls, often from outside clinical psychology, to a real impetus for change from within. PCP is built around a clearly defined shared set of aims that are increasingly considered mainstream within the field. We set out our mission statement in a special issue of Clinical Psychology Review (Wood & Tarrier, 2010, as clarified in Johnson & Wood, in press). This has proved seminal to the acceptance in mainstream clinical psychology of calls to increase a focus on the “positive” alongside the “negative.” PCP, as we envision it, aims to change the discipline of clinical psychology into one “which has an integrated and equally weighted focus on both positive and negative functioning in all areas of research and practice” (Wood & Tarrier, 2010, p. 819). The distinctive feature of PCP is the emphasis on integration; PCP points out the illogicality and impossibility of studying only the “positive” or the “negative” in clinical psychology (or for that matter, in any discipline), and it seeks to better integrate research and practice toward a joint focus on both. We are staggered by how much this message has resonated amongst clinical psychologists in the last six years, including the expert contributors for this book, to whom we are very grateful for enthusiastically contributing outstanding chapters. This Handbook, the first of its kind, represents the culmination of six years of increasing acceptance of PCP. It is built on decades of scholarship from the contributors to this book and others, without whom the development of PCP would not be possible.

The purpose of this chapter is to provide an overview of the development of PCP and to overview the empirical and theoretical evidence as to why the movement is needed. This burgeoning area seeks to draw together the two fields of Positive Psychology and Clinical Psychology, which have generally developed independently of each other despite many convergences in research foci and aims. We suggest that further integration between positive and clinical psychologies could serve to advance the research, knowledge, goals, and practice of both. Our hope is that this book can contribute to this endeavor. We have been overawed by the responses we received from authors we approached to write on this topic for the book, each leaders in their field. As such, the book represents a bringing together of expert clinical psychologists, keen to consider how a recognition of the positive relates to their work, and the expert positive psychologists, keen to integrate their research with the wider clinical research base and move towards a PCP.

Positive Clinical Psychology An Introduction

Alex M. Wood and Judith Johnson

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4 Alex M. Wood and Judith Johnson

The Historical Development of Positive Clinical Psychology

Prior to the Second World War, psychology had the key aim of curing distress and fostering optimal functioning (see Linley, Joseph, Harrington, & Wood, 2006). In the immediate aftermath of the war, there was an urgent need within war‐torn countries to explain and address the psychological distress and trauma that the war had created. Within clinical psychology, there was a renewed focus on curing distress, particularly that related to trauma (later known as post‐traumatic stress disorder). Within social psychology, there was a focus on such topics as conformity that aimed to explain why the atrocities associated with the war had occurred. This was all valuable, and much needed, but it had two undesired side effects. First, it led to an over‐ focusing of psychology on distress and dysfunction. Second, and potentially more seriously, it led to distress and dysfunction becoming viewed as a discrete subject of enquiry, rather than as part of a broader enquiry into the full continuum of human functioning. In the United States, this process was accelerated by the development of the National Institute of Mental Health in 1947 (which exclusively focused on ill health) and the Veterans’ Administration in 1949. Both organizations funded excellent research and treatment, but by providing financial incentives (e.g., research grants) to study the dysfunctional side of the mental ill‐health continuum, there was perhaps too much encouragement for researchers to focus on these topics. Furthermore, the tendency of academics to teach in their areas of research is likely to have led this focus upon poor mental health and distress to be transferred to their students. As such, it can be seen how well‐ meaning and valuable funding into distress led to new generations of psychologists viewing the discipline of psychology as one focused upon maladaptive, rather than adaptive, functioning. As Abraham Maslow warned over half a century ago:

The science of psychology has been far more successful on the negative than on the positive side. It has revealed to us much about man’s shortcomings, his illness, his sins, but little about his poten tialities, his virtues, his achievable aspirations, or his full psychological height. It is as if psychology has voluntarily restricted itself to only half its rightful jurisdiction, and that, the darker, meaner half. (Maslow, 1954, p. 354)

This situation largely persisted throughout the latter half of twentieth century. A concerted attempt to reintroduce the “positive” into psychology arose from the positive psychology movement initiated by the American Psychological Association (APA) President Martin Seligman, with his joint special issue and the accompanying influential editorial (Seligman & Csikszentmihalyi, 2000). This, and the ensuing movement, had a huge impact on psychology in a very short space of time, with millions of dollars in funding, the development of new psychotherapeutic techniques, specialist masters courses across the world, and several special issues of journals and handbooks (see Linley et al., 2006). A quantitative bibliometric analysis (Rusk & Waters, 2013) charted the growth of positive psychology, showing that 18,000 papers linked to positive psychology topics have been published, and that there has been a steady year‐on‐year increase in the number of publications. In their 2011 census year, there were 2,300 papers published, representing 4% of those indexed by the representative PsychInfo® database. If these papers were classed together as a field, they would be at the median of disciplines indexed in the Journal Citation Reports®, and the 2011 impact factor would be 2.64, showing that the number of citations to the papers would respectably rank amongst other academic fields. The increase in number of papers was seen in each field in which the papers were published, including psychology (and all sub‐areas), psychiatry, sports science, business, and management. This quantitative analysis showed that positive psychology can no longer be considered a minority or fringe endeavor.

The uncontroversial message from positive psychology was that psychology (and other fields) must consider the positive as well as the negative. The movement can be credited with raising the profile of topics that are considered “positive,” and making them as likely to receive funding

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Positive Clinical Psychology: An Introduction 5

and to be published as those considered “negative.” However, in the intervening years since the initial rush of enthusiasm, and despite the ever‐growing impact of the field, the wider field of psychology has arguably become somewhat ambivalent about positive psychology (see Wood, et al., in press), and many critical pieces have been written against the movement (e.g., Bohart, 2002; Lazarus, 2003; Tennen & Affleck, 2003; Held, 2004; Coyne & Tennen, 2010; Coyne, Tennen, & Ranchor, 2010).

Perhaps one reason for this ambivalence within wider psychology relates to the movement’s lack of clear aims. The most distinguishable goal of the movement was that psychology should focus more upon the positive, a message which most psychologists endorsed. However, this perhaps led to a growing tension between those who wanted to integrate the study of the positive and the negative, and those who wanted to create a separatist field of positive psychology. Notably, Rusk’s and Water’s (2013) bibliometric analysis focused on papers on positive psychology topics, but many of these would not have been self‐identified as “positive psychology”; they were just seen by the authors as “psychology.” The growth of the study of positive psychology topics is undeniable. The nature of the “movement,” whether there is even still a movement, the aims of this movement, and its consequences are more controversial. A separation (not often made by critics) needs to be clearly made between the research on topics associated with positive psychology (which, other than isolated examples, attract no more criticism than other areas of psychology) and a possible straw man of a positive psychology movement. It is on the latter most criticisms have been leveled.

The critical narrative around the positive psychology movement often seems to be dominated by concerns of separatism, with “positive” research and interventions sometimes seen to be developing in isolation from the wider literature. It could be argued that this branding of positive approaches within “positive psychology” helped to raise their profile and served to highlight the importance of their study. However, we would suggest that any separation between positive psychology and other fields – particularly from clinical psychology – comes at the cost of the advancement of each. Both positive and clinical psychology research psychological treatments, often in similar groups (e.g., those with depression), but sometimes independently and without either fully recognizing or utilizing the findings of the other. In failing to acknowledge the full influence from clinical psychology research, the positive psychology movement has failed to fulfil its full potential to influence clinical psychology in return. PCP aims to address these concerns through transforming the discipline of clinical psychology into one that equally studies and intervenes in topics branded as “positive” or “negative.” It is designed to utilize the great scholarship within positive psychology to the full effect within clinical psychology by making it inseparably a part of the fabric of the field.

The development of PCP is also aimed to help positive psychology research more broadly by making it accessible to new audiences and addressing some of the previous criticisms. Perhaps if there had been a greater focus on the message of those within positive psychology movement seeking to integrate positive with the negative (e.g., Joseph & Linley, 2006a,b), then greater advances would already have been made toward building a more holistic psychology. The danger that the positive psychology movement faces is that it will be dominated by a different separatist message, the content of which seems to be leading to a growing consternation in wider psychology, including clinical psychology, where it is in some quarters seen as being a research‐lite “happiology.” Whether or not this characterization is appropriate is moot; the perception itself is hampering attempts to focus clinical psychology more on the positive.

Through promoting a fundamentally integrative message between positive and clinical psychologies, between the focus on maladaptive and adaptive functioning, this Handbook aims to help positive psychology regain its true vision of a holistic and balanced psychology, through showing common ground between different approaches and fundamentally challenging any separatist message with conceptual, evidential, and pragmatic arguments. We also seek to address the (often unfair) criticisms of positive psychology that have been raised.

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6 Alex M. Wood and Judith Johnson

Criticisms of Positive Psychology

Several concerns were raised about positive psychology, in addition to the increasingly perceived separatist message. First, the original paper (Seligman & Csikszentmihalyi, 2000) included factually untrue statements about humanistic psychology lacking an evidence base. This was particu larly unfortunate considering the similarities in the goals of both fields (see the Maslow quote above). This avoided the opportunity to engage with the very community that may have been most supportive to the integrative aim of positive psychology (see Sanders and Joseph, Chapter 28, this volume, for the fit between positive and humanistic approaches). With PCP we aim to rebuild bridges between communities, and some of the chapters in this book are dedicated to showing how many areas are already incorporating what may be classed otherwise as positive psychology.

Second, the quality of the research in the field was questioned from inception (e.g., Lazarus, 2003). This was probably an unfair criticism as: (a) the complaints often overgeneralized from isolated examples of research in the field; (b) many of the criticisms (e.g., a reliance on self‐ report) apply to psychology as a whole; and (c) the critiques did not recognize that the research methods that were being criticized were often commensurate with the developmental stage of research into new topics (e.g., showing correlation before causation). Nevertheless, PCP needs to hold itself to the highest level of methodological account, building on the increasing refinement within positive psychology and the best clinical psychology practice.

Third, there are concerns that there has perhaps been an overwillingness to put positive psychology research into practice before interventions are tested to the same level as clinical interventions. In our opinion, the flaws highlighted in the second and third criticisms may have been due to the foundations of the movement in personality psychology. Indeed, most positive psychologists had begun as personality psychologists, and the studies that they designed to test interventions were based on common designs for proof of concept studies published in top rated personality journals. Here, the interest is in showing a potentially causal impact of a characteristic rather than providing a full interventional trial. Whilst this was often appropriate for the research questions in the original publications, this strategy became problematic and potentially dangerous when this evidence base (and not a clinical trial) was used to make recommendations for interventions. In part, this reflected a poor tendency amongst psychology researchers in general, reinforced by journal reviewers, to make “practical recommendations” as part of the discussion in a research study. From a proof of concept study, such recommendations should not go beyond suggesting that a clinical trial be conducted. However, the claim is that the tendency has instead been to overspeculate about the implications of the findings. In some cases this has involved claiming that a study with undergraduate participants, and no follow‐up, was a basis for recommending a therapeutic approach. There has also been more general concern about how the media reporting of scientific studies make claims that go beyond the evidence base, which seems to originate from the press release of the institution (Sumner et al., 2014). The early proof of concept studies within positive psychology have been seminal in suggesting what might work (analogous to the early stages of a drug trial), and there now needs to be more full clinical trials that completely test interventions using the clinical psychology methods that have emerged from the best practice within medicine. The increased linkage that this Handbook seeks to provide between positive and clinical psychologists is hoped to help build the multidisciplinary teams that this kind of work will require.

Possibly these three criticisms of positive psychology culminated in the attraction to the field of untrained, unaccredited, and unregulated “positive psychology coaches.” This development has been particularly harmful to the field of psychology, as whilst such a title is unprotected, and essentially meaningless, it seems to infer that psychology has leant its credibility and regulatory procedures to this “profession.” Claimants of this approach have been keen to stress the “scientific basis” of their studies (which have usually been the proof of concept studies within personality psychology journals, at best). As might have been predicted, there has been a backlash

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Positive Clinical Psychology: An Introduction 7

against this approach, and this backlash has not been confined simply to positive psychology. To the wider population not familiar with the distinction between “positive psychology” and “clinical psychology,” both psychologies have been at risk of being discredited. Unsurprisingly, it seems that this has led to some resentment amongst clinical psychologists of their positive psychology colleagues. PCP aims to utilize the existing regulatory frameworks within clinical psychology to provide public assurance of safety of interventions and thus increase their acceptabil ity and usability amongst many communities, including amongst those who are most vulnerable.

We stress that many of these criticisms are concerns for psychology at large, and that they are perhaps unfair characterizations of positive psychology. However, irrespective of whether one accepts them with regard to positive psychology, it seems apt to raise them here as PCP must avoid these pitfalls and characterizations. We stress that we are positive psychologists, in the sense of promoting an integrative message between studying both the positive and the negative, and that we both work and publish within both positive and clinical psychology. Our emphasis here on criticisms of positive psychology is simply based on our desire to be aware of the (real or imagined) pitfalls of the movement and to ensure that these do not reoccur with PCP.

The PCP Solution

PCP aims to address the separatist criticism of positive psychology and redress any imbalanced focus on either the “positive” or “negative” in both positive and clinical psychologies in order to promote a more fully integrative field of psychology. Incorporating the strengths of positive psychology, and responding to the criticisms, PCP aims to develop a field where adaptive and maladaptive func tioning are considered holistically, as inseparable, and as deserving of an equal amount of attention in both research and practice. It aims, at least within a clinical setting, to reset the positive psycho logy movement, having it originate from within clinical psychology. PCPs aim is that positive psychology will not be (or be seen to be) a separatist endeavor, but would instead both influence and work with the existing field of clinical psychology. The potential benefits of this approach are considerable and bidirectional between positive and clinical psychology. These benefits include:

1 The attraction of a new population of researchers and practitioners to work on the integration of maladaptive and adaptive functioning.

2 The likely attraction of those with a healthy degree of skepticism about the value of studying adaptive functioning. Having such critics on board will help maintain credibility and the focus on trying to disprove the importance of the “positive,” in line with how positivistic science should be conducted. Where such attempts to disprove the hypotheses fail, we can have more confidence in the research base.

3 The influence on positive psychology of clinical psychology standards of what is deemed optimum interventional research. As clinical psychology standards have arisen in part from medicine, they tend to be of a higher standard than the proof of concept studies within personality psychology. For example, clinical journals are moving towards requiring that trials involve: (a) pre‐trial registration; (b) a sample from the population to which the authors generalize; (c) use of best practice CONSORT guidelines for the conduct of clinical trials; (d) adequately powered designs; (e) proper and active control groups; (f ) avoidance of demand characteristics with steps in place to prevent selection effects (e.g., where those interested in positive psychology are most likely to take part); (g) replication; and (h) conclusions that do not go beyond the data. Positive psychology has much to offer such trials, including highly novel ways of viewing mental health, its correlates, antecedents, and consequences. As such, an integration of both these fields is likely to lead to a raising of research standards in both, and more generally we do strongly encourage researchers in all fields to adopt these best practice approaches.

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8 Alex M. Wood and Judith Johnson

4 The well‐established accreditation and regulation procedures to safeguard client well‐being within clinical psychology, which can be used to ensure that positive psychology interventions are given to the most vulnerable people by the most appropriately trained and accountable practitioners.

5 Overall, the key aim of PCP is to engender a change within clinical psychology, so that the field examines functioning holistically, at both the adaptive and maladaptive end, and makes use of a full range of treatment techniques – including those from traditional and positive psychology – in a balanced manner to individual client need.

Why Do We Need a Positive Clinical Psychology?

In many ways, all chapters within this Handbook are focused on stating the need for PCP. Each author was asked – interpreting the question and issues as they chose – to consider whether the “positive” and “negative” should be considered together by clinical psychologists with respect to their expert topic area. Although a selected and self‐selecting group, it notable that not a single author concluded that they should not. The book is organized into five parts, which largely correspond to the topics forming the argument for PCP: “Developing a Positive Clinical Psychology,” “Personality and Individual Differences,” “Disorders,” “Positive Psychology Interventions in Clinical Practice,” and “Reinterpreting Existing Therapies.” We highlight and integrate the core arguments for PCP from across the book here.

Characteristics Are on a Continuum from Low to High

As we have previously argued (Joseph & Wood, 2010; Johnson, Wood, Gooding, & Tarrier, 2011; Johnson & Wood, in press) and discussed by Joseph and Patterson (Chapter 4, this volume), a simple fact that has been ignored by both the positive and clinical psychology communities is that all characteristics range from low to high. Consider the traits that Peterson and Seligman (2004) highlight in the “Values in Action” (VIA) project, which they consider “virtues.” These included humility, fairness, kindness, integrity, gratitude, optimism, open‐mindedness, and (one assumes high) social intelligence. A moment’s reflection shows that each of these is on continua from arrogance to humility, unfairness to fairness, unkindness to kindness, dishonesty to integrity, ingratitude to gratitude, pessimism to optimism, closed‐ to open‐mindedness, low to high social intelligence. Obviously, one cannot say the whole continuum is positive; rather, researchers seem to simply be referring to the “high end.” It then becomes theoretically nonsensical for a field to focus only on the high end of a continuum, and even more so to write papers as if the other half of the continuum did not exist. It is no less a mistake to focus on only the low end of a continuum and write papers as if the high end does not exist.

To claim that positive psychologists are normally studying anything other than the high end of a bipolar continuum would be inconsistent with both the methods and the findings of the field. Normally the characteristics are studied with self‐report scales that include items that are reverse coded prior to analysis. Thus, for example, the GQ6 measure of gratitude includes items measuring ingratitude, and the scale has been shown to be a single continuum (McCullough, Emmons, & Tsang, 2002). The same can be said for most of the measures in positive psychology. Indeed, when the “positive psychology” scales were developed, given that there was generally a balance of positively and negatively worded items (or should have been with normal psychometric practice), it was an arbitrary choice which of the items to reverse code. The gratitude scales, for example, could equally be called ingratitude scales if the arbitrary decision to recode the ingratitude items had not been made in favor of the equally arbitrary decision to recode the gratitude items.

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Positive Clinical Psychology: An Introduction 9

In such a case, it would be called the ingratitude scale, although it would be the same scale. At the moment we have the absurd situation where if one codes the scales in one direction it can go to a positive psychology journal, and if one codes it the other it can go to a clinical psychology journal.

Johnson (Chapter 6) considers the implications of not realizing that constructs are on a continuum from high to low with respect to the literature on resilience, where it has been typical to take the same characteristic (such as social support) and call low levels risk and high levels resilience (Johnson, Gooding, Wood, and Tarrier, 2010). With these definitions, the construct of resilience is meaningless as it is just a word for low risk. Instead, this chapter proposes that resilience lies in the particular interaction between two characteristics. Each characteristic (the resilience variable and the risk variable) goes from low to high, but the interaction between the two contributes more than the sum of its parts (e.g., the presence of high levels of one mitigates low levels of another). This model has previously been used to explain resilience to suicide in both non‐ clinical populations (where coping self‐efficacy moderates the impact of negative life events; Johnson et al., 2010) and clinical populations (where coping self‐efficacy moderates the effect of hopelessness; Johnson, Gooding, Wood, Taylor, Pratt, and Tarrier, 2010).

It seems, then, that some positive psychologists have failed to recognize that factors fall on a continuum from high to low, and as such, they have failed to recognize where their research studies the “negative.” However, clinical psychologists have also fallen into this trap. For example, assessment of global functioning is often included as part of a diagnostic assessment of clinical disorders, and functioning ranges from highly impaired to superior. As such, clinical psychologists are in fact already measuring the “positive,” often without fully acknowledging this. Furthermore, given concerns about the scientific basis and usefulness of the diagnostic categories in general, there have been calls to replace these with a greater focus on global functioning. James Maddux (Chapter 2) makes a powerful argument as to how the focus on continua of functioning within PCP can help depathologize and destigmatize mental illness, by moving the focus away from “mental illness” and instead toward “wellness,” a continuum upon which we all exist.

Some measures of global functioning might include “subjective well‐being” (SWB) and “psychological well‐being” (PWB). As discussed by Joseph and Patterson (Chapter 4), SWB is a higher‐order factor comprising positive affect, negative affect, and satisfaction with life. Ruini and Ryff provide a chapter on PWB (Chapter 11), which they see as comprising self‐acceptance, positive relationships with others, purpose in life, environmental mastery, and autonomy. It is important to realize that the higher‐order constructs of both SWB and PWB are continua ranging from low to high. Specifically, SWB ranges from low positive effect, high negative effect, and low life satis faction to high positive effect, low negative effect, and high life satisfaction. PWB ranges from self‐rejection, impaired relationship with others, purposelessness, environmental incompetence, and subjugation to self‐acceptance, positive relationships with others, purpose in life, environ mental mastery, and autonomy. Clearly, neither SWB nor PWB are inherently positive, but rather two very different ways of conceptualizing continua of functioning (and in the measurement of both, commonly positively and negatively worded items are used to measure both sides of the con tinuum). As they measure different conceptions of well‐being, each as full continua, they will be somewhat factorially distinct not because one is positive and the other negative, but simply because they are assessing different forms of functioning. The factorial distinctiveness is shown in a large body of work (e.g., Linley Maltby, Wood, Osborn, and Hurling, 2009). Interestingly, these two higher‐order factors are very highly correlated (at around r = .76; Linley et al., 2009), which fits in with what Joseph and Patterson (Chapter 4) present as a humanistic meta‐theory. This theory suggests that people do not generally feel good (high SWB) whilst behaving in a personally and socially destructive manner (low PWB; as expanded upon by Pete Sanders and Stephen Joseph in Chapter 28), although these factors are still factorially distinct.

The factorial distinctiveness between SWB and PWB has caused much confusion in the field and has worked against the integration that PCP proposes. For example, Westerhof and Keyes

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10 Alex M. Wood and Judith Johnson

(2010) influentially argue for a dual‐continuum model of mental health, consisting of ill‐being and positive functioning. This is based on SWB and PWB being two (highly correlated but) separate factors. As discussed in Johnson and Wood (in press), their interpretation misses the point that both SWB and PWB are bipolar continua from high to low, and that they are simply measuring different concepts. Thus, one may talk about dual‐continua in the sense of our need to assess more than one kind of functioning, but one cannot claim one is positive and the other negative, and to do so directly goes against the integration that we are trying to promote. This obvious although influential error of interpretation has hindered the development of PCP (although we value the author’s contributions to the popularization of the important PWB concept). With Westerhof and Keyes (and Maddux, Chapter 2), we would support a shift away from a sole focus on diagnostic categories toward a larger focus on global assessment, and we agree that SWB and PWB are a good starting point. However, it is critical to have a balanced, holistic, and accurate field that recognizes the fact that each factor ranges from high to low.

Global functioning is one area in which clinical psychologists are already intuitively imple menting the core PCP recommendation to focus on full continua from maladaptive to adaptive functioning (even if the implications of this are not normally considered). However, there is a second area in which this is already occurring which is more subtle and even less acknowledged. Almost all clinical disorders, or the processes that underlie them, range from maladaptive to adaptive. Wood, Taylor and Joseph (2010) have shown this directly with respect to depression. This was based on the observation that the Center for Epidemiological Studies Depression (CES‐D) scale (one of the five most used) includes both normal depression items as well as reverse coded ones such as “I am happy.” Clearly, then, on the logic above, this can be said to measure a continuum from depression to “happiness.” The factor analyses reported in that paper support the view that these items comprise a single continuum. Similarly, Siddaway, Taylor, and Wood (2016) have investigated the State‐Trait Anxiety Inventory (STAI), which again has items measuring both anxiety and reverse coded items measuring calmness, and which also we find form a single continuum. As highlighted by Wood and Joseph (2010), work on depression or anxiety that has used these measures is probably already in line with PCP, as a full continuum of well‐being has already been measured. It is simply an error of interpretation that has led to this not being recognized.

Despite our work having shown that the CES‐D measures a continuum from depression to happiness, and the STAI from anxiety to calmness, we prefer not to see the constructs in such simplistic terms (and the use of the word “happiness” is particularly problematic, as this is a deep philosophical issue, and what defines happiness is possibly the choice of the individual). Instead, we would suggest that the findings emerge as it is the forms of functioning underlying the diagnostic criteria for mental disorders that range from adaptive to maladaptive. For example, most diagnostic criteria for depression involves high negative affect, low positive affect (anhedonia), lack of engagement, poor sleep, impaired appetite, and poor social relationships. Each of these is clearly on continua from maladaptive to adaptive; respectively, low negative affect, high positive affect, engagement, good sleep, appropriate eating, and good social relationships. Thus, irrespective of our results of studies analyzing depression questionnaires, the criteria on which the construct of depression is based can be said to logically range from maladaptive to adaptive. The same can be said of nearly all mental disorders.

The approach of focusing on the full continuum of the process underlying mental disorders allows for even the most categorical appearing disorders to be seen as existing on a maladaptive to adaptive continuum, consistent with PCP. Thomas Widger (Chapter 18) makes this argument with respect to personality disorders. These disorders are amongst those most frequently viewed as dichotomously “present” or “absent” in the mental health literature (indeed, they are often referred to as “categorical disorders”). In contrast, Widger shows that they arise from particular extreme “normal” personality continua, each of which range from high to low. His model of personality is the Five Factor model, which focuses on the observable psychological differences

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Positive Clinical Psychology: An Introduction 11

between people. It arose from factor analyzing responses to sets of person adjectives sourced from representative dictionaries (excluding skills or not‐psychological differences), and thus represents the basic differences in behavioral propensities between people. Treatment, from a PCP perspective, should not then focus on removing the categorical disorder (which turns out to be epiphenomena of the personality process), but rather helping the individual change their levels of behavioral propensities toward what is most adaptive in their lives. Quite how this may be done is shown by Christopher Taylor and Arnoud Arntz (Chapter 30) who make the same argument, but focus on another definition of personality; the particular schematic beliefs about the world which lead to these behavioral propensities. Referring to the work of Lockwood and Perris (2012), they argue that parenting and early life conditions (ranging from traumatic to optimum) lead to needs being met to varying degrees, which in turn leads to eighteen schematic ways of viewing the world (each of which ranges from maladaptive to adaptive). With these additions to Schema Therapy there is an approach with the potential to be an ideal PCP therapy, with the aim of helping all clients move toward the adaptive end of each of the core schemas. The theory would predict that in such a case not only would personality disorders be removed (which arise from certain constellation of schemas), but rather all other psychopathology, and indeed this would foster full psychological development.

Central to our argument for the need for a PCP are the observations that (a) most of the concepts studied by positive psychologists range from low to high, and (b) most of the topics of study for clinical psychologists are equally on continua from maladaptive to adaptive. It is not logical, and perhaps not even possible, to study only half of a continuum. If we have seemed critical here, it is only in order to promote a joining of clinical and positive psychologies into one holistic discipline to better understand and help people.

No Characteristic is “Positive” or “Negative”

In her inimitable style, Barbara Held (Chapter 3) has chosen as her focus a critique of one of our own papers, the editorial paper of the special issue on PCP (Wood & Tarrier, 2010). A prominent “positive psychology critic,” she shows her trademark authenticity, and her critique is much needed and welcome. Whilst endorsing the rationale above that all characteristics range from low to high, Held thinks that we should go further in our criticism of a sole focus on the “positive” or “negative.”

Held highlights a core reason of why PCP is needed, namely, that neither the low or high end of any characteristic is inherently “positive” or “negative,” as nothing is good for everyone all of the time. She suggests that we should instead consider where something is adaptive for individual clients in individual situations. Optimism, for example, is considered a “positive psychology” characteristic, and it is generally positively linked to well‐being, although it can also lead to overly risky behavior. Conversely, for some individuals “defensive pessimism” is constructive. In previous work, Boyce, Wood, and Brown (2010) focused on how conscientiousness, a trait generally seen as adaptive for everything from well‐being to team performance, becomes maladaptive and leads to greater decreases in life satisfaction following unemployment. Wood, Emmons, Algoe, Froh, Lambert, and Watkins, Chapter 10, this volume, argue that “gratitude” can in some situations be mal adaptive, as when it is inappropriately placed (such as toward an abuser, or when it is being used by a power elite to keep a population subjugated). Warren Mansell explores these issues with respect to bipolar disorder in Chapter 16, arguing that there is nothing inherently negative about any level of the positive or negative moods that characterize the disorder, but rather that problems emerge with how these conflict with each other and the other goals of the individual. Eamonn Ferguson (Chapter 8) shows how high levels of empathy are not indiscriminately desirable, noting that psychopaths have high levels of some kinds of empathy whilst being notably deficient in others. Furthermore, Sedikides and Wildschut (Chapter 9) explore the bittersweet nuances of nostalgia, also a factor, they argue, which is not wholly “positive” at either the high or low end.

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12 Alex M. Wood and Judith Johnson

Thus, even accepting the point above, that most characteristics range from low to high, we cannot then say that the high (or for that matter, the low), are desirable, as this would be an overgeneralization. Indeed, Aristotle (350 bc/1999) wrote the most conclusive work on virtues, which was based around culturally valued characteristics, and he was very explicit that (a) the behavior associated with the characteristic ranged from low to high, and (b) both too high and too low levels of the characteristics are unvirtuous (lit. vicious). Rather, the virtue (and desirability) lies within situationally appropriate displays of the correct level between these two extremes. Thus, views about the future may be said to range from dysfunctionally strong pes simism, to an appropriate point, to a Pollyanna‐like dysfunctional expectation of constant positive outcomes. Deviations from the situationally appropriate point in either direction may lead to inappropriate actions. Where this appropriate point lies will depend on the situation and other characteristics of the person, and where the point lies on the continuum would vary between the two extreme poles between individuals or in different situations. This wisdom is consistent with Held’s account.

To Held’s points, we would like to make a brief response, as we believe that the issues she raises need to be prominently and directly considered by PCP. First, in response to her suggestion that talking about when something is adaptive or maladaptive is of the utmost importance, we agree, but suggest that to make this claim there first needs to be a wider acceptance of the PCP premise that all factors exist on a continuum (from high to low). Only with this in place can it be considered in what situations and for whom different points along the continuum are most adaptive. Second, she correctly chastises errors in our earlier paper (Wood & Tarrier, 2010) in which we, on the one hand, suggested that all factors exist on a continuum from high to low, and, on the other hand, referred to constructs popularized by positive psychology (like gratitude) as “positive,” in direct opposition to the former point. We correct and discuss this extensively in Johnson and Wood (in press). Essentially, the point we raise here is that whilst the constructs studied by positive psychologists cannot be described as “positive” (or those by clinical psy chologists described as “negative”), the characteristics studied by positive psychologists are qualitatively different traits than those typically studied by clinical psychologists. That is, where positive psychology research has often investigated personality characteristics such as gratitude, optimism or self‐efficacy, traditional clinical psychology has tended to focus more upon cognitive and symptom‐related variables. As such, there may be value in considering both sets of characteristics. We hope that these responses address some of Held’s criticisms of PCP, and look forward to future dialogue with critics of PCP. We suggest that it is only through welcoming contributions like Held’s that PCP can be ultimately be successful, useful, and accurate, and avoid the allegations of isolationist and unscientific practice sometimes leveled at certain parts of the positive psychology movement.

If we accept the argument that high (or low) levels of characteristics are not always adaptive for all people, then there are three implications as to why we need PCP. First, it is meaningless for one field to study some characteristics and another field to study others on the basis that some are “positive” and the others “negative,” as whether any variable is “positive” or “negative” will depend upon the individual and the context. The designation of what is positive and negative is also sometimes more of a value judgment of the researchers than being rooted in science, philosophy, or objective reality.

Second, individual case conceptualizations should consider an individual’s life holistically – examining characteristics that are generally seen as “good” or “bad” – whilst keeping an open mind as to the role of these in the particular client’s life, given their biology, early experiences, life history, current environment, and constellations of traits, attitudes, and functioning levels. Only through a PCP approach, where the need for such a holistic approach is emphasized, does this true integration become possible.

Third, interventional techniques – from both traditional and positive psychology – that may be helpful to one client may be harmful for another. Again, we draw on our recent work in

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Positive Clinical Psychology: An Introduction 13

personality psychology showing that personality interacts with situation (e.g., Boyce and Wood, 2011a,b), so one cannot just promote any one thing out of context. This shows the need for PCP in that clinicians need to be aware of the full range of techniques, in order to match the best technique with the individual client. Geraghty, Wood, and Hyland (2010a,b), for example, show that in one specific situation (online interventions where drop‐out is expected to be high) a technique based on increasing gratitude is as effective on the presenting problem, and results in lower drop‐out than automatic thought monitoring and changing. However, as argued by Wood et al., Chapter 10, this volume, on gratitude, there is the potential for carelessly administered gratitude techniques in some situations to be harmful (as where a person is already excessively subjugating their needs to an abusive other, and incorrectly uses the intervention to deepen this problem). The key message is that we have to move away from talking about characteristics as positive or negative, even if this is their impact on average, and rather consider the role of – and advisability of fostering – any characteristic for the specific client. And to do this, we have to stop arbitrarily focusing on one or other, and certainly stop situating the two in separate fields of study, based more on history and value judgments than reality.

Much more work is needed to establish the optimum point on various characteristics. Statistically, Aristotle’s argument implies an inverted “U” relationship between the behaviors underlying virtuous characteristics and their outcomes, where high and low levels are maladap tive and some point in the middle is optimum. Whilst the assumption of linear relationships is tested as a matter of course in fields like economics, this is very rarely seen in psychology. In contrast, it rarely seems to occur to psychological researchers to check that linear regression is appropriate, except in the unusual cases when this is the whole hypothesis under consideration, even though there are very well‐known cases of non‐linearity effects in the well‐being literature (such as adaptation: Boyce and Wood, 2011b). A prominent counterexample to our case here is Park, Peterson, and Seligman (2004), who show that there is a linear relationship between the VIA characteristics and life satisfaction (ruling out inverted “U”s or other nonlinearities appropriately). There are, however, three answers to this.

First, the predictors themselves must actually measure the full continuum of the characteristic. Self‐report of highly socially desirable characteristics (that they call virtues) will likely share high method variance with life satisfaction as outcome, so it is perhaps not surprising that people who say they are extremely high on modesty might also say they are very satisfied with their lives.

Second, by accident or by design the predictors may not be intended to ask about a full continuum of behavior, but rather the extent to which those behaviors are displayed in a moderate or situationally appropriate manner. In this case, we would expect a linear relationship between the measure and healthy functioning, as the focus on the moderation and situational appropriateness avoids the high end of the measure picking up dysfunctionally immoderate and excessive displays of the underlying behavior. This type of measurement may well be appropriate for many a usage, but precludes an Aristotelean‐influenced test of nonlinearities, which would require a measurement of the full continuum of the underlying behaviors. Also, the outcomes must be the appropriate ones. For example, it is quite possible that increasing levels of a characteristic are related to a sense of smugness that is captured by life satisfaction, but that the individual is still not living a good life (under various socially held definitions of the “good life”). Analogically, it has been observed clinically that part of the problem with treating personality disorders is that a sense of entitlement feels good and individuals are not motivated to change until they see how it is destructive to other areas of their lives (i.e., until they change their out come measure from life satisfaction to something else). Future work in PCP will have to address this directly.

Third, we believe that some characteristics are by their nature always more positive as one moves up the continuum (which is why, after considering Held’s points, we retain the language “maladaptive” and “adaptive” in places within this chapter). If one accepts certain humanistic assumptions about human nature (described by Sanders and Joseph in Chapter 28), then movement

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toward core nature may always be seen as positive. To the extent that Taylor and Arntz (Chapter 30) correctly identify these, movement from maladaptive to adaptive ends of schemas will always be positive. Here, however, we show our core assumptions of humanity and with which, whilst unavoidable in clinical practice (Wood & Joseph, 2007), readers are free to disagree.

Positive Psychology Characteristics have Incremental Validity in Predicting Clinical Distress

With the qualification above that the characteristics studied by positive psychologists are not inher ently positive, there remains huge evidence that the characteristics that they highlight are novel to psychology, and the topics of study of positive psychologists have incremental validity in predicting clinical outcomes beyond what has previously been studied. Taking gratitude (Wood, Froh, & Geraghty, 2010; Wood et al., Chapter 10, this volume) as an example, it substantially predicts both life satisfaction (Wood, Joseph, & Maltby, 2008) and PWB (Wood, Joseph, & Maltby, 2009) above each of the thirty facets of the NEO‐PI R measure of the Big Five, which incorporate the most commonly studied traits in psychology as a whole and are meant to be an exhaustive com pilation. Notably, the NEO includes individual trait measurement of trait levels of the clinical characteristics of anxiety, stress, depression, vulnerability, and impulsivity. Gratitude also longi tudinally predicts decreases in depression (and concomitant increases in happiness), decreases in stress, and increases in perceptions of social support, again beyond the Big Five (Wood, Maltby, Gillett, Linley, & Joseph, 2008). Finally, gratitude predicts improved quality of sleep, also beyond the Big Five (Wood, Joseph, Lloyd, and Atkins, 2009). Whilst there is nothing inherently positive about a characteristic that ranges from ingratitude to gratitude (but see our language clarifications in Chapter 10), it is clearly a measure originating from the field of positive psychology that is cap turing something new to psychology and that has considerable clinical relevance. Much of Parts II and III of this book on individual differences and disorders, respectively, are dedicated to making these arguments, including contributions from David Watson on positive affect (Chapter 5), James Maddux and Evan Kleiman on self‐efficacy (Chapter 7), Adam Davidson and George Valliant on understudied characteristics in positive ageing (Chapter 12), and Chiara Ruini and Carol Ryff on PWB (Chapter 11). Philip Watkins and Andrew Pereira discuss the role of positive psychological characteristics in anxiety (Chapter 14), and Peter Taylor in the context of childhood disorders (Chapter 19). The absence of positive mood and expectations are explored by Barney Dunn and Henrietta Roberts in relation to depression (Chapter 13), and in relation to suicide by Andrew MacLeod (Chapter 20). Finally, Elizabeth Addington, Richard Tedeschi, and Lawrence Calhoun (Chapter 15) consider the importance of focusing on growth in response to trauma rather than just suffering. Although we do not see the characteristics studied by positive psychologists as always wholly “positive,” we do see them as highly understudied and of great utility to clinical psychology theory and practice (Johnson & Wood, in press), as each of these chapters highlight.

Positive Psychology Techniques have Potential to be Used in Clinical Practice

Part IV considers specific techniques that have developed from, or are associated with, positive psy chology and their application to clinical psychology. Five are deigned to be fully‐fledged therapies: positive psychotherapy (Tayyab Rashid, Chapter 22); forgiveness therapy (Everett Worthington et al., Chapter 24); mindfulness (Shauna Shapiro, Sarah de Sousa and Carley Hauck, Chapter 25); well‐being therapy (Giovanni Fava, Chapter 26); and quality of life therapy (Michael Frisch, Chapter 27). Each has the potential to be a positive clinical therapy, as although they developed based on the learnings of positive psychology, they remain grounded in traditional therapeutic approaches, keeping a holistic core. As the authors acknowledge, with the exception of mindfulness, the evidence base is still preliminary for these relative to traditional approaches. Nevertheless, each shows promise

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Positive Clinical Psychology: An Introduction 15

and has early supportive evidence. It is hoped that their inclusion here will encourage attention to these highly novel approaches and motivate (and help fund) more multicenter randomized control trials, conducted to the highest standards. In future these therapies may routinely replace more traditional approaches, although further research studies will need to assess which, if any, will amass that evidence base. We hope that they will. For now, they are promising and interesting therapies raising issues that all therapists should consider. Finally, two chapters provide excellent overviews of the specific techniques to have emerged from positive psychology (positive psychological approaches, Acacia Parks and Liudmila Titova, Chapter 21, and positive activities and interventions, Lilian Shin and Sonja Lyubomirsky, Chapter 23). We believe that these positive activities have particular potential to be incorporated into existing clinical psychology therapies. For example, in our previous work we explored the effectiveness of the Broad Minded Affective Coping procedure (BMAC) protocol (Johnson, Gooding, Wood, Fair, & Tarrier, 2013). The BMAC is a positive mood induction technique based on the client’s own memories, and is suitable for use in clinical therapy sessions to boost positively valenced affect. This is consistent with how we generally see the use of positive psychology techniques in clinical psychology. Not as replacements for existing therapies, but rather as specific techniques that can be applied based on individual clinical judgment in collaborative dialogue with the client. These chapters provide a wealth of novel suggestions and discuss the variable evidence base for these. We hope that the next few years will see more rigorous trials in clinical settings testing the relative benefits of adding these positive activities to well‐validated therapies.

Many Existing Therapies are Already PCP if Viewed Through this Lens

Finally, PCP is first and foremost intended to be a new way of viewing the fields of positive psy chology and clinical psychology. We are delighted that for our Part V, leading experts from major therapeutic approaches have considered how their therapies, as currently practiced, are already working with a full continuum of well‐being (or simultaneously working on reducing maladaptive aspects whilst improving adaptive ones). Pete Sanders and Stephen Joseph (Chapter 28) consider person‐centered therapy, Timothy Feeney and Steve Hayes (Chapter 29) consider acceptance and commitment therapy, and Christopher Taylor and Arnold Arntz (Chapter 30) consider schema therapy. We hope that the next few years will see wider consideration within other therapies of how they too may already be focusing on the full spectrum of well‐being.

Conclusion

Thomas Kuhn (1962), in The Structure of Scientific Revolutions, describes the progress of science as distinctly nonlinear and as influenced by the existing zeitgeist. A paradigm develops encapsulating the standard interpretation of the evidence base at the time. This paradigm is strengthened by new evidence, which is generally interpreted as consistent with this paradigm if such an interpretation is possible. Eventually, however, sufficient disconfirming evidence emerges that topples the paradigm, creating a period of healthy crisis. Out of this crisis arises a new paradigm, around which a new critical mass of evidence emerges, until this in turn is toppled; it is such that human knowledge progresses. Until positive psychology came along, the paradigm was based around only understanding and reducing what was seen as the negative within clinical research and practice. Positive psychology successfully provided enough disconfirming evidence to topple this paradigm and create a crisis in the field. Whilst some expected positive psychology to be the next paradigm, arguably this has not happened, possibly due to divisive isolationist factions, lack of acknowledgment of previous approaches, some (isolated) research quality problems, and a lack of openness to criticism. Rather, some might see positive psychology as causing and epitomizing the crisis. This is a massive contribution to psychology, as knowledge

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16 Alex M. Wood and Judith Johnson

progresses only through the toppling of paradigms and no greater compliment can be made than to have toppled a paradigm. We do not know yet if PCP is the next paradigm for clinical psychology, as history shows that only years after the event can this be judged. PCP may very well be simply a refinement of the criticisms that are contributing to the fall of an untenable paradigm. In that case, it will have provided an invaluable service and we hope to live to see the next paradigm emerge. We are grateful to all our contributors for being a part of this landmark development of PCP, representing a step change in clinical psychology research and practice. The involvement of so many prominent people in the present volume evidences that the PCP approach is now part of the mainstream. We hope that readers will be provoked by the chapters and, even if they disagree with what they read here, that they will leave with more reflections upon assumptions about their work and a new determination to improve the quality of clinical psychology research and practice.

References

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Journal of Clinical Psychology, 58, 1037–1043. Boyce, C. J. & Wood, A. M. (2011a). Personality and the marginal utility of income: Personality interacts

with increases in household income to determine life satisfaction. Journal of Economic Behavior & Organization, 78, 183–191.

Boyce, C. J. & Wood, A. M. (2011b). Personality prior to disability determines adaptation: Agreeable indi viduals recover lost life satisfaction faster and more completely. Psychological Science, 22, 1397–1402.

Boyce, C. J., Wood, A. M., & Brown, G. D. A. (2010). The dark side of conscientiousness: Conscientious people experience greater drops in life satisfaction following unemployment. Journal of Research in Personality, 44, 535–539.

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Geraghty, A. W. A., Wood, A. M., & Hyland, M. E. (2010a). Attrition from self‐directed interventions: Investigating the relationship between psychological predictors, intervention content and dropout from a body dissatisfaction intervention. Social Science & Medicine, 71, 31–37.

Geraghty, A. W. A., Wood, A. M., & Hyland, M. E. (2010b). Dissociating the facets of hope: Agency and pathways predict dropout from unguided self‐help therapy in opposite directions. Journal of Research in Personality, 44, 155–158.

Held, B. S. (2004). The negative side of positive psychology. Journal of Humanistic Psychology, 44, 9–46. Johnson, J., Gooding, P. A., Wood, A. M., & Tarrier, N. (2010). Resilience as positive coping appraisals:

Testing the schematic appraisals model of suicide. Behavior Research and Therapy, 48, 179–186. Johnson, J., Gooding, P. A., Wood, A. M., Fair, K. L., & Tarrier, N. (2013). A therapeutic tool for boosting

mood: The broad‐minded affective coping procedure (BMAC). Cognitive Therapy and Research, 37, 61–70.

Johnson, J., Gooding, P. A., Wood, A. M., Taylor, P. J., Pratt, D., & Tarrier, N. (2010). Resilience to suicidal ideation in psychosis: Positive self‐appraisals buffer the impact of hopelessness. Behavior Research and Therapy, 48, 883–889.

Johnson, J., Wood, A. M., Gooding, P., & Tarrier, N. (2011). Resilience to suicidality: The buffering hypothesis. Clinical Psychology Review, 31, 563–591.

Johnson, J. & Wood, A. M (in press). Integrating positive and clinical psychology: Viewing human functioning as continua from positive to negative can benefit clinical assessment, interventions and understandings of resilience. Cognitive Therapy and Research.

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Joseph, S. & Linley, P. A. (2006a). Positive therapy: A meta‐theory for positive psychological practice. London: Taylor & Francis.

Joseph, S. & Linley, P. A. (2006b). Positive psychology versus the medical model? American Psychologist, 61, 332–333.

Kuhn, Thomas S. (1962). The structure of scientific revolutions. Chicago: University of Chicago Press. Lazarus, R. S. (2003). Does the positive psychology movement have legs? Psychological Inquiry, 14, 93–109. Linley, P. A., Joseph, S., Harrington, S., & Wood, A. M. (2006). Positive psychology: Past, present, and

(possible) future. Journal of Positive Psychology, 1, 3–16. Linley, P. A, Maltby, J., Wood, A. M., Osborne, G., & Hurling, R. (2009). Measuring happiness: The

higher order factor structure of subjective and psychological well‐being measures. Personality and Individual Differences, 47, 878–884.

Lockwood, G. & Perris, P. (2012). A new look at core emotional needs. In: J. B. M. van Vreeswijk & M. Nadort (Eds.), The Wiley‐Blackwell handbook of schema therapy: Theory research and practice (pp. 41–66). Chichester: Wiley‐Blackwell.

Maslow, A. H. (1954). Motivation and personality. New York: Harper. McCullough, M. E., Emmons, R. A., & Tsang, J. (2002). The grateful disposition: A conceptual and

empirical topography. Journal of Personality and Social Psychology, 82, 112–127. Park, N., Petterson, C., & Seligman, M. E. P. (2004). Strengths of character and well‐being. Journal of

Social and Clinical Psychology, 23, 603–619. Rusk, R. D. & Waters, L. E. (2013). Tracing the size, reach, impact, and breadth of positive psychology.

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Psychologist, 55, 5–14. Siddaway, A. P., Taylor, P. J., & Wood, A. M. (2016). The State‐Trait Anxiety Inventory (STAI) measures a

linear continuum from anxiety to calmness: Potential implications for the professional “agenda” of mental health services [working title], unpublished manuscript, available at: www.alexwoodpsychology.com.

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Tennen, H. & Affleck, G. (2003). When accentuating the positive, don’t forget the negative or Mr. In‐between. Psychological Inquiry, 14, 163–169.

Westerhof, G. J. & Keyes, C. L. M. (2010). Mental illness and mental health: The two continua model across the lifespan. Journal of Adult Development, 17, 110–119.

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Wood, A. M. & Joseph S. (2010). The absence of positive psychological (eudemonic) well‐being as a risk factor for depression: A ten year cohort study. Journal of Affective Disorders, 122, 213–217.

Wood, A. M., Joseph, S., Lloyd, J., & Atkins, S. (2009). Gratitude influences sleep through the mechanism of pre‐sleep cognitions. Journal of Psychosomatic Research, 66, 43–48.

Wood, A. M., Joseph, S., & Maltby, J. (2008). Gratitude uniquely predicts satisfaction with life: Incremental validity above the domains and facets of the five factor model. Personality and Individual Differences, 45, 49–54.

Wood, A. M, Joseph, S., & Maltby, J. (2009). Gratitude predicts psychological well‐being above the Big Five facets. Personality and Individual Differences, 46, 443–447.

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Wood, A. M., Taylor, P. T., & Joseph, S. (2010). Does the CES‐D measure a continuum from depression to happiness? Comparing substantive and artifactual models. Psychiatry Research, 177, 120–123.

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This chapter is concerned with how clinical psychologists traditionally have conceived the difference between psychological illness and wellness and how they should conceive this difference. Thus, the major purpose of this chapter is to challenge traditional conceptions of psychological wellness and illness and to offer a new conception a corresponding new vision of and mission for clinical psychology. We will do this by offering a “deconstruction” of what we refer to as the illness ideology in general and psychiatric diagnosis in particular.

A conception of the difference between wellness and illness is not a theory of either wellness or illness (Wakefield, 1992). Conceptions of wellness and illness attempt to define these terms – to delineate which human experiences are to be considered “well” or “ill.” A theory of wellness and illness, however, is an attempt to explain those psychological phenomena and experiences that have been identified by the conceptions as well and ill (see also Maddux, Gosselin, & Winstead, 2016).

As medical philosopher Lawrie Reznek (1987) has said in writing about the elusiveness and arbitrariness of the word disease: “Concepts carry consequences – classifying things one way rather than another has important implications for the way we behave towards such things” (p. 1). How we conceive psychological illness and wellness has wide‐ranging implications for individuals, medical and mental health professionals, government agencies and programs, and society at large. It determines what behaviors we consider it necessary to explain with our theories, thus determining the direction and scope of our research efforts. It also determines how we conceive the subject matter of clinical psychology, the roles and functions of clinical psychologists, and the people with whom they work.

Conceptions of psychological wellness and illness cannot be subjected to tests of empirical validation. They are social constructions grounded in values, not science, and socially constructed values cannot be proven true or false by science, as we will later discuss. Because this chapter deals with socially constructed conceptions, it offers no new “facts” or “research findings” intended to persuade the reader of the greater value of one conception of psychological wellness and illness over another or one view of clinical psychology over another. Instead, this chapter offers a different perspective based on a different set of values.

Toward a More Positive Clinical Psychology

Deconstructing the Illness Ideology and Psychiatric Diagnosis

James E. Maddux

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20 James E. Maddux

The Illness Ideology and Clinical Psychology

Words can exert a powerful influence over thought. Long after the ancient roots of the term clinical psychology have been forgotten, they continue to influence our thinking about the discipline. Clinical derives from the Greek klinike or “medical practice at the sickbed,” and psychology derives from psyche, meaning “soul” or “mind.” (Webster’s Seventh New Collegiate Dictionary, 1976). Many practitioners and most of the public still view clinical psychology as a kind of “medical practice” for people with “sick souls” or “sick minds.” The discipline is still steeped not only in an illness metaphor, but also an illness ideology. Although the illness metaphor (sometimes referred to as the medical model) prescribes a certain way of thinking about psychological problems (e.g., a psychological problem is like a biological disease), the illness ideology goes beyond this and tells us to what aspects of human behavior we should pay attention. It dictates that the focus of our attention should be disorder, dysfunction, and disease rather than health. It emphasizes abnormality over normality, poor adjustment over healthy adjustment, and sickness over health. It promotes dichotomies between normal and abnormal behaviors, between clinical and nonclinical problems, and between clinical and nonclinical populations. Thus, it narrows our focus on what is weak and defective about people to the exclusion of what is strong and healthy. It also locates human adjustment and maladjustment inside the person rather than in the person’s interactions with the environment and encounters with sociocultural values and societal institutions. Finally, it views people who seek help for problems in living as passive victims of intrapsychic and biological forces beyond their direct control. As a result, people who seek help for distress are relegated to the role of passive recipient of an expert’s care as opposed to an active participant in solving their own problems and taking control of their own lives.

Ideologies are captured by language, and the language of clinical psychology remains the language of medicine and pathology. Terms such as symptom, disorder, pathology, illness, diagnosis, treatment, doctor, patient, clinic, clinical, and clinician are all consistent with both a metaphor and an ideology of illness and disease (Maddux, 2008). The more we use these words when talking about clinical psychology and the work of clinical psychologists, the more we indoctrinate ourselves to the illness ideology.

The illness ideology has outlived its usefulness for clinical psychology. Decades ago, the field of medicine began to shift its emphasis from the treatment of illness to the prevention of illness and then moved from the prevention of illness to the enhancement of health. Furthermore, over three decades ago, the field of health psychology acknowledged the need to emphasize illness prevention and health promotion. Unless clinical psychology embraces a similar change in emphasis, it will struggle for identity and purpose in much the same manner as psychiatry has for the last several decades (Wilson, 1993; Francis, 2013). In fact, it already is. For example, over half a century ago in the United States, clinical psychologists overtook psychiatrists as the major providers of psychotherapy. Now, social workers have overtaken clinical psychologists in the provision of these same services. Clinical psychology needs to redefine itself as a science and a profession, and expand its roles and opportunities in order to survive and thrive in the rapidly changing marketplace of mental health services. The best way to do this is to abandon the illness ideology and replace it with a more positive clinical psychology grounded in positive psychology’s ideology of health, happiness, and human strengths. We do not have to change the name of the discipline to “positive clinical psychology,” but we do have to change its scope and its mission.

Historical Roots of the Illness Ideology in Clinical Psychology

Clinical psychology was not steeped in the illness ideology at its start. Some historians of psychology trace the beginnings of clinical psychology in the United States back to the 1886 founding of the first “psychological clinic” at the University of Pennsylvania by Lightner Witmer

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(Reisman, 1991; Benjamin & Baker, 2004). Witmer and the other early clinical psychologists worked primarily with children who had learning or school problems – not with “patients” with “mental disorders” (Reisman, 1991; Routh, 2000; Benjamin & Baker, 2004). Thus, they were more influenced by psychometric theory and its emphasis on careful measurement than by psychoanalytic theory and its emphasis on psychopathology and illness. Following Freud’s 1909 visit to Clark University, however, psychoanalysis and its derivatives came to dominate both psychiatry and clinical psychology (Korchin, 1976; Barone Maddux, & Snyder, 1997; Benjamin & Baker, 2004). Psychoanalytic theory, with its emphasis on hidden intrapsychic processes and sexual and aggressive urges, provided a fertile soil into which the illness ideology deeply sank its roots.

Several other factors encouraged clinical psychologists to devote their attention to psy- chopathology and thereby strengthened the hold of the illness ideology on the field. First, although clinical psychologists were trained academically in universities, their practitioner training occurred primarily in psychiatric hospitals and clinics where they worked primarily as psycho‐diagnosticians under the direction of psychiatrists trained in medicine and psychoanal- ysis (Morrow, 1946; Benjamin & Baker, 2004). Second, the US Veterans Administration (VA) was founded after the Second World War, and soon joined the American Psychological Association in developing standards for training clinical psychologists and centers for training them in VA hospitals. Thus, the training of clinical psychologists continued to occur primarily in psychiatric settings steeped in both biological and psychoanalytic models. Third, the US National Institute of Mental Health (NIMH) was founded in 1947. Very soon “thousands of psychologists found out that they could make a living treating mental illness” (Seligman & Csikszentmihalyi, 2000, p. 6). By the 1950s, clinical psychologists in the United States had come “to see themselves as part of a mere subfield of the health professions” (Seligman & Csikszentmihalyi, 2000, p. 6), and the practice of clinical psychology was grounded firmly in the illness ideology.

This ideology is characterized by four basic assumptions about the scope and nature of psychological adjustment and maladjustment (Barone, Maddux, & Snyder, 1997). First, clinical psychology is concerned with alleviating mental illness or psychopathology: deviant, abnormal, and maladaptive behavioral and emotional conditions. Thus, its focus is not on the everyday problems in living experienced by millions or on increasing the well‐being of the relatively well adjusted, but on severe conditions experienced by a relatively small number of people. Common problems in living, instead, became the purview of counseling psychology, social work, and child guidance.

Second, psychopathology, clinical problems, and clinical populations differ in kind, not just in degree, from normal problems in living, nonclinical problems, and nonclinical populations. Psychopathologies are disorders, not merely extreme variants of common problems in living and expected human difficulties and imperfections. As such, understanding psychopathology requires theories different from those theories that explain normal problems in living and effective psychological functioning. Wellness and illness demand separate explanatory processes.

Third, psychological disorders are analogous to biological or medical diseases in that they reflect distinct conditions inside the individual that cause the individual to think, feel, and behave maladaptively. This principle does not necessarily imply that psychological disorders directly caused by biological dysfunctions, but it does hold that the causes of emotional and behavioral problems are located inside the person, rather than in the person’s interactions with his or her environment, including his or her relationships with other people and society at large.

Fourth, the psychological clinician’s task, similar to the medical clinician’s task, is to iden- tify (diagnose) the disorder (disease) that resides inside the person (patient), to prescribe an intervention (treatment) to eliminate (cure) the internal disorder (disease), either biological or psychological, that is responsible for the symptoms. Even if the attempt to alleviate the

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problem is a purely verbal attempt to educate or persuade, it is still referred to as treatment or therapy, unlike often equally beneficial attempts to educate or persuade on the part of teachers, ministers, friends, and family (see Szasz, 1978). In addition, these “psychother- apeutic” interactions between clinicians and their “patients” differ in quality from helpful and distress‐reducing interactions between the “patient” and other people in his or her life, as understanding these “psychotherapeutic” interactions requires special theories (see Maddux, 2010).

Albee (2000) suggests that “the uncritical acceptance of the medical model, the organic explanation of mental disorders, with psychiatric hegemony, medical concepts, and language” (p. 247) was the “fatal flaw” of the standards for clinical psychology training in the United States that were established in 1950 by the American Psychological Association at a conference in Boulder, Colorado. Albee argues that this fatal flaw “has distorted and damaged the development of clinical psychology ever since” (p. 247). Little has changed since 1950. The basic assumptions of the illness ideology continue as implicit guides to clinical psychologists’ activities, and they permeate the view of clinical psychology held by the public and policy makers.

The Illness Ideology and the DSM

The influence of the illness ideology has increased over the past three‐and‐a‐half decades as clinical psychologists have acquiesced to the influence of the American Psychiatric Association’s (APA) Diagnostic and Statistical Manual of Mental Disorders (DSM) (APA, 2013). First published in the early 1950s (APA, 1952), the DSM is now in its fifth edition, and its size and influence have increased with each revision, especially beginning with the greatly expanded third edition in 1980.

The influence of the DSM has increased with the increasing size and scope of the subsequent revisions. The first edition (including all appendices) ran to 130 pages; the fifth edition runs just over 900 pages. The number of official mental disorders recognized by the APA has increased from six in the mid‐nineteenth century to close to 300 in the DSM‐5 (Francis & Widiger, 2012). The growth in the role of third‐party funding for mental health services in the United States during this same period fueled the growth of the influence of the DSM as these third parties began requiring a DSM diagnostic label as a condition for payment or reimbursement for mental health services.

Although most of the previously noted assumptions of the illness ideology are disavowed in the DSM‐5 introduction (APA, 2013), most of the manual is inconsistent with this disavowal. For example, still included in the revised definition of mental disorder is the notion that a mental disorder is “a dysfunction in the individual” (p. 20). Numerous common problems in living are viewed as mental disorders (Francis, 2013), and several others are listed as “conditions for further study” (e.g., Persistent Complex Bereavement Disorder, Caffeine Use Disorder, Internet Gaming Disorder), and therefore likely to find their way into DSM‐6. DSM‐5 does pay greater attention to alternative dimensional models for conceptualizing psychological problems and to the importance of cultural considerations in determining whether or not a problematic pattern should be viewed as a “mental disorder,” and these are steps in the right direction. Yet it remains steeped in the illness ideology for most of its 900 pages.

So closely aligned are the illness ideology and the DSM, and so powerful is the influence of the DSM over clinical psychology (at least in the United States) that clinical psychology’s rejection of the illness ideology must go hand in hand with its rejection of the DSM and other categorical schemes such as the ICD as the best way to conceive of psychological difficulties. This must begin with the acknowledgment that the DSM is not a scientific document, but a social and political document – a topic we next address.

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Toward a More Positive Clinical Psychology 23

The Social Construction of Conceptions of Psychological Wellness and Illness

A more positive clinical psychology rejects the illness ideology as the most accurate or effective approach for conceiving of the psychologically problematic aspects of human life. As such, a more positive clinical psychology refutes the basic premise of the illness ideology and the DSM that normal problems in living are symptoms of “psychopathologies” – that is, psychological illnesses, diseases, or disorders – and that giving a person a formal diagnosis for a problem in living contributes to the understanding to that person and his or her problem. This refutation is based on the assumption that the illness ideology is not a scientific theory or set of facts but rather a socially constructed ideology. Social constructionism is concerned with “examining ways in which people understand the world, the social and political processes that influence how people define words and explain events, and the implications of these definitions and explanations – who benefits and who loses because of how we describe and understand the world” (Muehlenhard & Kimes, 1999, p. 234). The process of social construction involves “elucidating the process by which people come to describe, explain, or otherwise account for the world in which they live” (Gergen, 1985, pp. 3–4; 1999). Because the prevailing views depend on who has the power to determine them, universal or “true” conceptions and perspectives do not exist. The people who are privileged to define such views usually are people with power, and their conceptions reflect and promote their interests and values (Muehlenhard & Kimes, 1999). Because the interests of people and institutions are based on their values, debates over the definition of concepts often become clashes between deeply and implicitly held beliefs about the way people should live their lives and differences in moral values.

The social constructionist perspective can be contrasted to the essentialist perspective that is inherent in the illness ideology and the DSM. Essentialism assumes that there are natural categories and that all members of a given category share important characteristics (Rosenblum & Travis, 1996). For example, the essentialist perspective views our categories of race, sexual orientation, and social class as objective categories that are independent of social, cultural, and political processes and that represent “empirically verifiable similarities among and differences between people” (Rosenblum & Travis, 1996, p. 2). In the social constructionist view, such categories represent not what people are, but rather the ways that people think about and attempt to make sense of differences among people. Social, cultural, and political processes also determine what differences among people are more important than other differences (Rosenblum & Travis, 1996).

From the essentialist perspective, the distinctions between psychological wellness and illness and among various so‐called psychopathologies and mental disorders, such as those described in the DSM (and the ICD) are natural distinctions that can be discovered and described. From the social constructionist perspective, however, these distinctions are not scientifically verifiable “facts” or even scientifically testable theories. Instead, they are abstract ideas that have been constructed by people with particular personal, professional, and cultural values. The meanings of these and other concepts are not revealed by the methods of science, but are negotiated among the people and institutions of society who have an interest in their definitions. They reflect shared world views that were developed and agreed upon collaboratively over time by the members of society, including theorists, researchers, professionals, clients and patients, the media, business and finance, and the culture in which all are embedded.

For this reason, the illness ideology, its conception of “mental disorder,” and the various specific categories of mental disorders found in traditional psychiatric diagnostic schemes (such as the DSM and ICD) are not psychological facts about people, nor are they testable scientific theories. Instead, they are social artifacts that serve the same sociocultural goals as do our constructions of race, gender, social class, and sexual orientation – maintaining and expanding the power of certain individuals and institutions, as well as maintaining social order as defined by those in power

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(Becker, 1963; Beall, 1993; Parker, Georgaca, Harper, McLaughlin, & Stowell‐Smith, 1995; Rosenblum & Travis, 1996). As are these other social constructions, our concepts of psychological normality and abnormality are tied ultimately to social values – in particular, the values of society’s most powerful individuals, groups, and institutions – and the contextual rules for behavior derived from these values (Becker, 1963; Parker et al., 1995; Rosenblum & Travis, 1996).

Reznek (1987) has demonstrated that even our definition of physical disease “is a normative or evaluative concept” (p. 211) because to call a condition a disease “is to judge that the person with that condition is less able to lead a good or worthwhile life” as defined by the person’s society and culture (p. 211). If this is true of physical disease, it certainly is true of psychological “disease.”

Given these precursors, it comes as no surprise that a highly negative clinical psychology evolved during the twentieth century. The socially constructed illness ideology and associated traditional psychiatric diagnostics schemes, also socially constructed, have led to the pathologization of normal psychological phenomena and thus the proliferation of “mental illnesses” (Francis, 2013; Greenberg, 2013). Sociologists view this as an aspect of an even more general medicalization of a wide range of normal human problems and ailments, whereby “a problem is defined in medical terms, described using medical language, understood through the adoption of a medical framework, or ‘treated’ with a medical intervention” (Conrad, 2007, p. 5). As the socially constructed boundaries of “mental disorder” have expanded with each DSM revision, more and more relatively common human problems and frailties human have become pathologized and medicalized. Mental health professionals have not been content to label only the obviously and blatantly dysfunctional patterns of behaving, thinking, and feeling as “mental disorders.” As a result, the number of people with a diagnosable “mental disorder” has continued to grow. If this continues, eventually everything that human beings think, feel, do, and desire that is not perfectly logical, adaptive, or efficient, or that “creates trouble in human life” (Paris, 2013, p. 43) will become a mental disorder (Francis, 2013; Paris, 2013). DSM‐5 has made normality “an endangered species,” partly because we live in a society that is “perfectionistic in its expectations and intolerant of what were previously considered to be normal and expectable distress and individual differences” (Francis & Widiger, 2012, p. 116), but also partly because pharmaceutical companies are constantly trying to increase the market for their drugs by encouraging the loosening and expanding of the boundaries of mental disorders described in the DSM and encouraging the creation of new disorders, often through direct‐to‐consumers advertising (Conrad, 2007; Horwitz & Wakefield, 2007; Francis, 2013; Greenberg, 2013; Paris, 2013). The APA also has a strong financial interest in the marketing of psychopathology given that sales of the DSM account for about 10% of its annual income (Greenberg, 2013). (The World Health Organization’s ICD, on the other hand, can be downloaded for free from its website.)

The powerful sociocultural, political, professional, and economic forces that constructed the illness ideology now continue to sustain it. The debate over the conception of psychological wellness and illness is not a search for “truth.” Rather, it is a struggle over the definition of a socially constructed abstraction and over the personal, political, and economic benefits that flow from determining what and whom society views as normal and abnormal. This struggle is played out in the continual debates involved in revision of the DSM (Kirk & Kutchins, 1992; Kutchins & Kirk, 1997; Conrad, 2007; Horwitz & Wakefield; 2007; Francis, 2013; Greenfield; 2013).

The Illness Ideology and the Categories versus Dimensions Debate

Embedded in the illness ideology’s conception of psychological wellness and illness is a categorical model in which individuals are determined to either have or not have a disorder – that is, to be either psychologically well or psychologically ill – and, if they do have a disorder, that it is a specific type of disorder. This view is embodied in the DSM and the ICD. An alternative model

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is the dimensional model, which assumes that normality and abnormality, wellness and illness, and effective and ineffective psychological functioning lie along a continuum. In this dimensional approach, so‐called psychological “disorders” are simply extreme variants of normal psychological phenomena and ordinary problems in living (Keyes & Lopez, 2002; Widiger, 2016). Great differences among individuals on the dimensions of interest are expected, such as the differences we find on formal tests of intelligence. As with intelligence, divisions made between normality and abnormality may be demarcated for convenience or efficiency, but they are not to be viewed as reflecting a true discontinuity among “types” of phenomena or “types” of people. Inherent in the dimensional view is the assumption that these distinctions are not natural demarcations that can be “discovered”; instead, they are created or constructed “by accretion and practical necessity, not because they [meet] some independent set of abstract and operationalized definitional criteria” (Francis & Widiger, 2012, p. 111).

Understanding the research supporting the dimensional approach is important because the vast majority of this research undermines the illness ideology’s assumption that we can make clear, scientifically‐based distinctions between the psychologically well or healthy and the psychological ill or disordered. The empirical evidence for the validity of a dimensional approach to psychological adjustment is formidable and can be found in research on personality disorders (Costello, 1996; Maddux & Mundell, 2005; Trull & Durrett, 2005; Crego & Widiger, 2016); the variations in normal emotional experiences (e.g., Oatley & Jenkins, 1992); adult attachment patterns in relationships (Fraley & Waller, 1998); self‐defeating behaviors (Baumeister & Scher, 1988); children’s reading problems or “dyslexia”; (Shaywitz, Escobar, Shaywitz, Fletcher, & Makuch, 1992); attention deficit/hyperactivity disorder (Barkeley, 1997); post‐traumatic stress disorder (Anthony, Lonigan, & Hecht, 1999); depression (Costello, 1993a); somatoform disorders (or somatic symptom disorders) (Zovlensky, Eifert, & Garey, 2016); anxiety disorders (Williams, 2016); sexual dysfunctions and disorders (Gosselin, 2016); and of the symptoms of schizophrenia and affective psychoses (Costello, 1993b; Claridge, 1995; Nettle, 2001). To ignore this research and continue to cling to categories is to ignore science and reason.

Social Constructionism and the Role of Science in Clinical Psychology

A social constructionist perspective is not “anti‐science.” To say that conceptions of psychological wellness and illness are socially constructed rather than scientifically constructed is not to say that the patterns of thinking, feeling, and behaving that society decides to label as “ill” – including their causes and treatments – cannot be studied objectively and scientifically. Instead, it is to acknowledge that science can no more determine the “proper” or “correct” conceptions of psychological wellness and illness than it can determine the “proper” and “correct” conception of other social constructions such as beauty, justice, race, and social class.

We nonetheless can use the methods of science to study the psychological phenomena that our culture refers to as “well” or “ill.” We can use them to understand a culture’s conception of psychological wellness and illness, how this conception has evolved, and how it affects individ- uals and society. We also can use them to understand the origins of the patterns of thinking, feeling, and behaving that a culture considers psychopathological and to develop and test ways of modifying those patterns.

The science of medicine is not diminished by the acknowledgment that the notions of health and illness are socially constructed (Reznek, 1987). The science of economics is not diminished by the acknowledgment that the notions of poverty and wealth are socially constructed. Likewise, the science of clinical psychology will not be diminished by the acknowledgment that its basic concepts are socially constructed and not scientifically constructed (Lilienfeld and Marino, 1995).

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Beyond the Illness Ideology: Toward a More Positive Clinical Psychology

The viability and survival of clinical psychology depends on its ability to build a more positive clinical psychology that breaks with its “pathological” past. In building a more positive clinical psychology, we must adopt not only a new ideology, but also a new language for talking about human behavior that reflects this ideology. In this new language, ineffective patterns of behaviors, cognitions, and emotions are construed as problems in living, not as disorders or diseases. Likewise, these problems in living are construed not as located inside individuals, but in the interactions between the individual and other people that are embedded in situations that include rules for behavior that are, in turn, embedded in the larger culture. Also, those who seek assistance in enhancing the quality of their lives are clients or students, not patients. The professionals who specialize in facilitating psychological health are teachers, counselors, consultants, coaches, or even social activists, not clinicians or doctors. Strategies and techniques for enhancing the quality of lives are educational, relational, social, and political interventions, not medical treatments. Finally, the facilities to which people will go for assistance with problems in living are centers, schools, or resorts, not clinics or hospitals. Such assistance might even take place in community centers, public and private schools, churches, and people’s homes rather than in specialized facilities.

A more positive clinical psychology would emphasize goals, well‐being, satisfaction, happiness, interpersonal skills, perseverance, talent, wisdom, and personal responsibility. It would be concerned with understanding what makes life worth living, with helping people become more self‐organizing and self‐directed, and with recognizing that “people and experiences are embedded in a social context” (Seligman & Csikszentmihalyi, 2000, p. 8).

These principles offer a conception of psychological functioning that gives at least as much emphasis to mental health as to mental illness and that gives at least as much emphasis to identifying and understanding human strengths and assets as to human weaknesses and deficits (see Lopez & Snyder, 2003). A more positive clinical psychology would be as much concerned with understanding and enhancing subjective well‐being and effective functioning as with alleviating subjective distress and maladaptive functioning. This does not entail a shift away from relieving suffering, but rather “an integrated and equally weighted focus on both positive and negative functioning in all areas of research and practice” (Wood & Tarrier, 2010, p. 819).

Consistent with our social constructionist perspective, we are not arguing that the positive psychology ideology is more “true” than the illness ideology. Both ideologies are socially constructed views of the world, not scientific theories or bodies of facts. We do argue, however, that positive psychology offers an ideology that is more useful to clinical psychology than the obsolete illness ideology. As Bandura (1978) has observed: “Relatively few people seek cures for neuroses, but vast numbers of them are desirous of psychological services that can help them function more effectively in their everyday lives” (p. 99).

Unlike a traditional negative clinical psychology based on the illness ideology, a positive clinical psychology is concerned not just with identifying weaknesses and treating or preventing “disorders,” but also with identifying human strengths and promoting “mental health.” It is concerned not just with alleviating or preventing “suffering, death, pain, disability, or an important loss of freedom” (APA, 2000, p. xxxi), but also with promoting health, happiness, physical fitness, pleasure, and personal fulfillment through the free pursuit of chosen and valued goals.

A clinical psychology that is grounded not in the illness ideology, but in a positive psychology ideology rejects: (1) the pathologization and categorization of humans and normal human experiences, problems, and frailties; (2) the assumption that so‐called mental disorders exist in individuals rather than in the relationships between the individual and other individuals and the culture at large; and (3) the notion that understanding what is worst and weakest about us is more important than understanding what is best and bravest.

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A more positive psychological assessment will emphasize the evaluations of people’s strengths and assets along with their weaknesses and deficiencies (Keyes & Lopez, 2002; Wright & Lopez, 2002; Lopez, Snyder, & Rasmussen, 2003; Joseph & Wood, 2010; Wood & Tarrier, 2010). More often than not, strategies and tactics for assessing strengths and assets will borrow from the strategies and tactics that have proven useful in assessing human weaknesses and deficiencies (Lopez, Synder, & Rasmussen, 2003; Wood & Tarrier, 2010). Positive psychological interven- tions will emphasize the enhancement of people’s strengths and assets in addition to, and at times instead of, the amelioration of their weaknesses and deficiencies, secure in the belief that strengthening the strengths will weaken the weaknesses. The interventions most often will derive their strategies and tactics from traditional “treatments” of traditional psychological “disorders” (Wood & Tarrier, 2010).

One can argue about whether or not what is now called “positive psychology” is really anything new, but it is difficult to deny that it has sparked a healthy dose of “soul searching” among many clinical psychologists. The greater utility of a more positive clinical psychology is found in its expanded view of what is important about human behavior and what we need to understand about human behavior to enhance people’s quality of life, which results in an expanded view of what clinical psychology has to offer society.

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Many years ago, Aldo Llorente, MD, my friend and colleague who directed a small community- hospital inpatient psychiatric unit, offhandedly remarked, “You know, even psychiatric patients have problems.” Although I initially thought that Aldo was stating the obvious, I should have known better. He meant that life confronts us all with many problems, independently of whether any of us is diagnosed with a mental illness. In one way or another, we all must come to terms with our individual particularities – our temperaments, personality traits, relational/interpersonal styles, cognitive capacities and styles, physical health/characteristics, as well as our many social contexts, such as family environment, employment/socioeconomic situation, geographic location, to name just a few.

To be clear, Aldo was not a fan of Thomas Szasz’s (1960) (in)famous position that mental illness is a myth. Contra Szasz, Aldo did not deny the existence of bona fide mental illness, nor did he accept Szasz’s replacement of the term “mental illness” with the term “problems in living,” to emphasize the historical and sociocultural relativity of the former term and thus to dismiss its (realist) ontological status. Instead, Aldo meant that those who suffer from mental illness are also burdened with everyday life problems, just like those who do not so suffer. He humanized those who suffer from mental illness in his own unique way, that is, without even a nod to the depathologizing and growth fundamentals of humanistic psychologists, to whom editors Alex Wood and Nicholas Tarrier (2010) sometimes appeal in their call for a “Positive Clinical Psychology” in a special issue of the Clinical Psychology Review.

Aldo developed a unique group format that reflected his philosophy of inpatient treatment. Each evening, every patient on the twelve‐bed unit (with an average stay of five days) who was able to participate in the group did so. The group had three rules: (1) the group members selected the topic of discussion each evening; (2) when a patient was to be discharged the next day, he or she said goodbye to the group; and (3) there was no discussion of personal details. What?! Right, no personal details. Aldo believed that patients had been trained by the mental health system to focus so much on their symptoms, on their illness, on their status as mental patients, that they forgot how to be persons in an ordinary sense, that is, in a non‐(psychiatric) patient sense (cf. Sarbin, 1969).

Each evening, Aldo asked the group to settle on a topic that everyone could discuss, rather than discuss the unique problems of members’ personal lives, past and present, for example, their individual histories and attributions of blame. This forced the group members to discuss

Why Clinical Psychology Should Not Go “Positive” – and/or “Negative”

Barbara S. Held1

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32 Barbara S. Held

the universal themes of personhood, such as phenomenal experiences of hurt and anger, fear, anxiety, shame, confusion, contentment, love, loss of relationships, physical illness, the weather, politics, sports – you name it. When patients inevitably started to mention the details of their own personal problems or deviated from that night’s chosen theme, Aldo reminded them of the rules and got them back on track. He insisted that the point of the group was to make it possible for discharged patients “to go downtown and sit at the counter of the local doughnut shop, have a cup of coffee, and talk to the guy sitting next to them about the weather instead of their mental illness, just like any regular person.” Although there were no formal outcome studies, the group enjoyed much success, so much so that others who worked on the unit at the time learned this format from Aldo and taught it to their students. The group is no longer practiced on that unit, nor any others to my knowledge, and Aldo died in 1995. Yet his legacy lives on informally, and his philosophy of treatment struck me as a good way to begin my chapter in this volume. What could be more positive in a clinical (inpatient) setting than Aldo’s group, with its aim to (re)establish the personhood of its members!

The title of my chapter is meant to give away the punch line. In their special issue of the Clinical Psychology Review, Wood and Tarrier (2010) make a thoughtfully nuanced case on behalf of their “Positive Clinical Psychology,” with all due awareness of the profound problems created for the entire discipline of psychology by the positive psychology movement. Nonetheless, I cannot tumble to the concept of a positive clinical psychology, at least as it was made there, if not in this follow‐up volume, in progress as I write. In this chapter, I cite instances from that special issue, to help “concretize” my analysis.

To make my case, I begin with the conceptual problems that arise when positive psychologists use the terms “positive” and “negative,”2 which problems lead us into the very dualist traps that Wood and Tarrier, in their integrationist spirit, seek to avoid. Next, I challenge the claim that clinical practice itself can be understood as either “positive” or “negative” in any sense, owing not only to conceptual problems but also to the highly idiographic/circumstantial nature of practice (even in applying the nomothetic findings of science). Of special import is the considerable body of research by psychologists who for three decades have consistently found functional coping value in “negative” emotions and thoughts. In short, eliminating or reducing “negative” emotions, thoughts, and coping strategies can, in many circumstances, be detrimental to constructive/adaptive, or even optimal, functioning.

Throughout this chapter I return repeatedly and critically to the positive psychology distinction between “negative” and “positive” interventions – those in which therapists aim to decrease “negative” states and functioning directly, with “negative” or traditional clinical interventions,3 and those in which therapists aim to increase “positive” states and functioning directly, with “positive” clinical interventions (Linley & Joseph, 2004a; Seligman, Rashid, & Parks, 2006; Joseph & Wood, 2010; Wood & Tarrier, 2010; Schueller & Parks, 2014).4 Especially problem- atic, as I shall explain, is the application of positive/negative terminology to different domains – for example, in the domains of psychological states and interventions versus the domain of goal‐directed functioning, where, as it turns out, “positivity” in the former two can erode func- tionality, and “negativity” in the former two can enhance functionality.

In my conclusion, I return to Aldo Llorente’s worry about the loss of personhood status by those treated in inpatient settings. This loss may be reformulated as a loss of agency in ordinary terms, so much so that I am inclined to see an overarching goal for most, if not all, psychological interventions as the restoration of agency to those whose agency has been diminished owing to psychological problems and their treatment. By agency I mean the universal human rational capacity to deliberate about goals and thus act with good reason(s) on the products of those deliberations (Fulford, 1994; Martin, Sugarman, & Thompson, 2003; Evnine, 2008; Held, 2010). And so I conclude with just that issue – rational agency – as it pertains to psychological interventions of any sort.

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Why Clinical Psychology Should Not Go “Positive” 33

The Conceptual Quagmire of the Positive/Negative Distinction

I make no quarrel with the positive/negative distinction as it appears in mathematics, where negative numbers hold their own, nor in medical pathology, where negative results indicate the absence of pathology and so are to be celebrated. In positive psychology, by contrast, “negative” characteristics should be diminished and replaced with “positive” characteristics. And so we see the polysemantic (or polysemous) nature of the terms “positive” and “negative,” each of which can mean either good or bad (or neutral) depending on their domain of application. Yet positive psychologists tend to make a priori5 designations of positivity and negativity in reference to psychological states, functioning, and interventions, which creates considerable conceptual muddles that defy elimination logically within their conceptual framework of positivity and negativity.

And so, with ambiguity built into the meanings of the terms “positive” and “negative” themselves, the very concept of a positive (or negative) psychology, clinical or otherwise, is dubious at best. Even Wood’s and Tarrier’s (2010) circumspect, repeated call for a thoroughgoing integration of the “positive” and “negative” within (clinical) psychology, “based on a balanced and equally weighted focus on the positive and negative aspects of life”6 (p. 820), opens a Pandora’s box of questions. Not least, we may ask why they seek integration. After all, if no positive/negative compartmentalization of psychological reality had been imposed by positive psychologists in the first place, then need for such integration would not exist. Moreover, their own retention of the positive/negative distinction destines them to perpetuate the very dualism that they seek to integrate/synthesize – or so I shall argue.7

Consistent with their call for integration, Wood and Tarrier (2010) propose a dimensional approach, in which, for example, happiness and depression constitute two opposite anchors of a single bipolar dimension rather than two categories:

There are strong conceptual and empirical arguments that no emotion or characteristic can be uniformly positive or negative. . . . A more fundamental and less considered issue [is] a lack of appreciation that most characteristics have both positive and negative poles. For many characteristics, presumably due to historical or zeitgeist reasons, focus is predominantly on only one pole, with the other becoming forgotten or ignored, and a lack of appreciation of the polarity of the construct. (p. 825)

Fair enough. But what about appreciation of the possible benefits of the designated negative pole? These presumably cannot be seen by positive psychologists, owing perhaps to their adherence to their a priori designation of what is “positive” (i.e., good) and “negative” (i.e., bad, or at least not as good as what is “positive”).

Wood and Tarrier rightly expand their concerns about dimensionality to encompass the arbitrary nature of what is considered positive versus negative, in two distinct respects:

[a] The designation of the characteristic [humility, kindness, open‐mindedness, integrity, fairness, high social intelligence] and their [polar] opposites [arrogance, unkindness, closed‐mindedness, dis- honesty, unfairness, and low social intelligence] as either positive or negative is totally arbitrary, depending on which pole is focused on (or which way a scale is coded). Indeed, had the authors not been working within positive psychology, they could have easily reverse coded their scales, named them after the opposite pole, and conducted mainstream clinical work. . . . [b] Any designation of a characteristic as positive or negative is simplistic and inaccurate, as any trait or emotion can be “positive or negative” depending on the situation and concomitant goals and motivations. (pp. 826–827)

Regarding “a,”8 since one of the meanings of positivity and negativity is the dimensional fea- ture described by Wood and Tarrier, the applications of these terms to relevant domains are, as they say, “totally arbitrary” – that is, which pole is considered “positive” and which “negative” is just what any researcher or group of researchers decides them to be. In that case, positive and

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34 Barbara S. Held

negative states, functioning, and interventions do not exist ontologically prior to (and so independently of) our designations of them as positive or negative; they are not just out there “waiting” to be discovered by us, as in a standard view of realist ontologies (Held, 2007, ch. 5). This may suggest an antirealist ontological underpinning of the psychological science of positivity and negativity, about which most positive psychologists would, I suspect, be less than pleased (Held, 2002, 2004, 2005). Moreover, if the distinction between positive and negative characteristics is arbitrary, simplistic, and inaccurate, then it follows that the distinction between positive and negative interventions (both in “mainstream clinical work” and otherwise), which distinction depends logically on the positive/negative characteristic distinction, is also arbitrary, simplistic, and inaccurate. And yet, the positive/negative dualism obtains for interventions too.

“Positive” versus “Negative” Interventions

Retention of positive/negative terminology was surely destined to beget positive clinical psychologists, those who use, in addition to the negative/clinical interventions that directly target the decrease of negative/pathological states and functioning, the positive interventions that directly target the increase of positive/healthy states and functioning. And so we move with apparent ease from positive versus negative states and functioning to positive versus negative interventions, despite this shift in the domains of application of the positive/negative distinction. As Wood and Tarrier (2010) proclaimed: “It is not logical to study either negative or positive functioning in isolation [of each other], as … this prevents interventions being designed to both decrease the negative and promote the positive” (p. 827; emphasis added). Thus, the solution to the problem of integration remains dualistic: retain the negative‐intervention/positive‐intervention dichotomy, and develop a positive clinical psychology composed of both kinds of interventions, rather than adhere to a (negative) clinical psychology, allegedly composed of only negative interventions. Dropping the positive/negative distinction does not seem to be an option, especially since it was “institutionalized” by Seligman’s movement.

Positive interventions and negative interventions, then, are cast as two distinct kinds of interventions, each of which expressly targets two distinct kinds of states and two distinct kinds of functioning. However, this conceptualization may be more apparent than real. For example, Joseph and Wood (2010) believe that existing (pre‐positive clinical psychology and thus presumably negative/clinical) interventions increase positive functioning if they are theoretically compatible with a “growth” view (as in client‐centered therapy) (p. 836). And Kashdan and Rottenberg (2010) go further, stating that “even when psychological interventions do not explicitly discuss flexibility as an aim of treatment … flexibility is such an integral part of psychological functioning that it is almost inevitable that it will in some way be impacted” (p. 874). In this the inviolate positive/negative intervention divide begins to blur, since even certain negative interventions can in principle (i.e., logically) impact certain positive states/functioning, such as flexibility, at least indirectly.

As Kashdan and Rottenberg (2010, pp. 866–867) appreciate, an underlying problem is the arbitrary designation of mental states and functioning as positive or negative a priori – that is, independent of circumstantial particularity (see n. 5, below). I prefer the terms “constructive” and “destructive” (or “adaptive” and “maladaptive”) because they at least hint at the necessity of case‐specific empirical observation and evidence, to determine whether any one state or process is helpful or harmful in the pursuit of a particular goal by a particular person facing particular circumstantial demands, both interpersonal and intrapersonal (e.g., McNulty & Fincham, 2012). And let us be clear that interventions designed to (a) build up what we deem adaptive and to (b) tear down what we deem maladaptive are both not only circumstance dependent but also

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Why Clinical Psychology Should Not Go “Positive” 35

constructive, even though we tear down in the latter case. This way of thinking entails obstacles for Barbara Fredrickson’s “broaden‐and‐build theory of positive emotions,” which strongly limits the value of negative emotions in constructive endeavors. The problem is, this limiting is also a profound limitation; it flies in the face of extensive empirical evidence that supports the constructive value of “negativity,” a value that transcends the limitations imposed by Fredrickson.

The Broaden‐and‐Build Theory of Positive Emotions

Garland, Fredrickson, Kroing, Johnson, Meyer, and Penn (2010) succinctly summarize the broaden‐and‐build theory of positive emotions, which is promoted enthusiastically in the positive psychology literature, not least in such canonical texts as the Oxford Handbook of Positive Psychology (Lopez & Snyder, 2009) and The Encyclopedia of Positive Psychology (Lopez, 2009):

Negative emotions have long been held to narrow the scope of people’s attention and thinking. . . . The broaden‐and‐build theory … holds that positive emotions broaden individuals’ thought–action repertoires, enabling them to draw flexibly on higher‐level connections and wider‐than‐usual ranges of percepts, ideas, and action urges; broadened cognition in turn creates behavioral flexibility that over time builds personal resources, such as mindfulness, resilience, social closeness, and even physical health. . . . Importantly, unlike the transient nature of positive emotions, these resources are durable. . . . Thus, according to the theory and data, pleasurable positive emotions, although fleeting, can have a long‐lasting impact on functional outcomes, leading to enhanced well‐being and social connectedness. (Garland et al., 2010, p. 850)

This theory and the evidence gathered on its behalf have now been challenged extensively in a debate between Fredrickson and Losada, on the one side, and Brown, Sokal, and Friedman, on the other.9 Yet it continues to stick with positive psychologists. In the next section, I present extensive research that demonstrates the “positive power” of negative emotions, thinking, and coping.

Just here I make the obvious point that all clinical interventions are designed to help people function better, whether they target positive or negative states/functioning directly. And so they are designed to be “positive” by being constructive in just that way, even if they consist in “tearing down” what is destructive to adaptive functioning. The crucial corollary that seems to get lost in the rush to positivity is this: improving coping/functioning is not always compatible with feeling happy, with positive affect, and thus with interventions that are positive in virtue of aiming to increase positive emotional states directly, which is one component of standard definitions of “positive interventions.”

Practice and Nomothetic versus Idiographic Principles

Both the research and the rhetoric of the positive psychology movement are nomothetic in their promotion of generalizations, though they are generalizations of different sorts. Wood and Tarrier (2010) rightly criticize the generalizations made in the rhetoric of the movement, which, they maintain, overpromote the movement’s research findings, findings which, they note, are not themselves without problems.

Here I contrast the generalities of positive psychology research with the particularities that necessarily inhere in any kind of psychotherapy practice. That is, whereas science entails nomo- theticity in its search for law‐like if not lawful generalizations, practice entails individualized particularity. As I once put it: “No two schizophrenics are alike for all therapeutic purposes” (Held, 1995, p. 19). To be clear, I do not deny the logic of subjecting (clinical) psychological

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36 Barbara S. Held

questions (about human/mental kinds) to scientific scrutiny (Held, 2007) – after all, all scientists study particular instantiations of kinds to arrive at generalities of some sort, if not the universal laws of physics.

My point about the idiographic nature of practice is twofold. First, the old adage about working with the client’s (temperamental etc.) tendencies, not against them. Second, to do this, we need to appreciate each client as a unique individual with unique features, including strengths and weaknesses, as well as a member of some categorical set, or even a point on a dimension. These do not readily reduce to the attributes that positive psychologists have designated positive or negative. Thus, as with any clinical intervention, even positive interventions can cause negative/ deterioration effects.10 For example, J. Wood, Perunovic, and Lee (2009) found that repeating positive self‐statements (such as “I accept myself completely”) or focusing on ways in which the statement was true caused those with low self‐esteem to feel worse and boosted those with high self‐esteem only mildly. They speculate that positive self‐statements may backfire for those with low self‐esteem because the attempt to “avoid negative thoughts [unsuccessfully] … may have signified that the positive self‐statement was not true of them … the very people they are designed for” (p. 865). And McNulty and Fincham (2012) challenge the positive/negative labeling of traits and processes altogether, on conceptual as well as empirical/circumstantial grounds: “the psychological characteristics that benefit people experiencing optimal circumstances may not only fail to help people experiencing suboptimal circumstances, but may harm them” (p. 106).11 The a priori positive/negative dichotomy in psychology, then, is arguably a false dichotomy.

Returning to practice, how to guide the idiographics of practice with the nomothetics of science continues to elude us. Still, we must have some general principles, even if only at the highest level of generality (Held, 1995). For example, I agree with Kashdan’s and Rottenberg’s (2010) view of “Psychological Flexibility as a Fundamental Aspect of Health,” if for no other reason than the semantic fact that health (physical or mental) entails flexibility, whereas pathology constricts. Although this may sound like the broaden‐and‐build theory of positive emotions, in which only positive emotions increase options for living, that is not the case. Positive and negative emotions (and thoughts) do not determine adaptive and maladaptive functioning, respectively, certainly not as robustly as positive psychologists often suppose: adaptive functioning can in some cases entail feeling bad, and maladaptive functioning can in some cases entail feeling good, as I now explain.

When “Negative” Interventions are Constructive/“Positive”: The Case of Defensive Pessimism

Recall that those who promote a positive clinical psychology call for, in addition to the use of negative/clinical interventions, the use of positive interventions, those that directly target building up the states and processes that are alleged to be conducive to more adaptive/constructive, even optimal,12 functioning (Wood & Tarrier, 2010; Schueller & Parks, 2014). But what about the wealth of research that demonstrates how negative coping strategies, including the negative emotions and thinking that constitute such strategies, can be highly advantageous to adaptive/ constructive functioning? That is, what about the cases in which negative states are crucial for adaptive/constructive functioning?

The coping strategy of defensive pessimism, so studied for some three decades by Julie Norem, provides the most prominent case in point, not least in her popular book, The Positive Power of Negative Thinking (2001). Despite the consistent finding of the adaptive functional value of defensive pessimism for those whose functioning is impaired by debilitating anxiety, there is scant attention to Norem’s findings about the value of defensive pessimism in the positive psychology literature.

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Why Clinical Psychology Should Not Go “Positive” 37

Let us begin with Norem’s (2008) own recent definition and description of defensive pessimism, namely, a “motivated cognitive strategy” that entails (a) “setting low expectations (being pessimistic) and then thinking through, in concrete and vivid detail, all the things that might go wrong as one prepares for an upcoming situation or task” (p. 123) and that (b) “helps people manage their anxiety and pursue their goals” (abstract, p. 121). Like Joseph and Wood (2010) and Kashdan and Rottenberg (2010), Norem examines executive functioning or self‐regulation/control/determination (even in regard to some clinical issues), although she also emphasizes the complexities (in enhancing such self‐regulation) that implicate a role for “negative” coping:

Research on a variety of phenomena, from self‐handicapping to stereotype threat, demonstrates the potential effectiveness of defensive pessimism as a self‐regulation strategy. . . . Understanding how and why defensive pessimism works requires an integrated understanding [of] the role of traits, motiva- tions, and self structures within the individual, the resultant goals toward which strategies are directed, and the particular constraints of different situations and cultural contexts. (abstract, p. 121)

Norem (2008) explains how defensive pessimism works by means of certain kinds of negativity, kinds which she later (Norem, 2014) calls “the right tool for the job.” Thus, negative affect effect and thinking “function as positive motivation for defensive pessimists,” in that in distinction to, for example, rumination and catastrophizing, defensive pessimists’ “negative reflections are directed toward the future, and focus on potential negative scenarios that are directly relevant to the situation or goal he or she wants to approach” (p. 126). The point is that what seemingly begins as a “negative” process in fact functions as a definite “positive” process, that is, functions adaptively or constructively: “The defensive pessimist is able to shift emphasis from anxious feelings to thoughts about possible specific problems, and then to actions to prevent those problems from derailing progress [see Norem & Cantor, 1986]” (p. 126).

Norem (2008) also explains how “different personalities” require the use of “different strategies” for adaptive functioning: compared to those who deploy strategic optimism,13 defensive pessi- mists report greater degrees of trait anxiety, neuroticism, lower self‐esteem, and negative affect in general; they also “generate more negative potential outcomes and plans” (p. 124). And it is those crucial findings that tend to be under (or un)appreciated:

By themselves, those results do little to demonstrate that defensive pessimism is more than a generally negative view of self and the world; this raises the question of why those using the strategy cannot just “lighten up,” especially given that they typically perform as well as the strategic optimists. . . . Yet, just as saying “hey, relax” to an anxious person rarely helps, the research evidence makes clear that simply trying to be more optimistic will not work for defensive pessimists. (pp. 124–125)

Of equal importance, Norem delineates the effects of positive versus negative manipulations – that is, interventions – with defensive pessimists:

Attempts to disrupt or make more optimistic any component of their strategy seem to interfere with the defensive pessimists’ performance, and lower their satisfaction after the fact. . . . (Further analyses showed that anxiety indeed mediated these results.). (p. 125)

And so it should come as no surprise that Norem’s extensive findings point to a familiar punch line, namely, one size does not fit all. Surely this is as true of coping as it is of clothing: “Both defensive pessimists and strategic optimists perform best when allowed to pursue (or avoid) mental simulation according to their preferences” (p. 126). This conclusion hardly shocks. Yet that circumstance‐dependent message is lost on those committed to “accentuating the positive.” Referring expressly to mood, Norem (2008) warns of the dangers of “cheering up” defensive pessimists:

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While it is possible to put defensive pessimists in a better mood, doing so leads to poorer performance (Sanna, 1998; Norem & Illingworth, 2004). . . . Defensive pessimists appear to use their negative feelings as a cue to work harder, which then typically leads to better performance. (p. 126)

With their determination to enhance adaptive functioning, one might think that positive psychologists would happily embrace Norem’s extensive findings about defensive pessimism. Instead, her findings are most commonly ignored (e.g., Linley & Joseph, 2004a; Parks & Schueller, 2014), especially in positive psychology’s aforementioned canonical texts, or when mentioned, they tend to be dismissed as “negative” and thus problematic.14 For example, early on Scheier and Carver (1993) certainly conceded that “defensive pessimism does seem to work,” in that defensive pessimists perform better than “real [i.e., dispositional] pessimists.” But they also said that “people who use defensive pessimism in the short run report more psychological symptoms and a lower quality of life in the long run than do optimists. Such findings call into serious question the adaptive value of defensive pessimism” (p. 29). And more recently, Peterson and Seligman (2004) weighed in critically.15 The problem is, the evidence does not support Scheier and Carver’s and Peterson and Seligman’s claims. For example, Norem and Chang (2002), in comparing anxious people who used defensive pessimism to those who did not, found that

defensive pessimists show significant increases in self‐esteem and satisfaction over time, perform better academically, form more supportive friendship networks, and make more progress on their personal goals than equally anxious students who do not use defensive pessimism. . . . Taking away their defensive pessimism is not the way to help anxious individuals. (p. 997)

Norem readily concedes precise benefits and costs of both strategic optimism and defensive pessimism. We may therefore ask why the negatives of defensive pessimism are typically consid- ered “true negatives” by positive psychologists who discuss Norem’s findings, whereas the negatives of strategic optimism tend to be ignored by positive psychologists who compare defensive pessimism, a context‐dependent coping strategy, to dispositional/traitlike optimism instead of to strategic optimism or to the functioning of anxious persons who do not use defensive pessimism (see Scheier & Carver, 1993, p. 29 and Held, 2004, pp. 23–24).

Norem (2014) reminds us that an important question for adaptive functioning is what negative thoughts and affects do, what kind of functioning they motivate, not simply how they feel. Thus, we should consider functionality itself to be an important outcome category, distinct from affect. In particular, Norem (2014, p. 259) acknowledges the “hedonic failure” of defensive pessimism, but asks us to consider how it improves adaptive functioning nonetheless. Of interest is that this distinction between hedonic and functionality variables permeates the positive psychology literature as well, in the distinction between “subjective well‐being” and “psychological well‐being,” respectively (e.g., Ryan & Deci, 2001).

Not surprisingly, Norem (2014) now wishes that she had not used the term “defensive pessimism,” because “defensive” is too negative:

If I could go back in time, I would change the name defensive pessimism to reflective pessimism, as opposed to non‐reflective optimism. . . . By choosing defensive to label the pessimistic strategy we were studying, but strategic to label the optimistic counterpart, we inadvertently implied that there was something better (i.e., more “strategic”) about strategic optimism compared to defensive pessimism before we had gathered any data. (pp. 265–266, n. 4)

I would add to this that the term “pessimism” can be poison to positive psychologists who cannot get past their toxic reaction, even when confronted with the undeniable positives of defensive pessimism.16

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And so we see that terminology matters. Norem is surely most prominent among those who study the “positive power of negativity.” And the failure of positive psychologists to integrate, or better still to synthesize, Norem’s consistent findings across three decades of research into their own research is the single most glaring example of how what is deemed negative a priori by them cannot possibly contribute to bona fide positive functioning. That is because positive functioning for them logically entails enhancing, via “positive” interventions, what they deem to be in “positive” territory, and anything less remains in “negative” territory, even if that territory becomes significantly less “negative.”17 Put differently, if allegedly “negative” interventions and states can be demonstrated to enhance adaptive/constructive – dare I say positive – outcomes/ functioning, then the entire positive psychology enterprise collapses.

A More “Integrative” Research Program

Earlier I asked what positive (clinical) psychologists mean by integration, and why they seek integration. Recall that Wood and Tarrier (2010, p. 280) express a common‐sense view of integration, namely, “a balanced and equally weighted focus on the positive and negative aspects of life,” so that we should use both “positive” and “negative” interventions in practice. But just what are the “positive and negative aspects of life”? As Norem demonstrates, what is positive/ functional for some, may be negative/dysfunctional for others, even within any given situation. Again, the assumption that positivity and negativity have stable meanings/referents independent of circumstantial particularity does not hold in psychology. And as I said earlier, the need for this integration, or combined use, would not press if positive psychologists had not made the ontologically dubious move of carving psychological reality a priori into positive and negative components, which components then must be put back together again, much like Humpty Dumpty, alas.

One possible reason for seeking integration besides putting psychological reality back together again is the desire to be comprehensive or complete, as an empirical precondition not to disregard or exclude, on ideological grounds, any aspect of reality, as any legitimate science should strive to do. But scrapping the divisive and dubious positive/negative distinction altogether does not seem to be an option or even to occur to those who seek a more complete clinical science via such integration.

As an antidote to all this, what if psychologists seeking to integrate negative/clinical interventions with positive interventions studied how clinicians might work with, not against, “negative” thinking, moods/emotions, and coping styles? Could this prescription have the potential to ground a more comprehensive research program?

In The Positive Side of Negative Emotions, editor Gerrod Parrott (2014) compiled twelve chapters written by psychologists who, taken collectively, have conducted three decades of research in which they demonstrate how various negative emotions – including sadness; anxiety; such social emotions as embarrassment, shame, guilt, jealousy; and negative coping styles such as defensive pessimism – can be functional/adaptive.18 Since people seeking treatment often experience emotions and thoughts (and behave in ways) that are bothersome (to someone), it seems obvious that this line of research would be a prime candidate for integration into a positive clinical psychology, to work with each patient’s tendencies (both positive and negative) as well as against them. But as with Norem’s findings, to my knowledge this has not yet come to pass, at least not in any sustained, thoroughgoing way.

In his preface, Parrott begins conceptually by examining what is meant by positive versus negative emotions. He notes that there is agreement historically about which emotions are negative and which are positive (Colombetti, 2005).19 However, there is disagreement about “what makes an emotion positive or negative” (p. x). Regarding the criteria or boundary condi- tions for the use of these two terms, he cites Solomon and Stone (2002), who

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40 Barbara S. Held

listed 18 ways in which positive and negative emotions have been distinguished. Some of the distinctions are ethical: virtue versus vice, right versus wrong, socially approved versus socially unacceptable. Other distinctions … focus more on the emotions’ effects: healthy or unhealthy, calming or upsetting, strength- ening or weakening, satisfying or dissatisfying, motivating approach or motivating avoidance. Yet other interpretations focus on the various appraisals and judgments that are attached to the emotions: is the situation in accord with one’s wishes or not. . . . Positive and negative have also been taken to refer to qualities of phenomenal experience: perhaps the former emotions are pleasant whereas the latter are painful. (Parrott, 2014, p. x)

Of prime empirical importance, Parrott adds, “One commonality is that both positive and negative emotions can be either functional or dysfunctional,” and so he is keen to study the “factors that help determine when an emotion will work adaptively in a particular context” (p. xiii).

Parrott does not reject the distinction between positive and negative emotions, and so some may charge him with perpetuating the dubious dualism. However, he and his contributors do not use it a priori, but rather in regard to circumstantial demands, both interpersonal and intrapersonal, thereby allowing negative emotions to have positive consequences. The retention of this non‐a priori use of positivity and negativity can be seen as a corrective step along the way to a more complete (and objective) psychological science, just as Wood’s and Tarrier’s (2010) call for integration can be seen as a corrective step, albeit one that is less radical. In any case, in addressing what psychologists might mean when they expressly categorize emotions as either positive or negative, Parrott says that the aforementioned eighteen senses of positive and negative are problematic because they “do not categorize the same emotion consistently. For example, anger can be painful or pleasurable or both, depending on the circumstances, so phenomenal experience does not explain why anger is considered a negative emotion” (p. x).

What is needed is of course a “consistent basis for justifying why each emotion is classified as positive or negative,” and Parrott finds “the most useful criterion [to be] the situation’s perceived compatibility with a person’s needs, goals, and values: negative emotions generally involve inter- preting something as being against one’s wishes” (p. xi). Needs, goals, values, and wishes are all highly pertinent to agency, the enhancement or restoration of which, I said at the outset, may arguably be seen as an overarching goal of all (clinical) psychological interventions. If this is so, then perhaps yet another answer to the “why” question of integration is to enhance agency as robustly as possible, in which case, I submit, the muddled positive/negative distinction hinders rather than helps. Put differently, if the overarching goal of clinical psychological interventions is agency, then that goal should reflect the aspect of reality to which that goal is applied. And the ontologically dubious conceptualization that carves reality into positive and negative domains, in which, as we have seen, “negativity” can enhance “positivity” and vice versa (Norem, 2008; Parrott, 2014), is, I again submit, not a conceptualization of reality that clearly or rationally serves that goal. With this in mind, I turn to consideration of rational agency in clinical psychology.

Agency and Psychological Interventions

Parrott’s preferred criterion for classifying an emotion as positive or negative resides in agency’s neighborhood, if not in the same house. As I have been using the term, agency consists in the ability to deliberate about one’s goals (usually based on one’s desires) and then act on the products of those deliberations. In deliberating about and acting on a goal rationally, one’s beliefs about how best to fulfill (or not to fulfill) a desire should be in accord with reality and each other and with what action (or nonaction) is realistic, given the circumstances.20 Rational agency may thus be said to entail self‐control/autonomy, which is surely a component of the executive functioning and psychological flexibility on which psychological well‐being necessarily depends (Joseph & Wood, 2010, pp. 834–835; Kashdan & Rottenberg, 2010, pp. 870–873).

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If this is so, restoration of agency, to whatever degree, must be at the conceptual core of a positive clinical psychology – or, in my parlance, of most if not all kinds of psychological interventions, whether they are considered positive or negative by anyone.

Being an agent, one who acts with intention/self‐control/autonomy, may now be said to depend on one’s rational agency. The inability to act rationally, then, means that one cannot be an agent, in which case one cannot act at all. To clarify, K. W. M. Fulford (1994) proposed that delusions, which, he asserts, are “the paradigm symptoms of mental illness” (p. 205), reflect a lack of agency, in that the delusional person lacks good reasons for his or her actions (at least in the delusional domain), and in so lacking lacks action itself (in the delusional domain). This is so because for Fulford (and other philosophers) bona fide action (logically) entails good/rational reasons for that action. So, no (rational) reason for an “action,” no action – period. (In which case the term “rational agency” or “rational action/acts” is redundant; agency/action entails reason/rationality.) Indeed, loss of agency as broadly defined here may be thought of as a superordinate characteristic of mental illness and psychological distress, in their diverse mani- festations. Put differently, loss of agency entails loss of personhood, which depends on agency (Evnine, 2008; Held, 2010), to return to Aldo Llorente, with whom we began.

Since Parrott’s contributors demonstrate how various negative emotions may, in their relevant circumstances, contribute to adaptive functioning and thus to rational action/agency, we may again wonder why positive psychologists of all stripes have not been happily inclined to integrate this large body of research into their research programs rigorously. One reason may be the blinders worn by many of them owing to their a priori understanding of the terms “positive” and “negative.” Alternatively, if most positive psychologists have been aware of this research and have deliberately chosen not to entertain it seriously, then they may not be quite as integrative/ inclusive as they may suppose.

Conclusion

To advance a comprehensive science of clinical psychology in which agency gets top billing, it is just as important to study the adaptive/constructive enhancement of “negativity” as it is to study the adaptive/constructive enhancement of “positivity.” I would therefore broaden Wood’s and Tarrier’s conceptualization of integration: in addition to their proposed use of both “positive” interventions, those that directly target enhancing “positive” states, and “negative”/ clinical interventions, those that directly target diminishing “negative” states, I propose the use of what I will now call “positive–negative” interventions, those that directly target enhancing “negative” states that benefit adaptive/constructive/rational or “positive” functioning, as in the case of defensive pessimism interventions for anxious people.

All of these I prefer to call “psychological interventions,” in a synthesizing semantic/ conceptual move that allows what has been labeled “negative” to be construed as “positive” (and vice versa) where warranted – if we absolutely must continue to use the misleading termi- nology of “positivity” and “negativity” in psychology.

Notes

1 The author thanks Michael Katzko, Robert Sheehan, Lisa Osbeck, and William Meehan for their helpful comments on earlier drafts of this manuscript. Thanks also to Emily Martin for her help in the preparation of the manuscript itself.

2 Accordingly, I sometimes place the terms “positive” and “negative” and their variants in scare quotes, especially when I want to emphasize the misleading and dubious meanings given to them by positive psychologists.

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42 Barbara S. Held

3 The term “positive clinical psychology” suggests that “clinical psychology” is actually “negative clinical psychology,” meaning it does not employ positive psychology interventions, as defined above.

4 Seligman, Rashid, and Parks (2006) state, “Positive Psychotherapy (PPT) contrasts with standard interventions for depression by increasing positive emotion, engagement, and meaning rather than directly targeting depressive symptoms” (abstract, p. 774). Smith, Harrison, Kurtz, and Bryant (2014) state, “By positive intervention, we mean a structured activity ‘aimed at cultivating positive feelings, positive behaviors, or positive cognitions’ (Sin & Lubomirsky, 2009, p. 467)” (p. 45).

5 By “a priori,” I do not mean that designations of positivity and negativity in positive psychology were themselves derived independently of all experience, as in a strict definition of a priori. Instead, I mean that these designations, having been determined, are certainly used independently of the experiential/circumstantial particularities of any and all individuals to whom those designations are then applied by positive psychologists.

6 Wood and Tarrier state, “Positive psychology research can best impact on the scientific knowledge base of psychology, and be utilized to improve people’s lives, if it avoids becoming embroiled in a movement and rather becomes fully integrated with the daily research and practice of mainstream disciplines (so that positive functioning is included alongside negative functioning in research designs, and increasing the positive is as impor- tant a focus of therapy as decreasing the negative)” (p. 820). In Authentic Happiness, positive psychology movement founder Seligman (2002) himself calls for integration and balance: “Positive Psychology aims for the optimal balance between positive and negative thinking. . . . Positive psychology is a supplement to negative psychology, not a substitute” (pp. 288–289, n. 96).

7 Vella‐Brodrick (2014) challenges the “positive and negative divide” and calls for its removal: “The divide between positive and negative is not helpful or representative of best prac- tice and more work is needed to remove this dichotomy and create a more blended and inclusive concept of mental health” (p. 421). But then she reinstates that very dualism by “emphasizing the need for positive processes” (p. 421).

8 I return to “b” in my discussion of the relation of goals and motivations to what is considered positive and negative.

9 Fredrickson (2009) and Fredrickson and Losada (2005) touted the evidence for this theory repeatedly in the now‐famous 3:1 and 12:1 ratios of positive to negative emotions (i.e., “tipping points”), in which only scores within those ranges allegedly predict “flourishing.” In their debate, Fredrickson’s and Losada’s (2005) “nonlinear dynamic model” of positive emotions was challenged convincingly by Brown, Sokal, and Friedman (2013). As Brown and colleagues (2014) summarize, “Fredrickson and Losada (2013) withdrew [that] model, but Fredrickson (December 2013) reaffirmed some claims concerning positivity ratios on the basis of empirical studies” (p. 629), which “evidential” basis they also challenge clearly and dismiss convincingly.

10 Barlow (2010) said, “Greater emphasis on more individual idiographic approaches to studying the effects of psychological interventions would seem necessary if psychologists are to avoid harming their patients” (abstract, p. 13; emphasis added).

11 McNulty and Fincham (2012) demonstrate how forgiveness, optimism, benevolent attributions, and kindness – favorite “positives” of positive psychologists – have backfired. Also see Held (2013).

12 Linley and Joseph (2004b) designate “optimal functioning” the “desired outcomes of positive psychology” (p. 5).

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13 Norem (2008) defines strategic optimism as a strategy used by people who “do not feel anxious or out of control in performance situations, . . . set high expectations, and … avoid thinking very much about what might happen, whether good or ill. They do what they need to do, without the effort of mentally simulating various possible outcomes (but … they also begin without the defensive pessimists’ anxiety)” (p. 124).

14 See Held (2005, pp. 9–10) for quotation of positive psychologists (e.g., Aspinwall & Staudinger, 2003; Gable & Haidt, 2005) who speak of defensive pessimism with unquali- fied approbation.

15 Peterson and Seligman (2004) said, “We do not deny that defensive pessimism can prove useful in some circumstances, but the relevant research also shows that defensive pessimists annoy others” (p. 528). They evidently miss the point of defensive pessimism, which is to decrease debilitating anxiety so as to improve functioning. And need it be said that optimists can be annoying?

16 Seligman (2002) said, “Pessimism is maladaptive in most endeavors. . . . Thus, pessimists are losers on many fronts” (p. 178).

17 As Seligman (2002) put it, “Lying awake at night, you probably ponder, as I have, how to go from plus two to plus seven in your life, not just how to go from minus seven to minus three and feel a little less miserable every day” (p. xi).

18 For earlier research on the benefits of negative emotions conducted by contributors to Parrott (2014), see, for example, Forgas (2007) on sadness, Perkins & Corr (2005) on anxiety, Van Kleef and Côté (2007) on anger, and Tamir and Ford (2009) on fear.

19 Typically, negative emotions include “fear, anxiety, loneliness, guilt, shame, embarrassment, regret, disappointment, sadness, envy, jealousy, disgust, scorn, anger, frustration, and irritability,” and positive emotions include “pride, contentment, relief, hope, exhilaration, delight, eagerness, amusement, cheerfulness, happiness, wonderment, desire, admiration, infatuation, and love” (Parrott, 2014, p. x).

20 One can have defective desires, which are by definition irrational and so should not be pursued. See Erwin (2011) for a detailed exposition of defective desires, especially in psychotherapy.

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For the past 30 years clinical psychology research and practice has largely been driven by the psychiatric terminology of the Diagnostic and Statistical Manual, now in its fifth edition (American Psychiatric Association, 2013). What this has meant is that clinical psychologists have traditionally not been concerned with the promotion of well‐being, but with the alleviation of disorder, leading to a call for clinicians to go beyond the zero point in their assessment of psychopathology (Joseph & Lewis, 1998). Since the introduction of the positive psychology perspective (Seligman, 1999; Seligman & Csikszentmihalyi, 2000), there has been an increasing emphasis in psychology on the promotion of optimal functioning defined by the presence of certain emotions, cognitions, and behaviors.

At first glance, the study of positive psychology would seem not to be of concern to clinical psychologists, but indications are that the positive psychology perspective can add value to clinical practice (Duckworth, Steen, & Seligman, 2005). It may be that interventions to increase positive functioning can help to alleviate disorder in some patients where traditional methods have not worked, or where an increase in well‐being may help to prevent future relapse. But it is not only in the pursuit of the traditional goals of clinical psychology to alleviate disorder or prevent relapse that the positive psychology perspective promises to be useful; the promotion of well‐being may also be a goal of value in itself to clinical psychology (Joseph & Linley, 2006a). As such, the agenda of clinical psychology has begun to change as the ideas of positive psychology permeate practice and research.

There is a need for clinical psychologists to introduce the measurement of optimal functioning. As straightforward as this may sound, it requires consideration of the theories underpinning clinical psychology practice and research. Our approach to this task is influenced by humanistic psychology, which allows us to step back from the medical model assumptions of traditional clinical psychology and consider alternative meta‐theoretical views that may be better suited to the development of a positive clinical psychology.

In this chapter we will: (1) discuss the place of meta‐theory in clinical psychology, followed by (2) an examination of the three different ways in which clinical psychologists can introduce measures and assessment procedures into their research and practice, and, finally, (3) a discussion of the implications for professional identity.

A Practical Guide to Positive Functioning Assessment in Clinical

Psychology Stephen Joseph and Tom G. Patterson

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48 Stephen Joseph and Tom G. Patterson

The Place of Meta‐Theory

By meta‐theory what we mean are the deep‐seated core assumptions underpinning practice and research. In this respect, clinical psychology has traditionally been grounded in the medical model (Joseph & Linley, 2006a). As familiar as the term “medical model” is, it is worth spending some time describing what we mean by the medical model as in our view it is often misunderstood.

In short, the medical model is the idea that problems in living are akin to physical disorders. When we suffer from physical disorders we visit a practitioner who, because of their expert status, is able to identify the nature of our disorder and prescribe the appropriate treatment. If, for example, we have a stomach complaint we might be given indigestion tablets. If we have a broken leg we need to have it set in plaster so that the bone can heal. When we apply the medical model as a metaphor to psychology we do exactly the same – the practitioner must be expert in the different ways in which people experience problems in living so that they are able to dispense the correct treatment. So it is that textbooks lay out their contents according to psychiatric categories of disorder with summaries of research into the causes and treatments of those specific disorders.

It is true that recent debate within the clinical psychology profession has led to challenges to the medical model (e.g., Bentall, 2003; Marzillier, 2004; Johnstone, 2014). However, typically, leading texts on clinical and abnormal psychology, including the present volume, continue to be arranged according to clinical disorders: anxiety disorders, somatoform and dissociative disorders, mood disorders, personality disorders, substance‐related disorders, psychotic disorders, and so on. Within such textbooks, it is a taken for granted assumption that it is only through understanding the causes and treatments for each specific disorder that we can conduct research and find the most helpful treatments. Thus, even in a volume such as the present one, which proposes that we seek new positive psychological approaches, there remains an implicit medical ideology at the core.

The fact that the medical model became the dominant way of thinking about psychological problems is not surprising given the important historical role of psychiatry as a branch of medicine and its gatekeeper function over healthcare. Clinical psychology in its early history was servant to psychiatry and, as such, it is understandable that as it developed professionally over the years it took the metaphor of the medical model forward. By doing so, it may have served its own interests well in helping to establish itself as a mainstream profession alongside psychiatry. In contrast, counseling psychology with its roots in the humanistic tradition and its explicit rejection of the medical model struggled to find a similar status (Vossler, Steffan, & Joseph, 2015). Ironically, as clinical psychology moves toward challenging the medical model assumptions at its core and looks to positive psychology to provide a new vision for its practice, it now follows in the footsteps of counseling psychology several decades earlier.

However, after several decades of adopting the medical model, clinical psychology is well established internationally as a profession in its own right and no longer servant to psychiatry. Even so, the medical model remains a pervasive influence in clinical psychology. This last statement might surprise many readers who would see clinical psychology as having moved beyond the medical model, but what they often tend to mean is the biomedical model.

The biomedical model applies the same logic as the medical model, but additionally assumes a biological cause. The medical model as we have described it does not necessarily imply a biological cause. What is medical is that the approach taken is metaphorically a medical one requiring diagnosis and prescription. For example, an approach to depression and anxiety based on viewing them as distinct disorders requiring disorder‐specific psychological treatments is a medical model approach.

It is also true that the current context of the clinical psychology profession in the United Kingdom, which practices predominantly within the National Health Service (NHS), may serve

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Positive Functioning Assessment in Clinical Psychology 49

to promote the continuation of medical‐model informed approaches to mental health difficulties. For example, NHS services and professionals are expected to follow the National Institute for Health and Clinical Excellence (NICE) guidelines on the therapies or “treatments” considered effective for mental health difficulties, and these in turn are often based on evidence from randomized control trial (RCT) research designs that can often reinforce medical model conceptualization of mental health difficulties.

Diagnosis and prescription are terms that many clinical psychologists will not identify with and as such may not view themselves as medical model practitioners, and certainly there has been much criticism from within clinical psychology of the limitations of narrow diagnostic approaches over recent years (e.g., Bentall, 2003; Marzillier, 2004; Johnstone, 2014). However, clinical psychology does concern itself with formulation, an approach to making sense of the client’s distress and mental health difficulties.

Formulation is a broad concept, perhaps best considered as a continuum. At one extreme it is akin to person‐centered practice insofar as the client takes the lead in understanding their situation and the therapist offers no intervention as the client’s understanding is sufficient to drive the therapeutic process forward (see Sanders & Joseph, Chapter 28, this volume). At the other extreme, it is akin to medical model practice as the therapist takes the lead in formulating the problem and offering the solution. It is important to acknowledge that, between these two extremes, there are many different approaches to formulation and also that the importance of collaborative development of a formulation and of respecting service users’ views about accuracy and helpfulness of the formulation has been increasingly emphasized in recent years (Johnstone & Dallos, 2006; Division of Clinical Psychology, 2011) and underpins many clinical psychologists’ approach to formulation.

Formulation in clinical psychology increasingly attempts to value clients’ perspectives in making sense of difficulties. For example, clinical psychologists adopting a social constructionist informed perspective such as in systemic formulation do not assume that a position of certainty can be reached, but will instead strive to collaboratively develop working hypotheses that are constantly open to revision, drawing upon social and relational factors while also recognizing that the therapist’s assumptions and values are inherently present in any hypothesis (Johnstone & Dallos, 2006). However, it is important to emphasize that whenever guided by a professional‐as‐expert stance, formulation simply becomes another form of medical model practice, insofar as it requires the practitioner to apply his or her expert knowledge to understand a client’s problems in such a way as to recommend the best course of treatment.

By turning our attention to well‐being we have the opportunity to rethink our adherence to the medical model, but a further misunderstanding is that positive psychology is by definition not a medical model approach (Joseph & Linley, 2006b). Insofar as we seek to find ways to prescribe interventions for people to increase certain aspects of well‐being, positive psychology is also grounded in the medical model. Instructing people to use gratitude exercises, for example, to overcome depression may make use of positive psychology, but it does so within a medical model framework.

As already noted, even this book on positive clinical psychology continues to propagate the notion of the medical model insofar as it, like traditional texts, is structured in terms of psychiatric categories. An alternative meta‐theoretical framework to the medical model is the humanistic person‐centered approach that posits that people are intrinsically and naturally motivated toward their full potential and optimal functioning unless this tendency is usurped and thwarted by social environmental conditions leading to incongruence between self and experience (Joseph & Worsley, 2005a). As such, the person‐centered approach is a nonmedical model as there is no need for specific diagnosis and prescription of specific treatments as all psychological problems result from this same underlying cause – incongruence between self and experience or self‐alienation (Joseph, 2015).

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It may be that how problems in living manifest are different from person to person in the ways described in the typical clinical psychology text book, but this is an irrelevant observation for person‐centered therapists insofar as the problems are always at root caused by alienation between self and experience. For those that adopted the humanistic approach, diagnosis was often rejected because the medical model was rejected. If, as in the person‐centered tradition, all problems in living stem from inauthenticity there is no need for diagnosis because there is no need to determine specific treatments for specific problems. In person‐centered psychology this is known as the specificity myth as it is understood that all psychological problems can be helped through accepting, empathic, and genuine relationships that foster the client’s agency (Bozarth & Motomasa, 2005). This approach, which has been at the core of person‐centered psychology for over 50 years, emphasizes the therapeutic relationship over and above the use of techniques (Sanders & Joseph, Chapter 28, this volume).

The point is that the core issue when considering measurement is always first and foremost a consideration of underpinning theoretical frameworks and thus the selection of theory consistent instruments and assessment procedures (Patterson & Joseph, 2007; Joseph, 2015). As such, clinical psychologists have traditionally tended to work within the medical model framework and use diagnostically based measurement, whereas counseling psychologists when they have used measurement have tended to prefer those that emphasize growthful functioning, authenticity, and the ways in which people find meaning and purpose.

Next we will offer the reader a practical framework for the selection and use of various measurement tools. We will summarize what we see as the most important theoretical issue confronting the positive clinical psychologist: whether the positive psychology perspective adds value to the existing business of clinical psychology, but does not change its essential medical model nature, or whether the positive psychology perspective revolutionizes the way clinical psychologists conceptualize people’s problems.

Three Forms of Measurement

First, the most obvious approach is to introduce new measures of positive functioning alongside existing clinical scales. For example, there are several measures of well‐being and life satisfaction available that have proved popular among positive psychologists (e.g., Diener, Suh, Lucas, & Smith, 1999; Lyubomirsky & Lepper, 1999; Tennant, Hillier, Fishwick, Platt, Joseph, Weich, Parkinson, Secker, & Stewart‐Brown, 2007). This would seem to be an obvious way forward, but it can be problematic. The needs of the positive psychologist are different to those of the positive clinical psychologist. Positive psychologists may choose these new measures without necessarily having to consider their conceptual relationship to psychopathology. For the positive clinical psychologist, however, this consideration should be uppermost in their mind. Otherwise, the danger is that measures are selected that are derived from incompatible theoretical frameworks. For example, in recent years the study of post‐traumatic growth has gained attention as researchers and clinicians seek to understand how people may thrive in the aftermath of adversity. It is relatively easy to select both measures of post‐traumatic stress disorder and post‐traumatic growth for inclusion in the same study. No alarm bells ring if you do this. It is relatively easy to administer paper‐and‐pencil tests and then conduct statistical analysis on the association between measures. It is not unusual to see such studies. But this is to misunderstand that the concepts themselves can be understood from mutually exclusive paradigms such as the medical model and humanistic psychology, respectively, and as such it is like mixing oil and water (Joseph & Linley, 2005, 2006b).

What does it mean to say that a medical model construct such as post‐traumatic stress disorder is correlated with a humanistic construct of posttraumatic growth? Such data can be interpreted

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Positive Functioning Assessment in Clinical Psychology 51

only from one of these mutually exclusive paradigms. Either post‐traumatic growth is viewed through the lens of the medical model, or post‐traumatic stress is seen through a humanistic lens. This can be seen most clearly in the evidence wars for the effectiveness of therapies for specific treatments when outcomes are defined in terms of medical model categories regardless of their meta‐theoretical assumptions. However, reliance on symptom reduction as the key indicator of effectiveness in research into therapeutic effectiveness implies an assumption that symptom reduction is a neutral concept that is shared by all the different therapeutic approaches. This assumption of neutral objectivity is erroneous in the same way that claims that a neutral language of scientific observation exists have been shown to be erroneous (Popper, [1959] 1980). For example, how do humanistic therapies compare with cognitive therapies in the treatment of depression? Traditionally, the answer to this question would be determined on that basis of comparison of “treatments” using RCT studies with symptoms of depression as the measured outcome. This approach was developed within a biomedical model paradigm, initially to compare treatments for physical illnesses and later extended to study effectiveness of treat- ments for mental health difficulties. The choice of depression as the outcome is, however, not theoretically compatible with those humanistic therapies that do not conceptualize problems as symptoms of disorder, but as problems of self‐alienation and lack of authenticity (Joseph & Wood, 2010).

Despite the fact that humanistic therapies do not focus on symptom reduction as the key indicator of therapeutic effectiveness, approaches such as client‐centered therapy still perform relatively well in RCT studies (see, e.g., Elliott, 1996; Friedli, King, Lloyd, & Horder, 1997; King, Sibbald, Ward, Bower, Lloyd, Gabbay, & Byford, 2000; Sanders & Joseph, Chapter 28, this volume). However, that does not mean we should ignore the fact that the basis for comparison in such studies is a conceptualization of mental distress and an indicator of recovery that is not congruent with nonmedicalized approaches. A more balanced question, one that respects the different paradigms within which each of these therapeutic approaches has evolved, would be how do these therapies compare in the facilitation of authenticity and the treatment of depression? In this latter way, each therapy is evaluated on the basis of its own epistemological framework and that of the other therapy.

The second way in which clinical psychologists can introduce positive psychology into their practice is to re‐evaluate their existing tools. Some existing clinical measures may already be inadvertently assessing positive functioning. An example of such a measure would be the Center for Epidemiological Studies Depression Scale (CES‐D, Radloff, 1977). The CES‐D is one of the most widely used tools to measure depression. The CES‐D consists of twenty items, sixteen of which are negatively worded (e.g., “I felt sad”; “I felt I could not shake the blues even with help from my family or friends”; “I thought my life had been a failure”), and four of which are positively worded items (“I felt happy”; “I enjoyed life”; “I felt that I was just as good as other people”; “I felt hopeful about the future”). Scoring of the CES‐D involves reverse coding the positive items and totaling all items to form a single score ranging from 0 to 60. A score of zero means that the respondent has rated all negative items as “rarely or none of the time” and all the positive items as “most or all of the time.” As such, it is evident that a score of zero does not simply indicate the absence of depression, but also the presence of happiness. Researchers have traditionally used the CES‐D to measure levels of depression, but have not paid attention to the fact that it can equally be conceptualized as a measure of happiness (Joseph, 2006, 2007), a fact supported by a factor analysis conducted during the initial development of the measure that identified “positive affect” as one of four underlying factors that together account for 48% of the total variance in the scale (Radloff, 1977; see also Wood, Taylor, & Joseph, 2010). Thus, one can imagine how by a re‐evaluation of existing instruments in light of positive psychology it will be possible to select instruments that serve a dual purpose. By selecting such instruments it is possible to accommodate the ideas of positive psychology. However, the challenge of this approach is that it requires us to reconceptualize what it is that we are measuring in the first place.

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Depression in psychiatric terms is a categorical variable, but it is not unusual for psychologists to assess depression dimensionally. An example of this is the use of the Beck Depression Inventory (BDI; Beck, Ward, Mendelson, Mock, & Erbaugh, 1961), a widely used measure of depression. Originally developed as a taxonomic tool, it has since been used in many studies to provide a dimensional score of depressive experiences. Scores on the BDI have a potential range of 0 to 63. A score of 63 indicates intense depressive experience, whereas a score of 0 indicates the absence of depression. But a score of zero on the BDI does not imply positive functioning (Joseph & Lewis, 1998). What does it imply if we think of depression dimensionally and more importantly what is the nature of that dimensional construct? As discussed, the CES‐D goes beyond the zero point of the absence of depression to the presence of happiness. At a practical level such an approach has its uses as it allows clinicians to seemingly maintain their business as usual approach while incorporating positive psychology, but at a theoretical level such an approach is more complex as it challenges the original conceptualization of the measure. In the case of the CES‐D, the implication is that the constructs of depression and happiness are essentially synonymous, representing opposite end‐points of a single continuum (Wood, Taylor, & Joseph, 2010). As such it may be that one rejects the traditional psychiatric system for its neglect of the positive aspects of living, and for painting an incomplete and skewed portrayal of clients, but nonetheless adopts the medical model (Joseph & Linley, 2006b). The medical model need not be a deficit‐based approach. Positive clinical assessment within the medical model can explore strengths as well as weaknesses.

The idea that depression and anxiety can be studied dimensionally in this way offers a useful positive clinical psychology perspective (Joseph & Wood, 2010). Such a measure is the twelve‐ item Positive Functioning Inventory (Joseph & Maltby, 2014), which addresses the traditional needs of clinical psychologists to assess levels of depression and anxiety, but within a framework of positive psychology that recognizes that when assessed dimensionally, these are statistically bipolar continuous states with happiness and contentment.

Going beyond the specific categories of depression and anxiety, one groundbreaking example of a comprehensive nondeficit strengths‐based approach to the medical model is presented by Rashid (2015), who conceptualizes symptoms of major psychological disorders in terms of lack or excess of strengths. For example, depression can result, in part, because of lack of hope, optimism, and zest, among other variables; likewise, a lack of grit and patience can explain some aspects of anxiety, and a lack of fairness, equity, and justice might underscore conduct disorders. The above are approaches that are consistent with the language of the medical model, but extend thinking to new forms of continuous assessment with a positive psychology focus.

The third way is to use measures developed specifically for positive clinical psychology, which move away from diagnostic terminology and the medical model and are developed on the basis of new understandings of well‐being. The humanistic approach is one such example, particularly person‐centered psychology with its meta‐theoretical perspective of actualization as the core motivation underpinning psychological development (Joseph & Linley, 2006a). Specifically, there is an important philosophical distinction to be made between hedonic well‐being and eudaimonic well‐being, or subjective well‐being (SWB) and psychological well‐being (PWB), respectively, in the contemporary language of positive psychology. As illustrated in the section above, the traditional focus of clinical psychology has been on SWB, which has been conceptualized as decreasing negative affective states such as depression and anxiety, and, more recently, drawing upon positive psychology to also increase positive states such as happiness and contentment.

In contrast, PWB reflects engagement with the existential challenges of life (see Ryan & Deci, 2001), and is often operationalized as involving autonomy, self‐acceptance, environmental mastery, purpose in life, positive relationships with others, and personal growth (Ryff & Keyes, 1995). Although SWB and PWB are related, philosophically (Ryff & Keyes, 1995; Ryff & Singer, 1996) and empirically, they can be considered separable (Waterman, 1993; Compton, Smith, Cornish, & Qualls, 1996; Keyes, Shmotkin, & Ryff, 2002).

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Previously, while SWB has been the focus of clinical psychology, PWB has been the focus of humanistic and existential psychology (e.g., Rogers, 1959; Joseph, 2015). But with the emergence of positive psychology and now positive clinical psychology, in conjunction with challenges to the illness ideology, clinical psychologists are beginning to rediscover the ideas of humanistic and existential psychology. For example, above we considered the difficulties in bringing together post‐traumatic stress and post‐traumatic growth as they can represent competing meta‐theoretical systems. Viewing post‐traumatic growth as an expression of the humanistic orientation we can begin to reconceptualize post‐traumatic stress as a process rather than as an outcome variable. Another example of measures based on nonmedical model frameworks is the Authenticity Scale (Wood, Linley, Maltby, Baliousis, & Joseph, 2008), which was designed to be consistent with person‐centered psychology (Rogers, 1959). Absence of authenticity is viewed as arising through a lack of congruence between conscious awareness, inner emotional and cognitive states, and the social environment, and is the cornerstone of all expressions of psychopathology that are not biological in origin (Joseph & Worsley, 2005b).

Similarly consistent with the person‐centered goal of facilitating a loosening of the client’s rigid internalized rules and values, resulting in less constrained and less contingent self‐relating, the Unconditional Positive Self‐Regard Scale (Patterson & Joseph, 2006, 2013) provides a brief and theoretically congruent measure of therapeutic change within a humanistic paradigm. As such, although humanistic psychologists such as Rogers have discussed fully‐functioning authenticity and unconditional positive self‐regard, these notions did not evolve in an organized system of clinical assessment and intervention, as in that approach there is no need for such an organized system. Indeed, such a system is contrary to the aim of therapy which is to foster agency in the client.

Professional Issues

Described above are the three ways in which positive psychology measurement can be intro- duced into clinical psychology. Each in its own way demands reflection on the rationale for the choice of measures and assumptions about how the negative and the positive relate to each other. These are also issues of professional concern, as in their different ways they redefine clinical psychology. The first approach would simply involve introducing measures of positive functioning alongside existing clinical measures. The second approach emphasizes the promotion of positive functioning within a strengths‐based approach that continues to adopt the medical model. The third approach challenges the medical model and looks to alternatives such as the humanistic approach. The latter approach is the most controversial because it challenges the nature of the clinical psychology profession and puts it into alignment with the traditional aims of counseling psychology. Historically, counseling psychology was aligned with the humanistic tradition of psychology and its emphasis on self‐actualization and fully functioning behavior.

Conclusion

While traditionally, clinical psychology has largely adopted psychiatric terminology, it has more recently started to question the medical model of mental distress, and it is now important that practitioners begin to introduce positive functioning into their practice. In this chapter we have discussed ways in which clinical psychologists can engage with this new agenda by using measures that are based on alternative conceptualizations of functioning. We find that humanistic psychology offers new ideas that can inform how to conceptualize the relationship between

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negative and positive functioning. Each tool offers a conceptualization of well‐being, either explicitly or implicitly. It is becoming ever more important to build evidence for positive change over the course of therapy. It is reasonable to expect that funders should want to see evidence for effectiveness. But how effectiveness is defined is not straightforward. Traditionally, it has been based on quite specific diagnostic criteria and the psychiatric terminology of symptom reduction, which has suited some forms of clinical practice but not all. However, we can now expect to see how outcomes are defined begin to change to include newer constructs drawn from positive clinical psychology.

In changing the outcomes that we are interested in, we also change the parameters of therapeutic engagement. Typically, clients perceive therapy as a time to talk about their distress and dysfunction and to seek ways to find relief. But in changing the discourse to be about the absence of positive functioning or authenticity, for example, expectations for therapy may change to include seeking positive changes, and to learn to value oneself unconditionally or to grow from adversity. As such, not only are such measures of positive functioning useful in tracking change, but they can also play a valuable therapeutic role if used skillfully and in the client’s interests. As clinical psychologists increasingly adopt the ideas of positive psychology we hope our discussion will prove helpful to practitioners and researchers in choosing their assessment tools.

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