CBT to Increase Optimism in Adults

Adapted from: Pretzer, J. L. & Walsh, C. A. (2001) Optimism, Pessimism, and Psychotherapy: Implications for Clinical Practice. In: Chang, E.C. (Ed.) Optimism & Pessimism: Implications for Theory, Research, and Practice. Washington, D.C.: American Psychological Association.

Interest in optimism and pessimism has increased greatly in recent years, particularly since research has provided evidence that an optimistic outlook conveys significant health benefits (Scheier & Carver, 1992) as well as benefits for psychological well-being and better performance in achievement settings (see Chang 2001).

Cognitive Therapy has traditionally focused on the impact of specific thoughts, beliefs, and cognitive distortions rather than emphasizing broad biases in cognition such as optimism/pessimism. Relatively little attention has been focused on the question of whether persistent individual differences in optimism/pessimism are relevant to psychotherapy or the question of whether such individual differences can be modified. For example, a recent volume which provides a comprehensive review of research into cognitive factors which contribute to vulnerability to depression (Ingram, Miranda, & Segal, 1998) does not explicitly discuss optimism/pessimism at all.

It is only in recent years that a few investigators have begun to consider optimism and pessimism from a Cognitive or cognitive-behavioral perspective. However, if one understands optimism and pessimism in terms of generalized expectancies (Scheier & Carver, 1992), in terms of attributional style (Peterson & Seligman, 1984), or in terms of a consistent positive or negative bias in the interpretation of events (Riskind, Sarampote & Mercier, 1996), it is not hard at all to conceptualize optimism and pessimism from a Cognitive perspective.

One of the most widely known cognitive-behavioral perspectives on optimism/pessimism has been developed by Seligman (1990). From Seligman’s perspective (1990), optimism and pessimism are a matter of the explanatory style which the individual acquires over the course of development. He argues that pessimism is a result of persistently attributing negative events to personal, pervasive, and permanent causes while optimism results from attributing misfortune to temporary, specific, and external causes.

Riskind and his colleagues (Riskind, et al., 1996) present a somewhat different Cognitive perspective on optimism and pessimism. They note that studies have found that the correlation between positive and negative thought content can be low (Ingram & Wisnicki, 1988), that a decrease in negative thinking does not necessarily result in and increase in positive thinking (Watson, Clark & Carey, 1988), and that the outcome of Cognitive Therapy is more strongly correlated with increases in positive thinking than with decreases in negative thinking (Garamoni, Reynolds, Thase, Frank, & Fasiczka, 1992). Consequently, they argue that pessimism is not simply the result of specific negative thoughts and that, in order to adequately understand pessimism and develop an effective intervention approach, the standard cognitive model needs additional development. They start from Beck’s (1967) early suggestion that rigid, absolute schemas may lead to greater vulnerability to hopelessness and pessimism and argue that some individuals hold schemas which seem to promote pessimism and/or suppress optimism. Examples would include beliefs such as “If I think too positively, I’ll just be disappointed,” “If I’m optimistic, I’ll overlook something and fail,” or “If I think positively, I’m just kidding myself.”

Riskind and his colleagues point out that when optimism-suppressing schemas are present, successful treatment could result in a reduction in negative thinking without a concomitant rise in positive thinking. In a recent study, Stewart and colleagues (1993) found that a sub-group of depressed patients who did not believe that they could positively affect their own futures responded poorly to Cognitive Therapy. Riskind, et al suggest that the impact of optimism-suppressing schemas may explain this finding and that interventions designed to address optimism-suppressing schemas and to increase the frequency of positive automatic thoughts might overcome the poor treatment response observed in “demoralized” individuals. This perspective suggests that modifications to standard Cognitive Therapy might significantly increase its effectiveness as an approach to decreasing pessimism and increasing optimism.

In terms of intervention, Seligman advocates Cognitive Therapy as a treatment approach. In fact, he goes as far as to assert that the effectiveness of Cognitive Therapy as a treatment of depression is due to Cognitive Therapy’s ability to reduce pessimism (Seligman, 1990, p. 91). Seligman seems to assume that all that a therapist needs to do in order to produce a lasting decrease in pessimism is to help the individual identify pessimistic thoughts and dispute them. He does not propose that therapists make any adaptations or adjustments to “standard” Cognitive Therapy when the goal is to decrease pessimism and increase optimism.

Fresco and his colleagues (Fresco, Craighead, Sampson, Watt, Favell, & Presnell, 1995; Fresco, Sampson, Craighead, Clark, & Enns, 1995) do not present a detailed theoretical discussion of optimism/pessimism but propose adapting standard cognitive-behavioral interventions to more directly focus on increasing optimism. The implicit assumption is that interventions which are explicitly directed towards increasing optimism will prove to be more efficient and effective than interventions which target negative thinking in the hopes of indirectly increasing optimism.

Riskind and his colleagues (Riskind, et al., 1996) present the most extensive proposal regarding how to best modify standard Cognitive Therapy in order to maximize its impact on optimism/pessimism. These authors argue that “standard” Cognitive Therapy focused on decreasing the amount of negative thinking is not necessarily sufficient to produce increases in optimism. They advocate using cognitive techniques explicitly to challenge optimism-suppressing schemas, to enhance positive thinking, and to increase optimistic thought content as a way of increasing the effectiveness of Cognitive Therapy. This perspective suggests that interventions specifically intended to increase Art’s optimism may be more effective than either interventions focused on decreasing his negative thinking and his pessimism or interventions focused on decreasing his social anxiety and improving his social skills.

There are both commonalties and differences among the approaches to increasing optimism advocated by Seligman, by Riskind and his colleagues, and by Fresco and his colleagues. Despite the differences between the approaches, it is possible to integrate them into a more comprehensive approach to increasing optimism. In doing so, it is important to note that the intervention approaches advocated by Seligman (1990) and Riskind and his colleagues (1996) are intended to be used in the context of on-going Cognitive Therapy, and that, while the approach developed by Fresco and his colleagues (1995 a, b) was designed as a self-administered treatment, the techniques used are ones which are equally appropriate in the context of on-going Cognitive Therapy. We propose integrating the three approaches to increasing optimism within a more comprehensive approach to Cognitive Therapy.

As Seligman (1990) has suggested, a variety of “standard” Cognitive Therapy interventions which focus on identifying and modifying dysfunctional thoughts can be used in an attempt to replace pessimistic thinking with more optimistic thinking. For example, in situations where Art (the on-going case example in Pretzer & Walsh, 2001) assumed that a particular woman would have no interest in him, his therapist helped him to look critically at his thoughts, to consider both any indications that she was not interested as well as any indications of interest on her part, and to draw realistic conclusions about her likely level of interest. In many situations, Art did not have sufficient information to know whether she was likely to be interested in him or not so his therapist presented the idea of initiating a conversation as a way of finding out whether there were signs of interest or not. Art was surprised to discover that several women showed interest in him.

While this type of intervention approach was initially designed to modify dysfunctional cognitions believed to contribute to psychopathology, the intervention approach is flexible enough that it can be used to increase optimism without significant modification. However, given the evidence that interventions which reduce the amount of negative thinking do not necessarily result in a corresponding increase in positive thinking (Watson, Clark, & Carey, 1988), these interventions alone may not prove sufficient to produce lasting increases in optimism.

If an individual is to adopt a less pessimistic outlook, what sort of alternative view would be best for them to adopt? Clients often assume that the alternative which the therapist has in mind is the polar opposite ( i.e. instead of expecting a negative outcome, trying to always expect a positive outcome). Is this indeed the most promising alternative? Consider our case example. Art’s tendency was to approach his date with a mindset of “I’ll be boring. She’ll have a lousy time. She won’t want to go out with me again. There’s no point to trying.” Do we want to try to get him to switch to the other extreme (“I’ll be charming. She’ll have a great time. We’ll date for a few months and then get married and live happily ever after.” )?

Certainly, if Art could believe this alternative view, it would make a big difference both in his mood and in his behavior. However, two problems are apparent. First, it is hard to imagine how Art could reach a point where he honestly believes this alternative view since it is so discrepant from his current view. Second, suppose Art was able to adopt this view, what would happen when he went on his date? It seems that there is a significant chance that his experiences on the date would disconfirm his “optimistic” view. It would appear that any increase in optimism which is based on his adopting such an extreme positive view is likely to prove to be transitory.

There are a variety of other alternatives to Art’s extreme pessimism which are worth considering (see Table 2 in Pretzer & Walsh, 2001). We would advocate working collaboratively with the client to consider the alternatives and choose a promising one to try out in real-life. Theoretically, it would seem that the ideal alternative would be one which the client finds relatively easy to believe, which results in beneficial changes in the individual’s mood and behavior, which is practical to implement in real-life situations, and which is likely to be supported by his or her experience in daily life.

To his therapist, Art appeared to be a fairly ordinary guy who was neither remarkably charming nor remarkably boring. Art and his therapist chose to combine the approaches labeled “Adopt a mildly positive view” and “Accept realistically negative aspects of the situation and plan how to cope with them” (i.e. “I’m an OK guy. Some women will be interested in me and some won’t. I should try to meet women who like me the way I am rather than trying to look cool. If I get nervous, it is better to go ahead anyway than to avoid it.” ). This alternative worked well in real-life situations.

In addition to using “standard” Cognitive Therapy interventions, one can tailor standard techniques to focus more specifically on optimism. Fresco and his colleagues (1995a, b) adapted the cognitive-behavioral techniques of self-monitoring and cognitive restructuring by combining them into a self-administered format and instructing subjects to keep a “daily diary” in which they monitored both good and bad events and rated the causes of the events in terms of their stability, internality, and globality. He directed the subjects to then think of other possible causes of the events and to rate those causes on the same dimensions. In theory, tailoring “standard” interventions to address aspects of cognition which are directly related to optimism/pessimism should increase their impact.

It is also possible to design interventions which are specifically designed to decrease pessimism and/or increase optimism. One intervention technique which Riskind, et al. (1996) propose consists of the therapist helping the client to identify and modify dysfunctional “optimism-suppressing” beliefs. Their assumption is that an individual who holds a belief such as “I don’t deserve positive things or good outcomes” or “Happiness, positive thinking, and optimism are illusions” will be more prone to engage in optimistic thinking if the therapist can help him or her adopt an alternative view which supports optimism. In Art’s case, he assumed that optimistic thinking was “dangerous” because an optimistic outlook would result in his attempting social interactions with attractive women who would then find him boring and reject him. As long as he believed that optimistic thinking would lead directly to rejection, he was reluctant to adopt a more optimistic outlook. After his therapist helped him to examine these beliefs and to adopt alternative views (“Avoiding rejection at all costs results in my being isolated. I can take small chances and cope with rejection if it happens. If I take small chances, I can find out if women react the way the way I anticipate and I can learn how to get relationships to go better.”) he was more willing to approach interpersonal situations with a guardedly optimistic outlook.

A second intervention which Riskind, et al. (1996) propose is termed “Positive Visualization”. In this technique, the therapist asks the client to choose a problematic situation and to visually rehearse attaining a positive outcome. The client is instructed to imagine the outcome he or she would like to achieve rather than visualizing the outcome he or she expects and to visualize the specific steps needed to achieve these results. The visualization can specifically target the challenges the client would be likely to encounter in real life. Thus, Art might be asked to visualize a casual conversation with an attractive acquaintance from beginning to end, to imagine encountering the problems which he would normally encounter in such a situation, to imagine coping successfully with each problem as it arises, and to imagine a successful outcome. In order for Art to be able to imagine coping successfully with the problems he encounters, the therapist would need to help him to identify the problems he would be likely to encounter and to identify promising ways of coping with those problems.

Riskind, et al. (1996) present two variations on the Positive Visualization technique. In the “Story Board” technique, the client is instructed to visualize a series of discrete scenes which lead to a desired outcome. For example, a salesman who has difficulty making unsolicited calls might be asked to first visualize making calls to potential customers, then to visualize some of the calls resulting in appointments, and finally to visualize some of the appointments resulting in sales. At each step, the client would imagine coping with any difficulties which arise and would imagine a successful outcome such as being pleased that he or she carried out their task. In “Invulnerability Training” the client would visualize feeling good about how he or she handled the situation when things do not turn out the way the client hoped they would. Riskind and his colleagues propose that when positive visualizations of these types are repeated across a variety of situations and different areas of life, there may be a point at which the effects of the visualizations generalize and have beneficial effects which are not confined to the specific situations which have been visualized.

The “Silver Lining” technique (Riskind, et al., 1996) is a simple technique in which the client is assigned the task of taking a negative experience and identifying one genuinely positive element in the experience. The client’s task is not simply to mouth positive platitudes but to identify genuinely positive aspects of the experience. Riskind argues that this simple exercise can have a significant impact. For example, at the outset of therapy, whenever Art had a social interaction which did not result in a date, he was inclined to declare it to have been a total failure. After identifying the realistic positive outcomes of some of these “failures” (i.e. “At least I got myself to try,” “I’m getting less anxious about striking up a conversation,” “She seems to be getting more comfortable too,” or “I didn’t get a date but she did show some interest.”) he found it easier to persist with his efforts long enough to start getting some dates.

A fourth technique recommended by Riskind, et al. (1996) is “Pump Priming.” This technique is based on the principle of cognitive priming. Events relevant to a particular cognitive construct or schema can increase the salience of the schema and increase the likelihood of its being spontaneously elicited by subsequent events. Riskind gives the example of an individual who reads an article about cats over coffee in the morning and subsequently is more likely to think spontaneously about cats, to notice references to cats, and to recall memories of cats, throughout the day. He suggests that by having individuals intentionally attend to experiences relevant to a schema which we wish to encourage, intentionally repeat relevant self-statements, or visualize relevant stimuli, it may be possible to increase spontaneous attention to positive experiences, increase spontaneous use of an optimistic explanatory style, etc.

It is likely that a variety of other cognitive-behavioral interventions could be modified to more specifically address optimism/pessimism. For example, Burns’ (1980) “Antiprocrastination Sheet” technique asks the client to record his or her anticipations about how difficult and how rewarding it will be to perform a particular task and then, following completion of the task, to rate how difficult the task actually turned out to be and how rewarding it was to actually perform the task. This technique can easily be modified to target the specific expectancies which are relevant for decreasing an individual’s pessimism and/or increasing their optimism.

The “Antipessimism Sheet” (see Figure 3 in Pretzer & Walsh, 2001) is one possible way of doing this. Clients are asked to identify upcoming events which they are likely to approach with a pessimistic outlook and to list each event in the first column of the form. Before the event, the individual is asked to record the best they can foresee happening, the worst they can foresee happening, and the outcome which seems most likely. Following the event they are asked to record the actual outcome. After a number of events have been recorded, therapist and client can examine the correspondence between the individual’s anticipations and the actual outcome, the impact a pessimistic outlook has on the actual outcome, and what the client can do to influence the outcome.

The “Antipessimism Sheet” was not used with Art because it had not yet been developed. Instead, the same type of intervention was used in a less structured way. Art was asked to rate the level of anxiety he anticipated experiencing in up-coming interactions, the degree of interest he anticipated that the woman would display, and the level of satisfaction he expected to experience following the interaction. Following the interactions, he and his therapist discussed his actual experience, looked for consistent biases in his expectancies, and identified positive outcomes which Art tended to overlook (i.e. decreases in his anxiety, opportunities to test his preconceptions, and improvements in his social skills). This process seemed to facilitate Art’s recognizing that his anticipations were unduly negative and to increase his ability to appreciate the positive aspects of interactions which produced mixed results.

When therapy has been successful, there remains a risk of relapse at some point in the future. Borrowing ideas from Marlatt and Gordon’s (1985) work on relapse prevention in the treatment of substance abuse, at the conclusion of treatment a Cognitive therapist typically helps the client to identify “high-risk” situations where there is an increased risk of relapse, to plan how to cope with these events if they occur, and to practice the skills needed for the client to cope effectively. For example, as Art had his initial success in interpersonal relationships, he gradually accepted the idea that he was not inherently boring and began to believe that people could genuinely be interested in him once they got to know him. However, if he were to experience rejection in a relationship or if he were to encounter someone who accused him of being boring, he could easily revert to his original negative outlook, especially if he experienced several such experiences. Art’s treatment concluded with his therapist helping him to identify adaptive self-statements to use in coping with rejection (i.e.: “Things didn’t work out with her but I know from experience that other women can be interested in me.”) and to plan active steps for him to take in coping with rejection (i.e.: “Avoiding rejection just makes things worse, I need to continue reaching out to others even if it is hard at first.”).

Only a limited amount of research has directly examined the effectiveness on cognitive-behavioral interventions designed specifically to modify optimism/pessimism. Fresco, et al. (1995a, 1995b) combined the cognitive-behavioral techniques of self-monitoring and cognitive restructuring into a self-administered format and investigated the effects of one month of self-administered “optimism training” on pessimistic college students. Analysis of subjects’ attributional styles before and after treatment indicated that one month of minimally-supervised, self-guided intervention produced a greater reduction in pessimistic explanatory style than did a no-treatment control group.

Riskind and his colleagues (1996) compared the effects of three group treatments, (standard cognitive therapy, optimism training, and cognitive priming) with progressive relaxation training (as a control group) in a sample of 83 college students. This study’s results yielded promising initial support for the effectiveness of the optimism training condition. The optimism training group was superior to the control group on four out of five measures. This included a significantly higher level of optimistic interpretations for negative events and a higher level of positive self-statements. Interestingly, optimism training’s effects appeared to be specific to positive thinking. It did not demonstrate a significant effect on the level of negative self-statements. In this study, the other treatment approaches did noticeably less well. Standard cognitive therapy was superior to the control group on two out of five measures (positive self-statements and problem-solving self-efficacy), while the cognitive priming treatment was not significantly more effective than the control group on any of the measures.

The findings reported by these investigators are encouraging. Unfortunately, these studies have only been conducted with college undergraduates and have not yet been replicated, thus their generalizability is severely limited. It goes without saying that more extensive research with a broader range of populations will be needed before we have grounds for drawing firm conclusions.

The association between optimism and a wide variety of positive outcomes (Scheier & Carver, 1992; Chapters 6, 7, 9, 10 and 11 in this volume) makes it tempting to assume that interventions which increase an individual’s optimism will produce manifold benefits. However, this proposition has not yet received extensive scrutiny. Fresco and his colleagues (1995a) found that, in a sample of 125 college undergraduates, one month of self-administered optimism training produced a significant increase in the use of an optimistic explanatory style, and a non-significant trend towards lower depression scores and health symptom scores. A hierarchical multiple regression analysis found that the cross-product of attributional style by life-stress significantly predicted level of depression and health symptoms for control subjects but not for subjects who received the optimism training. These results were interpreted as suggesting that one month of optimism training may have moderated the effects of the diathesis-stress interaction in pessimistic college students. However, findings such as this provide encouragement rather than a convincing demonstration of the benefits of optimism training.

The authors’ clinical experience is consistent with the research which suggests that cognitive-behavioral interventions can produce significant changes in optimism/pessimism and that this can have substantial benefits. In Art’s case, initial interventions led Art to reevaluate his pessimism regarding relationships. After 5 sessions, he began initiating conversations and was surprised to find that some women responded positively. By session 7 he had begun dating and started experimenting with allowing himself be genuine rather than trying to appear “cool”. At that point in therapy he was considering a sexual relationship and talked with his therapist about how to let his girlfriend know that he had an erectile dysfunction. He subsequently discussed his sexual dysfunction with his girlfriend and they initiated a sexual relationship.

In his tenth therapy session, Art spontaneously expressed the opinion that “Anyone can be interesting once you get to know them” and, as he did so, he seemed to be expressing an honest conviction that this applied to him as well as to others. After eleven sessions of treatment, Art reported that he felt comfortable while dating and while facing other social situations. He was dating actively and, while he was not completely satisfied with his primary romantic relationship, he expressed confidence that he could successfully pursue relationships on his own. Treatment was terminated by mutual agreement with the option of Art’s resuming treatment in the future if he encountered difficulty.

REFERENCES

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Fresco, D. M., Sampson, W. S., Craighead, L. W., Clark, J. & Enns, C. (1995, November). Self-administered optimism training: The process of lessening the impact of pessimistic explanatory style. A poster presented at the annual meeting of the Association for Advancement of Behavior Therapy, Washington, DC.

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Stewart, J. W., Mercier, M. A., Quitkin, F. M. McGrath, P. J., Nunes, E. Young, J. Ocepek-Welikson, K. & Trocamo, E. (1993). Demoralization predicts nonresponse to cognitive therapy in depressed outpatients. Journal of Cognitive Psychotherapy, 7, 105-116.

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