Positive Psychology is a relatively new domain in the field of psychology. While Psychology in the 20th century looked at the relief of suffering, positive psychology shifted its focus on improving wellbeing. Rather than trying to fix what is broken, it aims to foster human flourishing. On that note it aligns itself well with the current salutogenetic (health promoting) shift in medicine. This shift focusses on encouraging psychological traits and behaviours that have been shown to support resilience in the view of adverse life events, and as a consequence promote physical and psychological health (1,6,9).
Seligman et al (2016) put forward the idea of the human species as a “Homo Prospectus”. Positive psychology suggests that the prospection of our personal future will manipulate which elements we register from past and present circumstances. From the endless possibilities at any given time, the one that seems to enlist the most prominent simulation is the one which has the highest subjective salience (meaning attention-grabbing). To enlist support for a prospective future scenario our brain circuits will draw on any available past and present sensory information that is supportive to what we expect to happen next, often to the disadvantage of contrary or otherwise distracting data. The scope of our prospecting about possible future scenarios depends on how free we are in our thinking (level of perceived control); how informed and creative we can be as well as our personalities. The question is – does neurobiology support those claims?
Seligman’s idea links in well with the theory of intrinsic brain networks: the default mode network (DMN), salience network (SN), sensorimotor network and the central executive network in the brain. The Default mode network (DMN) is active in a state of wakeful rest, as such when we are not engaged in a task that requires external attention but focussed on our own cognitions, e.g. day-dreaming (prospecting about something in the future). This network functions anticorrelated to the Salience network (SN), which is responsible for the detection of any salient internal and external stimuli that stand out from concurrent sensory or emotional data. The SN serves an important role in allocating our limited perceptual and cognitive resources to the seemingly most relevant individual task at hand. It acts likes a switch from the DMN (internal cognition) to the Central executive network in the fronto-parietal regions (external cognition, such as analysing, problem solving, decision making). Under normal circumstances the DMN is not connected to the Sensorimotor network, or the attention networks meaning that harmless sensory information will under normal circumstances not be processed in a resting state. However, a recent Article by Hermington et al (2018) has shown that alterations within DMN and cross-network (DMN-SM) connectivity can be linked to lower or higher resilience scores as well as to increased or decreased pain perception. They have proposed that if sensorimotor afferents and attention networks are hyperconnected to our DMN it will significantly influence what we expect to happen next (future prospecting) and hence guide pain/health behaviour (e.g. as it has already been shown in patients with PTSD (3) and the elderly (2)).
While we still can’t pinpoint the neural correlates of ‘resilience’, being able to successfully ‘bounce back’ from adverse life events also seem to manifest itself in pain-related outcomes such as pain acceptance, catastrophizing (rumination) and flexibility to adjust. For example, an ‘adjustment disorder’ is defined by the medical encyclopedia as a “group of symptoms, such as stress, feeling sad or hopeless, and physical symptoms that can occur after you go through a stressful life event. The symptoms occur because you are having a hard time coping. Your reaction is stronger than expected for the type of event that occurred.”
While Positive Psychology has yet to be researched more closely with regards to pain, it has been useful in the understanding of biological sources for depression and PTSD. Maier and Seligman (2016), demonstrated a distinct cortico-limbic neural circuit that, if switched on, seem to reduce symptoms of “learned helplessness” (which equals 8/9 signs of depression) in both animal and human studies. They termed this neural connection the “Hope circuit”, as they postulated that it is activated through hope for the future, experience of mastery, and anticipation of control and concluded that the activation of this circuit is necessary for preventing learned helplessness/depression. Maier, Seligman and their team showed that in ‘Helplessness experiments’ they were 2/3 of people who the researchers could not make helpless and they shifted their research into what makes people resilient? This connected well with Seligman and Petersen’s earlier work which had investigated quantifying optimism and pessimism as ‘attributional styles’ to causes of external events:
- Optimistic style responds to bad event with “its local, non permanent and controllable”
- Pessimistic style: “generalisation, (e.g. bad math test to I am a failure), it is going to last forever, and pervasive, (e.g. it will underlie everything I do – linked with a tendency to catastrophise)”
Important for us in the clinic to understand is that the internal activity of prospecting either positive or negative future events will significantly evoke biological consequences (e.g. cardiovascular, vagal tone, hormonal release), in a similar manner to as if we would be exposed to external events that make us feel either positive or negative emotions (7).
As many of our pain patients also suffer from depression and/or often feel helpless/hopeless in their perspective to deal with their pain in the future, it might be worthwhile to look for those attributional styles. However, before we do this, is there plausible scientific reason to believe that you can change a pessimist into an optimist or teach resilience? Research on positive psychology has shown promising results:
- Experiments in middle school by utilising techniques of cognitive therapy (e.g. positive self-talk, thought challenging) showed that depression in puberty halved in trained school kids (4)
- US Army – looking at occurrence of PTSD in soldiers to awful events. Improvement in Resilience training lower PTSD and substance abuse (5)
- Geelong grammar school (Victoria, Australia) adopted Positive Psychology trough the Institute of Positive Education ggs.vic.edu.au – results showed that students developed lesser depression (8)
So over to you: what has been your experience with fostering HOPE in your patients? Have you had any experiences that this has improved either pain perception or depressive symptoms? If so – how have you done it?
Martina is a German physiotherapist with postgraduate qualifications from Curtin University Perth, and extensive clinical work experience in the area of acute and chronic pain management in Australia, Germany and Switzerland. She is currently working in a multidisciplinary outpatient pain management team Precision Ascend and at the Barbara Walker Centre for Pain Management, St.Vincent’s hospital Melbourne. She has been an enthusiastic educator with 17 years of teaching undergraduates and postgraduates in Australia, Switzerland, Austria, and Germany. Martina has been a NOI instructor since 2003 and is primarily responsible for the German translation of Explain Pain, Graded Motor Imagery and the Problem Pain Patient.
- Antonovsky A, Unraveling the Mystery of Health: How People Manage Stress and Stay Well, Jossey-Bass, San Francisco, Calif, USA, 1987.
- Bauer H et al (2016). Resilience moderates the association between chronic pain and depressive symptoms in the elderly. Eur J Pain; 20:1253–65.
- Bluhm RL et al (2009). Alterations in default network connectivity in posttraumatic stress disorders. J Psychiatry Neurosci;34:187
- Brunwasser SM et al (2009). A meta-analytic review of the Penn Resilience Program’s effect on depressive symptoms. Journal of Consulting and Clinical Psychology, 77: 1042-1054.
- Harms P (2013). The comprehensive soldier and family fitness evaluation: Report no 4. Evaluation of resilience training in mental and behavioural health outcomes. University of Nebraska, Lincoln. http://digitalcommons.unl.edu/pdharms/10/
- Hermington KS Rogachov, A et al (2018). Patients with chronic pain exhibit a complex relationship triad between pain, resilience, and within- and cross-network functional connectivity of the default mode network. Pain, 159 (8), 1621-30.\
- Nikrahan G et al (2016). Effects of positive psychology interventions on risk biomarkers in coronary patients: a randomized, wait-list controlled pilot trial. Psychosomatics, 57: 359-368.
- Norrish M (2015). Positive Education: The Geelong Grammar School Journey. Oxford University Press.
- Seligman M (2018). The Hope Circuit – a psychologist journey from helplessness to optimism.
- Maier S & Seligman M (2016). Learned helplessness revisited fifty years later: Insights from Neuroscience. Psychological Review 123, 349-367.
- Definition of ‘Adjustment Disorder’ – https://medlineplus.gov/ency/article/000932.htm