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Article on application of poistive psychology

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For many years, the prime focus of psychology was to diagnose and treat people with mental health problems and psychopathological issues.

In 1998, pioneers Dr. Martin Seligman and Dr. Mihaly Csikszentmihalyi popularized the concept of positive psychology, an offshoot of clinical psychology that shifted the focus of interventions from problems to solutions.

Positive psychology is uniquely solution-focused. It is not merely corrective and limited to offering solution only when something goes downhill.

Positive psychology works by improving on what is already there and extends its help by cultivating inner strengths. As defined by Gable and Haidt, 2005:

"Positive psychology is the study of conditions and processes that contribute to flourishing or optimal functioning of people, groups, and institutions."

The strategies and skills included in positive psychology interventions guide us through a visionary change to look into the same things with a different perspective. Positive psychology has five key aspects to it:

It helps us look at life with optimism.

It allows us to appreciate the present.

Positive psychology lets us accept and make peace with the past.

It helps us to be more grateful and forgiving.

It helps us to look beyond the momentary pleasures and pains of life.

Positive psychology is not a remedy for problems. By building our inner strength and making us more aware of our capabilities, the interventions help us to see the positive around us and make our life more worthy and fulfilling.

What Are Positive Psychology Interventions?

Positive psychology interventions, or PPIs, are a set of scientific tools and strategies that focus on increasing happiness, well-being, and positive cognitions and . (Keyes, 2002). Existing research shows that over the years, psychologists have focused more on treatment than on prevention (Bolier, Haverman, 2013). Psychotherapy and assessments developed and popularized in the past mostly offered solutions to anomalies like depression, anxiety, stress, panic, and trauma, etc.

There was a little resource available, until the last two decades, on tools that could flourish and promote individual well-being, even in the absence of any psychopathological conditions. Sin and Lyubomirsky (2009) defined PPI as a psychological intervention that primarily focuses on raising positive feelings, positive thoughts, and positive behavior. According to Sin and Lyubomirsky, all positive psychology interventions have two essential components:

Focusing on enhancing happiness through positive thoughts and emotions

Sustaining the effects for long-term

Studies have suggested that can be achieved and enhanced through various channels, including sensory awareness, social communication, gratitude practices, and cognitive reformations. As such, all these factors were clustered together in practical techniques called the positive psychology interventions (Parks and Schueller, 2014).

These measures were applied in both clinically distressed and non-distressed populations, and the results were consistent in both the instances (Bolier, et al., 2013). By far, the most detailed definition of PPI was proposed by Park and Biswas-Diener in 2013. According to them, positive psychology interventions are the ones that:

Have an existing body of research to support its reliability

Address one or more constructs of positive psychology

Are scientifically proven and evidence-based

Benefit us for a lifetime

Types Of Positive Psychology Interventions (PPIs)

Positive Psychology Interventions can be divided into seven categories (Park and Schueller, 2014).

1. Savoring PPIs

Savoring interventions focus on a particular experience and aim to enhance their effects for maximizing happiness (Peterson, 2006). The core principle of these interventions is to encourage the person to grab every little aspect of experience - physical, sensory, emotional, or social (Jon Kabat-Zinn, 2009).

Due to its emphasis on wholesome perception, the savoring PPIs resemble mindfulness strategies, but they are not entirely alike.

Savoring interventions can be connected to everyday experiences like eating, smelling, or observing, only with a little more orientation and focus to what we are consciously attending to (Bryant, Smart, & King, 2005). Savoring PPIs can be reliably used for treating depression and mood disorders, as they produce happiness and self-satisfaction (Bryant, 2003).

2. Gratitude Interventions

Steve Maraboli said, " If you want to find happiness, find gratitude " - which is precisely the target of gratitude-based positive psychology interventions. evokes strong feelings of positivity in the person who gives it and the person who receives it (Schueller & Parks, 2013).

Gratitude interventions are categorized into two parts:

Self-reflective practices, for example, writing a gratitude journal that we keep to ourselves and use as a tool for self-expression.

Interactive methods where we actively express our gratitude to others by saying 'thank you,' giving small tokens of appreciation, or paying gratitude visits.

3. Kindness Boosters

Kindness is a trait all happy people possess. Studies have shown that happiness and kindness go hand in hand and complement each other (Aknin, Dunn, and Norton, 2012).

Positive psychology interventions focusing on compassion can be simple acts like buying someone a small token of love, volunteering for a noble cause, donating something, or helping a stranger in need. Kindness reinforces happiness and positivity.

An example of a related PPI is ' prosocial spending '. The activity includes willingly buying something for someone as a gesture of goodwill. It can be anything like taking your spouse out for a romantic dinner at your favorite place, giving your child the toy he/she has been asking for, or buying a meal to the homeless person you see every day at the bus stop.

It is not about how much money you spend. The goal of kindness activities is to promote happiness through such altruistic and selfless contentment (Howell and Iyer, 2012).

4. Empathy PPIs

Empathy-oriented PPIs focus on strengthening positive emotions in interpersonal relationships. Healthy social bonds - both at personal and professional fronts are essential for happiness and inner peace. (Diener and Seligman, 2002).

The core principle behind this is to let us understand others' perspective and build a strong connection to them. (Hodges, Clark, & Myers, 2011).

5. Optimistic Interventions

Optimistic interventions create positive outcomes by setting realistic expectations. An example of an optimistic PPI is the 'Imagine Yourself' test where participants are asked to note down where they see themselves in the future.

Evidence suggests that although this may seem to be an easy task, non-directed imagination is a great way for people to understand how positive they are about themselves and others in life (King, 2001).

Another interesting optimism oriented PPI is the Life Summary technique that was administered by Seligman, Rashid, and Parks in 2006. This practice involves assuming that we are happy and prosperous in our lives and writing a summary of our lives based on that assumption.

The review focuses on our strengths, our achievements, and all the fruitful aspects of our lives so far. The method works exceptionally well in gaining insight into where we are going wrong in our daily lives and what we can do to pursue the ideal life we want to.

6. Strength-Building Measures

Strength in positive psychology refers to internal capacities and values (Parks and Biswas-Diener, 2013).

Studies have illustrated that awareness and acknowledgment of power help in reducing symptoms of depression and increases self-contentment (Seligman et al., 2005). As the famous saying goes, " It is within yourself that you will find the strength you need," strength-based PPIs convey a similar message.

They are what psychologists refer to as 'practical wisdom' (Schwartz and Sharpe, 2005) and help us use our vitality wisely.

7. Meaning Oriented PPIs

This category of PPIs helps in understanding what is meaningful to us in life and why, and what we can do to achieve the things that matter in life. A person who has clarity of goals and expectations is more likely to feel happier and content (Steger, Kashdan, & Oishi, 2008; Steger, Oishi, & Kashdan, 2009).

If we follow Abraham Maslow's Theory of Need Hierarchy, the highest level of human needs include self-enhancement and self-esteem, both of which are intertwined with finding the true meaning of life.

Meaning-oriented PPIs include activities like finding meaning in our daily activities, setting realistic goals and employing effective means to achieve them, or just reflecting on our thoughts and emotions (Grant, 2008).

Meaning-oriented PPIs are widely used for treating stress disorders, especially PTSD, where a person needs guidance to find the lost happiness in life and cope with the after-effects of a disaster (Folkman and Moskowitz, 2000).

How Do They Work?

Unlike general psychology interventions that target to bring about a change at a cognitive or affective level, PPIs are directed towards improving on what is already there inside us.

PPIs never rely on symptomatic treatment or a quick relief. Whether treating a psychopathological condition or guiding someone to improve their well-being, PPIs target to dig into the root cause of the trouble. Not only that, but it also lets the individual realize the source of his/her problems and enlighten them to embody the changes wholeheartedly.

There are overwhelming pieces of evidence and research findings that suggest the effectiveness and efficacy of positive psychology interventions. However, why they work so well, and how their effects are so deep-rooted is still a vast area of study.

A study conducted on the role of time focus and the effectiveness of PPIs revealed that the two operating factors that contribute to the success of these interventions are - a shift of attention from negative to positive and internalization of positive emotions.

The study was conducted on a sample size of 695, and each of the participants was assigned to either an experimental group or a controlled group. Results showed that subjective feelings of well-being significantly improved from pre- to post-intervention, indicating the effectiveness of the PPIs in real life (Wellenzohn, Sara, Proyer, Ruch, Willibald, 2016).

How Effective are They?

Positive psychology encompasses both treatment and prevention.

PPIs can be useful for treating , and disorders (Seligman, Rashid, Parks, 2006). This fact was validated in a study conducted on terminally ill adolescent patients. The purpose of the experiment was to evaluate how positive thinking influenced coping strategies and helped the patients battle their disease with resilience.

In the study, teenager cancer patients were treated with PPIs and showed improved coherence and better stress management. The study was a milestone in the field of positive psychology as besides proving the effectiveness of these interventions; it also showcased the incredible power adolescents possess when it comes to dealing with life-threatening situations or critical health conditions.

Fordyce's 14 Fundamentals Of Happiness

The effectiveness of positive psychology interventions was also proved by Michael Fordyce (1977, 1983) whose study found that some students in a happiness program derived more happiness because of the fourteen fundamentals of happiness psychology.

Fordyce's fourteen fundamentals include:

1. Being more active and busy

2. Spending more time socializing

3. Being productive at work

4. Being more organized and well-planned

5. Reducing worries and negative contemplations

6. Fewer expectations, and having more realistic ones

7. Practicing positivity through optimistic thinking and reasoning

8. Getting more focused and mindfully aware of the present

9. Developing and maintaining a healthy personality

10. Becoming more empathetic

11. Being ourselves at all times

12. Replacing negative thoughts with positive ones

13. Valuing close relationships

14. Thinking about enhancing our happiness

Fordyce's findings suggested that PPIs improve our state of well-being permanently by impacting these fourteen fundamental factors of happiness.

A Look at the Research Article: Positive Psychology Progress: Empirical Validation of Interventions

Positive Psychology Progress: Empirical Validation of Interventions was an honest effort by authors Seligman, Tracy, and Peterson (2005), to outline the surprising benefits of the science of happiness and related interventions.

With a host of empirical findings, cross-cultural studies, and books (including DSM), this research paper focuses on how and why PPIs enhance individual happiness.

The roots of positive psychology lie in the pioneering theories of Rogers (1951), Maslow (1962), Erikson (1982), and Jahoda (1958), among many others. From there, researchers like Murray (2000), Vaillant (2000), and Csikszentmihalyi (2001) flourished and extended the scope of the science of happiness to understand how positive emotions and a strong character helps us to lead better lives.

The target of the research was to:

Review and assess the recent growth in the field of positive psychology

Explain significant chunks of evidence that promotes PPIs

Analyze data obtained by survey and assessments to ascertain the benefits of using these interventions in practical life.

What is CSV?

Character Strengths and Virtues (CSV) was a compact handbook of the critical aspects of positive psychology, the active interventions, and bits of evidence promoting happiness as a scientifically attainable state of mind.

Authors Seligman and Peterson (2004) argued that like the DSM or the ICD that encompass almost all aspects of psychopathologies, the CSV encircles all the tidbits of psychological well-being.

The research paper on Positive Psychology Progress based its explanations on the six virtues that determine how happy we feel about ourselves and the world.

List of strengths in CSV with their corresponding characteristics

1. Wisdom and Knowledge

1. Creativity, curiosity, flexible thinking, inquisitiveness, wide perception, quick learning.

2. Courage

2. Genuineness, bravery, high intrinsic motivation, perseverance.

3. Humanity

3. Gratitude, empathy, social intelligence, emotional intelligence.

4. Justice

4. Fairness, leadership qualities, conformity, high-performing nature.

5. Temperance

5. Humbleness, self-regulation, reasoning skills, vigilance.

6. Transcendence

6. Spirituality, appreciation, hopefulness, high spirits

The study asserted that people derive happiness according to the virtues they follow (Peterson, Park, and Seligman 2005).

By using assessments like Beck Depression Inventory (BDI), Steen Happiness Index (SHI), and Centre for Epidemiological Studies - Depression Scale (CES-D), the research established the correlation between PPIs and emotional prosperity (Lyubomirsky & Lepper, 1999).

This research also used internet-based faculties to administer and assess the effectiveness of PPIs. Web-based tactics included encouraging participants to download free sheets of positivity inventories and based on the number of registrations per week; an estimation was reached of how curious we are about happiness (Prochaska, DiClemente, Velicer, & Rossi, 1993).

Three interventions were used in this research:

1. Placebo Control Exercise - where the respondents wrote about their experiences in a journal every day.

2. Gratitude Visits - where the participants wrote letters expressing their thankfulness to someone they had never thanked enough.

3. The 3 Good Things Task - where the participants recorded three things in life that make them happy and explain the reason those things make them feel better.

Participants performed these tasks for seven days, and results were evaluated after that. The research work presented by Seligman and Peterson revealed the impact of PPIs on happiness levels and positive responses. Evaluation and statistical analysis showed a marked reduction in the scores of BDI and other depression scales after treating participants with positive psychology interventions.

The authors revealed that we have a natural inclination toward finding out ways to be happy, and PPIs serve this purpose accurately. This article, thus, provides a solid research base that validates the potency of PPI and PPT (Positive Psychology Therapy) in clinical and non-clinical use (Fordyce, 1977, 1983).

Read more about this research.

5 Examples of Interventions in Use

1. Mindful Interventions

The works of Kabat-Zinn manifested how mindfulness fosters happiness and awareness. As a positive psychology intervention, mindfulness is used in combination with other psychotherapeutic practices, life coaching, and clinical fields. The popular mindfulness-based PPIs include activities like sensory awareness, guided meditation, breath control, and careful observation.

2. Gratitude Exercises

"Gratitude turns what we have into enough"

Melody Beattie
Simple gratitude practices like journaling, self-compliments, or sending thank you notes have the power to bring sanctity and authentic happiness. Studies have shown practicing gratitude exercises regularly enhance cognizance and we can derive more pleasure from social relationships (Ryan and Deci, 2001).

3. Objective Assessments

In clinical setups and counseling practices, PPIs are often administered in the form of objective measures like the Mental Health Continuum, Authentic Happiness Inventory, Orientations To Happiness Questionnaire, and Positive Relationships And The Accomplishment Scale.

These tests are mostly conducted under supervision, although some of them are self-evaluative. The scores of these interventions indicate the happiness level of the respondents and indicate how positive interventions impact them.

4. Positive CBT

Cognitive Behavior Therapy (CBT) has been there since the advent of psychotherapy and is still a widely used approach for treating many psychological disorders.

For example, when if a person who has been diagnosed having OCD seeks positive CBT, the therapist, besides working on reducing his obsessive ideations, will also pay equal attention to the positive sides (loving nature, communicative, insightful, etc.) of the person' character and work on building them.

The principle of CBT is to make the individuals feel better by helping them identify their potencies (Bannink and Jackson, 2011).

5. Active Aging PPI

Active aging, also called positive aging, healthy aging, or optimal aging (Cosco et. al, 2013) promotes the idea of growing old gracefully.

Much like the famous quote by William Shakespeare " With mirth and laughter, let old wrinkles come ", the active aging PPI encourages the older population to accept their aging and live through it with joy.

A study by Vera Roos and Ronette Zaaiman on active aging revealed that older people who were guided to look into the brighter sides of life and motivated to live the rest of their lives with dignity and joy survived diseases and losses better than others.

Participants of the program, all of who were 60 or above, reported having found the lost meaning of their lives and agreed to practice positivity as a daily habit after that.

A List of Positive Psychology Interventions

The purpose of positive psychology, as announced by Dr. Carol Kauffman (2006), is to " develop sound theories of optimal functioning and to find empirically supported ways to improve the lives of ordinary and extraordinary people."

And PPIs are the means to achieve this goal and invite happiness back in our lives. Out of the heaping PPIs that mental health professionals use today, here is a run-down of some of the popular ones that you might find useful.

The Imagined Self Technique

Imagined self is a guided PPI that involves imagining your ideal self and feeling the joy that you would have felt then. Research showed that this exercise acts as a catalyst and provokes people to enact on achieving the life they want to live and derive utmost pleasure like they imagined they would (Lyubomirsky and Sheldon, 2006).

The steps are simple:

Imagine yourself in the future, living the life you have dreamt of - with all the people you want to share it with.

Imagine that you achieved everything that you are struggling for now, and you are proud of your achievements.

Immerse yourself into that imagined self of yours and try to impersonate the happiness and positivity that you think you might feel then.

Next, ask yourself what you can do to get to that stage in life, and journal your responses.

Yoga

Positive psychology is secular in all aspects. It gives equal importance to quantitative analyses like depression and happiness scales, and at the same time also embraces qualitative and self-enhancing practices like , meditation, and mindfulness.

It envelops Buddhist principles of mindfulness and fosters spiritual liberation through yoga postures and meditation (Cerezo, Ortiz Tallo, Cardenal, & De La Torre Luque, 2014; Cohn, Pietrucha, Saslow, Hult, & Moskowitz, 2014). Any yoga practice, be that flow meditation, hatha yoga, or other popular methods, renders a relaxing feeling to the mind and the body and is a feasible way to enhance subjective feelings of wellness.

If you are a beginner, here is a snippet of some positivity enhancing yoga techniques that you can follow.
Yoga for self-doubt Positive energy boosting yoga Meditation for positivity Yoga for self-confidence
Forgiveness Exercise

This exercise helps us to free ourselves from past resentments and focus on life in a brand new way. And the practice is uber simple.

Take a piece of paper and name all the people and the incidents of the past that hurt you.

Beside each name, describe how the negative encounter shattered you. Try to name all the feelings you experienced in that phase (for example - sad, angry, insulted, hopeless, heartbroken, betrayed, hateful, and the like).

While you are scribbling about all the hurtful encounters, notice how those depressing feelings start coming back to you.

Now, close your eyes, take two deep breaths and relax for a few seconds.

Next, imagine each name on the list and in your heart, say 'I forgive you'. Alternatively, if you were at fault, admit it and ask for their forgiveness.

Notice how this exchange of forgiveness liberates you from the pent up grudges and make you feel empowered from the core.

Open your eyes and on the paper where you had listed the grievances, write in bolds, FORGIVEN and FREE.

Positive Affirmations

Positive affirmations, like compliments, are " verbal sunshine " that brings an immediate sense of pleasure and pride in us. As a PPI, affirmations redirect the mind to focus on the positive sides in ourselves and push ourselves to act positively. They can be simple statements that we say aloud to ourselves .

Here are some positive affirmations that we can choose to say to ourselves and let the light enter in our mind, as happiness is a choice that we should make every day.

I deserve to be happy

I love my body and my mind deeply

Today, I will reflect only on the good things in life

I forgive myself for all past mistakes

I hold no grudges against anyone

Whatever has happened, is for the good

I will live in the present

From today, I will abandon old habits and embrace new and better ones

I am grateful for everything I have got so far

I am a fighter, and I will overcome this

I will love myself more from today

Everything is okay and I am at peace with myself

4 Interventions Designed to Promote Well-Being (PDF)

1. Positive Psychology Activities to Improve Performance and Well-Being

This is a seven-week positivity workout plan designed and used by life coach Deb Levy. The worksheet is a handy compilation containing positive psychology interventions that create insight into happiness and works on improving it. Each PPI is a weekly task that the participants should perform for seven days and move on to the next one on the list.

The functions include:

Week 1 - The 'What went well' Exercise
Participants set aside some time each day for writing about any three good things, big or small, that happened on that day.

Week 2 - The 'Best possible future' Exercise
Participants are directed to imagine themselves in their best and more successful form and journal their thoughts.

Week 3 - The 'Signature strength' Log
Inspired by the CSV model of Seligman, this exercise focus on identifying one's strengths and writing down how they use them every day, for one week.

Week 4 - The Gratitude Journal
Where participants are encouraged to write about the things that they are grateful for.

Week 5 - The BGIF Workout
BGIF stands for 'Be grateful it's Friday'. This is a simple exercise put in an interesting way, where the respondents make a list of the people they are thankful to, and on Friday, take some time out to express their gratitude in the form of letters, emails, or a quick visit.

Week 6 - Self-love Meditation
Where the participants are guided to focus on themselves and their emotions, and journal the thoughts that passed their minds.

Week 7 - Relationship Workout
The final weekly task of this program is to foster happiness by nurturing relationships. This task is full of useful hacks that the participants are asked to follow for the rest of the week and notice how they change the quality of the respondents' interpersonal relationships.

You are welcome to learn more about this workbook.

2. Wellness And Well-being Workbook

Dr. John Barletta, a well-known Australian Clinical Psychologist, gave a list of some useful PPIs that helps to enhance mental well-being and promote happiness. He uses the worksheet in his practice, as well as in his mentoring sessions, and the exercise includes fifteen prompt-based and self-assessable questions that render immediate clarity to the respondent in terms of his goals, his way of thinking, and what aspects of life can be modified to bring more happiness.

3. Because I Am Happy - A Happiness Guide

Dr. Scott Bolland and Dr. Bernadette Alizart designed this manual and call it the 'hidden driver of success'. It comes as a handbook and besides having easy-to-follow PPIs, also contains valuable resources and orientations about the science of happiness. With beautiful pictorial descriptions, relatable references, and point-blank practical tips, this is a valuable resource that we can follow to let happiness in our lives.

4. Action For Happiness

The ' Action for Happiness ' worksheet is a set of exercises explicitly promoting and enhancing happiness in our lives. The activities are objective, easy to administer, and is designed in a beautiful way that will grab eyes instantly.

Know more about this manual.

Using Interventions in the Workplace

Employee well-being is a significant concern for organizations today. With high rates of clinical depression, poor work-life balance, and stress disorders among professionals all over the world, promoting happiness at work is a sheer necessity now.

According to Shawn Achor, " Happiness inspires productivity " at work, and this is the primary driving force behind implementing positive psychology principles at work.

Using PPIs at the workplace promote a healthier and better performance culture. The PPIs that are executed focus on elements like - empathy, meaning, communication, strong character, and self-confidence, with a target on creating job satisfaction, emotional resilience, and healthy competition among employees.

Workplace environment traces how an individual accepts and reacts to the different pros and cons of his work life (Hart and Cooper, 2001).

PPIs in the workplace can be implemented in various forms, such as:

1. Mindfulness Programs at Work

Organizing mindfulness campaigns at the workplace is a growing trend nowadays. These programs focus on building emotional awareness at work, enhancing decision-making power, fostering self-esteem and expressing gratitude.

Example of such a training is the Mindfulness At Work program that delivers an array of useful work-related mindful exercises that promote the overall well-being of employees and managers.

2. Health Promotion Workshops

We know that " Happiness is the highest form of health " - Dalai Lama.

An individual who is struggling with health conditions is less likely to derive pleasure at work. Health promotion in the workplace is beneficial in many ways.

It promotes awareness of different health issues that may be related to stress and burnout.

It reduces employee dissatisfaction that leads to unexpected resignations and absconds from work.

Health awareness curtails health insurance burdens from organizations.

It ensures a healthy work-life balance among employees.

3. Happiness Coaching Sessions

Many professionals prefer one on one happiness and life coaching sessions that focus on helping the participants express themselves by guided facilitation. Instances of such courses are the Career Happiness Coaching by Marina Ofner and the Happiness Life Coaching training methods.

5 Interventions to Use in a Working Environment

1. The Innovation Time Technique

This is a very popular workplace related PPI, where the participants are encouraged to spend some time brainstorming and pursuing their passion project. The motive of this intervention is to let the individuals enjoy autonomy and invest in something they love to engage in.

2. Gratitude Interventions

Gratitude interventions in all forms are an essential part of PPIs at work. They are used alone or in combination with other interventions with the purpose of enhancing self-contentment and joy among employees.

Some examples of gratitude interventions include:

Gratitude journaling

Group gratitude exchange sessions

Sending gratitude notes

Self-gratitude exercises

Guided gratitude meditation

3. Feedback Mechanisms

Feedbacks are a great source of self-improvement. Employees who can accept criticisms and use them to build their professional skills are happier and more satisfied with their jobs than others.

Some ways of incorporating active feedback mechanisms in workplace PPIs are:

Daily stand-ups where employees and supervisors discuss their progress and share their plans ahead.

Feedback assessments and surveys administered frequently.

One on one feedback sessions where both the employee and the supervisor have the freedom to present their opinions and work for a peaceful resolution.

4. Stress Management Exercises

Stress and burnout is an integral part of most professions. Stress management exercises and assessments are a sure shot way to promote overall physical and mental well-being of employees and managers.

Here is an example of a useful workplace stress management PPI.

5. Self-Management And Emotional Awareness

Designed and used by the organization Quartner and associates, this self-management worksheet is a complete collection of the most useful pieces of information on mental health among employees and workplace happiness. The tips and exercises focus on making the respondents more aware of themselves and identify the stressors at work, thereby providing the scope for replacing their negative emotions and enhance happiness at work.

Learn more about this exercise.

How Can Interventions be Used to Increase Student Happiness?

Professor Shannon Fuldo, the face of a leading school psychology program at the University of Florida conducted a large study on why the happiness levels are different for different students in the same situation, and what are the factors that influence their mindsets. Her research on youth happiness in educational institutions emphasized on the use of positive psychology interventions for fostering student happiness and joy (Suldo, 2016).

The study conducted on student happiness by Lea Waters (University of Melbourne) is noteworthy here. In his research, he mentioned that 25% of Australian adolescents suffer from mental disorders or distress owing to several factors like family disputes, financial crises, body shaming, and even due to the indirect effects of global warming.

Anxious and distressed children, according to Waters, promoting PPIs in schools by teachers or school counselors can go a long way in helping the kids out of their anxiety, depression, and stress.

Waters' study mentioned about PPIs that are immensely effective for enhancing student happiness, some of them being:

Hope inducing interventions like motivational speeches and one on one coaching sessions. These can help students to look ahead and understand self-worth (Synder, 1995).

School-based gratitude interventions like offering gifts and thank you notes. Small expressions of gratitude enhanced life-satisfaction and reduced symptoms of depression among the students (Froh, Sefick, and Emmons, 2008).

Peace-enhancing positive psychology interventions like mindfulness practices, compassion exercises, and group meditation sessions that helped students discover serenity and release stress (Keegan and Levine, 2009).

5 Interventions to Use in School

1. Character Strengths

Professors Chris Peterson and Martin Seligman named the Character Strengths test as the VIA Classification of the CSV Model, VIA standing for Values in Action. The intervention targets working on these six character strengths:

(Peterson & Seligman, 2004).

2. Positive Relationships Intervention

This intervention is flexible and straightforward. It involves some structured open-ended questions that students answer. The questions are insightful, thought-provoking, and look something like this:

Think of a family member you admire and mention why

Mention one strength that your friend has

Write about someone who has struggled in life and have come out of it successfully

For the person you mentioned above, write about the skills that you think helped him fight stress and get his happiness back

3. Bounce Back Resilience Program For Kids

The contents of the program help kids to identify their emotions, bounce back from the sadness and chase their aspirations.

4. The Passport Program

Passport program is used in schools, training, and workshops for adolescents, usually in grades 9-12. The intervention aims to prevent depression among kids by promoting positive education concepts like self-confidence, self-esteem, problem-solving, adjustment, and decision-making.

The curriculum comes in a handy booklet form.

5. Self-esteem Sentence Completion Worksheet

The best way to help children become happier and more satisfied is to let them express. The self-esteem sentence completion test is a cluster of open-ended statements that youngsters fill up according to their subjective feelings.

The way they fill the empty spaces uncovers to them how they think and what they want out of something. It is a beautiful and self-explorative way of making students more aware of their identity and mindset.

Learn more about the test.

Interventions to Use with Depression

Dealing with depression is like " being colorblind and constantly told about how the colorful the world is " - Atticus. Positive psychology contributed a lot in helping people understand and fight depression. Here are some PPIs that help people overcome 'the blues' and look into the brighter sides of life.

MoodJuice Self-Help Depression Guide

The MoodJuice workbook helps in identifying the symptoms of depression, acknowledging the same, and find ways to overcome it. The exercises involve multiple choice questions related to our thoughts, feelings, and physical symptoms, and the scores indicate the intensity of the depression symptoms.

With lucid pictorial explanations and evidence-backed examples, this workbook is the first choice for many professionals and help-seekers dealing with depression.

Depression Self-Management Toolkit (DSMT)

Created by Angela Gervais and Sheila Olver Szakács, leading professionals in the field of mental health and occupational therapy, the DSMT is a step-by-step guide to fight depression in an organized way.

The toolkit contains brief explanations of the causes and symptoms of depression, followed by standardized tests and assessments to understand the severeness of the present condition. The exercises focus on allied conditions that are related to depression such as physical disorders (hypertension, cardiac dysfunction, sleep disorders, etc.) and stress, and focus on alleviating each negative aspect from its very core.

Antidepressant Skills Workbook

The Antidepressant Skills Workbook (ASW) is a collection of all the essential strategies that help in fighting and overcoming depression.

Authors Dr. Dan Bilsker, Dr. Randy Paterson, have put their years of research into this manual that shows us how by shifting focus from the negative to the positive, we can emerge as happier individuals and combat depression with a very scientific approach.

A Take Home Message

Happiness is always there around us; we only need to look for it in the right place. As Colette had beautifully put it,

"What a wonderful life I have... I only wish I had realized it sooner".

Positive psychology is not a resort to fight distress or disappointments. It is a gentle way of reminding us that life isn't all about adding glories and abandoning pains. If we have the power to love ourselves and others, the determination to work dedicatedly, and the gift of waking up with new energy each day, we already have enough to be thankful for.

References

A Review Of School-Based Psychology Interventions - https://www.strengthswitch.com/wp-content/uploads/2017/05/Waters-2011-Positive-psychology-review-of-school-based-programs-1.pdf

Bryant, F. B. (2003). Savoring Beliefs Inventory (SBI): A scale for measuring beliefs about savoring. Journal of Mental Health, 12, 175-196

Counseling adolescents with cancer: Using positive psychology to enhance coping skills. Dissertation Abstracts International: Section B: The Sciences and Engineering, 66, 5688

Emmons, R. A., & McCullough, M. E. (2003). Counting blessings versus burdens: An experimental investigation of gratitude and subjective well-being in daily life. Journal of Personality and Social Psychology, 84, 377-389

Hendriks, T. (2018) : Positive psychology interventions in a multi-ethnic and cross-cultural context

Lyubomirsky, S., Sheldon, K. M., & Schkade, D. (2005) : Pursuing happiness -The architecture of sustainable change. Review of General Psychology, 9, 111-131.

McCullough, M.E., Root, L.M., & Cohen, A.D. (2006) : Writing about the benefits of an interpersonal transgression facilitates forgiveness. Journal of Consulting and Clinical Psychology, 74, 887-897

Mindfulness Tools For Happiness And Well-Being by EAP - https://humanresources.vermont.gov/sites/humanresources/files/Winter_2018_Messenger_State.pdf

Seligman, M. E. P. (2002) : Authentic happiness - Using the new positive psychology to realize your potential for lasting fulfillment.

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19 Best Positive Psychology Interventions + How to Apply Them

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Last Updated on For many years, the prime focus of psychology was to diagnose and treat people with mental health problems and psychopathological issues. In 1998, pioneers Dr. Martin Seligman and Dr. Mihaly Csikszentmihalyi popularized the concept of positive psychology, an offshoot of clinical psychology that shifted the focus of interventions from problems to solutions.

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Uses of positive psych in practice.

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Last Updated on

"The aim of Positive Psychology is to catalyze a change in Psychology from a preoccupation only with repairing the worst things in life to also building the best qualities in life."

- Martin Seligman

Positive Psychology is first and foremost psychology, but its focus is the scientific study of positive experiences, states and traits. It was born out of the awareness that the focus on the dysfunctional and pathological needed to be complemented by the understanding of the conditions that lead to optimal functioning.

This scientific understanding is translated into multiple exercises and interventions aimed to increase life satisfaction, well-being, positive emotions or other desirable states, of individuals, organizations and societies. That's what makes it an applied science.

"Once you start making the effort to "wake yourself up" - that is, be more mindful in your activities - you suddenly start appreciating life a lot more."

- Robert Biswas-Diener

Here is a list of some positive psychology examples or positive psychology interventions, as we call it:

5 Examples of Positive Psychology Interventions:

1. Gratitude Journal

It's probably one of the most well-known positive psychology interventions. The world's leading expert on gratitude Robert Emmons defines gratitude as:

" A felt sense of wonder, thankfulness and appreciation for life".

Gratitude is a great buffer against negative emotions such as envy, hostility, worry and irritation. It involves a focus on the present moment and appreciating what is, instead of focusing on what could be. People who are frequently grateful are:

Happier

More energetic

More hopeful

Experience more frequent positive emotions

If you enjoy writing, keeping a gratitude journal is a great way to practice gratitude. Pick a time of the day when you can reflect and relax for a while and ponder on the 3 to 5 things for which you are grateful for, no matter how small or big they are.

Try doing this every day for a week and notice how you feel. As with all the different activities, you might need to customize this exercise to best fit your characteristics and values.

To customize you can adjust:

The frequency;

The format (you might simply choose to contemplate instead of writing);

Or the amount of things to focus on (just one instead of three).

Some people will notice an ungrateful thought and replace it with a grateful one, for example, my husband forgot our anniversary but he is working very hard so that we can go on our dream vacation. The point is to make this exercise work for you and fit it into your lifestyle.

And remember that when we habituate to certain things, their impact might diminish, so coming up with ways of keeping the strategy fresh will also affect its outcome.

Here's a short video of Emmons on gratitude:

2. The Gratitude Visit

Researchers have found that the practice of gratitude may be especially effective when expressed directly to another person.

If there's someone who had a significant impact in your life, someone who went out of their way to help or support you, or someone you feel very blessed to have in your life, write a gratitude letter to that person. State in detail what he or she did and express your appreciation in concrete terms.

Then, if possible, arrange so that you can read the letter out loud to that person, either on a special day or just a random day. As part of my Executive Masters in Positive Psychology, we did all the positive psychology interventions and found that in general, this was one of the most powerful exercises.

Martin Seligman, one of the founders of Positive Psychology, and his colleagues tested the benefits of this intervention in a study. In the experimental condition, they got participants to complete the gratitude visit over a course of a week.

In the other conditions, participants were given different self-guided happiness exercises. The participants in the gratitude visit condition experienced the largest effects in the entire study and reported feeling happier and less depressed, even one month after the study.

Another study by Sonja Lyubomirsky's laboratory found that simply writing the gratitude letter and not sending or reading it to the other person, still produced significant boosts in happiness.

We encourage you to try it out for yourself, adding your own personal twist to it. Afterwards reflect on:

The impact the exercise had

How you felt while you were doing it

How you felt after the exercise and how long it lasted

How you are going to continue your gratitude practice

3. Best Possible Self

Laura King, professor at the University of Missouri, Columbia, designed a systematic optimism intervention.

She asked participants to come to her laboratory for four days in a row. Every day participants were asked to spend twenty minutes writing a narrative description of their "best possible future selves". They were basically asked to contemplate the best possible future for all the different areas of their lives.

This intervention involves imagining your most important and deeply held goals, picturing life after you've accomplished them, in as much detail as you can.

Laura King found that participants who wrote about their visions for twenty minutes, four days in a row:

Had immediate increases in positive moods,

Were happier several weeks later,

Reported being sick less often than participants who were asked to write about other topics.

So reflect about your most significant goals, for the different areas of your life: professional, social, romantic, physical or any other category of your choice. And then imagine your life after everything has gone as well has it possibly could.

What would you be doing?

Where you would be living?

How would your days look like?

How would you feel?

You can think of it as a realization of your dreams and potential.

4. Daily Strength Awareness

Character Strengths and Virtues is a groundbreaking classification of widely valued positive traits. The authors Martin Seligman and Chris Peterson studied all the major religions and philosophical traditions to find that the same 6 virtues were valued across all cultures.

These virtues (humanity, courage, wisdom, etc.) needed to be subjected to scientific study, so they focused their research on the character strengths that lead to those virtues. They followed that by creating tools for their measurement.

Positive Psychology draws on many different tools to help individuals and organizations identify their strengths and use them to increase and maintain their levels of well-being.

The development of strengths requires a process of self-examination, self-discovery and reflection. For someone to really understand what their strengths are, they need to look inward. This tool is a valuable way to enhance self-awareness when it comes to strengths.

Use the table below to list:

Date

Brief description of the activity

What you experienced during the activity

How much you enjoyed the activity

The amount of energy the activity provided

The possible strength or strengths being used

5. Mindfulness Meditation

Mindfulness meditation is a focus on the present moment achieved through the directing of attention towards one's immediate experience, thoughts, feelings, emotions and sensations.

It involves paying attention to our thoughts and feelings with a sense of acceptance and non-judgment. In very simple terms, it implies that instead of focusing on what we should be feeling or experiencing we are present and aware of how we are really feeling. Not trying to change anything, just attuned to our experience in the moment.

With its roots in Buddhist meditation, mindfulness meditation has made its way to mainstream culture, largely through the work of Jon Kabat-Zinn and his Mindfulness- Based Stress Reduction (MBSR) program.

A large body of research has established mindfulness meditation as one of the most powerful and effective tools to promote psychological well-being.

According to APA (American Psychological Association), the research on mindfulness as identified as benefits:

Reduced rumination

Stress reduction

Increases in working memory

Increased ability to focus

Less emotional reactivity

More cognitive flexibility

Relationship satisfaction

One of the most common forms of mindfulness meditation is the Body Scan, below is a guided 5 Minute Body Scan to help you experience first hand the benefits of mindfulness meditation.

Positive psychology has shown that our well-being and satisfaction can be increased through our efforts and intentional activities. It takes practice, it might not always be easy but it will most certainly be worth the effort.

Have you tried any of these interventions before? Which one had the biggest impact in your life? We'd love to hear from you so leave a comment below.

References

American Psychological Association, A.P.A. (2016). What are the benefits of mindfulness? Retrieved from here.

Lyubomirsky, S. (2007). The how of happiness: a scientific approach to getting the life you want. New York: Penguin Audiobooks.

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Positive Psychology Examples: 5 Ways to Put it Into Practice

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Last Updated on "The aim of Positive Psychology is to catalyze a change in Psychology from a preoccupation only with repairing the worst things in life to also building the best qualities in life." - Martin Seligman Positive Psychology is first and foremost psychology, but its focus is the scientific study of positive experiences, states and traits.

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Take on injury and effects on mind

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NCAA.org - The Official Site of the NCAA

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Injuries, while hopefully infrequent, are often an unavoidable part of sport participation. While most injuries can be managed with little to no disruption in sport participation and other activities of daily living, some impose a substantial physical and mental burden. For some student-athletes, the psychological response to injury can trigger or unmask serious mental health issues such as depression, anxiety, disordered eating, and substance use or abuse.

When a student-athlete is injured, there is a normal emotional reaction that includes processing the medical information about the injury provided by the medical team, as well as coping emotionally with the injury.

Those emotional responses include:

Sadness

Isolation

Irritation

Lack of motivation

Anger

Frustration

Changes in appetite

Sleep disturbance

Disengagement

How student-athletes respond to injury may differ, and there is no predictable sequence or reaction. The response to injury extends from the time immediately after injury through to the post-injury phase and then rehabilitation and ultimately with return to activity. For most injuries, the student-athlete is able to return to pre-injury levels of activity. In more serious cases, however, a student-athlete's playing career may be at stake, and the health care provider should be prepared to address these issues. The team physician is ultimately responsible for the return-to-play decision, and addressing psychological issues is a significant component of this decision.

It's important for athletic trainers and team physicians, as well as student-athletes, coaches and administrators, to understand that emotional reactions to injury are normal. However, problematic reactions are those that either do not resolve or worsen over time, or where the severity of symptoms seem excessive. Examples of problematic emotional reactions are in the accompanying table.

One problematic reaction is when injured student-athletes restrict their caloric intake because they feel that since they are injured, they "don't deserve" to eat. Such a reaction can be a trigger for disordered eating. When a student-athlete is already at risk for disordered eating, this problematic reaction only heightens the likelihood these unhealthy behaviors will worsen.

Another problematic response to injury is depression, which magnifies other responses and can also impact recovery. Depression in some student-athletes may also be related to performance failure. When student-athletes sustain significant injuries, such as knee injuries associated with time loss from sport, they can suffer both physically as well as emotionally with a decrease in their quality of life. When Olympic skier Picabo Street sustained significant leg and knee injuries in March 1998, she battled significant depression during her recovery. She stated: "I went all the way to rock bottom. I never thought I would ever experience anything like that in my life. It was a combination of the atrophying of my legs, the new scars, and feeling like a caged animal." Street ultimately received treatment and returned to skiing before retiring.

Kenny McKinley, a wide receiver for the Denver Broncos, was found dead of a self-inflicted gunshot wound in September 2010 after growing despondent following a knee injury. He had undergone surgery and was expected to be sidelined for the entire season. He had apparently made statements about being unsure what he'd do without football and began sharing thoughts of suicide.

These case examples demonstrate how injury can trigger significant depression and suicidal ideation.

Concussion is another injury that can be very challenging for student-athletes to handle emotionally. An injury like an ACL - while it poses a serious setback to the student-athlete - at least comes with a somewhat predictable timeline for rehabilitation and recovery. What makes concussion particularly difficult is that unlike most injuries, the timeline for recovery and return to play is unknown. With concussion, the initial period of treatment includes both cognitive and physical rest, which counters the rigorous exercise routine many student-athletes often depend on to handle stressors. Given the emotional and cognitive symptoms associated with concussion, student-athletes often struggle with their academic demands. In addition, compared with some injuries where a student-athlete is on crutches, in a sling, or obviously disabled in some way, with the concussed student-athlete, he or she "looks normal," making it even more challenging to feel validated in being out of practice or play.

For the student-athlete with concussion, it is especially important - and difficult - to watch for problematic psychological responses to the injury. Some student-athletes experience emotional symptoms as a direct result of the brain trauma that can include feeling sad or irritable. If these symptoms don't seem to be going away it is important to explore whether they might be related to a mental health issue such as depression and not directly to the injury itself. In some cases, the psychological reaction to the concussion - rather than the concussion itself - can be the trigger for the depression. When this is the case, simply waiting for the brain to recover isn't enough: the depression also needs to be treated.

It is also important to be aware that with increasing media attention being paid to neurodegenerative diseases such as chronic traumatic encephalopathy (CTE) among professional athletes, some student-athletes might fear that even the mildest concussive injury will make them susceptible to these highly distressing outcomes. Though there is very little known about what causes CTE or what the true incidence of CTE is, the concern for possibly developing permanent neurodegenerative disease can be paralyzing. Athletic trainers and team physicians can help educate injured student-athletes about the known risks associated with concussions and can help them focus on managing the injury in the present. They should also be aware that student-athletes who are expressing a high level of anxiety could be experiencing a mental health condition that requires treatment by a mental health professional.

Seeking treatment

Injured student-athletes who are having a problematic psychological response to injury may be reticent to seek treatment. They may be afraid to reveal their symptoms, may see seeking counseling as a sign of weakness, may be accustomed to working through pain, may have a sense of entitlement and never had to struggle, and may not have developed healthy coping mechanisms to deal with failure. In addition, many student-athletes have not developed their identity outside of that as an athlete. Thus, if this role is threatened by injury or illness, they may experience a significant "loss." Getting a student-athlete to consider treatment can be challenging (and it is complicated by privacy issues), so coaches, athletic trainers and team physicians as the support network for the student-athlete should work together to provide quality care.

As an athletic trainer or team physician, it's important to be aware of common signs and symptoms for various mental health issues and understand the resources available to treat them. Those personnel also must do everything possible to "demystify" mental health issues and allow student-athletes to understand that symptoms of mental health issues are as important to recognize and treat as symptoms for other medical issues and musculoskeletal issues. Underscoring the availability of sports medicine staffs to provide for early referral and management of mental health issues is essential.

It's also important for coaches, athletic trainers and team physicians to support injured student-athletes and do what they can to keep athletes involved and part of the team. This might include keeping student-athletes engaged, and at the same time encouraging them to seek help and not try to "tough their way through" situations that include mental health factors.

For coaches, one of the most powerful actions is to "give the student-athlete permission" to seek treatment (see Mark Potter's article in Chapter 1 emphasizing this notion). This is often incredibly helpful in encouraging student-athletes to seek care. Having programs available to educate student-athletes as well as sports medicine and administrative staffs regarding the resources available and the importance of collaborative programming helps provide appropriate care.

It is important to understand the mental health resources available on each campus and consider both early referral as well as establishing multidisciplinary teams that include athletic trainers, team physicians, psychologists, psychiatrists and other health care providers to provide care for mental health issues in student-athletes. If this can be incorporated into the overall goal of optimizing performance, along with nutrition and strength and conditioning, it may be better received by student-athletes and coaches, thereby increasing the compliance with management and treatment.

Given all that is known about mental health issues in athletes - and the role of injury and the barriers to treatment - the bar is raised in terms of what athletic trainers and team physicians can do in the future. Having a comprehensive plan in place to screen for, detect and manage student-athletes with problematic response to injury is an important first step.
Margot Putukian is the director of athletic medicine and head team physician at Princeton University, where she is also an assistant director of medical services at University Health Services. She has an academic appointment as an associate clinical professor at Rutgers Robert Wood Johnson Medical School. Putukian has a B.S. in biology from Yale University, where she participated in soccer and lacrosse, and an M.D. from Boston University. She completed her internship and residency in primary care internal medicine at Strong Memorial Hospital in Rochester, New York, and her fellowship in sports medicine at Michigan State University. Putukian is a past president of the American Medical Society for Sports Medicine. She currently works with US Soccer and US Lacrosse as a team physician, and several organizations advocating for health and safety issues, including the NCAA, the NFL, USA Football, the American College of Sports Medicine, US Soccer and US Lacrosse. She can be reached at putukian@princeton.edu.

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Mind, Body and Sport: How being injured affects mental health

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Injuries, while hopefully infrequent, are often an unavoidable part of sport participation. While most injuries can be managed with little to no disruption in sport participation and other activities of daily living, some impose a substantial physical and mental burden.

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Article on stresses added to someone after injury

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Coping with the stress of an injury requires both physical and psychological resilience. Sports injury recovery typically focuses on physical rehab, but it's also important to include sports psychology techniques to help recover mentally and emotionally.

Athletes react to injuries with a wide range of emotions which may include denial, anger, sadness, and even depression. An injury often seems unfair to anyone who has been physically active and otherwise healthy. Although these feelings are real, it's important to move beyond the negative and find more positive strategies to cope with this setback. In many cases dealing gracefully with an injury helps an athlete become more focused, flexible, and resilient.

Here are some sports psychology strategies you can use for faster injury recovery.

The more you know about the cause, treatment, and prevention of your injury, the less it can cause fear or anxiety. You should learn how to talk to your doctor.

Ask the following questions of your doctor, trainer, coach or therapist until you know exactly what you can do to heal quickly and fully.

What is my diagnosis (what type of injury do I have)?

How long will recovery take?

What is the purpose of the treatments I am receiving?

What should I expect during rehab?

What alternative workouts can I safely do?

What are the warning signs that I am getting worse?

By understanding the injury and knowing what to expect during the rehabilitation process, you will feel less anxiety and a greater sense of control.

This is not to say that the injury is your fault. What this means is that your mindset needs to change. Instead of focusing on performance, you need to accept that now you have an injury and you are the only one that can fully determine your outcome.

By taking responsibility for your recovery process, you will find a greater sense of control and will quickly progress in recovery, rather than pushing yourself to perform at your pre-injury level.

To heal quickly you need to be committed to overcoming your injury by showing up for your treatments, and listening and doing what your doctor and/or athletic trainer recommend. You also need to monitor your self-talk-what you are thinking and saying to yourself regarding the injury and the rehab process.

Your self-talk is important. To get the most out of your daily rehab, you need to work hard and maintain a positive attitude. Remain focused on what you need to do, not what you are missing out on.

Growing research shows that it may be possible to speed up the healing process by using specific mental skills and techniques such as imagery and self-hypnosis. Imagery techniques use all of the senses to create mental images, feelings, and sensations related to the desired outcome as though it is happening now or has already happened.

A common response after an injury is to isolate yourself from teammates, coaches, and friends. It's important to maintain contact with others as you recover. Your teammates, friends, and coach can listen when you need to vent or can offer advice or encouragement during the rehab process.

Just knowing you don't have to face the injury alone can also be a tremendous comfort. So, go to practice; remain around the locker room and the weight room. Be visible by being an active member of the group.

Just because you are injured doesn't mean you stop planning or setting goals. Rather than viewing the injury as a crisis, make it another training challenge. Your goals will now focus on recovery rather than performance. This will help keep you motivated.

By monitoring your goals you will also be able to notice small improvements in the rehab of your injury. You will feel more confident that you are getting better and improving.

Remember to work closely with your therapist or doctor. They can help you set realistic goals that are in line with each stage of your rehab. Most athletes have a tendency to try to speed up the recovery by doing too much too soon. It is important to accept that you are injured and know your limits.

Depending upon the type of injury you have, you may be able to modify your training or add alternate forms of training to maintain cardiovascular conditioning or strength. Work with your trainer, therapist, or physician to establish a good alternative workout program. If you can't run, perhaps you can cycle or swim.

Work on relaxation training and flexibility, as well. Create a modified strength training program, do a limited amount of exercise to maintain cardiovascular fitness or focus on better nutritional health.

With the right knowledge, support and patience an injury can be overcome without turning your whole world upside down. By taking things slow, setting realistic goals, and maintaining a positive, focused approach, most athletes can overcome minor injuries quickly and major injuries in time. Make sure you see your doctor for a proper diagnosis and treatment plan for any injury.

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7 Ways to Cope With the Emotional Stress of an Injury

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Coping with the stress of an injury requires both physical and psychological resilience. Sports injury recovery typically focuses on physical rehab, but it's also important to include sports psychology techniques to help recover mentally and emotionally. Athletes react to injuries with a wide range of emotions which may include denial, anger, sadness, and even depression.

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A recent definition of Positive psychology

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This article is about psychology. For the positive mental attitude, see Optimism.

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Descriprtion of positive psychology

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In less than a decade, positive psychology has caught the attention not only of the academic community but also the general public. I just did a Google search for "positive psychology' and found 419,000+ hits. That is obviously impressive, although keeping all of us positive psychologists humble is that my searches for the "Olsen twins" and "Britney Spears" produced 6,390,000+ and 113,000,000+ hits, respectively.

It is still good that larger world is interested in positive psychology, and probably even better that this interest does not entail morbid curiosity and the wish to witness a train wreck.

Regardless, the downside of whatever popularity positive psychology enjoys is the temptation for those of us associated with this new field to run ahead of what we know in pursuit of further popularity. So let me slow down and explain what positive psychology actually is and what we actually know.

Positive psychology is the scientific study of what makes life most worth living. It is a call for psychological science and practice to be as concerned with strength as with weakness; as interested in building the best things in life as in repairing the worst; and as concerned with making the lives of normal people fulfilling as with healing pathology.

Nowhere does this definition say or imply that psychology should ignore or dismiss the very real problems that people experience. Nowhere does it say or imply that the rest of psychology needs to be discarded or replaced. The value of positive psychology is to complement and extend the problem-focused psychology that has been dominant for many decades.

Several truisms underpin positive psychology. First, what is good in life is as genuine as what is bad--not derivative, secondary, epiphenomenal, illusory, or otherwise suspect. Second, what is good in life is not simply the absence of what is problematic. We all know the difference between not being depressed and bounding out of bed in the morning with enthusiasm for the day ahead. And third, the good life requires its own explanation, not simply a theory of disorder stood sideways or flipped on its head.

Positive psychology is psychology-psychology is science-and science requires checking theories against evidence. Accordingly, positive psychology is not to be confused with untested self-help, footless affirmation, or secular religion-no matter how good these may make us feel. Positive psychology is neither a recycled version of the power of positive thinking nor a sequel to the secret.

Positive psychology will rise or fall on the science on which it is based. So far, the science is impressive. Consider what has been learned in recent years about the psychological good life, none of which was mentioned in any of the psychology courses I took a few decades ago:

* Most people are happy.
* Happiness is a cause of good things in life and not simply along for the happy ride. People who are satisfied with life eventually have even more reason to be satisfied, because happiness leads to desirable outcomes at school and work, to fulfilling social relationships, and even to good health and long life.
* Most people are resilient.
* Happiness, strengths of character, and good social relationships are buffers against the damaging effects of disappointments and setbacks.
* Crisis reveals character.
* Other people matter mightily if we want to understand what makes like most worth living.
* Religion matters.
* And work matters as well if it engages the worker and provides meaning and purpose.
* Money makes an ever-diminishing contribution to well-being, but money can buy happiness if it is spent on other people.
* As a route to a satisfying life, eudaimonia trumps hedonism.
* The "heart" matters more than the "head." Schools explicitly teach critical thinking; they should also teach unconditional caring.
* Good days have common features: feeling autonomous, competent, and connected to others.
* The good life can be taught.

This latter point is especially important because it means that happiness is not simply the result of a fortunate spin of the genetic roulette wheel. There are things that people can do to lead better lives, although I hasten to say that all require that we live (behave) differently ... permanently. The good life is hard work, and there are no shortcuts to sustained happiness.

My goals for the blog entries that will follow are two-fold. First, I plan to discuss recent research findings about the psychological good life. And second, I plan to discuss the most promising applications based on these findings. I hope you find what I say interesting, and I invite your reactions, positive or negative. But let's try and base the discourse on what the evidence shows. As the saying goes, the plural of anecdote is not data.

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What Is Positive Psychology, and What Is It Not?

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In less than a decade, positive psychology has caught the attention not only of the academic community but also the general public. I just did a Google search for "positive psychology' and found 419,000+ hits. That is obviously impressive, although keeping all of us positive psychologists humble is that my searches for the "Olsen twins" and "Britney Spears" produced 6,390,000+ and 113,000,000+ hits, respectively.

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Fear after injuyr of ACL

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Erin H. Hartigan, PT, PhD, ¹ Andrew D. Lynch, PT, DPT, PhD, ² David S. Logerstedt, PT, PhD, ³ Terese L. Chmielewski, PT, PhD, ⁴ and Lynn Snyder-Mackler, Pt, ScD, FAPTA ³

Abstract

STUDY DESIGN

Secondary-analysis, longitudinal cohort study.

OBJECTIVES

To compare kinesiophobia levels in noncopers and potential copers at time points spanning pre- and post-anterior cruciate ligament (ACL) reconstruction and to examine the association between changes in kinesiophobia levels and clinical measures.

BACKGROUND

After ACL injury, a screening examination may be used to classify patients as potential copers or noncopers based on dynamic knee stability. Quadriceps strength, single-leg hop performance, and self-reported knee function are worse in noncopers. High kinesiophobia levels after ACL reconstruction are associated with poorer self-reported knee function and lower return-to-sport rates. Kinesiophobia levels have not been examined before ACL reconstruction, across the transition from presurgery to postsurgery, or based on potential coper and noncoper classification.

METHODS

Quadriceps strength indexes, single-leg hop score indexes, self-reported knee function (Knee Outcome Survey activities of daily living subscale, global rating scale), and kinesiophobia (Tampa Scale of Kinesiophobia [TSK-11]) scores were compiled for potential copers (n = 50) and noncopers (n = 61) from 2 clinical trial databases. A repeated-measures analysis of variance was used to compare TSK-11 scores between groups and across 4 time points (before preoperative treatment, after preoperative treatment, 6 months post-ACL reconstruction, and 12 months post-ACL reconstruction). Correlations determined the association of kinesiophobia levels with other clinical measures.

RESULTS

Presurgery TSK-11 scores were significantly higher in noncopers than in potential copers. Postsurgery, no group differences existed. TSK-11 scores in both groups decreased across all time points; however, TSK-11 scores decreased more in noncopers in the interval between presurgery and postsurgery. In noncopers, the decreases in TSK-11 scores from presurgery to postsurgery and after surgery were related to improvements in the Knee Outcome Survey activities of daily living subscale, whereas the association was only present in potential copers after surgery.

CONCLUSION

Kinesiophobia levels were high in both noncopers and potential copers preoperatively. Restoration of mechanical knee stability with surgery might have contributed to decreased kinesiophobia levels in noncopers. Kinesiophobia is related to knee function after surgery, regardless of preoperative classification as a potential coper or noncoper.

Keywords: ACL, fear, functional outcomes, knee, rehabilitation, Tampa Scale of Kinesiophobia-11

Anterior cruciate ligament (ACL) rupture is common in athletes and usually prohibits sports participation. ACL reconstruction surgery is the standard of care in the United States. The surgery is performed to stabilize the knee joint to prevent further injuries and to allow the patient to return to previous levels of activity. However, many people do not return to sport after ACL reconstruction, and kinesiophobia (eg, fear of movement/reinjury) is one potential underlying reason. Up to 24% of patients with ACL reconstruction do not return to sport because of fear of reinjury. Kinesiophobia levels have been objectively quantified with the Tampa Scale of Kinesiophobia (TSK-11). Based on TSK-11 scores, kinesiophobia levels generally decrease through the early and advanced phases of ACL reconstruction rehabilitation, but higher TSK-11 scores are associated with worse self-reported knee function and a lower return-to-sport rate. Thus, kinesiophobia is an important psychosocial construct in ACL rehabilitation.

Following ACL injury, there is a differential response among patients in dynamic knee stability and knee function (self-reported and performance based), with some people faring better than others. A screening examination was developed to distinguish individuals soon after ACL injury, based on the potential to dynamically stabilize the knee during high-demand activities. Those who do not pass the screening examination (classified as noncopers) are considered to be less able to dynamically stabilize the knee and are recommended for ACL reconstruction. In contrast, those who do pass the screening examination (classified as potential copers) are considered to be potentially able to dynamically stabilize the knee in the short term and are allowed to attempt high-demand activities following a specialized nonoperative rehabilitation program. The classifications of noncoper and potential coper are not based on the psychosocial phenomenon of coping with the injury. Potential copers demonstrate the functional requirements with their existing level of knee function, as defined by the screening examination that includes 4 specific cutoff criteria, whereas noncopers are unable to meet each of the 4 specific cutoff criteria (). In addition to experiencing more episodes of the knee giving way and poorer performance-based and self-reported knee function, noncopers demonstrate more asymmetries between limbs in their movement patterns. An inability to dynamically stabilize the knee soon after injury could lead to higher levels of kinesiophobia in noncopers.

TABLE 1

Meeting All 4 Criteria Below
Classifies a Patient as a Potential Coper

Meeting Any 1 of the Criteria Below
Classifies a Patient as a Noncoper

A neuromuscular training program that includes the application of perturbations to the lower extremity has been developed and used in the preoperative rehabilitation of both potential copers and noncopers. Potential copers treated with neuromuscular training have demonstrated superior return-to-sport outcomes compared to those who participated in traditional rehabilitation. A neuromuscular training program has been shown to improve indicators of dynamic knee stability, such as decreasing muscle cocontraction and improving knee kinematics, for both potential copers and noncopers. It is unknown whether a neuromuscular training program helps to reduce kinesiophobia or whether reduced kinesiophobia is related to improvements in clinical measures (eg, quadriceps strength, hop tests, and self-reported knee function). Because noncopers have poorer dynamic knee stability acutely after injury, this group has the potential to obtain greater improvements in clinical measures. For this reason, noncopers may show greater reductions in kinesiophobia after a neuromuscular training program than potential copers. In addition, surgical reconstruction restores mechanical stability of the knee and may lead to reduced kinesiophobia levels. To date, no study has examined changes in kinesiophobia levels after ACL injury in response to neuromuscular training that includes perturbation training or ACL reconstruction, both of which aim to eliminate instability in the knee.

The purpose of this study was to compare kinesiophobia levels between noncopers and potential copers across periods spanning pre- and post-ACL reconstruction and to examine the association between changes in kinesiophobia levels, quadriceps strength, and self-reported and performance-based knee function. We hypothesized that noncopers would have higher levels of kinesiophobia before, but not after, ACL reconstruction. We also hypothesized that kinesiophobia would decrease over time in both groups, specifically, after (1) a period of preoperative rehabilitation that included a neuromuscular training program known to improve dynamic stability, (2) ACL reconstruction, and (3) a period of 6 to 12 months post-ACL reconstruction. Finally, we hypothesized that changes in kinesiophobia would correlate with changes in quadriceps strength and self-reported and performance-based knee function. Examining kinesiophobia in potential copers and noncopers can increase knowledge about this psychosocial construct after ACL injury, particularly in reference to dynamic knee stability. In addition, examining kinesiophobia before and after a preoperative neuromuscular training program and ACL reconstruction would provide information about the potential for the interventions to influence this psychosocial construct.

METHODS

Patients

This is a secondary analysis of data from 2 longitudinal clinical studies involving patients with ACL injury. Patients were eligible for this study if they (1) were between 13 and 55 years of age, (2) had a unilateral ACL rupture confirmed with magnetic resonance imaging and at least a 3-mm side-to-side difference in anterior knee laxity determined with a knee arthrometer (KT1000; MEDmetric Corporation, San Diego, CA), (3) regularly participated (more than 50 hours per year) in level 1 and 2 sports (jumping, cutting, pivoting, and lateral movements) prior to surgery and desired to return to a level 1 or 2 sport, (4) underwent ACL reconstruction, and (5) had TSK-11 scores collected from at least 1 data-collection time point. Patients with any of the following were excluded from the study: bilateral injury, concomitant injury (eg, other ligamentous injury of grade 3, full-thickness chondral defect of greater than 1 cm ²), concomitant surgery that required a modified rehabilitation protocol (eg, meniscal repair or articular cartilage microfracture), pregnancy, or previous knee surgery. Approval for the 2 parent studies was granted by the University of Delaware Institutional Review Board, rights of the patients were protected, and all patients gave written informed consent. Patients who were minors gave assent to participate in the study, and informed consent was obtained from a parent or guardian.

Testing Overview

Data were collected at 4 time points: the time of the screening examination (before preoperative treatment), after a preoperative neuromuscular training program (after preoperative treatment), 6 months after ACL reconstruction, and 12 months after ACL reconstruction. Demographic data collected during the screening examination included the patient's age, time from the injury to the screening examination, height, weight, and sex. At all 4 time points, data were collected for a quadriceps strength index, 4 single-leg hop tests, self-reported questionnaires rating daily knee function (Knee Outcome Survey activities of daily living subscale [KOS-ADL]), global knee function (global rating scale [GRS]), and kinesiophobia levels (TSK-11).

Screening Examination

Prior to undergoing the screening examination, each patient participated in a standardized physical therapy protocol that focused on minimizing knee impairments, including gait deviations, knee joint effusion, knee range-of-motion limitations, thigh muscle strength deficits (primarily quadriceps strength deficits), and knee pain. Screening was allowed when the patient demonstrated a knee effusion of less than 1+ (zero or trace), full knee range of motion, no pain with vertical hopping on the injured leg, normal gait, and a quadriceps strength index of at least 70%.

Quadriceps strength was measured with an electromechanical dynamometer (Kin-Com; Isokinetic International, Chattanooga, TN) during a maximum voluntary isometric contraction of the knee extensors in sitting. Isometric testing is a reliable and accurate way to measure quadriceps strength. The quadriceps strength index was calculated as the force produced by the injured limb divided by the force produced by the uninjured limb, expressed as a percentage. Prescreening physical therapy continued until patients achieved a 70% quadriceps strength index, with testing every 2 to 3 weeks.

The screening consisted of 4 single-leg hop tests, the KOS-ADL, GRS, and self-reported number of episodes of the knee giving way since the injury. All patients were required to wear an off-the-shelf functional knee brace during hop testing (DJO, LLC, Vista, CA). Multiple sizes of left and right knee braces were available, and physical therapists fit the patient with the appropriate knee brace. The 4 hop tests were the single hop, crossover hop, triple hop for distance, and 6-meter timed hop. A symmetry index was computed for each hop test by dividing the hop distance on the injured limb by the hop distance on the uninjured limb, expressed as a percentage. Because lower numbers indicate better performance on the 6-meter timed hop test, the symmetry index for this test was calculated as hop time on the uninjured limb divided by hop time on the injured limb, expressed as a percentage. Single-leg hop testing is a valid and reliable measure of functional performance.

After hop testing, patients completed the KOS-ADL and GRS, and reported the number of episodes of knee giving way since the injury. The self-reported questionnaires were administered after hop testing to allow patients to better estimate their functional status. The KOS-ADL includes 14 items, with lower scores representing greater knee symptoms and functional limitations during activities of daily living. The GRS asks patients to rate their perceived level of knee function on a scale of 100 percentage points, with anchors of 0% (unable to perform any activity) and 100% (able to perform all preinjury activities, including sports, without limitation). The KOS-ADL and GRS are valid and reliable for evaluating self-reported knee function, as well as for differentiating a noncoper from a potential coper.

When screening was complete, the patients were classified as potential copers or noncopers, based on previously determined cutoff scores on 4 screening elements: number of episodes of knee giving way and scores on the 6-meter timed hop test, KOS-ADL, and GRS (). The cutoff scores reflect values that were 2 standard deviations below the group mean for patients who were unable to successfully return to sports after ACL rupture. If a patient failed to meet the established criteria on any of the 4 tests, the patient was classified as a noncoper, even if adequate scores were achieved on the other 3 tests. Patients who met the cutoff scores for all 4 tests were classified as potential copers. The data collections after the preoperative treatment, at 6 months post-ACL reconstruction, and at 12 months post-ACL reconstruction were conducted in the same manner, using the same testing protocol and order as the screening examination.

Tampa Scale of Kinesiophobia

The TSK-11 was added to the testing protocol approximately 1 year after recruitment for the 2 parent studies was initiated. The questionnaire was administered along with the other questionnaires in the screening protocol and was the last questionnaire to be completed in the packet. The TSK-11 was collected before and after the preoperative intervention, and 6 and 12 months post-ACL reconstruction. The TSK-11 includes 11 items, with scores ranging from 11 to 44 points, and higher scores indicating higher levels of kinesiophobia. Test-retest reliability, validity, responsiveness, and internal consistency have been assessed in patients with chronic low back pain, and psychometric properties are adequate and comparable to a longer version of the questionnaire. A clinically meaningful change in the level of kinesiophobia has been determined to be a 4-point difference in TSK-11 scores.

Physical Therapy Overview

All patients received preoperative and postoperative physical therapy at the University of Delaware Physical Therapy Clinic, following practice guidelines. The physical therapy plan of care was individualized based on impairments, activity limitations, and participation restrictions. Treatment components, frequency, and duration were based on patient needs and the ability to meet established clinical milestones. Although rehabilitation sessions were individualized to the patient's needs, the average session lasted approximately 1 hour. Kinesiophobia was not formally addressed during preoperative or postoperative rehabilitation, and no goals to reduce kinesiophobia were established.

Preoperative Neuromuscular Training Program

Patients typically received 10 preoperative physical therapy sessions (2 to 3 times per week for a 2- to 4-week period) that began after the screening examination and prior to undergoing ACL reconstruction. Specific goals after screening included unilateral strengthening to maximize quadriceps force output in the involved limb and neuromuscular rehabilitation, including perturbation training (described in detail elsewhere) to improve muscle reaction response time to specific directions and magnitudes of forces or perturbations to the limb's base of support. Preoperative goals were to minimize impairments, maximize quadriceps strength in the ACL-deficient limb, promote dynamic knee stability and symmetrical use of the lower extremities, and educate the patient on proper techniques with therapeutic exercises as part of the postoperative rehabilitation protocol.

ACL Reconstruction

All patients underwent an arthroscopic-assisted ACL reconstruction, performed by a single orthopaedic surgeon, using a quadrupled semitendinosus-gracilis (single-bundle) autograft or a soft tissue allograft.

Postoperative Rehabilitation

Goals after ACL reconstruction were to minimize impairments incurred during the surgical procedure by progressively achieving established postoperative clinical milestones. The criterion-based postoperative rehabilitation protocol included impairment resolution, progressive quadriceps strengthening, a high-intensity neuromuscular electrical stimulation protocol for quadriceps strengthening, and neuromuscular training to achieve progression through a walk/jog program and agility protocol. Perturbation training was not administered as part of the postoperative neuromuscular training protocol. Patients practiced low-level skills and progressed to more advanced sport-specific skills as milestones were reached. Treatment frequency varied, with greater frequency immediately after surgery and less frequency leading up to discharge. Most patients were discharged to independent programs by 6 months postsurgery, and returned only for testing sessions to acquire clinical measures until they passed all criteria deemed necessary to return to sports (eg, 90% or greater on all 7 components: quadriceps strength index, 4 single-leg hop tests, KOS-ADL, and GRS).

Data Analysis

Data were analyzed with SPSS Statistics 19 (IBM Corporation, Armonk, NY), and descriptive statistics were generated for demographic data, quadriceps strength, hop test scores, and KOS-ADL, GRS, and TSK-11 scores at all 4 time points. TSK-11 scores at the 4 testing time points were compared between noncopers and potential copers using 2 separate 2-way, mixed-model, repeated-measures analyses of variance (ANOVAs), with group as the between-patient variable and time as the within-patient variable. The first model was conducted only for those patients with a complete TSK-11 data set (ie, TSK-11 scores at all 4 testing time points). The second model was conducted with all patients in the study, including those with missing TSK-11 scores, consistent with an intention-to-treat analysis. Regression imputation was used to estimate missing TSK-11 scores, regardless of where the missing data point existed. Specifically, a multiple-imputation method was chosen, as this method produces the most valid imputed values when approximately 30% of the data are missing. Multiple imputation involves mathematical linear equations, using the observed data to estimate missing data points. For example, the data observed before and after the preoperative treatment were used to calculate the predicted values that were missing after the preoperative treatment (). In both ANOVA models, the interactions between group and time were first examined, and, if no interaction was present, group and time main effects were examined. If significant differences were observed, then post hoc pairwise comparisons were used to investigate differences.

Correlations were calculated between change in TSK-11 scores and change in the quadriceps strength index, 6-meter timed hop, KOS-ADL, and GRS for each group over 3 time intervals (from before to after the preoperative treatment, from after the preoperative treatment to 6 months post-ACL reconstruction, and from 6 months to 12 months post-ACL reconstruction). No values were imputed for missing data from the clinical measures (quadriceps strength values, 6-meter timed hop scores, KOS-ADL, or GRS). Therefore, if subjects had missing data for change scores in their clinical measures, those values were dropped from the correlation analysis. Reasons for missing data on clinical measures included the patient's quadriceps strength exceeding the limits of the Kin-Com, the patient not passing the clinical guidelines to complete the hop testing, or the patient not having data for 1 of the times needed to compute the change score. Parametric or nonparametric correlations were chosen based on classification of data types and statistical assumptions. The strength of the correlations was interpreted based on the following criteria: little or no relationship (0.00-0.25), fair relationship (0.25-0.50), moderate to good relationship (0.50-0.75), and good to excellent relationship (above 0.75). Statistical significance was set a priori at P < .05.

RESULTS

A total of 132 patients (79 noncopers, 53 potential copers) met the inclusion criteria for this study. Of these, 111 patients (61 noncopers, 50 potential copers) completed the TSK-11 questionnaire, and their data were analyzed further. Of 444 possible cells for TSK-11 scores (111 patients times 4 time points), 150 cells were missing data and 294 cells were filled with observed data, including 152 cells belonging to 38 patients (22 noncopers, 16 potential copers) with TSK-11 scores at all 4 time points. Each of the 150 missing values were replaced with predicted values from the multiple-imputation regression model. Of the 73 patients with missing TSK-11 scores, 20 patients (11 noncopers, 9 potential copers) only had data for 1 time point, 37 patients (21 noncopers, 16 potential copers) had data for 2 time points, and 16 (7 noncopers, 9 potential copers) had data for 3 time points. Missing TSK-11 scores varied randomly over the 4 testing time points ().

Demographic data for the 111 patients analyzed can be found in . TSK-11 scores for the patients with data available at all time points and for the entire sample are shown in . The result of the ANOVA model using 38 patients was similar to the ANOVA model using 111 patients; therefore, results for the model using the entire sample (ie, intention-to-treat analysis) are reported. A time-by-group interaction ( P < .001) was found. The source of the interaction occurred between the completion of the preoperative neuromuscular training program and 6 months post-ACL reconstruction, with TSK-11 scores improving more in noncopers than in potential copers (). TSK-11 scores were significantly worse in noncopers than in potential copers before ( P = .011) and after ( P = .022) preoperative treatment, but no differences were found between groups at 6 ( P = .331) and 12 months ( P = .667) after ACL reconstruction (). TSK-11 scores statistically decreased (less kinesiophobia) over time in both groups, from before to after preoperative treatment (noncopers, P < .001; potential copers, P < .001), after preoperative treatment to 6 months postoperative (noncopers, P = .002; potential copers, P < .001), and 6 to 12 months postoperative (noncopers, P < .001; potential copers, P = .002).

TABLE 2

TABLE 3

Descriptive statistics for quadriceps strength indexes, the 4 hop test indexes, and the 3 self-report questionnaires (KOS-ADL, GRS, TSK-11) were compiled for all 111 patients and reported for each group at the 4 time points (). Spearman rho correlations were used due to the nonparametric nature of our change scores. In the noncoper group, a statistically significant negative correlation was found between changes in TSK-11 scores and changes in the KOS-ADL after the preoperative treatment session to the 6-month postoperative session (n = 46, r = -0.366, P = .012). Also, a statistically significant negative correlation was found between changes in TSK-11 scores and changes in KOS-ADL scores from the 6- to 12-month postoperative sessions (n = 47, r = -0.343, P = .018) in the noncoper group. The magnitudes of these significant associations were fair, and the direction indicated that a decrease in kinesiophobia level was associated with an increase in knee function over the given times (from presurgery to postsurgery and from 6 to 12 months postsurgery, respectively). No other statistically significant correlations were found in the noncoper group.

TABLE 4

Time Point/Variable

Potential Copers With TSK-11 Data

Noncopers With TSK-11 Data

In the potential coper group, statistically significant negative correlations were found between changes in the TSK-11 scores and changes in the KOS-ADL from the 6- to 12-month postoperative sessions (n = 35, r = −0.422, P = .013). The magnitude of the association was fair, and the direction indicated that a decrease in kinesiophobia level was associated with an increase in knee function from 6 to 12 months postsurgery. No other statistically significant correlations were found in the potential coper group.

DISCUSSION

This study compared kinesiophobia levels between individuals with ACL injury, classified as potential copers or noncopers, at specific time points from before to after ACL reconstruction. The relationship between changes in kinesiophobia levels (TSK-11 scores) and self-reported knee function (KOS-ADL, GRS), muscle performance (quadriceps strength index), and performance-based knee function (6-meter timed hop test) across time intervals was also examined in each group. We hypothesized that noncopers would have higher levels of kinesiophobia than potential copers preoperatively, and that no group differences would be present after ACL reconstruction. Our findings support this hypothesis and suggest that better knee stability (either dynamic or through surgical intervention) may influence kinesiophobia levels, and that decreasing kinesiophobia levels are associated with improvements in self-reported knee function during daily activities (KOS-ADL).

Prior to surgery, both noncopers and potential copers were similar in that they were ACL deficient, but dynamic knee stability was worse in noncopers, based on clinical measures (number of episodes of the knee giving way, 6-meter timed hop test, KOS-ADL, GRS) and laboratory measures (movement patterns). Higher preoperative TSK-11 scores in noncopers compared to potential copers suggest that kinesiophobia levels are associated with the level of dynamic knee stability. To the best of our knowledge, this is the first study to report TSK-11 scores in athletes who are ACL deficient. The magnitude of TSK-11 scores in both groups (noncopers, 25.3 points; potential copers, 22.9 points) was similar to TSK-11 scores in people with chronic disorders such as work-related upper extremity disorders, chronic low back pain, fibromyalgia, and osteoarthritis. Thus, kinesiophobia levels are high after ACL injury and need to be addressed during preoperative rehabilitation, specifically in people with poor dynamic knee stability.

Kinesiophobia levels were slightly reduced in both groups after participation in a preoperative neuromuscular training program. We expected that TSK-11 scores in noncopers would show more change after the preoperative intervention because they start at a lower level of dynamic knee stability. However, the change in TSK-11 scores from before to after the preoperative neuromuscular training program was not different between groups. In addition, the magnitude of change was less than 4 points, which has been determined to be the minimal clinically important difference in people with chronic low back pain. Perturbation training has had positive effects on dynamic knee stability in noncopers and potential copers, but the changes appear to be more subtle in noncopers. Therefore, the neuromuscular intervention was only mildly successful at improving kinesiophobia levels. Others have reported successful outcomes after a longer bout of nonoperative rehabilitation in noncopers and potential copers; however, kinesiophobia levels were not reported. Noncopers and potential copers were able to successfully return to preinjury sports 12 months after ACL rupture, and group assignment did not dictate who returned to sports after nonsurgical management. Because over 70% of noncopers demonstrate the functional ability to return to sports 12 months after surgery or 12 months after ACL rupture, noncopers, given the opportunity, may be able to demonstrate clinically meaningful reductions in kinesiophobia levels while they are ACL deficient; however, if and when this may occur remains unknown.

Both groups showed a significant decrease in TSK-11 scores from the end of preoperative rehabilitation to 6 months after ACL reconstruction, but the reduction in kinesiophobia was larger in noncopers. Additionally, the reductions in kinesiophobia were significantly related to self-reported knee function during daily activities in noncopers only. These findings suggest that restoring knee stability has a beneficial effect on kinesiophobia levels, and individuals with poorer dynamic stability benefit the most. However, to more directly determine the effect of ACL reconstruction, it would be necessary to measure kinesiophobia levels sooner than 6 months postsurgery. In addition, comparison to a control group that did not have surgery would provide insight on whether the reductions in kinesiophobia occur over time regardless of surgical status. Importantly, the reductions in TSK-11 scores in this time frame were the largest across the study and met the criteria for a minimal clinically important difference.

Interestingly, surveys of orthopaedic surgeons in the United States show that they often discuss fear of reinjury with athletes, and most surgeons agree that athletes with ACL deficiency will be unable to participate in all recreational sporting activities without surgery. The large decrease in kinesiophobia after surgery could also reflect expectations passed between surgeons and patients, with the recommendation for ACL reconstruction influencing patient expectations that surgery is necessary to restore knee stability. Pain studies have shown that outcomes are related to expectations suggested to, or perceived by, the patient. Specifically, better outcomes were observed when there was an expectation that the intervention would be successful and worse outcomes were observed when low expectations were suggested to the patient. Additionally, a social-learning response can occur when one observes a positive response to an intervention. For example, the knowledge of a known sports figure, teammate, or friend returning to sports after ACL reconstruction may instill a positive expectation that surgery will be a successful intervention. Thus, in the United States, the expectation that ACL reconstruction is needed to return to preinjury levels may contribute to high kinesiophobia levels preoperatively and reduced kinesiophobia after ACL reconstruction.

TSK-11 scores were not different between noncoper and potential coper groups at 6 or 12 months after ACL reconstruction. Similar kinesiophobia levels after ACL reconstruction indicate that the effect of preoperative group assignment on kinesiophobia does not extend to the postoperative period. TSK-11 scores in noncopers (16.15 points) and potential copers (16.90 points) were similar to those reported for other athletes (17.75 points) at 6 months after ACL reconstruction; however, noncoper scores (14.98 points) and potential coper scores (15.28 points) at 12 months were lower than those at 12 months postoperation reported elsewhere (18.23 points). Importantly, both groups' mean TSK-11 scores at 6 months postsurgery fell between the scores reported for people who did (15.3 points) and did not (19.6 points) return to sports at 12 months postsurgery, suggesting that not all members of either group are psychologically ready to return to sports, whereas by 12 months after ACL reconstruction, the mean TSK-11 scores in both groups (noncopers, 14.98; potential copers, 15.28) were more similar to TSK-11 scores of those who had returned to preinjury sports 12 months after ACL reconstruction (15.3 points). Though the purpose of this investigation was not to compare clinical measures between the noncopers and potential copers postoperatively, quadriceps strength indexes and self-reported and performance-based (hop tests) knee outcomes of both groups appear similar, and the clinical measures were greater than 90% at both postoperative time points for noncopers and potential copers (). Although, clinically, values greater than or equal to 90% meet the established criteria to clear a patient to return to sport, individual performance is not reflected in average performance measures, as less than half of noncopers passed established criteria to return to sports 6 months after surgery. Perhaps kinesiophobia levels influence the large variability in noncopers who pass criteria to return to sport 6 months after ACL reconstruction, especially given the relationship between kinesiophobia levels and the established return-to-sport criterion of a KOS-ADL score of greater than or equal to 90%.

TSK-11 scores continued to decrease from 6 to 12 months after surgery, despite the already large decreases in kinesiophobia levels from presurgery to 6 months after surgery. Although the postoperative reductions in TSK-11 scores were significant, the magnitude of change was less than 4 points, which is similar to that found by Lentz and colleagues. Thus, the magnitude did not reach the threshold for a clinically meaningful reduction as determined in low back pain research. The limited reductions in kinesiophobia suggest that we need to identify people with continued high kinesiophobia and then address it. Though reductions in kinesiophobia from 6 to 12 months after surgery were not clinically meaningful, these reductions were significantly related to improvements in self-reported knee function during activities of daily living for noncopers and potential copers. No statistically significant relationships between reduced kinesiophobia and improved quadriceps strength symmetry and improved symmetry on the 6-meter timed hop test were found. Others also found significant relationships between kinesiophobia and self-reported knee function during daily activities but not between kinesiophobia and quadriceps strength and hop score indexes. Performance-based (eg, muscle strength and dynamic hop tests) and patient self-reported knee function measures appear to represent 2 distinct and different constructs. Also, psychological recovery and physical recovery have previously been reported to not occur simultaneously. Perhaps self-reported knee function is influenced by patient perception, or maybe performance-based function is the sum total of many factors, including kinesiophobia, strength, and neuromuscular control, and the influence of kinesiophobia does not predominate across patients after ACL rupture and reconstruction. It is also possible that kinesiophobia and self-reported deficits in knee function may not be captured by maximal quadriceps strength indexes and maximal hop score indexes alone. In addition, kinesiophobia may be justified by a mismatch between physical ability and demands, and other aspects of physical performance that were not measured in our study may be associated with kinesiophobia. Perhaps when increased levels of kinesiophobia are present, additional physical impairments, environmental/activity demands, and psychological considerations should all be considered as potential contributors to worse knee stability. Though many questions remain, the need to continue to address factors that influence kinesiophobia throughout the late phases of recovery is evident, as those who become less fearful of reinjury also report fewer limitations in their activities of daily living.

Physical therapists should be aware that the TSK-11 questionnaire can be used to measure kinesiophobia levels after ACL rupture and reconstruction. Noncopers have greater kinesiophobia preoperatively, but have the potential to reach kinesiophobia levels similar to those reported for individuals who have returned to sports 12 months after ACL reconstruction. A better understanding of factors that influence kinesiophobia levels is needed, so that interventions can be targeted to individuals who will benefit the most. Our findings indicate that differences in dynamic knee stability following ACL injury appear to influence kinesiophobia levels preoperatively but not postoperatively. Therefore, further research is needed to determine the factors that cause some people to continue to have high kinesiophobia levels. In addition, interventions will be needed to reduce kinesiophobia levels in these individuals. Because kinesiophobia levels are elevated early after ACL rupture and contribute to postoperative reduction or cessation of sports participation, future research is warranted to investigate the efficacy of psychological interventions. Psychological counseling or interventions to address psychological recovery that parallel physical recovery are recommended after traumatic injury; thus, counseling/interventions that address kinesiophobia may benefit patients who sustain an ACL rupture. Measures of physical, psychological, and self-reported knee function should be evaluated independently to provide a comprehensive picture of each athlete's progression throughout recovery after ACL injury and rehabilitation and perhaps addressed separately.

Limitations

Our findings may not extend to a more sedentary population or to people with multiple ligamentous injury. All patients in this study were level 1 and 2 athletes, who incurred a unilateral ACL rupture, received preoperative and postoperative care at the same clinic, and underwent ACL reconstruction by the same orthopaedic surgeon using a hamstring autograft or allograft. Therefore, our findings cannot be generalized to patients who do not fit our inclusion criteria. Also, about 30% of the TSK-11 scores were missing, and such a high rate of missing data might have undermined the precision of our estimates. Although TSK-11 scores were missing at random, and a regression imputation method was used to handle missing data points, an estimated value is less precise than a measured one. Regression imputation uses a single-value imputation method, which tends to underestimate variances and overestimate correlations, and may introduce additional sampling variability that is not adequately accounted for. Furthermore, the change in TSK-11 scores that occurs over time may not be linear in nature, which could not be accounted for in regression imputation.

CONCLUSION

Kinesiophobia levels were elevated prior to ACL reconstruction, especially in those with poorer dynamic knee stability (ie, noncopers). After ACL reconstruction, kinesiophobia levels reduced the most in noncopers, and the reductions in kinesiophobia were significantly related to improvements in self-reported knee function during activities of daily living. Clinically, kinesiophobia levels remained high at 6 months and plateaued between 6 and 12 months postsurgery, when athletes are typically cleared to return to sports. Kinesiophobia levels should be monitored from the time of ACL rupture to 12 months after surgery.

​

Acknowledgments

This project was supported by funding awarded to Dr Snyder-Mackler at the University of Delaware from the National Institutes of Health (R01AR048212 and R01HD037985), to Dr Chmielewski at the University of Florida from the National Institutes of Health (K01HD052713), to Drs Hartigan and Logerstedt from the Foundation for Physical Therapy Scholarships (PODS I and II), and to Dr Hartigan from the University of Delaware Dissertation Fellowship, awarded during her time as a graduate student at the University of Delaware. Both clinical trials were approved by the University of Delaware Institutional Review Board.

The authors acknowledge the outstanding clinical services provided to our patients by the University of Delaware Physical Therapy Clinic, the efforts of Airelle Hunter-Giordano in her role as research/ clinical liaison, and Dr Michael J. Axe for his patient referrals. We also acknowledge Dr Praphul Joshi, PhD, MPH, BDS, assistant professor at the University of New England, for his statistical expertise and consultation.

Footnotes

The authors certify that they have no affiliations with or financial involvement in any organization or entity with a direct financial interest in the subject matter or materials discussed in the article.

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Kinesiophobia After Anterior Cruciate Ligament Rupture and Reconstruction: Noncopers Versus Potential Copers

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Erin H. Hartigan, PT, PhD, 1 Andrew D. Lynch, PT, DPT, PhD, 2 David S. Logerstedt, PT, PhD, 3 Terese L. Chmielewski, PT, PhD, 4 and Lynn Snyder-Mackler, Pt, ScD, FAPTA 3 Secondary-analysis, longitudinal cohort study.

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Great article on Imagery and assistance with rehab

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