Maybe Stuart Smalley Was Right All Along

To many people, the self-help movement—with its positive self-talk, daily feel-good affirmations, and emphasis on vague concepts like “gratitude” and “acceptance”—seems like cheesy psychobabble.  Take, for instance, Al Franken’s fictional early-1990s SNL character Stuart Smalley: a perennially cheerful, cardigan-clad “member of several 12-step groups but not a licensed therapist,” whose annoyingly positive attitude mocked the idea that personal suffering could be overcome with absurdly simple affirmative self-talk.

Stuart Smalley was clearly a caricature of the 12-step movement (in fact, many of his “catchphrases” came directly from 12-step principles), but there’s little doubt that the strategies he espoused have worked for many patients in their efforts to overcome alcoholism, drug addiction, and other types of mental illness.

Twenty years later, we now realize Stuart may have been onto something.

A review by Kristin Layous and her colleagues, published in this month’s Journal of Alternative and Complementary Medicine, shows evidence that daily affirmations and other “positive activity interventions” (PAIs) may have a place in the treatment of depression.  They summarize recent studies examining such interventions, including two randomized controlled studies in patients with mild clinical depression, which show that PAIs do, in fact, have a significant (and rapid) effect on reducing depressive symptoms.

What exactly is a PAI?  The authors offer some examples:  “writing letters of gratitude, counting one’s blessings, practicing optimism, performing acts of kindness, meditation on positive feelings toward others, and using one’s signature strengths.”  They argue that when a depressed person engages in any of these activities, he or she not only overcomes depressed feelings (if only transiently) but can also can use this to “move past the point of simply ‘not feeling depressed’ to the point of flourishing.”

Layous and her colleagues even summarize results of clinical trials of self-administered PAIs.  They report that PAIs had effect sizes of 0.31 for depressive symptoms in a community sample, and 0.24 and 0.23 in two studies specifically with depressed patients.  By comparison, psychotherapy has an average effect size of approximately 0.32, and psychotropic medications (although there is some controversy) have roughly the same effect.

[BTW, an "effect size" is a standardized measure of the magnitude of an observed effect.  An effect size of 0.00 means the intervention has no impact at all; an effect size of 1.00 means the intervention causes an average change (measured across the whole group) equivalent to one standard deviation of the baseline measurement in that group.  An effect size of 0.5 means the average change is half the standard deviation, and so forth.  In general, an effect size of 0.10 is considered to be "small," 0.30 is "medium," and 0.50 is a "large" effect.  For more information, see this excellent summary.]

So if PAIs work about as well as medications or psychotherapy, then why don’t we use them more often in our depressed patients?   Well, there are a number of reasons.  First of all, until recently, no one has taken such an approach very seriously.  Despite its enormous common-sense appeal, “positive psychology” has only been a field of legitimate scientific study for the last ten years or so (one of its major proponents, Sonja Lyubomirsky, is a co-author on this review) and therefore has not received the sort of scientific scrutiny demanded by “evidence-based” medicine.

A related explanation may be that people just don’t think that “positive thinking” can cure what they feel must be a disease.  As Albert Einstein once said, “You cannot solve a problem from the same consciousness that created it.”  The implication is that one must seek outside help—a drug, a therapist, some expert—to treat one’s illness.  But the reality is that for most cases of depression, “positive thinking” is outside help.  It’s something that—almost by definition—depressed people don’t do.  If they were to try it, they may reap great benefits, while simultaneously changing neural pathways responsible for the depression in the first place.

Which brings me to the final two reasons why “positive thinking” isn’t part of our treatment repertoire.  For one thing, there’s little financial incentive (to people like me) to do it.  If my patients can overcome their depression by “counting their blessings” for 30 minutes each day, or acting kindly towards strangers ten times a week, then they’ll be less likely to pay me for psychotherapy or for a refill of their antidepressant prescription.  Thus, psychiatrists and psychologists have a vested interest in patients believing that their expert skills and knowledge (of esoteric neural pathways) are vital for a full recovery, when, in fact, they may not be.

Finally, the “positive thinking” concept may itself become too “medicalized,” which may ruin an otherwise very good idea.  The Layous article, for example, tries to give a neuroanatomical explanation for why PAIs are effective.  They write that PAIs “might be linked to downregulation of the hyperactivated amygdala response” or might cause “activation in the left frontal region” and lower activity in the right frontal region.  Okay, these explanations might be true, but the real question is: does it matter?  Is it necessary to identify a mechanism for everything, even interventions that are (a) non-invasive, (b) cheap, (c) easy, (d) safe, and (e) effective?   In our great desire to identify neural mechanisms or “pathways” of PAIs, we might end up finding nothing;  it would be a shame if this result (or, more accurately, the lack thereof) leads us to the conclusion that it’s all “pseudoscience,” hocus-pocus, psychobabble stuff, and not worthy of our time or resources.

At any rate, it’s great to see that alternative methods of treating depression are receiving some attention.  I just hope that their “alternative-ness” doesn’t earn immediate rejection by the medical community.  On the contrary, we need to identify those for whom such approaches are beneficial; engaging in “positive activities” to treat depression is an obvious idea whose time has come.

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9 Responses to Maybe Stuart Smalley Was Right All Along

  1. aek says:

    Excellent points all, Steve. But what PAI’s require is an “other” to act upon – someone or something to be grateful to or for, someone to cherish and appreciate, someone to be kind to, etc.

    For people who are ostracized, these others are precisely who have been intentionally removed. The prescription to practice PAIs becomes a double whammy – the realization that there is no one else and the sense of failure of being unable to perform PAIs. There is a dearth of study and publication around ostracism – who wants to touch literal untouchables? But C Fred Alford wrote about them in the guise of whistleblowers. There is a review paper of his study Whistleblowers: the experience of choiceless choice. His book is called Whistleblowers: Broken Lives and Organizational Power.

    What then? Alford found that overall, whistleblowers get sick and die early. I think that’s a “blessed” relief to an unending and unbearable social death sentence. But it also explains why people who are bullied suffer so – that’s a form of ostracism, too. The demoralization that occurs – realizing that there is indeed no hope and that one is powerless to change the trajectory of what is being done to him, is overwhelming. I wrote Alford and asked him if he knew of any success stories – of any person who by their own definition – had a satisfactory outcome. He replied that he didn’t, nor did he know of any resources for treatment.

    That’s where I find American culture so wanting: its every-man-for-himself brutality dominance makes it nigh unto impossible for ostracized people – who have been lethally and deliberately untethered from the world – to ever find a way back in – if they even want to, given the broken trust and brutality they experience at the hands of people and organizations who are given trust via social contract.

    Are you aware of any therapist of any recognized ilk who even addresses ostracism?

    I think that PAIs will have utility for people who have caring and trustworthy people in their lives. But for those who don’t, encouraging this would further a sense of freakish otherness and isolation. /.02.

  2. Rob Lindeman says:

    Brilliant stuff, Steve. Keep telling it, Brother!

  3. 12-step programs strike me as uniquely successful, largely due to the group support and accountability – not present when simply thinking positive thoughts alone in one’s bedroom. And aek, in the comment above, makes an excellent point about the brutality of being ostracized. Personally, I have a strong negative reaction to those who push positive thinking as a solution to life’s problems. Barbara Ehrenreich made an excellent case for the dark side of positive thinking in her book “Bright-sided.”

    “[P]ositive thinking has made itself useful as an apology for the crueler aspects of the market economy. If optimism is the key to material success, and if you can achieve an optimistic outlook through the discipline of positive thinking, then there is no excuse for failure. The flip side of positivity is thus a harsh insistence on personal responsibility: if your business fails or your job is eliminated, it must [be] because you didn’t try hard enough, didn’t believe firmly enough in the inevitability of your success.”

    When it comes to health — physical or mental — personal responsibility cuts two ways. I would certainly support the efforts of any individual who finds positive thinking helpful. But I am also suspicious of those who advocate personal responsibility (the snack food industry, neoliberal economists/politicians), since it all too easily can be an excuse to blame the individual and conveniently escape the need to address the larger social issues (inequality, the environment) that account for poor health in the first place.

    I’m not disagreeing with you, Steve, and I do appreciate the argument you make. This just happens to be a soapbox I frequently find myself standing on.

  4. A Non says:

    First of all, four thumbs up to aek. Wow. Thank you.

    How about more reasons it’s not tried:

    * patient rejects “Don’t Worry. Be Happy” out of hand. Which is anyone’s right in today’s universe.

    * patient has self-image problems, and is not dysmorphic, but in fact, pretty damn ugly?

    * patient is socially isolated and almost completely a social retard? A super-annoying nerd?

    I’ve read Ehrenreich, and also recommend David Rakoff’s “Half Empty”. It’s not really a psych-centric book (although his dad was one, which enters into his tales, and he tells a very good story about his own experiences with his own therapist, who became ill and died).

    (FWIW, I finished the original blog post and wanted to punch somebody. Am I “resistant”?)

    Also currently making my way through “Positive Power of Negative Thinking” (Norem), but so far, I’m stopping short of giving it a recommendation. Maybe it gets better…

  5. Mariam Cohen, MD says:

    Perhaps the problem is not so much that positive things like affirmations and counting blessings are so helpful but that when people are depressed, they stop doing a lot of the positive thinking things that most of us undepressed people do automatically. There is something about depression that robs the suffering person of his or her ability to think positively about himself or herself. Then “intervening” with instructions to count one’s blessings or think of things you’ve done well today is not so much an intervention as it is replacing something that should be there innately.
    mcohenmd

  6. Laura says:

    On the one hand, I agree with aek very strongly. Telling someone to just “think positive!” when they feel crappy, can just make them feel worse.

    On the other hand, people respond to what you project yourself to be. So when you project yourself as an unhappy, un-fun loser, people don’t really want to hang around with you. Which then reinforces your belief that no one likes you or cares about you. But if you at least pretend to be a happy, fun person, people will want to be around you, and the pretending can make it real.
    …At least until the next depressive episode, when everyone stops hanging out with you because you’re no fun anymore, and you end up feeling worse than before. lol

  7. thealienist says:

    Overall, I like the post. I am trying to collect a menu of positive actions for people to engage in that have helped others overcome their suffering.

    One critical point, though. The effect size, as usually reported, is related to the proportion of variance accounted for by the experimental factor, not the number of people affected. An effect size of 0.2 is an effect that accounts for 20% of the standard deviation of observations. An effect size of 1.0 would explain all of the observed variation. The size and importance of the variation are not specified in the effect size (i.e. you can explain all of the variation in a very small effect (1.0 effect size) but this can be less important than explaining a small amount of variation, say 0.2, of a very large variation). I know this is picky, but some of my students might come by here. Still, your point holds.

  8. Dr. D says:

    Not sure where you learned about effect sizes, my friend. But an easier (and more accurate) way to think about them is how many standard deviations of a continuous variable the treatment group improves vs. the control group.

    So if a (hypothetical) treatment increases IQ by 7.5 points, the effect size would be 0.5; if it increases IQ by 15 points, the effect size would be 1.0; if it increases IQ by 30 points, the effect size would be 2.0, etc.

    The largest effect sizes in psychiatry are seen in stimulant medications for ADHD, with effect sizes in the neighborhood of 0.8 to 1.1. See http://www.medscape.org/viewarticle/569729 for a pharma-sponsored explanation of effect sizes as they’re generally used in psychiatry research.

    • stevebMD says:

      Wow. Duly noted. Text changed and link updated. I agree, it is overly simplistic (not to mention just plain wrong) to say that an effect size of 1.00 means the intervention “works in everybody.” (Although it is darn good.) BTW, the Medscape link is to an article funded by Shire, makers of Vyvanse.

      Anyway, my bad. Thanks for the comment.

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