The general components of positive psychotherapy (PPT).
The content of thought, which emerges from the processing of information from the social context lived, is a critical factor that guides whether the behavior is psychopathological or not. In cases where worry, anxiety and fear are dominant in the content of thought, the individual may find himself in some psychopathological processes. Adversity and uncertainty are the main factors that lead to the experience of worry, anxiety and fear which is the last point of these. Uncertainty of information from the social context lived, when matched with adversity, may lead to chaotic situations at the cognitive level, e.g., thought contents such as distortions in thought, severe anxiety and fear. Obsessive compulsive disorder derives from severe worry and anxiety. Although the disorder is classified under anxiety disorders, it is actually a thought distortion disorder. The individual finds himself repeating the strange behavior patterns accompanied by strange thought contents in order to get rid of the severe anxiety and accelerated thought cycle he is exposed to. Ambiguity and uncertainty also may lead to the accelerated thought cycle, ruminations, severe thought distortions, over-generalizations. Ruminations, especially, impair the individual’s ability to think and process emotions gradually. Obsessive Compulsive Disorder will be discussed in terms of ambiguity and uncertainty with the combination of adversity. Positive Psychotherapy, which is one of the latest effective technique in recovery processes of the diseases, will be mentioned.
- Obsessive Compulsive Disorder
- Positive Psychotherapy
The concept of mental health corresponds to the individual’s ability to function satisfactorily in his intellectual, emotional and behavioral adjustment. Events experienced in the ongoing flow of daily life, when combined with certain conditions, negatively affect mental health and even physical health. As long as the conditions that cause these negative effects persist, the groundwork is prepared for the occurrence of mental health disorders. That’s why there is a motto among mental health professionals: “No mental health illness can occur overnight.” This is a process. The content of thought, which emerges from the processing of information from the social context lived, is a critical factor that guides whether the behavior is psychopathological or not. In cases where worry, anxiety and fear are dominant in the content of thought, the individual may find himself in some psychopathological processes. Adversity and uncertainty are the main factors that lead to the experience of worry, anxiety and fear which is the last point of these. Uncertainty of information from the social context lived, when matched with adversity, may lead to chaotic situations at the cognitive level, e.g., thought contents such as distortions in thought, severe anxiety and fear. When this process is not managed properly, the disorders may occur.
The World Health Organization (WHO) defines being healthy as follows: “… It is not only the absence of disability or illness, but also the state of all mental and social well-being” . Dealing with mental health, the organization describes that mental health includes, as well as other things, subjective well-being, perceived self-efficacy, self-confidence, autonomy, competitiveness, intergenerational dependence, and the ability to realize own intellectual and emotional potential. The World Health Organization (WHO) also adds the following to the definition of mental health; “It also includes the individuals’ well-being to realize their abilities, cope with daily stress, be productive and beneficial to the society”. As can be understood from the definitions, mental health is a complex phenomena. Therefore mental health disorders are not occurred due to one factor. Multiple factors come together and reveal about the relevant mental health disorder. These factors are called as “risk factors”. The risk factors can be discussed under three subheadings. These are biological, psychological and social factors. These factors shortly explained as follows;
Having all these or some of the risk factors do not necessarily mean being exposed to a mental disorder indeed. However the combination of these risk factors and difficult life events/conditions may somehow create a predisposing ground for mental disorder in some individuals.
Adversity may lead to lots of short and long-term psychological problems. It may compromise functioning of the nervous system and even immune system. The more adverse experiences in everyday life routine, the greater the likelihood of mental health problems.
Adversity has a critical influence on especially anxiety related disorders such as obsessive compulsive disorder (OCD), adjustment disorder, post traumatic stress disorder (PTSD), phobic disorders, panic disorder, and somatoform disorders. The somatoform disorders correspond to the symptoms being ambiguous, in other words it means that no physical cause that could explain the current discomfort was found as a result of the medical examination. From the definition, it is also directly related to uncertainty too. Moreover there is an interactive relation between adversity and worry especially during uncertain times and under pressure. Weinberg  pointed out two components of anxiety; 1. Cognitive anxiety, 2. Somatic anxiety. He defined cognitive anxiety as “a mental component of anxiety during worry, and apprehension.” As known cognitive component of anxiety deals with the thought content in feeling pressure and threatening during adverse and uncertain situations. Naman  stated that worry and rumination are transdiagnostic and both worry and rumination are include in DSM 5 under the three disorder categories. These are OCD, PTSD and GAD. While stating that OCD is a though disturbance, she also mentioned that “OCD is a disorder including recurrent and persistent thoughts, urges or images being experienced at some time during disturbance, as intrusive and unwanted and that in most individuals cause marked anxiety”. She added that “in order to relieve distress from intrusive and repetitive worries, individuals engage in compulsions. Rumination is a common type of compulsion.” It is well known that thought disturbance is triggered by adverse and uncertain conditions.
Psychosocial adversity is taken into account as life-influencing happening that may be concluded obsessive thoughts and compulsions.
2.1 Resiliency after experiencing adversity
There are many theories that go beyond the classical theories of mental health. One and most effective of them is Positive Psychology. Number of studies throughout human mental health have demonstrated that there is an interconnected and mutually reinforcing gain/achievement to be found in suffering during last two decades. It is also known by mental health professionals positive gains can come about as a result of suffering [4, 5, 6, 7, 8].
Resiliency is defined as the individual’s ability to cope with adversity and uncertainty. In other words, resiliency deals with a successful adaptation to highly adverse conditions, and situations. Resilient individual is able to bounce back from adverse conditions with competent functioning. To be resilient is not an unusual capacity or ability. Every individual, by the way, have this ability as there is a tendency to handle with the adverse conditions. It is a kind of process rather than a characteristic to be had. A resilient individual develop healthy coping strategies allowing him to effectively deal with the adverse conditions. There is a critical key in the thinking atmosphere of a resilient individual, this is creating a balance between adversity and positivity of the conditions. As everyone has already this ability, it is functional to let the individual to realize their resilient abilities. For this, positive psychologists have been identified the components that make the individual resilient . Some of them are as follows;
Optimistic thinking style
An ability to regulate emotions
A positive attitude
An ability to perceive negative events as a form of helpful feedback
According to positive psychologists, everyone has these characteristics. During therapy, it is aimed to raise awareness that they have them and to teach to use when they need all of these.
Uncertainty is associated with the future and what happens. It is often experienced in the routine of everyday life. It causes fundamental restrictions on the behavior of the individual, whatever the decision is, regardless of his observation, in daily life. Lack of sufficient clues about any observed situation may cause worry, anxiety and even fear about the situation or related situations. Uncertainty has three main components. These are respectively 1. A feeling in the individual that the situation cannot be controlled, 2. Feeling and worrying that there will be some negative consequences in the future, 3. Perceiving an imaginary experience or situation as a threat as if it were experienced.
Uncertainty, although, is not expressed as a cause for anxiety according to Quantum physics, it also has a tendency to create a serious problem in the process of human behavior. How can uncertainty, which is in the usual routine of life, act as a factor that negatively affects human life? Human being strives to minimize uncertainty in the face of life events. For this, assumptions are put forward, and tested. Individuals’ perceptions of what happened may differ according to their preferences, lifestyle, and even educational status. On the other hand, the perceptions about what should be, in other words, the perceptions about the value system can appear as a life order with more certain and defined it’s border, far from uncertainty. The differentiation between values, that is, what should be and the life routine, that is, what happens, directly corresponds to the need for change. If the individual tries to survive through a resistant personality structure to change, uncertainty may lead to severe psychopathological situations. Under the resistant structure, an interactive process takes place in every social situation where there are many layers and many actors in these layers. Which decision is taken for whom for what and why is passed through the reasoning filter of the mind and the situation is tried to be made certain. In order to avoid uncertainty, participatory, fair and open ways of coping where the opinions of others are included and are applied. Under the imperceptible circumstances, uncertainty clues are percept and this may elevate the tendency of control the process. Today it has been demonstrated when the dynamics in the social situation are imperceptible, and therefore not mobilized, the tendency to control processes is increased [9, 10, 11, 12].
There is a term for explaining why some people much more effected in uncertain situation; “Uncertainty Paralysis”. It is defined as “Uncertainty Paralysis represents a sense of being stuck and unable to respond effectively when faced with uncertainty, resulting in a paralysis of cognition and action” . However intolerance of uncertainty plays a major role in the formation of psychopathology especially anxiety and mood disorders. Many studies have demonstrated intolerance of uncertainty, worry and emotional regulation process [14, 15, 16, 17]. It is described “tendency of a person to consider the possibility of a negative event occurring as unacceptable and threatening irrespective of the probability of its occurrence” . Intolerance of Uncertainty (IU) have been taken into account a vulnerability factor for OCD.
4. Obsessive compulsive disorder as a way of coping with adversity and uncertainty
As in all mental disorders, the roots of obsessive – compulsive disorder come from the risk factors such as biological, psychological and social factors for mental health. The interaction of these factors may lead to suffering from the disorder. Although the disorder is classified under the anxiety disorders, the main component is on the thinking and perception style. The content of thought, which emerges from the processing of information from the social context lived, is a critical factor. In cases where worry, anxiety and fear are dominant in the content of thought, the individual may find himself in some psychopathological thinking style processes. Obsessive–compulsive disorder (OCD) derives from severe worry and anxiety. Within the atmosphere of the severe anxiety, the individual finds himself repeating the strange behavior patterns accompanied by strange thought contents in order to get rid of the severe anxiety and accelerated thought cycle he is exposed to. In this point it is a thought disturbance disorder. In the disorder, compulsions, that’s why, is so resistant to stop as they are automatic response in the habitual way that are easy to perform them without thinking. For every rehearsal, the individual can avoid the anxious thoughts content. In all cases, the triggering stimuli is uncertainty, adversity and the resistance to change. Today it is well known that OCD symptoms may worsen in the times of severe adversity conditions and uncertainty.
Ruminations are another thought distortion problem. The individual thinks about the same thoughts which tend to be in two-ended, good or bad, sad and dark. This thinking circle goes on and on avoiding the tension from anxious thought content. In the content of OCD thinking style, ruminations become a kind of habitations. The individual cannot stop himself, this process, unfortunately impair the healthy thinking ability and emotions. They leads to isolation as the individual push his social environment away. The isolation also may cause gradually intensive depression. Which factors cause ruminating? Personality traits, perfectionism, low self-esteem, difficulty in expressing emotions and self, excessive focus on one’s relationships with others, encountering ongoing stressors either from uncertainty and the conditions cannot be controlled, over generalized thinking style, ineffective and/or maladaptive coping style, poor social skills and so on.
Why the individual has difficulty in stopping obsessions and compulsions? The answer is on the road of adversity and uncertainty dichotomy. The main characteristic of Obsessive Compulsive Disorder is trying to make situations certain. This effort is the result of the controlling thought content. As the individual cannot bear uncertainty, he produces symptoms to reduce the anxiety caused by uncertainty. As will be remembered, one of the common thought contents in Obsessive Compulsive disorder is resistance to uncertainty, innovation and change. This resistance develops with the belief that the individual is attributing these situations potentially dangerous. Uncertainty sometimes feeds ambiguity. In situations perceived both uncertain and ambiguous, the individual experiences discomfort, tension, worry and reacts in the form of rigidity, anxiety and avoidance behaviors as he cannot stop the obsessive thoughts from running through his mind. There are number of research studies related to causal role of uncertainty [14, 15, 18]. They have studied the causal role of intolerance to uncertainty. For example Gentes and Ruscio  found that higher anxiety level may come from the intolerance of uncertainty. Dugas et al.  describes the term of intolerance to uncertainty as the “individual’s dispositional incapacity to endure the aversive response triggered by the perceived absence of salient, key, or sufficient information and sustained by the associated perception of uncertainty”. They found intolerance of uncertainty was related to obsessions/compulsions in nonclinical sample. Further the relationship between intolerance and worry statistically significant with combined adversity. Fergus and Wu  have examined the intolerance of uncertainty and the symptoms of Obsessive Compulsive Disorder (OCD) and the related cognitive process such as threat estimation, perfectionism, desire to certainty, and the control thoughts. They found that the only intolerance of uncertainty was the cognitive component predicting the unique variance in OCD symptoms. Fourtounas and Thomas  examined two hypothesis; 1. The prospective intolerance of uncertainty (IU) was associated with checking behaviors 2. The inhibitory IU was associated with procrastination.
Childhood Trauma and the severity of the symptoms of OCD had been studied by Carpenter & Chung in 2011 . They pointed out that a significant correlation between severity of OCD and intolerance of uncertainty. Boger et al.  reached the same results. However as in the all this kind of studies, their sample size is so small and the intermediate variables could not be controlled so the results of the studies are far from being scientific evidence. Longitudinal studies should be done.
4.1 What can be done?
There are number of ways to bear with uncertain situations and adversity. In uncertain situations, to stop ruminations,
It is so helpful to find a distraction for breaking the thought cycle. For example watching something i.e. film, movies, documentary etc. This will help to reduce over valued ideations in thinking content .
It is so functional to realize repeating the same thought over and over again does not work. For planning to take an action; Analyzing the problem causing the thought cycle by using stepwise method with paper-pencil method will be helpful for deciding what to do. Writing is a good tool in first step, and then the second and so on, up to understand what is the problem. It is critical to be specific as possible and realistic .
Since avoiding from some worried thoughts, not only efforts to control occur but also to cope with the situation. This process also create some psychological problems with paradoxical effects. These are related to rule governed behaviors. Realizing what to do, it is good to take an action. After taking an action, the ruminative thoughts finish as the obsessing stimuli is not strong anymore .
Questioning the thought cycle. While ruminating a troubling thought, it is helpful to put the repetitive thoughts in perspective .
Realizing perfectionism and unrealistic problem solving ways may cause ruminations. Perfectionism may lead to use unrealistic problem solving ways as it refers to beliefs about situations in almost every segment of your life. A perfectionist believes that everything must be perfect in environment, relationships and at work. Please start writing; what is perfectionism for you? Are you a perfectionist? If your answer is “Yes”, in what areas of your life are you a perfectionist? Then make a costs and benefits table on to be a perfectionist. Is “to be a perfectionist” something that helps to you solve problems really? This awareness method also will help to overcome depressive episode combined with OCD [24, 25].
Enhancing self-esteem; exercising to realize strengths of personality, and social support and sources .
Joining a positive group therapy and/or positive therapy sessions.
5. Positive psychotherapy for elevated symptoms of obsessive compulsive disorder
Group/individual therapies are systematic evidence-based improvement methods used in the rehabilitation process of social skill deficiencies or insufficiencies, impairments in thought content, and thus behavioral problems.
Positive group and/or individual therapies aim at uncovering five main components of self-actualization. These are in a nutshell trust, responsibility, self-awareness, adaptability, and sense of purpose. It is rooted on the strength-based approach explored by Chris Peterson , and primarily is based on Martin E.P. Seligman’s  work on happiness and psychological well-being. He has formulated to be happy via PERMA which has scientifically measurable and teachable five components. The formulation of PERMA corresponds to (P) Positive emotion, (E) Engagement, (R) Relationships, (M) Meaning and (A) Accomplishment. Rashid [28, 29] explains that positive therapy consists of 14 sessions, the topic of each session and the strengths the session corresponds to. These 14 sessions are general components of Positive Psychotherapy (Table 1).
|1||Orientation to PPT||Emotional Intelligence, Authenticity, Courage|
|2||Character Strengths||Emotional Intelligence, Perspective|
|3||Signature Strengths & Positive Emotions||Creativity, Hope & Optimism & Gratitude|
|4||Good & Bad Memories||Gratitude, Appreciation of Beauty & Excellence|
|5||Forgiveness||Forgiveness & Merry, Kindness, Social Intelligence, Self-Regulation|
|6||Gratitude||Gratitude, Love, Social and Emotional Intelligence, Authenticity|
|7||The Forgiveness and Gratitude Assignments Follow up, Review of Signature Strengths||Perseverance, Perspective, Self-Regulation|
|8||Satisficing vs. Maximizing||Self-Regulation, Gratitude|
|9||Hope and Optimism||Hope & Optimism|
|10||Positive Communication||Love, Kindness, Curiosity, Social Intelligence|
|11||Signature Strengths of Others||Love, Social Intelligence|
|12||Savoring||Appreciation of Beauty and Excellence, Gratitude|
|13||Positive Legacy & Gift of Time||Teamwork, Kindness|
|14||The Full Life||Perspective|
Throughout the sessions the individual realized his not only personal resources but also social ones. By discussing the each subject of the sessions, it is gained awareness on confidence, responsibility, emotional mastery, open to challenging beliefs and assumptions, able to manage adversity, and sense of purpose in their life. As working through on positive exercises during sessions, the individual cultivates positive emotions such as gratitude, and savoring. In contrast the negative thinking content and emotions which is the basement of ruminations were constricted.
Obsessive Compulsive Disorder (OCD) derives from severe worry and anxiety. Within the atmosphere of the severe anxiety, the individual finds himself repeating the strange behavior patterns accompanied by strange thought contents. At this point OCD is a thought disturbance disorder.
Stopping obsessions and compulsions is a serious problem in obsessive compulsive disorder. Worry and ruminations together may lead to obsessions as well known ruminations are a common type of compulsions. On the other hand worry is a cognitive process which is directly related to feeling anxiety coming from a threats and/or danger. In all cases, the triggering stimuli is uncertainty, adversity and the resistance to change. Today it is well known that OCD symptoms may worsen in the times of severe adversity conditions and uncertainty [31, 32, 33].
Positive psychotherapy directly helps to increase self-esteem, self-confidence, to build optimistic thinking style, courage, perseverance, and flexibility.