Substance use presents a significant public health concern given the high degree of subsequent negative consequences that accompany substance use disorders (SUDs). Recent calls have gone out for substance use treatment providers to move their focus beyond reducing or eliminating symptoms, and instead shift their attention to increasing positive experiences and well-being (McKay, 2017). One field of psychology that may be especially well-suited for this challenge is positive psychology. The goal of the positive psychology movement is to move beyond the disproportionate focus on pathology and disorders and to work toward building positive qualities in individuals and institutions (Seligman & Csikszentmihalyi, 2000). Surprisingly, while the field of addiction research has widened its lens to be more positivity focused with the emergence of the recovery movement (White, 2000), there is little cross-pollination between this field and that of positive psychology (Krentzman, 2013). While the idea of assessing quality of life indices has gained momentum in the field of addiction recovery research broadly (Tiffany, Friedman, Greenfield, Hasin, & Jackson, 2012), little work has been done examining quality of life and positivity indices as direct treatment targets.
The field of positive psychology has led to the development of positive psychology interventions (PPIs): brief exercises with the goal of increasing positive emotions and positive states. In the general population, there is promising evidence pointing towards their effectiveness. One meta-analysis examining fifty-one studies testing positive psychology interventions found that these interventions increase overall well-being (r=0.29) and decrease depressive symptomatology (r=-0.31; Sin & Lyubomirsky, 2009). Further, there is evidence that these positive effects last over time. Another meta-analysis among thirty-nine studies and n=6,139 participants found that those who showed improvements in well-being sustained these benefits three to six months later (Bolier et al., 2013).
Despite these promising findings, PPIs have seldom been tested in SUD populations. Concerns about feasibility tend to surface when attempts are made to apply positive psychology advancements to SUD treatment. Recovery is difficult, and some have raised the thought that interventions aimed at increasing happiness might serve as an unfriendly reminder of the happiness they are generally lacking during the recovery process. Still, efforts have been made to develop PPIs to support remission from SUDs, as evidenced by three pilot studies. One such study found evidence for the feasibility of implementing positive psychology exercises within a small sample of adolescents undergoing drug and alcohol treatment services (Akhtar & Boniwell, 2010). The experimental group that attended weekly positive psychology exercise workshops showed marked increases in well-being, happiness, optimism, positive emotions, and significant decreases in alcohol dependence as compared to a control group. Similarly, another study found evidence for the feasibility and acceptability of a particular gratitude exercise, entitled “Three Good Things,” (Seligman, Steen, Park, & Peterson, 2005) when administered to a sample of persons in recovery from alcohol use disorder (Krentzman et al., 2015). Finally, a third study tested a five-session positive affect supplement to contingency management therapy in twenty-one methamphetamine-using men who have sex with men (Carrico et al., 2015). Results demonstrated feasibility and acceptability, with the participants randomized to the positive affect supplement largely completing the treatment (98 percent), and demonstrating short-term increases in positive affect (i.e., two months). However, these results did not appear to be sustainable over the long-term (Carrico et al., 2015).
Recovery is not easy, and positive experiences need to be attainable along the way. Stigma continues to surround current treatment models. Individuals cite this stigma, among other drawbacks, as a reason to not seek treatment (Luoma et al., 2007). Thus, non-stigmatizing and accessible PPIs appear promising for this population. Thus, the goal of the present study was to test the general effectiveness of several brief, self-administered PPIs in a large online sample of persons in recovery from problematic substance use. Specifically, we aimed to find whether these happiness exercises increase in-the-moment happiness in people in recovery, and which exercises are most effective at doing so. Additionally, we explored the general feasibility and value of these exercises from the perspectives of individuals in recovery.
There were 531 adults who self-described as being in recovery from problematic substance use who were recruited online between 09/15/2016 and 02/09/2018 via posts on recovery support social network sites, on Craigslist, and on shared posts through various individuals’ social media. Participants answered four questions—recovery stage, recruitment source, their belief in the role of happiness to recovery, and the importance of happiness to recovery—then rated their current happiness (i.e., the preactivity happiness rating). Individuals were then randomized to complete one of five happiness exercises or one of two control exercises. Finally, participants reported their current happiness once again (i.e., the postactivity happiness rating).
Participants were, on average, fifty-one years of age, predominantly female (65 percent), and predominantly non-Hispanic Caucasian (91 percent). Sixty-five percent of participants were employed or enrolled in school. Many of our participants self-described as being in early recovery (i.e., 18 percent were either seeking recovery or had been in recovery for less than one month; 21 percent were within their first year of recovery). The most frequently used substance was alcohol (67 percent of the sample).
Three of the five happiness exercises used in the present study were modified versions of exercises that have been previously shown to be effective in enhancing positive affect (Lyubomirsky, Sheldon, & Schkade, 2005; Otake, Shimai, Tanaka-Matsumi, Otsui, & Fredrickson, 2006; Seligman et al., 2005). These exercises were:
Two exercises were created by our team based on relevant findings and existing practices. These exercises were:
The control exercises were variations of the “Three Good Things” exercise, the mostly widely-used happiness exercise of our five happiness exercises. Namely, these exercises were:
The “Three Hard Things” is a clinically relevant comparison because treatment frequently addresses encountered challenges. The “Three Things” exercise is an effort to create a theoretically neutral comparison, which acts as an attention-control without valence.
Before and after completing a random exercise, participants rated their in-the-moment happiness again. They were also asked to rate ease of completion and whether they could and would complete the exercise daily. Participants were also given the choice to complete any of the additional exercises to which they were not initially randomized.
We used a repeated measures mixed effects model with momentary happiness rating as the dependent variable and treatment (happiness exercise vs. neutral/negative exercises), time (pre vs. post), and their interaction as predictors. In a follow-up analysis, exercise type (seven groups) was used as a predictor instead of treatment type (two groups), and specific contrasts were used to examine whether happiness change from pre- to postexercise differed between each exercise. In another follow-up analysis, we examined the impact of preexercise happiness on changes over time and as a moderator in the effects of treatment over time. Preexercise rating was dichotomized as “low” and “high,” where “low” indicates a happiness rating of <50 (25 percent of sample), which represented a natural breaking point in the distribution of scores. Some participants skipped the survey item requiring a “post” rating of happiness (n=91, 17 percent). Thus, we conducted a sensitivity analysis by rerunning each analysis and replacing missing observations of postexercise happiness with preexercise ratings, all under the conservative assumption that happiness remained stable if participants did not provide a postexercise rating.
Those who completed happiness exercise experienced a significant increase in their in-the-moment happiness ratings compared to those completing our neutral or negative control conditions. When comparing the specific happiness exercises to the negative “Three Hard Things” exercise, the greatest effects were found for three exercises: “Savoring” (F(1, 438) = 7.29, p = .007), “Rose, Thorn, Bud,” (F(1, 438) = 6.21, p = .01), and “Reliving Happy Moments” (F(1, 438) = 12.07, p < .001). When comparing the specific happiness exercises to the neutral “Three Things” exercise, only “Reliving Happy Moments” was found to have an effect on pre- to post-in-the-moment happiness ratings, (F(1, 439) = 6.65, p = .01).
Participants took on average 4.4 minutes (SD = 4.5 minutes) to complete happiness exercises, and rated them as easy to complete (M=81.7 on a scale from 0 = “extremely difficult” to 100 = “extremely easy”). The easiest exercise to complete appeared to be “Savoring,” as 100 percent of participants randomized to this condition did complete the exercise, while the lowest exercise completion rate (88 to 89 percent) was demonstrated for the “Experiencing Kindness,” “Reliving Happy Moments,” and “Three Good Things” exercises. Happiness exercises did not significantly differ in the time required to complete exercise (F(4, 313) = 0.51, p = .07). Most participants indicated that they could see themselves doing a happiness-boosting exercise as part of their daily routine (93.8 percent), and many reported plans to do so for the next several weeks (32.2 percent), indicating a high degree of acceptability. Further, qualitative examination of participant answers to exercises revealed that all participants who completed their exercises appeared to do so with thoughtful effort. For instance, no answers appeared nonsensical or inappropriate to the prompt being raised.
Most participants reported that happiness was a goal of, a pathway towards, or both a goal of and a pathway towards their successful recovery from SUDs (94.1 percent). The majority also endorsed the belief that completing happiness-boosting exercises, such as the ones presented to them in the present study, could be of use to them in boosting or maintaining their happiness (86.3 percent). These ratings varied across exercises, with “Savoring” being perceived as most useful (91.5 percent endorsing their usefulness), and “Reliving Happy Moments” being perceived as least useful (86.3 percent endorsing their usefulness). It is worth noting that participants with lower pre-exercise ratings of in-the-moment happiness were least likely to rate these exercises as being particularly useful.
Results from this study are promising, while preliminary evidence showed that brief, self-administered, text-based happiness exercises can be effective in impacting in-the-moment happiness. Further, participants in this study indicated that these exercises were easy to complete, taking only three to four minutes on average. These findings support the notion that happiness is an important target that can and should be addressed during substance use treatment and efforts to support recovery.
These happiness exercises under the umbrella of PPIs were originally tested for use in nonclinical populations, though a growing body of research suggests that they may be useful tools to supplement treatment for a wide variety of presenting concerns (Seligman, Rashid, & Parks, 2006). They have been tested to support health behavior change in a variety of areas, including smoking cessation (Kahler et al., 2014, 2015), chronic pain management (Hausmann, Parks, Youk, & Kwoh, 2014), and increasing physical activity in cardiac patients (DuBois et al., 2012; Nikrahan et al., 2016). They have also been leveraged to address various psychological concerns, including schizophrenia (Meyer, Johnson, Parks, Iwanski, & Penn, 2012) and suicidality (Huffman et al., 2014).
With regards to misuse of substances other than nicotine, far less work has been done. This is surprising, given that a focus on happiness is well aligned with conceptualizations of recovery which aim to increase positive well-being in addition to decreasing distress (Kelly & Hoeppner, 2015). It seems clear that a decrease in individuals’ symptoms does not automatically translate to well-being and increased happiness. By adding these goals into treatment, patients can build upon the upward spiral towards well-being that has been found to result from happiness (Fredrickson & Joiner, 2002) and increase their positive resources. This includes capitalizing on their character strengths, increasing social connections, and finding a vocation which is meaningful to them, which may then be protective against future mental health concerns (Kobau et al., 2011), potentially including substance use relapse.
While the findings of this study add to our understanding of happiness as a viable target for intervention in substance use treatment, they should be considered in the context of several limitations. Firstly, because this was an online survey, there is the potential that some participants who may have enjoyed the happiness exercises less chose to discontinue partway through the survey or that responses to the survey reflected inaccurate or dishonest reporting. Further, in our attempts to dissuade dishonest responses (i.e., by not offering compensation to individuals who completed our survey) or to ensure accurate reading of survey items (i.e., by including check items), our sample is primarily white, female, and college-educated. This precludes our ability to generalize findings to the general population, which is significant given the disparities seen in rates of substance use and misuse across demographic groups (McCabe et al., 2007; Niv & Hser, 2006; Niv, Pham, & Hser, 2009). As such, future research is needed to examine potential moderators of the effectiveness of these exercises so as to better understand for whom they will be most beneficial.
Participants in the present study overwhelmingly reported that happiness is not just a goal to achieve in recovery, but a pathway to sustained recovery, underlining the importance of identifying tools by which they can increase their happiness. Our findings suggested that brief, self-administered, text-based happiness exercises are effective in impacting in-the-moment ratings of happiness. Further, they appear to be easy for individuals to complete and acceptable as an option for an activity to add into their daily routines. These findings are well aligned with models of recovery that seek to increase well-being as well as decrease distress (Kelly & Hoeppner, 2015), and provide a promising option for clinicians seeking a simple addition to their existing courses of treatment.