Positive psychology is generating growing interest in the healthcare field, including palliative care, with a focus on both its potential advantages, as suggested recently by the review of Austin et al. (Reference Austin, Siddall and Lovell2024) on posttraumatic growth, and the critical discussions surrounding its legitimacy, as exemplified by Stiefel et al. (Reference Stiefel, Bourquin and Michaud2023). Two general approaches have been developed for the psychological care of patients: on the one hand, classical psychopathological approaches based on the recognition and reduction of psychological suffering, and, on the other, the positive psychology approach that values and aims to reinforce the positive experiences, emotions, and personality traits of individuals. In this editorial, we will argue for an integration of these two approaches in order to adequately address the highly heterogeneous needs of patients at the end of life and their families, and to avoid a binary and simplistic vision between these two approaches.
Positive psychology: A paradigm centered on the notion of well-being
Despite being a recent discipline (Seligman and Csikszentmihalyi Reference Seligman and Csikszentmihalyi2000), positive psychology draws on a rich historical backdrop: it is based on Erikson’s stages of psychosocial development, Maslow’s theory of needs, Deci and Ryan’s theory of self-determination, and theories on emotions. Some of its elements have been integrated in the third wave of cognitive-behavioral therapies, which advocates a broader approach beyond the focus on symptomatic manifestations (Hayes and Hofmann, Reference Hayes and Hofmann2021).
Seligman and Csikszentmihalyi set out the objectives of positive psychology, focusing on the examination of conditions and processes contributing to the well-being of individuals and society. Considering the issues of the end of life context, healthcare professionals should rather privilege and foster the determinants of the so-called “psychological well-being” that tend to be more sustainable and less subject to fluctuating external conditions, as is the case with emotions (Dambrun and Ricard Reference Dambrun and Ricard2011).
This approach corresponds to the definition of health promoted by the World Health Organization (WHO), which underscores the importance of well-being and refrains from reducing mental health solely to the absence of symptoms. Consequently, care is not only about relieving from pathology, it requires a more global approach also consisting in promoting, preventing, and supporting health. Importantly, this conception of health relies on scientific evidence, especially the work of Westerhof and Keyes, who demonstrated that mental health and illness are correlated but distinct dimensions (Westerhof and Keyes Reference Westerhof and Keyes2010). It is therefore crucial to recognize the coexistence of positive and negative poles within the same individual. Studies on gratitude, for instance, have illustrated that the experience of pain and suffering may lead to a heightened awareness of what has been lost (Wood et al. Reference Wood, Froh and Geraghty2010). In palliative care, the study of gratitude letters of patients or families emphasized both the difficulty of the situation and the gratitude toward caregivers (Aparicio et al. Reference Aparicio, Centeno and Carrasco2017).
Thus, identifying and fostering positive experiences and aspects of life should not be understood as a negation of distress, but rather as a complementary avenue to the indispensable psychopathological approach. This integration allows patients to broaden their focus of attention, identify “dormant” resources, and thus enhance mental health and quality of life. In the realm of health promotion and prevention, this approach mirrors the concept of salutogenesis, which prioritizes the reinforcement of an environment conducive to health and individual resources.
A second and third wave of positive psychology
This emphasis on well-being and personal fulfillment may have contributed to a polarization of the scientific discourse surrounding positive psychology. The positive psychology approach has been mischaracterized as a way of leading patients to deny their negative emotions, at the risk of eliciting guilt feelings or even manipulating patients if they fail to meet the positive expectations that seemingly define this paradigm (Stiefel et al. Reference Stiefel, Bourquin and Michaud2023). It is indeed crucial to differentiate between positive psychology, which requires scientific and methodological rigor, and the commercialization of positive psychology. The latter can be seen as part of a neoliberal and capitalist ideological context (van Zyl et al. Reference van Zyl, Gaffaney and van der Vaart2023), but certainly also reflects needs which are prevalent in the general population.
Positive psychology has undergone a significant evolution on this point. Numerous authors have stressed the importance of considering the negative experiences, distress, and traumas as undeniable aspects of the human experience. Over the past decade, they have contributed to the development of the so-called “positive psychology 2.0,” or “second wave of positive psychology” has emerged. This evolution recenters the debate by underscoring the importance of incorporating the experience of suffering into both research and clinical practice (Abbas et al. Reference Abbas, Ekowati and Suhariadi2022). The notions of resilience, post-traumatic growth, meaning in life (MIL), awareness of death, or compassion can be understood and fostered even within the context of adverse life events such as bereavement, confrontation with illness or relational ruptures. There is currently mention of a third wave of positive psychology (Wissing Reference Wissing2021), which aims to recognize the complexity of human experience and promotes a transdisciplinary approach to integrate it more effectively.
It is important to note that positive psychology does not intend to exclude psychological suffering. This is a stark reality for patients at the end of life, as evidenced by the prevalence rates of various psychiatric diagnoses: around 25% for all type of depression combined, 15% for adjustment disorders, and 10% for anxiety disorders. However, while suffering is an undeniable reality, it does not universally characterize all patients, and its intensity can vary significantly from one patient to another.
Positive psychology interventions and palliative care
In palliative care, there are 2 main groups of positive psychology interventions. The first one concerns MIL. MIL represents a key dimension of spirituality, which is an integral component of palliative care according to its definition by the WHO. Most MIL interventions occur in a classic therapeutic setting through face-to-face sessions. Not all MIL interventions are labeled as positive psychology interventions. Nevertheless, MIL is known to contribute significantly to psychological well-being. They are currently many interventions aimed at improving MIL (e.g., logotherapy, meaning-centered psychotherapy, meaning-making intervention, “managing cancer and leaving meaningfully” therapy) with a well-established body of evidence supporting their efficacy. Their total effect size of 0.62 is comparable to many conventional psychotherapeutic approaches (Manco and Hamby Reference Manco and Hamby2021). The challenge lies in their feasibility within the context of end-of-life care, particularly with fragile patients who may be unable to commit to a long-term and protocolized follow-up. In this respect, narrative approaches appear to be the most promising.
The second group comprises positive psychology interventions which are mostly designed as self-interventions proposed to the patient (i.e., gratitude-based or hope-based interventions). Several studies show promising effects in palliative care (Tan et al. Reference Tan, Tan and Lam2021), but they display methodological limitations concerning sample size or design. Beyond the palliative care context, several systematic reviews and meta-analyses have noted the still limited efficacy of these interventions (Chakhssi et al. Reference Chakhssi, Kraiss and Sommers-Spijkerman2018; White et al. Reference White, Uttl and Holder2019). One of the answers may lie in the self-administration nature of these interventions, which do not rely on a supportive relationship between a therapist and a patient. This aspect is crucial not only because the therapeutic alliance is a decisive factor of success in psychotherapy but also because of the “containing” role of this alliance when undesirable effects emerge. For example, we have identified anxiety and sadness resulting from a gratitude-based intervention (Bernard et al. Reference Bernard, Poncin and Bovet2023; Poncin et al. Reference Poncin, Bovet and Tamches2024). A further concern of some interventions is the lack of flexibility and adaptability to individual patient characteristics. Most of these interventions are based on a “one-size-fits-all” approach. Thus, positive effects that may be significant for a subgroup of patients could get diluted in the statistical analysis of the whole population.
Given the impressive and irreducible heterogeneity of the patients in palliative care and their families, it is imperative to develop and assess interventions which are more flexible and adjustable to patients’ individual characteristics and needs. For some patients, it may be best to leave them alone and just provide a safe space, while others may profit from positive psychology interventions or “classical” psychotherapy, or both. To adequately respond to the fundamental heterogeneity of our patient population, we need to develop a diverse array of tools and evidence-based interventions, and then let the patients guide us.
Toward an integrative approach
The existing body of evidence supports the assertion that patients can indeed benefit from a positive psychology approach in palliative care. Although it is legitimate to question the use of certain principles of evidence-based research in the context of palliative care due to the fragility of patients and heterogeneity of the population(Aoun and Nekolaichuk Reference Aoun and Nekolaichuk2014), we still need to strive to reach as high a level of evidence as possible. We are deeply convinced of the complementarity rather than opposition between conventional approaches based on psychopathology and positive psychology. Such an approach was already embraced in a psychotherapy study with promising results in terms of efficacy (Wong et al. Reference Wong, Owen and Gabana2018). The current challenge lies in adapting this integrative approach within the unique context of palliative care. Finally, positive psychology also offers an opportunity to understand the processes at play in patients who do not experience significant suffering in the last phase of their lives. This group of patients is often neglected by research, whereas insight gained from their experiences might conceivably benefit all patients.
