George Scott, M.S.
Axel Ramos-Lucca, M.S., Ph.D.
Karla Martínez-Casiano, Ph.D.
Liliana Hernandez-Martínez, Psy.D.
Javier Hernández-Justiniano, Psy.D.
Julio Jiménez-Chávez, M.D.
Clinical Psychology Program, School of Behavioral and Brain Sciences, Ponce Health Sciences University. Ponce, Puerto Rico
Behavioral Medicine and Neuropsychology Rehabilitation Unit, Damas Hospital. Ponce, Puerto Rico
For positive psychology-oriented clinicians embedded in medical settings, there is a perceived mismatch between the “fix what is broken” approach of the prevailing traditional biomedical model and the pragmatic implementation of the “build what is strong” spirit of positive psychology interventions (PPIs). Time constraints, clinical documentation nomenclature, low-level mastery in implementing PPIs, and the lack of a standardized PPI approach all further lend to a widening of the seemingly opposing approaches in these settings. In this brief article, we aim to offer a novel, solution-focused, and practical a priori framework through which PPIs can be implemented in medical settings.
Efficiency and effectiveness in achieving individual and organizational-level health outcomes in the 21st Century era of healthcare are primarily determined by maximizing patient well-being while minimizing the costs to do so. Achieving these aims requires healthcare providers to equip patients with a skillset to adequately self-manage their chronic conditions so they can enjoy optimal functioning while avoiding excessive healthcare utilization which translates into higher costs and burden on the system and individual. Equipping patients with such a skillset is especially challenging considering patients spend an average of 60 face-to-face minutes per year with their physicians in outpatient care settings (Gaffney et al., 2022). Is this really enough time to facilitate the mastery of self-management skills?
Positive Psychology
The ‘positive’ in positive psychology is a source of contention and misunderstanding. One of the most common critiques is that positive psychology overemphasizes the subjective feeling of happiness while ignoring individual problems and suffering (Yakushko & Blodgett, 2021). However ‘positive’ in this context should be understood in the mathematical sense – the presence of something as opposed to its absence. Throughout the ideological history of positive psychology, ‘positive’ has been associated with, but not limited to the presence of values and self-actualization (Maslow, 1954), pleasant subjective emotions (Diener, 1984), Aristotelian eudaimonia/well-being/meaning (Ryff, 1989), and attributes, strengths, and resources (Seligman & Csikszentmihalyi, 2000). A detailed discussion of the philosophical underpinnings and theoretical conceptualizations of positive psychology is beyond the scope of this article. However, it is worth noting the three distinct yet overlapping foci of positive psychology are subjective experiences, individual traits, and social institutions that foster well-being (Seligman & Csikszentmihalyi, 2000).
Six Evidenced-Based Strength-Based Techniques
Positive psychology interventions are reported to have a small to medium effect on enhancing well-being and psychosocial outcomes and reducing psychological symptoms (Boiler et al., 2013). They have amassed a convincing body of empirical support in medical settings (Macaskill, 2016) and traditional behavioral health clinical settings (Duckworth et al., 2005) in the treatment of depression (Pan et al., 2022), bipolar disorder (Celano et al., 2020), suicidal ideation (Huffman et al., 2013), and patients with heart disease (Huffman et al., 2011). A more nuanced analysis (Gorlin et al., 2018) of the effectiveness of PPIs has revealed six core intervention domains, listed here in order from largest to smallest effect: Positive processing of future events (d = .37), Goal pursuit (d = .32),Acts of kindness (d = .31), Gratitude (d = .20),Strength identification (d = .20), and Positive processing of past events (d – .17). Refer to the Gorlin et al., (2018) article for a list of the specific interventions that belong to each domain. Specific interventions from these domains can be applied in medical settings as a stand-alone or adjunct treatment.
GRACE Model
The GRACE model is a transdiagnostic framework to guide the positive psychology-oriented clinician in delivering comprehensive assessment, treatment intervention, and follow-up. This model was birthed from our clinical experiences of treating medically complex patients with comorbid behavioral health challenges in tertiary care settings such as the emergency department, ICU, and coronary care units, among others. The approach is intended for clinicians embedded in medical settings who are faced with balancing the clinical requirements of the biomedical system (assessing symptomology, diagnosing, implementing brief treatment interventions, and consulting) while attempting to identify and leverage patient’s assets and strengths in service of enhancing well-being and capacity for self-care management. GRACE is an acronym that stands for Gain, Recognize, Assess, Cultivate, and Evaluate. These five components are by no means novel strategies but are common to other therapeutic frameworks. However, they are grouped in a manner that is intended to facilitate the integration of the fix-what-is-broken and build-what-is-strong approaches with an emphasis on well-being enhancement. We recommend a sequential approach and implementation of each of the five domains to guide patient encounters; however, we are fully aware that adherence to the prescribed sequence is largely dependent on factors such as patient characteristics and immediate clinical goals. Below we will explore each of the components of the GRACE model and how they can be implemented.
Gain Alliance
This is by far the most fundamental component of the GRACE model. We use the term ‘gain’ because it communicates the effort required on part of the clinician to build rapport. The positive psychology-oriented clinician approaches the patient with a curious mindset and does not assume the role of the expert – the patient is the expert, and we are facilitators who are joining forces with them to assist in their journey toward well-being. They set the tone and goals and we offer a menu of empirically supported options to aid them. Gaining alliance entails getting to know the patient in all of their contexts (i.e., home, school/work, interpersonal, spiritual, leisure, and health).
Recognize Suffering and Desired Future
Recognizing the patient’s current suffering and desired future is vital to enhancing well-being. It can be done through Socratic questioning or through more direct methods such as scaling – our preferred method. For example, asking a patient to rate the intensity of their pain, anxiety, or depression on a scale of 0 to 10, with 10 being the worst possible and 0 the opposite, validates their experience while collecting measurable symptom levels that can be targeted in intervention planning. Immediately after exploring suffering, the simple, yet powerful ‘instead of’ question is asked to recognize the patient’s desired future. This too can be scaled from 0 to 10. It goes something like this ‘instead of feeling depressed, isolated, and leading a sedentary lifestyle, how would you like to feel’? While the answer to ‘instead of’ questions may seem obvious (e.g., the exact opposite of suffering) many patients have not imagined a life without their current suffering, intense pain, anxiety, or depression. This is a perfect opportunity to allow them to envision a different future as well as develop a SMART plan as the first step toward achieving well-being. It is important to remember to qualify the patient’s suffering and desired future with FID (frequency, intensity, duration) when scaling.
Assess Symptoms and Strengths
This is done using existing validated psychological and behavioral symptom screenings, questionnaires, and batteries. The main difference between recognizing current suffering and desired future through scaling versus assessing symptoms through validated instruments is that the former uses the patient’s subjective identification and rating of current suffering and desired future, as opposed to using predetermined symptoms categories as is the case with validated instruments. For assessing strengths consider the PERMA profiler (Butler & Kern, 2016) and Classification of Character Strengths (McGrath, 2019). Unlike other humanistic-oriented models, the GRACE model is not opposed to the diagnostic classification of mental and behavioral syndromes and disorders. However, we emphasize the assessment of psychosocial strengths and targeting well-being enhancement not mere symptom reduction.
Cultivate Well-Being
This component requires implementing empirically supported PPIs to enhance well-being. Refer to Gorlin et al. (2018) for a list of domain-specific interventions. Unlike many therapeutic models, the GRACE model encourages the positive psychology-oriented clinician to implement well-being-enhancing interventions during the first encounter. We believe even in the deepest despair, patients can benefit from the immediate cultivation of well-being. Having patients write (or talk about) their best-possible future plus one SMART (specific, measurable, achievable, relevant, and time-bound) goal to take one step toward their future is one of our preferred and anecdotally highly effective PPI.
Evaluate Self-Efficacy
In the spirit of Bandura’s Social Cognitive Theory (Bandura, 1998) evaluating the patient’s perceived self-efficacy to carry out interventions implemented in the Cultivate component is the final task in the GRACE model. This can be done through scaling as well. Evaluating self-efficacy will allow the patient to reflect on the strengths needed to cultivate well-being, manage symptoms, and engage in self-care. These strengths may be endogenous and need boosting or exogenous and require acquisition and mastery.
Conclusion
The GRACE model is a transdiagnostic framework intended for the positive psychology-oriented clinician. It can be flexibly adapted for use in other therapeutic models as a guiding approach aimed at well-being enhancement, not merely symptom reduction. Empirical testing of the feasibility and utility of implementing the GRACE model is needed and forthcoming.
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