Chapter 27
Positive Psychology in Rehabilitation Psychology Research and Practice

CLAUDIO PETER, SZILVIA GEYH, DAWN M. EHDE, RACHEL MÜLLER AND MARK P. JENSEN

In this chapter, we first provide an introduction to rehabilitation psychology as a field concerned with disability. We then discuss how rehabilitation psychology is related to positive psychology and the “good life,” and summarize the current state of rehabilitation research with respect to positive psychology. Next, we describe common psychosocial rehabilitation interventions and examine the extent to which positive psychology interventions have been applied in rehabilitation practice. Finally, we discuss and suggest future directions contributing to the integration of positive psychology and rehabilitation psychology research and practice.

The term rehabilitation stems from the medieval Latin word rehabilitationem (“restoration”) from rehabilitare, composed of re- (“again”) and habitare (“make fit”), and from the Latin habilis (“easily managed, fit”) (Harper, 2013). Rehabilitation has been defined as “a set of measures that assist individuals who experience, or are likely to experience, disability to achieve and maintain optimal functioning in interaction with their environments” (World Health Organization & World Bank, 2011, p. 96).

Disability has traditionally been understood from a biomedical perspective as a decrease or interference in functioning resulting from disease or trauma, caused and fully determined by the pathogenic process (Boorse, 1977). Today, the World Health Organization's International Classification of Functioning, Disability and Health (ICF) provides a widely accepted conceptual framework that expands simple biomedical thinking into a comprehensive biopsychosocial formulation of human functioning (World Health Organization, 2001). According to the ICF's biopsychosocial framework, the health condition (e.g., disease or trauma) of an individual interacts with environmental (e.g., physical and social barriers and facilitators) and personal factors (e.g., age, gender, but also coping strategies or lifestyle), and thus gives rise to the phenomenon of functioning and its opposite: disability. Disability is defined as impairments in bodily functions and structures, limitations in individual activities, and restrictions in social participation.

Disability is on the rise worldwide and represents a universal challenge that many people share. This is partly due to the aging of individuals across societies due to advances in medical technology. The World Health Organization has estimated the prevalence of moderate to severe disability worldwide as 15% of the population (World Health Organization & The World Bank, 2011).

Rehabilitation psychology is an applied discipline rooted in the scientific foundations of psychology and strongly relying on a research-practitioner model. The American Psychological Association (APA) defines rehabilitation psychology as:

A specialty area within psychology that focuses on the study and application of psychological knowledge and skills on behalf of individuals with disabilities and chronic health conditions in order to maximize health and welfare, independence and choice, functional abilities, and social role participation across the lifespan. Rehabilitation psychologists are uniquely trained and specialized to engage in a broad range of activities including clinical practice, consultation, program development, service provision, research, teaching and education, training, administration, development of public policy and advocacy related to persons with disability and chronic health conditions. (American Psychological Association Division 22: Rehabilitation Psychology, 2014)

Clinical rehabilitation psychologists work in interdisciplinary rehabilitation settings. They provide information and education, support and counseling, training and therapy for individuals with disabilities. They use diagnostic, preventive, and curative strategies. Their clients are not only the affected individuals, but also the partners and relatives of those individuals and the entire rehabilitation team (American Psychological Association Division 22: Rehabilitation Psychology, 2014; Gordon, 2000). Rehabilitation psychology is related to and draws on the expertise of other psychological fields, such as clinical psychology and psychotherapy, medical and health psychology, and neuropsychology. Although rehabilitation psychology lacks institutionalization in some countries, in all countries there are academic and clinical research and clinical practices that qualify as rehabilitation psychology.

How Is Rehabilitation Psychology Related to Positive Psychology and “The Good Life”?

Positive psychology and its study of “the good life” aims to counterbalance the overemphasis on pathology in psychological research and practice and turns instead to human potential and those “positive features that make life worth living” (Seligman & Csikszentmihalyi, 2000, p. 5). Positive psychology focuses on what is best in people and has been defined as “the scientific study of optimal human functioning” (Linley, Joseph, Harrington & Wood, 2006, p. 8). Positive psychology has sought to update and integrate hedonic as well as eudaimonic conceptualizations of well-being, happiness, and “the good life”—crudely put, to reconcile pleasure with excellence. In this section, we identify three commonalities between rehabilitation psychology and positive psychology: (1) positive principles, (2) a focus on individual strengths and resources, and (3) well-being, participation, and growth as key outcomes.

Positive Principles

Both rehabilitation psychology and positive psychology have followed positive principles from the beginning of each discipline. But just as the disease model dominated psychology until the 1980s, when positive psychology gained momentum (Seligman & Csikszentmihalyi, 2000), rehabilitation research was traditionally dominated by the biomedical deficit model of disability (Dunn & Brody, 2008; Ehde, 2010), although this model has always been rejected by prominent scholars within the field of rehabilitation psychology and disability advocacy (Wright, 1972, 1983).

For example, in 1972, Wright formulated 20 “value-laden” guiding principles that underlie rehabilitation psychology (Wright, 1972, 1983). These principles continue to have a strong influence on the field. She stressed the dignity and rights of persons with disabilities, the relevance of psychological factors throughout the rehabilitation process, the importance of considering the embeddedness of the persons with disabilities in immediate and larger social and physical environments, and the importance of involving and empowering the affected persons themselves in shaping rehabilitation, community, and policy processes. She stated that “it is essential that society as a whole continuously and persistently strives to provide the basic means toward the fulfillment of the lives of all its inhabitants, including those with disabilities” (Wright, 1983, p. xv). Wright further emphasized that “the assets of the person must receive considerable attention in the rehabilitation effort” (Wright, 1983, p. xii).

Rehabilitation psychology does not solely focus on deficits, but considers the whole-life situation of the person from physical, psychological, and social perspectives, adhering to the dictum of Lewin that behavior is influenced by both personal and environmental factors, B = f(P,E) (Larson & Sachs, 2000; Lewin, 1936). It considers the physical and social environment of individuals with disabilities ranging from assistive devices, architectonical barriers, family caregivers, societal attitudes, or the availability and affordability of support services. Rehabilitation psychology examines what still works and strives for constructive and creative solutions in the interaction of person, body, psyche, and physical and social environment (Dunn & Dougherty, 2005). Positive psychology, in contrast, pays less attention to environmental factors, with the exception of social resources (Ehde, 2010). Research indicates that a full 10% of the variation in well-being is dependent on environmental circumstances (Lyubomirsky, 2007). Given these findings, it seems important to take person–environment interactions into account when developing models of well-being (see also Layous, Sheldon & Lyubomirsky, Chapter 11, this volume).

Focus on Individual Strengths and Resources

Both rehabilitation psychology and positive psychology view personal strengths and psychological resources as foundational elements that contribute to well-being and flourishing. Dunn and Dougherty (2005) state: “The presence of disability does not negate an individual's existing assets, nor does it preclude the acquisition of new ones” (p. 306). In rehabilitation psychology, disability is seen as “only one aspect—and not a defining characteristic—of an individual's identity” (Dunn & Dougherty, 2005, p. 306). People with disabilities, like all individuals, possess a range of strengths, resources, assets, and abilities that exist despite disability and chronic disease. In individuals with disabilities, the optimal use of strengths and a resource-based approach is essential, because they will not necessarily “heal,” but will need to manage and thrive despite persistent impairments and limitations.

Dunn and Dougherty (2005) suggest that rehabilitation psychologists “identify, enhance, and encourage reliance on each consumer's strengths, thereby maximizing mental and physical recovery” (p. 306). The perspective taken by positive psychology is similar: Knowing, using, and developing one's own strengths is a key issue in what Seligman calls the “engaged life” in authentic happiness theory (Seligman, 2011). Accordingly, positive psychology proponents developed a systematic classification of 24 character strengths that are structured according to six major virtues: wisdom, courage, humanity, justice, temperance, and transcendence. They can be measured, for example, with the Values in Action–Inventory of Strengths (VIA-IS; Peterson & Seligman, 2004).

Although rehabilitation psychology and positive psychology share a focus on strengths and resources, their operationalization of these concepts differ. Rehabilitation psychology research often addresses single resources such as self-efficacy or self-esteem. Positive psychology usually considers a broad range of character strengths simultaneously (e.g., self-regulation, persistence, or social intelligence). Hope, optimism, and purpose in life are considered in both disciplines. Overall, whether addressing character strengths in the tradition of positive psychology can be relevant and helpful for individuals with disabilities needs to be determined through thorough testing in future research.

Well-Being, Participation, and Growth as Key Outcomes

Both rehabilitation psychology and positive psychology share the common goals to enhance well-being, participation, and growth. Historically, however, their perspectives and their conceptualizations of these key outcomes have differed to some extent.

Well-Being

The notion of “well-being” is central to positive psychology and has been increasingly recognized in rehabilitation psychology research. The related concept of quality of life, however, is far more salient (Fuhrer, 2000; Tulsky & Rosenthal, 2003). How quality of life is understood in rehabilitation contexts has changed during the past decades.

Initially, quality of life was primarily conceptualized from a negative or deficit perspective in the health and rehabilitation context. So-called health-related quality of life questionnaires, such as the Medical Outcomes Study Short-Form Health Survey (SF-36; Ware, Snow, Kosinski, & Gandek, 1993), have been used to assess disease symptoms, functional disability, and/or psychiatric and psychological dysfunction.

More recently, positive accounts of quality of life have been recognized in rehabilitation contexts. One example is Diener's influential conceptualization of subjective well-being (Diener, Suh, Lucas, & Smith, 1999). Subjective well-being is a multidimensional construct consisting of a cognitive component, including general life satisfaction and satisfaction with specific life domains, and an emotional component, including positive and negative affect as independent dimensions. Accordingly, frequently used questionnaires in rehabilitation ask for satisfaction/dissatisfaction with life as a whole and various life domains, including self-care, work, finances, leisure, relationships or sexuality; some examples include the Life Satisfaction Questionnaire (LISAT; Fugl-Meyer, Bränholm, & Fugl-Meyer, 1991) or the Quality of Life Index (QLI; Ferrans & Powers, 1985).

Satisfaction questionnaires cover the hedonic aspect of well-being. However, a conceptualization of well-being in the sense of flourishing or “the full life,” which stresses an eudaimonic approach without neglecting the hedonic, has not yet arrived in rehabilitation. The full life is characterized as not only leading a “pleasant life” of positive experiences (positive emotions, pleasures, and gratifications), but also an “engaged life” (exercising and developing one's own strengths and virtues) and a “meaningful life” (an experience of being part of and serving a larger good; Seligman, 2011). The Orientations to Happiness Scale (OTH) is one example of an instrument assessing three aspects of the full life: pleasure, engagement, and meaning (Peterson, Park, & Seligman, 2005).

More recently, Seligman (2011) suggests an understanding of well-being as a latent construct, operationalized and measureable through five distinct elements: Positive experience or positive emotion, Engagement and flow, positive Relationships with others, Meaning and purpose, and Accomplishment/achievement (PERMA). The PERMA model states that through these five elements individuals can flourish. Overall, rehabilitation psychology research and practice have only started to recognize these eudaimonic conceptual models and to explore their potential to enhance theory, research, and practice (Chou, Lee, Catalano, Ditchman, & Wilson, 2009; Dunn & Brody, 2008; Dunn & Dougherty, 2005).

Social Participation

A second key outcome, which is common to positive psychology as well as rehabilitation psychology, is social participation. Rehabilitation psychology aims for the full inclusion of people with disabilities in society and to “maximize health and welfare, independence and choice, functional abilities, and social role participation” (American Psychological Association Division 22: Rehabilitation Psychology, 2014). According to the ICF, areas of social participation include, among others: interpersonal relationships, socializing, and assisting others; work and education; exercise and creativity; community and political life, citizenship, and human rights. These are the same life areas in which, according to positive psychology, an engaged and meaningful life can be fulfilled and in which the PERMA elements (positivity, engagement, relationships, meaning, and achievement) can be realized.

However, rehabilitation psychology research has more often had a negative than a positive approach toward the study of participation. Participation is typically operationalized and measured referring to difficulties in life areas rather than referring to life fulfilment (Magasi & Post, 2010). A similar focus on the negative can be found in questionnaire items assessing participation in the areas of social relationships, engagement, or work. Research often refers to the need for or the amount of support received by a person with a disability. However, little research has examined the beneficial effects of active social support on the well-being of individuals with disabilities (Brown, Nesse, Vinokur, & Smith, 2003). Likewise, low employment rates of individuals with disabilities and the achievement of returning to work are a major concern (Blessing, Golden, Pi, Bruyere, & Van Looy, 2012), and positive work experience, including the experiences of flow, meaning, or purpose, has not yet been considered in rehabilitation psychology research (Warr, 1999).

Growth

Both positive psychology and rehabilitation psychology acknowledge the potential for growth and positive changes following the onset of a disability. Posttraumatic growth as a conceptualization of eudaimonic well-being is one of the most salient concepts referring to these positive changes (Tedeschi & Calhoun, 2004; see also Tedeschi, Calhoun, & Groleau, Chapter 30, this volume). Common synonyms are adversarial growth, thriving, finding benefits, or stress-related growth (Zoellner & Maercker, 2006). Posttraumatic growth is different from “recovery” because the individual does not merely return to pretraumatic levels of functioning. Rather, the concept involves an experience of additional and higher states of functioning than existed before the trauma or disability onset—something has changed for the better.

Accounts of posttraumatic growth have been observed in about 30% to 70% of individuals affected by trauma (Joseph, 2013), including individuals with a history of cancer, heart attack, multiple sclerosis, or HIV (Helgeson, Reynolds, & Tomich, 2006). Similarly, in spite of the serious bodily, social, and psychological consequences associated with spinal cord injury (SCI), individuals with SCI may experience positive changes following the injury, such as an increased appreciation of life with changing values and life perspectives, enhanced relationships, or a feeling of more personal strength (McMillen & Cook, 2003).

To summarize, positive psychology and rehabilitation psychology share positive principles and the emphasis on well-being, social participation, and growth as key outcomes. Rehabilitation psychology research and practice could benefit from positive psychology's comprehensive and systematic approach toward the strengths and resources of individuals as well as from a stronger consideration of the eudaimonic aspects of “the good life” (e.g., meaning and purpose) in relation to participation of persons with disabilities. On the other hand, positive psychology could benefit from a stronger consideration of person–environment interactions.

Current State of Research in Rehabilitation Psychology

Empirical scientific research on psychological issues in individuals with disabilities has been guided by the main aims of rehabilitation: to ameliorate the negative impact of disability, optimize functioning, support reintegration, and increase quality of life and well-being of individuals with disabilities. Rehabilitation psychologists search for answers to questions such as: How do persons respond to the onset of disability? What are the challenges and obstacles individuals with disabilities might face? Which potentially malleable factors could be targeted in interventions to support and empower individuals with disabilities?

Disability onset can affect well-being and cause stress, anxiety, depression, or other disorders calling for psychological intervention, as it has been shown in individuals with coronary heart disease, cancer, diabetes, osteoporosis, rheumatoid arthritis, epilepsy, multiple sclerosis, brain injury, or SCI (e.g., Craig, Tran, & Middleton, 2009; Glassman & Shapiro, 1998; Hoppe & Elger, 2011; Kubzansky & Kawachi, 2000). Although disability can have a negative impact on well-being, not all persons are equally affected. Indeed, it is more common for individuals with a disability to be resilient rather than to suffer from elevated levels of distress (Bonanno, Westphal, & Mancini, 2011).

Differences in how well individuals function after the onset of a disability are determined by a multifactorial process. Sociodemographic factors such as gender, ethnicity, or current age can act as predictors or moderators of response to disability (Stanton, Revenson, & Tennen, 2007). Similarly, health condition–related factors such as age at disability onset, disability severity, or time since disability onset (or diagnosis) can influence physical and psychological functioning in individuals with disabilities. Findings, however, are mixed and partly health condition–specific (Livneh & Martz, 2012).

Coping and appraisal processes are extensively studied in rehabilitation psychology research. The findings suggest that the use of engagement-type (active) coping, such as planning, is generally associated with better outcomes, whereas the use of deengagement-type coping, such as avoidance, is associated with poorer outcomes. Illness-related appraisals, such as persons' perceptions regarding the controllability, cause, and consequences of disability, have also been identified as key predictors of functioning (Dennison, Moss-Morris, & Chalder, 2009; Galvin & Godfrey, 2001; Livneh & Martz, 2012; Stanton et al., 2007). Likewise, a number of psychosocial factors consistently demonstrate associations with better well-being and positive mental health in individuals with a disability. Among these are self-efficacy and (internal) locus of control, self-esteem, purpose in life and optimism, social support, spirituality, and positive affect (Livneh & Martz, 2012; Luszczynska, Pawlowska, Cieslak, Knoll, & Scholz, 2013; Peter, Müller, Cieza, & Geyh, 2012).

To what extent have positive psychology and related concepts been considered and investigated in individuals with disabilities? To get a more systematic answer to this question, we analyzed the titles and abstracts of articles published in the journal Rehabilitation Psychology, other rehabilitation journals, and selected health condition–specific journals since 2000. The analysis shows that positive psychology concepts such as character strengths and virtues have received very little attention in rehabilitation research. More emphasis has been placed on quality of life and mental health variables, as well as concepts such as self-efficacy or purpose in life (see Table 27.1), which are viewed as contemporary examples of positive psychology, although their conceptualization and examination preceded positive psychology by decades (Duckworth, Steen, & Seligman, 2005). The fact that positive psychology journals have published very few studies with individuals with disabilities reinforces the impression that efforts toward an application of positive psychology in rehabilitation practice could be intensified (see Table 27.2). Do we observe a similar picture when we move our focus from observational to interventional research and practice?

Table 27.1 Selected Positive Psychology, Well-Being, Mental Health Resources and Strengths Mentioned in Title or Abstract of Articles Published in Rehabilitation Psychology and Other Rehabilitation and Health Condition–Specific Journals Since 2000

Rehabilitation Psychology Rehabilitation Journalsa Health Condition–Specific Journalsb
Anxiety 29 225 763
Bravery 0 0 0
Character strength 0 0 0
Creativity 0 2 1
Curiosity 0 1 2
Depression 122 536 883
Forgiveness 1 2 1
Gratitude 1 2 3
Happiness 0 9 11
Hope 8 22 121
Humor 1 4 16
Life satisfaction 20 99 60
Locus of control 1 18 29
Mastery 5 14 11
Mental health 33 180 166
Motivation 10 87 59
Optimism 8 15 83
Persistence 4 24 20
Personality 16 44 61
Positive affect 7 10 20
Positive psychology 5 1 2
Posttraumatic growth 3 6 37
Posttraumatic stress 25 24 31
Purpose in life 17 4 12
Quality of life 42 780 1475
Resilience 9 6 30
Self-efficacy 32 166 114
Self-esteem 13 42 62
Sense of coherence 2 16 25
Spirituality 8 14 70
Well-being 27 217 414
Wisdom 0 2 8

aPubMed search considering the following journals: Archives of Physical Medicine and Rehabilitation, Clinical Rehabilitation, European Journal of Physical and Rehabilitation Medicine, Disability and Rehabilitation, Disability and Health Journal, and Neurorehabilitation.

bPubMed search considering the following journals: Nature Reviews Cancer, Lancet Oncology, Supportive Care in Cancer, European Journal of Cancer Care, Psycho-Oncology, Multiple Sclerosis International, The Journal of Spinal Cord Medicine, Spinal Cord, Topics in Spinal Cord Injury Rehabilitation, Topics in Stroke Rehabilitation, and Stroke Research and Treatment.

Table 27.2 Selected Chronic Health Conditions and Diseases Mentioned in Title or Abstract of Articles Published in Positive Psychology Journals

Hits in the Journal of Positive Psychology and the Journal of Happiness Studies
Amputation 1
Brain injury 0
Cancer 2
Cardiovascular 1
Chronic pain 1
Congenital condition 0
Hearing disorder 0
Hearing loss 0
HIV 2
Multiple sclerosis 2
Spinal cord injury 0
Stroke 0
Vision disorder 0
Vision loss 0
Rehabilitation 1
Rehabilitation psychology 0

How Is Positive Psychology Applied in Rehabilitation Practice?

Today, psychological and psychosocial interventions are an integral part of interdisciplinary inpatient treatment as well as community-based rehabilitation of individuals with disabilities. Rehabilitation psychology practice is strongly rooted in a behavioral or cognitive-behavioral approach and applies person-centered and supportive counseling. Which psychosocial interventions are typically applied in rehabilitation practice? To what extent do these focus on positive aspects of the human experience after disability? And to what extent have positive psychotherapy interventions been conducted and examined in individuals with disabilities?

Psychosocial Interventions in Individuals With Disabilities

The evidence on the beneficial effects of cognitive-behavioral and psychosocial interventions on emotional distress and mental health in individuals with disabilities is rich and robust, for example, in cancer, cardiovascular diseases, fibromyalgia, spinal cord injury, multiple sclerosis, stroke, arthritis, and traumatic brain injury (e.g., Osborn, Demoncada, & Feuerstein, 2006; Thomas, Thomas, Hillier, Galvin, & Baker, 2006; Whalley et al., 2011). In individuals with disabilities, depression, anxiety, and pain can be effectively reduced, and coping and quality of life can be enhanced by psychosocial interventions.

The typical repertoire of rehabilitation psychology interventions includes coping-skills development, stress management, relaxation training, pain management, problem-solving training, self-management interventions, social and communication skills training, social support interventions, contingency management, and patient education, often in the form of “packaged” interventions labeled cognitive-behavioral psychotherapy (Ayers et al., 2007; Frank & Elliott, 2000; Wilson et al., 2009).

Coping-skills training, for example, according to Sharoff (2004), facilitates the development of self-esteem, tolerance, and accommodation skills after the onset of chronic illness and treats irrational responses to suffering, guilt, or bitterness, primarily by using cognitive restructuring. Stress-management interventions assist people in dealing with stressors, negative emotions, physiological arousal, and negative health consequences of distress (Kenny, 2007). They can include a variety of specific strategies, such as cognitive restructuring, relaxation techniques, development of coping and problem-solving skills, anger management, social-skills training, and lifestyle education, all of which can be applied in individual or group settings. Relaxation techniques, including mindfulness-based approaches (Grossman, Niemann, Schmidt, & Walach, 2004; Stahl & Goldstein, 2010), progressive muscle relaxation (Jacobsen, 1929), autogenic training (Stetter & Kupper, 2002), guided imagery, hypnotherapeutic techniques (Robertson, 2013), and biofeedback can have beneficial effects on pain, fatigue, medication use, and health-related quality of life in individuals with osteoarthritis, multiple sclerosis, SCI, fibromyalgia, or cancer (e.g., Dimeo, Thomas, Raabe-Menssen, Pröpper, & Mathias, 2004; Jensen et al., 2009). Within multimodal pain management, psychological interventions emphasize the mutual influences between psychological states and the experience of pain and use educational components, cognitive restructuring, attention management, relaxation, hypnosis, and biofeedback to ameliorate the experience of pain, increase pain coping skills, and increase meaningful activity (e.g., Jensen et al., 2009; Thieme, Flor, & Turk, 2006). Problem-solving training typically includes a series of steps, from recognizing and defining the problem, to collecting strategies to fix the problem, identifying the best way(s) to deal with the problem, planning concrete actions, realizing the actions in everyday life, and finally evaluating the solution (Hopko et al., 2011). Self-management interventions teach participants and their significant others the skills necessary for the everyday management of “symptoms, disability, emotional impact, complex medication regimens, and difficult lifestyle adjustments and obtaining helpful health care” (Redman, 2004, p. 4). Social support interventions may also be provided for individuals with disabilities in rehabilitation settings, and these can include involvement of significant others in individual therapy, professional-led support groups, peer support or self-help groups, and assertiveness and social-skills training.

Positive Aspects Integrated in Psychosocial Interventions for Individuals With Disabilities

Many of the previously mentioned rehabilitation psychology interventions focus on reducing negative outcomes as opposed to increasing positive ones. Nevertheless, several positive aspects are embedded in these interventions. Their primary aim is to enhance quality of life and well-being of individuals with disabilities. Several of these interventions focus on strengths and elicit positive emotional states. For example, they strengthen psychosocial resources of the individuals when targeting and building self-efficacy, assertiveness, and adaptive skills. Pain management directs the attention toward positive emotional states and meaningful activity despite the experience of pain. Relaxation techniques and hypnoses are used to induce positive experiences, and support groups imply not only receiving support but also giving support to others.

Outlook and Future Directions

Newly developed positive psychology intervention programs are currently not part of typical rehabilitation psychology practice. These programs have not yet been applied to individuals with disabilities and have not been empirically tested in the rehabilitation context. Positive psychotherapy interventions build on individuals' strengths and virtues (e.g., using one's signature strengths) and include a broad range of exercises that promote positive activities, cognitions, and feelings (Sin & Lyubomirsky, 2009). Well-being therapy (Fava, Rafanelli, Cazzaro, Conti, & Grandi, 1998) targets the six dimensions autonomy, personal growth, environmental mastery, purpose in life, positive relations, and self-acceptance (Ryff & Singer, 1998; see also Ruini & Fava, Chapter 28, this volume). Quality of life therapy (Frisch, 2006) aims to enhance satisfaction in 16 life domains (e.g., work, play, or relationships) and integrates positive psychology with cognitive-behavioral therapy.

Positive psychology exercises, which have been examined in randomized controlled trials, include writing letters of gratitude, counting one's blessings, practicing optimism, performing acts of kindness, meditating on positive feelings toward others, and using one's signature strengths (Seligman, Steen, Park, & Peterson, 2005). Results of two meta-analyses of positive psychology-based interventions revealed that they can significantly increase well-being (mean effect size ranging from 0.20 to 0.34) and decrease depressive symptoms (mean effect size ranging from 0.23 to 0.31; Bolier et al., 2013; Sin & Lyubomirsky, 2009) even in the long term (Seligman et al., 2005). For comparison, a meta-analysis of 375 psychotherapy studies in the general population found that psychotherapy demonstrated an average effect size of 0.32 for outcomes such as self-esteem and psychosocial functioning (Smith & Glass, 1977).

Positive psychology interventions have a number of advantages. Consisting of brief, simple, and self-administered positive activities, they are less expensive and time consuming to administer compared with psychotherapy. They promise to yield rapid improvements of mood symptoms, show long-lasting effects, hold little to no stigma, and carry no negative side effects (Lyubomirsky, Dickerhoof, Boehm, & Sheldon, 2011; Seligman et al., 2005). Overall, applied to individuals with disabilities, they could add to and improve, broaden, and diversify current rehabilitation psychology practices.

Rehabilitation Psychology Practice

Rehabilitation psychologists such as Dunn (Dunn & Brody, 2008; Dunn & Dougherty, 2005), Ehde (2010), and Elliott (Elliott, Kurylo, & Rivera, 2005) have started to promote a connection of their discipline with positive psychology. Whereas the programmatic principles by Wright (1972) contain a strong positive core, rehabilitation psychology practice still works only to a limited extent applying explicit positive strategies. Positive psychology interventions, techniques, or exercises that directly address the experience of positive emotion, cultivate clients' strengths and resources, enhance meaning and purpose in life, and promote citizenship and client's contributions to community and social life could supplement the typical repertoire of rehabilitation psychology interventions. Future rehabilitation psychology practice could incorporate elements from well-being therapy and quality of life therapy. Intervention programs and manuals could be developed to explicitly include positive psychology elements and modules. Rehabilitation psychologists could guide and encourage individuals with disabilities to participate in positive psychology–based activities such as counting blessings, appreciation of life circumstances, and gratitude toward persons; writing about best possible future selves (optimism); doing good deeds for others (engagement, meaning, and purpose in life); strengthening and enjoying relationships by creating a routine to get together and reunite (socializing); or striving for states of intense and complete absorption (flow).

Within comprehensive multidisciplinary rehabilitation practice, disciplines closely related to rehabilitation psychology, such as art or music therapy, can also promote the tenets of positive psychology. These therapies have been proposed as a way to find and make meaning; to induce flow experience; to use personal signature strengths, such as creativity; and to generate positive emotions (Croom, 2012; Wilkinson & Chilton, 2013).

Overall, via a connection with positive psychology, rehabilitation psychologists could move toward a truly integrated and balanced perspective in their everyday practice by following the goals of promoting growth, well-being, and meaningful participation in individuals with disabilities. Although the connection of rehabilitation psychology with approaches toward “the good life” seems to be a promising avenue for further development, the proposed applications and potential benefits need to be put through rigorous scientific testing.

Rehabilitation Psychology Research

Although rehabilitation psychology has gathered considerable evidence in relation to individuals' well-being and response to disability onset, several content-related and methodological gaps have been identified (Dennison et al., 2009; Livneh & Martz, 2012; Ownsworth, Hawkes, Steginga, Walker, & Shum, 2009; Stanton et al., 2007). Research efforts in rehabilitation psychology should be directed toward:

  • An intensified focus on the influence of environmental factors, such as access to quality health care, and on indicators of well-being and mental health.
  • The examination of multidimensional models, including mediating and moderating processes, to better understand the mechanism underlying processes following disability onset.
  • The use of prospective, possibly intensive longitudinal study designs and appropriate statistical methodologies to help disentangle cause from effect.
  • A consistent use of specific measurement instruments to allow for a population comparison both within and between specific disability populations.
  • The disentanglement of the conceptual overlap between psychosocial factors, appraisals, coping, and rehabilitation outcomes.
  • The translation from current knowledge to interventions.

Positive psychology can contribute to these future endeavors from both conceptual/theoretical and applied research perspectives. Rehabilitation psychology research suffers from ambiguity and overlap of concepts (e.g., mastery, self-efficacy, control) as well as the lack of an agreed overarching framework or meta-theory (Chou et al., 2009; Rath & Elliott, 2012). Positive psychology could bring new dynamics and fresh input into rehabilitation psychology theory when researchers consider and discuss their concepts and models in connection and in comparison across the disciplines. Because incorporating and considering these concepts might also carry the risk of adding further ambiguity, we emphasize the need for clear definitions and conceptual differentiation.

Future basic research aimed at understanding the factors that contribute to well-being following disability onset could not only help clarify the factors that buffer the effects of disability on negative outcomes, but could also help clarify the factors that contribute to positive outcomes. Research should target not only disability, but also positive functioning; not only emotional distress, but also well-being; not only impairments, difficulties, and barriers to activity and participation, but also facilitators, strengths, and resources. There is also a need for greater preventive focus in rehabilitation psychology research that would help us understand how positive characteristics, positive activities, and positive relationships can lower the risk for secondary health conditions or further deterioration and enhance physical health in individuals with disabilities. There is a need to apply, validate, and, if indicated, modify positive psychology measurement instruments for individuals with disabilities.

Future intervention research is needed to determine whether positive psychology interventions are transferable to populations of individuals with disabilities. Which techniques work in individuals with disabilities and which do not? Are certain positive psychology exercises more effective than others? Do positive psychology exercises work better, as well, or less effectively than problem-based “traditional” approaches in the rehabilitation of individuals with disabilities? How can positive interventions be tailored to specific disability groups and individual characteristics?

Conclusion

In this chapter, our aim was to build a bridge between rehabilitation psychology and positive psychology. Rehabilitation psychology is on its way toward a fuller consideration of “the good life” for individuals with disabilities. Positive psychology as a research stream examining “the good life” has the potential of contributing to the future pathways of rehabilitation psychology. It can give input on conceptual, basic, and applied research levels. At the same time, positive psychology could also benefit from rehabilitation psychology and its focus on person–environment interactions.

However, rehabilitation psychology still needs to be aware of some cautionary notes regarding positive psychology. The danger of one-sidedness is to be avoided: Negative reductionism should not be replaced by positive reductionism. Positive reductionism could lead to romanticizing disability and chronic disease and neglecting the full realities of an individual's experience. It could also put additional pressure on individuals with disabilities and their families by “blaming the victim” or creating a “tyranny” or “prison of positive thinking” through a prescriptive or perfectionistic tone. We strongly assert the need to advance rehabilitation psychology research and practice according to the notions of “the good life” while following an integrated and balanced perspective that acknowledges both the positive as well as the negative.

Summary Points

  • Rehabilitation psychology is the application of psychological knowledge and understanding on behalf of individuals with disabilities and includes activities such as research, clinical practice, teaching, public education, and development of social policy and advocacy.
  • The main aims of rehabilitation encompass ameliorating the negative impact of disability, optimizing functioning, supporting reintegration, and increasing quality of life and well-being of individuals with disabilities.
  • Disability onset can have a negative impact on well-being; however, it is more common for individuals with a disability to be resilient rather than to suffer from a psychological dysfunction.
  • Differences in how persons respond to the onset of a disability result from a multifactorial process involving sociodemographic and health condition–related variables, appraisals, coping, and other psychosocial, biological, and environmental factors.
  • Rehabilitation psychology and positive psychology share three key commonalities: (1) positive principles; (2) focus on individual strengths and resources; and (3) well-being, participation, and growth as key outcomes.
  • The evidence on the beneficial effects of cognitive-behavioral and psychosocial interventions on psychological functioning in individuals with a disability is rich and robust.
  • Positive psychology interventions have rarely been applied to individuals with disabilities, have not been empirically tested in rehabilitation contexts, and are currently not part of typical rehabilitation psychology practices.
  • Future intervention research needs to determine whether positive psychology interventions are transferable to populations of individuals with disabilities.
  • While integrating positive psychology and rehabilitation psychology, a balanced perspective acknowledging both the positive as well as the negative is essential.

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