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A Positive Psychology Intervention for Patients with an Acute Coronary Syndrome: Treatment Development and Proof-of-Concept Trial

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Positive psychological constructs are associated with superior outcomes in cardiac patients, but there has been minimal study of positive psychology (PP) interventions in this population. Our objective was to describe the intervention development and pilot testing of an 8-week phone-based PP intervention for patients following an acute coronary syndrome (ACS). Initial intervention development and single-arm proof-of-concept trial, plus comparison of the PP intervention to a subsequently-recruited treatment as usual (TAU) cohort. PP development utilized existing literature, expert input, and qualitative interview data in ACS patients. In the proof-of-concept trial, the primary outcomes were feasibility and acceptability, measured by rates of exercise completion and participant ratings of exercise ease/utility. Secondary outcomes were pre-post changes in psychological outcomes and TAU comparisons, measured using effect sizes (Cohen’s d). The PP intervention and treatment manual were successfully created. In the proof-of-concept trial, 17/23 PP participants (74 %) completed at least 5 of 8 exercises. Participants rated the ease (M = 7.4/10; SD = 2.1) and utility (M = 8.1/10, SD = 1.6) of PP exercises highly. There were moderate pre-post improvements (ds = .46–.69) in positive affect, anxiety, and depression, but minimal effects on dispositional optimism (d = .08). Compared to TAU participants (n = 22), PP participants demonstrated greater improvements in positive affect, anxiety, and depression (ds = . 47–.71), but not optimism. A PP intervention was feasible, well-accepted, and associated with improvements in most psychological measures among cardiac patients. These results provide support for a larger trial focusing on behavioral outcomes.

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This work was supported by the National Institutes of Health (NIH) Grant R01HL113272.

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Correspondence to Jeff C. Huffman.

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Appendix: Manual Table of Contents

Study Calendar




List of 12 Emotions


Week One

(Gratitude for Positive Events)


Week Two

(Personal Strengths)


Week Three

(Gratitude Letter)


Week Four

(Enjoyable and Meaningful Activities)


Week Five

(Remembering Past Success)


Week Six

(Acts of Kindness)


Week Seven—Choice 1

(Exercise of Your Choice)


Week Eight—Choice 2

(Exercise of Your Choice)


Next Steps


Positive Activity Schedule


Toolbox of Best Activities


Sample Exercise

2.1 Introduction

In this exercise, we will focus on identifying and re-experiencing three positive events that happened in the past week. People often focus on negative events but less frequently pay attention to good things that happen. It makes sense to analyze bad events so that we can learn from them and avoid them in the future. However, it can be easy to overdo this focus on the negative, and this can impact one’s health. One way to keep this from happening is to develop our ability to think about the good in life.

Most of us are not nearly as good at savoring and appreciating good events as we are at analyzing bad events, so this is a skill that needs practice. As you become better at focusing on the good in your life, it may become easier to feel even more grateful for what you have and more hopeful about the future.

The following exercise will ask you to identify three good things in your life that occurred in the past week. We recognize that this has been a very serious (and probably very stressful) time for you, and as a result, you may have barely noticed anything positive happening during the stress of the week. However, by looking back carefully and specifically searching for good things that may have happened, you may be surprised to find that there were small (or even large) positive events and blessings to be counted.

  • I am in the hospital for a heart problem—how can I possibly identify good things that are happening in my life?

At first, it can seem hard to identify positive events during a medical crisis. However, this is one reason we do this exercise first: now may be the most important time to remember that good things—even small ones—can happen, even in the midst of serious medical issues. As you get skilled at focusing your attention on pleasant moments that happen during the day—a kind gesture from someone, a greatly-appreciated visit, good news about family or friends— you may find the good things in your life becoming much more obvious.

2.2 Instructions

Take 10–15 min to complete this exercise. Use this time to write down three positive things that happened this week. Use the space on the next pages to write about the events—it is important that you have a written record of your thoughts on paper. The things you list can be relatively small in importance (“I enjoyed my lunch today”) or relatively large in importance (“I’m feeling much better after my procedure”). They can be related to your hospitalization or heart problem, or completely separate.

As you write, please follow these instructions:

  1. 1.

    Give the event a title (e.g., “sister remembered my birthday”)

  2. 2.

    Write down exactly what happened in as much detail as possible, including what you did or said, and if other people were involved, what they did or said.

  3. 3.

    Record how this event made you feel at the time. Use the most specific positive emotional words that you can think of to describe how you felt: Joy? Satisfaction? Relief?

  4. 4.

    Record how this event makes you feel now as you remember it.

Some important tips:

The goal of the exercise is to remember the good event and then enjoy the positive emotions that come with it. Don’t analyze the event itself in too much detail—the important thing here is being able to:

  • Take your time to experience and savor the positive emotion, and then

  • Name and describe that positive feeling (like joy, pride, relief, or contentment) as specifically as possible—not just that you felt “good”.

  • Refer to the list of positive emotions (page 11) to help you describe the good feelings you experienced.

  • You may also find yourself wanting to write something like “I felt less stressed.” It’s good to note this but try to describe the feeling or thought using positive emotions and words. So, for example, instead of writing “I felt less stressed,” you might write “I felt a little bit of relief.”

  • Focus on the positive. If you find yourself focusing on negative feelings or emotions, turn your mind from the negative feeling and refocus yourself on the good event and the positive feelings that came along with it. This can take effort, but it gets easier with practice and can make a real difference in how you feel.

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Huffman, J.C., Millstein, R.A., Mastromauro, C.A. et al. A Positive Psychology Intervention for Patients with an Acute Coronary Syndrome: Treatment Development and Proof-of-Concept Trial. J Happiness Stud 17, 1985–2006 (2016).

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