The Say ‘Yes’ to Life (SYTL) Program: A Positive Psychology Group Intervention for Depression

Abstract

Patients and referrers are increasingly seeking effective psychological treatments for depression as an alternative or adjunct to antidepressant medication. This paper describes a new group-based psychological intervention for major depressive disorder—the Say ‘Yes’ to Life (SYTL) program. This program integrates evidence-based interventions from cognitive behavior therapy (CBT) and positive psychology, spans 20 2-hour sessions, and is offered to groups of up to 14 participants.

Full text

ORIGINAL PAPER
The Say ‘Yes’ to Life (SYTL) Program: A Positive Psychology
Group Intervention for Depression
Alan Carr •Linda Finnegan
Published online: 15 May 2014
ÓSpringer Science+Business Media New York 2014
Abstract Patients and referrers are increasingly seeking
effective psychological treatments for depression as an
alternative or adjunct to antidepressant medication. This
paper describes a new group-based psychological inter-
vention for major depressive disorder—the Say ‘Yes’ to
Life (SYTL) program. This program integrates evidence-
based interventions from cognitive behavior therapy (CBT)
and positive psychology, spans 20 2-hour sessions, and is
offered to groups of up to 14 participants.
Keywords Positive psychology Positive
psychotherapy Mindfulness Depression CBT
Introduction
The aim of this paper is to describe the Say ‘Yes’ to Life
(SYTL) program, a group-based intervention for major
depressive disorder (MDD). The program is informed by
research on cognitive behavior therapy (CBT), positive
psychology, and group-based psychological interventions
(Carr 2011; Feng et al. 2012; Kleinberg 2012).
The lifetime prevalence rate for MDD is 6–25 %
(Kessler and Wang 2009). It is one of the most prevalent
psychological problems for which outpatients seek treat-
ment and entails a highly significant disease burden inter-
nationally (World Health Organization 2008). Best practice
guidelines recommend a stepped-care approach to the
treatment of MDD, with less intense interventions pre-
ceding more intensive treatment (American Psychiatric
Association 2010;NICE2009). Within a stepped-care
approach, it is recommended that when patients do not
respond to brief interventions, antidepressant medication
be combined with structured psychological interventions
(notably CBT), since the combination of these two treat-
ment modalities leads to a lower relapse rate than either
alone (Khan et al. 2012). With these research findings in
mind, the SYTL program was developed as a treatment that
combines effective CBT practices, interventions grounded
in positive psychology, and principles of effective group
therapy. The SYTL program was designed to be offered
alone or in combination with antidepressant medication as
a second tier intervention within a stepped-care approach
when clients have not responded to brief low-intensity
interventions.
Cognitive Behavior Therapy
CBT for MDD is based on cognitive and behavioral the-
ories of depression, which argue with considerable empir-
ical support, that depressive mood states are maintained by
behavioral and cognitive factors (Beck et al. 1979; Lew-
insohn and Gotlib 1995). CBT for MDD aims to reduce
negative affectivity by increasing activity and reducing
negative thoughts and related cognitive processes. Cogni-
tive behavior therapy for MDD includes two main com-
ponents: behavioral activation in which clients are helped
to increase their activity levels, and cognitive restructuring
in which the focus is on accessing and challenging
depression-maintaining thoughts and cognitive processes.
Where clients have comorbid anxiety, anger control or
A. Carr (&)
School of Psychology, UCD, Belfield, Dublin 4, Ireland
e-mail: alan.carr@ucd.ie
L. Finnegan
St James Hospital, Dublin, Ireland
123
J Contemp Psychother (2015) 45:109–118
DOI 10.1007/s10879-014-9269-9

interpersonal skills deficits, anxiety management training,
anger control training and assertiveness skills training may
be incorporated into CBT for MDD (Barlow et al. 2011).
The effectiveness of CBT (alone and combined with anti-
depressant medication), offered on an individual therapy
basis has been well established (Butler et al. 2006). There
is also a growing body of evidence that group-based CBT
(alone and combined with antidepressant medication) is
more effective than routine care for MDD, although
somewhat less effective than individual CBT (Huntley,
Araya and Salisbury, Huntley et al. 2012). With these
research findings in mind, behavioral activation, cognitive
restructuring, anxiety and anger management training, as
well as assertiveness training were included in the SYTL
program.
Mindfulness Based Cognitive Therapy
One difficulty with CBT is that a significant proportion of
clients relapse following effective treatment of a depressive
episode. Mindfulness-Based Cognitive Therapy (MBCT,
Segal et al. 2002) was developed to address this problem.
MBCT integrates mindfulness meditation from Kabat
Zinn’s (1990) mindfulness-based stress reduction (MBSR)
program for chronic pain with CBT for MDD. However,
instead of helping clients challenge negative automatic
thoughts, in MBCT patients are trained, though mindful-
ness meditation, to observe them in a disengaged manner.
In MBCT over 8-sessions of group-based treatment, clients
develop a conceptual understanding of mindfulness medi-
tation and depression within the context of a CBT frame-
work, practice meditation exercises, and use these to cope
with negative mood states. In a meta-analysis of 6 ran-
domized controlled trials, Piet and Hougaard (2011) found
that MBCT significantly reduced the risk of relapse among
people with recurring major depression. These research
findings provided the rationale for including mindfulness
meditation in the SYTL program.
Positive Psychotherapy
While CBT aims to treat MDD by reducing negative
affectivity, positive psychology interventions treat depres-
sion by increasing positive affectivity and building per-
sonal strengths. These strategies derive from broaden and
build theory (Fredrickson 2013) which argues, with con-
siderable empirical support, that positive psychology
interventions increase positive mood states. Positive
affectivity broadens thought-action repertoires. This facil-
itates the development of personal resources. These
enhanced personal resources may be used to induce further
positive mood states. Meta-analyses of 25 studies by Sin
and Lyubomirsky (2009) and 14 studies by Boiler et al.
(2013) involving over 3000 individuals showed that a range
of positive psychology interventions decreased depressive
symptoms in clinical and non-clinical cases. Interventions
evaluated in studies included in these meta-analysis
included self-monitoring well-being, engaging in enjoyable
activities, pursuing valued personal goals, using signature
strengths, visualizing best possible selves, practicing for-
giveness, engaging in or recalling acts of kindness,
counting blessings or expressing gratitude, expressing hope
or optimism, recalling or writing about positive life events,
practicing meditation, cultivating sacred moments, engag-
ing in physical exercise, and participating in programs that
combine multiple positive psychology interventions.
Longer multi-element programs involving extensive prac-
tice were more effective than shorter single element
programs.
A number of multi-element clinical positive psychology
intervention programs have been developed (Fordyce 1977;
Frisch 2006; Fava and Ruini 2013; Rashid 2013). Rashid
and Seligman’s positive psychotherapy is a particularly
significant application of findings from contemporary
positive psychology to psychotherapy practice, since
Martin Seligman, the founder of contemporary positive
psychology, is one of the authors (Rashid 2013; Seligman
et al. 2006). The 14-session program aims to promote, what
Seligman refers to as the pleasant life, the engaged life, and
the meaningful life through structured interventions and
related homework assignments. The program includes
interventions such as savoring that enhance pleasure and
promote the pleasant life; interventions that encourage the
use of signature strengths such as optimism, gratitude and
forgiveness to foster the engaged life; and interventions
that enhance relationships within families and institutions
to promote the meaningful life.
Results of two small trials show that positive psycho-
therapy reduces depression and enhances well-being for
people with mild to moderate depression and major
depressive disorder (Seligman et al. 2006). In a controlled
trial involving 37 adults with mild to moderate depressive
scores on the Beck Depression Inventory, Seligman et al.
(2006) found that compared with a no-treatment control
group, a six session version of the positive psychotherapy
program led to a significant reduction in depressive
symptoms and this improvement was maintained at 1 year
follow-up. In a second controlled trial involving 35 adults
with major depressive disorder, Seligman, Rashid and
Parks (Seligman et al. 2006) found that a 14 session
positive psychotherapy program led to significantly
higher remission rates after treatment than routine psy-
chotherapy or psychotherapy combined with antidepressant
medication.
110 J Contemp Psychother (2015) 45:109–118
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Drawing on the positive psychology literature, positive
psychology interventions focusing on personal strengths,
humor, forgiveness, gratitude, strengthening relationships,
and savoring were incorporated into the SYTL program.
Group Therapy
In a meta-analysis of 23 studies of the efficacy of group
therapy for major depressive disorder Huntley, Araya and
Salisbury (Huntley et al. 2012) found that at post-treatment
and follow-up group CBT was more effective than usual
care. Individual CBT was more effective than group CBT
at post-treatment, but at 3 months follow-up, both group
and individual CBT were equally effective in decreasing
depressive symptoms. The meta-analysis included two
studies of dialectical behavior therapy, one study of inter-
personal therapy and one trial which evaluated self-control
therapy. In all of these trials, group therapy led to greater
reductions in depressive symptoms than usual care.
Research on contemporary group therapy for a range of
adult mental health problems provides evidence for the
importance of a number of common factors which con-
tribute to effective group interventions (Burlingame et al.
2013; Kleinberg 2012). These include induction of group
members into the group program prior to treatment and
during early sessions, fostering group cohesion, flexible use
of treatment manuals, managing conflict within sessions,
facilitating appropriate emotional expression, and dealing
with potential adverse outcomes or tensions in a timely and
thoughtful way. All of these elements were incorporated
into the SYTL program.
The Say ‘Yes’ to Life (SYTL) Program
The SYTL program spans 20 2-hour sessions, with each
session focusing on a core theme or ‘pathway’ to well-
being as shown in Table 1and detailed in later sections of
this paper. The SYTL program contains four carefully
sequenced stages. In the first there is a focus on developing
a positive perspective. In the second clients learn CBT
skills for challenging a negative, dysphoric perspective. In
the third, the focus is on skills for coping with life chal-
lenges. Skills for enhancing well-being are facilitated in the
final stage of the program. Sessions are thematically
sequenced in this way to facilitate the generation of a
strengths-based, optimistic, goal-directed perspective and
positive emotions as early as possible in the program, and
to avoid initial sessions being dominated by pessimistic
discourse and negative affectivity. This sequence is
informed by broaden and build theory mentioned above
(Fredrickson 2013). Central to CBT for depression is the
practice of identifying and challenging negative cognitions
which induce negative mood states (Beck et al. 1979), so
the development of these skills is facilitated in sessions
four through six once a positive perspective has been
established during the first three sessions. The remaining
two skills sets of the program—coping with life challenges
and enhancing well-being—rest on this bedrock of skills
for developing a positive perspective and challenging a
negative perspective. In sessions seven through fourteen,
clients develop coping strategies for regulating anxiety,
anger and grief and for communicating effectively in a
range of different types of relationships. These elements of
the program are drawn from both CBT and positive psy-
chology. The final six sessions are concerned with for-
giveness, gratitude, savoring and social network
strengthening, all of which are positive psychology inter-
ventions designed not only to alleviate depression but also
to enhance quality of life (Carr 2011).
In the SYTL program skills are learned within sessions
and then practiced between sessions as homework assign-
ments. For example, from the first session onwards par-
ticipants learn and practice mindfulness mediation skills.
The number of skills to be practiced between sessions
gradually increases as the program progresses, so that
homework supports lifestyle change. Participants receive
supportive weekly phonecalls to inquire about between-
session-practice, which is reviewed at the start of each
session. Group members keep a record of their progress
over the course of the program in a journal and after each
session read specific pathways, listed in Table 1, from the
SYTL self-help book (Finnegan and Kenneally, Finnegan
and Kennally 2013). Homework assignments, phone-call
reminders, homework review, and reading the self-help
book facilitate mastery of the program curriculum.
The SYTL program may be offered to groups with 6–14
members, although the optimal group size is 12. It is
offered as a closed group with participants committing to
attending all 20 sessions. The SYTL program is a psy-
choeducational therapeutic group intervention. It is psy-
choeducational insofar as clients learn a range of positive
psychology and CBT skills. However, it is also a therapy
group in which relationships among group members and
facilitators provide a therapeutic context for recovery.
Therapists have the dual role of both coaching partici-
pants in skills development, and optimizing the group’s
social climate so that it is a supportive context for skills
development. In coaching clients in skills development,
therapists explain skills, model them, invite clients to
practice skills in pairs, observe this practice, give con-
structive feedback, facilitate a group discussion of these
exercises, and invite clients to practice skills between
sessions. In optimizing the social climate of the group,
therapists facilitate gradual self-disclosure of clients,
J Contemp Psychother (2015) 45:109–118 111
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alliance building, resolution of conflicts and tensions
between group members, and addressing issues of loss as
the program draws to a close or members drop out
(Kleinberg 2012).
Over the 20 sessions of the SYTL program, clients
gradually build up a repertoire of positive psychology and
CBT skills. They also form significant relationships within
the therapeutic group. Through conducting skills develop-
ment exercises, and reflecting on their experiences of these
in plenary group discussions, clients gradually let other
group members know about their depressive disorders, the
challenges they have faced in their lives and how they have
tried to cope with these. They also unconsciously engage in
their habitual, and typically maladaptive coping strategies
or defenses within the group context. The therapist helps
group members learn to recognize these maladaptive cop-
ing strategies and defenses, and consider adaptive alter-
natives. In early sessions this process is predominantly
‘therapist-led’. However, in later sessions as group cohe-
sion strengthens, group members are encouraged to give
each other feedback on the use of maladaptive and adaptive
coping strategies.
The SYTL program was developed primarily by LF, a
clinical psychologist and integrative and humanistic psy-
chotherapist who has worked for many years treating
people with MDD both individually and in groups, in
consultation with a number of clinical and academic col-
leagues. Therapists delivering the program follow a struc-
tured treatment manual (Finnegan and Kenneally, Finnegan
and Kennally 2014). Because of the complex demands that
the program places on therapists, it was designed to be
facilitated by clinical psychologists with training in psy-
chopathology, psychotherapy (especially CBT), and group
therapy. It is helpful if other staff in the setting where the
SYTL program is delivered understand and are supportive
of the program.
Session 1: Program Introduction
In the first session participants make a therapeutic contract
which includes elements such as regular attendance, active
participation, group safety, and completion of between-
session assignments. The positive psychology conceptual
framework of the program is outlined. Participants are
Table 1 Say Yes to Life (SYTL) program
Session title Theory Skills Assigned reading from SYTL
Skills for developing a positive perspective
1. Introduction CBT & PP Forming a therapeutic contract
2. Recognise your resilience PP Identifying personal strengths Pathway 1
3. Reach beyond PP & CBT Identifying possibilities, potential and goals Pathways 2 & 13
Skills for challenging a negative perspective
4. Challenge your thinking (1) CBT Cognitive restructuring Pathway 3
5. Challenge your thinking (2) CBT Cognitive restructuring Pathway 3
6. Talk back to negative self-talk CBT Self-talk Pathway 4
Skills For Coping With Life Challenges
7. Let laughter in PP Constructive use of humor Pathway 5
8. Speak from the heart PP Communication & giving compliments Pathway 6
9. Worry your worries CBT Anxiety management Pathway 7
10. Face your anger CBT Anger management Pathway 10
11. Accept yourself CBT Dealing with perfectionistic beliefs Pathway 11
12. Learn to live well with loss PP Facilitating healthy grieving Pathway 12
13. Nourish your relationships PP Strengthening adult attachments Pathway 17
14. Assert yourself CBT Assertiveness training Pathway 14
Skills for enhancing well-being
15. Decide to forgive (1) PP Forgiveness facilitation Pathway 15
16. Decide to forgive (2) PP Forgiveness facilitation Pathway 15
17. Be thankful PP Thankfulness facilitation Pathway 16
18. Connect with your community PP Strengthening social networks Pathway 18
19. Rediscover nature PP Savoring positive experience Pathway 20
20. Closing session PP & CBT Reviewing lessons learned
CBT cognitive behavior therapy, PP positive psychology, SYTL say yes to life self-help book by Finnegan and Kennally (2013)
112 J Contemp Psychother (2015) 45:109–118
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provided with a copy of the self-help book: Say Yes to Life.
Key elements of the weekly program are introduced such
as journaling, physical exercise, meditation, and music.
They are also invited to engage in 5 min of physical
exercise and 5 min of meditation per day until the next
session and to record their experience of doing this and of
the first session in their journal. A volunteer is selected to
bring in a piece of music to share with the group at the next
session. To close the session participants are invited to say
one word which expresses how they feel as the meeting
ends.
Session 2: Recognize Your Resilience
The second and subsequent sessions begin with a routine
format. Sessions start with participants each saying one-
word to describe how they are feeling as the session begins.
This is followed by a guided 10-minute meditation, and
listening to music selected by a volunteer at the end of the
previous session. Volunteers briefly explain why the
musical piece was selected. There is also a review of
homework assignments. The central theme of the session is
then introduced by reading aloud an anecdote, poem or
passage from the relevant pathway of the SYTL self-help
book. Participants are invited to share their responses to
this opening reading.
The goal of the second session is to help participants
identify overlooked personal strengths. Participants are
asked to rate their resilience on a scale of 0–10 before and
after completing the following exercise in which the
characteristics of resilient people, and their own personal
strengths are explored. The exercise, like many in the
program involves participants working in pairs initially,
and then sharing their reflections on the exercise in a ple-
nary group discussion. Participants select an inspiring
resilient character from a movie, book or TV show;
describe the challenges the character faced; and how they
demonstrated their resilience. This process is then repeated
twice, with the focus being first on a real person from
participants’ lives, and then on themselves. Participants
identify challenges which they have faced and personal
strengths that they have used to overcome these challenges.
During the plenary group discussion which follows this
exercise, input is provided on key aspects of resilience, i.e.
external supports and resources, social and interpersonal
skills and personal qualities and strengths. Participants are
guided through a process of identifying and reconnecting
with their unique, and often overlooked core strengths.
At the conclusion of the second session participants are
invited to each day write down strengths that they have
used to overcome challenges which they have faced that
day. They are also invited to ask a trusted member of their
family or social network to list the participant’s strengths,
and compare this list of strengths to the list of strengths that
they believe they have.
At the conclusion of the second and subsequent sessions,
a standard closing routine is followed. Participants are
invited to complete a 5-minute daily meditation and a daily
5-minute period of physical exercise. However, the dura-
tion of these exercises is gradually increased over the
course of the program. For example, the duration of both
exercises is increased to 15 min in session six, 20 min in
session 12, and the physical exercise assignment is
increased to 30 min per day in session 16. A volunteer is
identified to select a piece of music to be played at the next
session. Where appropriate, there is a brief reading of a
poem or piece of prose relevant to the core theme of the
session. This is followed by a one word closing round
where participants are invited to say one word that best
expresses how they feel as the group ends.
Session 3: Reach Beyond
The theme of the third session is setting life goals and
anticipating obstacles to achieving these. Working in pairs,
participants are guided through a process where they
explore their experience over the course of their lives of
being encouraged to, or discouraged from pursuing their
hopes and dreams. They also reflect on ways in which the
encouraging and discouraging messages from parents and
others have been internalized, and continue to help or
hinder them in pursuing their life goals.
To introduce the theme of goal achievement and making
the impossible possible, an excerpt about Christopher
Columbus from pathway 13 of the SYTL self-help book is
read aloud. Working in pairs, participants are invited to
reflect on instances where they were successful and
unsuccessful in setting and achieving goals. In the plenary
discussion following this exercise, the value of setting
specific, measurable, attainable, realistic, and timely
(SMART) goals is outlined. The following issues are also
considered. Goals may be set in different areas of life such
as work, fitness, relationships and so forth. Distinctions are
made between short, medium an long-term goals. The
chances of achieving goals is increased if big goals are
broken down into a number smaller goals; if personal
strengths are identified to help achieve goals; if obstacles
are anticipated and supports required to overcome these are
put in place; if the process of goal achievement is visual-
ized; and if success is celebrated. As part of homework,
participants are invited to identify and record personal
goals. Reviewing movement towards personal goals is
incorporated into the opening routine from the fourth ses-
sion onwards.
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Sessions 4 and 5: Challenge Your Thinking
The theme of sessions 4 and 5, and a central theoretical
proposition of CBT, is that negative mood states may be
ameliorated by challenging the negative thoughts from
which they arise. In these sessions a number of ideas from
CBT are explained and illustrated with examples. These
include negative automatic thoughts, assumptions, core
beliefs, and cognitive distortions. A guided discovery
exercise is used to help participants identify the impact of
cognitive distortions on mood and behavior. As part of
homework at the conclusion of session 4, participants are
invited to identify and record cognitive distortions.
The cognitive distortions homework assignment is
reviewed in the opening phase of session five. Participants
are introduced to a six-step guide for challenging these
distortions. Working in pairs, participants use this method
to review and challenge their own particular distortions,
and continue this process as homework. Participants are
also introduced to ways of recognizing negative assump-
tions, the downward arrow technique for accessing nega-
tive core beliefs, and procedures for challenging these.
Session 6: Talk Back to Negative Self Talk
Identifying common negative self-statements and counter-
ing these with positive affirmations is the theme of the sixth
session. Working in pairs, participants identify their top
three negative self-statements and explore the negative
impact of these on their mood and personal adjustment. In
a plenary group discussion participants are guided through
a three-step process to undermine the power of negative
self-talk. This involves becoming more aware of negative
self-talk, challenging negative self-statements by looking
for evidence that does not support them, and countering
negative self-statements with positive affirmations. Partic-
ipants are invited to use this procedure as homework. To
support the use of this three-step process, participants are
invited to compile and share with the group a list of 15
positive statements which they believe about themselves.
Session 7: Let Laughter In
An audio recording of laughter is played to introduce the
theme of the seventh session which is ‘Let Laughter In’ and
this is also played at the conclusion of the session. Key
points are presented about the positive effects of con-
structive humor. Constructive humor and laughter improve
mood, reduce tension and create solidarity among people
facing adversity. Constructive humor may be distinguished
from destructive or defensive humor such as put-downs,
sarcasm and satire which can hurt others. Participants are
guided through a process to help them explore how to let
more laughter into their lives. This involves remembering
movies, TV shows, comedians, novels, funny recent per-
sonal experiences and early childhood experiences of
playfulness. Participants are then invited to imagine what it
would be like if they allowed themselves to be humorous,
to laugh and to be more playful. As homework, participants
are invited to consider various strategies for reconnecting
with laughter including: making a collection of DVDs and
CDs of favorite comedy shows and setting aside some time
to watch these regularly; keeping a written collection of
jokes and funny stories and regularly adding to this col-
lection; keeping a list of things that make them smile and
regularly updating this list; when feeling stressed stepping
back mentally and trying to see the funny side of the sit-
uation; and taking a risk and being humorous or playful in
relationships with partners or friends.
Session 8: Speak from the Heart
The theme of the eighth session-speak from the heart—
focuses on giving and receiving compliments. Key points
about these processes are presented. Giving and receiving
complement enhances wellbeing and strengthens relation-
ships. Beliefs about the negative consequences of giving
and receiving complements may inhibit these activities.
Such beliefs include the idea that complementing others
induces and inflated sense of self-importance, and accept-
ing a complement is a sign of selfish grandiosity. Working
in pairs, participants are invited to engage in an exercise in
which they give and receive compliments, and in a plenary
group discussion reflect on their responses to these pro-
cesses. The exercise is designed to increase awareness of
beliefs that inhibit the capacity to give and receive com-
plements. As homework participants are invited to give two
compliments a day—one to themselves and one to
another—and to record their reflections on this process.
Session 9: Worry Your Worries
Worry and anxiety management are addressed in the ninth
session. Participants are invited to share their most com-
mon worries. These examples are used to illustrate the
downward spiral of anxiety and its effects. Future unsub-
stantiated threats to safety and well-being are anticipated
and vividly imagined. This gives rise to bodily tension and
other somatic symptoms of anxiety such as tachycardia,
hyperventilation, perspiration and so forth. These somatic
sensations, and the accompanying feelings of anxiety are
interpreted as proof that one’s safety and well-being are
threatened. This downward spiral of anxiety leads to
avoidance of many potentially enriching life-opportunities.
Participants are guided through a CBT process for man-
aging anxiety and invited to practice this as homework. It
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involves identifying and challenging anxiety-related neg-
ative automatic thoughts and cognitive distortions, such as
catastrophizing (discussed in session 4); confining worry-
ing to set periods of the day; and practicing breathing
exercises and progressive muscle relaxation.
Session 10: Face Your Anger
Anger management is addressed in the tenth sessions. Key
points about this theme are presented. Anger may be
constructively used to address injustice and improve soci-
ety, or destructively used to hurt others. Cognitive distor-
tions can lead to inappropriate anger. For example, we can
become angry because we misinterpret the actions of other
people as being directed against us. Anger may be used as a
defense. That is, when we have been hurt, rather than
allowing ourselves to feel sad and vulnerable, we feel
angry. Unfortunately expressing this anger can alienate
people who could support us by empathizing with our pain.
Processing these vulnerable feelings is essential for
‘moving on’ from defensive anger. We are all prone to
irritation when we are tired, stressed, hungry or when we
have previously suppressed anger. We can avoid inappro-
priate angry outbursts by paying attention to these
processes.
Participants are guided through a process to help them
explore the impact of anger on their relationships and
changes they would like to make in the way they deal with
anger. This is followed by coaching in anger management
where participants learn to recognize early warning signals
for anger, breathing and relaxation exercises for reducing
physiological arousal, cognitive techniques for reapprais-
ing situations in less threatening ways, constructive
responses to anger provoking situations, and positive ways
that anger can be channeled.
Participants are invited to practice anger management as
homework. They are also invited to write (but not send) a
letter to the person who hurt them, to help them process
unresolved anger. In this letter participants describe vividly
how the other person’s actions affected them, state what
they needed from the other person at the time, and ask
questions about issues that remain unclear.
Session 11: Accept Yourself
Self-acceptance and breaking the vicious cycle of perfec-
tionism and is the central theme of the eleventh session.
Key points about perfectionism are presented. Perfection-
ism is based on the belief that happiness will come from
achieving perfection through hard work. This belief fuels a
vicious cycle in which people work hard to attain perfec-
tion (and happiness), repeatedly fail to achieve this, and
consistently engage in severe self-criticism which leads to
unhappiness. Working in pairs, participants are invited to
review the emotional, social and physical costs of perfec-
tionism in their lives, and talk about their views in a ple-
nary discussion. They are then guided through a process for
freeing themselves from the paralysis of perfectionism
using CBT techniques. These include challenging perfec-
tionism-related negative automatic thoughts and cognitive
distortions; separating self-worth from work performance;
practicing making mistakes to overcome fear of failure;
valuing mistakes as learning opportunities; and setting
realistic obtainable goals.
Session 12: Learn to Live Well with Loss
Living well with loss is the core theme of the twelfth
session. Participants are invited to identify significant los-
ses that they have endured and state what has helped them
to deal with these. There is also an invitation to consider
what they have they learned from grieving. Key points
about the nature of the grief process are presented. Various
losses are considered including bereavements, illnesses,
injuries, miscarriages, unemployment, break-up of rela-
tionships, leaving home, etc. A range of grief reactions are
described including anticipatory grief, shock, numbness,
denial, anger, guilt, regret, sadness, longing and accep-
tance. An exploration of loss and grief is facilitated and
participants are guided through a process designed to
support healthy grieving.
Session 13: Nourish Your Relationships
The theme of session thirteen is nourishing relationships.
Working in pairs, participants complete a relationship
diagram in which they identify people who are very close,
somewhat close, supportive but not close, and distant. They
are then invited to identify people in their diagram with
whom they would like a closer relationship; to define the
qualities that make a good friend; and things that they
could do to make themselves a better friend (or partner in
the case of romantic relationships) to people to whom they
wish to be closer.
Session 14: Assert Yourself
Using assertiveness for getting needs met is the central
theme of the fourteenth session. Working in pairs, partic-
ipants are invited to explore the effects of getting their
needs met though aggression or non-assertive strategies
such as passive-aggression, sulking and guilt induction. In
the plenary discussion which follows this exercise it is
highlighted that the short-term benefits of these strategies
are outweighed by the long-term problems they create.
Passive-aggression, sulking and guilt induction allow
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immediate conflict to be avoided, but in the long-term
foster low self-esteem and relationship problems. Aggres-
sion may allow short-term goals to be achieved, but in the
long-term may lead to guilt, shame and social isolation.
These problematic aggressive and non-assertive ways of
having needs met may have been adaptive in childhood,
but are not useful in adulthood. Assertiveness is proposed
as a more adaptive style for communicating needs in
adulthood, in a way that promotes good relationships by
respecting the rights of the self and others. Working in
pairs participants role-play assertiveness skills including
identifying their rights, saying ‘no’ respectfully, requesting
other to change their behavior in a non-aggressive way, and
making ‘I-statements’. Reflections on this exercise are
considered in a plenary group discussion, and participants
are invited to practice assertiveness skills as homework.
Sessions 15 and 16: Decide to Forgive
Forgiveness in the central theme of sessions 15 and 16.
Over the course of these two sessions participants are
guided through a structured forgiveness process. Partici-
pants are invited to engage in individual, dyadic and whole
group experiential exercises, and to engage in forgiveness-
related exercises as homework. The process involves
understanding that the decision to forgive is an internal
series of events (and not external reconciliation), consid-
ering the pros and cons of forgiveness, making a decision
to forgive, understanding the life circumstances of the
transgressor, developing empathy and compassion for that
person, letting go of the possibility of revenge, and writing
(but not sending) a forgiveness letter.
Session 17: Be Thankful
Thankfulness is the theme of the seventeenth session. Key
points on gratitude and positive emotions are presented.
Giving and receiving thanks, and counting blessings for
which we are thankful at the end of each day enhance our
well-being and health. Unfortunately low mood inhibits the
expression and reception of gratitude. Working in pairs,
participants explore the effects of giving and receiving
thanks in an open and mindful way, and discuss their
reflections in a plenary session. Participants are invited to
write a letter of thanks in a heartfelt and emotional way to a
person who helped them, and whom the have never prop-
erly thanked. Working in pairs, participants are invited to
read the letter aloud, notice the effect of this on them, and
think about whether or not they should send this letter. The
effects of writing these letters is discussed in a plenary
session. As homework participants are invited to each day
write down and reflect on three things for which they are
thankful, and to practice giving and receiving thanks in an
open and mindful way.
Session 18: Connect with your Community
Connecting with community is the theme of the eighteenth
session. Key points on community involvement are pre-
sented. Living in a community fosters a sense of belonging.
Extended family, friends, neighbors, and acquaintances
constitute a social network that provide practical and social
support. These forms of support increase well-being. Well-
being is also enhanced by giving back to the community
though volunteering in community organizations. Working
in pairs, participants explore their experience of living in a
community and ways of increasing community involve-
ment. As part of homework participants are invited to
gather information about the range of social, sporting,
musical, educational and voluntary groups and organiza-
tions in their local community and to take steps towards
increasing their connections with their community by
joining or volunteering with one of these groups.
Session 19: Rediscover Nature
Rediscovering nature and savoring sensory experiences is
the theme of the nineteenth session. Key points about
enjoying nature and the value of savoring sensory experi-
ences are explored. Awareness of the beauty of nature may
be overshadowed by preoccupations with other aspects of
busy lives. ‘Doing’ may distract us from ‘being’. Either the
seasons of life exercise and the sensory walk exercise, both
of which facilitate savoring and are described in pathway
20 of the SYTL self-help book, are completed in this
session.
There are four parts to the seasons of life exercise, one
for each of the seasons. Each part opens with a poem being
read aloud which depicts vivid images of the season in
question. Participants are invited to visualize favorite
images of the season. Then for each season they are invi-
ted, while holding vivid images of the season in mind, to
reflect on a life process metaphorically related to the sea-
son. For spring, they reflect on areas of their lives in which
they are experiencing signs of new growth. For summer
they reflect on ways in which they can express more of the
vitality of summer in their lives. For autumn they reflect on
aspects of their lives that have reached fruition and can be
celebrated. For winter they identify aspects of themselves
that need to slow down and be protected.
The sensory walk meditative exercise opens by noting
that when we are depressed, stressed or very busy we
engage with the world in a limited way through our dom-
inant sense, and pay minimal attention to sensations from
our other four senses. Participants are invited to identify
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their dominant sense and to engage in a meditative walk in
which they become aware of sensations from all five sen-
ses. In the plenary discussion which follows this exercise,
participants reflect on how savoring sensations from all five
senses affected their well-being. As homework participants
are invited to increase their sensory engagement with nat-
ure, and to prepare a short presentation for the closing
session.
Session 20: Closing Session
Participants’ journey through the program and graduation
from it is the main theme of the final session. Participants
make short presentations to the group outlining their per-
sonal journeys and reflections on it as the program comes
to an end. Ways of maintaining gains achieved during the
program are explored.
Discussion and Conclusions
The principal limitation of the SYTL program is that it is
suitable for some, but not all depressed clients. It was
designed to be offered to literate clients with major
depressive disorder on an outpatient basis. Clients must be
literate so that they can read the self-help manual and
conduct written homework assignments. They must also be
outpatients so that they can use the homework assignments
to gradually change their lifestyle. Lifestyle change is the
mechanism by which gains made during the program are
maintained after the program concludes. In view of this, the
SYTL program, as it is currently designed, is not suitable
for inpatients with literacy problems. It is also not suitable
for depressed clients with comorbid conditions that would
significantly interfere with engaging in the program. These
comorbid conditions include psychosis, severe substance
use disorders, and neurocognitive disorders involving sig-
nificant memory impairment.
The SYTL psychoeducational approach to group-based
skills development, using dyadic exercises followed by
plenary group discussions, has the advantage of providing
up to 14 participants with opportunities to learn and prac-
tice skills in dyadic exercises, and also to engage in group
discussions about their experiences of this. However, this
format has the disadvantage of limiting opportunities for
clients display’s of maladaptive coping strategies and
defense mechanisms within the group context becoming
the principal focus of group discourse, as commonly occurs
in other forms of group therapy. This is because only about
half of each session involves whole group discussion and
because there are usually a relatively large number of cli-
ents (12–14) in a SYTL therapy group.
The SYTL program shares much in common with other
approaches based on an integration of CBT and positive
psychology (e.g. Bannink 2014; Karwoski et al. 2006). In
the SYTL program there is a focus in early sessions on
strengths, resilience and the establishment of positive
goals, and throughout the program the therapeutic process
involves both developing skills for coping with challenges
and building strengths. The principal differences between
the SYTL program and other similar programs is the range
of theoretical influences and session content. For example,
in Bannink’s (2014) positive CBT, there is a strong
emphasis on translating negative problems into positive
goals, identifying and building on exceptions to problems
and other solution focused therapy techniques. Karwoski
et al. (2006) integration of CBT and positive psychology
both frameworks are drawn on in helping clients to identify
strengths, develop hope and optimism, endow life events
with meaning, and use humor as a coping strategy. CBT
pleasant event scheduling is integrated with the positive
psychology intervention of finding flow. Mindfulness is
used to help clients accept unsolvable problems. Both
Bannink’s (2014) and Karwoski et al. (2006) approaches
are presented as a basis for conducting individual psy-
chotherapy, whereas the SYTL program is a group psy-
choeducational intervention.
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